does fluid responsiveness imply fluid need?...does fluid responsiveness imply fluid need? s magder...
TRANSCRIPT
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Does fluid responsiveness imply fluid need?
S MagderDivision of Critical Care,
McGill University Health Centre
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What is the importance of fluid for
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What is the importance of fluid for
• Water is the primary solvent for all the bodies chemicals:
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What is the importance of fluid for
• Water is the primary solvent for all the bodies chemicals: – Allows convective and diffusional transport
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What is the importance of fluid for
• Water is the primary solvent for all the bodies chemicals: – Allows convective and diffusional transport– Allows proteins to form their tertiary structures that
are essential for their function
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Water is 60% of total weight
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Water is 60% of total weight
Extra-cellularWater 18%
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Water is 60% of total weight
Extra-cellularWater 18%
Plasma water 5%
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IC
EC
Inter-stitial
Plas
ma
40% 60%
General Schema
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IC
EC
Inter-stitial
Plas
ma
40% 60%
General Schema
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IC
EC
Inter-stitial
Plas
ma
40% 60%
General SchemaPlasma vol ~ 3.5 l
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IC
EC
Inter-stitial
Plas
ma
40% 60%
General SchemaPlasma vol ~ 3.5 l
~ 12 l
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When “volume resuscitating” consider-----
• Hydration• Extracellular volume• Intravascular volume
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What is hydration?
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What is hydration?
• The state of hydration refers to the amount of water relative to the amount of solute particles–Dehydration -- not enough water for the solute
( ie osmolality is above normal)–Excess hydration -- too much water for the
solute ( ie osmolality is below normal)• Hydration is assessed by examining the solutes
– Primarily Na+
– Also glucose, urea, alcohol, ketones etc
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Assessment of extracelluar
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Assessment of extracelluar
• Excess volume
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Assessment of extracelluar
• Excess volume– Peripheral edema
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Assessment of extracelluar
• Excess volume– Peripheral edema– Acites
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Assessment of extracelluar
• Excess volume– Peripheral edema– Acites– Pulmonary edema and pleural effusions
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Assessment of extracelluar
• Excess volume– Peripheral edema– Acites– Pulmonary edema and pleural effusions
• Decreased volume
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Assessment of extracelluar
• Excess volume– Peripheral edema– Acites– Pulmonary edema and pleural effusions
• Decreased volume– Loss of skin turgor
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Assessment of extracelluar
• Excess volume– Peripheral edema– Acites– Pulmonary edema and pleural effusions
• Decreased volume– Loss of skin turgor– Loss of sweat
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Fluid status is not really about water balance but rather “salt solution balance”
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Assessment of vascular volume
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Assessment of vascular volume
• Excess volume
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Assessment of vascular volume
• Excess volume– Elevated jugular veins
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Assessment of vascular volume
• Excess volume– Elevated jugular veins– S3
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Assessment of vascular volume
• Excess volume– Elevated jugular veins– S3 – Pulmonary venous congestion
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Assessment of vascular volume
• Excess volume– Elevated jugular veins– S3 – Pulmonary venous congestion
• Decreased volume
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Assessment of vascular volume
• Excess volume– Elevated jugular veins– S3 – Pulmonary venous congestion
• Decreased volume– Postural hypotension
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Assessment of vascular volume
• Excess volume– Elevated jugular veins– S3 – Pulmonary venous congestion
• Decreased volume– Postural hypotension– Flat neck veins
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Assessment of vascular volume
• Excess volume– Elevated jugular veins– S3 – Pulmonary venous congestion
• Decreased volume– Postural hypotension– Flat neck veins– Tachycardia (not a strong sign)
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Increasing evidence of harmful effects of excess fluid
• Adesanya A et al Vasc Endovascular Surg 2008; 42:531-536.• Vincent JL et al. Crit Care Med 2006; 34:344-353.• Joshi GP et al Anesth Analg 2005; 101:601-605• Wiedemann HP et al N Engl J Med 2006; 354:2564-2575.• Boyd et al (VASST trial). CCM 2011;39:259-265Durairaj L & Schmidt.
Chest 2008;133:252-263
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Increasing evidence of harmful effects of excess fluid
• Adesanya A et al Vasc Endovascular Surg 2008; 42:531-536.• Vincent JL et al. Crit Care Med 2006; 34:344-353.• Joshi GP et al Anesth Analg 2005; 101:601-605• Wiedemann HP et al N Engl J Med 2006; 354:2564-2575.• Boyd et al (VASST trial). CCM 2011;39:259-265Durairaj L & Schmidt.
Chest 2008;133:252-263
- therefore try to avoid excess volume - Key is to identify likelyhood of lack of volume responsiveness- tests are useful in the negative
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Patient has low urine output and is thought to be “pre-renal”
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Patient has low urine output and is thought to be “pre-renal”
How does volume increase the flow of urine?
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Patient has low urine output and is thought to be “pre-renal”
How does volume increase the flow of urine?
1. Increase renal blood flow
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Patient has low urine output and is thought to be “pre-renal”
How does volume increase the flow of urine?
1. Increase renal blood flow2. By increasing blood pressure
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Patient has low urine output and is thought to be “pre-renal”
How does volume increase the flow of urine?
1. Increase renal blood flow2. By increasing blood pressure3. By increasing cardiac output
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What determines flow?
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What determines flow?
Review of cardiovascular basics
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Volume stretches the veins and creates the “recoil” pressure that drives flow back to the heart
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Volume stretches the veins and creates the “recoil” pressure that drives flow back to the heart
![Page 47: Does fluid responsiveness imply fluid need?...Does fluid responsiveness imply fluid need? S Magder Division of Critical Care, McGill University Health Centre What is the importance](https://reader030.vdocument.in/reader030/viewer/2022040322/5e5fb0f1198e0d7f025849e4/html5/thumbnails/47.jpg)
Volume stretches the veins and creates the “recoil” pressure that drives flow back to the heart
![Page 48: Does fluid responsiveness imply fluid need?...Does fluid responsiveness imply fluid need? S Magder Division of Critical Care, McGill University Health Centre What is the importance](https://reader030.vdocument.in/reader030/viewer/2022040322/5e5fb0f1198e0d7f025849e4/html5/thumbnails/48.jpg)
Volume stretches the veins and creates the “recoil” pressure that drives flow back to the heart
Heart has a “permissive”
function. It lowers the outflow
pressure and allows veins to
empty
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Volume stretches the veins and creates the “recoil” pressure that drives flow back to the heart
Heart has a “permissive”
function. It lowers the outflow
pressure and allows veins to
empty
![Page 50: Does fluid responsiveness imply fluid need?...Does fluid responsiveness imply fluid need? S Magder Division of Critical Care, McGill University Health Centre What is the importance](https://reader030.vdocument.in/reader030/viewer/2022040322/5e5fb0f1198e0d7f025849e4/html5/thumbnails/50.jpg)
Volume stretches the veins and creates the “recoil” pressure that drives flow back to the heart
Heart has a “permissive”
function. It lowers the outflow
pressure and allows veins to
empty
Determinants of flow
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Stressed VolumeCv x RvQ =
Volume stretches the veins and creates the “recoil” pressure that drives flow back to the heart
Heart has a “permissive”
function. It lowers the outflow
pressure and allows veins to
empty
Determinants of flow
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Stressed VolumeCv x RvQ =
Heart has a “permissive”
function. It lowers the outflow
pressure and allows veins to
empty
Determinants of flow
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Stressed VolumeCv x RvQ =
Heart has a “permissive”
function. It lowers the outflow
pressure and allows veins to
empty
Determinants of flow
![Page 54: Does fluid responsiveness imply fluid need?...Does fluid responsiveness imply fluid need? S Magder Division of Critical Care, McGill University Health Centre What is the importance](https://reader030.vdocument.in/reader030/viewer/2022040322/5e5fb0f1198e0d7f025849e4/html5/thumbnails/54.jpg)
Stressed VolumeCv x RvQ =
Heart has a “restorative”
function
Heart has a “permissive”
function. It lowers the outflow
pressure and allows veins to
empty
which refills the veins
Determinants of flow
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MCFPStressed volume
Unstressed volume
Pra
Rv
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MCFPStressed volume
Unstressed volume
Pra
Cardiac function
Rv
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Frank-Starling’s Law“the greater the preload the greater the Q--
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Frank-Starling’s Law“the greater the preload the greater the Q--
Pra (mmHg)
Q (l/min)
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Frank-Starling’s Law“the greater the preload the greater the Q--
Pra (mmHg)
Q (l/min)
0
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Frank-Starling’s Law“the greater the preload the greater the Q--
Pra (mmHg)
Q (l/min)
0 10
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Frank-Starling’s Law“the greater the preload the greater the Q--
Pra (mmHg)
Q (l/min)
0 10
5
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Frank-Starling’s Law“the greater the preload the greater the Q--
Pra (mmHg)
Q (l/min)
0 10
5
-- up to a maximum”
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Frank-Starling’s Law“the greater the preload the greater the Q--
Pra (mmHg)
Q (l/min)
0 10
5
plateau
-- up to a maximum”
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MCFPStressed volume
Unstressed volume
Pra
Cardiac function
Rv
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MCFPStressed volume
Unstressed volume
Pra
Cardiac function
Return Function
Rv
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MCFPStressed volume
Unstressed volume
Pra
Cardiac function
Return Function
Rv
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Q
Pra
Pra/CVP
Cardiac output
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Q
Pra
Pra/CVP
Cardiac output
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Q
PraCardiacPreload
Pra/CVP
Cardiac output
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Q
PraCardiacPreload
Pra/CVP
Gradient for VR
Cardiac output
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Q
PraCardiacPreload
Cardiac limited“Wasted preload”
Pra/CVP
Gradient for VR
Cardiac output
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If cardiac function becomes limited the volume infusion will not increase cardiac output
Pra
Q
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If cardiac function becomes limited the volume infusion will not increase cardiac output
Pra
“Plateau”Q
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If cardiac function becomes limited the volume infusion will not increase cardiac output
Pra
“Plateau”Q
Volume does not increase cardiac output
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If cardiac function becomes limited the volume infusion will not increase cardiac output
Pra
“Plateau”Q
Volume does not increase cardiac output
= ‘wasted preload” (excess volume)
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Q
Pra
Pra/CVP
Cardiac output
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Q
Pra
Maximal return“Cardiac independent”
Pra/CVP
Cardiac output
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Q
Pra
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Q
Pra
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Q
Pra
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Q
Pra
Lowering Pra further will not increase Q
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Q
Pra
Lowering Pra further will not increase Q
VR = -Pra
RvMCFP
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Q
Pra
Lowering Pra further will not increase Q
VR = -Pra
RvMCFP
max
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Q
Pra
Lowering Pra further will not increase Q
VR = -Pra
RvMCFP
max
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Q
Pra
Lowering Pra further will not increase Q
VR = -Pra
RvMCFP
max
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Q
Pra
Lowering Pra further will not increase Q
VR = -Pra
RvMCFP
max
Stressed volume must increase to increase Q
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Version 1
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Version 11. Is this pt volume responsive?
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Version 11. Is this pt volume responsive?2. Does this pt need volume?
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Version 11. Is this pt volume responsive?2. Does this pt need volume?
Version 2
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Version 11. Is this pt volume responsive?2. Does this pt need volume?
Version 21. Does this pt need volume?2. Is this pt volume responsive?
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Version 11. Is this pt volume responsive?2. Does this pt need volume?
Version 21. Does this pt need volume?2. Is this pt volume responsive?
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Version 11. Is this pt volume responsive?2. Does this pt need volume?
Version 21. Does this pt need volume?2. Is this pt volume responsive?
ie is the patient on the flat part of the cardiac function curve?
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Crit Care Med 2010 Vol. 38, No. 11
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Fluid Protocol
CI < 4 and CVP < 12 ?
Chest tube drainage > 200mL/hror Hb < 80 mg/dL ?
Protocol Fluid Bolus
Check CI and
CVP
PRBC’s+ Platelets
+ FFP
CVP incr. > 2 and
CI incr. < 0.3
CVP incr. < 2 and
CI incr. > 0.3
CI < 2.2 or
MAP < 70 or
SBP < Target or
CVP < 3
Total Protocol
Fluid >1L/24hr?
Bleeding Corrected?
No
Exclude
250 mL NS Bolus until 24
hrs
CatecholamineProtocol
Weaning Protocol
Patient on Catecholamines
?
No
No
NoYes
Yes
Yes Yes
No
Yes
Observe
No
Yes
Yes
No
Patient on Catecholamines?
Observe
Yes
No
CI < 2.2or
MAP < Targetor
SBP < Targetor
CVP < 3
CatecholamineProtocol
Weaning Protocol
CVP incr. < 2 and
CI incr. < 0.3
CVP incr. > 2 and
CI incr. > 0.3
Exclude bleeders
Limit Q&
CVP
Inadequatechallenge
Cardiac response ok
Cardiac response ok
Limit HES to 1 l
Pt not volume responsive
Targets
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Triggers for considering fluids
• Decreased Q• Decreased BP• Decreased urine output• Decreased CVP• ? Increased lactate• ? Decreased ScVO2
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Estimate of CVP is readily available from Jugular Venous Pressure
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Estimate of CVP is readily available from Jugular Venous Pressure
SternalAngle
5 cm
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Estimate of CVP is readily available from Jugular Venous Pressure
SternalAngle
5 cm8 cm
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Estimate of CVP is readily available from Jugular Venous Pressure
SternalAngle
5 cm8 cm 13
cm H2O
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It is often argued that CVP is of no value
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It is often argued that CVP is of no value
It is true!!
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It is often argued that CVP is of no value
It is true!!• CVP must be used in the context of
the hemodynamics (especially Q) and the changes over time
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It is often argued that CVP is of no value
It is true!!• CVP must be used in the context of
the hemodynamics (especially Q) and the changes over time
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It is often argued that CVP is of no value
It is true!!• CVP must be used in the context of
the hemodynamics (especially Q) and the changes over time
• Think of use of PCO2 – it must always be in the context of the pH
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Consider the following:
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Consider the following:
In the sitting position the CVP of a normal person is < 0 mmHg,
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Consider the following:
In the sitting position the CVP of a normal person is < 0 mmHg,
yet cardiac output (Q) and blood volume are normal
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Consider the following:
In the sitting position the CVP of a normal person is < 0 mmHg,
yet cardiac output (Q) and blood volume are normal
&
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Consider the following:
In the sitting position the CVP of a normal person is < 0 mmHg,
yet cardiac output (Q) and blood volume are normal
&There is no need for fluid infusion
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What does CVP tell you?
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What does CVP tell you?
• Is the CVP high and therefore it is unlikely that volume loading will help?– There is no “optimal” CVP – Concept should be “high” vs “low” CVP
• What happened to the CVP in relation to a change in hemodynamics (especially cardiac output)
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Approach
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Approach• Although not perfect, CVP is a reasonable
start
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Approach• Although not perfect, CVP is a reasonable
start– Should be used in the “negative”
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Approach• Although not perfect, CVP is a reasonable
start– Should be used in the “negative”– a “high” CVP means that fluids are unlikely to
help
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Approach• Although not perfect, CVP is a reasonable
start– Should be used in the “negative”– a “high” CVP means that fluids are unlikely to
help– The pattern helps, especially relationship of
CVP to Q• fall in Q with rise in CVP indicates “pump
problem” - give inotropes• Fall in Q with a fall in CVP indicates return
function - give fluid
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Large overlap between responders and non responders
Bafaqeeh & Magder JICM 2007
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Large overlap between responders and non responders
0
5
10
15
20C
VP (m
mH
g)
Bafaqeeh & Magder JICM 2007
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Large overlap between responders and non responders
0
5
10
15
20C
VP (m
mH
g)
Responders
Bafaqeeh & Magder JICM 2007
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Large overlap between responders and non responders
0
5
10
15
20C
VP (m
mH
g)
Responders
69
Bafaqeeh & Magder JICM 2007
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Large overlap between responders and non responders
0
5
10
15
20C
VP (m
mH
g)
Responders
Non-responders
69
Bafaqeeh & Magder JICM 2007
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Large overlap between responders and non responders
0
5
10
15
20C
VP (m
mH
g)
Responders
Non-responders
69
49
Bafaqeeh & Magder JICM 2007
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Some Patients at all values of CVP fail to respond to fluids
totalresnon res
Bafaqeeh & Magder JICM 2007
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Some Patients at all values of CVP fail to respond to fluids
totalresnon res
Num
ber o
f Pt
mmHg
Bafaqeeh & Magder JICM 2007
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Some Patients at all values of CVP fail to respond to fluids
totalresnon res
Num
ber o
f Pt
mmHg
Bafaqeeh & Magder JICM 2007
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Some Patients at all values of CVP fail to respond to fluids
totalresnon res
Num
ber o
f Pt
mmHg
Bafaqeeh & Magder JICM 2007
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Some Patients at all values of CVP fail to respond to fluids
totalresnon res
Num
ber o
f Pt
mmHg
Bafaqeeh & Magder JICM 2007
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Some Patients at all values of CVP fail to respond to fluids
totalresnon res
Num
ber o
f Pt
mmHg
25%
Bafaqeeh & Magder JICM 2007
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Some Patients at all values of CVP fail to respond to fluids
totalresnon res
Num
ber o
f Pt
mmHg
25% 45%
Bafaqeeh & Magder JICM 2007
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Some Patients at all values of CVP fail to respond to fluids
totalresnon res
Num
ber o
f Pt
mmHg
25% 45% 82%
Bafaqeeh & Magder JICM 2007
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Some Patients at all values of CVP fail to respond to fluids
totalresnon res
Num
ber o
f Pt
mmHg
25% 45% 82% 100%
Bafaqeeh & Magder JICM 2007
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Fluids in pt with high CVP
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Fluids in pt with high CVP
• Systemic capillaries are upstream from the CVP
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Fluids in pt with high CVP
• Systemic capillaries are upstream from the CVP
• Therefore – if CVP is high, capillary pressure must be even higher
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Fluids in pt with high CVP
• Systemic capillaries are upstream from the CVP
• Therefore – if CVP is high, capillary pressure must be even higher
• The consequence is that raising the cap pressure further will increase capillary leak
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Fluids in pt with high CVP
• Systemic capillaries are upstream from the CVP
• Therefore – if CVP is high, capillary pressure must be even higher
• The consequence is that raising the cap pressure further will increase capillary leak
• This could further compress the heart and create the need for even higher levels of CVP
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Gold standard of responsiveness is a volume challenge
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Gold standard of responsiveness is a volume challenge
• To test Starling’s law the fluid needs to be given quickly – the faster it is given the less that is needed– It makes no sense to test “preload” responses
over long periods of time (eg Kumar et al 2004)
• The type of fluid is not critical if given quickly enough
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Gold standard of responsiveness is a volume challenge
• To test Starling’s law the fluid needs to be given quickly – the faster it is given the less that is needed– It makes no sense to test “preload” responses
over long periods of time (eg Kumar et al 2004)
• The type of fluid is not critical if given quickly enough
• There needs to be a change in CVP to know that Starling’s Law has been tested
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Fluid Challenge with Q measurement
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Fluid Challenge with Q measurement
1 Assess the value of Pra ( NOT the wedge).
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Fluid Challenge with Q measurement
1 Assess the value of Pra ( NOT the wedge).
2 Give sufficient fluid to raise Pra by ~2mmHg and observe Q.
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Fluid Challenge with Q measurement
1 Assess the value of Pra ( NOT the wedge).
2 Give sufficient fluid to raise Pra by ~2mmHg and observe Q. Pra
Q
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Fluid Challenge with Q measurement
1 Assess the value of Pra ( NOT the wedge).
2 Give sufficient fluid to raise Pra by ~2mmHg and observe Q. Pra
Q
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Fluid Challenge with Q measurement
1 Assess the value of Pra ( NOT the wedge).
2 Give sufficient fluid to raise Pra by ~2mmHg and observe Q. Pra
Q
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Fluid Challenge with Q measurement
1 Assess the value of Pra ( NOT the wedge).
2 Give sufficient fluid to raise Pra by ~2mmHg and observe Q. Pra
Q
+ve
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Fluid Challenge with Q measurement
1 Assess the value of Pra ( NOT the wedge).
2 Give sufficient fluid to raise Pra by ~2mmHg and observe Q. Pra
Q
+ve
![Page 149: Does fluid responsiveness imply fluid need?...Does fluid responsiveness imply fluid need? S Magder Division of Critical Care, McGill University Health Centre What is the importance](https://reader030.vdocument.in/reader030/viewer/2022040322/5e5fb0f1198e0d7f025849e4/html5/thumbnails/149.jpg)
Fluid Challenge with Q measurement
1 Assess the value of Pra ( NOT the wedge).
2 Give sufficient fluid to raise Pra by ~2mmHg and observe Q. Pra
Q
+ve
![Page 150: Does fluid responsiveness imply fluid need?...Does fluid responsiveness imply fluid need? S Magder Division of Critical Care, McGill University Health Centre What is the importance](https://reader030.vdocument.in/reader030/viewer/2022040322/5e5fb0f1198e0d7f025849e4/html5/thumbnails/150.jpg)
Fluid Challenge with Q measurement
1 Assess the value of Pra ( NOT the wedge).
2 Give sufficient fluid to raise Pra by ~2mmHg and observe Q. Pra
Q
+ve
-ve
![Page 151: Does fluid responsiveness imply fluid need?...Does fluid responsiveness imply fluid need? S Magder Division of Critical Care, McGill University Health Centre What is the importance](https://reader030.vdocument.in/reader030/viewer/2022040322/5e5fb0f1198e0d7f025849e4/html5/thumbnails/151.jpg)
Fluid Challenge with Q measurement
1 Assess the value of Pra ( NOT the wedge).
2 Give sufficient fluid to raise Pra by ~2mmHg and observe Q.
Type of fluid is not of importance if given fast enough
Pra
Q
+ve
-ve
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Change in CVP of even 1 mmHg should be sufficient to test the Starling response
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Change in CVP of even 1 mmHg should be sufficient to test the Starling response
Pra (mmHg)
Q (l/min)
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Change in CVP of even 1 mmHg should be sufficient to test the Starling response
Pra (mmHg)
Q (l/min)
0
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Change in CVP of even 1 mmHg should be sufficient to test the Starling response
Pra (mmHg)
Q (l/min)
0 10
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Change in CVP of even 1 mmHg should be sufficient to test the Starling response
Pra (mmHg)
Q (l/min)
0 10
5
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Change in CVP of even 1 mmHg should be sufficient to test the Starling response
Pra (mmHg)
Q (l/min)
0 10
5
plateau
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Change in CVP of even 1 mmHg should be sufficient to test the Starling response
Pra (mmHg)
Q (l/min)
0 10
5
plateau
![Page 159: Does fluid responsiveness imply fluid need?...Does fluid responsiveness imply fluid need? S Magder Division of Critical Care, McGill University Health Centre What is the importance](https://reader030.vdocument.in/reader030/viewer/2022040322/5e5fb0f1198e0d7f025849e4/html5/thumbnails/159.jpg)
Change in CVP of even 1 mmHg should be sufficient to test the Starling response
Pra (mmHg)
Q (l/min)
0 10
5
Slope = 500 ml/min/mmHg
plateau
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Inspiratory fall in Pra
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Inspiratory fall in Pra
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Inspiratory fall in Pra
Q
Pra
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Inspiratory fall in Pra
Q
Pra
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Inspiratory fall in Pra
Q
Pra
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Inspiratory fall in Pra
Q
Pra
↓ Ppl
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Inspiratory fall in Pra
Q
Pra
↓ Ppl
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Inspiratory fall in Pra No Inspiratory fall in Pra
Q
Pra
↓ Ppl
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Inspiratory fall in Pra No Inspiratory fall in Pra
Q
Pra
↓ Ppl Q
Pra
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Inspiratory fall in Pra No Inspiratory fall in Pra
Q
Pra
↓ Ppl Q
Pra
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Inspiratory fall in Pra No Inspiratory fall in Pra
Q
Pra
↓ Ppl Q
Pra
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Inspiratory fall in Pra No Inspiratory fall in Pra
Q
Pra
↓ Ppl Q
Pra
↓ Ppl
![Page 172: Does fluid responsiveness imply fluid need?...Does fluid responsiveness imply fluid need? S Magder Division of Critical Care, McGill University Health Centre What is the importance](https://reader030.vdocument.in/reader030/viewer/2022040322/5e5fb0f1198e0d7f025849e4/html5/thumbnails/172.jpg)
Inspiratory fall in Pra No Inspiratory fall in Pra
Q
Pra
↓ Ppl Q
Pra
↓ Ppl
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‘a’0-‘c’
20-
‘y’
‘v’
Prominent ‘y’
13 mmHg
Unlikely to respond to fluids when ‘y’ ≥ 4 mmHg
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Systolic or Pulse Pressure Variation
0-
150-
75-
mmHg
E1
![Page 175: Does fluid responsiveness imply fluid need?...Does fluid responsiveness imply fluid need? S Magder Division of Critical Care, McGill University Health Centre What is the importance](https://reader030.vdocument.in/reader030/viewer/2022040322/5e5fb0f1198e0d7f025849e4/html5/thumbnails/175.jpg)
Systolic or Pulse Pressure Variation
0-
150-
75-
mmHg
Insp Insp Insp
PAP
CVP
E1
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Systolic or Pulse Pressure Variation
0-
150-
75-
mmHgBaseline(“apnea”)
Insp Insp Insp
PAP
CVP
E1
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Systolic or Pulse Pressure Variation
0-
150-
75-
mmHg
dUP
Baseline(“apnea”)
Insp Insp Insp
PAP
CVP
E1
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Systolic or Pulse Pressure Variation
0-
150-
75-
mmHg
dUP
dDown
Baseline(“apnea”)
Insp Insp Insp
PAP
CVP
E1
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Systolic or Pulse Pressure Variation
0-
150-
75-
mmHg
dUP
dDown SPV
Baseline(“apnea”)
Insp Insp Insp
PAP
CVP
E1
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Systolic or Pulse Pressure Variation
0-
150-
75-
mmHg
dUP
dDown SPV
Baseline(“apnea”)
Insp Insp Insp
PAP
CVP
E1
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Raising the pressure with fluids vs NE
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Aorta Ra
Raising the pressure with fluids vs NE
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Aorta Ra
Baseline
Raising the pressure with fluids vs NE
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Aorta Ra
BaselineFluid
Raising the pressure with fluids vs NE
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Aorta Ra
BaselineFluid
Raising the pressure with fluids vs NE
Norepinephrine
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Aorta RaCapillaries
BaselineFluid
Raising the pressure with fluids vs NE
Norepinephrine
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Aorta RaCapillaries
BaselineFluid
Raising the pressure with fluids vs NE
Norepinephrine
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Aorta RaCapillaries
BaselineFluid
Raising the pressure with fluids vs NE
Norepinephrine
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Aorta RaCapillaries
BaselineFluid
Raising the pressure with fluids vs NE
Norepinephrine
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Use fluids judiciously
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Avoid the Michelin Man syndrome
Use fluids judiciously
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Avoid the Michelin Man syndrome
Use fluids judiciously
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IC
EC
Plas
ma
Normal Saline in Patient with Large Extra-cellular Volume
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IC
EC
Plas
ma
Plas
ma
Normal Saline in Patient with Large Extra-cellular Volume
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IC
EC
Plas
ma
Inter-stitialPl
asm
a
Normal Saline in Patient with Large Extra-cellular Volume
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IC
EC
Plas
ma
EC
Inter-stitialPl
asm
a
Normal Saline in Patient with Large Extra-cellular Volume
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IC
EC
Plas
ma
IC
EC
Inter-stitialPl
asm
a
Normal Saline in Patient with Large Extra-cellular Volume
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IC
EC
Plas
ma
IC
EC
Inter-stitialPl
asm
a
Normal Saline in Patient with Large Extra-cellular Volume
The rule that saline distribution is 1/3 vascular 2/3 interstitial is no longer true
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Determinants of Fluid Filtration(Starling Forces)
Jv = Kf,c [(Pc-Pt)-σd(πc –πt)]
where: Jv = vol flow across the wall Kf,c = filtration coefficient Pc = Capillary pressure Pt = tissue pressure πc =capillary oncotic pressure πt = tissue oncotic pressure σd = reflection coefficient
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Determinants of Fluid Filtration(Starling Forces)
Jv = Kf,c [(Pc-Pt)-σd(πc –πt)]
where: Jv = vol flow across the wall Kf,c = filtration coefficient Pc = Capillary pressure Pt = tissue pressure πc =capillary oncotic pressure πt = tissue oncotic pressure σd = reflection coefficient
Out
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Determinants of Fluid Filtration(Starling Forces)
Jv = Kf,c [(Pc-Pt)-σd(πc –πt)]
where: Jv = vol flow across the wall Kf,c = filtration coefficient Pc = Capillary pressure Pt = tissue pressure πc =capillary oncotic pressure πt = tissue oncotic pressure σd = reflection coefficient
Out In
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IC
EC
Inter-stitial
Plas
ma
Effect of Normal Saline
Plasma & Interstitial spaces are expanded
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IC
EC
Inter-stitial
Plas
ma
EC
Effect of Normal Saline
Plasma & Interstitial spaces are expanded
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IC
EC
Inter-stitial
Plas
ma
ECPl
asm
a
Effect of Normal Saline
Plasma & Interstitial spaces are expanded
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IC
EC
Inter-stitial
Plas
ma
EC
Inter-stitialPl
asm
a
Effect of Normal Saline
Plasma & Interstitial spaces are expanded
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IC
EC
Inter-stitial
Plas
ma
IC
EC
Inter-stitialPl
asm
a
Effect of Normal Saline
Plasma & Interstitial spaces are expanded
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IC
EC
Plas
ma
Normal Saline in Patient with Large Extra-cellular Volume
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IC
EC
Plas
ma
Plas
ma
Normal Saline in Patient with Large Extra-cellular Volume
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IC
EC
Plas
ma
Inter-stitialPl
asm
a
Normal Saline in Patient with Large Extra-cellular Volume
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IC
EC
Plas
ma
EC
Inter-stitialPl
asm
a
Normal Saline in Patient with Large Extra-cellular Volume
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IC
EC
Plas
ma
IC
EC
Inter-stitialPl
asm
a
Normal Saline in Patient with Large Extra-cellular Volume
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IC
EC
Plas
ma
IC
EC
Inter-stitialPl
asm
a
Normal Saline in Patient with Large Extra-cellular Volume
The rule that saline distribution is 1/3 vascular 2/3 interstitial is no longer true
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IC
EC
Inter-stitial
Plas
ma
35% 65%
General Schema
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Vascular Capacitance
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Vascular Capacitance
• Cannot be measured clinically
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Vascular Capacitance
• Cannot be measured clinically• Increased by vasodilators, α-adrenergic
blockers, and sedation
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Vascular Capacitance
• Cannot be measured clinically• Increased by vasodilators, α-adrenergic
blockers, and sedation• Reserves can be determined from the
“volume history of the patient”
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Vascular Capacitance
• Cannot be measured clinically• Increased by vasodilators, α-adrenergic
blockers, and sedation• Reserves can be determined from the
“volume history of the patient”Beware of narcotics or vasodilators in
patients with increased sympathetic tone
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Change in Volume
P
Q
Pra
V
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Change in Volume
P
MCFPQ
Pra
V
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Change in Volume
PMCFP ↑
MCFPQ
Pra
V
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Change in Volume
PMCFP ↑
MCFPQ
Pra
V
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Change in Volume
PMCFP ↑
MCFPQ
Pra
Q
V
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Q
PraCardiacPreload
Cardiac limited“Wasted preload”
Maximal return“Cardiac independent”
Pra/CVP
Gradient for VR
Cardiac output
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Distinguish fluid challenge and
fluid infusion
• “Challenge” is a small amount of fluid given rapidly while you observe a clinical effect
• Infusion of fluids are to maintain normal physiological status
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Importance of
volume
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Importance of
volume
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Increase the initial
volume
Importance of
volume
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Increase the initial
volume
Importance of
volume
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Increase the initial
volume
Importance of
volume
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Increase the initial
volume
Importance of
volume
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Increase the initial
volume
Stressed volume
Importance of
volume
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Increase the initial
volume Greater flow
Stressed volume
Importance of
volume
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Greater flow
Stressed volume
Importance of
volume
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Greater flow
Stressed volume
Importance of
volume
Determinants of flow
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Greater flow
Stressed volume
Importance of
volume
Stressed VolumeCv x RvQ =
Determinants of flow
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Greater flow
Stressed volume
Importance of
volume
Stressed VolumeCv x RvQ =
Determinants of flow
Cv
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Greater flow
Stressed volume
Importance of
volume
Stressed VolumeCv x RvQ =
Determinants of flow
Cv
Rv
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What CVP is a “high CVP”?i.e. at what value does Q plateau?
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What CVP is a “high CVP”?i.e. at what value does Q plateau?
Bafaqeeh & Magder JCCM 2007
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What CVP is a “high CVP”?i.e. at what value does Q plateau?
• 66 ICU patients – variety of disorders
Bafaqeeh & Magder JCCM 2007
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What CVP is a “high CVP”?i.e. at what value does Q plateau?
• 66 ICU patients – variety of disorders• 135 measurements
Bafaqeeh & Magder JCCM 2007
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What CVP is a “high CVP”?i.e. at what value does Q plateau?
• 66 ICU patients – variety of disorders• 135 measurements• Fluid challenges ordered by treating clinician
based on presumed clinical need
Bafaqeeh & Magder JCCM 2007
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What CVP is a “high CVP”?i.e. at what value does Q plateau?
• 66 ICU patients – variety of disorders• 135 measurements• Fluid challenges ordered by treating clinician
based on presumed clinical need• “Successful” fluid challenge = increase in
CVP ≥ 2 mmHg ( n = 118)
Bafaqeeh & Magder JCCM 2007
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What CVP is a “high CVP”?i.e. at what value does Q plateau?
• 66 ICU patients – variety of disorders• 135 measurements• Fluid challenges ordered by treating clinician
based on presumed clinical need• “Successful” fluid challenge = increase in
CVP ≥ 2 mmHg ( n = 118)• Increase in CI ≥ 0.3 L/min/m2 considered
“responders” & < 0.3 “non-responders”
Bafaqeeh & Magder JCCM 2007
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Q
PraCardiacPreload
Pra/CVP
Cardiac output
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Q
PraCardiacPreload
Maximal return“Cardiac independent”
Pra/CVP
Cardiac output
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Non-flow indications for fluids
• Correct hydration (ie high Na+)• Replete interstitial reserves• Replete unstressed volume reserves
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Change in Capacitance(can change by 10-15 ml /kg)
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Change in Capacitance(can change by 10-15 ml /kg)
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Change in Capacitance(can change by 10-15 ml /kg)
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Change in Capacitance(can change by 10-15 ml /kg)
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What about a low CVP?