fluid responsiveness hans

8/19/2019 Fluid Responsiveness Hans

1/23

JOURNAL READING AND INTERPRETATION

Fluid Responsiveness : An evolution in ourunderstanding

BY NURSHAWINA KAMALUDIN

112014180

Facult o! "edicine

#rida $acana %&ristian universit 'U(rida)

%o*assistantDepart"ent o! Anest&esiolog

'+, August -,+. / -0 August -,+.)

TARA#AN General Districts 1ospital


2/23

WHAT IS FLUIDRESPONSIVENESS?

Fluid responsiveness is an increase o s!ro"e

volu#e o $%&$'( a!er !)e pa!ien! receives

'%% #l o cr*s!alloid over $%&$' #inu!es

Fluid responsive pa!ien!s )ave +preload

reserve, and -ill )ave an increase in s!ro"e

volu#e .and usuall* cardiac ou!pu!/ -)en

0uid is ad#inis!ered


3/23

I2PORTANT?3 WHAT WEUNDERSTAND A4OUT FLUIDRESPONSIVENESS?

T)e PRESU2PTION is !)a! increased cardiac

ou!pu! -ill lead !o increased o5*6en deliver*

.DO7/ and increased !issue o5*6ena!ion Fluid !)erap* ac!s 8* increasin6 !)e s!ressed

venous volu#e9 !)ere8* increasin6 venous re!urn

!o !)e )ear!:

Venous s*s!e# )as a #uc) 6rea!er capaci!* or8lood co#pared -i!) !)e ar!erial s*s!e#9 i! is a

nor#al p)*siolo6ic condi!ion !o 8e a 0uid

responder:

O!)er )ae#od*na#ic para#e!ers are so#e!i#esused as surro6a!es or s!ro"e volu#e:


4/23

WHAT WE 2ISUNDERSTOOD A4OUTFLUID RESPONSIVENESS?

;linicians -ould a6ree !)a! 8o!) )*povolae#ia and volu#e

overload increase !)e #or8idi!* and #or!ali!* o pa!ien!s

4ein6 a 0uid responder is no! e


5/23

WHAT WE SHOULD @NOW A4OUTFLUID RESPONSIVENESS?

W)en a 0uid c)allen6e is 6iven on+clinical 6rounds,9 onl* '%( o)ae#od*na#icall* uns!a8le pa!ien!s .in!)e OT9 I;U9 or ED/ are volu#e

responders:

Fluid loadin6 per se is no! al-a*s !)ecorrec! !)erap* or )*po!ension or areduced urine produc!ion:

Our )o#eos!a!ic #ec)anis#s )aveevolved .over !)ousands o *ears/ !o deal-i!) )*povolae#ia .!ac)*cardia9vasocons!ric!ion9 and 8lood 0o-

redis!ri8u!ion/9 -)ereas volu#e overload


6/23

WHAT HAPPENED IF PATIENT4E;O2E FLUID UNRESPONSIVE ?

As pa!ien!s 8eco#e less 0uid responsive9

EVLW.and !issue oede#a/ increases #ar"edl*

8ecause o !)e increased cardiac llin6 pressures

and !rans#i!!ed )*dros!a!ic pressures:

T)is process is accen!ua!ed in pa!ien!s -i!)

endo!)elial da#a6e .sepsis9 ARDS9 pancrea!i!is98urns/: Increased cardiac llin6 pressures !ri66er

!)e release o na!riure!ic pep!ides9 presu#a8l* !o

assis! in 0uid re#oval:

T)ereore9 e5cessive volu#e e5pansion increases!)e release o na!riure!ic pep!ides9 -)ic) in !urn

da#a6es !)e endo!)elial 6l*cocal*59 and !)is is

ollo-ed 8* a rapid s)i! o in!ravascular 0uid in!o

!)e in!ers!i!ial space leadin6 !o a #ar"ed increase

in EVLW and !issue oede#a:


7/23


8/23

TE;HNIBUES FOR ASSESSINC FLUIDRESPONSIVENESS


9/23

PREDI;TINC FLUIDRESPONSIVENESS

S!a!ic !es!s .less sensi!ive9 less specic and lessuseul !)an d*na#ic !es!s/

;linical s!a!ic endpoin!s .e:6: )ear! ra!e9 8loodpressure9 collapsed veins9 capillar* rell !i#e9previous urine ou!pu!/

no! sensi!ive

poor in!er&o8server relia8ili!*

;VPP;WP .also del!a ;VP pos! 0uid c)allen6e/poor predic!ors

;R .c)es! 5&ra*/

loo" or pul#onar* ede#aunrelia8le

Pi;;O EVLW and In!ra T)oracic 4lood Vol


10/23

D*na#ic !es!s

Passive le6 raisin6

!ransien!l* increases venous re!urn in pa!ien!s -)o

are preload responsive9 as suc) i! is a dia6nos!ic !es!

no! a !rea!#en!

i! is a predic!or o 0uid responsiveness .i:e )elps

iden!i* pa!ien! -)o are on !)e ascendin6 por!ion o

!)eir S!arlin6 curve9 and -ill )ave an increase in s!ro"e

volu#e in response !o 0uid ad#inis!ra!ion

can use -i!) pulse pressure c)an6e9 PPV9 VTI .ec)o/9NI;;O29 caro!id Doppler 0o-9 or ET;O7 .i ven!ila!ion

and #e!a8olic s!a!us cons!an!/


11/23

TE;HNIBUE

si! pa!ien! a! ' de6rees )ead up se#i&

recu#8en! posi!ion . induces a lar6er increase

in cardiac preload 8eacuse i! induces !)e s)i!

o venous 8lood no! onl* ro# 8o!) le6s 8u!

also ro# a8do#inal co#par!#en!/

lo-er pa!ien!,s upper 8od* !o )oriGon!al and

passivel* raise le6s a! ' de6rees up

#a5i#al eec! occurs a! %&J% seconds

assess or a $%( increase in s!ro"e volu#e

.cardiac ou!pu! #oni!or/ or usin6 a surro6a!e

suc) as pulse pressure .usin6 an ar!erial line/


12/23


13/23

PERFOR2AN;E ;HARA;TERISTI;S

o J( increase in s!ro"e volu#e )as M( sensi!ivi!* and

J%( specici!*o $%( increase in pulse pressure )as J( sensi!ivi!* and

'( specici!*

ADVANTACES

Reversi8le . i!,s eec! are reversed once !)e le6s are !il!

do-n/

non&invasive

Eas* !o peror# in pa!ien!s 8rea!)in6 spon!aneousl* and

-i!) arr)*!)#ias .8u! #us! use #easures o!)er !)an s!ro"e

volu#e varia!ion and pulse pressure varia!ion/

can 8e repea!ed #an* !i#es !o reassess preload

responsiveness -i!)ou! an* ris" o inducin6 pul#onar*

ede#a or cor pul#onale in po!en!ial nonresponders


14/23

DISADVANTACES

unrelia8le in severel* )*povole#ic pa!ien!s

!)e 8lood volu#e #o8iliGed 8* le6&raisin6 .-)ic) is

dependen! on !o!al 8lood volu#e/ could 8e s#all

and can s)o- #ini#al !o no increase in ;O and

8lood pressure9 even in 0uid responsive pa!ien!s

need !o s!op an* o!)er in!erven!ions durin6 !)e

!es!

posi!ional c)an6es #a* 8e con!ra&indica!ed in

so#e pa!ien!s

no! useul in pa!ien!s -i!) raised in!ra&a8do#inal

pressure .i#pair venous re!urn reduces !)e

a8ili!* o PLR !o de!ec! 0uid responsiveness/


15/23

End&e5pira!or* occlusion !es!

Occludin6 !)e circui! a! end&e5pira!ion preven!s

!)e c*clic eec! o inspira!ion !o reduce le!

cardiac preload and ac!s li"e a 0uid c)allen6e

A $' second e5pira!or* occlusion is peror#ed

and an increase in pulse pressure or cardiac inde5

predic!s 0uid responsiveness -i!) a )i6) de6reeo accurac*

T)e pa!ien! #us! 8e a8le !o !olera!e !)e $'

second in!errup!ion !o ven!ila!ion -i!)ou!

ini!ia!in6 a spon!aneous 8rea!)


16/23

Durin6 #ec)anical ven!ila!ion9 eac) insuQa!ion

increases increases in!ra!)oracic pressure9 !)us

reduces !)e s*s!e#ic venous re!urn

In!errup!in6 #ec)anical insuQa!ion durin6 an

end& e5pira!or* occlusion can increase cardiac

preload sucien!l* or suc) a !es! 8ein6 used !o

predic! 0uid response:

Pa!ien! -)o -ill increase !)eir ;O $'( in

response !o se8se


17/23


18/23

;ONT:

Ul!rasound .can 8e used d*na#icall*/

Ec)ocardio6rap)*

su8aor!ic veloci!* !i#e inde5 .VTI/ allo-s

#easure#en! o s!ro"e volu#e

End dias!olic volu#e .EDV/ appro5i#a!es

preload

Lun6 ul!rasound

can 8e used !o de!ec! pul#onar* ede#a9 i:e:

lac" o 0uid !olerance


19/23

CONT.

Respira!or* varia!ion !es!s .can 8e used d*na#icall*/

Inerior Vena ;ava .IV;/ ul!rasound

assess siGe and de6ree o inspira!or* collapse

correla!es -i!) ;VP9 8u! ;VP is a poor indica!or o

0uid responsiveness

s*s!olic pressure9 pulse pressure .PPV/ and s!ro"e

volu#e .SVV/

6enerall* li#i!ed !o #ec)anicall* ven!ila!ed

pa!ien!s in sinus r)*!)#

aor!ic 8lood veloci!*


20/23

THINCS THAT WE SHOULD @NOW INFLUID THERAP1

Fluid responsiveness does no! #ean !)a! a pa!ien!

s)ould 8e 6iven 0uids3

Ho-ever9 i a pa!ien! )as lo- cardiac ou!pu! !)a!

re


21/23


22/23

CONCLUSION

As our unders!andin6 o !)is co#ple5 !opic evolves9

i! is li"el* !)a! ne- and i#proved #e!)ods o

assessin6 0uid responsiveness and #ore

p)*siolo6ical !ar6e!s o 0uid !)erap* -ill e#er6e:

T)e #e!)ods or assessin6 0uid responsiveness )ave

evolved ro# s!a!ic pressure and volu#e

para#e!ers9 -)ic) are una8le !o predic! 0uid

responsiveness9 !o d*na#ic indices 8ased on )ear!

lun6 in!erac!ions durin6 #ec)anical ven!ila!ion9

-)ic) )ave a #odes! de6ree o accurac*9 !o !)ose

!ec)ni


23/23

T)an" *ou

For 1our Ti#e

fluid responsiveness hans

Documents