Monitoring Fluid Responsiveness

Murat Sungur, MDErciyes University Medical School

Department of MedicineDivision of Critical Care Medicine

• If we are giving fluids we should have a cardiovascular response.

• SV and CO should rise

Stroke volume

Preload

Fluid responsiveness

Fluid unresponsiveness

Fluid responsiveness is related to cardiac responsiveness

Do we need monitoring ?

• Phycial exam

• Chest X-ray

• Urine output

• Heart rate

• Blood pressure

Or just a fluid challenge with crystalloids or colloids !

«Crying baby may be thirsty or hungry» CONCEPT !

• Quantitation of the cardiovascular response during volume infusion.

• Prompt correction of fluid deficits.

• Minimizing the risk of fluid overload and its potentially adverse effects, especially on the lungs.

Crit Care Med 2006; 34:1333–1337

Cristalloids 500 – 1000 ml, orColloids 300 – 500 ml

Safety limit:CVP of 15 mmHg !!

CVP as a Preload Marker

Chest 2008;134;172-178

CVP does not predict actual blood volume

Chest 2008;134;172-178

CVP measurement is methodologically difficult

50 health care worker

Anesth Analg 2009;108:1209 –11

Stroke volume

Preload

Fluid responsiveness is related to cardiac responsiveness

Normal heart

Failing heart

Fluid responsiveness

Fluid unresponsiveness

Pre-infusion CVP values are similar in responders and non-responders

Crit Care Med 2007; 35:64–68

Cristalloids 500 – 1000 ml, orColloids 300 – 500 ml

Safety limit:CVP of 15 mmHg !!

Problems with fluid challenge• Not a test, a treatment• Irreversible• Significant amount of volume should be given

• Only 50 % of the patients are responsive• CVP is not a good predictor of preload• Should be repeated multiple timesCristalloids 500 – 1000 ml, or

Colloids 300 – 500 ml

Multiple fluid challenges increases the risk for volume overload

Sepsis in European intensive care units: Results of the SOAPStudy. Crit Care Med 2006; 34:344–353.

• Initial resuscitation (first 6 hrs)• ● Begin resuscitation immediately in patients with

hypotension or elevated serum lactate 4• mmol/L; do not delay pending ICU admission

(1C)• ● Resuscitation goals (1C)

– CVP 8–12 mm Hg– Mean arterial pressure 65 mm Hg– Urine output 0.5 mLkg1hr1– Central venous (superior vena cava) oxygen saturation

70% or mixed venous 65%

Who knows how much CVP affected from PEEP or hyperinflation

• Both sides of the heart can be assessed

• PAWP, an important indicator of pulmonary edema can be measure

• CO can be measured

• Mixed venous oxygen saturation, an important parameter of Co and tissue oxygenation can be measured

PULMONARY ARTERY CATHETER

PAC MisusePAC Misuse

Group % Correct

Attendings (US) 74

Attendings (Europe) 77

PGY 4 75

PGY 2-3 66

PGY 1 51

ICU Nurses 57

Iberti JAMA 1990;264:2928-2932Gnaegi Crit Care Med 1997;25:213-220Burns Am J Crit Care 1996;5:49-54

Cost versus length of stayCost versus length of stay

• Connors* et al conducted a prospective, multi-center cohort study

• PAC vs Non-PAC groups• Compared survival, cost,

intensity of care and length of stay

• Multiple complicated statistical analysis of the data

• Increased mortality in PAC group (odds ratio:1.24)

0

10

20

30

40

50

$/Days

Cost LOS

PAC Non-PAC

Connors J JAMA,1996 276(11):889-897

PAC may be associated with increased mortality

Connors JAMA 1996;276:889-897

Sandham et al. NEJM 2003Sandham et al. NEJM 2003

Objective: To compare goal-directed therapy guided by a PAC with standard therapy among high-risk elderly patients undergoing surgery

Design: RCT, not masked

Patients: surgical

Intervention: PAC vs standard care

Primary Outcome: in-hospital mortality

Secondary: 6-month mortality, 12-month mortality, in-hospital morbidity: MI, arrythmias, pneumonia, PE, renal/liver insufficiency, sepsis from CR-BSI

Sandham JD et al. N Engl J Med 2003; 348:5-14, Jan 2, 2003

PAC directed therapy does not PAC directed therapy does not decrease mortalitydecrease mortality

Sandham JD et al. N Engl J Med 2003; 348:5-14, Jan 2, 2003

Standard Care(n=997)

PAC group(n=997)

% In-hospital mortality * 7.7 7.8

% 6-mo mortality 11.9 12.6

% 12-mo mortality 16.1 17.0

Hospital LOS (days) 10 10

Myocardial infarction 3.4 4.3

CHF 11.2 12.6

Supravent. tachycardia 9.1 8.9

Pulmonary embolism (%) # 0 0.9

Renal insufficiency 9.8 7.4

Hepatic insufficiency 2.7 2.4

Sepsis from CR-BSI 1.3 1.3

Adverse events from PAC or CVP placement

0.7 1.5

We need dynamic and non-invasive

parameters that shows preload and

cardiac reserve rather than static

preload parameters

Pulse Pressure Variation

Anesthesiology 2005; 103:419–28

Stroke volume

Preload

Fluid responsiveness

Fluid unresponsiveness

Fluid responsiveness is related to cardiac responsiveness

Pulse pressure variation

Pulse pressure variation may be a better tool to predict fluid resposiveness

Am J Respir Crit Care Med Vol 162. pp 134–138, 2000

Stroke volume variation

SVV = SV max – SV min / SV mean

Crit Care Med 2011; 39: 402-3

Problems with PPV and SVV

• Spontaneously breathing patients

• Arrhythmias

• Significant tachycardia

• Very low tidal volumes

Passive Leg Raising

Venous blood from legs and abdomen increases preload

İt is just like fluid challenge but it is reversible

Needs real time CO monitoring

Should be quick and for 30 – 90 seconds

PLR compared with volume expansion

HRSVVF

Baseline 1 PLR Baseline 2Post Volume expansion

HRSVVF

HRSVVF

HRSVVF

500 ml colloid infusion

Crit Care Med 2010; 38:819–825

SPONTANEOUSLY BREATHİNG PATİENTS

PLR accurately predict fluid responsiveness

Crit Care Med 2010; 38:819–825

SAME STUDY PROTOCOL WITH

VENTILATED PATIENTS

Crit Care Med 2006; 34:1402–1407

ALERT: Do not use PLR in patients with abdominal hypertension

Echocardiography to asses fluid status and responsiveness

• Static parameters– LVEDA

– IVC

• Dynamic parameters– SVV with repeated SV measurements

– Change in IVC/SVC diameter

– IA septum position

• For assessment of– Heart lung interactions

– Passive leg raising

– Fluid challenge

Summary

• There are many parameters to use

• Static measurements are not accurate

• We need less invasive and more dynamic parameters

• PPV and SVV are good parameters to use

• Echocardiography done by intensivist will be more and more popular