volume/fluid responsiveness in the icu

8/18/2019 Volume/Fluid Responsiveness in the ICU

1/42

Fluid responsiveness in

the ICU To bolus or not to bolus

…that is the question.

PulmCrit.com


2/42

Case49 yo M is I ambulance a!ter bein" !ound do#n by !riends $ last seen 4% hours earlier

Initial &'( )*).+F %+,+* )*- - %/0,12 Poor mental status

P3 si"nicant !or an unresponsive obese disheveled man5 63 edema5 crac7les on lun"e8am C'

In 3:( Intubated5 anti;b85 -6 crystalloid5 6evo!ed. 2!ter intubation requirin" %*0 FI)+* C?3M( )/),4.9,)**,)%,-%,-.,-**

edside 3cho sho#in" tachycardia but normal cardiac !unction5 no 1& !ailure

C@1 $ lar"e inltrate in 166 and 666

AP 4+*5 Trops ne"5 lactate 4.45 U2B Cultures pendin"


3/42

Case The patient is anuric5 hypotensive5 septic5 hypo8emic and has

bilateral lo#er e8tremity edema

hat do you do ne8tD

2 $ ive a )6 Crystalloid challen"e

$ ive a +** cc Crystalloid challen"e

C $ ive )-.+ "rams albumin

: $ 'tart &asopressin

3 $ Per!orm a passive le" raise EP61 #hile monitorin" PP&


4/42


5/42

hat is Huid responsiveness a7avolume responsivenessD2 measure o! the patients response to a chan"e in preload

2im is to try to combat tissue hypoper!usion

Increase in stro7e volume by )*;)+0 a!ter the patientreceives +** ml o! crystalloid over )*;)+ minutes

Fluid responsive patients have preload reserve so #illincrease stro7e volume #hen "iven Huids

Predictors o! Huid response can be dynamic or static

Crit Care Med -*)/4)()4$%).


6/42

'i"ns o! tissue hypoper!usion:ecreased venous o8y"en saturation

Increased lactate levels


7/42

Clinical use o! Huid responsiveness To predict Huid responsiveness5 t#o methods must be

combined( enerate the chan"es in preload

Measure the subsequent changes in stroke volume


8/42

Cardiac


9/42

Preload2rthur uyton superimposed the venous return curve on the

cardiac !unction curve5 as both are a !unction o! 12P

&enous return can be raised by ) lo#erin" 12P - decreasin"

1v5 and / increasin" M'FP

M'FPJMean 'ystemic Fillin" Pressur


10/42

&enous return curve( 1i"ht atrialpressure E12P vs. cardiac output

Aeth ?eart K. -*)/ :ec -)E)-( +/*$+/


11/42

Fluid challen"es $ #hy not Gust"ive to everyone a Huid bolusDCohort5 multiple;center5 observational study )9% intensive

care units in -4 3uropean countries./5)4 adult patients5median a"e o! L4 yrs5 )5) E/.40 had sepsis ; A positivefuid balance was among the strongest prognosticactors or death

21:'Aet ( Cumulative Huid balance day 4 #as predictive o!hospital mortality as #ell as ventilator; and ICU;!ree days

Crit Care Med -**L /4( /44$+/.


12/42

Mechanical &entilation Cardiac


13/42

M& vs. 'pontaneous reathin"aNects C


14/42

?emodynamic eNects o!mechanical ventilation


15/42

M& eNects on PP&


16/42

'tatic and dynamic predictors o!Huid responsivenessStatic tests

Clinical static endpoints Ee.". heart rate5 blood pressure5 collapsedveins5 capillary rell time5 previous urine output

C&P,PCP

C@1

PiCC<

3&6


17/42

'tatic and dynamic predictors o!Huid responsiveness

Dynamic test

Passive le" raise

3nd;e8piratory occlusion test

Ultrasound( cardiac5 I&C5 '&C5 lun"

'ystolic pressure5 pulse pressure EPP& and stro7e volumeE'&&


18/42

'tatic vs. dynamic predictors o!Huid responsivenessC&P is the classic static measure $ many studies sho# poor

predictors o! Huid responsiveness

6o# cardiac llin" pressures do not imply that a patient isHuid responsive

:espite C&P bein" a reHection o! 12P Eand determinant o!ri"ht ventricular llin" it is NO a reliable indicator o!preload or Huid responsiveness

Curr


19/42

C&P cannot predict Huidresponsiveness

3vid ased Med doi()*.))/L,eb;-*)/;)*)49


20/42

'tatic parameters are in!erior todynamic parameters in predictin"Huid responsiveness

Aeth ?eart K. -*)/ :ec -)E)-( +/*$+/


21/42

1i"ht and le!t ventricular end;diastolic area or volume1i"ht and le!t ventricular end;diastolic area , volume cannot

establish the patients position on the combined venousreturn,cardiac !unction curve

2 decline in cardiac per!ormance decreases the slope o! therelationship bet#een end;diastolic volume and stro7e volume

1i"ht and le!t ventricular end;diastolic area , volume cannotaccurately predict an increase in stro7e volume upon Huidloadin" either


22/42

Pleth &ariability Inde8 EP&I P&I( an automated measure o! the dynamic chan"e in the

per!usion inde8 that occurs durin" a respiratory cycle

Per!usion inde8( an in!rared pulsatile si"nal inde8ed a"ainstthe non;pulsatile si"nal and reHects the amplitude o! thepulse o8imeter #ave!orm

P&I( si"nicant correlation and "ood a"reement #ith the PP&and has accurately predicted Huid responsiveness

http(,,###.masimo.cn,pvi,


23/42

3chocardio"raphy1espiratory chan"es in aortic Ho# velocity and stro7e volume

can be assessed by :oppler echocardio"raphy

2ssumes that the aortic annulus diameter is constant overthe respiratory cycle5 the chan"es in aortic blood Ho# shouldreHect chan"es in 6& stro7e volume

Feissel et al( respiratory chan"es in aortic blood velocitypredicted Huid responsiveness in mechanically ventilatedpatients $ but not reproducible by other studies

Chest -**) ))9( %L$/.


24/42

Positive Pressure &entilation

Induced Chan"es in &ena Caval:iameterCyclic chan"es in superior E'&C and in!erior vena caval EI&C

diameter as measured by echocardio"raphy have been usedto predict Huid responsiveness

'&C collapsibility inde8( more reliable than the I&Cdistensibility inde8 in predictin" Huid responsiveness

MaGor dra#bac7( '&C can only be adequately visualiQed by T33 ; not conducive to continuous monitorin".


25/42

:ynamic monitorin"( '&& and PP& Pulse pressure( pulse contour analysis methods usin" the

arterial pressure #ave!orms continously calculates stro7evolume

1emoves need !or invasive pulmonary artery catheteriQation

'tro7e volume calculation is determined by the pressuredecay prole and ma"nitude o! the arterial pressure !or a"iven arterial input impedance


26/42

Testin" Huid responsiveness( '&&and PP& To test Huid responsiveness5 a chan"e in preload must be provo7ed

#hile monitorin" the subsequent chan"e in stro7e volume or itsderivatives such as pulse pressure

'tro7e volume variation E'&& ; usin" mechanical ventilation;induced chan"es in preload resultin" in variation o! stro7e volume

Pulse pressure variation EPP& ; usin" mechanical ventilation;induced chan"es in preload resultin" in variation o! pulse pressure!ulse pressure variation "!!#$ % "!!ma& ' !!min$ ( !pmean


27/42

PP&


28/42

PP& and '&& PP& is obtained directly !rom the peripheral arterial pressure #ave!orm

'&& is peripherally derived !rom pulse contour analysis o! arterialpressure #ave!orm

oth peripherally derived dynamic parameters are an accuratereHection o! central '&&

'&& and PP& have been !ound to be !ar better predictors than staticindicators

2 value = )-0 has sho#n to be hi"hly predictive o! Huidresponsiveness.


29/42

'ettin"s #here '&& use is limited'mall tidal volumes Etidal volume must be at least % m6,7"

'pontaneous breathin" Epatient must have )**0 controlled mechanicalventilations at a 8ed rate

21:' and lo# lun" compliance E!alse ne"atives more li7ely

P33P Emay increase '&&

2rrhythmia E1;1 interval must be re"ular on 3C

6o# heart rate,respiratory rate ratio


30/42

3quipment'&& !rom C?33T2? AIC


31/42

Pulse pressure vs stro7e volume Chan"es in cardiac output upon P61 have been demonstrated to have

a better predictive value compared #ith chan"es in pulse pressure

This diNerence e8plained by the !act that pulse pressure is not only adirect measure o! stro7e volume5 but also depends on arterialcompliance

1esponse o! arterial pressure upon Huid loadin" is dependent onarterial tone in contrast to the response o! stro7e volume

Intensive Care Med. -*)* 'ep/LE9()4+;%


32/42

2 #ord on arterial tone2rterial tone measured by dynamic arterial elastance E3adynJpulse

pressure variation EPP& , stro7e volume variation E'&& ratio *.***).

The only predictor o! M2P increase #as 3adyn E2UC5 *.9%L *.*- 9+0 CI5*.%4;)

2 baseline 3adyn value =*.%9 predicted a M2P increase a!ter Huidadministration #ith a sensitivity o! 9/.+0 and a specicity o! )**0

Critical Care-*)) )+(1)+ :


33/42


34/42

Clinical use o! Huid responsiveness To predict Huid responsiveness5 t#o methods must be

combined( )enerate the changes in preload

Measure the subsequent chan"es in stro7e volume on the otherhand


35/42

eneratin" chan"es in preload Passive le" raisin" EP61 creates a temporary increase in

biventricular preload #ith a ma8imum increase #ithin aminute ?as sho#n the capability to predict Huid responsiveness

Fluid bolus $ do#nside J since only appro8imately +*0 o!

critically ill patients respond to a Huid challen"e5 hal! o!patients #ill receive unnecessary Huid loadin".


36/42

Passive le" raise $ + rules

Crit Care. -*)+ )9E)( )%.


37/42

)* m6,7"


38/42

Protocol !or early "oal;directed

resuscitation o! patients #ithsepsis

K Cardiothorac &asc 2nesth. -*)/


39/42

Conclusion( To bolus or not tobolus… To success!ully predict Huid responsiveness5 i.e. the response

o! stro7e volume to Huid loadin"5 t#o requirements must bemet( Chan"e in preload must be "enerated

Measurin" subsequent chan"es in stro7e volume or its derivativessuch as pulse pressure


40/42

Conclusion( To bolus or not tobolus…'tatic mar7ers o! cardiac preload are unable to predict Huid

responsiveness ; dynamic mar7ers are superior

Problem #ith dynamic mar7ers( hi"h T&s5 mechanicalventilation5 re"ular heart rhythm

P61 #hen used #ith PP& ; predict Huid responsivenessdespite spontaneous breathin" activity or cardiacarrhythmias avoids unnecessary and potentially harm!ul Huid loadin" and

inotropics


41/42

Case The patient is anuric5 hypotensive5 septic5 hypo8emic and has

bilateral lo#er e8tremity edema

hat do you do ne8tD

2 $ ive a )6 Crystalloid challen"e

$ ive a +** cc Crystalloid challen"e

C $ ive )-.+ "rams albumin: $ 'tart &asopressin

* ' !erorm a passive leg raise "!+,$ while monitoring !!#


42/42

1e!erencesMari7 P35 CavallaQQi 1. :oes the central venous pressure EC&P predict Huid responsiveness( an update meta;analysis

and a plea !or some common sense. Crit Care Med -*)/4)()4$%).

Mari7 P35 CavallaQQi 15 &asu T5 ?irani 2. :ynamic chan"es in arterial #ave!orm derived variables and Huidresponsiveness in mechanically ventilated patients( a systematic revie# o! the literature. Crit Care Med. -**9'ep/E9(-L4-;.

Feissel M5 Michard F5 Man"in I5 et al. 1espiratory chan"es in aortic blood velocity as an indicator o! Huid responsivenessin ventilated patients #ith septic shoc7. Chest -**) ))9( %L$/.

MaiQel K5 2irapetian A5 6orne 35 et al. :ia"nosis o! central hypovolemia by usin" passive le" raisin". Intensive Care Med-** //( ))//$%.

6amia 5

volume/fluid responsiveness in the icu

Documents