Personalized Fluid...

PersonalizedFluidResuscitation

MorganSoffler,MD

InstructorinMedicine,HarvardMedicalSchool

Pulmonary,CriticalCare,&SleepMedicine

BethIsraelDeaconessMedicalCenterCOPYRIGHT

Disclosures

• None

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Objectives

• Definetheterm“volumeresponsive”

• Describetheinfluenceofvolumestatus,vasculartone,cardiaccontractilityandcardiactransmuralpressureonvenousreturn.

• DescribethelimitationsofCVPonpredictingvolumeresponsiveness

• Identifythestrengthsandlimitationsofdynamicmeasuresofvolumeresponsiveness.

• Evaluatetheresponsetoanempiricfluidchallenge.

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ACasetoconsider75yearoldwomanwithHFpEF isadmitted totheICUwithseptic shockfromUTI.

BP75/40à 2LoflactatedringersàBP95/45à BP80/35.

Requiring2LNCtomaintainO2sat>90%

WBC18,lactate4.5,oliguricAKI.

Givenceftriaxone, startedonperipheral norepinephrine andtransferredtothe ICU.

CVO270,CVP12.

USofIVCshowsdiameter>2-cm.

CXRshowspulmonaryedema.

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Whichofthefollowingbestdescribesyour

fluidmanagementstrategyandreasoning?

A. Iwouldgivemorefluids– shewasfluidresponsiveprior.

B. Iwouldgivemorefluids– shehaslacticacidosisandhasAKI.

C. IwouldNOTgivemorefluids– sheisnowhypoxemicandhasHFpEF

D. IwouldNOTgivemorefluids– CVPis12andIVCdistended.COPYRIGHT

BoydJetal.Crit CareMed 201139(2):259-265

AdjustedSurvivalCurves

FluidBalanceQuartilesDay4

Days**AdjustedforApachescore,ageandpressordose

Survival

Whypredictvolumeresponsiveness?

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Whypredictvolumeresponsiveness?

ARDSNet NEngl JMed 2006;354:2564-2575

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CardiacOutput

Allpossiblecardiacoutputvalues

Predictingfluidresponsiveness

RVEDP=RAP=CVP

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CardiacOutput

And

VenousReturn

RVEDP=RAP=CVP

Predictingfluidresponsiveness

VR CO

RAP

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GuytonAC.PhysiolRev1955;35:123-129

GuytonAC,etal.Phildelphiaa:W.B.Saunders, 1973

RVEDP=RAP=CVP

CardiacOutput

And

VenousReturn

Predictingfluidresponsiveness

ABILITY

AVAILABILITY

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MeanSystemicPressure

Venousreturn= I=V

R

MSP- RAP

RV

GuytonAC.PhysiolRev1955;35:123-129

GuytonAC,etal.Phildelphiaa:W.B.Saunders, 1973

RVEDP=RAP=CVP

CardiacOutput

And

VenousReturn

Predictingfluidresponsiveness

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ActualCardiacOutputandVenousReturn

GuytonAC.PhysiolRev1955;35:123-129

GuytonAC,etal.Phildelphiaa:W.B.Saunders, 1973

RVEDP=RAP=CVP

CardiacOutput

And

VenousReturn

Predictingfluidresponsiveness

ActualCVP

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Whatdefines“volumeresponsiveness”?

RVEDP=RAP=CVP

CardiacOutput

And

VenousReturnCOPYRIGHT

Anincreaseincardiacoutputinresponseto

increasedmeansystemicpressure– i.e.the

patientisontheascendinglimboftheir

Frank-Starlingcurve

Magder S.Curr Opin Crit Care200616:289–296

Definingfluidresponsiveness

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Fluidresuscitation:onesizefits…..

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8cmH2O

RVEDP=RAP=CVP

CardiacOutput

And

VenousReturn

Fluidresuscitation:CanweuseCVP?…..

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8cmH2O

RVEDP=RAP=CVP

CardiacOutput

And

VenousReturn

Fluidresuscitation:CanweuseCVP?…..

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Osman Detal.Crit CareMed 200735:64-68

Falsenegatives

Falsepositives

•150volumechallenges givento

septic ICUpatientsà

“Responders” =15%increase inCI

•CVP<12cmH2Oà PPV47%

•PAOP<12cmH20à PPV54%

CVP

PAOP

R

R

NR

NR

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“ThemostusefulwaytouseCVPistoobservetheclinicalresponsetoachangeinCVP…”

• Aretherewaystodothiswithoutgivingvolume?

Magder S.Curr Opin Crit Care200511:264-270

HowtouseCVP

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WhatISadynamicmeasureoffluid

responsiveness?

OurgoalistoshiftthevenousreturncurvetotheRIGHT….

Increasemeansystemic

fillingpressurewith

venousvolume

Changeinintrapleural

pressureà inRAP

(respiration)

• Passivelegraisetest

• Empiricboluschallenge

• Pulsepressurevariation

• IVCcollapsibility

• IVCdistensibility

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A65yearoldwomanwithchronickidneydiseaseisadmittedtotheICUwithfever,diarrhea,andhypotensionafterarecenthospitalizationforpneumonia.Afterreceiving3Lofintravenousfluidsherbloodpressureimprovesto85/50mmHgbutsheisnowrequiring3L/minuteofsupplementaloxygentomaintainanoxygenationsaturation>90%.

Whichofthefollowingisthemostappropriatemaneuvertoassesswhetherhercardiacoutputwillimprovewithfluidadministration?

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Question 8 – Dr. Hibbert

AnswerChoices

A. Passivelegraisetest

B. Pulsepressurevariation

C. IVCdistensibility

D. Centralvenousoxygensaturation

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Question 8 – Dr. Hibbert

AnswerChoices

A. Passivelegraisetest

B. Pulsepressurevariation

C. IVCdistensibility

D. Centralvenousoxygensaturation

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Boulain etal.Chest.2002;121(4):1245-1252

Dynamicmeasures:PassiveLegRaise

Non-InvasiveCardiacOutputMonitor(NICOM)

BloodPressure

Urineoutput

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Boulain etal.Chest.2002;121(4):1245-1252

Pros

•Easybedsidemaneuver

Cons

•Maybeinsufficient volumeto

increase CVP

•Elevated intra-thoracicorintra-

abdominal pressuresmayblunt

increase invenousreturn

•Maybecontraindicated in

traumaandneuroICUpatients

Dynamicmeasures:PassiveLegRaise

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•Measuredin40paralyzed,mechanicallyventilatedpatientswithsepsis.

• Volumechallengeprovidedwith500-mLofstarch,“responder”hadatleast15%increaseincardiacindex.

• Δ PPvalueof13%discriminatedbetweenrespondersandnon-responders(sens=94%,spec=96%)

Michard F,etal.AJRCCM2000162:134–138

Dynamicmeasures:Pulsepressurevariation

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Michard F,etal.AJRCCM2000162:134–138

Increasedintra-thoracicpressure

à decreasedvenousreturn

Decreasedvenousreturnà decreased

RVoutput

DecreasedRVoutputà decreased

LVoutput

**ΔPPwillbegreaterinpatientswhoareonthe

steeppartoftheirFrank-Starlingcurve

Dynamicmeasures:Pulsepressurevariation

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Michard F,etal.AJRCCM2000162:134–138

Pros

•Observational, nointervention

required

Cons

•NotvalidatedwithlowerVT

•Unclearapplicability topatients

withverylowlungcompliance

•Mustbeinsinusrhythm

Dynamicmeasures:Pulsepressurevariation

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Question 9 – Dr. Hibbert

A58year oldmandevelopssevereARDSduringanadmissiontothetraumaICUforpelvicandfemurfracturesfollowingaMVA. Heisputonlowtidalvolumeventilationwith 6cc/kg andaPEEPof12cmH20andstartedonparalytic.Onthethirddayofhisadmission,hedevelopshypotensionanddespitereceivingoneliterofnormalsalinehasabloodpressureof75/40mmHgandlactate 4. AnultrasoundofhisIVCisperformedanditisnotedthatduringinspirationhisIVCdiameterisgreaterthanIVC

diameterduringexhalation(percentdifference30%).

Whichofthefollowingisthemostaccuratestatementregardingassessmentofvolumeresponsivenessinthispatient?

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Question 9 – Dr. Hibbert

AnswerChoices

A. IncreasedIVCdiameterduringinhalationisduetoincreasedvenousreturnfromincreasedintrathoracicpressure.

B. AchangeinIVCdiameterof30%indicatesthatthispatientislikelytobevolumeresponsive

C. Pulsepressurevariationwillbemoresensitiveinthesettingoflowtidalvolumeventilation

D. Passivelegraisewouldbeabetterpredictorofvolumeresponsiveness inthispatientCOPYRIGHT

Question 9 – Dr. Hibbert

AnswerChoices

A. IncreasedIVCdiameterduringinhalationisduetoincreasedvenousreturnfromincreasedintrathoracicpressure.

B. AchangeinIVCdiameterof30%indicatesthatthispatientislikelytobevolumeresponsive

C. Pulsepressurevariationwillbemoresensitiveinthesettingoflowtidalvolumeventilation

D. Passivelegraisewouldbeabetterpredictorofvolumeresponsiveness inthispatientCOPYRIGHT

• 23mechanically ventilated patientsà nobaseline difference in

hemodynamics, respirophasic IVCchangesmeasured

• IVCdistention wasdefined as:

• Maximumdiameterwasobservedduring inhalationandminimumdiameter

wasobservedduringexhalation

• Volumeexpansion 7ml/kgwasgivenand“responders” hadanincrease inCIat

least15%

DMAX - DMIN

DMIN

Barbier C,etal.IntensiveCareMed200430:1740–1746

Dynamicmeasures:IVCDistensibility

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Barbier C,etal.IntensiveCareMed200430:1740–1746

Pros

• Observational

• Ultrasounds readilyavailable

• Highersensitivity (90%v40%)andspecificity (90%v80%)thanCVPcutoffof

7cmH20

Cons

• Requires experienced operator

• Sometimes difficulttogetadequate images

• HighPEEPorlowrespiratorysystemcompliancemaydecrease sensitivity

Dynamicmeasures:IVCDistensibility

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Question 7 – Dr. Hibbert

A 75-year-old woman with heart failure presents to the ED with alteredmental status and fever. Her temperature is 101° F, HR 115 bpm, BP 85/40mmHg, RR 16 breaths/minute, O2 saturation 94%. Her lab results are notablefor a WBC 17, creatinine 1.2, and lactate of 4.

Antibiotics are started and a central line is placed. She is given 2 liters ofintravenous crystalloid without significant improvement in blood pressure.The central venous pressure (CVP) is measured at 11 cm H2O and centralvenous saturation is 60%. Upon arrival to the ICU, another 500cc of IV fluidsare administered; her CVP increases from 11 to 13 cm H20 withoutimprovement in blood pressure.COPYRIGHT

Question 7 – Dr. Hibbert

AnswerChoices

A. ACVPof11cmH2Oindicatessheisfluidreplete

B. Thelackofimprovementinbloodpressurefollowingtheinitial2LofIVFindicatessheisnotvolumeresponsive.

C. TheincreaseinCVPof2cmH2Oaftervolumeadministrationindicatesthefluidchallengewasadequate.

D. Thecentralvenoussaturationindicatesshehascardiogenicshockandwillnotbenefitfromfurtherfluidadministration.

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Question 7 – Dr. Hibbert

AnswerChoices

A. ACVPof11cmH2Oindicatessheisfluidreplete

B. Thelackofimprovementinbloodpressurefollowingtheinitial2LofIVFindicatessheisnotvolumeresponsive.

C. TheincreaseinCVPof2cmH2Oaftervolumeadministrationindicatesthefluidchallengewasadequate.

D. Thecentralvenoussaturationindicatesshehascardiogenicshockandwillnotbenefitfromfurtherfluidadministration.

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CardiacOutput

and

VenousReturn

RVEDP=RAP=CVP

Chooseaparameter

tomonitor

•Thermodilution

(CO/CI)

•Pulsepressure

•SBP

•MAP

•Urineoutput

Assessingefficacyofempiricfluidchallenge

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Youmustgivesufficientintravascularvolumetoachieveanincreaseinmeansystemicpressure– thiswillbereflectedbyanincreaseinCVP(at

least2-3cmH2O).

Magder S.Curr Opin Crit Care2005;11:264-270

Wasadequatevolumegiven?

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• Definingfluidresponsiveness requiresunderstandingoftheintegratedeffectsofcardiacfunction,vasculartone,andintravascularvolume

• Predictingfluidresponsiveness isacoreskillincriticalcareandcanprotectpatientsfromnon-beneficialfluids.

• Dynamicmeasuresarebetterpredictorsoffluidresponsiveness thanstaticmeasures.

• Ifempiricfluidsaregiven,endpointstoassesschangeincardiacoutputandadequacyoffluidchallengearecrucial.

TakeHomePoints

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