Prof. Jean-Louis TEBOUL Medical ICU Bicetre hospital University Paris XI France What is the best way to assess What is the best way to assess fluid responsiveness

Prof. Jean-Louis TEBOULProf. Jean-Louis TEBOUL

Medical ICUBicetre hospital

University Paris XIFrance

What is the best way to assess What is the best way to assess

fluid responsiveness fluid responsiveness

in a spontaneously breathing patient ?in a spontaneously breathing patient ?

Member of the Medical Advisory Board of Pulsion Member of the Medical Advisory Board of Pulsion

Three different scenariosThree different scenarios

2- Patients in the ER for high suspicion of septic shock2- Patients in the ER for high suspicion of septic shock

3- Patients in the ICU, already resuscitated for several hours or days3- Patients in the ICU, already resuscitated for several hours or days

1- Patients in the ER for acute blood losses or body fluid losses1- Patients in the ER for acute blood losses or body fluid losses

1- Patients in the ER for acute blood losses or body fluid losses1- Patients in the ER for acute blood losses or body fluid losses

Diagnosis of hypovolemia is almost certainDiagnosis of hypovolemia is almost certain

Presence of clinical signs of hemodynamic instability clinical signs of hemodynamic instability

No therapeutic dilemmaNo therapeutic dilemma

good prediction of volume responsiveness prediction of volume responsiveness

although lacking of sensitivitylacking of sensitivity

2- Patients in the ER for high suspicion of septic shock2- Patients in the ER for high suspicion of septic shock

Most often, no needsno needs for searching sophisticated predictors predictors

of volume responsiveness of volume responsiveness since volume resuscitation is mandatory volume resuscitation is mandatory

in the first hours in the first hours (see Rivers et al NEJM 2001)

- with hemodynamic instability requiring therapy- with hemodynamic instability requiring therapy

- without certainty of volume responsiveness- without certainty of volume responsiveness

- with potential risks of pulmonary edema with potential risks of pulmonary edema

and/or excessive cumulative fluid balanceand/or excessive cumulative fluid balance



How to deal with this therapeutic dilemma?

Prediction Prediction of volume responsiveness ?of volume responsiveness ?

Fluid challenge ?Fluid challenge ?





Rate of infusion:Rate of infusion: 500-1000 mL crystalloids 500-1000 mL crystalloids or 300-500 mL colloids 300-500 mL colloids over 30 mins30 mins

Goal:Goal: reversal of the marker of perfusion failure that prompted the fluid challengereversal of the marker of perfusion failure that prompted the fluid challenge

(ex: hypotension, tachycardia, oliguria, etc)

Safety limits: Safety limits: CVPCVP

Crit Care Med 2006; 34:1333-1337

of 15 mmHg measured every 10 minsof 15 mmHg measured every 10 mins

Question: Question: benefit/risk ratio ?benefit/risk ratio ?

Fluid challenge successful in only 50% casesFluid challenge successful in only 50% cases

Crit Care Med 2006; 34:1333-1337

Rate of infusion: 500-1000 mL crystalloids or 300-500 mL colloids over 30 minsRate of infusion: 500-1000 mL crystalloids or 300-500 mL colloids over 30 mins

Goal: reversal of the marker of perfusion failure that prompted the fluid challenge Goal: reversal of the marker of perfusion failure that prompted the fluid challenge

(ex: hypotension, tachycardia, oliguria, etc)(ex: hypotension, tachycardia, oliguria, etc)

Safety limits: CVP of 15 mmHg measured every 10 minsSafety limits: CVP of 15 mmHg measured every 10 mins

CHEST 2002, 121:2000-8 CHEST 2002, 121:2000-8



Crit Care Med 2006; 34:1333-1337





Fluid challenge potentially riskyFluid challenge potentially risky Is a CVP of 15 mmHg a reasonable safety limit?Is a CVP of 15 mmHg a reasonable safety limit?

1) PAOP often > CVP1) PAOP often > CVP

2) Pulmonary capillary pressure (Pcap) > PAOP2) Pulmonary capillary pressure (Pcap) > PAOP

Collee et al. Anesthesiology 1987

Radermacher et al. Anesthesiology 1989

Radermacher et al. Anesthesiology 1990

Teboul et al J. Appl Physiol 1992

Benzing et al. Acta Anaesthesiol Scand.1994

Rossetti et al. Am J Respir Crit Care Med 1996

Benzing et al. Br J Anaesth. 1998

Nunes et al. Intensive Care Med. 2003

Her et al. Anesthesiology 2005

Pcap-PAOP difference is high in ALI/ARDSPcap-PAOP difference is high in ALI/ARDS



Crit Care Med 2006; 34:1333-1337





Fluid challenge potentially riskyFluid challenge potentially risky Is a CVP of 15 mmHg a reasonable safety limit?Is a CVP of 15 mmHg a reasonable safety limit?

1) PAOP often > CVP1) PAOP often > CVP

2) Pulmonary capillary pressure (Pcap) > PAOP2) Pulmonary capillary pressure (Pcap) > PAOP

3) Degree of pulmonary edema poorly evaluated by Pcap 3) Degree of pulmonary edema poorly evaluated by Pcap since lung capillary permeability is often altered in ICU ptssince lung capillary permeability is often altered in ICU pts

EVLWEVLW

Pulmonary capillary hydrostatic pressure Pulmonary capillary hydrostatic pressure

Pcrit

normal lung capillary lung capillary permeabilitypermeability

Increased Increased lung capillary lung capillary permeabilitypermeability

mmHgPVC: 15, PAOP:19 PVC: 15, PAOP:19


Crit Care Med 2006; 34:1333-1337





Fluid challenge potentially riskyFluid challenge potentially risky

Question:Question: benefit/risk ratio ?benefit/risk ratio ?


How to deal with this therapeutic dilemma?

Prediction Prediction of volume responsiveness ?of volume responsiveness ?

Fluid challenge ?Fluid challenge ?





Stroke Volume

Ventricular preload

preload-dependencepreload-dependence

preload-independencepreload-independence

Volume expansion will increase stroke volume Volume expansion will increase stroke volume only if ventricles are preload-dependentonly if ventricles are preload-dependent

How to predict preload-dependence How to predict preload-dependence

and hence volume responsiveness?and hence volume responsiveness?

1- By estimating cardiac preload 1- By estimating cardiac preload

- using filling pressures:- using filling pressures: RAP, PAOP RAP, PAOP

Stroke Volume

Ventricular preload



The lower the ventricular preload, The lower the ventricular preload, the more likely the preload-dependency the more likely the preload-dependency

0

10

20

Calvin Schneider Reuse WagnerCalvin Schneider Reuse Wagner 1981 1988 1990 19981981 1988 1990 1998

responders

nonresponders

**

mmHg

RAP before volume expansion in RAP before volume expansion in responders (R)responders (R) and and non-responders (NR)non-responders (NR)

number of ptsnumber of pts 28 28 18 18 41 41 25 25

SB pts (%) 54 33 24 6 SB pts (%) 54 33 24 6

**

Wagner et al. Wagner et al. Chest 1998Chest 1998

Baseline PBaseline PRARA (mmHg)(mmHg)

Ch

ange

s in

str

oke

volu

me

Ch

ange

s in

str

oke

volu

me

(%)

(%)

r = 0.45r = 0.45

0

10

20responders

nonresponders

mmHg

PAOP before volume expansion in PAOP before volume expansion in responders (R)responders (R) and and non-responders (NR)non-responders (NR)

Calvin Schneider Reuse DiebelCalvin Schneider Reuse Diebel 1981 1988 1990 19941981 1988 1990 1994

number of ptsnumber of pts 28 28 18 18 41 41 3232

SB pts (%) 54 33 24 31 SB pts (%) 54 33 24 31




- using filling pressures: RAP, PAOP - using filling pressures: RAP, PAOP

- using dimensions:- using dimensions: RVEDVi, LVEDViRVEDVi, LVEDVi

0

30

60

90

120

150

**

Calvin Schneider Reuse Diebel Diebel WagnerCalvin Schneider Reuse Diebel Diebel Wagner 1981 1988 1990 1992 1994 19981981 1988 1990 1992 1994 1998

**

respondersnonresponders

RVEDVi before volume expansion in RVEDVi before volume expansion in responders (R)responders (R) and and non-responders (NR)non-responders (NR)

number of ptsnumber of pts 28 28 18 18 41 41 22 22 32 25 32 25 SB pts (%) 54 33 24 16 31 6SB pts (%) 54 33 24 16 31 6

0

120

LVEDVi before volume expansion in LVEDVi before volume expansion in responders (R)responders (R) and and non-responders (NR)non-responders (NR)

responders

nonresponders

Calvin Schneider Calvin Schneider 1981 19881981 1988

mL/m2

40

80

number of pts 28 18number of pts 28 18

SB pts (%) 54 33SB pts (%) 54 33




- using filling pressures: RAP, PAOP - using filling pressures: RAP, PAOP

- using dimensions: RVEDVi, LVEDVi- using dimensions: RVEDVi, LVEDVi

markers of preload: markers of preload: poor markerspoor markers

of volume responsivenessof volume responsiveness

Why ?Why ?

Why do ventricular preload indicators notWhy do ventricular preload indicators notpredict fluid responsiveness ?predict fluid responsiveness ?

2- Because RAP, PAOP, RVEDVi, LVEDVi are not always accurate indicators 2- Because RAP, PAOP, RVEDVi, LVEDVi are not always accurate indicators of preloadof preload

1- In the available studies, pts were already resuscitated so that values 1- In the available studies, pts were already resuscitated so that values of markers of preload were rarely low. of markers of preload were rarely low.

It cannot be excluded that low values predict volume responsiveness, It cannot be excluded that low values predict volume responsiveness,

whereas high values well predict the absence of hemodynamic response to volumewhereas high values well predict the absence of hemodynamic response to volume

On the other hand, values were rarely high before fluid challengesOn the other hand, values were rarely high before fluid challenges

3- Because assessment of preload is not assessment of preload-dependence3- Because assessment of preload is not assessment of preload-dependence

.

Stroke volume

Ventricular preload

normal heart normal heart

failing heart failing heart



How to detect fluid responsiveness ?How to detect fluid responsiveness ?

1- By estimating cardiac preload ?1- By estimating cardiac preload ?

2- By using dynamic tests detecting2- By using dynamic tests detecting cardiac preload reserve ?cardiac preload reserve ?

2.1- using heart-lung interaction2.1- using heart-lung interaction

- SPV, PPV?- SPV, PPV?

. for physiological reasons, these indices must not work

. as confirmed in clinical studies

Patients with MVPatients with MV

Rooke et al Rooke et al Anesth & Analg 1995Anesth & Analg 1995

Systolic pressure variationSystolic pressure variation (mmHg)(mmHg)

Patients with SBPatients with SB

Systolic pressure variationSystolic pressure variation (mmHg)(mmHg)

Soubrier et al. Soubrier et al. ATS 2005ATS 2005

Non Oui

2,98

4,65

5,88

7,08

8,00

11,11

12,50

13,50

15,78

19,17

22,72

nonrespondersnonresponders respondersresponders

3 %3 %

23 %23 %

12 %12 %PPVPPVbefore

volume infusion

Patients breathing without mechanical supportPatients breathing without mechanical support

1 - specificity

PPV

sen

siti

vity

patients with SBpatients with SB

PPV (threshold: 12 %)

sedated patientssedated patients





- SPV, PPV?- SPV, PPV? NONO

- Inspiratory decrease in RAP?- Inspiratory decrease in RAP?

RAPRAP

20

0

mmHg

InspirationInspiration

J Crit Care 1992, 7:76-85

RAPRAP

20

0

mmHg

InspirationInspiration

RAP decrease by ≥RAP decrease by ≥ 1 mmHg1 mmHg at inspirationat inspiration

positive respiratorypositive respiratoryresponse response

no hemodynamic response no hemodynamic response to volume challengeto volume challenge

hemodynamic response hemodynamic response to volume challengeto volume challenge

RAP decrease by < 1 mmHgRAP decrease by < 1 mmHg at inspirationat inspiration

negative respiratorynegative respiratoryresponse response

- 0.6

0.0

0.6

1.2

1.8

2.4

Ch

ange

s in

CO

aft

er v

olu

me

load

ing

Ch

ange

s in

CO

aft

er v

olu

me

load

ing

(L

/min

)(L

/min

)

negative respiratorynegative respiratoryresponseresponse

positive respiratorypositive respiratoryresponse response

Magder et al J Crit Care 1992Magder et al J Crit Care 1992

Limitation : to be sure that the inspiratory effort is sufficient





- SPV, PPV?- SPV, PPV? NONO

- Inspiratory decrease in RAP?- Inspiratory decrease in RAP?

2.2- using passive leg raising2.2- using passive leg raising

Passive Leg RaisingPassive Leg Raising

45 °45 °

Venous blood shiftVenous blood shift (Rutlen et al. (Rutlen et al. 19811981, , Reich et al. 1989)Reich et al. 1989)

Increase in left ventricular preloadIncrease in left ventricular preload (Rocha 1987, Takagi 1989, De Hert 1999, Kyriades 1994 ) Reversible effects Reversible effects

Increase in right ventricular preloadIncrease in right ventricular preload (Thomas et al 1965)

BaseBase BaseBase

PLRPLR PLRPLR

post-PLRpost-PLRpost-PLRpost-PLR

RAP (mmHg)RAP (mmHg) PAOP (mmHg)PAOP (mmHg)

00

55

1010

1515

2020

00

55

1010

1515

2020

2525

3030

Chest 2002; 121: 1245-52

Passive Leg RaisingPassive Leg Raising

45 °45 °

Venous blood shiftVenous blood shift (Rutlen et al. (Rutlen et al. 19811981, , Reich et al. 1989)Reich et al. 1989)

Increase in right ventricular preload Increase in right ventricular preload (Thomas et al 1965)

Increase in left ventricular preload Increase in left ventricular preload (Rocha 1987, Takagi 1989, De Hert 1999, Kyriades 1994 )

Transient effect Transient effect (Gaffney 1982)(Gaffney 1982)

PLR could be used as a test to detect volume responsiveness PLR could be used as a test to detect volume responsiveness

rather than as a therapyrather than as a therapy

HypothesisHypothesis

The increase in pulse pressure during PLRThe increase in pulse pressure during PLR

predicts thepredicts the increase in stroke volume increase in stroke volume

afler volume loadingafler volume loading

Chest 2002; 121: 1245-1252

PLR-induced changes in Pulse Pressure PLR-induced changes in Pulse Pressure (mmHg)(mmHg)

Fluid-induced Fluid-induced changes in changes in

Stroke Volume Stroke Volume

(%)(%)n = 39n = 39r = 0.74r = 0.74

Chest 2002; 121: 1245-52

Real-time CO monitoring is mandatoryReal-time CO monitoring is mandatory

Hypothesis : a better surrogate of stroke volume than PP could do betterHypothesis : a better surrogate of stroke volume than PP could do better

Hypothesis

PLR-induced increase in mean aortic blood flowPLR-induced increase in mean aortic blood flow

provides a better prediction provides a better prediction

of volume responsiveness than of volume responsiveness than

PLR-induced increase in pulse pressurePLR-induced increase in pulse pressure


Base 1Base 1 Base 2Base 2 Post Post VEVEPLRPLR

500 mLsaline

-10

0

10

20

30

40

Base 1 PLR Base 2 Post VE

Changes in

aortic blood flow (%)

respondersresponders

nonrespondersnonresponders

-40

-20

0

20

40

60

80

RRNRNR

PLR-induced changes

in pulse pressure

* *

RRNRNR

% c

han

ge f

rom

Bas

elin

e%

ch

ange

fro

m B

asel

ine

1010

PLR-induced changes

in aortic blood flow

0

20

40

60

80

100

0 20 40 60 80 100

100 - specificity

0

20

40

60

80

100

0 20 40 60 80 100

100 - specificity

PPV

PLRPLR-induced changes in PP-induced changes in PP

PLRPLR-induced changes in ABF-induced changes in ABFse

nsi

tivi

ty

Monnet et al. Monnet et al. Crit Care Med 2006Crit Care Med 2006

patients patients with spontaneous with spontaneous

breathingbreathingn = 19n = 19


Hypothesis

PLR-induced increase in Pulse Contour COPLR-induced increase in Pulse Contour CO

provides a better prediction provides a better prediction

of volume responsiveness than of volume responsiveness than

PLR-induced increase in pulse pressurePLR-induced increase in pulse pressure

-10

0

10

20

30

40

50

60

70

80

90

100

cut-off = 12 %cut-off = 12 %

% increase in Pulse Contour CO during PLR% increase in Pulse Contour CO during PLR

Ridel ATS 2006Ridel ATS 2006

*Se = 70 %Sp = 92 %

nonrespondersnonresponders respondersresponders

ConclusionConclusion

In spontaneously breathing patientsIn spontaneously breathing patients

Prediction of volume responsiveness is a difficult issuePrediction of volume responsiveness is a difficult issue

markers of preloadmarkers of preload

PPV, SPV, SVVPPV, SPV, SVV

Inspiratory decrease in RAPInspiratory decrease in RAP

Response to passive leg raisingResponse to passive leg raising

unreliableunreliable

valuablevaluable

Thank you for your attentionThank you for your attention

but need to be confirmedbut need to be confirmed

Documents

Prof. Jean-Louis TEBOUL Medical ICU Bicetre hospital University Paris XI France What is the best way to assess What is the best way to assess fluid responsiveness