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5/9/2015
1
Goal-Directed Fluid Resuscitation
Christopher G. Choukalas, MD, MS Department of Anesthesia and Perioperative Care
University of California, San Francisco
Goal-Directed Fluid Resuscitation
Christopher G. Choukalas, MD, MS Department of Anesthesia and Perioperative Care
University of California, San Francisco
The case for why it matters
• Fluid balance a common concern
• Sepsis
• ALI/ARDS
• Sepsis PLUS ARDS!
• Patients with Sepsis who developed ALI
• 4 groups:
– Adequate initial + Conservative late fluids
– Adequate initial only
– Conservative late only
– Neither
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Murphry, CV, et al. 2009. Chest. 136(1)
It matters
• And it’s hard…
• … and we’re really bad at it!
• Retrospective, 8000 cases,
uncomplicated, elective
• mL/kg/hr by center, case type, provider
– 6.7 vs 8.2
– Huge inter-provider differences
• 700 vs 5.4
• Exceeded differences due to blood loss,
hemodynamic factors, case type
It matters
• And it’s hard…
• So how do we do it?
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I would posit two factors:
• Hemodynamic:
– Is the circulation adequate?
• Metabolic
– Are oxygen delivery and utilization adequate?
• Both have their own goals.
Hemodynamic Goals
• Blood pressure
• CVP
• Dynamic respiratory indices:
– Pulse pressure/systolic pressure/perfusion
index variation
Hemodynamic Goals
• Blood pressure
• CVP
• Dynamic respiratory indices:
– Pulse pressure/systolic pressure/perfusion
index variation
Blood pressure
• A proxy for flow, end organ perfusion
• Flow = pressure/resistance
• Do we ever really KNOW resistance?
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Wax, et al.
• Non-cardiac cases with both ABP and
NIBP.
• Compared SBP, DBP, and MAP btwn
technologies:
– A-line alone vs A-line + cuff
Randomized trials
• This used to be the 2nd joke of the talk
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Interesting review
• Reviewed 2 trials and 1 meta-analysis (13
studies)
– Target BP
– Actual BP
• Dissociation
– BPs invariably higher than goal
– Higher goal ranges permitted higher actual
ranges: pressors
The NEJM study
• Randomized to MAP 65 vs 85 (800 total)
• Norepinephrine
• Mortality
• AKI/RRT, stratified by HTN
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Blood pressure
• Necessary but not sufficient
• Goals are nebulous
• We’re really bad at following them
• Supra-normal levels common, not helpful
Hemodynamic
• Blood pressure
• CVP
• Dynamic respiratory indices:
– Pulse pressure/systolic pressure/perfusion
index variation
Concept: assumptions
Adequate DO2
Adequate contractility
Optimal actin-myosin match
Normal CVP
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The data
• Critical target in EGDT for sepsis
• Incorporated into SSC guidelines
Sepsis + CVP = Death
• Retrospective analysis of VASST trial
– 778 pts w/ septic shock on NE
• CVP at 12 hrs did predict 28-d mortality in
patients:
Boyd, JH, et al. 2011. CCM. 39(2)
HR
CVP < 8 0.61
CVP 8-12 0.76
CVP >12 1
Marik, PE, et al. 2008. Chest. 134(1)
Fluid responsiveness and total
blood volume
• Volume responsiveness
• Cardiac output before and after fluid
challenge
• 19 evaluated CVP and volume
responsiveness
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Fluid responsiveness
• Calculated a Receiver Operating
Characteristic curve
• Likelihood that at any given point (CVP
level, score, etc) the true positives will
exceed false positives.
• Higher = better discrimination
Volume responsiveness
Marik, PE, et al. 2008. Chest. 134(1)
Deja vu
• 43 studies, half ICU
• Same design
– AUC btwn CVP and ΔSV
• Same pooled AUC
– 0.56
• Same aggressive conclusion
CVP
• Necessary?
• Certainly not sufficient
• Potentially misleading
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Hemodynamic
• Blood pressure
• CVP
• Dynamic respiratory indices:
– Pulse pressure/systolic pressure/perfusion
index variation
The Principles
Decreased RV SV
RV Preload
RV Afterload
LV Preload LV SV
Applies to lots of measures
• Systolic pressure variation
• Pulse pressure variation
• Plethysmogram variation
• Outcome is “fluid responsiveness”
Variations on a theme…
• A waveform…
• A peak and trough…
• And a proprietary algorithm:
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The data
• Small studies
• Mostly OR
SVV, Vigileo
40% MORE fluid
Lower lactate
Fewer “complications”
PVI, Masimo
1/3 LESS fluid
Lower lactate
• 29 studies, 685 patients
– 9 ICU
– 20 OR (15 in cardiac surgery)
• All included correlation/ROC between
SPV, PPV, or SVV and ΔSVI/CI after a
fluid challenge.
Measure r AUC for ROC Threshold
PPV 0.78 0.94 12.5%
SVV 0.72 0.84 15.3%
SPV 0.72 0.86
CVP 0.56
Now, keep in mind…
• Regular HR
• Sedated, mechanically ventilated
• Vt = 8 mL/kg
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Non-invasive CO toys Hemodynamic goals
• Numerous
• State of the art: Dynamic indices
– PPV
– SPV
– PVI
– VTI and esophageal doppler
• Necessary but not sufficient
Metabolic
• Mental status, urine output
• Lactate
• S(c)vO2
Metabolic
• Mental status, urine output
• Lactate
• S(c)vO2
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Metabolic
• Mental status, urine output
• Lactate
• S(c)vO2
Lactate
• The product of anaerobic respiration
• Presence implies inadequate oxygen
utilization, shock
• Easily, quickly measured in arterial blood
Lactate: the data
Two trials:
• JAMA: 300 patients, EGDT vs lactate
clearance
– Non-inferiority
• AJRCCM: 348 patients, EGDT vs lactate
clearance
– Improved mortality (multivariate)
– Less time on vent, in ICU
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How did they do it?
Jones, et al (JAMA) Jansen et al (AJRCCM)
Monitoring interval 2 2
Goal 10% clearance 20% clearance
Fluid totals (L) Control: 4.3
Intervention: 4.5ns
Control: 2.2
Intervention: 2.7*
Outcome Non-inferiority to EGDT Decreased time on vent,
in ICU
The underpinnings…
Metabolic
• Mental status, urine output
• Lactate
• S(c)vO2
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How it’s used:
ScvO2 attributed to:
Supply (cardiac output)
Demand (hypermetabolism)
• In either case, treat by increasing DO2
– Volume, inotropes, RBCs
• But does it work?
DOGS
Humans w/ sepsis
Humans w/ shock
Changes in SvO2 and ScvO2
But does it work?
• Rivers, et al.
Metabolic goals
• Lactate
• ScvO2
• Physiological rationale meets objective
data.
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Does any of this…
• Save lives?
• Save money?
• Actually work?
Single point design
• Close to the patient
• “does this surrogate metric predict optimal
filling/SV/some outcome”
• These seem to work
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Subgroup Mortality Complications
Jadad high --- +++
Jadad low +++ +++
1980s-1990s +++ +++
2000s --- +++
Taking a step back… Similar goals (SVV), similar
protocols…
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…different outcomes
• Fewer post-op complications
• Left the ICU and hospital a full day sooner
• No difference in fluid totals, RBCs, UOP
»VS
• No difference on any clinical measure
So is GDT no good, or…
• Basically shows the NICOM doesn’t work?
• Complication rate much lower than
expected (underpowered?)
• GDT group bolused starch and gelatin
(twice the control group)
• Indictment of GDT?
Does the PROCESS of GDT aRISE to the
challenge?
Does the PROCESS of GDT aRISE to the
challenge? Will GDT SURVIVE?
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Putting it all together:
• Volume isn’t easy
• Volume is important
• Common conditions; competing goals
• Stepwise plan
– Hemodynamic
– Metabolic
• It seems to work
The end
The End