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Prof.  Xavier  MONNET  

Measuring  fluid  responsiveness  . Prof.  Xavier  MONNET  . Medical  Intensive  Care  Unit   Paris-­‐Sud  University  Hospitals  . Link  of  interest  . Member  of  the    Medical  Advisory  Board   of  Pulsion  Medical  Systems  .

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Prof.  Xavier  MONNET  

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  1. Measuring  fluid  responsiveness   Prof.  Xavier  MONNET   Medical  Intensive  Care  Unit   Paris-­‐Sud  University  Hospitals  

  2. Link  of  interest   Member  of  the    Medical  Advisory  Board   of  Pulsion  Medical  Systems  

  3. The  4  key-­‐messages   1Fluid  overload  is  clearly  deleterious  in  sepJc  and  ARDS  paJents     2 3 4

  4. The  risk  of  volume  expansion   1,000  pts  with  ALI/ARDS   Comparison  of  conservaJve  vs.  liberal  fluid  strategies   →   We  should  limit  fluid  administraJon  in  ARDS  paJents  

  5. The  risk  of  volume  expansion   Cohort  study   3,147  pts  with  sepsis  

  6. The  risk  of  volume  expansion   778  sepJc  shock  pts  from  the  VASST  study   4th  quarJle   of  fluid  balance   →   Excessive  fluid  administraJon  is  deleterious  in  sepJc   shock  paJents  

  7. The  risk  of  volume  expansion   Extra-vascularlungwaterandpulmonaryvascularpermeabilityindexareindependentprognostic factorsinpatientswithacuterespiratorydistresssyndromeoracutelunginjury JozwiakM,SilvaS,PersichiniR,AnguelN,OsmanD,RichardC,TeboulJL, MonnetX Day-­‐28  mortality  (%)   100   80   60   40   20   0   CritCareMed,inpress 200  pts  with  ARDS   EVLW  measured  by  PiCCO   p  =  0.0001   70%   42%   Lung  water  is  an  independent   EVLWImax  >  21  mL/kg  EVLWImax  ≤  21  mL/kg   predictor  of  mortality  in  ARDS  

  8. The  4  key-­‐messages   1Fluid  overload  is  clearly  deleterious  in  sepJc  and  ARDS  paJents  and   must  be  avoided   2 3 4 →   How  to  avoid  fluid  overload  ?  

  9. The  concept  of  fluid  responsiveness   Stroke   volume   normal  ventricular  func5on   impaired  ventricular  func5on   →   All  paJents  do  not  "respond"  to  fluid   administraJon   A   B   Cardiac  preload  

  10. The  concept  of  fluid  responsiveness   R/NR 20/8 13/5 26/15 17/16 13/9 26/39 20/16 21/14 13/16 16/24 16/24 10/9 211/195 R(%) 71% 72% 63% 52% 59% 40% 56% 60% 45% 40% 40% 53% 52% Calvin(Surgery81) Schneider(AmHeartJ88) Reuse(Chest90) Magder(JCritCare92) Diebel(ArchSurgery92) Diebel(JTrauma94) Wagner(Chest98) Tavernier(Anesthesiology98) Magder(JCritCare99) Tousignant(AAnalg00) Michard(AJRCCM00) Feissel(Chest01) Mean

  11. The  4  key-­‐messages   1Fluid  overload  is  clearly  deleterious  in  sepJc  and  ARDS  paJents  and   must  be  avoided   2Volume  expansion  does  not  always  result  in  the  expected  increase  in   cardiac  output   3 →   How  could  we  predict  fluid  responsiveness?   4

  12. PredicJon  of  fluid  responsiveness  Respiratory  variaJon  of  HD  signals   A   B  

  13. PredicJon  of  fluid  responsiveness  pulse  pressure  variaJon   Meta-­‐analysis   29  studies   685  paJents   →   A  large  base  of  evidence  

  14. PredicJon  of  fluid  responsiveness   Respiratory  variaJon  of  HD  signals  limitaJons   mmHg   110   PPmax   PPmin   90   70   PPV  =  32  %   50   PPmax  -­‐  PPmin   (PPmax  +  PPmin)  /  2   PPV  =   Cannot  be  used  in  case  of:     spontaneous  breathing  acJvity   cardiac  arrhythmias   ARDS  with  low  Vt  /  compliance   3  frequent  situaJons   in  the  ICU  

  15. PredicJon  of  fluid  responsiveness  Respiratory  variaJon  of  HD  signals  limitaJons   PulsepressurecannotbeusedinalargemajorityofICUpatients forpredictingfluidresponsiveness submitted 200  volume  expansions   Validity  of  PPV  as  a  marker  of  fluid  responsiveness   JozwiakM,TeboulJL,RichardC,MonnetX others 5% 10% validPPV 16% 24% Vt<7mL/kg spontaneous breathingactivity 38% noarterialcatheter 15% atrialfibrillation →   Are  there  alternaJves  to  PPV  ?  

  16. PredicJon  of  fluid  responsiveness  end-­‐expiratory  occlusion  test   A   B   ↗  systemic  venous   return  

  17. PredicJon  of  fluid  responsiveness  end-­‐expiratory  occlusion  test   Easier  with  a  conJnuous  measurement  of  cardiac  output  

  18. PredicJon  of  fluid  responsiveness  end-­‐expiratory  occlusion  test   34  paJents  with  acute  circulatory  failure   monitored  by  PiCCO  device   Effectsofend-expiratoryocclusion oncontinuouscardiacindex increase  ≥  5%   Se  =  91%   Sp  =  100  %   50 40 30 20 10 0 -10 N R

  19. PredicJon  of  fluid  responsiveness  passive  leg  raising  test   A   B  

  20. PredicJon  of  fluid  responsiveness  passive  leg  raising  test   Volumeexpansion ABF PLR

  21. PredicJon  of  fluid  responsiveness  passive  leg  raising  test   EsoDoppler PiCCO EsoDoppler echo echo echo bioreactance PiCCO echoandarterialflow USCOM Flotrac/vigileo

  22. PredicJon  of  fluid  responsiveness  passive  leg  raising  test   Meta-­‐analysis  of  8  studies  with  PLR   and  volume  expansion   →   A    large  base  of  evidence  

  23. PredicJon  of  fluid  responsiveness  passive  leg  raising  test   EsoDoppler PiCCO EsoDoppler echo echo echo bioreactance PiCCO echoandarterialflow USCOM Flotrac/vigileo

  24. PredicJon  of  fluid  responsiveness  passive  leg  raising  test   PLR-­‐induced  changes  in   arterial  pulse  pressure   80   60   →   We  need  a  real-­‐Jme  measurement  of  cardiac  output  for   assessing  the  effects  of  the  PLR  test   40   20   0   *   False-­‐negaJve  cases   -­‐20   -­‐40   NR   R  

  25. PredicJon  of  fluid  responsiveness  passive  leg  raising  test   65  pts  receiving  volume  expansion   Monitoring  of  end-­‐expiratory  CO2   volumeexpansion passiveleg raising 4 0 CO2 (mmHg) 0 30 sec

  26. PredicJon  of  fluid  responsiveness  passive  leg  raising  test   65  pts  receiving  volume  expansion   Monitoring  of  end-­‐expiratory  CO2   100   →   Non-­‐invasive  assessment  of  the  effects  of  the  PLR  test   80   60   40   20   0   SensiJvity   PLR-­‐induced  changes  in  cardiac  index   PLR-­‐induced  changes  in  EtCO2   PLR-­‐induced  changes  in  arterial  pulse  pressure   *   0   20   40   60   80   100   100-­‐Specificity  

  27. The  4  key-­‐messages   1Fluid  overload  is  clearly  deleterious  in  sepJc  and  ARDS  paJents  and   must  be  avoided   2Volume  expansion  does  not  always  result  in  the  expected  increase  in   cardiac  output   3Several  tests  are  now  available  for  predicJngfluidresponsiveness   4

  28. Circulatory  failure   Risk  of  fluid  overload   (PAOP,  lung  water)   ?   no   Fluid  responsiveness   PPV,  SVV…   yes   ?   PLR  test   EEO  test   +   -­‐   volume  expansion   How  to  assess    the   hemodynamic  effects  ?  

  29. The  concept  of  fluid  responsiveness   Stroke   volume   normal  ventricular  func5on   impaired  ventricular  func5on   →   How  should  we  assess  the  effects   of  volume  expansion  ?   A   B   Cardiac  preload  

  30. How  should  we  assess  the  effects  of  volume  expansion  ?   228  pts  receiving  volume  expansion   145  paJents  with  increase  of  NE   Arterial   pressure   PAC   PiCCO   ProAQT/PulsioFlex   Nexfin   Esophageal   Doppler   FloTrac/Vigileo   Echo  

  31. How  should  we  assess  the  effects  of  volume  expansion  ?   228  pts  receiving  volume  expansion   145  paJents  with  increase  of  NE   r=0.56 n=228 ChangesinPP inducedbyVE(%) 300 250 200 150 100 50 0 -50 -50 0 50100150200250300 ChangesinCIinducedbyVE(%)

  32. How  should  we  assess  the  effects  of  volume  expansion  ?   228  pts  receiving  volume  expansion   145  paJents  with  increase  of  NE   changes  in  PP  (%)   100   80   changes  in  CI  (%)   100   80   60   40   60   40   6%  false  +   20   0   20   0   +15%   -­‐20   -­‐20   22%  false  -­‐   non  responders   responders   non  responders   responders  

  33. How  should  we  assess  the  effects  of  volume  expansion  ?   51  pts  receiving  volume  expansion   Arterial  pressure  is  a  rough  surrogate  of  cardiac  output   In  high-­‐risk  paJents,  we  need  a  direct  measurement  of   cardiac  output  for  assessing  the  effects  of  fluids  

  34. Circulatory  failure   Risk  of  fluid  overload   (PAOP,  lung  water)   ?   no   Fluid  responsiveness   PPV,  SVV…   yes   ?   PLR  test   EEO  test   +   -­‐   volume  expansion   Assess  the  effects  on  cardiac  output  

  35. The  4  key-­‐messages   1Fluid  overload  is  clearly  deleterious  in  sepJc  and  ARDS  paJents  and   must  be  avoided   2Volume  expansion  does  not  always  result  in  the  expected  increase  in   cardiac  output   3Several  tests  are  now  available  for  predicJngfluidresponsiveness   4For  a  precise  assessment  of  the  response  to  fluid  administraJon,  we   need  a  direct  measurement  of  cardiac  output  

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