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Noninvasive and Continuous Fluid Responsiveness Monitoring with Pleth Variability Index (PVI)

Noninvasive and Continuous Fluid Responsiveness Monitoring with Pleth Variability Index (PVI). PVI Overview. Physiology Fluid administration challenges PVI method PVI clinical evidence. Physiology Background. Oxygen delivery components Cardiac output x oxygen saturation x hemoglobin

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Noninvasive and Continuous Fluid Responsiveness Monitoring with Pleth Variability Index (PVI)

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  1. Noninvasive and Continuous Fluid Responsiveness Monitoring with Pleth Variability Index (PVI)

  2. PVI Overview • Physiology • Fluid administration challenges • PVI method • PVI clinical evidence

  3. Physiology Background • Oxygen delivery components • Cardiac output x oxygen saturation x hemoglobin • Cardiac output components • Stroke volume • Preload • Afterload (Systemic Vascular Resistance) • Contractility • Heart rate • Primary methods to increase cardiac output • Increase preload (volume expanders) • Increase contractility (inotropes) • Decrease afterload (vasodilators) • Key point • Administering volume may increase intravascular volume and preload but not stroke volume and cardiac output

  4. Frank-Starling Relationship Stroke Volume 0 0 Preload

  5. Fluid Administration Challenges • Fluid administration is critical to optimizing oxygen delivery by optimizing cardiac output 1 • Unnecessary fluid administration may be harmful2 • Traditional methods to guide fluid administration often fail to predict fluid responsiveness • Accurate only 50-60% of time 3 • Newer dynamic methods that can predict fluid responsiveness are invasive, complex, and/or costly 4 • Many patients are not candidates for this level of monitoring 1 Perel A. Anesth Analg. 2008; 106 (4):1031-33 2 Bundgaard-Nielsen M et al. Acta Anaesthesiol Scand. 2007; 51(3):331-40 3 Michard F et al. Chest. 2002; 121(6):2000-08 4 Joshi G et al. Anesth Analg. 2005; 101:601-5

  6. Pleth Variability Index (PVI) • Masimo PVI is clinically proven to help clinicians assess fluid responsiveness and improve fluid management to reduce patient risk.1,2 • Once your Masimo Pulse CO-Oximeter is enabled with PVI-monitoring capability, PVI is automatically displayed for every patient receiving pulse oximetry monitoring 1 Cannesson M et al. Br J Anaesth. 2008;101(2):200-6. 2 Forget P et al. Anesth & Anal. 2010;111(4):910-4.

  7. Pulse Pressure Variation and Changes in PPW During Ventilation Arterial Pulse Pressure Variation PPmax- PPmin (PPmax + PPmin) ÷ 2 ΔPP= Pleth Waveform Variation PPWmax – PPWmin (PPWmax + PPWmin) ÷ 2 ΔPPW= Ventilatory Cycle PPWmax PPWmin Adapted from: Cannesson M et al

  8. PVI Calculation • Automated measurement • Changes in plethysmographic waveform amplitude over the respiratory cycle • PVI is a percentage from 1 to 100%: • 1 - no pleth variability • 100 - maximum pleth variability

  9. 2011 Radical-7

  10. PVI to Help Clinicians Optimize Preload / Cardiac Output Stroke Volume Lower PVI = Less likely to respond to fluid administration 10 % 24 % Higher PVI = More likely to respond to fluid administration 0 0 Preload Maxime Cannesson, MD, PhD

  11. PVI to Help Clinicians Assess Fluid Responsiveness During Surgery: Similar to Arterial Pulse Pressure / Superior to CI, PCWP, CVP Adapted from Cannesson M. et. al. Br J Anesth 2008;101(2):200-206

  12. PVI to Help Clinicians Assess Fluid Responsiveness During Surgery:Similar to Stroke Volume Variation / Superior to CVP Zimmermann M, et al. Eur J Anaesthesiol. 2010;27(66):555-561.

  13. PVI to Assess Fluid Responsiveness in the ICUSimilar to Pulse Pressure Variation / Superior to Cardiac Output PPV PVI CO Loupec T et al. Crit Care Med 2011 Vol. 39, No. 2

  14. PVI to Help Clinicians Predict Hypotension During Surgery Tsuchiya M et al. Acta Anaesthesiol Scand. 2010.

  15. PVI to Help Clinicians Predict Hemodynamic Instability by PEEP Desebbe O et al. Anesth Analg 2010;110:792–798.

  16. PVI to Help Clinicians Improve Fluid Management and Reduce Patient Risk Forget P et al. Anesth Analg 2010.

  17. Overall Conclusions: Clinical Utility of PVI • Fluid administration is critical to optimizing patient status • Traditional methods to guide fluid administration are not sensitive or specific 1 • Newer methods to improve fluid administration may improve patient outcomes but are impractical, invasive, or costly 2 • PVI is noninvasive and proven to predict fluid responsiveness in mechanically ventilated patients in the OR and ICU 3,4 • PVI improves fluid management and reduces patient risk as evidenced by lower lactate levels 5 1 Michard F, Teboul JL. Chest. 2002 Jun;121(6):2000-8. 2 Joshi G. et al. Anesth Analg. 2005; 101:601. 3 Cannesson M et al. Br J Anaesth. 2008 Aug;101(2):200-6. 4Feissel M et al. Critical Care. 2009;13(1):P219.5 Forget P et.al. Critical Care. 2009; 13(1):P204.

  18. Reference Slides

  19. PVI to Assess Fluid Responsiveness During Surgery: Summary • Methods • 25 surgical patients under general anesthesia • Recorded CVP, PCWP, cardiac index, delta PP, PVI • Before and after volume expansion (500 ml of hetastarch 6%) • Fluid responsiveness was defined >15% increase in cardiac index • Results • Response to volume expansion • Cardiac index increase from 2.0 to 2.5 l/min/m2 • PVI decrease of 14 to 9 • PVI >14% before volume expansion • Discriminated between responders and non-responders with 81% sensitivity and 100% specificity • Significant relationship between PVI before volume expansion and change in cardiac index after volume expansion (R=0.67; P<0.01) • Conclusion • PVI can predict fluid responsiveness non-invasively in mechanically ventilated patients during general anesthesia Cannesson M et al. Br J Anaesth. 2008 Aug;101(2):200-6

  20. PVI to Help Clinicians Assess Fluid Responsiveness During Surgery: Summary • Method • 20 patients scheduled for elective major abdominal surgery • After induction of anesthesia, all hemodynamic variables were recorded immediately before (T1) and subsequent to volume replacement (T2) by infusion • Results • The volume-induced increase in SVI was at least 15% in 15 patients (responders) and less than 15% in five patients (non-responders). • Baseline SVV correlated significantly with changes in SVI as did baseline PVI whereas baseline values of central venous pressure showed no correlation to DSVI • No significant difference between the area under the receiver operating characteristic curve for SVV (0.993) and PVI (0.973) • The best threshold values to predict fluid responsiveness were more than 11% for SVV and more than 9.5% for PVI • Conclusion • SVV and PVI can serve as valid indicators of fluid responsiveness in mechanically ventilated patients undergoing major surgery Zimmermann M, et al. Eur J Anaesthesiol. 2010;27(66):555-561.

  21. PVI to Assess Fluid Responsiveness in the ICU: Summary • Method • Forty mechanically ventilated patients with circulatory insufficiency • Fluid challenge with 500 mL of 130/0.4 hydroxyethyl-starch if respiratory variations in arterial pulse pressure were >13% or with passive leg raising if variations in arterial pulse pressure were <13% • Results • 21 were responders and 19 were non-responders. • Differences in responders vs. non-responders • PVI 28 + 13% vs. 11 + 4% (p<0.05) • Arterial pulse pressure variation 22 + 11% vs. 5 + 2% (p<0.05) • PVI correlation with change in cardiac output after fluid challenge (0.72, p<0.0001) • Values at baseline were significantly higher in responders than in non-responders • Conclusion • PVI can predict fluid responsiveness noninvasively in intensive care unit patients under mechanical ventilation Loupec T et al. Crit Care Med 2011 Vol. 39, No. 2

  22. PVI to Help Clinicians Predict Hypotension During Surgery: Summary • Method • Measured PVI, HR, SBP, DBP, and MAP in 76 adult healthy patients under light sedation with fentanyl to obtain pre-anesthesia control values • Anesthesia induced w/bolus administrations of 1.8 mg/kg propofol and 0.6 mg/kg rocuronium • During the 3-min period from the start of propofol administration, HR, SBP, DBP, and MAP were measured at 30-s intervals • Results • HR, SBP, DBP, and MAP were significantly decreased after propofol administration by 8.5%, 33%, 23%, and 26%, respectively, as compared with the pre-anesthesia control values • Linear regression analysis that compared pre-anesthesia PVI with the decrease in MAP yielded an r value of -0.73 • Conclusion • PVI can predict a decrease in MAP during anesthesia induction with propofol. Its measurement may be useful to identify high-risk patients for developing severe hypotension during anesthesia induction Tsuchiya Acta Anaesthesiol Scand. 2010.

  23. PVI to Help Clinicians Predict Hemodynamic Instability by PEEP: Summary • Method • 21 mechanically ventilated and sedated patients in the postoperative period after coronary artery bypass grafting • Patients were monitored with a pulmonary artery catheter and a pulse oximeter sensor attached to the index finger • Cardiac index [CI], PVI, pulse pressure variation, central venous pressure) were recorded at 3 successive tidal volumes • Results • PEEP induced changes in CI and PVI for VT of 8 and 10 mL/kg. • For VT of 8 mL/kg, a PVI threshold value of 12% during ZEEP predicted hemodynamic instability with a sensitivity of 83% and a specificity of 80% (area under the receiver operating characteristic curve 0.806; P 0.03) • Conclusion • PVI may be useful in automatically and noninvasively detecting the hemodynamic effects of PEEP Desebbe O et al. Anesth Analg 2010;110:792–798.

  24. Optimization of Fluid Management by PVI: Summary • Methods • Randomized Clinical Trial • Intra-operative PVI-directed fluid management vs. standard care • Abdominal surgery patients • PVI Group – 41 patients • 500 ml crystalloids followed by 2ml/kg/hr • Colloids added at 250ml for PVI values between 10-13 • Control Group – 41 patients • 500 ml crystalloids followed by standard fluid management care (challenges and CVP) • Outcomes • Primary: Perioperative lactate levels • Secondary: Hemodynamic data and post-op complications Forget P et al. Anesth Analg 2010.

  25. Optimization of Fluid Management by PVI: Summary Cont. • Results • PVI group had lower lactate levels • Max intraoperative (1.2 vs. 1.6, p<0.05) • 24 hours (1.4 vs. 1.8, p<0.05) • 48 hours (1.2 vs. 1.4, p<0.05) • PVI group received lower amounts of intra-operative crystalloids • 1363 vs. 1818 mL (p<0.01) • No significant differences in morbidity or mortality • Conclusion • PVI-based goal-directed fluid management reduced the volume of intraoperative fluid infused and reduced intraoperative and postoperative lactate levels Forget P et al. Anesth Analg 2010.

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