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Is Volume-Responsiveness the Same as Preload?

Is Volume-Responsiveness the Same as Preload?. Michael R. Pinsky, MD, Dr hc Department of Critical Care Medicine University of Pittsburgh. No. Not Now Not Ever. Is cardiac output responsive to intravascular fluid loading?.

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Is Volume-Responsiveness the Same as Preload?

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  1. Is Volume-Responsiveness the Same as Preload? Michael R. Pinsky, MD, Dr hc Department of Critical Care Medicine University of Pittsburgh

  2. No Not Now Not Ever

  3. Is cardiac output responsive to intravascular fluid loading? • Assumes that venous return and LV preload are the primary determinants of cardiac output (Starling’s Law of the Heart) • Assumes low LV end-diastolic volume (EDV) equals preload-responsiveness • Attempts to assess EDV through surrogate measures • CVP, Ppao, LV end-diastolic area, RV EDV, intrathoracic blood volume

  4. CVP before volume expansion in Responders (R) and Non-Responders (NR) * * 12 10 8 Pra (mm Hg) 6 4 2 0 Calvin Schneider Reuse Wagner Michard 1981 1988 1990 1998 2000 Michard & Teboul. Chest 121: 2000-8, 2002

  5. CVP does not predict volume responsiveness r = 0.45 Changes in stroke volume (%) Baseline PRA(mm Hg) Wagner et al. Chest 1998

  6. Ppao (mm Hg) before volume expansion inResponders (R)and Non-responders (NR) R NR Calvin(Surgery 81)8 ± 17 ± 2 Schneider(Am Heart J 88)10 ± 210 ± 2 Reuse(Chest 90)10 ± 410 ± 3 Diebel(J Trauma 94)16 ± 615 ± 5 Tavernier(Anesthesiology 98)10 ± 412 ± 3 Michard (AJRCCM 00)10 ± 311 ± 2 Wagner(Chest 98)10 ± 314 ± 4 Tousignant(Anesth Analg 00)12 ± 316 ± 3 p < 0.05 p < 0.05 Michard & Teboul. Chest 121: 2000-8, 2002

  7. Ppao does not predict preload-responsiveness Non-responders Responders $ * Ppao (mm Hg) $ Pre Post Pre Post Tousignant et al. Anesth Analg 90:351-5, 2000

  8. Neither DCVP or DPpao Mirror DSV Lichtwarck-Aschoff et al. Intensive Care Med 18: 142-7, 1992

  9. But individual subjects have markedly different relations Changes in global EDV predict DSV Lichtwarck-Aschoff et al. Intensive Care Med 1992; 18: 142-7

  10. RVEDV (mL/m2) before volume expansion in Responders (R) and Non-responders (NR) * 150 * 120 90 60 30 0 Calvin Schneider Reuse Diebel Diebel Wagner 1981 1988 1990 1992 1994 1998 Michard & Teboul. Chest 121: 2000-8, 2002

  11. Echocardiographic LVEDA (cm2/m2) R NR Feissel (Chest 01) 10 ± 4 10 ± 2 Tavernier (Anesthesiology 98) 9 ± 3 12 ± 4 * Tousignant (Anesth Analg00) 15 ± 5 20 ± 5 * (cm2) * p < 0.05

  12. LV EDV in Responders and Non-responders of fluid resuscitation 16 LVEDA before fluid infusion (cm2/m2) _ 14 12 10 8 _ 6 4 responders non responders Feissel et al. Chest 119:867-73, 2001

  13. End-diastolic Area (EDA) to Predict Preload-Responsiveness Non-responders Responders ** * EDA cm2 Pre Post Pre Pre Pre Post Tousignant et al. Anesth Analg 90:351-5, 2000

  14. 5 15 10 0 5 End-expiration: The pressure which is important to a distensible structure is the transmural pressure Inside pressure minus outside pressure Transmural pressures determine Starling’s forces across capillaries Ventricular preload 10 10 5

  15. Transmural Pressure is the Amount Above the Surface

  16. Pra, Ppao, RVEDV and LVEDA are not always accurate indicators of preload 1- Pra and Ppao are rarely expressed as transmural pressures 2- Even transmural Ppao depends on LV compliance 3- RVEDV measures are influenced by tricuspid regurgitation 4- LVED Area may not reflect LVED Volume 5- All these parameters are supposed to give information on the preload of one ventricle but not on the global cardiac preload Or……

  17. Neither CVP or Ppao reflect Ventricular Volumes or Tract Preload-Responsiveness Preload  Preload Responsiveness Kumar et al. Crit Care Med 32:691-9, 2004

  18. Starling’s Law of the Heart Lives! Kumar et al. Crit Care Med 32:691-9, 2004

  19. Hemodynamic Truths • Tachycardia is never a good thing • Hypotension is always pathological • There is no normal cardiac output • CVP is only elevated in disease • Peripheral edema is of cosmetic concern

  20. Hemodynamic Effects of Changes in Intrathoracic Pressure LV Ejection Venous Return Thorax

  21. Positive-Pressure Ventilation Spontaneous Ventilation SVrv (ml/kg) Time (sec) Pratm (mm Hg) Ppl (mm Hg) CVP (mm Hg) Pinsky. J Appl Physiol 56:1237-45, 1984

  22. IPPV 20 ml/kg IPPV 20 ml/kg Effect of IPPV on LV Pressure and Volume Stroke Volume Variation Cardiac Compression

  23. PPV and SVV Predict Preload-Responsiveness • Jardin et al. Circulation 83: 266-27, 1983 IPPV • Perel et al. Anesthesiology 67: 498-502, 1987 SPV-IPPV • Tavernier et al. Anesthesiology 89: 1313-1321, 1998 SPV-IPPV • Ornstein et al. J Clin Anesth 10:137-140, 1998 SPV-IPPV • Michard et al. Am J Respir Crit Care Med 159:935-939, 1999 • Dalibon et al. Brit J Anaesth 82:97-103, 1999 • Michard et al. Am J Respir Crit Care Med 162: 134-138, 2000 • Michard & Teboul JL Crit Care 4: 282-289, 2000 • Feissel et al. Chest 119: 867-873, 2001 • Berkenstadt et al. Anesth Analg 92: 984-989, 2001SPV-IPPV • Reuter et al. Intensive Care Med 28: 392-398, 2002 • Boulain et al. Chest 121:1245-52, 2002 • Reuter et al. British J Anaesth 88: 124-126, 2002 • Slama et al. Am J Physiol 283:H1729-33, 2002 • Reuter et al. Crit Care Med 31: 1399-1404, 2003 • Vieillard-Baron et al. American J Resp Crit Care Med168:671-676, 2003 • Marx et al. European J Anaesth 21: 132-138, 2004

  24. Systolic pressure variations correlate with stroke volume variations measured by the pulse contour technique In general: SPV under estimates SVV by 5% Reuter et al. Brit J Anaesth 88:124-6, 2002.

  25. Practical Limitations of PPV • Requires fixed HR • Atrial fibrillation, frequent PVCs • Requires no spontaneous ventilatory efforts • Can not use during CPAP, PSV • Magnitude of PPV or SVV will change with changing tidal volume • Heart failure may give false positive response!

  26. Spontaneous Ventilation Alters LV Filling by Ventricular Interdependence Taylor et al. Am J Physiol 213:706-10, 1967

  27. Effect of ventilation on RV and LV Output Ventricular Interdependence Spontaneous inspiration Minimal Ventricular Interdependence Positive-pressure Inspiration Pinsky et al. J Appl Physiol 58:1189-98, 1985

  28. Effect of Positive-Pressure Ventilation on Dynamic LV Volumes and Pressure Protocol: Measured LV areas using echocardiographic imaging IPPV during closed and open chest Pre and post CPB Denault et al. Chest 116:176-86,1999

  29. Changes in SAP can not be explained by changes in LV Volumes Neither end-diastolic volume or end-systolic volume changes parallel SPV Denault et al. Chest 1999; 116:176-86

  30. There is no relation between pulse pressure variation and initial LV end-diastolic area (EDA) in patients during CABG surgery 20 Preload  Preload Responsiveness 15 EDA (cm2) 10 n = 9 r2 = 0.11 5 0 0% 2% 4% 6% 8% 10% 12% 14% 16% PPV (%) Gunn et al. Crit Care & Shock 5: 170-6, 2002

  31. Primary harmonic Fourier Analysis: The changes in SAP poorly reflect airway pressure induced changes in LV volumes, but reflect very well changes in airway pressure Denault et al. Chest 1999; 116:176-86

  32. SVrv SVlv PAo Platm Ppatm Pratm Paw Ppl Asynchronous High Frequency Jet Ventilation in Acute Ventricular Failure Pinsky et al. J Appl Physiol 58:1189-98, 1985

  33. Asynchronous High Frequency Jet Ventilation in Acute Ventricular Failure Pinsky et al. J Appl Physiol 58:1189-98, 1985

  34. SVlv ml/kg QAo PAo mm Hg early systolic early systolic late systolic late systolic Cardiac cycle-specific increases in ITP during Acute Ventricular Failure Pinsky et al. J Appl Physiol 60:604-12, 1986

  35. Pressure-Volume Loops During Positive Pressure Ventilation End systole Transmural Pressure Airway Pressure Time (sec) End diastole Left Ventricular Volume Denault et al . J Appl Physiol 91:298-308,2001

  36. Positive-Pressure Ventilation Alters Both Preload and Afterload Denault et al. J Appl Physiol 91:298-308, 2001

  37. IVC occlusion CPAP 5 mm Hg 160 160 140 140 120 120 100 100 80 80 LV Pressure (mm Hg) LV Pressure (mm Hg) 60 60 40 40 20 20 0 0 -20 -20 15 20 25 30 35 40 15 20 25 30 35 40 LV Volume (ml) LV Volume (ml) CPAP 15 mm Hg CPAP 10 mm Hg 160 160 140 140 120 120 100 100 80 80 LV Pressure (mm Hg) LV Pressure (mm Hg) 60 60 40 40 20 20 0 0 -20 -20 15 20 25 30 35 40 15 20 25 30 35 40 LV Volume (ml) LV Volume (ml) Kim et al. Proc Am Thorac Soc 3:A297, 2006

  38. 15 ml/kg 5 ml/kg 20 ml/kg 10 ml/kg Effect of Tidal Volume on LV Pressure and Volume Kim et al. Proc Am Thorac Soc 3:A297, 2006

  39. PPV and SVV during IPPV • Reflect complex interactions between preload and afterload • Potential false positive PPV with inspiration • Severe CHF-Reverse Bernheim Effect • Cor pulmonale- Minimize ventricular interdependence • Potential false positive SVP with inspiration • Stiff chest wall + large tidal volume: Valsalva Maneuver • Whenever ITP increases rapidly • These limitations dissolve with passive leg raising

  40. Limits of Preload-Responsiveness • Preload  Preload-responsiveness • Preload-responsiveness  Need for fluids • The means of altering preload matters • Size of Vt, passive leg raising, spontaneous breaths • Different measures of pressure or flow variation will have different calibrations • Pinsky Intensive Care Med 30: 1008-10, 2004

  41. Thank You

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