1 / 49

Dr Xavier MONNET

Assessing volume responsiveness in spontaneously breathing patients. Dr Xavier MONNET. Medical Intensive Care Unit Bicêtre Hospital FRANCE. Conflicts of interest. Lilly. Arrow. Deltex Medical. Pulsion Medical Systems. Stroke volume. b'. a'. b'. a'. A. B. A. B.

sade-jordan
Download Presentation

Dr Xavier MONNET

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Assessing volume responsiveness in spontaneously breathing patients Dr Xavier MONNET Medical Intensive Care Unit Bicêtre Hospital FRANCE

  2. Conflicts of interest Lilly Arrow Deltex Medical Pulsion Medical Systems

  3. Stroke volume b' a' b' a' A B A B Ventricular preload Prediction of fluid responsiveness Concept When we administer fluid, we expect an increase in SV All patients do not « respond » to fluid administration VE VE

  4. Prediction of fluid responsiveness Concept 2 situations must be distinguished initial phase of septic shock hypovolemic shock a positive « response » to fluid is certain fluid must be administered immediately septic shock after the initial phase previous fluid administration lung injury fluid responsiveness is not certain

  5. Prediction of fluid responsiveness Concept Stroke volume b' deleterious effects  lung edema gas exchange alteration in case of ARDS a' b'  interstitial edema alteration in tissue oxygenation a' ? How to predict fluid responsiveness  A B A B Ventricular preload

  6. Prediction of fluid responsiveness CVP

  7. Prediction of fluid responsiveness CVP  CVP does not enable predicting fluid responsiveness ?

  8. Stroke volume b' a' b a CVP Ventricular preload Prediction of fluid responsiveness CVP impaired ventricular function effects on SV impaired ventricular function "fluid challenge"  preload

  9. A B Prediction of fluid responsiveness respiratory variation of stroke volume

  10. Prediction of fluid responsiveness pulse pressure variation

  11. limitations Respiratory variation of stroke volume The respiratory variation of hemodynamic signals cannot be used in case of cardiac arrhythmias low Vt

  12. limitations Respiratory variation of stroke volume PPmin PPmin PPmax PPmax

  13. limitations Respiratory variation of stroke volume PPmax mmHg PPmin 110 90 70 50

  14. limitations Respiratory variation of stroke volume The respiratory variation of hemodynamic signals cannot be used in case of cardiac arrhythmias low Vt spontaneous breathing

  15. limitations Respiratory variation of stroke volume 100 PPV for predicting a 15% increase in cardiac index 31 patients with spontaneous breathing activity 80 60 sensitivity 40 PPV cannot be used in case of spontaneous breathing activity  20 PPV 0 0 20 40 60 80 100 100 - specificity

  16. limitations Respiratory variation of stroke volume PPV for predicting a 15% increase in cardiac index 21 patients with spontaneous breathing activity

  17. limitations Respiratory variation of stroke volume PPV for predicting a 15% increase in cardiac index 32 patients with SB

  18. limitations Respiratory variation of stroke volume The respiratory variation of hemodynamic signals cannot be used in case of cardiac arrhythmias frequent in the ICU low Vt spontaneous breathing

  19. How to predict fluid responsiveness ? cardiac arrhythmias, low Vt, spontaneous breathing ? no yes ? respiratory variation

  20. 45° Passive leg raising hemodynamic effects  Blood shift toward the intrathoracic compartment

  21. CVP PAOP base PLR base base PLR base Passive leg raising hemodynamic effects  Passive leg raising is enough for increasing right cardiac preload left cardiac preload

  22. CVP PAOP base PLR base base PLR base Passive leg raising hemodynamic effects  PLR acts like a ″self volume challenge ″

  23. Aortic blood flow (% change from baseline) 70 60 50 40 30 20 10 0 After fluid infusion After fluid infusion During PLR Monnet et al., Crit Care Med, 2006 Passive leg raising prediction of fluid responsiveness ? 76 ICU patients with acute circulatory failure esophageal Doppler monitoring non responders responders

  24. Volume expansion PLR Passive leg raising prediction of fluid responsiveness ? ABF

  25. Aortic blood flow (% change from baseline) 70 60 50 40 30 20 10 0 After fluid infusion After fluid infusion During PLR During PLR Monnet et al., Crit Care Med, 2006 Passive leg raising prediction of fluid responsiveness ? 76 ICU patients with acute circulatory failure esophageal Doppler monitoring non responders responders

  26. * Cut-off 10% Se = 97 % Sp = 94 % Passive leg raising prediction of fluid responsiveness ? PLR-induced changes in ABF % 80 The PLR test allows a reliable prediction of fluid responsiveness  60 40 20 0 -20 NR R -40

  27. PLR effects on ABF Passive leg raising prediction of fluid responsiveness ? 100 The PLR test remains reliable in case of SB  80 60 31 patients with spontaneous triggering of the ventilator sensitivity 40 20 PPV 0 0 20 40 60 80 100 100 - specificity

  28. How to predict fluid responsiveness ? cardiac arrhythmias, low Vt, spontaneous breathing ? no yes respiratory variation indices PLR PLR

  29. Passive leg raising ?  Which monitoring tool for assessing PLR effects

  30. Passive leg raising which monitoring tool ? EDM 10 % increase in ABF 10 % increase in ABF 12 % increase in aoVTI echo 12 % increase in aoVTI PiCCO

  31. Passive leg raising which monitoring tool ? EDM 10 % increase in ABF 10 % increase in ABF 12 % increase in aoVTI echo 12 % increase in aoVTI 10 % increase in PCCI PiCCO ?  Which method for performing PLR

  32. 45° 45° semi-recumbent position PLR position 45° recumbent position PLR position PLR test method importance of the postural change

  33. PLR test importance of the postural change 35 patients All responders to PLR % change in cardiac index from baseline 37.5 25 12.5 0

  34. PLR test importance of the postural change

  35. 35 patients (all responders to fluid administration) 35 responders 20 responders 15 non responders (not correctly classified) PLR test importance of the postural change

  36. PLR test limitations PLR-induced changes in PP 80 false negative cases 60 40 * 20  0 PLR test effects cannot be assessed by arterial pressure changes -20 NR R -40

  37. PLR test limitations  cannot be assessed with arterial pressure  cannot be used in the OR

  38. How to predict fluid responsiveness ? cardiac arrhythmias, low Vt, spontaneous breathing ? no yes respiratory variation indices ? ? PLR PLR

  39. Vasalva maneuver ? 30 patients without MV Prediction of a 15% increase in SV with fluid

  40. Vasalva maneuver ?

  41. Vasalva maneuver ?

  42. Vasalva maneuver ? 9 pigs with SB Prediction of a 15% increase in SV with fluid Breathing against an I and/or E 7.5 cmH2O resistance

  43.      OAP de sevrage de la ventilation mécanique mécanismes Mise en VS  pression intrathoracique  pression intrathoracique retour veineux systémique  pression transmurale VG  précharge VG  postcharge VG  postcharge cardiaque gauche  travail cardiaque POD OAP  retour veineux systémique

  44. A B Tele-expiratory occlusion tele-expiratory occlusion

  45. Tele-expiratory occlusion Tele-expiratory occlusion test 34 patients with SB or cardiac arrhythmias

  46. Tele-expiratory occlusion test 34 patients with SB or cardiac arrhythmias

  47. Tele-expiratory occlusion test Effects of end-expiratory pause on cardiac index Effects of end-expiratory pause on pulse pressure 50 50 40 40 30 30 20 20 increase  5% Se = 91% Sp = 100 % increase  5% Se = 87 % Sp = 100 % 10 10 0 0 -10 -10

  48. How to predict fluid responsiveness ? cardiac arrhythmias, low Vt, spontaneous breathing ? no yes respiratory variation indices PLR PLR TEO TEO

More Related