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Monitoring Fluid Responsiveness

Monitoring Fluid Responsiveness. Murat Sungur, MD Erciyes University Medical School Department of Medicine Division of Critical Care Medicine. If we are giving fluids we should have a cardiovascular response. SV and CO should rise. Fluid responsiveness is related to cardiac responsiveness.

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Monitoring Fluid Responsiveness

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  1. Monitoring Fluid Responsiveness Murat Sungur, MD Erciyes University Medical School Department of Medicine Division of Critical Care Medicine

  2. If we are giving fluids we should have a cardiovascular response. • SV and CO should rise

  3. Fluid responsiveness is related to cardiac responsiveness Stroke volume Fluid unresponsiveness Fluid responsiveness Preload

  4. Do we need monitoring ? • Phycial exam • Chest X-ray • Urine output • Heart rate • Blood pressure Or just a fluid challenge with crystalloids or colloids !

  5. «Crying baby may be thirsty or hungry»CONCEPT ! • Quantitation of the cardiovascular response during volume infusion. • Prompt correction of fluid deficits. • Minimizing the risk of fluid overload and its potentially adverse effects, especially on the lungs. Crit Care Med 2006; 34:1333–1337

  6. Cristalloids 500 – 1000 ml, or Colloids 300 – 500 ml Safety limit: CVP of 15 mmHg !!

  7. CVP as a Preload Marker Chest 2008;134;172-178

  8. CVP does not predict actual blood volume Chest 2008;134;172-178

  9. CVPmeasurement is methodologically difficult 50 health care worker Anesth Analg 2009;108:1209 –11

  10. Fluid responsiveness is related to cardiac responsiveness Stroke volume Fluid unresponsiveness Normal heart Fluid responsiveness Failing heart Preload

  11. Pre-infusion CVP values are similar in responders and non-responders Crit Care Med 2007; 35:64–68

  12. Cristalloids 500 – 1000 ml, or Colloids 300 – 500 ml Safety limit: CVP of 15 mmHg !!

  13. Problems with fluid challenge • Not a test, a treatment • Irreversible • Significant amount of volume should be given • Only 50 % of the patients are responsive • CVP is not a good predictor of preload • Should be repeated multiple times Cristalloids 500 – 1000 ml, or Colloids 300 – 500 ml

  14. Multiple fluid challenges increases the risk for volume overload Sepsis in European intensive care units: Results of the SOAP Study. Crit Care Med 2006; 34:344–353.

  15. Initial resuscitation (first 6 hrs) • ● Begin resuscitation immediately in patients with hypotension or elevated serum lactate 4 • mmol/L; do not delay pending ICU admission (1C) • ● Resuscitation goals (1C) • CVP 8–12 mm Hg • Mean arterial pressure 65 mm Hg • Urine output 0.5 mLkg1hr1 • Central venous (superior vena cava) oxygen saturation 70% or mixed venous 65% Who knows how much CVP affected from PEEP or hyperinflation

  16. PULMONARY ARTERY CATHETER Both sides of the heart can be assessed PAWP, an important indicator of pulmonary edema can be measure CO can be measured Mixed venous oxygen saturation, an important parameter of Co and tissue oxygenation can be measured

  17. PAC Misuse Iberti JAMA 1990;264:2928-2932 Gnaegi Crit Care Med 1997;25:213-220 Burns Am J Crit Care 1996;5:49-54

  18. Cost versus length of stay • Connors* et al conducted a prospective, multi-center cohort study • PAC vs Non-PAC groups • Compared survival, cost, intensity of care and length of stay • Multiple complicated statistical analysis of the data • Increased mortality in PAC group (odds ratio:1.24) Connors J JAMA,1996 276(11):889-897

  19. PAC may be associated with increased mortality Connors JAMA 1996;276:889-897

  20. Sandham et al. NEJM 2003 Objective: To compare goal-directed therapy guided by a PAC with standard therapy among high-risk elderly patients undergoing surgery Design: RCT, not masked Patients: surgical Intervention: PAC vs standard care PrimaryOutcome: in-hospital mortality Secondary: 6-month mortality, 12-month mortality, in-hospital morbidity: MI, arrythmias, pneumonia, PE, renal/liver insufficiency, sepsis from CR-BSI Sandham JD et al. N Engl J Med 2003; 348:5-14, Jan 2, 2003

  21. PAC directed therapy does not decrease mortality Sandham JD et al. N Engl J Med 2003; 348:5-14, Jan 2, 2003

  22. We need dynamic and non-invasive parameters that shows preload and cardiac reserve rather than static preload parameters

  23. Pulse Pressure Variation Anesthesiology 2005; 103:419–28

  24. Fluid responsiveness is related to cardiac responsiveness Stroke volume Fluid unresponsiveness Fluid responsiveness Preload Pulse pressure variation

  25. Pulse pressure variation may be a better tool to predict fluid resposiveness Am J Respir Crit Care Med Vol 162. pp 134–138, 2000

  26. Stroke volume variation SVV = SV max – SV min / SV mean

  27. Crit Care Med 2011; 39: 402-3

  28. Problems with PPV and SVV • Spontaneously breathing patients • Arrhythmias • Significant tachycardia • Very low tidal volumes

  29. Passive Leg Raising Should be quick and for 30 – 90 seconds Venous blood from legs and abdomen increases preload İt is just like fluid challenge but it is reversible Needs real time CO monitoring

  30. PLR compared with volume expansion Post Volume expansion Baseline 2 PLR Baseline 1 HR SV VF HR SV VF HR SV VF HR SV VF SPONTANEOUSLY BREATHİNG PATİENTS 500 ml colloid infusion Crit Care Med 2010; 38:819–825

  31. PLR accurately predict fluid responsiveness Crit Care Med 2010; 38:819–825

  32. SAME STUDY PROTOCOL WITH VENTILATED PATIENTS ALERT: Do not use PLR in patients with abdominal hypertension Crit Care Med 2006; 34:1402–1407

  33. Echocardiography to asses fluid status and responsiveness • Static parameters • LVEDA • IVC • Dynamic parameters • SVV with repeated SV measurements • Change in IVC/SVC diameter • IA septum position • For assessment of • Heart lung interactions • Passive leg raising • Fluid challenge

  34. Summary • There are many parameters to use • Static measurements are not accurate • We need less invasive and more dynamic parameters • PPV and SVV are good parameters to use • Echocardiography done by intensivist will be more and more popular

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