Your SlideShare is downloading. ×
0
What is the best way to assess  fluid responsiveness  in a spontaneously breathing patient  ? Edward M. Omron MD, MPH, FCC...
Case Example <ul><li>46 yo female presents to IRMC with 24 hours of left flank and left lower quadrant pain, 8/10 severity...
<ul><li>Exam:  </li></ul><ul><ul><li>Anxious, uncomfortable </li></ul></ul><ul><ul><li>97.9   F, 136/84, 91, 20, 100% sat...
<ul><li>Admission Labs </li></ul><ul><ul><li>WBC 3.4 </li></ul></ul><ul><ul><li>Total CO2 = 18 </li></ul></ul><ul><ul><li>...
<ul><li>Within 24 hours patient becomes febrile to 103 ˚ F, BP 71/50, HR 122 </li></ul><ul><li>Transferred to ICU </li></u...
<ul><li>In a spontaneously breathing patient how do you determine how much fluid to administer? </li></ul><ul><ul><li>Eyeb...
What is the best way to assess  fluid responsiveness  in a spontaneously breathing patient ? Definition : fluid responsive...
Three different  scenarios <ul><li>1  Patients in the ER for acute blood losses or body fluid losses </li></ul><ul><li>2  ...
1- Patients in the ER for acute blood losses or body fluid losses Diagnosis of hypovolemia is almost certain Presence of  ...
2- Patients in the ER for high suspicion of septic shock Most often,   no needs   for searching sophisticated   predictors...
- with hemodynamic instability requiring therapy - without certainty of volume responsiveness <ul><li>with potential risks...
Cumulative Fluid Balance is a Predictor of Mortality in Septic Shock Critical Care Medicine 2006; 34: 344-353
3- Patients in the ICU, already resuscitated for several hours or days How to deal with this therapeutic dilemma? Predicti...
Rate of infusion: 500-1000 mL crystalloids  or  300-500 mL colloids  over  30 mins Goal:   reversal of the marker of perfu...
CHEST 2002, 121:2000-8
Fluid Challenge only successful in 50% of cases <ul><li>If no response to fluid challenge, what happens if you continue ag...
Stroke Volume Ventricular preload Volume expansion will increase stroke volume  only if ventricles are preload-dependent p...
How to predict preload-dependence  and hence volume responsiveness in spontaneously  Breathing patients? <ul><ul><ul><li>1...
Normal Subjects spontaneously breathing  Critical Care Medicine 2004; 32: 691-699 N =40  More to the story than meets the ...
Relationship of initial CVP prior to  3L infusion and RVEDVI and CI after infusion:  NONE  Relationship of   CVP to 3L in...
Relationship of initial PCWP to LVEDVI and CI after 3 L infusion:  NONE Relationship of   PCWP to  LVEDVI and CI after 3 ...
Assessment of preload is not assessment of preload dependence ! . Stroke volume Ventricular preload normal heart  failing ...
Passive Leg Raising Increase in left ventricular preload   ( Rocha 1987, Takagi 1989, De Hert 1999, Kyriades 1994 ) Revers...
Passive Leg Raising Increase in right ventricular preload  (Thomas et al 1965) Increase in left ventricular preload  ( Roc...
Hypothesis The increase in pulse pressure during PLR predicts the   increase in stroke volume  afler volume loading   Puls...
PLR-induced changes in Pulse Pressure  (mmHg) Fluid-induced  changes in  Stroke Volume  (%) n = 39 r  = 0.74 Chest 2002; 1...
- 40 -20 0 20 40 60 80 R NR PLR-induced changes  in pulse pressure * * R NR % change from Baseline 10 PLR-induced changes ...
Conclusion In spontaneously breathing patients Prediction of volume responsiveness is a difficult issue markers of preload...
Upcoming SlideShare
Loading in...5
×

Fluid Responsiveness In Spontaneously Breathing Patient

1,367

Published on

Published in: Health & Medicine, Technology
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
1,367
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
55
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide

Transcript of "Fluid Responsiveness In Spontaneously Breathing Patient"

  1. 1. What is the best way to assess fluid responsiveness in a spontaneously breathing patient ? Edward M. Omron MD, MPH, FCCP Critical Care Alta Bates Summit
  2. 2. Case Example <ul><li>46 yo female presents to IRMC with 24 hours of left flank and left lower quadrant pain, 8/10 severity, fevers, nausea and vomiting </li></ul><ul><ul><li>PMH: GERD </li></ul></ul><ul><ul><li>PSH: BAH+TSO </li></ul></ul><ul><ul><li>Med: prilosec </li></ul></ul><ul><ul><li>NKDA </li></ul></ul>
  3. 3. <ul><li>Exam: </li></ul><ul><ul><li>Anxious, uncomfortable </li></ul></ul><ul><ul><li>97.9  F, 136/84, 91, 20, 100% sat room air </li></ul></ul><ul><ul><li>Pupils equal, sclera non-icteric </li></ul></ul><ul><ul><li>Tachicardia, Nl S1, S2 </li></ul></ul><ul><ul><li>B CTA </li></ul></ul><ul><ul><li>TTP LLQ, +CVAT, no guarding or rebound </li></ul></ul><ul><ul><li>No edema or mottling </li></ul></ul><ul><ul><li>Alert and Oriented, Appropriate MSE </li></ul></ul>
  4. 4. <ul><li>Admission Labs </li></ul><ul><ul><li>WBC 3.4 </li></ul></ul><ul><ul><li>Total CO2 = 18 </li></ul></ul><ul><ul><li>B/C = 16/0.8 </li></ul></ul><ul><li>Pyelonephritis secondary to obstructive nephrolithiasis is diagnosed </li></ul><ul><li>Levafloxacin is started with narcotics, maintainance crystalloid at 125 cc/ Hr and patient is transferred to the medical floor </li></ul>
  5. 5. <ul><li>Within 24 hours patient becomes febrile to 103 ˚ F, BP 71/50, HR 122 </li></ul><ul><li>Transferred to ICU </li></ul><ul><ul><li>Levophed are started </li></ul></ul><ul><ul><li>Fluid resuscitation is initiated </li></ul></ul><ul><li>SHOCK is clinically apparent </li></ul><ul><ul><li>Blood pressure normalizes and and a renal stent is placed </li></ul></ul><ul><ul><li>Patient crashes again and is mechanically ventilated on 2 pressors! </li></ul></ul><ul><ul><li>What Happened? </li></ul></ul>
  6. 6. <ul><li>In a spontaneously breathing patient how do you determine how much fluid to administer? </li></ul><ul><ul><li>Eyeball it? CVP? Swan Ganz and PCWP? </li></ul></ul><ul><ul><li>Wait and see if the BP increases? </li></ul></ul><ul><ul><li>Is to much fluid harmful? </li></ul></ul><ul><ul><li>Why not increase the vasopressors and forget about the fluid? </li></ul></ul><ul><ul><li>Does mechanical ventilation change any of the above parameters? </li></ul></ul>
  7. 7. What is the best way to assess fluid responsiveness in a spontaneously breathing patient ? Definition : fluid responsiveness denotes an increase in cardiac output after infusion of a crystalloid, colloid, or PRBC
  8. 8. Three different scenarios <ul><li>1 Patients in the ER for acute blood losses or body fluid losses </li></ul><ul><li>2 Patients in the ER for high suspicion of septic shock </li></ul><ul><li>3 Patients in the ICU, already resuscitated for several hours or days </li></ul>
  9. 9. 1- Patients in the ER for acute blood losses or body fluid losses Diagnosis of hypovolemia is almost certain Presence of clinical signs of hemodynamic instability No therapeutic dilemma good prediction of volume responsiveness although lacking of sensitivity
  10. 10. 2- Patients in the ER for high suspicion of septic shock Most often, no needs for searching sophisticated predictors of volume responsiveness since volume resuscitation is mandatory in the first hours (Rivers et al NEJM 2001 )
  11. 11. - with hemodynamic instability requiring therapy - without certainty of volume responsiveness <ul><li>with potential risks of pulmonary edema </li></ul><ul><li>and/or excessive cumulative fluid balance </li></ul>3- Patients in the ICU, already resuscitated for several hours or days OUR PATIENT
  12. 12. Cumulative Fluid Balance is a Predictor of Mortality in Septic Shock Critical Care Medicine 2006; 34: 344-353
  13. 13. 3- Patients in the ICU, already resuscitated for several hours or days How to deal with this therapeutic dilemma? Prediction of volume responsiveness ? Fluid challenge ? - with hemodynamic instability requiring therapy - without certainty of volume responsiveness <ul><li>with potential risks of pulmonary edema </li></ul><ul><li>and/or excessive cumulative fluid balance </li></ul>
  14. 14. Rate of infusion: 500-1000 mL crystalloids or 300-500 mL colloids over 30 mins Goal: reversal of the marker of perfusion failure that prompted the fluid challenge (ex: hypotension, tachycardia, oliguria, etc) Safety limits : CVP of 15 mmHg measured every 10 mins Crit Care Med 2006; 34:1333-1337
  15. 15. CHEST 2002, 121:2000-8
  16. 16. Fluid Challenge only successful in 50% of cases <ul><li>If no response to fluid challenge, what happens if you continue aggressive resuscitation? </li></ul><ul><li>Pulmonary and interstitial edema with secondary complications </li></ul><ul><li>Risky and potentially quite harmful </li></ul>
  17. 17. Stroke Volume Ventricular preload Volume expansion will increase stroke volume only if ventricles are preload-dependent preload-dependence preload-independence
  18. 18. How to predict preload-dependence and hence volume responsiveness in spontaneously Breathing patients? <ul><ul><ul><li>1- By estimating cardiac preload </li></ul></ul></ul>- using filling pressures: RAP, PAOP ?
  19. 19. Normal Subjects spontaneously breathing Critical Care Medicine 2004; 32: 691-699 N =40 More to the story than meets the eye!
  20. 20. Relationship of initial CVP prior to 3L infusion and RVEDVI and CI after infusion: NONE Relationship of  CVP to 3L infusion And RVEDVI and CI: NONE Normal Spontaneously Breathing Patients Critical Care Medicine 2004; 32: 691-699
  21. 21. Relationship of initial PCWP to LVEDVI and CI after 3 L infusion: NONE Relationship of  PCWP to LVEDVI and CI after 3 L infusion: NONE Normal Spontaneously Breathing Patients Critical Care Medicine 2004; 32: 691-699
  22. 22. Assessment of preload is not assessment of preload dependence ! . Stroke volume Ventricular preload normal heart failing heart preload-dependence preload-independence
  23. 23. Passive Leg Raising Increase in left ventricular preload ( Rocha 1987, Takagi 1989, De Hert 1999, Kyriades 1994 ) Reversible effects Increase in right ventricular preload (Thomas et al 1965) 45 ° Venous blood shift (Rutlen et al. 1981 , Reich et al. 1989)
  24. 24. Passive Leg Raising Increase in right ventricular preload (Thomas et al 1965) Increase in left ventricular preload ( Rocha 1987, Takagi 1989, De Hert 1999, Kyriades 1994 ) Transient effect (Gaffney 1982) PLR could be used as a test to detect volume responsiveness rather than as a therapy 45 ° Venous blood shift (Rutlen et al. 1981 , Reich et al. 1989)
  25. 25. Hypothesis The increase in pulse pressure during PLR predicts the increase in stroke volume afler volume loading Pulse pressure = SV/Arterial Compliance Chest 2002; 121: 1245-1252
  26. 26. PLR-induced changes in Pulse Pressure (mmHg) Fluid-induced changes in Stroke Volume (%) n = 39 r = 0.74 Chest 2002; 121: 1245-52
  27. 27. - 40 -20 0 20 40 60 80 R NR PLR-induced changes in pulse pressure * * R NR % change from Baseline 10 PLR-induced changes in aortic blood flow
  28. 28. Conclusion In spontaneously breathing patients Prediction of volume responsiveness is a difficult issue markers of preload CVP, PCWP Response to passive leg raising CCI, SVO2, Delta PCO2 unreliable valuable
  1. A particular slide catching your eye?

    Clipping is a handy way to collect important slides you want to go back to later.

×