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Predicting fluid response in the ICU
 

Predicting fluid response in the ICU

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    Predicting fluid response in the ICU Predicting fluid response in the ICU Presentation Transcript

    • Predicting fluid response in the critically ill Dr. Andrew Ferguson Consultant in Anaesthesia & Intensive Care Medicine Craigavon Area Hospital
    • Approach to shock
      • Fluid challenge central to therapy
      • +/- CVP (and/or PA) monitoring
      • Repeat if CVP/PAWP still low
      • Stop if CVP/PAWP goes high
      • Surrogate markers for CO
        • Lactate
        • SvO 2
    •  
    • So what’s the problem?
      • ? validity of CVP as end-point
      • ? validity of PAWP as end-point
      • Preload-SV relationship unknown
      • Only 50% of patients fluid-responsive
      • Excess fluid problems
        • Interstitial fluid excess
        • Worsened gas exchange
        • Limitation of oxygen diffusion
    • Variability of fluid response rates Michard (Chest 2002; 121: 2000-2008)
    • Preload does not guarantee response
    • To be a fluid responder, both ventricles must be on ascending portion of Frank-Starling curve Response depends on contractility and diastolic function as well as load
    • Common measures used to indicate likelihood of response
      • CVP
      • PAWP
      • RVEDV (thermodilution)
      • LVEDA (echo)
    • R 2 = 0.2 In spontaneous resp. a fall > 1 mmHg in RAP has positive predictive value of 77-84% and negative predictive value of 81-93% for response
    • R 2 = 0.33
    •  
    • ROC curve minimal correlation
    •  
    • They don’t work --- what next??
    •  
    • BP change relates to SV change
    • Cardio-pulmonary interactions Changes in SV, PP, SBP with positive pressure ventilation
    • Increased pleural pressure RV preload falls LV afterload falls Increased transpulmonary pressure RV afterload increases LV preload increased by alveolar vessel squeeze Decreased RVSV Increased LVSV
    • Inspiratory decrease in RVSV Expiratory decrease in LVSV Expiratory decrease in LV preload Pulmonary transit time
    • Stroke volume variation and LVEDP
    •  
    •  
    • Potential tools
      • Stroke volume variation
      • Systolic pressure variation
      • Pulse pressure variation
      • Peak aortic blood flow velocity variation
    •  
    • Systolic Pressure Variation  down is the important one for fluid response
    • Systolic pressure variation
    •  SP as indicator of fluid response
    • Pulse pressure variation
    •  PP as indicator of fluid response
    • Measures of response to volume
    • Predictive values Study No. of patients Measure Threshold Positive pred. val. Negative pred. val. Magder 33  RAP (SPONT) 1 mmHg 84 93 Tavernier 35  Down 5 mmHg 95 93 Magder & Lagonidis 29  RAP (SPONT) 1 mmHg 77 81 Michard 40  PP 13% 94 96 Feissel 19  VPeak 12% 91 100
    • Problems with  PP and  SV
      • Equipment not universal
      • Need sinus rhythm
      • False positive in severe abdominal distension
    • Normal values
      •  PP 13%
      • SPV  down 5%
      •  Vpeak (aortic blood flow velocity) 12%
      •  SV 10%
    • Conclusions
      • Conventional measures often not valid
      • New and accurate measures available
      • Consider passive leg raising!
      • Know cardio-pulmonary interactions