3. How do we assess fluid overload ?
Intra-abdominal pressure
Weight gain
Extravascular lung water
CVP
(negative) indices of fluid responsiveness
Fluid balance
Clearly associated with prognosis
4. How do we assess fluid overload ? Fluid balance
5. Cohort study
1,177 pts with sepsis
Fluid balance associated
with mortality during sepsis
How do we assess fluid overload ? Fluid balance
7. 173 patients with
sepsis
Multivariate analysis
Positive fluid balance:
OR=1.014 [1.008ā1.021] per ml/kg increase
p <0.001
Fluid balance associated
with mortality during sepsis
How do we assess fluid overload ? Fluid balance
8. p value
EVLWImax (1 unit = 1 mL/kg) 1.07 (1.02 - 1.12) 0.007
Maximum blood lactate (1 unit = 1 mmol/L) 1.29 (1.14 - 1.46) 0.0001
Minimum PaO2/FiO2 (1 unit = 1 mmHg) 0.98 (0.97 - 0.99) 0.006
Mean PEEP (1 unit = 1 cmH2O) 0.78 (0.67 - 0.91) 0.002
SAPS II (1 unit = 1 point) 1.03 (1.01 - 1.05) 0.02
Mean cumulative fluid balance (1 unit = 1 mL) 1.0004 ( 1.0001 - 1.0008) 0.02
Odds Ratio ( CI 95%)
200 pts with ARDS
Fluid balance associated
with mortality during ARDS
How do we assess fluid overload ? Fluid balance
9. How do we assess fluid overload ?
Intra-abdominal pressure
Extravascular lung water
CVP
(negative) indices of fluid responsiveness
Weight gainWeight gainClearly associated with prognosis
Rather easy to measure
Not specific of any organ
Fluid balance
10. 60 pts after cardiac
surgery or in the ED
SDF measurements
How do we assess fluid overload ? Fluid balance
No correlation between FB
and sublingual oedema
11. How do we assess fluid overload ?
Intra-abdominal pressure
Extravascular lung water
CVP
(negative) indices of fluid responsiveness
Weight gainClearly associated with prognosis
Rather easy to measure
Not specific of any organ
Fluid balance
Easier to measure than fluid balance
Neverthelessā¦
Weight gain
ā¦ imperfect
correlation
12. How do we assess fluid overload ?
Fluid balance
Extravascular lung water
CVP
(negative) indices of fluid responsiveness
Weight gain
Clearly associated with prognosis
Intra-abdominal pressure
13. How do we assess fluid overload ? Intra-abdominal pressure
285 ICU patients in Canada
15. How do we assess fluid overload ?
Fluid balance
Extravascular lung water
CVP
(negative) indices of fluid responsiveness
Weight gain
Clearly associated with prognosis
Accessible to specific treatments
Intra-abdominal pressure
17. Cold bolus
ln Ts
t
Td
inj
Blood temperature
(Ts)
inj
Ttm
Thermodilution
curve
Logarithmic
transformation
Extravascular lung water
Indexed for ideal body weight
The volume of
lung oedema
How do we assess fluid overload ? Lung water
4 arguments
3
1
2
4
Is the estimation of
lung water reliable?
?
18. Validated in
humans
Lung water
estimated by
PiCCO
Lung water
measured by
the gold standard
30 pts
EVLW measured by TPTD and by
postmortem gravimetry
How do we assess fluid overload ? Lung water
20. p value
EVLWImax (1 unit = 1 mL/kg) 1.07 (1.02 - 1.12) 0.007
Maximum blood lactate (1 unit = 1 mmol/L) 1.29 (1.14 - 1.46) 0.0001
Minimum PaO2/FiO2 (1 unit = 1 mmHg) 0.98 (0.97 - 0.99) 0.006
Mean PEEP (1 unit = 1 cmH2O) 0.78 (0.67 - 0.91) 0.002
SAPS II (1 unit = 1 point) 1.03 (1.01 - 1.05) 0.02
Mean cumulative fluid balance (1 unit = 1 mL) 1.0004 ( 1.0001 - 1.0008) 0.02
Odds Ratio ( CI 95%)
200 pts with ARDS
EVLW measured by
PiCCO device
Estimation of lung water by transpulmonary
thermodilution makes sense
ā
Independently
predicts
mortality
How do we assess fluid overload ? Lung water
21. 10
15
EVLWi
(mL/kg)
Before After 1h 2h 4h 6h
*
*
Bronchoalv.
lavage
28 BALs
EVLW measured by
PiCCO device
+ 130 [100-160] mL
ā¦ only!
Detects
small changes
How do we assess fluid overload ? Lung water
22. 0
5
10
15
20
25EVLW (mL/kg)
*
Weaning-induced PE
Before SBT After SBT
ns
Before SBT After SBT
No weaning-induced PE
Lung water ā only in
patients with
weaning-induced POe
31 patients with a PA catheter
Weaning test on a T-piece
Independently
predicts
mortality
Validated in
humans
Detects
small changes
Detects
short term
changes
How do we assess fluid overload ? Lung water
23. How do we assess fluid overload ?
Fluid balance
CVP
(negative) indices of fluid responsiveness
Weight gain
Intra-abdominal pressure
Not easy to measure
Quantitative
Extravascular lung water
May guide fluid management
24. PAOP group
Time (hours)
Cumulative fluid balance (L)
7
3
1
5
-1
-3
-5
0 12 24 36 48 60 72
* *
*
*
* p < 0.0001 vs time 0
EVLW group
101 ARDS patients
EVLW-guided management vs.
PAOP-guided management
How do we assess fluid overload ? Lung water
25. 0
5
10
15
20
25
Ventilation days ICU days
PAOP
EVLW
*
*
101 ARDS patients
EVLW-guided management vs.
PAOP-guided management
PAOP
EVLW
Monitoring lung water
ā the duration
of ventilation
ā the length
of ICU stay
How do we assess fluid overload ? Lung water
26. How do we assess fluid overload ?
Intra-abdominal pressure
Fluid balance
Weight gain
CVP
(negative) indices of fluid responsiveness
Not easy to measure
Quantitative
May guide fluid management
Extravascular lung water
27. Lung water high
permeability
low
permeability
very high
permeability
PcapFluid
A given value of PAOP/CVP does
not indicate lung water worsening
PAOP
CVP
How do we assess fluid overload ? Central venous pressure
28. How do we assess fluid overload ?
Intra-abdominal pressure
Fluid balance
Weight gain
(negative) indices of fluid responsiveness
Not easy to measure
Not a direct marker of the
pulmonary risk
Extravascular lung water
CVP
Neverthelessā¦
30. 137 septic shock patients
Association between AKI
and haemodynamic variables
How do we assess fluid overload ? Central venous pressure
31. 584 cardiac surgical patients
Mean renal perfusion
pressure: 55 mmHg
Mean renal perfusion
pressure: 65 mmHg
How do we assess fluid overload ? Central venous pressure
32. How do we assess fluid overload ?
Extravascular lung water
Intra-abdominal pressure
Fluid balance
Weight gain
(negative) indices of fluid responsiveness
Not easy to measure
Not a direct marker of the
pulmonary risk
Safety variable for organ
perfsuion
CVP
(negative) indices of fluid responsiveness
Preload responsiveness is a
normal, physiological condition !
33. Resuscitation
Stabilisation
Avoid excessive fluid
administration !
>
No fluid without fluid
responsiveness !
How do we reduce
fluid overload ?
?
How do we manage fluid therapy ?
1
De-resuscitation
0
Fluid balance
Remove fluid
3
Avoid fluid if the
risk is too high!
Not too much fluid if high FB,
weight gain, lung water, IAP, CVP
2
How much fluid
to remove ?
?
34. Ultrafiltration
H1 H2 H3 Hnā¦PLR
39 medical ICU patients
Resolution phase of shock
PLR to guide fluid removal
How much fluid to remove ?
Does the PLR test before predict
hypotension during fluid removal ?
?
35. AUC = 0.89 (0.75 ā 0.97)
0 20 40 60 80 100
0
20
40
60
80
100
100-Specificity
Sensitivity
PLR-induced
changes in CI
PLR-induced
changes in PP
>13%
>9%
>7% >5%
>4% >-2%
>-3%
>14%
Prediction of intradialytic
hypotension
ā in cardiac index
during PLR ā„ 9%
Se = 77%
Sp = 96%
39 patients at the resolution phase of
shock
Haemodialysis with ultrafiltration
How much fluid to remove ?
36. How do we assess fluid overload ?
Intra-abdominal pressure
Fluid balance
Weight gain
Not easy to measure
Extravascular lung water
CVP
May help guide fluid removal
(negative) indices of fluid responsiveness
37. Prof. Xavier MONNET
Medical Intensive Care Unit
Paris-Sud University Hospitals
xavier.monnet@bct.aphp.fr
Assessment
of fluid overload