Fluid responsiveness in pratice
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This document discusses fluid responsiveness and methods for assessing preload responsiveness. It summarizes that dynamic indices of preload responsiveness like pulse pressure variation (PPV) and stroke volume variation (SVV) can help identify patients who will respond to fluid by increasing their stroke volume. However, these indices have limitations and may not be reliable in patients with spontaneous breathing, arrhythmias, low tidal volumes, low lung compliance, high frequency ventilation, open chest conditions, or severe right ventricular failure. In these situations where the indices cannot be interpreted reliably, other dynamic tests are needed to assess fluid responsiveness.
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Fluid responsiveness in pratice
- 1. Prof. Jean-Louis TEBOULProf. Jean-Louis TEBOUL Medical ICU Bicetre hospital University Paris South France Fluid responsiveness in practice
- 2. • presence of hemodynamic instability/peripheral hypoperfusion (mottled skin, hypotension, oliguria, hyperlactatemia…) • and presence of preload responsiveness • and limited risks of fluid overload Decision of starting fluid administration
- 3. CHEST 2002, 121:2000-8CHEST 2002, 121:2000-8
- 4. Predictors of fluid responsiveness/unresponsiveness Can help to choose the best fluid strategy by: 1) identifiying the pts eligible for fluid infusion 2) avoiding to fluid overload patients, who would be fluid unresponsive
- 5. preload responsiveness preload unresponsiveness Stroke Volume Ventricular preload Fluid infusion will increase LV stroke volumeFluid infusion will increase LV stroke volume only ifonly if both ventriclesboth ventricles areare preload responsivepreload responsive Fluid responsiveness equivalent to biventricular preload responsiveness
- 6. . normal heartnormal heart failing heartfailing heart preload responsiveness preload unresponsiveness Stroke volume Ventricular preload « static » measures of preload cannot reliably predict fluid responsiveness
- 7. 1802 pts Summary AUC 0.56 Crit Care Med 2013; 41:1774-1781 Crit Care Med 2013; 41: 1474-81
- 8. normal heartnormal heart failing heartfailing heart preload responsiveness preload unresponsiveness Stroke volume Ventricular preload . Dynamic indices of preload responsiveness
- 9. induces only in pts with biventricular preload responsiveness occurs only in pts with biventricular preload responsiveness correlates with the magnitude of the induced by cyclic changes in SV fluid responsivenessMV
- 10. A B Ventricular preload Stroke volume preload responsiveness preload unresponsiveness
- 11. PPmax PPmin PPPPmaxmax - PP- PPminmin (PP(PPmaxmax ++ PPPPminmin) /2) /2 PPV =PPV = Am J Respir Crit Care Med 2000; 162:134-8Am J Respir Crit Care Med 2000; 162:134-8 Arterial catheterArterial catheter
- 12. 0 5 10 15 20 25 30 35 40 45 ∆PP (%) before fluid Infusion responders n = 16 non-responders n = 24 13 %
- 14. SVV PVV PAOP CVP PPV SVV CVP CI PCWP 1- Specificity Sensitivity PPV 12.8 % Normal TV 0 20 40 60 80 100 0 20 40 60 80 100 Specificity(%) 100 - Specificity (%) PPV SVC collapsibility (AUC: 0.94) (AUC: 0.99) 12%
- 15. PPV Chest 2005;128;848-854 Chest 2004, 126:1563-1568 Crit Care Med 2005;33:2534-9 M. Cannesson, J. Slieker, O. Desebbe, F. Fahdi,O. Bastien, JJ. Lehot X. Monnet1,2* , L. Guerin1,2 , M. Jozwiak1,2 , A. Bataille1,2 , F. Julien1,2 , C. Richard1,2 , J-L. Teboul1,2 Anesth Analg 2011; 113:523-8
- 17. rr 22 = 0. 85= 0. 85 Fluid-induced changes in cardiac index (%) ∆PP (%) before fluid infusion 00 1010 2020 3030 4040 5050 00 1010 2020 3030 4040 5050 Am J Respir Crit Care Med 2000; 162:134-8Am J Respir Crit Care Med 2000; 162:134-8 The larger the ∆PP before fluid infusion, the larger the increase in CO after fluid infusion The smaller the PPV before fluid infusion, the smaller the increase in CO after fluid infusion
- 18. Calculated automatically and displayed in real-time by usual hemodynamic monitors Pulse Pressure VariationPulse Pressure Variation All these monitors are suitable to display PPV in real-time
- 19. Arterial Pressure Arterial pressure waveform analysis Stroke volume Stroke Volume Variation Calculated automatically and displayed in real-time by new hemodynamic monitors
- 20. Chest 2005;128;848-854 X. Monnet1,2* , L. Guerin1,2 , M. Jozwiak1,2 , A. Bataille1,2 , F. Julien1,2 , C. Richard1,2 , J-L. Teboul1,2 Assessing fluid responsiveness by stroke volume variation in mechanically ventilated patients with severe sepsis G. Marx, T. Cope, L. McCrossan, S. Swaraj, C. Cowan, SM. Mostafa, R. Wenstone, M. Leuwer European Journal of Anaesthesiology 2004; 21:132-138
- 21. SVVPPV 685 pts
- 23. PPVi PPVni Non-invasive finger blood pressure monitoring device
- 24. R NR ∆ABF % = ABF max - ABF min (ABF max + ABF min)/2 18% Esophageal DopplerEsophageal Doppler
- 25. Vpeakmin ∆Vpeak Vpeakmax ∆Vpeak (%) before fluid 4 8 12 16 20 24 28 32 36 responders non responders Vpeak max – Vpeak min (Vpeak max + Vpeak min) / 2 ∆Vpeak = Doppler-echoDoppler-echo
- 26. Cut-off values: PPV: 15 % ∆Ppleth: 15 % Arterial wave Plethysmographic wave
- 29. PPV SVV PVI GEDV
- 30. NE (-) NE (+)
- 31. ∆∆ dIVC %dIVC % == dIVCdIVCmaxmax - dIVC- dIVCminmin (dIVC(dIVCmaxmax + dIVCm+ dIVCminin)/2)/2 Subcostal view dIVCmaxdIVCmax dIVCmindIVCmin
- 32. 66 pts with MV Systematic fluid loading with 10 mL/kg HES
- 33. 0 20 40 60 80 100 0 20 40 60 80 100 Specificity(%) 100 - Specificity (%) PPV SVC collapsibility (AUC: 0.94) (AUC: 0.99) 12% 36 % PPV and SVC collapsibility perform equally for predicting fluid responsiveness Transesophageal approach is required
- 34. Volume responsiveness is a physiological phenomenon related to a normal preload reserve. Therefore,Therefore, detecting volume responsivenessdetecting volume responsiveness must notmust not lead to infuse fluidlead to infuse fluid systematically.systematically. The decision of fluid infusion must be based on the presence of criteria of peripheral hypoperfusion Limitations of respiratory variability indicesLimitations of respiratory variability indices
- 35. • impossible to interpret in pts with spontaneous breathing activity Limitations of respiratory variability indicesLimitations of respiratory variability indices
- 36. 1 - specificity PPV sensitivity patients with spontaneous breathing PPV (threshold: 12 %) fully adapted to ventilator
- 37. • impossible to interpret in pts with spontaneous breathing activity • impossible to interpret in patients with arrhythmias Limitations of respiratory variability indicesLimitations of respiratory variability indices 50 70 90 110 mmHg PPmax PPmin
- 38. • impossible to interpret in pts with spontaneous breathing activity • difficult to interpret if tidal volume is too low • impossible to interpret in patients with arrhythmias Limitations of respiratory variability indicesLimitations of respiratory variability indices
- 39. PPV 8 % 1- Specificity Sensitivity PPV 12.8 % Normal TV Low TV
- 40. • impossible to interpret in pts with spontaneous breathing activity • difficult to interpret if tidal volume is too low • impossible to interpret in patients with arrhythmias Limitations of respiratory variability indicesLimitations of respiratory variability indices • difficult to interpret if lung compliance is too low
- 41. Crs < 30 mL/cmH2O 0 20 40 60 80 100 100 80 60 40 20 0 100-Specificity (%) Sensitivity Crs ≥ 40 mL/cmH2O 30 ≤ Crs < 40 mL/cmH2O Ability of PPV to predict fluid responsiveness in function of lung compliance
- 42. • impossible to interpret in pts with spontaneous breathing activity • difficult to interpret if tidal volume is too low • impossible to interpret in patients with arrhythmias Limitations of respiratory variability indicesLimitations of respiratory variability indices • difficult to interpret if lung compliance is too low • difficult to interpret in case of high frequency ventilation PPV can be not reliable when the heart rate/respiratory rate is > 3.6 De Backer et al Anesthesiology 2009
- 43. • impossible to interpret in pts with spontaneous breathing activity • difficult to interpret if tidal volume is too low • impossible to interpret in patients with arrhythmias Limitations of respiratory variability indicesLimitations of respiratory variability indices • difficult to interpret if lung compliance is too low • difficult to interpret in case of high frequency ventilation • difficult to interpret under open-chest conditions • difficult to interpret in case of severe RV failure Mahjoub et al Crit Care Med 2009, Wyler von Ballmoos et al Crit Care 2010
- 44. • impossible to interpret in pts with spontaneous breathing activity • difficult to interpret if tidal volume is too low • impossible to interpret in patients with arrhythmias Limitations of respiratory variability indicesLimitations of respiratory variability indices • difficult to interpret if lung compliance is too low • difficult to interpret in case of high frequency ventilation • difficult to interpret under open-chest conditions • difficult to interpret in case of severe RV failure In all these situations and in case of any doubt about interpretation other reliable dynamic tests are required … and are now available
Editor's Notes
- In this meataanalysis, Marik and colleagues reviewed the studies that addressed the issue of predicting fluid responsiveness with CVP. Overall, a low value of the area under the curve was found confirming that CVP cannot predict fluid responsiveness. Importantly, they concluded that CVP should not be used to make clinical decisions regarding fluid management.