Illustrative case on the 4 questions of fluid therapy: 1) when to start fluids 2) when to stop fluids 3) when to start fluid removal 4) when to stop fluid removal

1. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 1
Should I bother about Ebb and
Flow phase of shock?
Series on Fluid Therapy
Episode 1: The 4 questions
Manu Malbrain

2. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 2
Therapeutic Dilemma - Conflict

3. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 3
Today’s Agenda
• The risks of fluid overload
• Interactive Case Discussion
• Meta-analysis
• 3-hit model
• Integrated approach
• Wrap it up

4. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 4
Fluid Overload
The Risk of
Fluids

5. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 5
What I really need to know is…
When do I start giving fluids?
When do I stop giving fluids?
When do I start emptying?
When do I stop emptying?
SEE
MORE
THAN
OTHERS
benefit of fluid administration?
risk of fluid administration?
benefit of fluid removal?
risk of fluid removal?

6. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 6
• Any measurement in the ICU stands or
falls with its accuracy and
reproducibility…
• No measurement has ever improved
survival, only a good a protocol can…
Introduction

7. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 7
Example of a Poor Protocol…
Trof RJ et al. CCM 2012; 40

8. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 8
Example of a Poor Protocol…
Trof RJ et al. CCM 2012; 40
EVLWI < 10
Fluid Challenge
GEDVI < 850https://vimeo.com/167771411

9. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 9
Example of a Poor Protocol…
Trof RJ et al. CCM 2012; 40
EVLWI < 10
Fluid Challenge
GEDVI < 850
We must NOT give a fluid challenge
https://vimeo.com/167771411

10. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 10

11. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 11
788694
SURGICAL SEPTIC
GEDVI < 850 ml/m2 is too high

12. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 12
Ebb Phase of SHOCK
“Ashen faces, a
thready pulse and
cold clammy
extremities…”
The Ebb Phase - Cuthbertson,
Quart. J. Med.25:233,1932
Flow Phase of SHOCK
Fluid Guidance:
MAP, SVV, PPV,
GEF/GEDVI,
PLR, TEO

13. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 13
Ebb Phase of SHOCK
“Ashen faces, a
thready pulse and
cold clammy
extremities…”
The Ebb Phase - Cuthbertson,
Quart. J. Med.25:233,1932
Flow Phase of SHOCK
“The patient warms
up, cardiac output
increases and the
surgical team
relaxes…”
The Flow Phase - Cuthbertson.
Lancet 1:233, 1942
Fluid Guidance:
MAP, SVV, PPV,
GEF/GEDVI,
PLR, TEO
Fluid Guidance:
Positive (Σ) Fluid
balance, IAP,
EVLWI

14. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 14
Ebb Phase of SHOCK
“Ashen faces, a
thready pulse and
cold clammy
extremities…”
The Ebb Phase - Cuthbertson,
Quart. J. Med.25:233,1932
Flow Phase of SHOCK
“The patient warms
up, cardiac output
increases and the
surgical team
relaxes…”
The Flow Phase - Cuthbertson.
Lancet 1:233, 1942
Fluid Guidance:
MAP, SVV, PPV,
GEF/GEDVI,
PLR, TEO
Fluid Guidance:
Positive (Σ) Fluid
balance, IAP,
EVLWI
EVLWI is NOT a trigger for Fluids

15. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 15
Septic Shock Patients (n=36)
Alsous et al. Chest 2000; 117: 1749-54

16. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 16
No excess extra-
pulmonary organ failure
Better lung
function:
-LIS↓
-FiO2/pO2 ↑
-Pplat ↓
-PEEP ↓
RCCT, N=1000
Cum FB: -136±494 ml
Cum FB: 6992±502 ml

17. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 17
Case Study
From Ebb to
Flow phase

18. LI, Male, 26 years old

19. LI, Male, 26 years old
• O2 debt during birth
• CVA, left hemiparesis
• Epilepsy
− Topamax, lamictal, tegretol
• Cognitive deficit
• Special daycare
• Since age of 17 known with
ideopathic CMP (LVEF 52%)
− Coversyl

20. Reason for admission
• General seizures
− Different from previous
• Syncope
• BP not palpable
• On ED: VT?
− DC biphasic 200J
• Transfer to ICU

21. Evolution Overnight

22. Evolution Overnight
• Hemodynamically stable
• No seizures
• Gradual increase in supplemental
O2-needs
– From 2L via nasal cannula
– To 15L with NRM
• Failure of NIV
• ETT and MV

23. After ETT

24. After ETT
• Hemodynamically Unstable
– CVP 16 mmHg
– MAP 51 mmHg
• On conventional MV
– Evita XL FiO2 100%
– 24 x 400 mL
– PEEP 10
– P/F ratio 74

25. Transthoracic Cardiac US
LVEF 30% MR 2 to 3/4

26. TT Cardiac US

27. TT Cardiac US
• Dilated CMP (Left atrium 65mm)
• CO: 6.2 L/min (CI 3.5)
• LVEF: 30-35%, FAC: 28.5%
• LVEDA: 28.7 cm2 – LVEDAi: 16.2 cm2
• E/E’: 15 - LVEDP: 25 mmHg
• MR 2 to ¾ (central + 2 eccentric jets)
• VCI: 21 mm

28. Question 1: What is your
treatment of choice?
1. Norepinephrine
2. Dobutamine
3. Fluids bolus
4. Diuretics
5. Other
MAP 59
CVP 16
CI 3.5
LVEDP 25
LVEF 30
LVEDA 28.7
P/F 74
IPAP 30
PEEP 10
Lactate
2.8

29. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 29
Further course…
• Norepinephrine was started
– Swiftly increased to 0.4 y
• Dobutamine started at 3y
• FiO2 was increased to 100%
• PEEP set according to PV loop
– BPsys drop to 40 mmHg during
recruitment
• Saturation poor at 88%
• Switch to HFPV – VDR4

30. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 30
PiCCO catheter - TPTD
• CI: 3.5
• PPV: 19%
• GEDVi: 757 ml/m2 – GEF: 13%
• EVLWi: 38 ml/kg PBW – PVPI: 7.4
• PLR = POSITIVE (15% increase in CI)
Normal Values:
PPV: <10 %
GEDVI: 600 – 850
GEF: 25-35%
EVLWI: 3 – 7
PVPI: 1 – 3

31. MAP 65
CVP 15
PPV 19
CI 3.5
GEF 13
GEDVi 757
EVLWi 38
P/F 57
IPAP 34
PEEP 15
1. Norepinephrine
2. Dobutamine
3. Fluids bolus
4. Diuretics
5. Other
HFPV
30/10
Question 2: What is your
treatment of choice?
Normal Values:
PPV: <10 %
GEDVI: 600 – 850
GEF: 25-35%
EVLWI: 3 – 7
PVPI: 1 – 3

32. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 32
Decision Tree..

33. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 33
General Question
• How do you explain the relative discrepancy
between the volumetric (low normal – GEDVi
757) and barometric (high normal – CVP 14)
preload indicators in this patient?
• Remember that the SSC guidelines state that
CVP must be resuscitated towards 8-12 mmHg

34. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 34
• CVP: 8-12 mmHg
• Chasing a CVP may
lead to:
→ OVER resuscitation
→ UNDER resuscitation
Surviving Sepsis Guidelines
IAP
11

35. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 35
0
5
10
15
20
Malbrain Hering Schachtrupp
CVP (BL)
CVP (60min)
• Don’t trust traditional BAROmetric
filling pressures (CVP or PAOP)
• Use Volumetric preload indicators
(GEDVI: PiCCO/EV1000 or RVEDVI: PAC)
Barometric vs Volumetric preload?
Malbrain et al. Current Opinion Crit Care 2004; 10(2): 132-145
0
200
400
600
800
1000
1200
Malbrain Hering Schachtrupp Hachenberg
GEDVI(BL)
GEDVI(IAH)
MV-IPPV
(auto)PEEP
Post CABG
Obesity
IAH-ACS

36. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 36
Crit Care Med 2008; 36:296-327
[published correction in Crit Care Med 2008; 36:1394-1396]

37. TT Cardiac US
• Small volume
resuscitation
(SVR):
Hyperhaes
4ml/kg/15min
• 2x 500ml
VolulyteIVCCI= 50%

38. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 38
Next morning
Dobu 9
Norepi 0.4

39. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 39
Evolution overnight
• CI h
• GEDVI h
• EVLWI i
• MAP h
CVP decreased from 14 to 6 mmHg with filling

40. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 40
Respiratory Support
overnight
HFPV NO
(stand-by)
• pO2 h
• P/F h
• FiO2 i
• IPAP
h

41. P/F 157
IPAP 32
PEEP 11
EVLWI 13
PVPI 2
Next morning on Day 2

42. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 42
Therapeutic Dilemma…
We gave fluids because:
• PPV was high and PLR was positive
• The GEDVI was relatively low (in relation
to GEF) despite the increased CVP,
LVEDAI and high EVLWI…
• IVCCI was almost 50%

43. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 43
So,…
What I really need to know:
• What is the Frank Starling curve of
my patient?
• Where is my patient on the curve?

44. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 44
• When to use?
Solution: GEF-corrected GEDVi
Malbrain M. et al. AAS 2010; 54(5): 622-631

45. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 45
LVED area on TTE
LVEDA
34cm2 28cm2
?
After 30% blood loss of CBV

46. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 46
EF corrected volumes?
GEF 0.15
GEF 0.25
GEF 0.35
Cardiac INDEX
GEDVI
Malbrain, Cheatham. Yearbook Intensive Care 2004

47. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 47
Pressures as preload?
ΔCVP ΔPCWP
ΔCI
X

48. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 48
Volumes as preload?
ΔRVEDV ΔGEDV
ΔCI
X

49. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 49
Corrected volumes vs preload?
ΔcRVEDV ΔcGEDV
ΔCI


50. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 50
GEDVi – GEF normogram

51. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 51
Question 3: The premature hump on the
transpulmonary thermodilution curve is…
1. Crosstalk phenomenon
2. Right-to-left shunt
3. Bolus mixing
4. Wrong/false measurement
5. I don't know

52. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 52
Question 3: The premature hump on the
transpulmonary thermodilution curve is…
1. Crosstalk phenomenon
2. Right-to-left shunt
3. Bolus mixing
4. Wrong/false measurement
5. I don't know

53. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 53
Premature hump = Hypovolemia
Septic shock 100% FiO2 – PEEP 12 – extremely underfilled
Pulmonary Hypertension
Before filling (at 8:40)
after filling with 500mL
Voluven (at 9:02)
GEDVi : 288 GEDVi : 537

54. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 54
Right-to-Left shunt on TPTD
RA LARV LVPBV
EVLW

55. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 55
37,1
37,2
37,3
37,4
37,1
37,2
37,3
37,4
ZEEP
37,1
37,2
37,3
37,4
PEEP
PEEP
Michard F et al. CCM 2004 Jan;32(1):308-9.
Our patient
became
extremely
hypotensive
during
recruitment

56. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 56
•West Lung Zones
ZONE 1: Palv > Part > Pven
ZONE 2: Part > Palv > Pven
ZONE 3: Part > Pven > Palv
❶
❷
Hypovolemia
High PEEP
❶
Right-to-Left Shunt

57. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 57
Evolution late afternoon D2
• Urine output only 350 over 12 hours…
• FiO2 increased from 45% to 65% (P/F 200)
• Lactate increased from 1.6 to 2.6
• Cumulative FB +4L
MAP 79
CVP 8
PPV 6
CI 5.4
GEF 23
GEDVi 1080
EVLWi 18
P/F 205
IPAP 34
PEEP 11

58. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 58
Urine Outpt Drops…

59. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 59
Question 4: What is your
treatment of choice?
1. Norepinephrine
2. Dobutamine
3. Fluids bolus
4. Diuretics
5. Other
MAP 79
CVP 8
PPV 6
CI 5.4
GEF 23
GEDVi 1080
EVLWi 18
P/F 205
IPAP 34
PEEP 11
Dobu 5
Norepi 0.2
Normal Values:
PPV: <10 %
GEDVI: 600 – 850
GEF: 25-35%
EVLWI: 3 – 7
PVPI: 1 – 3

60. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 60
Question 4: What is your
treatment of choice?
1. Norepinephrine
2. Dobutamine
3. Fluids bolus
4. Diuretics
5. Other
MAP 79
CVP 8
PPV 6
CI 5.4
GEF 23
GEDVi 1080
EVLWi 18
P/F 205
IPAP 34
PEEP 11
Dobu 5
Norepi 0.2
Normal Values:
PPV: <10 %
GEDVI: 600 – 850
GEF: 25-35%
EVLWI: 3 – 7
PVPI: 1 – 3
PEEP
18
Alb
20%
Lasix
3x100ml
Hyper
Haes
2x125ml
60mg/hr
For 2hrs
10mg/hr

61. Chest X-ray D3
P/F 266
IPAP 34
PEEP 18
EVLWI 15
PVPI 1.9
Dobu 3
Norepi 0.11

62. Chest X-ray D3
P/F 266
IPAP 34
PEEP 18
EVLWI 15
PVPI 1.9
Dobu 3
Norepi 0.11
Alb
20%
Lasix
2x100ml
40mg
bolus

63. P/F 295
IPAP 30
PEEP 6
EVLWI 12
PVPI 1.7
Dobu 1
Norepi STOP
HFPV
Chest X-ray D4

64. P/F 295
IPAP 30
PEEP 6
EVLWI 12
PVPI 1.7
Dobu 1
Norepi STOP
HFPV
When the going gets tough,
The tough get going
BUT…
Chest X-ray D4
Evita

65. Chest X-ray evolution
P/F 98
IPAP 30
PEEP 6
EVLWI 16
PVPI 2.1
P/F 308
IPAP 34
PEEP 19
EVLWI 12
PVPI 1.7
D5 D6
HFPV
PEEP
19
Lasix 10mg/hr
continuously

66. Chest X-ray evolution
D7 D8
P/F 355
IPAP 32
PEEP 10
EVLWI 10
PVPI 1.5
P/F 358
IPAP 26
PEEP 6
EVLWI 8
PVPI 1.3

67. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 67
General Question
• How do you explain the drop in EVLWI from 38
to 13 ml/kg PBW after the initial resuscitation
phase, while GEDVI increased from 757 to 921
ml/m2?

68. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 68
QUESTION 5: What is correct regarding a positive
cumulative fluid balance in septic shock?
1. Peripheral edema may look frightening for the
relatives but it is just of cosmetic concern
2. Fluid balance must initially always be positive for a
successful resuscitation of shock
3. Patients don’t die form anasarc edema they only die
from organ failure
4. A cumulative fluid balance is always a biomarker of
severity of illness
5. A positive fluid balance is harmful and an
independent predictor for morbidity and mortality.
6. None of the above

69. D7D5 D6
D4D2D1
D0
D3
D1
122638 18
81216 10
D8
NIV
Evita XL
HFPV
D5
38
ICU day
EVLWI
furosemide

70. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 70
Daily and Cumulative Fluid
Balance
-6000
-5000
-4000
-3000
-2000
-1000
0
1000
2000
3000
4000
5000
1 2 3 4 5 6 7 8
UO
FB
Cum FB
Lasix
Furosemide

71. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 71
EVLWI-GEDVI evolution
0
5
10
15
20
25
30
35
40
0
200
400
600
800
1000
1200
1400
1 2 3 4 5 6 7 8 9 101112131415161718192021
GEDVi
EVLWi
CVD
Filling
Diuretics

72. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 72
Fluid resuscitation:
when less becomes more…
The 4 fluids of life My Favourite Movie

73. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 73
Fluid resuscitation:
when less becomes more…
The 4 fluids of life
Avoid futile overresuscitation
The GOOD
The BAD
The UGLY
The TERMINATOR
My Favourite Movie

74. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 74
One more thing….

75. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 75
Fluid Overlad
An Integrated
Approach

76. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 76
PEEP ALBUMIN
N=114 MV patients

77. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 77
IAP change P/F change
EVLWi change Cumulative FB

78. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 78
Kaplan Meier curves
p = 0.037 p = 0.018
PAL
SURVIVAL MECHANICAL VENTILATION

79. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 79
Impact of fluid kinetics
0
10
20
30
40
50
60
70
80
EALC EALA ECLC ECLA
n
mortality
Data on 180 patients
EA defined as
fluid intake >
50ml/kg/1st
12-24 hours
LC defined as
2 negative
daily FB within
1st week

80. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 80
Fluid Overload
Wrap It Up

81. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 81
What I really need to know
When do I start giving fluids?
When do I stop giving fluids?
When do I start emptying?
When do I stop emptying?
SEE
MORE
THAN
OTHERS
benefit of fluid administration?
risk of fluid administration?
benefit of fluid removal?
risk of fluid removal?
GEF/GEDVi↓ PPV↑ PLR+
GEF/GEDVi↑ PPV↓ PLR-
EVLW↑/PVPI↑ IAP↑/APP↓ FB+
ICG-PDR↓ APP↓ ScvO2↓ FB--

82. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 82
Moving Targets…
1st HIT
MAP, SVV,
PPV, ScvO2
2nd HIT
P/F, EVLWi,
IAP
3rd HIT
PVPI, ICG-
PDR
Moving Goals…
EAGD LGFR
LCFM
Give the right fluid right
Use the right monitor right

83. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 83
Although…
Sometimes it’s better
to have a lucky doctor
than a smart doctor !
But…

84. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 84
It’s always better
trying to do something
even if you don’t
succeed than doing
nothing and succeed
However…

85. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 85
Therefore…
This will keep us

86. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 86
Therefore…
RELAX
I only have 1 statement left…

87. Series on Fluid Therapy - 2017 Should I bother about Ebb and Flow phase of shock 87
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