6. #ifad2019 how to measure fluid resppnsiveness (alonso inigo)

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This document discusses fluid responsiveness monitoring during surgery. It begins by outlining parameters used to evaluate fluid responsiveness, such as pulse pressure variation (PPV) and stroke volume variation (SVV). It notes that PPV directly measures pressure changes while SVV estimates volume changes. The document then examines other hemodynamic parameters like arterial elastance and dynamic elastance. It argues that a multiparameter model integrating pressures, perfusion, afterload, flow and dynamic vascular tone can better guide fluid management than any single parameter. The overall message is that fluid assessment during surgery requires considering multiple interconnected physiologic factors.

Health & Medicine

FLUID RESPONSIVENESS
MONITORING
JOSÉ MIGUEL
ALONSO ÍÑIGO MD,
PHD
DEPARTAMENT OF
ANESTHESIA AND
CRITICAL CARE
HOSPITAL
UNIVERSITARIO Y
POLITÉCNICO LA FE
VALENCIA
(SPAIN)
9th IFAD
2019
Valencia

Normovolemia HypervolemiaHypovolemia
Co-morbidities
Sepsis
Surgery - Anesthesia
 How clinicians can
control the amount of
fluids during surgery?
 Is there a place for
advance
hemodynamic
monitoring as a
routine in major
surgery?
Fluid Administration and Surgical Outcomes
9th IFAD
2019 Valencia

Marik et al. Annals of Intensive Care 2011, 1:1
Frank-Starling
relationship
Maneuvers to evaluate
fluid responsiveness
PLR
Fluid Bolus
Parameters to evaluate
fluid responsiveness
PPV
SVV
Preload Dynamic Parameters
9th IFAD
2019 Valencia

Marik et al. Annals of Intensive Care 2011, 1:1
Preload Dynamic Parameters
9th IFAD
2019 Valencia

Marik et al. Annals of Intensive Care 2011, 1:1
PPV Cut-off >13%
SVV Cut-off >10%
Preload Dynamic Parameters
9th IFAD
2019 Valencia

Preload Dynamic Parameters
9th IFAD
2019 Valencia

Preload Dynamic Parameters
9th IFAD
2019 Valencia
PPV threshold 10.5% (3.2%) ranging from 8% to 15%
SVV threshold 11.3% (3.1%) ranging from 7.15% to 15.5%%
THE GREY
ZONE

SVV and PPV are the same?
PPV represents dynamic
changes in pressure with
respiratory cycle
SVV represents dynamic
changes in volume with
respiratory cycle
Not always represent the same
Different optimal thresholds for fluid assessment
PPV is measured SVV is estimated
Preload Dynamic Parameters
9th IFAD
2019 Valencia

SVV and PPV are the same?
Savvas Eleftheriadis et al.Critical Care 2009, 13:R179 (doi:10.1186/cc8161)
FlowTrac/Vigileo® SVV is in practice a PPV?
Preload Dynamic Parameters
9th IFAD
2019 Valencia

PPV is measured SVV is estimated
PCMs: main differences
Adapted from Romano SM et al. – Crit Care Med 2002
A P
C
Calibration (external or internal) No calibration
Calibration (external or internal) No calibration (MostCare)
PWA at <200 Hz PWA at 1000 Hz
SD around
Mean
Arterial
Pressure
Preload Dynamic Parameters
9th IFAD
2019 Valencia

Beyond PPV or SVV Afterload Parameters
Arterial Elastance (Ea)
The ratio of changes in
pressure to changes in Volume
Elastic Arterial Tone
Dynamic Elastance
(PPV/SVV) (Eadyn)
The ratio of pulse pressure
variation (PPV) to stroke
volume variation (SVV) during
a single positive-pressure
breath
Dynamic Arterial Tone
Monge García et al. Critical Care 2011, 15:R15
Other Hemodynamic Parameters
9th IFAD
2019 Valencia

How can we integrate these new parameters into the hole picture?
Dynamic Elastance (PPV/SVV) (Eadyn)
Mathematic
al coupling?
Dynamic
Impedance
evaluation?
Other Hemodynamic Parameters
9th IFAD
2019 Valencia

Dynamic Elastance
(PPV/SVV) (Eadyn)
At baseline, an Eadyn value ≥0.73 predicted an
increase ≥10% in MAP after VE with a
sensitivity of 90.9% (95% CI: 75.7% to 98.1%)
and a specificity of 91.5% (95% CI: 79.6% to
97.6%)
Other Hemodynamic Parameters
9th IFAD
2019 Valencia

Eadyn can be an useful parameter to evaluate pressure reponse
after a fluid challenge in preload dependant patients
Should be validated in surgical patients
Esopahgeal Doppler limitations in dynamic cardiovascular
impedance estimation
Eadyn can be helpful for evaluating vascular tone in patients with
high PPV
…So, we are working on it
Other Hemodynamic Parameters
Dynamic Elastance
(PPV/SVV) (Eadyn)
9th IFAD
2019 Valencia

Hemodynamic assesment during surgery
Pressure-Perfusion-Afterload
Flow-Delivery
Preload asssesment
Dynamic Vascular Tone
By integrating all of these parameters jointly with
clinical and analytical evaluation can provide clinicians
valuable information
More than PPV or SVV
More than Fluid Responsiveness
9th IFAD
2019 Valencia

More than Fluid Responsiveness
9th IFAD
2019 Valencia

• Fluid assessment during surgery is more than a simple
PPV or SVV evaluation
• SVV and PPV are not the same parameter
• The CO estimation algorithm is important for dynamic
evaluation
• Eadyn and Ea are promising parameters to include into
clinical practice
• Multiparameter model could be the future of fluid
responsiveness monitoring
Take home messages
9th IFAD
2019 Valencia

Thank you for your attention
jmalonso@me.com
9th IFAD
2019
Valencia

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This document summarizes a lecture about hemodynamic optimization in patients with intra-abdominal hypertension. The lecturer discusses how IAH affects preload evaluation and fluid responsiveness. IAH can mimic signs of fluid overload and changes cardiovascular function by increasing intrathoracic pressure and compressing organs. The lecturer recommends using transmural filling pressures that account for IAP when evaluating preload in IAH patients. Dynamic indices like SVV and PPV may provide false negatives. Ultimately, the most effective strategy for hemodynamic optimization in IAH is reducing intra-abdominal pressure through drainage and decompression procedures.

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This document discusses static and dynamic indices used in hemodynamic monitoring. It provides a brief history of evidence-based medicine and emphasizes the importance of asking well-formulated clinical questions. Both static (e.g. CVP, PAOP) and dynamic (e.g. SVV, PPV, PLR) indices are covered. While static indices are poorly predictive of fluid responsiveness, dynamic indices can reliably assess volume responsiveness, even in spontaneously breathing patients or those with arrhythmias. The passive leg raise test is highlighted as a non-invasive alternative to fluid challenges for predicting fluid responsiveness. Overall, the document stresses the need for dynamic assessment to optimize fluid management and avoid potential harms of under- or

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Frederic Michard - Perioperative Fluid Management - IFAD 2012

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Dr. Frederic Michard discusses perioperative fluid management and optimization. He advocates using pulse pressure variation (PPV) or stroke volume variation (SVV) to guide fluid administration when possible. When those values cannot be used, stroke volume response to fluid challenges should be monitored. Compliance to fluid optimization protocols is important. Graphical displays and checklists may improve compliance, while closed-loop systems could achieve near 100% compliance, but their safety requires further clinical studies.

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Intraoperative oesophageal Doppler monitoring (ODM) guided fluid management was compared to standard central venous pressure (CVP) guided fluids in a randomized controlled trial of 128 colorectal surgery patients. ODM guided fluid optimization resulted in significantly shorter hospital length of stay, earlier return of gut function, fewer postoperative complications, and cost savings compared to CVP-guided fluids. ODM provided a more reliable assessment of intravascular volume status and cardiac preload than CVP alone.

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Oesophageal Doppler Monitoring (ODM) provides a non-invasive assessment of stroke volume and cardiac output during surgery. A randomized controlled trial found that using ODM to guide intraoperative fluid management in colorectal surgery patients resulted in shorter hospital length of stay, earlier return of gut function, fewer complications, better hemodynamic measurements, and cost savings compared to managing fluids to maintain CVP between 12-15 mmHg. ODM may help optimize fluid management and improve recovery in complex and orthopedic surgeries.

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This document discusses challenges with traditional measures for predicting fluid responsiveness in critically ill patients, such as central venous pressure and pulmonary artery wedge pressure. It notes that only about 50% of patients are actually fluid responsive. Newer dynamic indices using cardiorespiratory interactions, such as stroke volume variation and pulse pressure variation, have been shown to more accurately predict fluid responsiveness without the need for invasive monitoring. The document concludes that considering a patient's cardiorespiratory interactions and using dynamic indices can help clinicians better determine fluid responsiveness.

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This document discusses the importance of quality control for echocardiography interpretation and summarizes several studies on improving inter-observer reliability and accuracy. The first study found low agreement between experts in assessing diastolic function from the same patient data due to a lack of hierarchy for integrating parameters. A later study developed a consensus strategy to improve grading of aortic regurgitation severity from 70% to over 90% agreement. Another study reduced inter-observer variability in left ventricular ejection fraction measurements from echocardiograms by having readers review their measurements alongside cardiac MRI images. A final study showed quantitative measurements of right ventricular function improved accuracy and agreement compared to qualitative assessments alone. The studies demonstrate the value of quality improvement efforts like developing consensus guidelines

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This document discusses hemodynamic monitoring techniques to guide treatment for patients with hemodynamic failure. It describes using the PiCCO device to noninvasively monitor parameters such as cardiac output, lung water content, contractility, and fluid responsiveness to determine whether a patient needs vasopressors, volume expansion, inotropes, and when to stop fluid administration. Tests like pulse pressure variation, end-expiratory occlusion, and passive leg raising used with continuous cardiac output monitoring can predict fluid responsiveness, while extravascular lung water and pulmonary vascular permeability index measurements help avoid excessive fluid loading and lung injury.

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A neglected topic for way too long, the interest in fluid therapy seems to be quickly rising as the medical community is making a shift from looking at fluids as a mere method of stabilization towards the appreciation of its relevant side effects. Many questions remain to be answered indeed: Is the upgrade from saline 0.9% to balanced crystalloids worth the extra cost? Does HES still have a place in the OR? Do we have to fill the gap left by HES on ICU with crystalloids, other colloids or even albumin? Is it really impossible to avoid fluid overload by using only crystalloids? Is there still a definitive place for human albumin? How do we treat and monitor specific patient populations, like patients with trauma, liver failure, brain edema and right heart failure among others? How do we avoid a one-size-fits-all regimen in perioperative goal-directed therapy? What with the fluids beyond resuscitation? And what do the authors of the big fluid trials do in real life themselves? The 9th International Fluid Academy Day will again be a 1 day concise meeting on all aspects of fluid managament and hemodynamic monitoring in the critically ill. Date: October 26th 2019, 8:00 - 18:00

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