Assessment of fluid overload
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This document discusses various methods for assessing fluid overload in patients. Fluid balance (the difference between fluid intake and output) is strongly associated with outcomes like mortality in patients with sepsis or ARDS. Monitoring extravascular lung water, which can be estimated noninvasively using transpulmonary thermodilution, may help guide fluid management and is associated with improved outcomes. While central venous pressure is not a direct marker of pulmonary risk, maintaining an adequate mean arterial pressure and renal perfusion pressure is important to prevent organ dysfunction. Assessing fluid responsiveness with tests like passive leg raise can help determine how much fluid can safely be removed.
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Assessment of fluid overload
- 1. Prof. Xavier MONNET Medical Intensive Care Unit Paris-Sud University Hospitals xavier.monnet@bct.aphp.fr Assessment of fluid overload
- 2. Links of interest Pulsion Medical Systems Cheetah Masimo
- 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
- 6. 173 patients with sepsis Survivors had a lower fluid balance How do we assess fluid overload ? Fluid balance
- 7. 173 patients with sepsis Multivariate analysis Positive fluid balance: OR=1.014 [1.008–1.021] 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 Nevertheless… Weight gain … 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
- 14. Meta-analysis 14 studies 2 500 patients How do we assess fluid overload ? Intra-abdominal pressure
- 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
- 16. Central venous catheter Femoral arterial catheter How do we assess fluid overload ? Lung water
- 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
- 19. Independently predicts mortality Validated in humans 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 → 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 … 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 ↗ 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 ↘ the duration of ventilation ↘ 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 Nevertheless…
- 29. ΔP MAP CVP How do we assess fluid overload ? Central venous pressure
- 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 Hn…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 – 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 ↗ in cardiac index during PLR ≥ 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