It is very important for cardiologist or intensivist to determined fluid overload vs loss fluid. Misconception of hypervolemic and hypovolemic state was very important.

1. Fluid Management
in Intensive Cardiac Care
Isman Firdaus, MD, FIHA, FAsCC, FAPSIC, FESC, FAPSIC
Intervensionist and Critical Care Cardiologist Consultant
Departement of Cardiology and Vascular Medicine
Faculty of Medicine University of Indonesia

2. Body Fluid Compartments
• Total Body Water = 60% body weight
– 70Kg TBW = 42 L
• 2/3 of TBW is intracellular (ICF)
– 40% of body weight, 70Kg = 28 L
• 1/3 of TBW is extracellular (ECF)
– 20% of body weight, 70Kg = 14 L
– Plasma volume is approx 4% of total body weight,
but varies by age, gender, body habitus

3. Peran Pemberian Cairan pada
Gagal Jantung
Kontraktilitas Preload Afterload
Stroke
Volume
Heart
Rate
Cardiac Output
+ + -
+ +

4. Preload
Stroke
Volume
0
0
Frank-Starling Relationship

5. Kurva Frank-Starling
p197 Heart Failure
Normal
Increased
Contractility
Pulmonary Congestion
Hypotension
Left Ventricular End diastolic Pressure
(or End Diastolic Volume)
StrokeVolume
(orCardiacOutput)

6. Acute Heart Failure
Definitive
diagnosis
Diagnosis
Aｌgorithm
Definitive
treatment
Immediate
resuscitation
Patient distressed
or in pain
Arterial oxygen
saturation > 95%
Normal heart rate
and rhythm
YES
NO
YES
NO
YES
NO
If moribund
BLS, ALS
Analgesia or
sedation
Increase FiO2,
Consider CPAP,
NIPPV
Pacing,
Antiarrhythmics
etc…
Steps of care and treatment algorithm in AHF
ESC guidelines, Eur Heart J 2005;26:384-416
Reperfusion
therapy for
ACS etc.

7. Hemodynamic
Monitoring
Mean BP
> 70 mmHg
Adequate
preload
Adequate CO
reversal of acidosis
SvO2 > 65%
signs of adequate
organ perfusion
YES
NO
YES
NO
YES
NO
Vasodilators
Consider diuresis
if volume overload
Fluid challenge
Consider
inotropic
or further afterload
reduction
Reassess frequently
Steps of care and treatment algorithm in AHF
(cont.)
ESC guidelines. Eur Heart J 2005;26:384-416

8. Misconception on Fluid Management
• Cairan tidak boleh diberikan bila CVP tinggi
• Cairan tidak boleh diberikan bila rontgen
menunjukan pulmonary edema
• Cairan diberikan hingga tercapai target CVP 12
Vincent JL,Weil MH.
Crit Care Med 2006;24(5):133-37

9. Fluid Challange Test
• Menilai respon kardiovaskular
• Kekurangan cairan dapat dikoreksi dengan
cepat
• Meminimal risiko “overload cairan” dan
efeknya tidak diinginkan terutama di paru.
Vincent JL,Weil MH.
Crit Care Med 2006;24(5):133-37

10. Fluid Challenge Technique
1. 7 - 2 rules  Swan Ganz Guided (PCWP)
2. 5 - 3 rules  CVP/Echo guided
3. 4 - 2 rules  CVP/Echo guided

11. Fluid Challenge Rule
“5 – 2 rules” for PCWP
Steps PCWP/PADP
(mmHg)
Fluid Infusion Rate
Before Challenge
Observe PADP/PCWP for 10 min
before challenge
< 8
8-14
>14
200 cc / 10 minute
100 cc / 10 minute
50 cc / 10 minute
During challenge
During 0-9 min 
Immediate  following 10 min
infusion
> 5
< 2
2-5
 Stop
 Continue
 wait 10 min
After challenge
After 10 min wait 2
2
Wait 10 minutes
Stop
Repeated fluid challenge
Cardiovasc. Rev.rep. C Makabali, Weil, Hening. An Update on theurapeutic of Shock: current concept and
mechanism management of circulatory failure 3:899.1982

12. Fluid Challenge Rule
“7 – 3 rules” for PCWP
Steps PCWP/PADP
(mmHg)
Fluid Infusion Rate
Before Challenge
Observe PADP/PCWP for 10 min
before challenge
< 12
12-16
> 16
200 cc / 10 minute
100 cc / 10 minute
50 cc / 10 minute
During challenge
During 0-9 min 
Immediate  following 10 min
infusion
>7
<3
 Stop
 Continue
After challenge
After 10 min wait 3-7
> 3
<3
Wait 10 minutes
Stop
Repeated fluid challenge
Cardiovasc. Rev.rep. C Makabali, Weil, Hening. An Update on theurapeutic of Shock: current concept and
mechanism management of circulatory failure 3:899.1982

13. Weil & Henning
Fluid Challenge technique “rule of 4-2”
CVP < 6 6 - 10 >10
CVP > 4 2 - 4 < 2
4 ml/kg 2 ml/kg 1 ml/kg
> 2
> 3
Stop monitor
10’ monitor
If limit of rule exceeded consider inotropic
Elevation of
Weil MH, Henning RJ.
Anesth Analg 1979;58:124-132

14. Inferior Vena Cava (IVC) Assessment

16. Pulse Pressure Variation and Changes in PPW
During Ventilation
Ventilatory Cycle
Adapted from: Cannesson M et al
PPWmax
PPWmin
Arterial Pulse Pressure Variation
PPmax- PPmin
(PPmax + PPmin) ÷ 2
ΔPP =
Pleth Waveform Variation
PPWmax – PPWmin
(PPWmax + PPWmin) ÷
2
ΔPPW =

17. • Automated measurement
• Changes in plethysmographic waveform amplitude over the
respiratory cycle
• PVI is a percentage from 1 to 100%:
• 1 - no pleth variability
• 100 - maximum pleth variability
PVI Calculation

18. Preload
Stroke
Volume
0
0
Higher PVI = More likely to respond to fluid administration24 %
10 %
Lower PVI = Less likely to respond
to fluid administration
PVI to Help Clinicians
Optimize Preload / Cardiac Output
Maxime Cannesson, MD, PhD

21. Modifikasi “fluid challenge test”
• Tipe cairan
• Administrasi rate
• Target yang ingin dicapai (MAP)
• Batas aman

22. Contoh 1 Contoh 2
Base line +10 mnt +20 mnt baseline +10 mnt +20 mnt
Cairan RL
Rate infusion
500ml/30mnt
Target MAP 75 MAP 65 MAP 70 MAP 75 MAP 65 MAP67 MAP60
Batas aman CVP 15 CVP 12 CVP 13 CVP 14 CVP 12 CVP 14 CVP 15
lanjutkan stop lanjutkan stop
Fluid challenge berhasil Fluid challenge tidak berhasil

23. Drugs and Hemodynamic
BP IVC SVR TAPSE
Inotropik
(dobutamine)
Decrease Normal/distende
d
high/ Decrease
/normal
Vasopressor
(nor-adrenaline)
Decrease Collapse/distend
ed/normal
low normal
Milrinon Decrease/normal Distended/norm
al
high Decrease
/normal
IABP decrease distended high Low

24. Drugs Support and Hemodynamic
BP IVC SVR TAPSE
Inotropik
(dobutamine)
Low Normal/distended High Decrease
/Normal
Vasopressor
(nor-adrenaline)
Low Collapse/distended/n
ormal
Low Normal
Milrinon
(inodilator)
Low/normal Distended/normal High Decrease
/Normal
IABP Low Distended High Low
Nitrat Normal/high Normal/distended High Decrease
/Normal
Hydralazine/ ACE-
Inhibotor
High/normal Distended/normal High Decrease
/Normal
Fluid rescucitation Low/normal Collapse Low/high Increase/Normal
Adrenaline Low Collapse/normal Low-normal Decrease
Dr. Isman Firdaus, SpJP, FIHA, Jakarta 2012

25. Kesimpulan
• Pada kondisi syok atau gagal Jantung Akut
dengan hipotensi Status volume harus
ditentukan agar tidak terjadi hipoperfusi
berkelanjutan
• Fluid challenge merupakan cara yang terbaik
dan aman

26. THANK YOU