Xavier Monnet - Assessment of fluid therapy - IFAD 2011
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IFAD 2011
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Xavier Monnet - Assessment of fluid therapy - IFAD 2011
- 1. Prof. Xavier MONNET Medical Intensive Care Unit Bicêtre Hospital Assistance publique – Hôpitaux de Paris FRANCE Assessment of fluid therapy Use the right tool for the right job!
- 2. Conflict of interest Pulsion Medical Systems
- 3. Prof. Xavier MONNET Medical Intensive Care Unit Bicêtre Hospital Assistance publique – Hôpitaux de Paris FRANCE Assessment of fluid therapy Use the right tool for the right job!
- 4. AP CVP PiCCO Esophageal Doppler Echo ProAQT/PulsioFlex PAC FloTrac/Vigileo Nexfin Differents monitoring devices Different indications ?
- 7. Context Goals of monitoring Improves prognosis to detect hemodynamic deterioration to guide volume expansion High-risk surgical patients (except cardiac surgery) Peri-opmonitoring
- 8. 60 patients hip replacement hospital length of stay 100 high-risk surgical patients hospital length of stay 174 patients post cardiac surgery hospital length of stay 162 multiple trauma patients after surgery hospital length of stay ICU length of stay lactate level Peri-opmonitoring Improves prognosis with esophageal Doppler
- 9. 60-risk general surgical patients Goal directed therapy vs. conventional treatment Post-operative phase Peri-opmonitoring number of complications hospital length of stay 120 high-risk abdominalsurgery patients SVV-directed therapy vs. conventional treatment Per-operative phase LidCO monitoring number of complications hospital length of stay Improves prognosis with LidCO
- 10. 40 patients with hip replacement under regional anesthesia Goal directed therapy vs. conventional treatment Peri-opmonitoring number of complications Improves prognosis with Flotrac/Vigileo
- 11. Vigileo Eso Doppler preload dependance (Δ aortic blood flow) preload (FTc) Pulsioflex preload dependance (VVE and Δ PP) preload dependance (VVE and Δ PP) LidCOrapid preload dependance (VVE and Δ PP) continuous cardiac output continuous cardiac output (cardiac output)(AP curve analysis) continuous cardiac output (AP curve analysis) continuous cardiac output (AP curve analysis) Peri-opmonitoring
- 12. Arterial pressure Esophageal Doppler Flotrac/Vigileo Pulsioflex LidCOrapid PA catheter CVP PiCCO EV 1000 ICU monitoringOR monitoring Basic monitoring Advanced monitoring
- 13. Context Objectives of monitoring initial phase of shock after the ER assess the hemodynamic profile (type of shock) guide initial therapy fix some therapeutic goals Which basic monitoring? BasicICUmonitoring
- 15. Helps for :Helps for: determining the type of shock (preload) guiding fluid responsiveness (preload) CVP Arterial pressure deciding to give vasopressors deciding to give fluid (if ventilated) fixing some therapeutic goals BasicICUmonitoring DAP PPV MAP
- 16. Arterial pressure Esophageal Doppler Flotrac/Vigileo Pulsioflex LidCOrapid PA catheter CVP PiCCO EV 1000 ICU monitoring OR monitoring Basic monitoring Advanced monitoring ? ?
- 17. The only arterial pressure and CVP monitoring is not sufficient anymore critically ill patients Context because patients receive vasopressors dvancedICUmonitorin when shock persists after initial fluid therapy
- 18. r = 0.56 n = 228 r = 0.21 n = 145 * -50 0 50 100 150 200 250 300 -50 0 50 100 150 200 250 300 Changes in CI induced by VE (%) Changes in PP induced by VE (%) -50 0 50 100 150 200 250 300 -50 0 50 100 150 200 250 300 Changes in CI induced by NE (%) Changes in PP induced by NE (%) 228 pts receiving volume expansion 145 patients with increase of NE dvancedICUmonitorin
- 19. -20 0 20 40 60 80 100 non responders responders changes in CI (%) -20 0 20 40 60 80 100 non responders responders changes in PP (%) +15% 6% false + 228 pts receiving volume expansion 145 patients with increase of NE 22% false - dvancedICUmonitorin
- 20. dvancedICUmonitorin Vigileo Eso Doppler preload dependance (Δ aortic blood flow) preload (FTc) Pulsioflex preload dependance (VVE and Δ PP) preload dependance (VVE and Δ PP) LidCOrapid preload dependance (VVE and Δ PP) continuous cardiac output continuous cardiac output (cardiac output)(AP curve analysis) continuous cardiac output (AP curve analysis) continuous cardiac output (AP curve analysis) continuous cardiac output AP curve analysis uncalibrated continuous cardiac output AP curve analysis uncalibrated continuous cardiac output AP curve analysis uncalibrated
- 21. 20 40 60 80 100 120 0 = k . SV Uncalibrated devices estimate SV from the arterial pressure curve estimate arterial compliance by analysing the arterial waveform ?still valuable when the properties of the arterial curve change in a large extent (sepsis, vasopressors) Which device for advanced monitoring? dvancedICUmonitorin
- 22. 3.5 L/min PiCCO and EV1000 devices measure cardiac output by arterial pressure curve analysis Which device for advanced monitoring? dvancedICUmonitorin
- 23. PiCCO and EV1000 devices measure cardiac output by inj Blood temperature (Ts) Ttm cold bolus calibrated by transpulmonary thermodilution arterial pressure curve analysis Which device for advanced monitoring? dvancedICUmonitorin
- 24. Vigileo2 PiCCO calibrated cardiac index uncalibrated cardiac index changes induced by volume expansion (40 patients) changes induced by norepinephrine (40 patients) Ability to track Which device for advanced monitoring? dvancedICUmonitorin
- 25. -15 0 15 30 45 60 75 -15 0 15 30 45 60 75 DCItd (%) r = 0.78 p < 0.05 PiCCO r = -0.03 p = NS -15 0 15 30 45 60 75 90 105 120 -15 0 15 30 45 60 75 90 105 120 DCItd (%) Vigileo2 Changes induced by norepinephrine Changes induced by volume expansion PiCCO r = 0.72 p < 0.05 -15 0 15 30 45 60 75 90 105120 -15 0 15 30 45 60 75 90 105 120 DCIpc(%) DCItd (%) Vigileo2 r = 0.33 p < 0.05 -15 0 15 30 45 60 75 90 105120 -15 0 15 30 45 60 75 90 105 120 DCIpw(%) DCItd (%) Which device for advanced monitoring? dvancedICUmonitorin
- 26. 51 pts, 401 measurements Vigileo2 vs.Vigileo3 vs. PAC Vigileo3 is more accurate and as precise than Vigileo2 Which device for advanced monitoring? dvancedICUmonitorin
- 27. 33 patients Vigileo3 vs. esophageal Doppler Hemodynamic challenges by phenylephrine, ephedrine and whole-body tilting Which device for advanced monitoring? dvancedICUmonitorin
- 28. PA catheter Which device for monitoring cardiac output? PiCCO EV 1000 cardiac output cardiac output cardiac output dvancedICUmonitorin
- 29. Context Goals of monitoring predict fluid responsiveness precisely monitor the effects of therapy fix some therapeutic goals when shock persists after initial fluid therapy assess the risk of fluid expansion critically ill patients dvancedICUmonitorin
- 30. PA catheter PiCCO EV 1000 cardiac output cardiac output cardiac output SvO2 ScvO2 ScvO2 How to assess the need for fluid? dvancedICUmonitorin
- 31. Context Goals of monitoring predict fluid responsiveness precisely monitor the effects of therapy fix some therapeutic goals when shock persists after initial fluid therapy assess the risk of fluid expansion critically ill patients dvancedICUmonitorin
- 32. PA catheter PiCCO EV 1000 cardiac output cardiac output cardiac output PAOP SvO2 ScvO2 ScvO2 How to assess the need for fluid? PPV, SVV, PLR test, EEO test PPV, SVV, PLR test, EEO test dvancedICUmonitorin
- 33. How to assess the need for fluid? dvancedICUmonitorin
- 34. EV 1000PA catheter PiCCO cardiac output cardiac output cardiac output PAOP SvO2 ScvO2 ScvO2 How to assess the need for fluid? PPV, SVV, PLR test, EEO test PPV, SVV, PLR test, EEO test continuous continuous dvancedICUmonitorin
- 35. venous return How to assess the need for fluid? dvancedICUmonitorin
- 36. 34 patients with acute circulatory failure monitored by PiCCO device -10 0 10 20 30 40 50 Effects of end-expiratory pause on cardiac index increase 5% Se = 91% Sp = 100 % How to assess the need for fluid? dvancedICUmonitorin RNR
- 37. How to assess the need for fluid? dvancedICUmonitorin
- 38. Context Goals of monitoring predict fluid responsiveness precisely monitor the effects of therapy fix some therapeutic goals when shock persists after initial fluid therapy assess the risk of fluid expansion critically ill patients dvancedICUmonitorin
- 39. EV 1000PA catheter PiCCO cardiac output cardiac output cardiac output PAOP SvO2 ScvO2 ScvO2 PPV, SVV, PLR test, EEO test PPV, SVV, PLR test, EEO test lung water and lung permeability lung water and lung permeability How to assess the risk of volume expansion? dvancedICUmonitorin
- 40. Pcap lung water normal permeability very high permeability Pcap lung water How to assess the risk of volume expansion? high permeability dvancedICUmonitorin Lung permeability
- 41. Lung water for estimating the risk of volume expansion? Pcap Lung water normal permeability very high permeability Pcap lung water lung water high permeability Lung permeability dvancedICUmonitorin
- 42. Cold bolus PiCCO EV1000 Lung water for estimating the risk of volume expansion? dvancedICUmonitorin
- 43. validation in human beings→ Lung water for estimating the risk of volume expansion? 30 pts EVLW measured by TPTD and by postmortem gravimetry First validation of EVLW-TPTD evaluation in humans dvancedICUmonitorin
- 44. Lung water for estimating the risk of volume expansion? dvancedICUmonitorin
- 45. Extra-vascular lung water and pulmonary vascular permeability index are independent prognostic factors in patients with acute respiratory distress syndrome Jozwiak M, Silva S, Persichini R, Anguel N, Osman D, Richard C, Teboul JL, Monnet X 0 20 40 60 80 100 EVLWImax > 21 mL/kg EVLWImax ≤ 21 mL/kg 70% 42% p = 0.0001 Day-28 mortality (%) p value Maximal blood lactate 0.81 (0.71 - 0.93) 0.002 Mean PEEP 1.25 (1.07 - 1.47) 0.005 EVLWI max 0.94 (0.87 - 0.98) 0.01 SAPS II 0.97 (0.95 - 0.99) 0.02 Mean fluid balance 0.9996 ( 0.9993 - 0.9999) 0.02 Minimal P/F ratio 1.01 (1.00 - 1.02) 0.02 Minimal pH 35.97 (0.47 - 2769.52) 0.10 Odds Ratio ( CI 95%) 200 pts with ARDS EVLW measured by PiCCO device Lung water for estimating the risk of volume expansion? submitted dvancedICUmonitorin
- 46. PAOP group EVLW group Time (hours) Cumulative fluid balance (input - output; L) 7 3 1 5 -1 -3 -5 0 12 24 36 48 60 72 * ** * * p < 0.0001 vs time 0 Mitchell JP et al., Am Rev Respir Dis 1992 101 ARDS patients randomized to EVLW-guided management vs. PAOP-guided management Lung water for estimating the risk of volume expansion? dvancedICUmonitorin
- 47. 0 5 10 15 20 25 Ventilation days ICU days PAOP Group EVLW Group * * Management of fluid therapy with : functional benefit of lung water monitoring Mitchell JP et al., Am Rev Respir Dis 1992 101 ARDS patients randomized to EVLW-guided management vs. PAOP-guided management Lung water for estimating the risk of volume expansion? dvancedICUmonitorin
- 48. Lung water for estimating the risk of volume expansion Pcap Lung water normal permeability very high permeability Pcap lung water lung water high permeability Lung permeability dvancedICUmonitorin
- 49. lung water cold bolus pulmonary blood volume pulmonary vascular permeability index =PVPI PiCCO EV1000 Lung permeability for estimating the risk of volume expansion? dvancedICUmonitorin
- 50. 0 1 2 3 4 5 6 7 8 9 10 PVPI ALI/ARDS Hydrostatic pulmonary edema * Cut-off : 3 Se = 85 % Sp = 100 % 48 patients with pulmonary edema inflammatory vs. hydrostatic discriminated by experts PVPI by the PiCCO device Lung permeability for estimating the risk of volume expansion? dvancedICUmonitorin
- 51. PVPI = 4 PVPI= 7 ARDS AP = 90 / 40 mmHg Cardiac index = 2.0 L/min/m2 PaO2/FiO2 = 180 mmHg PLR test : positive ARDS AP = 90 / 40 mmHg Cardiac index = 2.0 L/min/m2 PaO2/FiO2 = 180 mmHg PLR test : positive volume expansion volume expansion vasopressors? Lung permeability for estimating the risk of volume expansion? dvancedICUmonitorin
- 52. PA catheter PiCCO EV 1000 cardiac output cardiac output cardiac output PAOP SvO2 ScvO2 ScvO2 PPV, VVE, PLR test, EEO test PPV, VVE, PLR test, EEO test lung water and lung permeability lung water and lung permeability Lung permeability for estimating the risk of volume expansion? dvancedICUmonitorin
- 53. AP CVP PiCCO Esophageal Doppler Echo ProAQT/PulsioFlex PAC FloTrac/vigileo Nexfin Differents monitoring devices Different indications !
- 54. Arterial pressure Esophageal Doppler Flotrac/Vigileo Pulsioflex LidCOrapid PA catheter CVP PiCCO EV 1000 ICU monitoring OR monitoring Basic monitoring Advanced monitoring