fluid responsiveness in critically ill

Fluid Responsiveness in Critically ill PatientsFluid Responsiveness in Critically ill Patients

Ubaidur RahamanSenior Resident, CCM, SGPGIMS

Lucknow, India

Definition:fluid responsiveness denotes an increase in cardiac index after infusion of a fluid either crystalloid or colloid.

FLUID RESPSONSIVENSS

Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow

FLUID RESUSCITATIONFLUID RESUSCITATION3 DIFFERENT SCENARIO3 DIFFERENT SCENARIO

Patients in the ERS for acute blood losses or body fluid lossePatients in the ERS for acute blood losses or body fluid lossess

Patients in the ERS for high suspicion of septic shockPatients in the ERS for high suspicion of septic shock

Patients in the ICU, Patients in the ICU, already resuscitated for several hours or daysalready resuscitated for several hours or days

No therapeutic dilemma regarding hypovolemia

EGDT- volume resuscitation mandatory in first 6 hours- mortality benefit


•• hemodynamic instability requiring therapyhemodynamic instability requiring therapy

•• Cumulative fluid balanceCumulative fluid balance

•• Risk of pulmonary oedema/ raised IAPRisk of pulmonary oedema/ raised IAP

••? Fluid responsiveness? Fluid responsiveness

Patients in the ICU, already resuscitated for several hours or dPatients in the ICU, already resuscitated for several hours or daysays


Cumulative fluid balance and mortality

Fluid resuscitation in septic shock: A positive fluid balance and elevated central venous pressure are associated with increased mortality.

Crit Care Med 2011 Vol. 39, No. 2; John H. Boyd, Jason Forbes, MD; Taka-aki Nakada, Keith R. Walley,James A. Russell,

A more positive fluid balance both early in resuscitation and cumulatively over 4 days is associated with an increased risk of mortality in septic shock.

Central venous pressure may be used to gauge fluid balance <12 hrs into septic shock but becomes an unreliable marker of fluid balance thereafter.

retrospective review of the use of intravenous fluids during the first 4 days of care.

Patients: VASST study enrolled 778 patients septic shock and receiving a minimum of 5 ug of norepinephrine per minute.


to give or not to give????


Assessment OF FLUID RESPONSIVENESS

PRELOAD CONTRACTILITY CARDIAC INDEX

PRELOAD DEPENDENCE

Both ventricles should be preload dependentUbaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow

Assessment of PRELOAD is not assessment of PRELOAD DEPENDENCE

Stroke volume

Ventricular preload

normal heart normal heart

failing heart failing heart

preloadpreload--dependencedependence

preloadpreload--independenceindependence


ASSESSMENT OF FLUID RESPONSIVENESS

•Filling pressures- CVP, Pawp

•Filling volumes- LVEDV/ RVEDV

•VENACAVAL DIAMETER- variation with respiration

•RAP - inspiratory fall

•Response to fluid challenge

•Prediction of preload dependence:PPV induced variation in CI parameters

ASSESSMENT OF PRELOAD

ASSESSMENT OF PRELOAD DEPENDENCE


ASSESSMENT OF PRELOADFilling pressures

oCentral Venous PressureoPulmonary artery Wedge Pressure


Central Venous Pressure

VR- function of

•MCFP•Vs

•Venous resistance

VR CARDIAC PUMPCVPFunction of

VR- venous return; MCFP- mean capillary filling pressureVs- stressed volume

Mean Capillary filling pressure(MCFP)

P

V

Vu

Vs

Vs- Stressed volume; Vu- unstressed volume


Central Venous Pressure

Venous function and central venous pressure. A physiologic story. Simon Gelman. Anesthesiology 2008;108:735-48

C.O. is determined by intersection of

Q

Pra

Q

PraQ

Pra

RETURN FUNCTION CARDIAC FUNCTION

How to use CVP measurements. Magder S. Current Opinion in Critical Care 2005, 11:264—270

CONCEPT OF LIMIT

Q

Pra

Limit of “RETURN FUNCTION” Limit of “CARDIAC FUNCTION”

Lowering Pra will notincrease VR

Increasing Pra will notIncrease C.O.

How to use CVP measurements. Magder S. Current Opinion in Critical Care 2005, 11:264—270

Is CVP a misleading variable?

Venous function and central venous pressure. A physiologic story. Simon Gelman. Anesthesiology 2008;108:735-48

“The correlation between CVP and circulating blood volume has never been found simply because it does not exist”

Body does everything to maintain homeostasisadequate transmural pressure

MCFPmore accurate measurement of volume status- difficult to measure

Ppawpis an even worse indicator than CVP as it is far removed from the action of MCFP

RAP and Ppawdo not always reflect true transmural pressure in patients on PEEP, increased IAP

Does Central Venous Pressure predicts fluid responsiveness?A systemic review of literature and the tale of seven mares.

Paul E. Marik, M. Baram, B. Vahid. Chest 2008;134:172-178

Expansive literature search to identify all trials evaluating the relationship between 1. CVP & blood volume

2. association between CVP or Δ CVP and fluid responsiveness

– 24 studies identified– 5 comparing CVP with measured blood volume;

-19 studied relationship between CVP/ΔCVP & change in cardiac performance after fluid challenge

Poor correlation between•CVP and blood volume

•CVP or ∆CVP and homodynamic response to fluid challenge overall 56% patients responded to fluid challenge

predicting fluid responsiveness in ICU patients: A critical analysis of evidences.

Frédéric Michard and Jean-Louis Teboul. Chest 2002;121;2000-2008

From medline (since 1966) Twelve studies were analyzed in which the parameters tested were as follows:

(1) static Indicators: RAP, PAOP, RVEDV, LVEDA;(2) dynamic parameters: inspiratory decrease in RAP, ddown, PPV, aortic blood

velocity(Vpeak)

Before fluid infusion, static indicators were not significantly lower in responders than in nonresponders.

When a significant difference was found, no threshold value could discriminate responders and nonresponders.

Before fluid infusion, inspiratory variation in RAP,SPV ddown, PPV, and Vpeakwere significantly higher in responders.

Positive predictive value: 77- 95%, negative predictive value: 81- 100%

ASSESSMENT OF PRELOADFilling Volumes

o RVEDVo LVEDV

Assessment OF PRELOADRespiratory variation in VENACVAL DIAMETER

This variation is affected by intravascular volume ( hydrostatic pressure)Less intravascular volume--- more variation

Spontaneous breathingNegative pleural pressure---- increased VR---- collapse of IVC

Positive pressure ventilationPositive pleural pressure---increased RA pressure---decreased VR

IVC- extrathoracic course--- increased transmural pressure---- distend

SVC- intrathoracic course--- decreased transmural pressure----collapse


IVC collapsibility index ≥ 50% is strongly associated with low CVP

Emergency department bedside ultrasonographic measurement of caval index for noninvasiveDetermination of low central venous pressure.

Nagdev AD, Merchant RC, Murphy MC. Ann Emerg Med. 2010 Mar;55(3):290-5

In healthy subjects inspiration decreased IVC diameter by approx. 50%.This cyclic change is abolished in high volume status, right ventricular failure, cardiac tamponade.

Applied Physiology in Intensive care Medicine. Pinsky, Mancebo. page 145

Could be affected by manner of respiration Could be affected by raised IAP

SPONTNEOUS BREATHING Patient


POSITIVE PRESSURE VENTILATED PATIENTS

IVC distensibility index (dIVC) ≥ 18% predictive of increase in C.I. of at least 15% Sensitivity-90%, Specificity-90%

Respiratory changes in inferior venacava diameter are helpful in predicting fluidresponsiveness in ventilated septic patients.Barbier C, Jardin F. Inten Car Med 2004;30:1740-6

divc=(Dmax-Dmin)/ Dmin

IVC distensibility index ( DDIVC) ≥ 12% predictive of increase in C.I. by at least 15%Positive predictive value- 93 %, negative predictive value- 92%

The respiratory variation in inferior venacava diameter as a guide to fluid therapy.Feissel M, Michard F. Inten Car Med 2004;30:1834-7

DDivc=(Dmax-Dmin)/ mean of 2 values



Could be affected by raised IAP


SVC collapsibility index ≥ 36% identified preload responders.Sensitivity- 90%, specificity- 100%

Superior venacaval collapsibility as a gauge of volume status in ventilatedseptic patients.

Vieillard Baron A, Chergui K, Rabiller A. Inten Care med 2004;30;1734-9


dSVC= (Dmax-Dmin)/ Dmax

Not affected by raised IAP

Assessment OF PRELOADInspiratory fall in right atrial pressure

Respiratory variation in RAP predicts the response to fluid challenge. Magder S, Geoorgiadis G, Cheong T. J Crit Care 1992; 7:76-85

13 of 14 patients had no fall in RAP-C.O. not increased with fluid challenge

16 of 19 patients who had a fall in RAP ≥ 1 mmHg-C.O. increased by> 250 ml/ min with fluid challenge

Sufficient inspiratory effort to lower Ppaw by 2 mmHg

Assessment OF PRELOAD DEPENDENCE

PREDICTION BY PPV inducedRESPIRATORY VARIATION

IN C.I. RELATED PARAMETERS

FLUID CHALLENGE


Assessment OF PRELOAD DEPENDENCE

change in filling pressures- CVP, RAP, Pawp

change in perfusion markers- C.O., MAP, CFT, ABG, SCVO2, B. lactate

Disadvantages

pulmonary edemaexcessive cumulative fluid balance

Response to FLUID CHALLENGE


Assessment of PRELOAD DEPENDENCEPREDICTION OF PRELOAD DEPENDENCE

Spontaneously breathing patientsPLR- ∆ stroke volume/ pulse pressure

Positive pressure ventilated patients

PLR- ∆ stroke volume/ pulse pressure

Respiratory cycle induced change in parameters related to cardiac index-SPV, SVV, PPV, pulse oxymetry plathysmography waveform variation,

Aortic blood flow velocity, aortic velocity time integral, aortic pre-ejection period

Respiratory systolic variation test ( RSVT)

end expiratory occlusion test


PASSIVE LEG RAISING

45 45 °°

Venous blood shiftVenous blood shift (Rutlen et al. (Rutlen et al. 19811981, , Reich et al. 1989)Reich et al. 1989)

Transient and reversible effect


PLR

Passive leg raising predicts fluid responsiveness in the critically illXavier Monnet, Mario Rienzo, David Osman, Nadia Anguel, C. Richard,

Michael R. Pinsky, Jean-Louis Teboul, Crit Care Med 2006; 34:1402–1407

homodynamic status assessed at baseline, after PLR, after volume expansion (500 mL NaCl 0.9% infusion over 10 mins)

71 mechanically ventilated patients considered for volume expansion. 31 patients had spontaneous breathing activity and/or arrhythmias.

In both groups, PLR induced increase in aortic blood flow ≥10% predictedvolume expansion induced increase in aortic blood flow ≥15%

(sensitivity- 97%, specificity 94%)

Assessment of PRELOAD DEPENDENCE

PREDICTION OF PRELOAD DEPENDENCE- PLR

563.3 ± 27.5 ± 3.7 dDown ( mmHg)

485.9 ± 2.411.3 ± 5.1SPV ( mmHg)

1014.1± 4.8 12.9 ± 4.5PAOP ( mmHg)

235.7 ± 1.14.5± 1.1Cardiac output( l/min)

Change (%)PLRBaseline

Immediate effect of PLR following induction of anesthesia for cardiac surgery in 18 patients

Functional hemodynamic monitoring. Pinsky and Payen, page 318

PREDICTION OF PRELOAD DEPENDENCEPositive pressure ventilation induced change in parameters related to

cardiac index

Paw

PAlvPpl

Transmural pressurecardiac chambers/ great

vesseles

Filling gradient of RV

Filling gradient of LV no effect

Transpulmonarypressure

alveoli

Zone 3 to zone 2/1 formation

PVR

RV afterload

RV preload

RV stroke volume

LV stroke volume

PulmonaryTransit time

PAlvPpl PalvPpl

Mainly responsible for change in stroke volume


PREDICTION OF PRELOAD DEPENDENCEPositive pressure ventilation change in parameters related to

cardiac index

Paw

Transmural pressurecardiac chambers

Transpulmonarypressure alveoli

squeezing of blood out of

alveolar vesseles

LV preloadLV afterload

LV stroke volume

PalvPpl

Predominant mechanism in hypervolemia

Predominant mechanism in LV systolic dysfunction


Pleuralpressure

transpulmonarypressure

RV preload

LV afterload

LV preload

RV afterload

RV ejection

LV ejection

LV ejection

LV preloadPumonarytransit time

Aortic velocityStroke volumeSystolic B.P.

Pulse Pressure

Aortic velocityStroke volumeSystolic B.P.

Pulse Pressure

MAXIMUM AT END OF INSPIRATION

MINIMUM AT END OF EXPIRATION

PREDICTION OF PRELOAD DEPENDENCEPositive pressure ventilation induced change in parameters related to

cardiac index


PREDICTION OF PRELOAD DEPENDENCERespiratory cycle induced change in parameters related to cardiac index

SYSTOLIC PRESSURE VARIATION- SPVPROPOSED BY COYLE IN 1983

dup inspiratory increase in systolic pressure:

increased LV Stroke volume-increased preloaddecreased afterload

Increase in extramural aortic pressure

DdownExpiratory decrease in systolic pressure:

decrease in LV stroke volume-decrease in preload


SYSTOLIC PRESSURE VARIATION- SPV

Systolic pressure variation as a guide to fluid therapy in patients withsepsis induced hypotension

Taverneir B, Dupont J. Anesthesiology 1998, 89:1313-1321

dup- increase in hypervolemia and LVFddown-not increased in RVF despite hypovolemia

*cardiovascular monitoring Chapter 32, page 1327, Miller’s Anesthesia 7th edi

In the presence of large dup, the PPV, SPV and SVV will be less effectivein predicting fluid responsiveness

ddown- threshold value of 5 mmHg was associated with Increase in stroke volume ≥ 15%

Positive predictive value- 95%, Negative predictive value- 93%


PULSE PRESSURE VARIATION- PPV

PPmax-PPmin

PPmax+PPmin/2PPV=



Relation between Respiratory Changes in Arterial Pulse Pressure and Fluid Responsiveness in Septic Patients with Acute Circulatory Failure

F. MICHARD, S. BOUSSAT, D. CHEMLA, NADIA ANGUEL, MICHAEL R. PINSKY, and JEAN-LOUIS TEBOULAm J Respir Crit Care Med Vol 162. pp 134–138, 2000

6 ± 49 ± 6∆SPV (%)

7 ± 514 ± 10∆PPV (%)

4.0 ± 0.93.6 ±0.9

CI (l/min/m2)

29 ± 624 ± 6Ppa (mmHg)

14 ± 310 ± 3Pcwp (mmHg)

12 ± 49 ± 3Pra (mmHg)

90 ± 1369 ± 13MAP

106 ± 2111o± 22HR (beats/min)

VEBaseline

Threshold value of 13% was associated with increase in C.I. ≥ 15% in response to

volume expansionSensitivity- 94%, specificity-

96%



increase in SPV

no change in PPV

Inspiratory increasein pleural pressure

Increase in extra-mural pressure

Equal increase inSystolic pressure

And Diastolic pressure

PPV better predictor than other SV derived variables



RESPIRATORY SYSTOLIC VARIATION TEST ( RSVT)

RSVT slope

RSVT slope 0.24 mmHg/ cmH2Opredicted

change in CI of 15%

Predicting fluid responsiveness in patients undergoing surgery: functional haemodynamic parameters including the Respiratory Systollic Variation Test and static preload indicators.

Preisman S, Kogan S, Berkenstadt H, et al Br J Anaesth 2005;95:746–55

“since during critical illness maintenance of the cardiac output may depend upon right ventricular function, the clinician need to be able to discern the presence of right ventricular dysfunction…”

William Hurford, 1988

Presence of fluid responsiveness is not an indication by itself to administer fluids

It is commonly said that a teacher fails if he has not been surpassed by his students

-Edmond H. Fischer

o PPVPulse pressure depends on stroke volume and arterial complianceChange in compliance may affect degree of PPV induced by increase in

stroke volume

Elderly- stiff arteries--- small increase in stroke volume--- large PPVYoung healthy adult- large increase in stroke volume – relatively small PPV

CVP

o Effect of pleural pressureo Effect of PEEP on pleural pressure

less than half of PEEP is transmitted to the pleural space

even less than that in pathological condition that require higher PEEP--- ARDSPEEP – <=10 cm H2O = 8 mmHg----- change in pleural pressure—2-3 mmHg

but at PEEP>10 changes in pleural pressure at end expiration become significant

o Effect of forced expiration on pleural pressure

Respiratory change in pleural pressure

o Respiratory change in Pcwpo Respiratory change in esophageal

pressure

Fluid challengeo Rapidity of fluid infusion is important- faster the fluid is given,

lesser the amount to be giventype of fluid- crystalloid or colloid does not matter

o Change in CVP and not the volume of infusion that is importanto Blood pressure is not a good guide as to whether C.O.

increased with fluid infusiono In ¾ patients in whom C.O. increased there was no increase in

B.P. ( Bafaqeeh F, Magder S. CVP and volume responsiveness of cardiac output. Am J

Respir Crit Car Med 2004, 169: A 343

Role of echocardiography

Assessment of inadequate resuscitation:

o Volume status and responsiveness – fluid resuscitationo Cardiac contractility -- ionotrope

Effect of Positive Pressure Mechanical Ventilation on Hemodynamics


contribution of transmission of pleural pressure effect on both systolic as well as diastolic pressure equally

Determination of aortic pressure variation during positive pressure ventilation in man.Denault, Gasior, Pinsky, Gorscan, Mandarino. Chest 2000;116:176-186

fluid responsiveness in critically ill

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