PRESENTATION TITLE

Fluid Responsiveness + Mini-Fluid BolusPaul Marik, MD, FCCP, FCCM

Historical Perspective

Blue Stage of the Spasmodic CholeraSketch of girl who died of cholera in Sunderland, November 1831Lancet, Feb 4 1832

His first patient was an elderly women who had reached the last moments of her earthly existence. Having no precedent to guide me I proceeded with much caution

His first patient was an elderly women who had reached the last moments of her earthly existence. Having no precedent to guide me I proceeded with much caution

Latta inserted a tube into the basilic vein and injected ounce after ounce of fluid, closely observing the patient.

His first patient was an elderly women who had reached the last moments of her earthly existence. Having no precedent to guide me I proceeded with much caution

Latta inserted a tube into the basilic vein and injected ounce after ounce of fluid, closely observing the patient.

Ounce after ounce of fluid, closely observing the patient.

His first patient was an elderly women who had reached the last moments of her earthly existence. Having no precedent to guide me I proceeded with much caution

Latta inserted a tube into the basilic vein and injected ounce after ounce of fluid, closely observing the patient.

Ounce after ounce of fluid, closely observing the patient.

the sunken eyes and fallen jaw, pale and cold extremities bearing the manifest imprint of deaths signet, began to glow with returning animation; the pulse returned to the wrist

From this to . The Rivers Protocol

Fluid overload in patients with severe sepsis and septic shock treated with EGDT405 patients with severe sepsis and septic shockAt 24 hours, 67% pts had clinical evidence of fluid overloadAt 72 hours, 48% pts had clinical evidence of fluid overloadFluid overload associated increased hospital mortalityOR 1.92 (1.16-3.22)

Kelm DJ, et al. SHOCK 2015;43:68

Early Goal Directed Therapy should be termed iatrogenic salt water drowning rather than resuscitation

Fluid resuscitation Give them as much as they need and not a drop more.

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J Crit Care 2011; 26:402

none of these parameters correlated with TPTD assessment of volume status, preload responsiveness or EVLWPhysical examination, CVP and CXR for predictors of Trans-Pulmonary Thermodilution parameters in critically ill patients

What is the question?

The WRONG QuestionsWhat is the preload?What is the CVP/PCWP?Is the tank full?What is the cardiac output?What is the SVV/PPV?Does the vena-cava collapse?

What is the right question?IS MY PATIENT FLUID RESPONSIVE?Where is my patient on his/her Frank-Starling Curve?

LV preload

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Why Give fluid?To increase stroke volumeOnly +/- 50% hemodynamically unstable patients are volume responsive

NormalDepressed contractility

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Fluid responsiveness is generally defined as a significant increase ( > 10%) in SV (or CO) in response to a fluid challenge

Fluid responsiveness occurs only in patients withbiventricularpreload responsiveness

Ognibene FP et al. Chest 1988;93:903

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The idea of giving large fluid boluses of 20-30 ml/kg to humans may violate the maxim, primum non nocere, and likely to lead to severe volume overload with an increased risk of complications and death

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SV

EVLW

Preload

Large increase in EVLW Large inc in filling pressures

Small increase in COThe Frank-Starling & Marik-Phillips Curves

Large increase in COSmall increase in EVLWSmall increase in filling pressures Inc.gradient between MCFP and CVP

SepsisMCFP= Mean Circulating Filling Pressure

Techniques to Assess Fluid Responsiveness

ExcellentFair-GoodWorthlessROC Curves & Diagnostic Accuracy

Assessment of fluid responsivenessTechniqueCVP/PAOPIVC/SVC diameterFTc (LVETc)RVEDV/LVEDA/GEDIIVC/SVC - respiratory variation PPV/SVV/PVIAortic blood flow - respiratory variation Passive Leg Raising (PLR)Volume Challenge

TechnologyCVP/PACNon calibrated pulse contourBioimpedanceUltrasound (IVC/SVC)Ultrasound (IVC/SVC resp. variability)Pleth waveform (PVI)ECHO- Aortic Doppler (resp. variability)Calibrated pulse contour (PPV/SVV)Esophageal Doppler / USCOM (PLR & volume)Calibrated pulse contour (PLR & volume)NICOM (PLR & volume)

43 studies: healthy controls (n=1), ICU (n=22) and operating room (n=20) patients57 13% of patients were fluid respondersAUC was 0.56 (95% CI; 0.54 to 0.58) ICU - AUC 0.56 (95% CI; 0.52 to 0.60) OR AUC 0.56 (95% CI; 0.54 to 0.58)There is no data in any group of patients to support using the CVP to guide fluid therapy. This approach to fluid resuscitation is potentially dangerous and must be abandoned. Crit Care Med 2013;41:1774

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9th April 2015

Fluids administered 0-72 hr and 90 day mortalityControl arm of EGDT Studies 2001-20152124211518.7APACHE II

Fluids administered 0-6 hr and CVP at 6 hoursEGDT Arm 2001-2015

ARISERivers et alR2=0.84PROMISEJones et al

Jansen et al

Assessment of fluid responsivenessTechniqueCVP/PAOPIVC/SVC diameterFTc (LVETc)RVEDV/LVEDA/GEDIIVC/SVCPPV/SVV/PVIAortic blood flowPLRVolume Challenge

Hemodynamic response to a real or virtual fluid challenge

Fluid Responsiveness & Passive Leg Raising

This test consists in automatically moving the bed from a starting position where the patient is in a semi recumbent position to a position where the head and trunk are horizontal and the legs elevated at 45.This manoeuvre induces a venous blood shift from the legs and from the abdominal compartment toward the intrathoracic compartment. This produces a reversible increase in cardiac preload due to an autotransfusion effect. It can be reasonably hypothesized the increase in preload induced by PLR will result in an increase in stroke volume in case of preload responsiveness that is to say in patients will respond to fluid infusion subsequently while PLR will not increase stroke volume in case of preload unresponsiveness.

Ventricular preload Stroke Volume

AB

a'b'

ab

preload unresponsivenessPLRpreload responsiveness

Fluid Responsiveness & Passive Leg Raising

This test consists in automatically moving the bed from a starting position where the patient is in a semi recumbent position to a position where the head and trunk are horizontal and the legs elevated at 45.This manoeuvre induces a venous blood shift from the legs and from the abdominal compartment toward the intrathoracic compartment. This produces a reversible increase in cardiac preload due to an autotransfusion effect. It can be reasonably hypothesized the increase in preload induced by PLR will result in an increase in stroke volume in case of preload responsiveness that is to say in patients will respond to fluid infusion subsequently while PLR will not increase stroke volume in case of preload unresponsiveness.

Ventricular preload Stroke Volume

AB

a'b'

ab

preload unresponsivenessPLRpreload responsiveness

Unlike fluid challenge, no fluid is infused, and, the effects are reversible and transient

PLR mimics fluid challengeFluid Responsiveness & Passive Leg Raising

This test consists in automatically moving the bed from a starting position where the patient is in a semi recumbent position to a position where the head and trunk are horizontal and the legs elevated at 45.This manoeuvre induces a venous blood shift from the legs and from the abdominal compartment toward the intrathoracic compartment. This produces a reversible increase in cardiac preload due to an autotransfusion effect. It can be reasonably hypothesized the increase in preload induced by PLR will result in an increase in stroke volume in case of preload responsiveness that is to say in patients will respond to fluid infusion subsequently while PLR will not increase stroke volume in case of preload unresponsiveness.

Study name sample size AUC Monnet CCM 2006 71 0.96Lafanchre CC 2006 22 0.95Lamia ICM 2007 24 0.96Maizel ICM 2007 34 0.89Monnet CCM 2009 34 0.94Thiel CC 2009 102 0.89Biais CC 2009 30 0.96Preau CCM 2010 34 0.94 0.95Study name sample size AUC Monnet CCM 2006 71 0.75Monnet CCM 2009 34 0.68Preau CCM 2010 34 0.86

139 0.76

PLR-induced changes in PP

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Fluid Responsive. What Next!NothingDo not need to increase COIncreased lung waterMini-Fluid bolus (200-500cc LR)Give vasoconstrictor increase venous return secondary to -agonist mediated decrease in venous capacitance

Dynamic Changes in Response to Fluids or a Cardiovascular agent

Hemodynamic Assessment

Hemodynamic Assessment

Stroke volume

Ventricular preload