5/9/2015

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Goal-Directed Fluid Resuscitation

Christopher G. Choukalas, MD, MS Department of Anesthesia and Perioperative Care

University of California, San Francisco

Goal-Directed Fluid Resuscitation

Christopher G. Choukalas, MD, MS Department of Anesthesia and Perioperative Care

University of California, San Francisco

The case for why it matters

• Fluid balance a common concern

• Sepsis

• ALI/ARDS

• Sepsis PLUS ARDS!

• Patients with Sepsis who developed ALI

• 4 groups:

– Adequate initial + Conservative late fluids

– Adequate initial only

– Conservative late only

– Neither

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Murphry, CV, et al. 2009. Chest. 136(1)

It matters

• And it’s hard…

• … and we’re really bad at it!

• Retrospective, 8000 cases,

uncomplicated, elective

• mL/kg/hr by center, case type, provider

– 6.7 vs 8.2

– Huge inter-provider differences

• 700 vs 5.4

• Exceeded differences due to blood loss,

hemodynamic factors, case type

It matters

• And it’s hard…

• So how do we do it?

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I would posit two factors:

• Hemodynamic:

– Is the circulation adequate?

• Metabolic

– Are oxygen delivery and utilization adequate?

• Both have their own goals.

Hemodynamic Goals

• Blood pressure

• CVP

• Dynamic respiratory indices:

– Pulse pressure/systolic pressure/perfusion

index variation

Hemodynamic Goals

• Blood pressure

• CVP

• Dynamic respiratory indices:

– Pulse pressure/systolic pressure/perfusion

index variation

Blood pressure

• A proxy for flow, end organ perfusion

• Flow = pressure/resistance

• Do we ever really KNOW resistance?

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Wax, et al.

• Non-cardiac cases with both ABP and

NIBP.

• Compared SBP, DBP, and MAP btwn

technologies:

– A-line alone vs A-line + cuff

Randomized trials

• This used to be the 2nd joke of the talk

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Interesting review

• Reviewed 2 trials and 1 meta-analysis (13

studies)

– Target BP

– Actual BP

• Dissociation

– BPs invariably higher than goal

– Higher goal ranges permitted higher actual

ranges: pressors

The NEJM study

• Randomized to MAP 65 vs 85 (800 total)

• Norepinephrine

• Mortality

• AKI/RRT, stratified by HTN

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Blood pressure

• Necessary but not sufficient

• Goals are nebulous

• We’re really bad at following them

• Supra-normal levels common, not helpful

Hemodynamic

• Blood pressure

• CVP

• Dynamic respiratory indices:

– Pulse pressure/systolic pressure/perfusion

index variation

Concept: assumptions

Adequate DO2

Adequate contractility

Optimal actin-myosin match

Normal CVP

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The data

• Critical target in EGDT for sepsis

• Incorporated into SSC guidelines

Sepsis + CVP = Death

• Retrospective analysis of VASST trial

– 778 pts w/ septic shock on NE

• CVP at 12 hrs did predict 28-d mortality in

patients:

Boyd, JH, et al. 2011. CCM. 39(2)

HR

CVP < 8 0.61

CVP 8-12 0.76

CVP >12 1

Marik, PE, et al. 2008. Chest. 134(1)

Fluid responsiveness and total

blood volume

• Volume responsiveness

• Cardiac output before and after fluid

challenge

• 19 evaluated CVP and volume

responsiveness

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Fluid responsiveness

• Calculated a Receiver Operating

Characteristic curve

• Likelihood that at any given point (CVP

level, score, etc) the true positives will

exceed false positives.

• Higher = better discrimination

Volume responsiveness

Marik, PE, et al. 2008. Chest. 134(1)

Deja vu

• 43 studies, half ICU

• Same design

– AUC btwn CVP and ΔSV

• Same pooled AUC

– 0.56

• Same aggressive conclusion

CVP

• Necessary?

• Certainly not sufficient

• Potentially misleading

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Hemodynamic

• Blood pressure

• CVP

• Dynamic respiratory indices:

– Pulse pressure/systolic pressure/perfusion

index variation

The Principles

Decreased RV SV

RV Preload

RV Afterload

LV Preload LV SV

Applies to lots of measures

• Systolic pressure variation

• Pulse pressure variation

• Plethysmogram variation

• Outcome is “fluid responsiveness”

Variations on a theme…

• A waveform…

• A peak and trough…

• And a proprietary algorithm:

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The data

• Small studies

• Mostly OR

SVV, Vigileo

40% MORE fluid

Lower lactate

Fewer “complications”

PVI, Masimo

1/3 LESS fluid

Lower lactate

• 29 studies, 685 patients

– 9 ICU

– 20 OR (15 in cardiac surgery)

• All included correlation/ROC between

SPV, PPV, or SVV and ΔSVI/CI after a

fluid challenge.

Measure r AUC for ROC Threshold

PPV 0.78 0.94 12.5%

SVV 0.72 0.84 15.3%

SPV 0.72 0.86

CVP 0.56

Now, keep in mind…

• Regular HR

• Sedated, mechanically ventilated

• Vt = 8 mL/kg

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Non-invasive CO toys Hemodynamic goals

• Numerous

• State of the art: Dynamic indices

– PPV

– SPV

– PVI

– VTI and esophageal doppler

• Necessary but not sufficient

Metabolic

• Mental status, urine output

• Lactate

• S(c)vO2

Metabolic

• Mental status, urine output

• Lactate

• S(c)vO2

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Metabolic

• Mental status, urine output

• Lactate

• S(c)vO2

Lactate

• The product of anaerobic respiration

• Presence implies inadequate oxygen

utilization, shock

• Easily, quickly measured in arterial blood

Lactate: the data

Two trials:

• JAMA: 300 patients, EGDT vs lactate

clearance

– Non-inferiority

• AJRCCM: 348 patients, EGDT vs lactate

clearance

– Improved mortality (multivariate)

– Less time on vent, in ICU

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How did they do it?

Jones, et al (JAMA) Jansen et al (AJRCCM)

Monitoring interval 2 2

Goal 10% clearance 20% clearance

Fluid totals (L) Control: 4.3

Intervention: 4.5ns

Control: 2.2

Intervention: 2.7*

Outcome Non-inferiority to EGDT Decreased time on vent,

in ICU

The underpinnings…

Metabolic

• Mental status, urine output

• Lactate

• S(c)vO2

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How it’s used:

ScvO2 attributed to:

Supply (cardiac output)

Demand (hypermetabolism)

• In either case, treat by increasing DO2

– Volume, inotropes, RBCs

• But does it work?

DOGS

Humans w/ sepsis

Humans w/ shock

Changes in SvO2 and ScvO2

But does it work?

• Rivers, et al.

Metabolic goals

• Lactate

• ScvO2

• Physiological rationale meets objective

data.

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Does any of this…

• Save lives?

• Save money?

• Actually work?

Single point design

• Close to the patient

• “does this surrogate metric predict optimal

filling/SV/some outcome”

• These seem to work

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Subgroup Mortality Complications

Jadad high --- +++

Jadad low +++ +++

1980s-1990s +++ +++

2000s --- +++

Taking a step back… Similar goals (SVV), similar

protocols…

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…different outcomes

• Fewer post-op complications

• Left the ICU and hospital a full day sooner

• No difference in fluid totals, RBCs, UOP

»VS

• No difference on any clinical measure

So is GDT no good, or…

• Basically shows the NICOM doesn’t work?

• Complication rate much lower than

expected (underpowered?)

• GDT group bolused starch and gelatin

(twice the control group)

• Indictment of GDT?

Does the PROCESS of GDT aRISE to the

challenge?

Does the PROCESS of GDT aRISE to the

challenge? Will GDT SURVIVE?

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Putting it all together:

• Volume isn’t easy

• Volume is important

• Common conditions; competing goals

• Stepwise plan

– Hemodynamic

– Metabolic

• It seems to work

The end

The End