Obligatory joke - UCSF Medical Education · Goal-Directed Fluid Resuscitation ... San Francisco...
Transcript of Obligatory joke - UCSF Medical Education · Goal-Directed Fluid Resuscitation ... San Francisco...
9/22/2012
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Goal-Directed Fluid Resuscitation
Christopher G. Choukalas, MD, MS Department of Anesthesia and Perioperative Care
University of California, San Francisco
Obligatory joke
• Keep your eye on the food.
The case for why it matters
• Fluid balance a common concern
• Sepsis
• ALI/ARDS• Sepsis PLUS ARDS!
Sepsis: More is more
• Some impressive fluid totals
Study Control Intervention
Jansen (8 hrs) 2.2L 2.7L
Jones (6 hrs) 4.5L 4.3L
Rivers (6 hrs) 3.5L 5L
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Or is it?
• Retrospective analysis of VASST trial– 778 pts w/ septic shock on NE
• Divided into quartiles based on total fluid in at 12 hrs, 4 days
Dry Quartile Wet Quartile
12 hours +0.7L +8.2L
4 days +1.6L +20.5L
Boyd, JH, et al. 2011. CCM. 39(2)
Sepsis + � CVP = Death
• Outcomes: Quartile x 28 d mortality
• Early (12 hrs) and Late (4 d) “dry-ness” saved lives:– HR 0.57 and 0.47, respectively
Survival Dry Quartile Wet Quartile
12 hours 81% 58%
4 days 83% 65%
Boyd, JH, et al. 2011. CCM. 39(2)
Just the FACTTs
• 1001 w/ ALI randomized to liberal or conservative fluid algorithms
• Varying amounts of fluid, furosemide, dobutamine Outcome Conservative Liberal
Fluid total (day 7; mL) -136 +6990
Vent-Free days
ICU-Free days
Dialysis
CNS failure free days
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Outcome Conservative Liberal
Mortality (60d) 25.5% 28.4% (ns)
Vent-Free days
ICU-Free days
Dialysis
CNS failure free days
Outcome Conservative Liberal
Mortality (60d) 25.5% 28.4% (ns)
Vent-Free days +++
ICU-Free days +++
Dialysis
CNS failure free days
Outcome Conservative Liberal
Mortality (60d) 25.5% 28.4% (ns)
Vent-Free days +++
ICU-Free days +++
Dialysis Less More (ns)
CNS failure free days +++
• 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
• So how do we do it?
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
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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?
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
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Randomized trials
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
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Blood pressure
• Necessary but not sufficient
• Goals are nebulous
• Supra-normal levels common, not helpful
Hemodynamic
• Blood pressure
• CVP
• Dynamic respiratory indices:– Pulse pressure/systolic pressure/perfusion
index variation
Concept: assumptions
Adequate DO2Adequate DO2
Adequate contractilityAdequate contractility
Optimal actin-myosin matchOptimal actin-myosin match
Normal CVPNormal CVP
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The data
• Critical target in EGDT for sepsis
• Incorporated into SSC guidelines
Marik, PE, et al. 2008. Chest. 134(1)
Fluid responsiveness and total blood volume
• Prong one:– 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)
CVP
• Necessary?
• Certainly not sufficient
• Potentially misleading
Hemodynamic
• Blood pressure
• CVP/wedge
• Dynamic respiratory indices:– Pulse pressure/systolic pressure/perfusion
index variation
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The Principles
Decreased RV SV�� RV Preload�� RV Afterload
Decreased RV SV�� RV Preload�� RV Afterload
� LV Preload� LV Preload � LV SV� 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:
The data
• Small studies
• Mostly OR
SVV, Vigileo40% MORE fluidLower lactateFewer “complications”
PVI, Masimo1/3 LESS fluidLower lactate
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• 29 studies, 685 patients– 9 ICU– 20 OR (15 in cardiac surgery)
• All included correlation/ROC between SPV, PPV, or SVV and ∆SVI/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
ECOM ECOM
• ETT-based electrodes
• Current generated by flow in ascending aorta
• Current + Nomogram = SV
• SV � CO, SVV• R2 = 0.63
Wallace, AW, et al. Under Review.
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Now, keep in mind…
• Regular HR
• Sedated, mechanically ventilated
• Vt = 8 mL/kg
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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Physical exam
• Evidence of end-organ perfusion and function
• Slow to change
• Numerous confounders
• Summarily dismissed
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
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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
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?
ScvO2
• The cornerstone of Early Goal-Directed Therapy.
• And we know that targeting SvO2 �mortality.– Septic, cardiogenic shock in humans, dogs– ScvO2 = SvO2?
DOGS
Humans w/ sepsis
Humans w/ shock
Changes in SvO2 and ScvO2
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Metabolic goals
• Lactate and ScvO2
– Base deficit?– A-V CO2 gradient?
• Physiological rationale meets objective data.
In summary…
• Supply/demand mismatch
• Detected by straightforward labs
• No target-specific therapies: just get more oxygen to the cells
Putting it all together:
• Volume isn’t easy
• Volume is important
• Common conditions; competing goals• Stepwise plan
– Hemodynamic– Metabolic
The end
The End