Obligatory joke - UCSF Medical Education · Goal-Directed Fluid Resuscitation ... San Francisco...

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9/22/2012 1 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

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