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
Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow
•• 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
Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow
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.
Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow
to give or not to give????
Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow
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
Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow
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
Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow
ASSESSMENT OF PRELOADFilling pressures
oCentral Venous PressureoPulmonary artery Wedge Pressure
Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow
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
Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow
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
Assessment OF PRELOADRespiratory variation in VENACVAL DIAMETER
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
Assessment OF PRELOADRespiratory variation in VENACVAL DIAMETER
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
Assessment OF PRELOADRespiratory variation in VENACVAL DIAMETER
POSITIVE PRESSURE VENTILATED PATIENTS
Could be affected by raised IAP
Assessment OF PRELOADRespiratory variation in VENACVAL DIAMETER
POSITIVE PRESSURE VENTILATED PATIENTS
Could be affected by raised IAP
Assessment OF PRELOADRespiratory variation in VENACVAL DIAMETER
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
POSITIVE PRESSURE VENTILATED PATIENTS
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
Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow
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
Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow
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
Assessment of PRELOAD DEPENDENCEPREDICTION OF PRELOAD DEPENDENCE
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
Assessment of PRELOAD DEPENDENCEPREDICTION OF PRELOAD DEPENDENCE
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
Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow
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
Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow
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
Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow
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
PREDICTION OF PRELOAD DEPENDENCERespiratory cycle induced change in parameters related to cardiac index
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%
PREDICTION OF PRELOAD DEPENDENCERespiratory cycle induced change in parameters related to cardiac index
PULSE PRESSURE VARIATION- PPV
PPmax-PPmin
PPmax+PPmin/2PPV=
PREDICTION OF PRELOAD DEPENDENCERespiratory cycle induced change in parameters related to cardiac index
PULSE PRESSURE VARIATION- PPV
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%
PREDICTION OF PRELOAD DEPENDENCERespiratory cycle induced change in parameters related to cardiac index
PULSE PRESSURE VARIATION- PPV
PREDICTION OF PRELOAD DEPENDENCERespiratory cycle induced change in parameters related to cardiac index
PULSE PRESSURE VARIATION- PPV
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
Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow
PREDICTION OF PRELOAD DEPENDENCERespiratory cycle induced change in parameters related to cardiac index
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
PULSE PRESSURE VARIATION- PPV
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
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