logging in or signing up Predicting fluid response in ICU fergusona Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 476 Category: Science & Tech.. License: All Rights Reserved Like it (1) Dislike it (0) Added: July 17, 2010 This Presentation is Public Favorites: 1 Presentation Description No description available. Comments Posting comment... Premium member Presentation Transcript Predicting fluid responsein the critically ill : Predicting fluid responsein the critically ill Dr. Andrew Ferguson Consultant in Anaesthesia & Intensive Care Medicine Craigavon Area Hospital Approach to shock : Approach to shock Fluid challenge central to therapy +/- CVP (and/or PA) monitoring Repeat if CVP/PAWP still low Stop if CVP/PAWP goes high Surrogate markers for CO Lactate SvO2 So what’s the problem? : So what’s the problem? ? validity of CVP as end-point ? validity of PAWP as end-point Preload-SV relationship unknown Only 50% of patients fluid-responsive Excess fluid problems Interstitial fluid excess Worsened gas exchange Limitation of oxygen diffusion Variability of fluid response rates : Variability of fluid response rates Michard (Chest 2002; 121: 2000-2008) Preload does not guarantee response : Preload does not guarantee response To be a fluid responder, bothventricles must be on ascendingportion of Frank-Starling curve : To be a fluid responder, bothventricles must be on ascendingportion of Frank-Starling curve Response depends on contractility and diastolic function as well as load Common measures used to indicate likelihood of response : Common measures used to indicate likelihood of response CVP PAWP RVEDV (thermodilution) LVEDA (echo) Slide 9: R2 = 0.2 In spontaneous resp. a fall > 1 mmHg in RAP has positive predictive value of 77-84% and negative predictive value of 81-93% for response Slide 10: R2 = 0.33 Slide 12: ROC curve minimal correlation They don’t work---what next?? : They don’t work---what next?? BP change relates to SV change : BP change relates to SV change Cardio-pulmonary interactions : Cardio-pulmonary interactions Changes in SV, PP, SBP with positive pressure ventilation Slide 18: Increased pleural pressure RV preload falls LV afterload falls Increased transpulmonary pressure RV afterload increases LV preload increased by alveolar vessel squeeze Decreased RVSV Increased LVSV Slide 19: Inspiratory decrease in RVSV Expiratory decrease in LVSV Expiratory decrease in LV preload Pulmonary transit time Stroke volume variation and LVEDP : Stroke volume variation and LVEDP Potential tools : Potential tools Stroke volume variation Systolic pressure variation Pulse pressure variation Peak aortic blood flow velocity variation Systolic Pressure Variation : Systolic Pressure Variation Ddown is the important one for fluid response Systolic pressure variation : Systolic pressure variation DSP as indicator of fluid response : DSP as indicator of fluid response Pulse pressure variation : Pulse pressure variation DPP as indicator of fluid response : DPP as indicator of fluid response Measures of response to volume : Measures of response to volume Predictive values : Predictive values Problems with DPP and DSV : Problems with DPP and DSV Equipment not universal Need sinus rhythm False positive in severe abdominal distension Normal values : Normal values DPP 13% SPV Ddown 5% DVpeak (aortic blood flow velocity) 12% DSV 10% Conclusions : Conclusions Conventional measures often not valid New and accurate measures available Consider passive leg raising! Know cardio-pulmonary interactions You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.
Predicting fluid response in ICU fergusona Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 476 Category: Science & Tech.. License: All Rights Reserved Like it (1) Dislike it (0) Added: July 17, 2010 This Presentation is Public Favorites: 1 Presentation Description No description available. Comments Posting comment... Premium member Presentation Transcript Predicting fluid responsein the critically ill : Predicting fluid responsein the critically ill Dr. Andrew Ferguson Consultant in Anaesthesia & Intensive Care Medicine Craigavon Area Hospital Approach to shock : Approach to shock Fluid challenge central to therapy +/- CVP (and/or PA) monitoring Repeat if CVP/PAWP still low Stop if CVP/PAWP goes high Surrogate markers for CO Lactate SvO2 So what’s the problem? : So what’s the problem? ? validity of CVP as end-point ? validity of PAWP as end-point Preload-SV relationship unknown Only 50% of patients fluid-responsive Excess fluid problems Interstitial fluid excess Worsened gas exchange Limitation of oxygen diffusion Variability of fluid response rates : Variability of fluid response rates Michard (Chest 2002; 121: 2000-2008) Preload does not guarantee response : Preload does not guarantee response To be a fluid responder, bothventricles must be on ascendingportion of Frank-Starling curve : To be a fluid responder, bothventricles must be on ascendingportion of Frank-Starling curve Response depends on contractility and diastolic function as well as load Common measures used to indicate likelihood of response : Common measures used to indicate likelihood of response CVP PAWP RVEDV (thermodilution) LVEDA (echo) Slide 9: R2 = 0.2 In spontaneous resp. a fall > 1 mmHg in RAP has positive predictive value of 77-84% and negative predictive value of 81-93% for response Slide 10: R2 = 0.33 Slide 12: ROC curve minimal correlation They don’t work---what next?? : They don’t work---what next?? BP change relates to SV change : BP change relates to SV change Cardio-pulmonary interactions : Cardio-pulmonary interactions Changes in SV, PP, SBP with positive pressure ventilation Slide 18: Increased pleural pressure RV preload falls LV afterload falls Increased transpulmonary pressure RV afterload increases LV preload increased by alveolar vessel squeeze Decreased RVSV Increased LVSV Slide 19: Inspiratory decrease in RVSV Expiratory decrease in LVSV Expiratory decrease in LV preload Pulmonary transit time Stroke volume variation and LVEDP : Stroke volume variation and LVEDP Potential tools : Potential tools Stroke volume variation Systolic pressure variation Pulse pressure variation Peak aortic blood flow velocity variation Systolic Pressure Variation : Systolic Pressure Variation Ddown is the important one for fluid response Systolic pressure variation : Systolic pressure variation DSP as indicator of fluid response : DSP as indicator of fluid response Pulse pressure variation : Pulse pressure variation DPP as indicator of fluid response : DPP as indicator of fluid response Measures of response to volume : Measures of response to volume Predictive values : Predictive values Problems with DPP and DSV : Problems with DPP and DSV Equipment not universal Need sinus rhythm False positive in severe abdominal distension Normal values : Normal values DPP 13% SPV Ddown 5% DVpeak (aortic blood flow velocity) 12% DSV 10% Conclusions : Conclusions Conventional measures often not valid New and accurate measures available Consider passive leg raising! Know cardio-pulmonary interactions