Fluid Responsiveness in Critically ill Patients

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Fluid Responsiveness in Critically ill Patients:

Fluid Responsiveness in Critically ill Patients Ubaidur Rahaman Senior Resident, CCM, SGPGIMS Lucknow, India

Slide 2:

Definition : fluid responsiveness denotes an increase in cardiac index after infusion of a fluid either crystalloid or colloid. FLUID RESPSONSIVENSS

FLUID RESUSCITATION 3 DIFFERENT SCENARIO:

FLUID RESUSCITATION 3 DIFFERENT SCENARIO Patients in the ERS for acute blood losses or body fluid losses Patients in the ERS for high suspicion of septic shock Patients in the ICU, already resuscitated for several hours or days No therapeutic dilemma regarding hypovolemia EGDT- volume resuscitation mandatory in first 6 hours- mortality benefit

Slide 4:

hemodynamic instability requiring therapy ? Fluid responsiveness Cumulative fluid balance Risk of pulmonary oedema/ raised IAP Patients in the ICU, already resuscitated for several hours or days

Cumulative fluid balance and mortality:

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: The Vasopressin in Septic Shock Trial (VASST) study enrolled 778 patients who had septic shock and who were receiving a minimum of 5 ug of norepinephrine per minute.

Assessment OF FLUID RESPONSIVENESS:

Assessment OF FLUID RESPONSIVENESS PRELOAD CONTRACTILITY CARDIAC INDEX PRELOAD DEPENDENCE Both ventrilcles should be preload dependent

Assessment of PRELOAD is not assessment of PRELOAD DEPENDENCE:

Assessment of PRELOAD is not assessment of PRELOAD DEPENDENCE Stroke volume Ventricular preload normal heart failing heart preload-dependence preload-independence

ASSESSMENT OF FLUID RESPONSIVENESS:

ASSESSMENT OF FLUID RESPONSIVENESS ASSESSMENT OF PRELOAD- Filling pressures- CVP, Pcwp, Filling volumes- LVEDV/ RVEDV VENACAVAL DIAMETER- variation with respiration RAP - inspiratory fall ( spontaneous breathing) ASSESSMENT OF PRELOAD DEPENDENCE- Response to fluid challenge Prediction of preload dependence- PPV induced respiratory variation in CI parameters

ASSESSMENT OF PRELOAD Filling pressures:

ASSESSMENT OF PRELOAD Filling pressures Central Venous Pressure: Pulmonary Capillary Wedge Pressure

Central Venous Pressure:

Central Venous Pressure Venous function and central venous pressure. A physiologic story. Simon Gelman. Anesthesiology 2008;108:735-48

Central Venous Pressure:

Central Venous Pressure VR- function of MCFP Vs Venous resistance CVP – function of VR Cardiac pump function

C.O. is determined by intersection of :

C.O. is determined by intersection of Q Pra Q Pra Q Pra RETURN FUNCTION CARDIAC FUNCTION How to use CVP measurements. Magder S. Current Opinion in Critical Care 2005, 11:264—270

CONCEPT OF LIMIT:

CONCEPT OF LIMIT Q Pra Limit of “RETURN FUNCTION” Limit of “CARDIAC FUNCTION” Lowering Pra will not increase VR Increasing Pra will not Increase C.O. How to use CVP measurements. Magder S. Current Opinion in Critical Care 2005, 11:264—270

Is CVP a misleading variable?:

Is CVP a misleading variable? Body does everything to maintain homeostasis- adequate transmural pressure MCFP- more accurate measurement of volume status- difficult to measure Ppawp is an even worse indicator than CVP as it is far removed from the action of MCFP RAP and Ppaw do not always reflect true transmural pressure in patients on PEEP, increased IAP “The correlation between CVP and circulating blood volume has never been found simply because it does not exist” Venous function and central venous pressure. A physiologic story. Simon Gelman. Anesthesiology 2008;108:735-48

:

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 CVP & blood volume 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 hemodynamic response to fluid challenge overall 56% patients responded to fluid challenge

Slide 16:

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 decrease in RAP, ddown, PPV, and Vpeak were significantly higher in responders. Positive predictive value: 77- 95% negative predictive value: 81- 100%

ASSESSMENT OF PRELOAD Filling Volumes:

ASSESSMENT OF PRELOAD Filling Volumes RVEDV LVEDV

Assessment OF PRELOAD Respiratory variation in VENACVAL DIAMETER:

Assessment OF PRELOAD Respiratory variation in VENACVAL DIAMETER IVC collapsibility index ≥ 50% is strongly associated with low CVP Emergency department bedside ultrasonographic measurement of caval index for noninvasive Determination 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 PRELOAD Respiratory variation in VENACVAL DIAMETER:

Assessment OF PRELOAD Respiratory 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 fluid responsiveness in ventilated septic patients. Barbier C, Jardin F. Inten Car Med 2004;30:1740-6 divc=(Dmax-Dmin)/ Dmin IVC distensibility index ( DD IVC) ≥ 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 PRELOAD Respiratory variation in VENACVAL DIAMETER:

Assessment OF PRELOAD Respiratory variation in VENACVAL DIAMETER POSITIVE PRESSURE VENTILATED PATIENTS Could be affected by raised IAP

Assessment OF PRELOAD Respiratory variation in VENACVAL DIAMETER:

Assessment OF PRELOAD Respiratory variation in VENACVAL DIAMETER POSITIVE PRESSURE VENTILATED PATIENTS Could be affected by raised IAP

Assessment OF PRELOAD Respiratory variation in VENACVAL DIAMETER:

Assessment OF PRELOAD Respiratory 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 ventilated septic 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 PRELOAD Inspiratory fall in right atrial pressure :

Assessment OF PRELOAD Inspiratory 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:

Assessment OF PRELOAD DEPENDENCE PREDICTION BY PPV induced RESPIRATORY VARIATION IN C.I. RELATED PARAMETERS FLUID CHALLENGE

Assessment OF PRELOAD DEPENDENCE:

Assessment OF PRELOAD DEPENDENCE change in filling pressures- CVP, RAP, Pcwp change in perfusion markers- C.O., MAP, CFT, ABG, SCVO2, B. lactate Disadvantages pulmonary edema excessive cumulative fluid balance Response to FLUID CHALLENGE

Assessment of PRELOAD DEPENDENCE PREDICTION OF PRELOAD DEPENDENCE:

Assessment of PRELOAD DEPENDENCE PREDICTION OF PRELOAD DEPENDENCE Spontaneously breathing patients PLR- ∆ 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 DEPENDENCE PREDICTION OF PRELOAD DEPENDENCE:

Assessment of PRELOAD DEPENDENCE PREDICTION OF PRELOAD DEPENDENCE PASSIVE LEG RAISING 45 ° Venous blood shift (Rutlen et al. 1981 , Reich et al. 1989) Transient and reversible effect

Assessment of PRELOAD DEPENDENCE PREDICTION OF PRELOAD DEPENDENCE PLR:

Assessment of PRELOAD DEPENDENCE PREDICTION OF PRELOAD DEPENDENCE PLR Passive leg raising predicts fluid responsiveness in the critically ill Xavier Monnet, Mario Rienzo, David Osman, Nadia Anguel, C. Richard, Michael R. Pinsky, Jean-Louis Teboul, Crit Care Med 2006; 34:1402–1407 hemodynamic 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 induce increase in aortic blood flow ≥10% predicted volume expansion induced increase in aortic blood flow ≥15% (sensitivity- 97%, specificity 94%) In group 1, PLR induce PPV >12% was predictive of volume responsivenes (sensitivity- 88%, specificity- 93%) In group 2, PLR induced PPV poorly predicted preload responsiveness

Assessment of PRELOAD DEPENDENCE PREDICTION OF PRELOAD DEPENDENCE- PLR:

Assessment of PRELOAD DEPENDENCE PREDICTION OF PRELOAD DEPENDENCE- PLR Baseline PLR Change Cardiac output ( l/min) 4.5± 1.1 5.7 ± 1.1 23 PAOP ( mmHg) 12.9 ± 4.5 14.1± 4.8 10 SPV ( mmHg) 11.3 ± 5.1 5.9 ± 2.4 48 dDown ( mmHg) 7.5 ± 3.7 3.3 ± 2 56 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 DEPENDENCE Effect of Positive Pressure Mechanical Ventilation on Hemodynamics:

PREDICTION OF PRELOAD DEPENDENCE Effect of Positive Pressure Mechanical Ventilation on Hemodynamics Paw PAlv Ppl Transmural pressure cardiac chambers/ great vesseles Filling gradient of RV Filling gradient of LV no effect Transpulmonary pressure alveoli Zone 3 to zone 2/1 formation PVR RV afterload RV preload RV stroke volume LV stroke volume Pulmonary Transit time PAlv Ppl Palv Ppl Mainly responsible for change in stroke volume

PREDICTION OF PRELOAD DEPENDENCE Effect of Positive Pressure Mechanical Ventilation on Hemodynamics:

PREDICTION OF PRELOAD DEPENDENCE Effect of Positive Pressure Mechanical Ventilation on Hemodynamics Paw Transmural pressure cardiac chambers Transpulmonary pressure alveoli squeezing of blood out of alveolar vesseles LV preload LV afterload LV stroke volume Palv Ppl Predominant mechanism in hypervolemia Predominant mechanism in LV systolic dysfunction

Slide 33:

Pleural pressure transpulmonary pressure RV preload LV afterload LV preload RV afterload RV ejection LV ejection LV ejection LV preload Pumonary transit time Aortic velocity Stroke volume Systolic B.P. Pulse Pressure Aortic velocity Stroke volume Systolic B.P. Pulse Pressure MAXIMUM AT END OF INSPIRATION MINIMUM AT END OF EXPIRATION PREDICTION OF PRELOAD DEPENDENCE Effect of Positive Pressure Mechanical Ventilation on Hemodynamics

Effect of Positive Pressure Mechanical Ventilation on Hemodynamics SYSTOLIC PRESSURE VARIATION- SPV:

Effect of Positive Pressure Mechanical Ventilation on Hemodynamics SYSTOLIC PRESSURE VARIATION- SPV PROPOSED BY COYLE IN 1983 dup inspiratory increase in systolic pressure: increased LV Stroke volume- increased preload decreased afterload Increase in extramural aortic pressure Ddown Expiratory decrease in systolic pressure: decrease in LV stroke volume- decrease in preload

Effect of Positive Pressure Mechanical Ventilation on Hemodynamics SYSTOLIC PRESSURE VARIATION- SPV:

Effect of Positive Pressure Mechanical Ventilation on Hemodynamics SYSTOLIC PRESSURE VARIATION- SPV Systolic pressure variation as a guide to fluid therapy in patients with sepsis induced hypotension Taverneir B, Dupont J. Anesthesiology 1998, 89:1313-1321 dup- increase in hypervolemia and LVF ddown-not increased in RVF despite hypovolemia * cardiovascular monitoring Chapter 32, page 1327, Miller’s Anesthesia 7 th edi In the presence of large dup, the PPV, SPV and SVV will be less effective in 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%

Effect of Positive Pressure Mechanical Ventilation on Hemodynamics PULSE PRESSURE VARIATION- PPV:

Effect of Positive Pressure Mechanical Ventilation on Hemodynamics PULSE PRESSURE VARIATION- PPV PPmax-PPmin PPmax+PPmin/2 PPV=

Effect of Positive Pressure Mechanical Ventilation on Hemodynamics PULSE PRESSURE VARIATION- PPV:

Effect of Positive Pressure Mechanical Ventilation on Hemodynamics 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 TEBOUL Am J Respir Crit Care Med Vol 162. pp 134–138, 2000 Baseline VE HR (beats/min) 11o± 22 106 ± 21 MAP 69 ± 13 90 ± 13 Pra (mmHg) 9 ± 3 12 ± 4 Pcwp (mmHg) 10 ± 3 14 ± 3 Ppa (mmHg) 24 ± 6 29 ± 6 CI (l/min/m2) 3.6 ± 0.9 4.0 ± 0.9 ∆PPV (%) 14 ± 10 7 ± 5 ∆SPV (%) 9 ± 6 6 ± 4 Threshold value of 13% was associated with increase in C.I. ≥ 15% in response to volume expansion Sensitivity- 94%, specificity- 96%

Effect of Positive Pressure Mechanical Ventilation on Hemodynamics PULSE PRESSURE VARIATION- PPV:

Effect of Positive Pressure Mechanical Ventilation on Hemodynamics PULSE PRESSURE VARIATION- PPV

Effect of Positive Pressure Mechanical Ventilation on Hemodynamics PULSE PRESSURE VARIATION- PPV:

Effect of Positive Pressure Mechanical Ventilation on Hemodynamics PULSE PRESSURE VARIATION- PPV increase in SPV no change in PPV Inspiratory increase in pleural pressure Increase in extra-mural pressure Equal increase in Systolic pressure And Diastolic pressure PPV better predictor than other SV derived variables

Effect of Positive Pressure Mechanical Ventilation on Hemodynamics RESPIRATORY SYSTOLIC VARIATION TEST ( RSVT):

Effect of Positive Pressure Mechanical Ventilation on Hemodynamics RESPIRATORY SYSTOLIC VARIATION TEST ( RSVT) RSVT slope RSVT slope 0.24 mmHg/ cmH2O predicted 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

Slide 41:

“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 function…” William Hurford, Inten Car Med, 1988 Presence of fluid responsiveness is not an indication by itself to administer fluids

Slide 42:

THANK YOU

Slide 43:

PPV Pulse pressure depends on stroke volume and arterial compliance Change in compliance may affect degree of PPV induced by increase in stroke volume Elderly- stiff arteries--- small increase in stroke volume--- large PPV Young healthy adult- large increase in stroke volume – relatively small PPV

CVP:

CVP Effect of pleural pressure 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--- ARDS PEEP – <=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 Effect of forced expiration on pleural pressure

Respiratory change in pleural pressure:

Respiratory change in pleural pressure Respiratory change in Pcwp Respiratory change in esophageal pressure

Fluid challenge:

Fluid challenge Rapidity of fluid infusion is important- faster the fluid is given, lesser the amount to be given type of fluid- crystalloid or colloid does not matter Change in CVP and not the volume of infusion that is important Blood pressure is not a good guide as to whether C.O. increased with fluid infusion 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:

Role of echocardiography Assessment of inadequate resuscitation: Volume status and responsiveness – fluid resuscitation Cardiac contractility -- ionotrope

Effect of Positive Pressure Mechanical Ventilation on Hemodynamics PULSE PRESSURE VARIATION- PPV:

Effect of Positive Pressure Mechanical Ventilation on Hemodynamic s 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