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Should I bother about Ebb and Flow phase of shock? (What did I learn last year)

Should I bother about Ebb and Flow phase of shock? (What did I learn last year). 17th November 2012 2nd iFAD– Interactive Case Discussion Manu Malbrain. Disclosure. The speaker consults for the following companies: KCI Pulsion Medical System ConvaTec Edwards Fresenius- Kabi.

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Should I bother about Ebb and Flow phase of shock? (What did I learn last year)

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  1. Should I bother about Ebb and Flow phase of shock? (What did I learn last year) 17th November 2012 2nd iFAD– Interactive Case Discussion Manu Malbrain

  2. Disclosure • The speaker consults for the following companies: • KCI • Pulsion Medical System • ConvaTec • Edwards • Fresenius- Kabi

  3. Therapeutic Dilemma - Conflict Kidney Lung Liver Heart

  4. Today’s Agenda • The risks of fluid overload • Interactive Case Discussion • Meta-analysis • 3-hit model • Integrated approach • Wrap it up

  5. Fluid Overload The Risk of Fluids

  6. What I really need to know is… SEE • When do I start giving fluids? • When do I stop giving fluids? • When do I start emptying? • When do I stop emptying? benefit of fluid administration? MORE risk of fluid administration? THAN benefit of fluid removal? OTHERS risk of fluid removal?

  7. Introduction • Any measurement in the ICU stands or falls with its accuracy and reproducibility… • No measurement has ever improved survival, only a good a protocol can… Hemodynamic treatment algorithms should follow physiology or they fail to improve outcome. Malbrain Manu and Reuter Daniel – CCM 2012;40:2923

  8. Example of a Poor Protocol… Fluid Challenge EVLWI < 10 GEDVI < 850 We must NOT give a fluid challenge Trof RJ et al. CCM 2012; 40

  9. SEPTIC SURGICAL 694 788 GEDVI < 850 ml/m2 is too high

  10. Flow Phase of SHOCK Ebb Phase of SHOCK Fluid Guidance: MAP, SVV, PPV, GEF/GEDVI, PLR, TEO Fluid Guidance: Positive (Σ) Fluid balance, IAP, EVLWI EVLWI is NOT a trigger for Fluids “The patient warms up, cardiac output increases and the surgical team relaxes…” “Ashen faces, a thready pulse and cold clammy extremities…” The Flow Phase - Cuthbertson. Lancet 1:233, 1942 The Ebb Phase - Cuthbertson, Quart. J. Med.25:233,1932

  11. Septic Shock Patients (n=36) Alsous et al. Chest 2000; 117: 1749-54

  12. Better lung function: • LIS↓ • FiO2/pO2 ↑ • Pplat ↓ • PEEP ↓ • Cum FB: 6992±502 ml No excess extra-pulmonary organ failure • Cum FB: -136±494 ml RCCT, N=1000

  13. Case Study From Ebb to Flow phase

  14. LI, Male, 26 years old • O2 debt during birth • CVA, left hemiparesis • Epilepsy • Topamax, lamictal, tegretol • Cognitive deficit • Special daycare • Since age of 17 known with ideopathic CMP (LVEF 52%) • Coversyl

  15. Reason for admission • General seizures • Different from previous • Syncope • BP not palpable • On ED: VT? • DC biphasic 200J • Transfer to ICU

  16. Evolution Overnight • Hemodynamically stable • No seizures • Gradual increase in supplemental O2-needs • From 2L via nasal cannula • To 15L with NRM • Failure of NIV • ETT and MV

  17. After ETT • Hemodynamically Unstable • CVP 16 mmHg • MAP 51 mmHg • On conventional MV • Evita XL FiO2 100% • 24 x 400 mL • PEEP 10 • P/F ratio 74

  18. Transthoracic Cardiac US LVEF 30% MR 2 to 3/4

  19. TT Cardiac US • Dilated CMP (Left atrium 65mm) • CO: 6.2 L/min (CI 3.5) • LVEF: 30-35%, FAC: 28.5% • LVEDA: 28.7 cm2 – LVEDAi: 16.2 cm2 • E/E’: 15 - LVEDP: 25 mmHg • MR 2 to ¾ (central + 2 eccentric jets) • VCI: 21 mm

  20. Question 1: What is your treatment of choice? Norepinephrine Dobutamine Fluids bolus Diuretics Other Lactate 2.8

  21. Further course… • Norepinephrine was started • Swiftly increased to 0.4 y • Dobutamine started at 3y • FiO2 was increased to 100% • PEEP set according to PV loop • BPsys drop to 40 mmHg during recruitment • Saturation poor at 88% • Switch to HFPV – VDR4

  22. PiCCO catheter - TPTD Normal Values: PPV: <10 % GEDVI: 600 – 850 GEF: 25-35% EVLWI: 3 – 7 PVPI: 1 – 3 • CI: 3.5 • PPV: 19% • GEDVi: 757 ml/m2 – GEF: 13% • EVLWi: 38 ml/kg PBW – PVPI: 7.4 • PLR = POSITIVE (15% increase in CI)

  23. Question 2: What is your treatment of choice? Normal Values: PPV: <10 % GEDVI: 600 – 850 GEF: 25-35% EVLWI: 3 – 7 PVPI: 1 – 3 Norepinephrine Dobutamine Fluids bolus Diuretics Other HFPV 30/10

  24. Decision Tree..

  25. General Question • How do you explain the relative discrepancy between the volumetric (low normal – GEDVi 757) and barometric (high normal – CVP 14) preload indicators in this patient? • Remember that the SSC guidelines state that CVP must be resuscitated towards 8-12 mmHg

  26. Surviving Sepsis Guidelines IAP 11 • CVP: 8-12 mmHg • Chasing a CVP may lead to: • OVER resuscitation • UNDER resuscitation

  27. Barometric vs Volumetric preload? MV-IPPV (auto)PEEP Post CABG Obesity IAH-ACS • Don’t trust traditional BAROmetric filling pressures (CVP or PAOP) • Use Volumetric preload indicators (GEDVI: PiCCO/EV1000 or RVEDVI: PAC) • Malbrain et al. Current Opinion Crit Care 2004; 10(2): 132-145

  28. Surviving Sepsis Guidelines

  29. Crit Care Med 2008; 36:296-327 [published correction in Crit Care Med 2008; 36:1394-1396]

  30. Surviving Sepsis Guidelines

  31. TT Cardiac US • Small volume resuscitation (SVR): Hyperhaes 4ml/kg/15min • 2x 500ml Volulyte IVCCI= 50%

  32. Next morning

  33. Evolution overnight • CI h • GEDVI h • EVLWI i • MAP h CVP decreased from 14 to 6 mmHg with filling

  34. Respiratory Support overnight HFPV NO (stand-by) • pO2 h • P/F h • FiO2 i • IPAP h

  35. Next morning on Day 2

  36. Therapeutic Dilemma… We gave fluids because: • PPV was high and PLR was positive • The GEDVI was relatively low (in relation to GEF) despite the increased CVP, LVEDAI and high EVLWI… • IVCCI was almost 50%

  37. So,… What I really need to know: • What is the Frank Starling curve of my patient? • Where is my patient on the curve?

  38. Solution: GEF-corrected GEDVi • When to use? Malbrain M. et al. AAS 2010; 54(5): 622-631

  39. ? LVED area on TTE LVEDA 34cm2 28cm2 After 30% blood loss of CBV

  40. EF corrected volumes? GEF 0.15 GEF 0.25 GEDVI GEF 0.35 Cardiac INDEX • Malbrain, Cheatham. Yearbook Intensive Care 2004

  41. X Pressures as preload? ΔCI ΔCVP ΔPCWP

  42. X Volumes as preload? ΔCI ΔRVEDV ΔGEDV

  43. Corrected volumes vs preload? ✓ ΔCI ΔcRVEDV ΔcGEDV

  44. Question 3: The premature hump on the transpulmonary thermodilution curve is… • Crosstalk phenomenon • Bolus mixing • Right-to-left shunt • Wrong/false measurement • I don't know

  45. Premature hump = Hypovolemia GEDVi : 288 GEDVi : 537 Pulmonary Hypertension Before filling (at 8:40) after filling with 500mL Voluven (at 9:02) Septic shock 100% FiO2 – PEEP 12 – extremely underfilled

  46. Right-to-Left shunt on TPTD EVLW LV RV PBV LA RA

  47. PEEP Our patient became extremely hypotensive during recruitment ZEEP PEEP Michard F et al. CCM 2004 Jan;32(1):308-9.

  48. West Lung Zones ZONE 1: Palv > Part > Pven Hypovolemia ❶ ZONE 2: Part > Palv > Pven High PEEP ZONE 3: Part > Pven > Palv ❷ ❶ Right-to-Left Shunt

  49. Evolution late afternoon D2 • Urine output only 350 over 12 hours… • FiO2 increased from 45% to 65% (P/F 200) • Lactate increased from 1.6 to 2.6 • Cumulative FB +4L

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