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Fluid Responsiveness

Fluid Responsiveness. Dr. Daniel Rankmore JHH ICU Junior Doctor Teaching 7 th March 2012. Today’s Topic. Why give fluids “Fluid responsive” What fluids are avalible. Why g ive fluids. the air goes in and out and the blood goes round and round. Oxygen Delivery (DO 2 ).

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Fluid Responsiveness

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  1. Fluid Responsiveness Dr. Daniel Rankmore JHH ICU Junior Doctor Teaching 7th March 2012

  2. Today’s Topic Why give fluids “Fluid responsive” What fluids are avalible

  3. Why give fluids the air goes in and out and the blood goes round and round Oxygen Delivery (DO2)

  4. Why give fluids

  5. DO2 > VO2 = Shock = Bad

  6. Oxygenation + DO2 Cardiac Output

  7. Tissue Diffusion FiO2 Gas Movement Heam Cytochrome Mitochonrial Airway Alveolar Diffusion Hb Oxygenation + DO2 Cardiac Output (Bersten & Soni, 2009, pp. 317-318):

  8. DO2 Cardiac Output x SV HR

  9. DO2 Cardiac Output x SV HR Preload Contractility Afterload Filling Time

  10. Frank Starling A ‘normal’ heart Stroke Volume A heart ‘failing’ ‘Preload’

  11. Frank Starling 500mlBolus Stroke Volume SVCO ‘Preload’

  12. Frank Starling Curve 500mlBolus Stroke Volume SVCO ‘Preload’

  13. Frank Starling Curve Pulmonary Oedema EVLW Stroke Volume SVCO 500mlBolus ‘Preload’

  14. Liberal Fluid Therapy compared with either Goal Directed Therapy or Restrictive Fluid Therapy • 3861 patients in 35 RCTs • Liberal vs Restrictive • Pneumonia RR 2.2 95% CI 1-4.5 • Pulmonary Oedema RR 2.8 95% CI 1.1-13 • Longer Hospital Stay Mean 2 Days 95% CI 0.5-3.4 • Goal Directed vs Not Goal Directed • Pneumonia RR 0.7 (CI 0.6-0.9) • Renal Complications RR 0.7 (CI 0.5-0.9) • Reduced Hospital Stay Mean 2 Days (CI 1-3) • Liberal • Prolonged Hospital StayMean 4 Days (CI 3.4-4.4) • Time to first bowel movement 2 Days (CI 1.3-2.3)

  15. RCT 1000 patients with ALI 60 day follow up • Primary end point – mortality. • Secondary end points – lung physiology, vent free days, organ failure free days • 7 day fluid balance 136ml vs. 6992mls.

  16. Three studies of colorectal surgery • Reduced incidence of cardiorespiratory and fewer post operative problems.

  17. 88 patients undergoing major abdo surgery. • PVI group – 500ml crystalloid bolus then 2ml/kg/hr if PVI <13% then 250ml colloid given, MAP maintained with vassopressors. • Control group – 500ml crystalloid then fluid management per CVP and MAP. • PVI group – improved intra-op and post op lactate and reduced total fluid input.

  18. Retrospective review of IV fluids in the first 4 days of 778 patients in the VASST (Vasopressin in Septic Shock Trial) • Conclusion: • A more positive fluid balance at 12 hours and 4 days was associated with increased mortality. • CVP correlated with IV Fluid given for the first 12 hours.

  19. When to give fluids Giving what the patient needs when the patient needs it Fluid Responsiveness

  20. Fluid Responsiveness >15% increase in Cardiac Output following 500-1000ml fluid bolus

  21. Static Measurements • BP (MAP) • UO • CVP • PAOP – ‘the wedge’ • ITBV • MVSaO2 • IVC Diameter • LVEDA

  22. Central Venous Pressure The number that keeps getting measured…

  23. Studies included • CVP & Blood volume (5 studies) • CVP or ΔCVP cf: SI and CI pre & post boluses (24 studies heterogeneous patient cohort including vascular surg, CABG, Sepsis, Health, 803 patients)

  24. Central Venous Pressure

  25. Central Venous Pressure • CVP & blood volume: 0.16 (95% CI: 0.03-0.28) • CVP & SVI/CI: 0.18 (95% CI: 0.08-0.28) ROC 0.56 • ∆CVP & SVI/CI: 0.11 (95% CI: 0.015-0.25) • ROC 0.5 true-positive = false positive • ROC 0.9+ an adequate test • Conclusion • In none of the included studies was CVP able to predict fluid responsive or blood volume.

  26. Central Venous Pressure

  27. Hea • 32 healthy people given 3L saline over 3 hours • CVP PAOP useless..

  28. Mixed Venous Saturations

  29. Dynamic Measurements • The Fluid Challenge • Passive Leg Raise • Waveform Analysis • Systolic Pressure Variation • Pulse Pressure Variation • Stroke Volume Variation • Echocardiography • Pleth Variability Index • Bioimpedance & Bioreactance

  30. Fluid Responsive Give some fluid… see what happens…

  31. Passive Leg Raise PLR. Free. Reversible. Effective.

  32. 39 patient. 4min PLR. 300ml bolus. Circ insufficiency and Mech Ventilation. • Measurements: PP (rad artline), HR, PAOP, CO. • Correlation between PLR and SV – 0.77 P < 000.1 • Correlation between PLR and Bolus – 0.84 P <000.1

  33. Question: Can PLR induced ΔCardiac Output ΔPulse Pressure predict fluid responsiveness • 9 articles 353 patients • PLR-cCO – sensitivity 89.4% specificity 91.4% • Not altered by ventilation mode or cardiac rhythm. • PLR-cCO – ROC 0.95 cf. PLR-cPP – ROC 0.76 P<0.001

  34. Thermodilution

  35. How much water is in my bucket?

  36. Thermodilution • Like the bucket analogy • Add to this concentration change over timeand • You can calculate flow

  37. Waveform Analysis Numerous. Complex. Useful.

  38. Stroke Volume Variance Invasive: pulse contour analysis (PICCO, LIDCO, Flotrac, Vigileo) Noninvasive: echo, pulse ox waveform,

  39. Pulse Pressure Variance

  40. Broad inclusion criteria: SVV, PVV, CVP, GEDI, ΔSV, & ΔCI compared with PEEP challenge or fluid challenge. • 29 studies 685 patients • Baseline and ΔCI • PPV (threshold 12.5%) – ROC 0.94 Sens 0.89 Spec 0.88 OR 59 • SVV (threshold 11.6%) – ROC 0.84 Sens 0.82 Spec 0.88 OR 27 • SBPV – ROC 0.86 • CVP – ROC 0.55 • GEDI – ROC 0.56 • LVEDI – ROC 0.64 • Limitation • Mandatory ventilation

  41. Picco Thermodilution Waveform analysis

  42. Vigileo

  43. Echocardiography Pretty. Skilled. Detailed. .

  44. Echo SV = VTI x CSA VTI – AUC of doppler CSA – valve area Changes in resp cycle 20% VTI 12% peak flow

  45. Bioreactance

  46. 110 Patients. PAC-CCO (thermodilution) cf. NICOM • Stable CO – correlation coefficient R = 0.82 • Increasing CO – correlation increased to 96% • Decreasing CO – correlation decreased to 84-90% • Changes seen on NICOM 3 +/- 3 minutes faster

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