Case 1; hypovolemic shock

• Fluid responsiveness St

roke

vo

lum

e

Preload

”fluid responsive”

Fluid responsiveness

• GEDV (PiCCO)

• Arterial pressure variations

• Passive leg raising test

• CVP / PCWP

• Echo (global ventricular volume / ICV collapsibility)

• Fluid challenge with CO monitoring

GEDV

CHEST 2003; 124:1900 –1908 36 ICU patients with “septic shock” (GEDVI normal 650 – 800 ml/m2)

Arterial pressure variations

Pulmonary vascular resistance va

scu

lar

resi

stan

ce

Lung volume FRC RV TLC

alveolar extra-alveolar

total

Arterial pressure variations

• SPV

• PPV

• SVV

• dDown

Arterial pressure variations

• Only controlled mechanical ventilation

• Vt > ca. 8ml/kg

• HR/RR > 3,6

• No arrhythmia’s

• Sufficient RV / LV function

• Closed abdomen

• (closed chest)

Arterial pressure variations

BMC anesthesiology 2014;14:90

9

Br J Anaesth. 2014 Apr;112(4):681-5

Arterial pressure variations

Passive leg raising

Passive leg raising (PLR)

Critical Care 2009; 13: R111

12

Intensive Care Med. 2013 Jan;39(1):93-100

PLR and capnography

ETCO2 > 5% with PLR CI > 15%

Passive leg raising

• Also in awake patients

• Few limitations

• Not with blood pressure!

• Needs fast CO methode (or echo-doppler)

• Some practical disadvantages

• Sympathic activation?

Echo (cava inferior)

Stro

ke v

olu

me

Preload

CVP, CO and fluid therapy

17

Curr Opin Crit Care 2015, 21:369–375

Optimal fluid challenge

• Small volume

• Fast (max 10 min)

• Measure cardiac output and CVP/PCWP before and after

• If CO (SV) increase > 10-15% => responder

• precision CO measurement

• small changes might be very beneficial

• No increase in CO + increase in CVP/PCWP (2 mmHg) => non

responder

Am J Respir Crit Care Med Vol 190, Iss 3, pp 252–257, Aug 1, 2014

Supine

• Axis 1: through fourth intercostal space

• Axis 2: midway between posterior surface and base

of xiphoid process

Supine or 60 degrees up

• 5 cm below sternal angle

Reference point CVP

Central venous trace

a c

x v

y

atrial contraction

bulging T valve with ventricular contraction

atrial relaxation and downward movement of contracting RV

Filling right atrium

atrial emptying, T valve opening

Central venous trace

a c

x v

y

1 2

3

Central venous trace

a c

x v

y

1 2

3

Central venous trace

a c

x v

y