fluid responsiveness
DESCRIPTION
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 ). - PowerPoint PPT PresentationTRANSCRIPT
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Fluid ResponsivenessDr. Daniel Rankmore
JHH ICU Junior Doctor Teaching 7th March 2012
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Today’s TopicWhy give fluids“Fluid responsive”What fluids are avalible
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Why give fluidsOxygen Delivery (DO2)the air goes in and out and the blood goes round and round
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Why give fluids
Intra-venous fluid
Intra-vascular volume
Cardiac Output
Tissue Perfusion
Oxygen Delivery
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DO2 VO2> = Shock= Bad
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DO2
Oxygenation
Cardiac Output+
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DO2
Oxygenation
Cardiac Output+
(Bersten & Soni, 2009, pp. 317-318):
FiO2
Airway
Gas Movem
entHeam
Hb
TissueDiffusio
nCytochro
meMitochon
rial
Alveolar
Diffusion
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DO2Cardiac Output
SV HR x
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DO2Cardiac Output
SV HR x
PreloadContractilityAfterloadFilling Time
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Frank StarlingSt
roke
Vol
ume
‘Preload’
A ‘normal’ heart
A heart ‘failing’
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Frank StarlingSt
roke
Vol
ume
‘Preload’
500mlBolus
SVCO
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Frank Starling CurveSt
roke
Vol
ume
‘Preload’
500mlBolus
SVCO
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Frank Starling CurveSt
roke
Vol
ume
‘Preload’
500mlBolus
SVCO
EVLWPulmonary Oedema
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Liberal Fluid Therapy compared with either Goal Directed Therapy or Restrictive Fluid Therapy3861 patients in 35 RCTsLiberal vs Restrictive
Pneumonia RR 2.2 95% CI 1-4.5Pulmonary Oedema RR 2.8 95% CI 1.1-13Longer Hospital Stay Mean 2 Days 95% CI 0.5-3.4
Goal Directed vs Not Goal DirectedPneumonia 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)
LiberalProlonged Hospital Stay Mean 4 Days (CI 3.4-4.4)Time to first bowel movement 2 Days (CI 1.3-2.3)
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RCT 1000 patients with ALI 60 day follow upPrimary end point – mortality.Secondary end points – lung physiology, vent free days, organ failure free days7 day fluid balance 136ml vs. 6992mls.
Conserve
Liberal
p
Mortality
25.5%
28.4%
0.3
Vent Free Days
14.6 12.1 <0.001
ICU free days
13.4 11.2 <0.001
Shock & RRT
10% 14% 0.6
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Three studies of colorectal surgeryReduced incidence of cardiorespiratory and fewer post operative problems.
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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.
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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.
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When to give fluids
Fluid ResponsivenessGiving what the patient needs when the patient needs it
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Fluid Responsiveness>15% increase in Cardiac Output following 500-1000ml fluid bolus
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Static MeasurementsBP (MAP)UOCVPPAOP – ‘the wedge’ ITBVMVSaO2
IVC DiameterLVEDA
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Central Venous PressureThe number that keeps getting measured…
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Studies includedCVP & 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)
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Central Venous Pressure
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Central Venous PressureCVP & 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 positiveROC 0.9+ an adequate testConclusion
In none of the included studies was CVP able to predict fluid responsive or blood volume.
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Central Venous Pressure
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Hea32 healthy people given 3L saline over 3 hoursCVP PAOP useless..
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Mixed Venous Saturations
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Dynamic MeasurementsThe Fluid ChallengePassive Leg RaiseWaveform Analysis
Systolic Pressure VariationPulse Pressure VariationStroke Volume Variation
EchocardiographyPleth Variability IndexBioimpedance & Bioreactance
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Fluid ResponsiveGive some fluid… see what happens…
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Passive Leg RaisePLR. Free. Reversible. Effective.
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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 < 000.1Correlation between PLR and Bolus – 0.84 P <000.1
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Question: Can PLR induced ΔCardiac Output ΔPulse Pressure predict fluid responsiveness9 articles 353 patientsPLR-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
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Thermodilution
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How much water is in my bucket?
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Thermodilution• Like the bucket analogy• Add to this concentration change over time
and • You can calculate flow
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Waveform AnalysisNumerous. Complex. Useful.
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Stroke Volume VarianceInvasive: pulse contour analysis (PICCO, LIDCO, Flotrac, Vigileo)Noninvasive: echo, pulse ox waveform,
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Pulse Pressure Variance
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Broad inclusion criteria: SVV, PVV, CVP, GEDI, ΔSV, & ΔCI compared with PEEP challenge or fluid challenge.29 studies 685 patientsBaseline and ΔCI
PPV (threshold 12.5%) – ROC 0.94 Sens 0.89 Spec 0.88 OR 59SVV (threshold 11.6%) – ROC 0.84 Sens 0.82 Spec 0.88 OR 27SBPV – ROC 0.86 CVP – ROC 0.55GEDI – ROC 0.56LVEDI – ROC 0.64
LimitationMandatory ventilation
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PiccoThermodilutionWaveform analysis
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Vigileo
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EchocardiographyPretty. Skilled. Detailed. .
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EchoSV = VTI x CSAVTI – AUC of dopplerCSA – valve area
Changes in resp cycle20% VTI12% peak flow
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Bioreactance
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110 Patients. PAC-CCO (thermodilution) cf. NICOMStable CO – correlation coefficient R = 0.82Increasing CO – correlation increased to 96%Decreasing CO – correlation decreased to 84-90%Changes seen on NICOM 3 +/- 3 minutes faster
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75 Adult patients post cardiac surgeryCorrelation between PLR FR and NICOM and FRBut I couldn’t get the article in time…
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Which fluids to give
Choice of IV therapyThink contentsThink compartmentsThink volume
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Compartments
(Ganong’s Review of Medical Physiology, 23e)
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The SalinesFluid Na Cl K Glucos
eOsmola
itypH
Plasma0.18% NaCl4% Glucose
30 30 - 40g/L637kJ
282 3.5-6.5
0.45% NaCl 76 76 - - 150 4.0-7.00.9% NaCl
“Normal Saline”154 154 - - 300 4.0-7.0
3%“Hypertonic”
513 513 - - 1000 4.5-7.0
23.4% 4000 4000 - - 80000.9% Saline + 30mmol KCL
154 184 30 - 368 3.5-7.0
0.9% NaCl + 40mmol KCL
100 140 40 - 280 4.0-7.0
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The SugarsFluid Na Cl Glucose Osmolali
typH
PlasmaWater - - - -
0.18% NaCl + 4% Glucose
30 30 40g/L637kJ
282 3.5-6.5
0.45% NaCl + 2.5% Glucose
77 77 25g/L398kJ
292 3.5-6.5
5% Glucose - - 55g/L835kJ
278 3.5-5.5
10% Glucose - - 100g/L796kJ
556 3.5-6.5
50% Glucose - - 500g/L~4000kJ
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Pre-mixed drinks and other concoctions
Fluid Na Cl Lactate
Ca K Bicarb
Mg Glucose
Osmality
pH
PlasmaCompou
nd Sodium Lactate“Hartma
n’s”
129 109
29 2 5 - - - 274 5.0-7.0
Plasma-lyte
140 98 - - 5 27Acetate
1.5 23 gluconat
e66kJ
294 4.0-6.0
Sodium Bicarb 8.4%
1000
- - - - 1000 - - 2000 7.2-8.7
Voluven 6%
154 154
- - - - - - 304 4.0-5.5
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Blood ProductsFluid Na Cl Octonat
eAlbumin pH Osmol
Plasma4% Albumex 140 128 Octonate
6.440g/L 250
20% Albumex 48-100 Octonate 32
200g/L
pRBC
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The Colloids
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Double Blinded, RCT, 0.9% saline vs. 4% Albumin.6997 pt critically ill patientsPrimary Outcome: 28 day mortality.Secondary Outcomes: length of stay (ICU & Hosp), days on vent, days on RRT, new onset organ dysfucntion.Result: No difference.
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Severe Sepsis subset analysis of SAFE Trial1218 patients AlbuminHR and CVP day 1-3 (p 0.002, 0.03)No diff Sequential Organ Failure Assessment (p. 0.98)Improved mortality 0.87 (CI 0.74-1.02, p 0.06)Multiriant logistic regression anaylsis mortality 0.71 (Ci 0.52-097, p 0.03)
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460 patients, GCS 3-8.Post hoc subgroup analysis with 2 year follow upEnd point mortalityTotal Alb 71 of 214 0.9% 42 of 206 (RR 1.63 p 0.003)GCS 3-8 Alb 61 of 146 0.9% of 32 of 144 (RR 1.88 p <0.001)
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Final ThoughtsConclusion
Understand the question you are asking.Think of fluids as you would a drug – dose, kinetics, dynamics, side effectsThink of alternatives – pressors or inotropes.Remember there are many tools in the toolbox.ABCD and repeat.
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