Fluid responsiveness. J.G. van der Hoeven

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Sebastiaan Lemmens
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1 Preoperatief wordt de hemodynamiek van deze patiënt verbeterd en de volgende dag ondergaat hij een slokdarm resectie met buis maag reconstructie. Peroperatief doen zich geen hemodynamische problemen voor maar bij aankomst op de intensive care afdeling is patiënt hypotensief (80/50 mmhg) en heeft hij het laatste uur op de OK slechts 20 cc urine geproduceerd. Het lactaat is 3.1 mmol/l en de ScvO2 52%. De thoraxfoto toont beginnend alveolair oedeem en de volgende hemodynamische waarden worden gemeten: Cardiac Index 1.9 l/min/m 2 Geïndexeerd globaal eind-diastolisch volume (GEDVI) 840 ml/m 2 Extravasculair longwater (EVLW) 10.3 ml/kg Vraag 9 Wat is naar uw mening nu de beste methode om te voorspellen of deze patiënt nu gunstig op vloeistof zal reageren d.w.z. een toename van het hartminuutvolume meer dan 10 15% zonder een belangrijke toename van longoedeem als: a) patiënt geheel spontaan zou ademen b) patiënt ondersteund wordt met pressure support c) patiënt volledig gecontroleerd beademd zou worden Vraag 10 Beschrijf hoe u praktisch een passive leg raising test zou uitvoeren

2 Fluid responsiveness J.G. van der Hoeven

3 Fluid challenge after initial resuscitation ± 50% of patients show an increase in cardiac output Responder benefits by treating occult tissue hypoperfusion Non-responder has a worse outcome due to fluid overload FACTT trial showed: usual care results in fluid overload Static (traditional) parameters do not predict FR

4 SPV and PPV

Pleura pressure RV preload RV output Blood pulmonary transit time LV preload LV output RV afterloa Ins PPmax PPmin Exp Transpulmonar y LV afterloa

5 Pleura pressure RV preload RV output Blood pulmonary transit time LV preload LV output RV afterloa Ins PPmax PPmin Exp Transpulmonar y LV afterloa LV output LV preload SP, PP and aortic blood velocity maximum at the end of inspiration SP, PP and aortic blood velocity minimum during expiration

6 Hypovolemia Hypervolemia

7 Arterial waveform derived variables PPV 29 full-text articles 685 patients P < SPV SVV LVEDAI P < GEDVI CVP 0,3 0,4 0,5 0,6 0,7 0,8 0,9 1 AUC Marik PE. Crit Care Med 2009;37:

8 Pulse pressure variation N = 807, Tv > 8 ml/kg - no spontaneous breathing / arrhythmias Yang X. Crit Care 2014;18:650

9 Pulse pressure variation Yang X. Crit Care 2014;18:650

10 Important conditions Passive mechanical ventilation Tidal volume 8 ml/kg No arrhythmia s No pulmonary hypertension No right ventricular failure

11 False positive False negative L Low HR/RR ratio Bradycardia or HFO I Irregular heart beats M Mechanical ventilation with low tidal volume i Increased abdominal pressure T Thorax open S Spontaneous breathing

12 Fluid responsiveness with low tidal volumes N = 57 Median Tv 5.5 ml/kg Responders with a PPV < 13% had a Pplat - PEEP 20 cm H2O 7% Sensitivity 68% - Specificity Muller L. Intensive Care Med 2010;36:

13 Important conditions Area%under%ROC%curve%PPV% 1, 0,9, 0,8, 0,7, 0,6, 0,5, 0,95, 0,917, 0,909, 0,869, 0,809, 0,817, 0,803, 0,788, 0,766, 0,691, 0,755, 0,691, 0,678, TV,>,7, TV,>,6.5, 0,64, TV,All, 0,513, TV<,7, 0,574, B.by.B,corr,TV, B.by.B, 30sec, 30sec+arrhyth,

14 Increase in CO (%) 15 Responder Non-responder Success zone Grey zone 12 Pulse pressure variation (%)

15 Decrease in post-surgical morbidity due to reduction in infectious-, cardiovascular- and abdominal complications Perioperative use Decrease in LOS Benes J. Crit Care 2014;18:584

16 PPV > 12% with RV dysfunction N = 35 (23 = 66% fluid responders) All on controlled MV with PPV > 12% Peak systolic velocity of T3 annular motion > 0.15 m/s had a sensitivity of 91% and a specificity of 83% for predicting FR (AUC 0.87) Mahjoub Y. Crit Care Med 2009;37:

17 Importance of RV PPV > 12% Normal RV function Responder PPV > 12% Abnormal RV function Non-Responder Mahjoub Y. Crit Care Med 2009;37:

18 Predictive value of PLR test 9 full-text articles 353 patients PLR-cCO P < PLR-cPP Controlled ventilation Partial support Sinus rhythm Arrhythmias Supine starting Semirecumbent starting 0,6 0,80 1 Area Under Curve Cavallaro F. Intensive Care Med 2010;36:

19 PLR test - do it well!!! Monnet X. Crit Care 2015;19:18

20 Jabot J. Intensive Care Med 2009;35:85-90

21 Effect only transient Increase in MAP no predictive value 15% increase in CO necessary Transesophageal doppler Pulse contour CO VTI with echocardiography

PLR incorporating CVPN = 102 43 responders after FC (10% in CO) Total group P = 0.007 PLRPP depending on CVP ( 2 mmhg) AUC 0.76 (0.67-0.84) AUC 0.89 (0.81-0.94) 8% cut off value AUC 0.91 (0.

23 PLR incorporating CVPN = responders after FC (10% in CO) Total group P = PLRPP depending on CVP ( 2 mmhg) AUC 0.76 ( ) AUC 0.89 ( ) 8% cut off value AUC 0.91 ( ) AUC 0.66 ( ) P = PLR induced preload increase No PLR induced preload increase AUC PLR CO after CVP 2mm Hg 0.98 (0.89-1) - cov 7% Lakhal K. Intensive Care Med 2010;36:

24 N = 41 N = 31 N = 10 N = 16 N = 15 Mahjoub Y. Crit Care Med 2010;38:

25 PLR with an increase in abdominal pressure 31 MV patients with a positive FR 16 (52%) patients had a positive PLR test Patients with a negative PLR test had a significantly higher IAP IAP 16 mmhg had a sens 100% and spec 87.5% for discriminating between responders and non-responders to PLR With IAP the PLR test becomes unreliable Mahjoub Y. Crit Care Med 2010;38:

26 What to do if we need to predict a MAP? Patients with septic shock do no need a further increase in CO but need an increase in blood pressure With marked vasodilation an increase in CO after fluid loading may not result in an increase in MAP PPV/SVV ratio > 0.89 predicts a MAP increase > 15% (sens 94%, spec 100%)

27 Dynamic arterial elastance Defined by ratio PPV/SVV during single MV breath N =25 - MAP responder 16, MAP non-responder 9 Responder# Non7responder# Responder" Non7responder" MAP$(mmHg)$ 100# 90# 80# 70# 60# 50# 40# Before# A0er# Cardiac'output'(l/min)' 9" 8" 7" 6" 5" 4" 3" 2" Before" A0er" Responder" Non4responder" Dynamic(arterial(elastance( 2" 1,5" 1" 0,5" 0" Before" A-er" García MIM. Crit Care 2011;15:R15

28 Dynamic arterial elastance Prediction of volume expansion on MAP AUC 95% CI Eadyn ± SVR ± MAP ± PP/SV 0.50 ± García MIM. Crit Care 2011;15:R15

N = 53 80 VEs All fluid responders (increase CO 10%) Eadyn& 1,4" 1,2" 1" 0,8" 0,6" 0,4" 0,2" ***

1000" 500" 0" Responder" Non2Responder" 0" Responder" Non1Responder" 0" Responder" Non0Responder"

29 N = VEs All fluid responders (increase CO 10%) Eadyn& 1,4" 1,2" 1" 0,8" 0,6" 0,4" 0,2" *** Ea#(mmHg/mL)# 3" 2,5" 2" 1,5" 1" 0,5" C"(mL/mmHg)" 2" 1,5" 1" 0,5" SVR$(dyn*s*cm-5)$ 2000" 1500" 1000" 500" 0" Responder" Non2Responder" 0" Responder" Non1Responder" 0" Responder" Non0Responder" 0" Responder" Non/Responder" MAP responders defined by increase MAP 10%) García MIM. Crit Care 2014;18:626

30 Predicting MAP after fluid challenge García MIM. Crit Care 2014;18:626

Eadyn also predicts MAP after NE N = 35 - Septic shock - decrease in NE 0.04 μg/kg/min (13 [37%] were NE responders - MAP > 15%) 2.0 1.8 AUC 95% CI 1.6 Eadyn 1.4 1.2 1.

31 Eadyn also predicts MAP after NE N = 35 - Septic shock - decrease in NE 0.04 μg/kg/min (13 [37%] were NE responders - MAP > 15%) AUC 95% CI 1.6 Eadyn Eadyn SVR Compliance Non-responders Responders < 0.90 gives 70% change of MAP Guinot PG. Crit Care 2015;19:14

32 Final conclusions Likelihood ratio s of SPV, PPV and SVV for predicting FR are probably insufficient in the general ICU population PLRCO (cut-off value 7%) after an adequate CVP increase has the highest predictive value - PLRPP is a reasonable alternative PPV/SVV ratio may predict an MAP

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