Prof. Jean-Louis TEBOUL Prof. Jean-Louis TEBOUL Medical ICU Bicetre hospital University Paris XI France What is the best way to What is the best way to assess assess fluid responsiveness fluid responsiveness in a spontaneously breathing in a spontaneously breathing patient ? patient ? Member of the Medical Advisory Board of Pulsion Member of the Medical Advisory Board of Pulsion
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Prof. Jean-Louis TEBOUL Medical ICU Bicetre hospital University Paris XI France What is the best way to assess What is the best way to assess fluid responsiveness.
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Prof. Jean-Louis TEBOULProf. Jean-Louis TEBOUL
Medical ICUBicetre hospital
University Paris XIFrance
What is the best way to assess What is the best way to assess
fluid responsiveness fluid responsiveness
in a spontaneously breathing patient ?in a spontaneously breathing patient ?
Member of the Medical Advisory Board of Pulsion Member of the Medical Advisory Board of Pulsion
Three different scenariosThree different scenarios
2- Patients in the ER for high suspicion of septic shock2- Patients in the ER for high suspicion of septic shock
3- Patients in the ICU, already resuscitated for several hours or days3- Patients in the ICU, already resuscitated for several hours or days
1- Patients in the ER for acute blood losses or body fluid losses1- Patients in the ER for acute blood losses or body fluid losses
1- Patients in the ER for acute blood losses or body fluid losses1- Patients in the ER for acute blood losses or body fluid losses
Diagnosis of hypovolemia is almost certainDiagnosis of hypovolemia is almost certain
Presence of clinical signs of hemodynamic instability clinical signs of hemodynamic instability
No therapeutic dilemmaNo therapeutic dilemma
good prediction of volume responsiveness prediction of volume responsiveness
although lacking of sensitivitylacking of sensitivity
2- Patients in the ER for high suspicion of septic shock2- Patients in the ER for high suspicion of septic shock
Most often, no needsno needs for searching sophisticated predictors predictors
of volume responsiveness of volume responsiveness since volume resuscitation is mandatory volume resuscitation is mandatory
in the first hours in the first hours (see Rivers et al NEJM 2001)
- with hemodynamic instability requiring therapy- with hemodynamic instability requiring therapy
- without certainty of volume responsiveness- without certainty of volume responsiveness
- with potential risks of pulmonary edema with potential risks of pulmonary edema
Rate of infusion:Rate of infusion: 500-1000 mL crystalloids 500-1000 mL crystalloids or 300-500 mL colloids 300-500 mL colloids over 30 mins30 mins
Goal:Goal: reversal of the marker of perfusion failure that prompted the fluid challengereversal of the marker of perfusion failure that prompted the fluid challenge
(ex: hypotension, tachycardia, oliguria, etc)
Safety limits: Safety limits: CVPCVP
Crit Care Med 2006; 34:1333-1337
of 15 mmHg measured every 10 minsof 15 mmHg measured every 10 mins
Question: Question: benefit/risk ratio ?benefit/risk ratio ?
Fluid challenge successful in only 50% casesFluid challenge successful in only 50% cases
Crit Care Med 2006; 34:1333-1337
Rate of infusion: 500-1000 mL crystalloids or 300-500 mL colloids over 30 minsRate of infusion: 500-1000 mL crystalloids or 300-500 mL colloids over 30 mins
Goal: reversal of the marker of perfusion failure that prompted the fluid challenge Goal: reversal of the marker of perfusion failure that prompted the fluid challenge
Safety limits: CVP of 15 mmHg measured every 10 minsSafety limits: CVP of 15 mmHg measured every 10 mins
CHEST 2002, 121:2000-8 CHEST 2002, 121:2000-8
Question: Question: benefit/risk ratio ?benefit/risk ratio ?
Fluid challenge successful in only 50% casesFluid challenge successful in only 50% cases
Crit Care Med 2006; 34:1333-1337
Rate of infusion: 500-1000 mL crystalloids or 300-500 mL colloids over 30 minsRate of infusion: 500-1000 mL crystalloids or 300-500 mL colloids over 30 mins
Goal: reversal of the marker of perfusion failure that prompted the fluid challenge Goal: reversal of the marker of perfusion failure that prompted the fluid challenge
Safety limits: CVP of 15 mmHg measured every 10 minsSafety limits: CVP of 15 mmHg measured every 10 mins
Fluid challenge potentially riskyFluid challenge potentially risky Is a CVP of 15 mmHg a reasonable safety limit?Is a CVP of 15 mmHg a reasonable safety limit?
Pcap-PAOP difference is high in ALI/ARDSPcap-PAOP difference is high in ALI/ARDS
Question: Question: benefit/risk ratio ?benefit/risk ratio ?
Fluid challenge successful in only 50% casesFluid challenge successful in only 50% cases
Crit Care Med 2006; 34:1333-1337
Rate of infusion: 500-1000 mL crystalloids or 300-500 mL colloids over 30 minsRate of infusion: 500-1000 mL crystalloids or 300-500 mL colloids over 30 mins
Goal: reversal of the marker of perfusion failure that prompted the fluid challenge Goal: reversal of the marker of perfusion failure that prompted the fluid challenge
Safety limits: CVP of 15 mmHg measured every 10 minsSafety limits: CVP of 15 mmHg measured every 10 mins
Fluid challenge potentially riskyFluid challenge potentially risky Is a CVP of 15 mmHg a reasonable safety limit?Is a CVP of 15 mmHg a reasonable safety limit?
3) Degree of pulmonary edema poorly evaluated by Pcap 3) Degree of pulmonary edema poorly evaluated by Pcap since lung capillary permeability is often altered in ICU ptssince lung capillary permeability is often altered in ICU pts
Fluid challenge successful in only 50% casesFluid challenge successful in only 50% cases
Crit Care Med 2006; 34:1333-1337
Rate of infusion: 500-1000 mL crystalloids or 300-500 mL colloids over 30 minsRate of infusion: 500-1000 mL crystalloids or 300-500 mL colloids over 30 mins
Goal: reversal of the marker of perfusion failure that prompted the fluid challenge Goal: reversal of the marker of perfusion failure that prompted the fluid challenge
Volume expansion will increase stroke volume Volume expansion will increase stroke volume only if ventricles are preload-dependentonly if ventricles are preload-dependent
How to predict preload-dependence How to predict preload-dependence
and hence volume responsiveness?and hence volume responsiveness?
1- By estimating cardiac preload 1- By estimating cardiac preload
- using filling pressures:- using filling pressures: RAP, PAOP RAP, PAOP
Stroke Volume
Ventricular preload
preload-dependencepreload-dependence
preload-independencepreload-independence
The lower the ventricular preload, The lower the ventricular preload, the more likely the preload-dependency the more likely the preload-dependency
How to predict preload-dependence How to predict preload-dependence
and hence volume responsiveness?and hence volume responsiveness?
1- By estimating cardiac preload 1- By estimating cardiac preload
- using filling pressures: RAP, PAOP - using filling pressures: RAP, PAOP
- using dimensions: RVEDVi, LVEDVi- using dimensions: RVEDVi, LVEDVi
markers of preload: markers of preload: poor markerspoor markers
of volume responsivenessof volume responsiveness
Why ?Why ?
Why do ventricular preload indicators notWhy do ventricular preload indicators notpredict fluid responsiveness ?predict fluid responsiveness ?
2- Because RAP, PAOP, RVEDVi, LVEDVi are not always accurate indicators 2- Because RAP, PAOP, RVEDVi, LVEDVi are not always accurate indicators of preloadof preload
1- In the available studies, pts were already resuscitated so that values 1- In the available studies, pts were already resuscitated so that values of markers of preload were rarely low. of markers of preload were rarely low.
It cannot be excluded that low values predict volume responsiveness, It cannot be excluded that low values predict volume responsiveness,
whereas high values well predict the absence of hemodynamic response to volumewhereas high values well predict the absence of hemodynamic response to volume
On the other hand, values were rarely high before fluid challengesOn the other hand, values were rarely high before fluid challenges
3- Because assessment of preload is not assessment of preload-dependence3- Because assessment of preload is not assessment of preload-dependence
.
Stroke volume
Ventricular preload
normal heart normal heart
failing heart failing heart
preload-dependencepreload-dependence
preload-independencepreload-independence
How to detect fluid responsiveness ?How to detect fluid responsiveness ?
1- By estimating cardiac preload ?1- By estimating cardiac preload ?
2- By using dynamic tests detecting2- By using dynamic tests detecting cardiac preload reserve ?cardiac preload reserve ?
2.1- using heart-lung interaction2.1- using heart-lung interaction
- SPV, PPV?- SPV, PPV?
. for physiological reasons, these indices must not work
. as confirmed in clinical studies
Patients with MVPatients with MV
Rooke et al Rooke et al Anesth & Analg 1995Anesth & Analg 1995
Magder et al J Crit Care 1992Magder et al J Crit Care 1992
Limitation : to be sure that the inspiratory effort is sufficient
How to detect fluid responsiveness ?How to detect fluid responsiveness ?
1- By estimating cardiac preload ?1- By estimating cardiac preload ?
2- By using dynamic tests detecting2- By using dynamic tests detecting cardiac preload reserve ?cardiac preload reserve ?
2.1- using heart-lung interaction2.1- using heart-lung interaction
- SPV, PPV?- SPV, PPV? NONO
- Inspiratory decrease in RAP?- Inspiratory decrease in RAP?
2.2- using passive leg raising2.2- using passive leg raising
Passive Leg RaisingPassive Leg Raising
45 °45 °
Venous blood shiftVenous blood shift (Rutlen et al. (Rutlen et al. 19811981, , Reich et al. 1989)Reich et al. 1989)
Increase in left ventricular preloadIncrease in left ventricular preload (Rocha 1987, Takagi 1989, De Hert 1999, Kyriades 1994 ) Reversible effects Reversible effects
Increase in right ventricular preloadIncrease in right ventricular preload (Thomas et al 1965)
BaseBase BaseBase
PLRPLR PLRPLR
post-PLRpost-PLRpost-PLRpost-PLR
RAP (mmHg)RAP (mmHg) PAOP (mmHg)PAOP (mmHg)
00
55
1010
1515
2020
00
55
1010
1515
2020
2525
3030
Chest 2002; 121: 1245-52
Passive Leg RaisingPassive Leg Raising
45 °45 °
Venous blood shiftVenous blood shift (Rutlen et al. (Rutlen et al. 19811981, , Reich et al. 1989)Reich et al. 1989)
Increase in right ventricular preload Increase in right ventricular preload (Thomas et al 1965)
Increase in left ventricular preload Increase in left ventricular preload (Rocha 1987, Takagi 1989, De Hert 1999, Kyriades 1994 )