Fluid responsiveness and extravascular lung water

Transcription

1 Fluid responsiveness and extravascular lung water Prof. Jean-Louis TEBOUL Medical ICU Bicetre hospital University Paris-South France

2 Conflicts of interest Member of the Medical Advisory Board of Maquet/Pulsion

3 Critically ill patients often experience hemodynamic instability Clinicians are tempted to give fluid to restore adequate hemodynamic conditions However, often, patients were already fluid-resuscitated for hours or days potential fluid overload with subsequent risks of pulmonary edema especially in conditions of increased lung permeability positive cumulative fluid balance: independent predictor of death

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5 Highest positive fluid balance

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8 Critically ill patients often experience hemodynamic instability Clinicians are tempted to give fluid to restore adequate hemodynamic conditions However, often, patients were already fluid-resuscitated for hours or days potential fluid overload with subsequent risks of pulmonary edema especially in conditions of increased lung permeability positive cumulative fluid balance: independent predictor of death no certainty of fluid responsiveness

9 CHEST 2002, 121: Only 52% of patients responded to fluid administration in terms of CO increase

10 Critically ill patients often experience hemodynamic instability However, Clinicians are tempted to give fluid to restore adequate hemodynamic conditions Fluid infusion benefit / risk ratio? often, patients were already fluid-resuscitated for hours or days potential fluid overload with subsequent risks of pulmonary edema especially in this condition of increased lung permeability Predictors of fluid responsiveness are required positive cumulative fluid balance: independent predictor of death no certainty of fluid responsiveness Markers of lung edema are required

11 SSC «static» approach «dynamic» approach

12 SSC approach: Stop IV fluids when a certain level of CVP has been reached Stroke Volume preload unresponsiveness CVP

13 Initial resuscitation 1. Protocolized, quantitative resuscitation of patients with sepsis-induced hypoperfusion (defined as hypotension persisting after initial fluid challenge or blood lactate 4 mmol/l). Goals during the first 6h of resuscitation: (a) pressure 8-12 mmhg Central venous pressure 8-12 mmhg (b) Mean arterial pressure (MAP) 65 mmhg (c) Urine output 0.5 ml.kg -1 h (d) Central venous or mixed venous oxygen saturation 70 or 65%, respectively (grade 1C) Central venous pressure mmhg if MV

14 normal heart preload responsiveness Stroke volume failing heart preload unresponsiveness. CVP

15 Responders Nonresponders

16 Crit Care Med 2013; 41: pts Summary AUC 0.56 Predicting fluid responsiveness with CVP is like

17 SSC «static» approach «dynamic» approach No. Statement/recommendation GRADE level of recommendation; quality of evidence 30. We recommend not to target any absolute value of ventricular filling pressure or volume 31. We recommend using dynamic over static variables to predict fluid responsiveness, when applicable Level 1; QoE moderate (B) Level 1; QoE moderate (B)

18 Dynamic indices of preload responsiveness normal heart Stroke volume preload responsiveness failing heart. preload unresponsiveness Ventricular preload

19 Stroke volume preload responsiveness preload unresponsiveness A B Ventricular preload

20 Sensitivity PPV CVP PAOP 1 - Specificity

21 Anesth Analg 2011; 113:523-8 Chest 2005;128; Chest 2004, 126: PPV Crit Care Med 2005;33: M. Cannesson, J. Slieker, O. Desebbe, F. Fahdi,O. Bastien, JJ. Lehot X. Monnet 1,2*,L. Guerin 1,2,M. Jozwiak 1,2,A. Bataille 1,2,F. Julien 1,2,C. Richard 1,2,J-L. Teboul 1,2

22 Pulse Pressure Variation Calculated automatically and displayed in real-time by usual hemodynamic monitors

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24 Threshold: 12% AUC: 0.94

25 Arterial pressure waveform analysis Stroke volume Arterial Pressure Stroke Volume Variation Calculated automatically and displayed in real-time by new hemodynamic monitors

26 Arterial pressure waveform analysis Stroke volume Arterial Pressure

27 X. Monnet 1,2* L., Guerin 1,2,M. Jozwiak 1,2,A. Bataille 1,2 F., Julien 1,2,C. Richard 1,2,J-L. Teboul 1,2 Assessing fluid responsiveness by stroke volume variation in mechanically ventilated patients with severe sepsis G. Marx, T. Cope, L. McCrossan, S. Swaraj, C. Cowan, SM. Mostafa, R. Wenstone, M. Leuwer European Journal of Anaesthesiology 2004; 21: Chest 2005;128;

28 685 pts

29 In all these situations and in case of any doubt about interpretation other reliable dynamic tests are required and are now available

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31 Stroke Volume PLR mimics fluid challenge preload responsiveness b' a' Unlike fluid challenge, no fluid is infused, preload unresponsiveness and, the effects are reversible and transient b a The hemodynamic response to PLR A PLR B Ventricular preload can predict the hemodynamic response to volume infusion

32 Crit Care 2015, 19:18

33 Real-time CO response to PLR 2012

34 PLR-induced changes in CO PLR-induced changes in AP Study name sample size AUC Study name sample size AUC Monnet CCM Lafanéchère CC Lamia ICM Maizel ICM Monnet CCM Thiel CC Biais CC Preau CCM Monnet CCM Monnet CCM Preau CCM

35 n = 30 pts n = 30 pts

36 Preload dependence group Control group

37 Control Preload dependence

38 Critically ill patients often experience hemodynamic instability Fluid infusion benefit / risk ratio? Predictors of fluid responsiveness are required Markers of lung edema are required

39 How to assess the risk of pulmonary edema? PAOP?

40 Increased lung capillary permeability Increased inflammation volume of lung edema 12 Pcrit mmhg Pulmonary artery occlusion pressure

41 Increased inflammation Amount of pulmonary edema Increased lung capillary permeability 12 mmhg Pcrit Pulmonary artery occlusion pressure

42 EVLW ml/kg PAOP mmhg

43 How to assess the risk of pulmonary edema? PAOP? EVLW? cannot reliably assess the risk of pulmonary edema

44 Central Venous Catheter (cold bolus injection) Thermodilution femoral arterial catheter

45 200 pts D 28 mortality: 54% Odds Ratio ( CI 95%) p value Maximal blood lactate 1.29 ( ) Mean PEEP 0.78 ( ) Minimal PaO 2 / FiO ( ) SAPS II 1.03 ( ) 0.02 EVLW max 1.07 ( ) Mean fluid balance ( ) 0.02

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47 Cumulative fluid balance (L) 7 5 * * * * PAOP group 3 1 EVLW group * p < vs time Time (hours)

48 * * PAOP group EVLW group 5 0 MV days ICU days

49 PVPI = EVLW/Pulmonary blood volume PVPI marker of lung µvessels permeability

50 200 pts D 28 mortality: 54% Odds Ratio ( CI 95%) p value Maximal blood lactate 1.27 ( ) Mean PEEP 0.78 ( ) Minimal PaO 2 / FiO ( ) SAPS II 1.03 ( ) PVPI max 1.07 ( ) 0.03 Mean fluid balance ( ) 0.03

51 Decision of starting fluid administration presence of hemodynamic instability/peripheral hypoperfusion (mottled skin, hypotension, oliguria, hyperlactatemia ) and presence of preload responsiveness and limited risks of fluid overload

52 Decision of stopping fluid administration disappearance of hemodynamic instability/peripheral hypoperfusion or appearance of preload unresponsiveness or appearance of fluid overload or marked increase in EVLW

53 Conclusion Before infusing fluids in critically ill patients, and especially in ARDS patients Fluid infusion benefit / risk ratio should be assessed patient per patient Predictors of fluid responsiveness are required Markers of lung edema are required

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