Preload optimisation in severe sepsis and septic shock
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1 Preload optimisation in severe sepsis and septic shock Prof. Jean-Louis TEBOUL Medical ICU Bicetre hospital University Paris South France
2 Conflicts of interest Member of themedical Advisory Board ofpulsion
3 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
4 Fluid Challenge Predictors of fluid responsiveness/unresponsiveness
5 Crit Care Med 2006; 34: Rate of infusion: ml crystalloids or ml colloids over 30 mins Goal:reversal of themarker of perfusion failurethat prompted the fluid challenge (ex: hypotension, tachycardia, oliguria, etc) Safety limits:cvpof 15 mmhg measured every 10 mins
6 Crit Care Med 2006; 34: Limitations Fluid challenge cannot serve as a test to predict fluid responsiveness First, it isnot a test but areal therapy ml crystalloids or ml colloids/30 mins Not negligible amounts! Second, by definition, itcannot predictfluid responsiveness Fluid challenge is successful in only 50% cases
7 CHEST 2002, 121:2000-8
8 Crit Care Med 2006; 34: Limitations Fluid challenge cannot serve as a test to predict fluid responsiveness First, it isnot a test but areal therapy ml crystalloids or ml colloids/30 mins Not negligible amounts! Second, by definition, itcannot predictfluid responsiveness Fluid challenge is successful in only 50% cases Fluid challenge is potentiallyrisky Assessing fluid responsiveness is a «every day» issue Repetition of fluid challenges could be harmful
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10 Tento obrázek nyní nelze zobrazit. Tento obrázek nyní nelze zobrazit.
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12 Fluid Challenge Predictors of fluid responsiveness/unresponsiveness Can help to choose the best fluid strategy by avoiding to fluid overload patients who would be fluid unresponsive
13 Fluid infusion will increase LV stroke volume only ifboth ventricles arepreload responsive preload unresponsiveness Stroke Volume Fluid responsiveness equivalent to preload responsiveness biventricular preload responsiveness Ventricular preload
14 Fluid Challenge Predictors of fluid responsiveness/unresponsiveness Static markers of preload
15 normal heart Stroke volume preload responsiveness «static» measures ofpreload cannot reliablypredict fluid responsiveness. preload unresponsiveness failing heart Ventricular preload
16 Tento obrázek nyní nelze zobrazit. neither baseline PAOP nor baseline CVP predicted volume responsiveness Responders Nonresponders Responders Nonresponders
17 Tento obrázek nyní nelze zobrazit. Tento obrázek nyní nelze zobrazit. Tento obrázek nyní nelze zobrazit. Tento obrázek nyní nelze zobrazit. Crit Care Med 2013; 41: pts Summary AUC 0.56 Crit Care Med 2013; 41:
18 Tento obrázek nyní nelze zobrazit.???
19 Dynamic indices of preload responsiveness normal heart Stroke volume preload responsiveness failing heart. preload unresponsiveness Ventricular preload
20 Fluid Challenge Predictors of fluid responsiveness/unresponsiveness Static markers of preload Dynamic markers of preload responsiveness o heart-lung interaction tests o variability of stroke volume and of its surrogates
21 MV induces cyclic changes in SV only in pts with biventricular preload responsiveness fluid responsiveness occurs only in pts with biventricular preload responsiveness correlates with the magnitude of the induced by
22 Fluid Challenge Predictors of fluid responsiveness/unresponsiveness Static markers of preload Dynamic markers of preload responsiveness o heart-lung interaction tests o variability of stroke volume and of its surrogates Invasive indices
23 Tento obrázek nyní nelze zobrazit. Stroke volume preload responsiveness preload unresponsiveness A B Ventricular preload
24 Tento obrázek nyní nelze zobrazit. Am J Respir Crit Care Med 2000; 162:134-8 PPV = PPmax- PPmin (PPmax +PPmin) /2 Arterial catheter PPmax PPmin
25 PP (%) before fluid Infusion 13 % non-responders n = responders n = 16
26 PPV Sensitivity CVP PAOP 1 -Specificity
27 Chest 2005;128; Anesth Analg 2011; 113:523-8 Chest 2004, 126: PPV Crit Care Med 2005;33: Tento obrázek ny ní nelze zobrazit. M. Cannesson, J. Slieker, O. Desebbe, F. Fahdi,O. Bastien, JJ. Lehot Tento obrázek ny ní nelze zobrazit. Tento obrázek ny ní nelze zobrazit. X. Monnet1,2*, L. Guerin1,2, M. Jozwiak1,2, A. Bataille1,2, F. Julien1,2, C. Richard1,2, J-L. Teboul1,2 Tento obrázek ny ní nelze zobrazit.
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29 The larger the PPbeforefluid infusion, the larger the increase in Am CO J Respir Crit after Care Med 2000; fluid 162:134-8 infusion Fluid-induced changes in cardiac index (%) r 2 = The smallerthe PPVbefore fluid infusion, PP (%) before fluid infusion the smaller the increase in CO after fluid infusion
30 Pulse Pressure Variation Calculated automatically and displayed in real-time by usual hemodynamic monitors All thesemonitors aresuitable todisplay PPV in real-time
31 Arterial pressure waveform analysis Stroke volume Arterial Pressure Stroke Volume Variation Calculated automatically anddisplayed inreal-time by new hemodynamic monitors
32 X. Monnet1,2*, L. Guerin1,2, M. Jozwiak1,2, A. Bataille1,2,F. Julien1,2, C. Richard1,2, J-L. Teboul1,2 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;
33 PPV SVV 685 pts
34 Average cut-off: 12.5%
35 Fluid Challenge Predictors of fluid responsiveness/unresponsiveness Static markers of preload Dynamic markers of preload responsiveness o heart-lung interaction tests o variability of stroke volume and of its surrogates Invasive indices Non invasive indices
36 PPVi PPVni Non-invasive finger blood pressure monitoring device
37 Esophageal Doppler 18% ABF % = ABF max-abf min (ABF max+ ABF min)/2 R NR
38 Doppler-echo Vpeak Vpeak (%) before fluid Vpeak max Vpeak min Vpeak = Vpeak max Vpeak min (Vpeak max + Vpeak min) / 2 4 responders non responders
39 Pulse oximeter
40
41 PPV SVV PVI GEDV
42 NE (-) NE (+)
43 Fluid Challenge Predictors of fluid responsiveness/unresponsiveness Static markers of preload Dynamic markers of preload responsiveness o heart-lung interaction tests o variability of stroke volume and of its surrogates o variability of (inferior or superior) vena cava diameter
44 Subcostal view divcmin divcmax divc% = divcmax-divcmin (divcmax + divcmin)/2
45 66 pts with MV Systematic fluid loading with 10 ml/kg HES
46 36 % 100 SVC collapsibility (AUC: 0.99) 80 PPV 12% (AUC: 0.94) Specificity (%) PPV and SVC collapsibility perform equally for predicting fluid responsiveness Transesophageal approach is required Specificity (%)
47 Limitations of respiratory variability indices impossible to interpret in pts with spontaneous breathing activity
48 PPV (threshold: 12 %) fully adapted to ventilator patients with spontaneous breathing sensitivity PPV 1 -specificity
49 Limitations of respiratory variability indices impossible to interpret in pts with spontaneous breathing activity impossible to interpret in patients with arrhythmias mmhg 110 PPmax PPmin
50 Limitations of respiratory variability indices impossible to interpret in pts with spontaneous breathing activity impossible to interpret in patients with arrhythmias difficult to interpret if tidal volume is too low
51 PPV 12.8 % PPV 8 % Sensitivity Normal TV Low TV 1- Specificity
52 Limitations of respiratory variability indices impossible to interpret in pts with spontaneous breathing activity impossible to interpret in patients with arrhythmias difficult to interpret if tidal volume is too low difficult to interpret if lung compliance is too low
53 Ability of PPV to predict fluid responsiveness in function of lung compliance Crs 40 ml/cmh 2 O Sensitivity Crs < 40 ml/cmh 2 O Crs < 30 ml/cmh 2 O Specificity (%)
54 Limitations of respiratory variability indices impossible to interpret in pts with spontaneous breathing activity impossible to interpret in patients with arrhythmias difficult to interpret if tidal volume is too low difficult to interpret if lung compliance is too low difficult to interpret in case of high frequency ventilation PPV can be not reliable when the heart rate/respiratory rate is> 3.6 De Backer et al Anesthesiology 2009
55 Limitations of respiratory variability indices impossible to interpret in pts with spontaneous breathing activity impossible to interpret in patients with arrhythmias difficult to interpret if tidal volume is too low difficult to interpret if lung compliance is too low difficult to interpret in case of high frequency ventilation difficult to interpret under open-chest conditions difficult to interpret in case of severe RV failure Mahjoub et al Crit Care Med 2009, Wyler von Ballmoos et al Crit Care 2010
56 Limitations of respiratory variability indices impossible to interpret in pts with spontaneous breathing activity impossible to interpret in patients with arrhythmias difficult to interpret if tidal volume is too low difficult to interpret if lung compliance is too low difficult to interpret in case of high frequency ventilation difficult to interpret under open-chest conditions In all these situations and in case of any doubt about interpretation other reliable dynamic tests are required difficult to interpret in case of severe RV failure and are now available
57 Fluid Challenge Predictors of fluid responsiveness/unresponsiveness Static markers of preload Dynamic markers of preload responsiveness o heart-lung interaction tests o variability of stroke volume and of its surrogates o variability of (inferior or superior) vena cava diameter o end-expiratory occlusion test
58 End-expiratory occlusion test Cyclic decrease in preload Transient increase in preload and hence in CO in case of preload-dependency Fluid responders should be identified by anincrease of theirco during theend-expiration occlusion test Systemic venous return
59 % 50 effects ofend-expiratory occlusion on Pulse contour CO % 50 effects ofend-expiratory occlusion on pulse pressure Any real-time CO monitor could be suitable A simple arterial catheter could be suitable NR R -10 NR R
60
61 Fluid Challenge Predictors of fluid responsiveness/unresponsiveness Static markers of preload Dynamic markers of preload responsiveness o heart-lung interaction tests o variability of stroke volume and of its surrogates o variability of (inferior or superior) vena cava diameter o end-expiratory occlusion test o passive leg raising test
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63 Passive Leg Raising: the advantages PLR provides a good prediction of fluid responsiveness Unlike fluid challenge, effects of PLR are rapidly reversible PLR may well assess fluid responsiveness in situations where PPVfails to do it
64
65 RAP (mmhg) PAOP (mmhg) PLR 0 PLR Base post-plr Base post-plr
66 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
67 The hemodynamic response to PLR can predict the hemodynamic response to fluid infusion Real-time CO response to PLR
68 VTI VTI +35%
69 24 pts with circulatory failure and SB TTE before and after 500 ml saline PLR-induced change in Velocity-Time Integral PLR-induced changes in VTIAo (%) goodprediction of volume responsiveness VTI * 12% -5 R NR
70
71
72 Passive Leg Raising: the advantages PLR provides a good prediction of fluid responsiveness Unlike fluid challenge, effects of PLR are rapidly reversible PLR may well assess fluid responsiveness in situations where PPVfails to do it
73 reversible hemodynamic effects ABF PLR ABF max 90 sec No risk of pulmonary edema
74 Passive Leg Raising: the advantages PLR provides a good prediction of fluid responsiveness Unlike fluid challenge, effects of PLR are rapidly reversible PLR may well assess fluid responsiveness in situations where PPVfails to do it Spontaneous Breathing activity
75 Pts with spontaneous breathing PLR-induced changes in ABF sensitivity PPV 1 -specificity
76 Passive Leg Raising: The advantages PLR provides a good prediction of fluid responsiveness Unlike fluid challenge, effects of PLR are rapidly reversible PLR may well assess fluid responsiveness in situations where PPVfails to do it Spontaneous Breathing activity Low lung compliance
77 Lung compliance 30 ml/cmh 2 O Lung compliance < 30 ml/cmh 2 O 100 PPV effects of PLR on CO 100 effects of PLR on CO Sensitivity Sensitivity PPV Specificity 100-Specificity
78 Passive Leg Raising: the limits PLRshould notstart from a horizontalpatient s position but from a semi-recumbent position
79 45 45 semi-recumbent position Passive Leg Raising horizontal position 45 Passive Leg Raising
80 37.5 % change in CO from baseline
81 35 patients (all responders to fluid administration) 35 pts correctly classified as responders 20 pts correctly classified as responders 15 pts classified as nonresponders
82 45 45 semi-recumbent position Passive Leg Raising rather than horizontal position 45 Passive Leg Raising
83 Passive Leg Raising: the limits PLRshould notstart from a horizontalpatient s position but from a semi-recumbent position The hemodynamic response to PLR should not be monitored with arterial pressure but with CO measurements
84 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
85 80 PLR-induced changes in aortic blood flow PLR-induced changes in pulse pressure 60 % change from Baseline 40 Following thechanges in arterial pressure * * during PLR is not suitable (false negative cases) Falses negative cases A real-time CO monitor is necessary NR R NR R
86 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
87 Decision of stopping fluid administration disappearance of hemodynamic instability/peripheral hypoperfusion or presence of preload unresponsiveness or high risks of fluid overload or severe hypoxemic lung injury Value ofevlw andpvpi
88 Conclusion Predictors of fluid responsiveness/unresponsiveness Pulse pressure variation orstroke volume variation PLR or end-expiratory occlusion tests Can help to choose the best fluid strategy by identifying patients eligible for fluid infusion and by avoiding to fluid overload patients who would be fluid unresponsive Thank you
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