3/14/2017. Disclosures. None. Outline. Fluid Management and Hemodynamic Assessment Paul Marik, MD, FCCP, FCCM

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1 Fluid Management and Hemodynamic Assessment Paul Marik, MD, FCCP, FCCM Disclosures Stocks Advisory boards Grants Speakers Bureau None Outline Hemodynamic Goals Fluid Resuscitation Historical Perspective Fluid responsiveness and the 6 Guiding principles of fluid resuscitation Techniques for assessment of fluid responsiveness Static CVP Dangers of a high CVP Dynamic Heart-lung interactions Passive leg raising Fluid Challenge Do I give fluid? The effects of a fluid bolus are short lived 1

2 Science Politics Money Religion Chest 2007;132:2020 2

3 Crit Care Med 2013; 41:34 n= Walsh M et al. Anesth 2013:119:507 n= Walsh M et al. Anesth 2013:119:507 3

4 Target Target NEJM 2014;370:1853 NEJM 2014;370:1853 Initial HR > 106 /min Heart rate 24 hours > 95 /min Highly predictive of death 4

5 N Engl J Med 1994; 330:1717 Goals of Hemodynamic Support MAP > 65 mmhg HR < 95 /min Adequate tissue perfusion Clinical examination CI > 2.0 l/min/m 2 CVP < 8 mmhg Fluid Resuscitation Reaching the hemodynamic goals 5

6 Historical Perspective Blue Stage of the Spasmodic Cholera Sketch of girl who died of cholera in Sunderland, November 1831 Lancet, Feb

7 His first patient was an elderly women who had reached the last moments of her earthly existence. Having no precedent to guide me I proceeded with much caution His first patient was an elderly women who had reached the last moments of her earthly existence. Having no precedent to guide me I proceeded with much caution Latta inserted a tube into the basilic vein and injected ounce after ounce of fluid, closely observing the patient. His first patient was an elderly women who had reached the last moments of her earthly existence. Having no precedent to guide me I proceeded with much caution Latta inserted a tube into the basilic vein and injected ounce after ounce of fluid, closely observing the patient. Ounce after ounce of fluid, closely observing the patient. 7

8 His first patient was an elderly women who had reached the last moments of her earthly existence. Having no precedent to guide me I proceeded with much caution Latta inserted a tube into the basilic vein and injected ounce after ounce of fluid, closely observing the patient. Ounce after ounce of fluid, closely observing the patient. the sunken eyes and fallen jaw, pale and cold extremities bearing the manifest imprint of deaths signet, began to glow with returning animation; the pulse returned to the wrist From this to. The Rivers Protocol The Not No evidence 8

9 Fluid overload in patients with severe sepsis and septic shock treated with EGDT Kelm DJ, et al. SHOCK 2015;43: patients with severe sepsis and septic shock At 24 hours, 67% pts had clinical evidence of fluid overload At 72 hours, 48% pts had clinical evidence of fluid overload Fluid overload associated increased hospital mortality OR 1.92 ( ) Crit Care 2015; 19:251 9

10 Day 1 Fluid Administration in Pts with Severe Sepsis and Septic Shock - Analysis of a large National Database (n=23 513) Day 1 Fluid Administration in Pts with Severe Sepsis and Septic Shock - Analysis of a large National Database (n=23 513) Day 1 fluid < 5 liters Day 1 fluid > 5 liters 0.7% per liter (95% CI 1.0%, 0.4%; p=0.02) 2.3% per liter (95% CI 2.0, 2.5%; p=0.0003) 10

11 Dry, Wet or Something Else Surviving Sepsis Campaign Acta Anaesth Scand 2009;53:843 Dry, Wet or Something Else Surviving Sepsis Campaign Acta Anaesth Scand 2009;53:843 Fluid Restrictive Strategy 11

12 High Filling Pressures High venous & pulmonary capillary pressures Release of ANP/BNP Shearing of glycocalyx + Decreased Lymphatic flow Organ edema/pulmonary edema Humans evolved to deal with hypovolemia and NOT hypervolemia (311 centers, 46 countries) current practice and evaluation of fluid management in critically ill patients seems to be arbitrary is not evidence-based and is likely harmful 12

13 Fluid resuscitation Give them as much as they need and not a drop more. PRO/CON Series 13

14 Six Principles of Fluid Resuscitation Fluid responsiveness is defined as a >10% increase in SV following a fluid challenge. Only 50% of hemodynamically unstable patients are fluid responsive Six Principles of Fluid Resuscitation Fluid responsiveness is defined as a >10% increase in SV following a fluid challenge. Only 50% of hemodynamically unstable patients are fluid responsive Clinical signs, CXR, CVP, ultrasonography CANNOT be used to determine fluid responsiveness Six Principles of Fluid Resuscitation Fluid responsiveness is defined as a >10% increase in SV following a fluid challenge. Only 50% of hemodynamically unstable patients are fluid responsive Clinical signs, CXR, CVP, ultrasonography CANNOT be used to determine fluid responsiveness The PLR or fluid challenge coupled with real-time SV monitoring are the only accurate methods for determining fluid responsiveness 14

15 Six Principles of Fluid Resuscitation Fluid responsiveness is defined as a >10% increase in SV following a fluid challenge. Only 50% of hemodynamically unstable patients are fluid responsive Clinical signs, CXR, CVP, ultrasonography CANNOT be used to determine fluid responsiveness The PLR or fluid challenge coupled with real-time SV monitoring are the only accurate methods for determining fluid responsiveness The hemodynamic response to a fluid challenge is short lived - usually less than an hour Six Principles of Fluid Resuscitation Fluid responsiveness is defined as a >10% increase in SV following a fluid challenge. Only 50% of hemodynamically unstable patients are fluid responsive Clinical signs, CXR, CVP, ultrasonography CANNOT be used to determine fluid responsiveness The PLR or fluid challenge coupled with real-time SV monitoring are the only accurate methods for determining fluid responsiveness The hemodynamic response to a fluid challenge is short lived - usually less than an hour Fluid responsiveness does not equate to the need for fluid boluses Six Principles of Fluid Resuscitation Fluid responsiveness is defined as a >10% increase in SV following a fluid challenge. Only 50% of hemodynamically unstable patients are fluid responsive Clinical signs, CXR, CVP, ultrasonography CANNOT be used to determine fluid responsiveness The PLR or fluid challenge coupled with real-time SV monitoring are the only accurate methods for determining fluid responsiveness The hemodynamic response to a fluid challenge is short lived - usually less than an hour Fluid responsiveness does not equate to the need for fluid boluses A high CVP is a major factor compromising organ perfusion 15

16 Fluid Responsiveness The only reason to give a patient fluid (fluid bolus) is to increase stroke volume (SV) and cardiac output (CO) A fluid bolus (fluid challenge) is most frequently given for hypotension or oliguria An analysis of 71 clinical studies (3617 pts) across a wide spectrum of patients demonstrated that only 52.7% of patients were fluid responsive Volume expansion cannot be regarded as the cornerstone of resuscitation The Frank-Starling & Marik-Phillips Curves SV EVLW Sepsis Large increase in EVLW Large inc in filling pressures Small increase in CO Large increase in CO Small increase in EVLW Small increase in filling pressures Inc.gradient between MCFP and CVP MCFP= Mean Circulating Filling Pressure Preload Ognibene FP et al. Chest 1988;93:903 16

17 Techniques to Assess Fluid Responsiveness ROC Curves & Diagnostic Accuracy Excellent Fair-Good Worthless Assessment of fluid responsiveness Technique Technology CVP/PAOP CVP/PAC IVC/SVC diameter FTc (LVETc) RVEDV/LVEDA/GEDI IVC/SVC - respiratory variation PPV/SVV/PVI Aortic blood flow - respiratory variation Passive Leg Raising (PLR) Volume Challenge Non calibrated pulse contour Bioimpedance Ultrasound (IVC/SVC) Ultrasound (IVC/SVC resp. variability) Pleth waveform (PVI) ECHO- Aortic Doppler (resp. variability) Calibrated pulse contour (PPV/SVV) Esophageal Doppler / USCOM (PLR & volume) Calibrated pulse contour (PLR & volume) NICOM (PLR & volume) 17

18 43 studies: healthy controls (n=1), ICU (n=22) and operating room (n=20) patients 57 ± 13% of patients were fluid responders AUC was 0.56 (95% CI; 0.54 to 0.58) ICU - AUC 0.56 (95% CI; 0.52 to 0.60) OR AUC 0.56 (95% CI; 0.54 to 0.58) There is no data in any group of patients to support using the CVP to guide fluid therapy. This approach to fluid resuscitation is potentially dangerous and must be abandoned. Crit Care Med 2013;41:1774 Mean CVP = 9 AUC 0.57 for CVP < 8 AUC 0.54 for CVP 8-12 AUC 0.56 for CVP > 12 Intensive Care Med 2016; epub 18

19 The Not High pressure transmitted backwards MCFP J. Physiol 1931;72:49 19

20 Association between systemic hemodynamics and AKI in patients with sepsis High CVP only factor predictive of AKI Legrund M, et al. Crit Care 2013;17:R278 High CVP only factor predictive of impaired microcirculatory flow BMC Anesthesiol 2013; 13:17 CVP - ARISE 20

21 Measuring the CVP.. leads to volume overload A normal CVP is between 0-2 mmhg this is necessary to ensure adequate venous return and cardiac output (venous return = MCFP CVP). Clinicians seem compelled to give fluid when the CVP is less than 8 mmhg The only solution to this pervasive problem is to stop measuring the CVP Crit Care Resus 2014; 16:245 The Swan is dead. PAC does not improve outcome PAC provides misleading data PAC provides data physician/nurses don t understand PAC is inaccurate 21

22 The GOLD STANDARD The closest the PAC comes to being a Gold Standard is the color of the catheter!! Assessment of fluid responsiveness Technique CVP/PAOP IVC/SVC diameter FTc (LVETc) RVEDV/LVEDA/GEDI IVC/SVC PPV/SVV/PVI Aortic blood flow Heart-lung interactions during mechanical ventilation PLR Volume Challenge Using heart-lung interactions to assess fluid responsiveness during mechanical ventilation 22

23 Using heart-lung interactions to assess fluid responsiveness during mechanical ventilation Limitations of PPV/SVV Sinus Rhythm Volume cycled ventilation with Vt of 8ml/kg IBW No ventilator-patient dyssynchrony Heart rate/respiratory rate ratio > 3.6 Chest wall compliance (Δ intra-pleural pressure) Cor pulmonale- pulmonary hypertension Increased intra-abdominal pressure Low pulmonary compliance Mechanical ventilation without spontaneous breathing Regular cardiac rhythm Vt 8 ml/kg ideal body weight Heart rate/respiratory rate ratio > 3.6 Total resp. system compliance 30ml/cmH 2 O Tricuspid annular peak systolic velocity 0.15 m/s Only 6 (2%) of the 311 patients satisfied all validity criteria MajoubY, BJA 2014;112:681 23

24 IVC Collapsibility Index An Indirect measure of RA pressure ROC Assessment of fluid responsiveness Technique CVP/PAOP IVC/SVC diameter FTc (LVETc) RVEDV/LVEDA/GEDI IVC/SVC PPV/SVV/PVI Aortic blood flow PLR Volume Challenge Hemodynamic response to a real or virtual fluid challenge Assessment of fluid responsiveness Technique PLR Volume Challenge Technology Esophageal Doppler/USCOM Calibrated pulse contour NICOM - Bioreactance 24

25 Fluid Responsiveness & Passive Leg Raising Fluid Responsiveness & Passive Leg Raising Stroke Volume preload responsiveness b' a' preload unresponsiveness b a A PLR B Ventricular preload Fluid Responsiveness & Passive Leg Raising Stroke Volume PLR mimics fluid challenge preload responsiveness b' a' preload unresponsiveness b a Unlike fluid challenge, no fluid is infused, and, the effects are reversible and transient A PLR B Ventricular preload 25

26 The volume challenge has to be given rapidly or most is lost from the intravascular space Blood Starch 26

27 Crit Care Med 2016 (in press) Fluid Responsive. What Next! Nothing Do not need to increase CO Increased lung water Fluid bolus (500cc LR) Give vasoconstrictor increase venous return secondary to α-agonist mediated decrease in venous capacitance Where's the Blood Volume? 27

28 Venodilation Venoconstriction Increase in MAP following Fluid Bolus mmhg 01 30min min Crit Care 2014;18:

29 Fluid Responsiveness in the FACCT trial Fluid bolus for hypotension, deceased UO 569 boluses in 127 patients 23% of patients were fluid responders At 1 hour MAP increased by 2 mmhg NO change in urine output Lammi MR, et al. Chest 2015; 148: postoperative patients 250 cc crystalloid bolus over 5 minutes 50% fluid responders Maximal change in CO occurred at 1.2 minutes At 10 minutes CO returned to baseline Crit Care Med 2016; 44:880 Hemodynamic Assessment 29

30 Hemodynamic Assessment 30