Hemodynamic Monitoring To Guide Volume Resuscitation
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1 Hemodynamic Monitoring To Guide Volume Resuscitation Nick Johnson, MD Acting Assistant Professor Division of Emergency Medicine Attending Physician, Medical & Neuro-Intensive Care Units Harborview Medical Center Disclosures No financial conflicts of interest No industry relationships Funding from NIH & Medic One Foundation Objectives Objectives 1. Understand a conundrum: hypoperfusion can hurt patients, but so can excess volume. 2. Discuss the challenges of evaluating hemodynamic monitoring tools when there is no gold standard. 3. Review several endpoints for volume resuscitation and discuss their utility. 4. Highlight a few interesting hemodynamic monitoring tools that can be used in a variety of clinical settings. 1
2 The Problem The Problem Boyd CCM 2011 Sadaka J Int Care Med 2014 FACCT NEJM 2006 Elofson J Crit Care 2015 Shim J Crit Care 2014 Payan Crit Care 2008 Goldilocks Principle Goldilocks Principle 2
3 The Gold Standard Conundrum The Gold Standard Conundrum The Gold Standard Conundrum The Gold Standard Conundrum PAC-Man Lancet 2005 FACCT NEJM 2006 Cochrane Review 2013 SUPPORT JAMA 1996 Sandham et al. NEJM 2003 Richard et al. JAMA 2003 Endpoints Tolerance 3
4 Endpoints Tolerance Responsiveness Responsiveness Cardiac Output Yes Preload Responsiveness No Cardiac Output Yes Preload 4
5 Endpoints Tolerance Responsiveness Organ Perfusion Endpoints Tolerance Responsiveness Organ Perfusion Patient-Centered Outcomes Upstream: Point-of-care ultrasound Mid-Stream: Pulse waveform analysis Downstream: End-tidal CO 2 Tissue O 2 Saturation 5
6 Point-of-Care Ultrasound: Holistic Approach Pre-test probability (history & exam) Ultrasound Heart Chamber size & function Lung B-lines IVC Tolerance Post-test probability (Volume: yes/no) Bedside Ultrasound: Cardiac Phenotype Parameters Vasodilated/High-Output EF >70%, CI >3.5, LV/RV full IVCd < 2cm, IVC 25-50% Hypovolemic Hummingbird Heart Normal x 3 Function, Volume, Resistance EF >55%, CI <3.5 LV/RV small IVCd <2cm, IVC >50% EF 55-70%, CI <2.5-4, LV/RV full IVCd 1-2cm, IVC 25-50% Dysfunctional Heart EF 40%, CI <3 LV/RV full IVCd >2cm, IVC <50%, Strumwasser J Trauma ACS Lung Ultrasound: B-lines Lung Ultrasound 6
7 IVC: Spontaneously Breathing IVC Ultrasound Gestalt The IVC looks full or empty Spontaneously breathing IVC Diameter or Percent Collapse Estimate CVP Tolerance Responsive Mechanically ventilated IVC distensability index or IVC Volume Responsive IVC: Mechanically Ventilated divc = Max-Min 18% Min D IVC = Max-Min 12% Mean All patients had tidal volume > 8 ml/kg Barbier ICM 2004, Feissel ICM
8 Bedside Ultrasound: Holistic Approach A-lines B-lines Lee. J Crit Care Upstream: Point-of-care ultrasound Mid-Stream: Pulse waveform analysis Downstream: End-tidal CO 2 Tissue O 2 Saturation Pulse Waveform Analysis Pulse Waveform Analysis Strumwasser J Trauma ACS
9 Pulse Waveform Analysis Flotrac/Vigileo LiDCO Rapid Upstream: Point-of-care ultrasound Mid-Stream: Pulse waveform analysis Downstream: End-tidal CO 2 Tissue O 2 Saturation End-Tidal CO 2 Monnet ICM
10 End-Tidal CO 2 Cardiac Index EtCO 2 Sensitivity Arterial pulse pressure Passive leg raise EtCO 2 5% ~ Cardiac index 15% with volume challenge 100-Specificity Monnet ICM 2013 Tissue Oxygen Saturation Inspectra S t O 2 Cohn et al 2007, Moore et al 2008, Guyette et al. 2012, Beekley et al 2012, Vorwerk et al 2012 Tissue Oxygen Saturation Sensitivity Systolic Blood Pressure S t O 2 Base Deficit 1 - Specificity Cohn et al
11 Summary 1. Give the right amount of volume, but not a drop more. 2. There is no gold standard hemodynamic monitor. 3. Endpoints: tolerance, responsiveness, perfusion, mortality? 4. A variety of monitoring tools exist, each with limitations. Use multiple tools along with your clinical judgement. Thank you! Nick Johnson, MD Additional References Flotrac Review of 45 published studies: Marik PE. J Cardiothorac Vasc Anesth 2013;27(1): st & 2 nd generation devices Slagt C, et al. Eur J Anaesthesiol 2015;32(1):5 12. Compton FD, et al. Br J Anaesth 2008;100(4): Hadian M, et al. Crit Care 2010;14(6):R212. De Backer D, et al. Intensive Care Med 2011;37(2): Monnet X, et al. Critical Care 2010;14(3):R rd generation devices Machare-Delgado E, et al. J Intensive Care Med 2011;26(2): Monnet X, et al. Br J Anaesth 2012;108(4): Monnet X, Lahner D. Care Med 2011;37(2): OR setting Benes J, et al. Crit Care 2010;14(3):R
12 Additional References CNAP Jeleazcov C, et al British Journal of Anaesthesia 2010;105(3): Ilies C, et al. British Journal of Anaesthesia 2012;108 (2): Jagadeesh A, et al. Ann. Card. Anaesth 2012;15(3): Siebig S, et al. International Journal of Medical Sciences 2009;6(1): Ilies, H. et al. British Journal of Anaesthesia 2012;109(3): Monnet X, et al. British Journal of Anaesthesia 2012Sep;109(3): Additional References Bioreactance Squara P, et al. Intensive Care Med 2007;33(7): Marik PE, et al. Chest 2013;143(2): Saugel B, et al. Br J Anaesth 2015;114(4): Fagnoul D, et al. Crit Care 2012;16(6):460. Han S, et al. PLoS ONE 2015;10(5):e
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