Nurse Driven Fluid Optimization Using Dynamic Assessments

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1 Nurse Driven Fluid Optimization Using Dynamic Assessments

2 WHAT WE BELIEVE We believe that clinicians make vital fluid and drug decisions every day with limited and inconclusive information Cheetah believes that with a complete hemodynamic profile, clinicians are empowered to make decisions better leading to improved outcomes We believe Cheetah s accurate, precise and non-invasive technology can help you optimize your patients fluid and perfusion status 2 Decisions Made Better

3 WHY VOLUME MATTERS FLUID IMBALANCE CAN LEAD TO SERIOUS CONSEQUENCES Every patient has unique and constantly changing hemodynamic needs Understanding a patient s volume status throughout their care is a challenge clinicians face every day Serious complications are associated with both under- and over-resuscitation of a patient, including organ failure and death Too Little Fluid 1,2,3 [Hypovolemia] Tissue Hypoperfusion Tissue Hypoxia Organ Failure Insufficient Perfusion Too Much Fluid 4,5,6,7,8 [Hypervolemia] Tissue Edema Organ Failure Increased ICU/ Ventilator Days Increased Mortality SEPSIS / SHOCK SURGERY (ERAS) Volume overload in septic patients is associated with an increased risk of mortality 1,2 Careful management of intraoperative fluids can greatly enhance patient outcomes 4 3 References: 1. Shoemaker W et al. Tissue oxygen debt as a determinant of lethal and nonlethal postoperative organ failure. CritCare Med 1988; 16: Vermeulen H et al. Intravenous fluid restriction after major abdominal surgery: A randomized blinded clinical trial. Trials 2009; 10: Rivers E et al. Early goal directed therapy in the treatment of severe sepsis and septic shock. NEJM 2001; 345: Gustafsson UO et al. Enhanced Recovery after Surgery Society. Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations. Clin Nutr. 2012; 31: Corcoran T et al. Perioperative Fluid Management Strategies in Major Surgery: A stratified meta-analysis. Anesth Analg 2012; 114: Boyd J et al. Vasopressin in Septic Shock Trial (VASST). Critical Care Medicine 2011; 39: Vincent JL et al. Sepsis in European ICU: Results of the SOAP Study. Critical Care Med 2006; 34: KelmD et al. Fluid overload in patients with severe sepsis and septic shock treated with early goal directed therapy is associated with increased acute need for fluid-related medical interventions and hospital death. Shock 2015; 43:

4 HEMODYNAMICS THE SCIENCE OF BLOOD FLOW HEMO DYNAMICS Blood Flow #1 Driver Tissue Perfusion Perfusion is critical for life delivery of oxygen, nutrients, and toxin removal at tissue level Optimized Hemodynamics Enables Perfusion 4

5 HOW DO WE CURRENTLY MEASURE PERFUSION? Blood Pressure BioMarkers Physiology MAP > 65 SBP > 90 O2 Delivery SvO2 Urine Output Critical Care Is About Optimizing Hemodynamics 5

6 DRAWBACKS TO USING PRESSURE TO ASSESS VOLUME Δ Pressure * Compliance = Δ Volume For pressure to accurately reflect volume compliance must remain constant Central Venous Pressure Pulmonary Wedge Pressure 6

7 OPTIMIZING HEMODYNAMICS Adequate Perfusion Volume IV Fluid PRELOAD Peripheral Resistance Vasopressors Vasodilators AFTERLOAD Cardiac Function Inotropes CONTRACTILITY 7

8 BREAKTHROUGH TECHNOLOGY MAKES THE DIFFERENCE 4 non-invasive sensor pads are applied to the thorax, creating a box around the heart A small electric current of known frequency (75kHz) is applied across the thorax between the outer pair of sensors A voltage signal is recorded between the inner pair of sensors The flow of blood in the thorax introduces a time delay or phase shift in our signal We have correlated these signal changes to known thermodilution cardiac output Phase Shift 8 65,000 patient samples in multiple clinical settings (ICU/OR/Cath Lab)

9 DYNAMIC ASSESSMENTS WHAT ARE THEY? Directly challenging the heart with volume to see the response Ideal for assessing fluid responsiveness Provides continuous feedback of volume response after an intervention May answer the following key questions regarding your patient: Will additional IV fluid increase cardiac output? Will additional IV fluid optimize perfusion? 9

10 ASSESSING FLUID RESPONSIVENESS METHODS OF FLUID BOLUS Passive Leg Raise Bolus Challenge Trending Therapy Before Therapy During Therapy FRANK-STARLING LAW 10

11 METHODS TO ASSESS VOLUME DYNAMIC ASSESSMENT Passive Leg Raise Reversible challenge ~ 300cc of acute volume High sensitivity & specificity Positive change in SVI of 10% is predictive of an increase in Cardiac Output Pro: Reversible Con: Contraindicated in certain patient populations Will Fluid Increase Stroke Volume? 11

12 METHODS TO ASSESS VOLUME DYNAMIC ASSESSMENT Bolus Challenge Reliable Rapid infusion of 250cc over 3-5 minutes High sensitivity /specificity Positive change in SVI of 10% or greater is predictive of an increase in CO and therefore flow Pro: Reliable Con: Irreversible Will Fluid Increase Stroke Volume? 12

13 METHODS TO ASSESS VOLUME Trending Therapy Minute-to-minute Information Assess Therapeutic Response Identify Early Trends Pro: Real Time / Continuous Con: None! Will Fluid Increase Stroke Volume? 13

14 WHO IS A CHEETAH PATIENT? Shock States: Severe Sepsis/Septic Shock Hypovolemic Cardiogenic Neurogenic Other Conditions characterized by hemodynamic instability Congestive Heart Failure (CHF) Acute Respiratory Distress Syndrome (ARDS) Acute Kidney Injury/Renal Insufficiency (AKI) Subarachnoid Hemorrhage (SAH) Care Pathways and Protocols Any patient where you ask yourself: ERAS & Perioperative Goal Directed Fluid Therapy CMS Severe Sepsis and Septic Shock Bundle (NQF #0500, SEP-1) Surviving Sepsis Campaign Emergency/Trauma Will additional IV fluid increase cardiac output and optimize perfusion? 14

15 CHEETAH SCENARIO SEPTIC PATIENT 42 year old male, paraplegic with large wound to coccyx, admitted with septic shock Pt had already received 6L fluid over night, however remained on low-dose Levophed that was unable to be weaned down further CVP reading 8-10, UOP >30mL/hr, MAP Cheetah monitor placed on patient to assess if more volume is needed as they were unable to wean the Levophed 15

16 STROKE VOLUME INDEX CHANGE 38 SVI (ml/m 2 /beat) Start of PLR Patient placed back in semirecumbent position 30 Time 16

17 RESULTS AND ORDERS Passive Leg Raise #1 Notice that CI increases with PLR (this is not always the case!) 10% change in SVI, patient is likely fluid responsive PLR indicated patient was likely fluid responsive. 1 Liter LR was ordered to be given and PLR to be repeated after infusion complete. 17

18 REPEAT PASSIVE LEG RAISE SVI (ml/m 2 /beat) Passive Leg Raise # Patient placed back in semi-recumbent position :23:21 PM1:24:21 PM1:25:21 PM1:26:21 PM1:28:11 PM1:29:11 PM1:30:11 PM1:32:07 PM1:33:07 PM1:34:07 PM1:35:08 PM1:36:08 PM1:37:08 PM Time Start of PLR 18

19 RESULTS AND OUTCOME Passive Leg Raise #2 Minimal change in CI compared to previous test (11.3%) < 10% change in SVI, patient unlikely to be fluid responsive PLR indicated patient was unlikely fluid responsive. Pt was able to be weaned off of Levophed following the 1 Liter LR infusion. 19

20 SUMMARY Volume matters Perform guided fluid resuscitation to optimize organ perfusion, oxygenation and prevention of organ failure Determine fluid responsiveness by means of simple, nurse-driven dynamic assessments Use of hemodynamics at the bedside by nurses can help to drive differential diagnosis and treatment of shock states 20 R-MRK-062

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