Jan M. Headley, R.N. BS

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1 Fluid First: Using PLR & SVV to Optimize Volume Jan M. Headley, R.N. BS Disclosure Director, Clinical Marketing & Professional Education Edwards Lifesciences

2 Does this Patient NEED Fluid??

3 WE Have a Problem Identified Problem Volume expansion 1st line of therapy. Only ½ of patients show an increase in CO as a response to fluid therapy. (Defined as responders) Need a reliable means to be able to determine the patients ability to respond to fluid. Teboul 2003: An Editorial Review

4 Static indices are poor predictors Preload indices such as CVP, RAP, PAOP, and LVEDP are poor predictors of preload responsiveness These are also known as static indices as they do not predict the patient s response to fluid Teboul 2003

5 Pressure Based Parameters Issues: CVP and PAOP poor predictors of fluid status Kumar CCM 2004

6 Osman CCM 2007

7 Dynamic Preload Predicting Teboul Parameters Dynamic preload parameters such as SPV and its delta up or down, PPV and SVV are better predictors of preload responsiveness than static indices.

8 SPV, PPV, SVV Defined All measure the difference between the maximum and minimum values over a full respiratory cycle. SPV: Systolic Pressure Variation (mmhg): SPMax SPMin Normal < 10 mmhg PPV: Pulse Pressure Variation (%): PPMax PPmin/ PP mean Normal <13% SVV: Stroke Volume Variation (SVV%): measured over the 20 second cycle. SVMax SVMin/SV mean Normal < 15 % JMHeadley 2007 AACN NTI News

9 SVV: The Basic Formula

10 Preload Responsiveness: SVV Predicting SVI changes >= 5%, CI > 15% Hofer, 2005 & Michard 1999

11 Pulsus Paradoxus: The Origin of SVV Pulsus Paradoxus is the origin of SVV value. Occurs with spontaneously breathing patients. Reverse Pulsus Paradoxus Occurs during positive pressure ventilation. Clinical use of this phenomenon remains marginal. Michard Anesthesiology 2005

12 Dynamic Response to Preload Parry-Jones During each respiratory cycle a virtual preload challenge occurs. Therefore, variations in the tidal volumes during a breath can impact the next systolic pressure.

13 Airway Pressure Arterial Waveforms Controlled Breath Spontaneous Breath Airway Pressure Inspiration Expiration Arterial Pressure SP Increases SP Decreases

14 F- S Curve for Preload Responsiveness Stroke Volume SVV 10% SVV 28% SVV 8% Patient A Patient B P Patient A Preload SV Patient B Patient A is preload responsive On steep portion of the curve Fluid bolus produces large increase in SV SVV > % Patient B is not preload responsive On flat portion of the curve Fluid bolus does not produce the same amount of increase in SV SVV < 10 15% Modified Concepts from Parry-Jones, Michard, et al.

15 SV to SVV Relationship Trend over time of SV and SVV. Note that when the SV is high the SVV is low. When SVV is increasing the SV decreases. McGee 2006 Crit Care Med suppl. Abs 227

16 SV to SVV Relationship McGee 2006 Crit Care Med suppl. Abs 227

17 Two Major Indications of SVV: 1. evaluate the response to fluid interventions 2. determine or predict the patient s potential response to fluid therapy If variability is low, need for fluid low If variability is high, need for fluid is high Michard 2005, Teboul 2003

18 Fluid Responsive?? Parameter Normal Fluid Responsive SPV mmhg 5 mmhg >10 mmhg PPV % < 13% >13% SVV % <10 % > 10-15%

19 The Clinical Value The value of dynamic parameters is the ability to predict fluid responsiveness and obviating the need for unnecessary fluid loading Michard Anesthesiology 2005

20 Issue of Predicting Fluid Responsiveness Not all patients respond to fluid by significant increase in CO Issues with fluid administration to nonresponders Harmful rather than beneficial Increase lung water Worsening of gas exchange Increase tissue edema RV dilation with leftward septal shift

21 Useful but has some limitations Teboul Some potential limitations: Arrhythmias Spontaneous breathing Varied ventilator delivered tidal volumes However, this does not represent a true limitation of the interpretation of large SVV as an indicator of fluid responsiveness

22 Altered SVV not Related to Fluid Need? Small tidal volumes Oscillating ventilation Increased juxtacardiac pressures High levels of PEEP Pneumotension Cardiac tamponade Constrictive Pericarditis Increased abdominal pressure Vasodilator therapy (nitroprusside) Never one number in isolation

23 CCM (20) ARDS pts Vt <7 ml/kg, PEEP <15 cmh2o High PEEP = PPV/SVV Low Vt = PPV/SVV Cause opposite direction on F-S curve PEEP offsets effect of low Vt Value ROC/AUC Sensitivity Specificity Threshold PPV % 100% 11.8% SVV CVP

24 In MV pts, ΔPP and ΔSP predicted fluid responsiveness with a sensitivity of 94% and 100%,respectively. In SB pts, sensitivity was only 63% and 47%, respectively. However, when their baseline value is high without acute right ventricular dysfunction in a participating patient, a positive response to fluid is likely.

25 Chest 2002;121;

26 PLR?? 45 Passive Leg Raising ml volume Effects < 30 sec.. Not more than 4 minutes Self-volume challenge Reversible

27 Hemodynamic Effects of PLR Increased venous return Increased RV preload Increased RV SV Increased LV filling Increased LV SV Increased CO If patient on ascending portion of Starling Curve

28 PLR Effects on Starling Curve If the increase in cardiac preload induced by PLR induces significant changes in SV (a to b), the patient will likely be fluid responsive If the same changes in cardiac preload during PLR do not significantly change SV (a to b ), the heart is likely preload dependent and should not be administered Monnet 2007

29 How to Perform a PLR SemiFowler s 45 Passive Leg Raising Pivot bed automatically (in some beds) Trunk is tilted supine, lower limbs raised to 45 angle Angle between the trunk and lower limbs remains unchanged (135 ) Monnet 2007, artwork from

30 PLR vs Trendelenburg 45 HOB lower than trunk Unknown amount of blood sequestered in head Baroreceptor activated Potential for gastric aspiration Passive Leg Raising HOB horizontal to trunk Approx ml transferred Baroreceptors may not be activated Avoids risk of gastric aspiration

31 AJCC 2005;14: USE OF THE TRENDELENBURG POSITION AS THE RESUSCITATION POSITION: TO T OR NOT TO T? N Bridges & A.A. Jarquin-Valdivia CONCLUSION: The general slant of the available data seems to indicate that the Trendelenburg position is probably not a good position for resuscitation of patients who are hypotensive. Further clinical studies are needed to determine the optimal position for resuscitation.

32 Monnet 2007 This very simple postural maneuver has been demonstrated to be a valuable tool for predicting fluid responsiveness: the response of estimates of SV to a short PLR is correlated to the response of CO to a subsequent fluid administration.

33 Monnet 2007 PLR induced increase in pulse contour CI reliably predicted fluid responsiveness.. Sensitivity 70% and Specificity of 92%.. patients were spontaneously breathing and/ or who had arrhythmias.

34 SVV: Pre and Post PLR Pre - PLR SVV 18 % SV 46 CO/CI 3.9/2.0 Post - PLR SVV 9 % SV 63 CO/CI 5.7/3.0 Simulated data

35 So did this patient need fluid? JMHeadley 2007 AACN NTI News

36 Fluid First: Using PLR & SVV to Optimize Volume Contact:

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