Fluid Responsiveness in Critically ill Patients

Ubaidur Rahaman Senior Resident, CCM, SGPGIMS Lucknow, India

FLUID RESPSONSIVENSS

Definition: fluid responsiveness denotes an increase in cardiac index after infusion of a fluid either crystalloid or colloid.

Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow

FLUID RESUSCITATION
3 DIFFERENT SCENARIO

Patients in the ERS for acute blood losses or body fluid losses
No therapeutic dilemma regarding hypovolemia

Patients in the ERS for high suspicion of septic shock

EGDT- volume resuscitation mandatory in first 6 hours- mortality benefit

Patients in the ICU, already resuscitated for several hours or days

Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow

Patients in the ICU, already resuscitated for several hours or days

hemodynamic instability requiring therapy Cumulative fluid balance Risk of pulmonary oedema/ raised IAP

? Fluid responsiveness

Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow

Cumulative fluid balance and mortality

Fluid resuscitation in septic shock: A positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med 2011 Vol. 39, No. 2; John H. Boyd, Jason Forbes, MD; Taka-aki Nakada, Keith R. Walley,
James A. Russell,

retrospective review of the use of intravenous fluids during the first 4 days of care. Patients: VASST study enrolled 778 patients septic shock and receiving a minimum of 5 ug of norepinephrine per minute.

A more positive fluid balance both early in resuscitation and cumulatively over 4 days is associated with an increased risk of mortality in septic shock.
Central venous pressure may be used to gauge fluid balance <12 hrs into septic shock but becomes an unreliable marker of fluid balance thereafter. Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow

to give or not to give????

Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow

Assessment OF FLUID RESPONSIVENESS

PRELOAD DEPENDENCE

PRELOAD

CONTRACTILITY

CARDIAC INDEX

Both ventricles should be preload dependent

Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow

Assessment of PRELOAD is not assessment of PRELOAD DEPENDENCE

normal heart

Stroke volume

preload-dependence preload-

failing heart
preload-independence preload-

Ventricular preload
Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow

ASSESSMENT OF FLUID RESPONSIVENESS

ASSESSMENT OF PRELOAD Filling pressures- CVP, Pawp Filling volumes- LVEDV/ RVEDV VENACAVAL DIAMETER- variation with respiration RAP - inspiratory fall ASSESSMENT OF PRELOAD DEPENDENCE

Response to fluid challenge Prediction of preload dependence:

PPV induced variation in CI parameters

Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow

ASSESSMENT OF PRELOAD Filling pressures

oCentral Venous Pressure oPulmonary artery Wedge Pressure

Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow

Central Venous Pressure

VR

Function of

CVP

CARDIAC PUMP

MCFP Vs Venous resistance

VR- venous return; MCFP- mean capillary filling pressure Vs- stressed volume

VR- function of

Mean Capillary filling pressure (MCFP)

Vs

Vu

P
Vs- Stressed volume; Vu- unstressed volume

Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow

Central Venous Pressure

Venous function and central venous pressure. A physiologic story.

Simon Gelman. Anesthesiology 2008;108:735-48

C.O.
Q

is determined by

intersection
Q

of

RETURN FUNCTION

CARDIAC FUNCTION

Pra

Pra

Pra
How to use CVP measurements. Magder S. Current Opinion in Critical Care 2005, 11:264270

CONCEPT OF LIMIT

Q
Limit of RETURN FUNCTION Limit of CARDIAC FUNCTION

Lowering Pra will not increase VR

Increasing Pra will not Increase C.O.

Pra

How to use CVP measurements. Magder S. Current Opinion in Critical Care 2005, 11:264270

Is CVP a misleading variable?

Body does everything to maintain homeostasis adequate transmural pressure MCFP more accurate measurement of volume status- difficult to measure Ppawp is an even worse indicator than CVP as it is far removed from the action of MCFP RAP and Ppaw do not always reflect true transmural pressure in patients on PEEP, increased IAP

The correlation between CVP and circulating blood volume has never been found simply because it does not exist

Venous function and central venous pressure. A physiologic story.

Simon Gelman. Anesthesiology 2008;108:735-48

Does Central Venous Pressure predicts fluid responsiveness? A systemic review of literature and the tale of seven mares.
Paul E. Marik, M. Baram, B. Vahid. Chest 2008;134:172-178

Expansive literature search to identify all trials evaluating the relationship between
2. 1. CVP & blood volume association between CVP or CVP and fluid responsiveness

24 studies identified 5 comparing CVP with measured blood volume; -19 studied relationship between CVP/CVP & change in cardiac performance after fluid challenge

Poor correlation between CVP and blood volume CVP or CVP and homodynamic response to fluid challenge overall 56% patients responded to fluid challenge

predicting fluid responsiveness in ICU patients: A critical analysis of evidences.

Frdric Michard and Jean-Louis Teboul. Chest 2002;121;2000-2008

From medline (since 1966) Twelve studies were analyzed in which the parameters tested were as follows: (1) static Indicators: RAP, PAOP, RVEDV, LVEDA; (2) dynamic parameters: inspiratory decrease in RAP, ddown, PPV, aortic blood velocity(Vpeak) Before fluid infusion, static indicators were not significantly lower in responders than in nonresponders. When a significant difference was found, no threshold value could discriminate responders and nonresponders.

Before fluid infusion, inspiratory variation in RAP,SPV ddown, PPV, and Vpeak were significantly higher in responders. Positive predictive value: 77- 95%, negative predictive value: 81- 100%

ASSESSMENT OF PRELOAD Filling Volumes

o RVEDV o LVEDV

Respiratory variation in VENACVAL DIAMETER

Assessment OF PRELOAD

Negative pleural pressure---- increased VR---- collapse of IVC

Spontaneous breathing

Positive pleural pressure---increased RA pressure---decreased VR

IVC- extrathoracic course--- increased transmural pressure---- distend SVC- intrathoracic course--- decreased transmural pressure----collapse

Positive pressure ventilation

This variation is affected by intravascular volume ( hydrostatic pressure) Less intravascular volume--- more variation

Respiratory variation in VENACVAL DIAMETER SPONTNEOUS BREATHING Patient

IVC collapsibility index 50% is strongly associated with low CVP Emergency department bedside ultrasonographic measurement of caval index for noninvasive Determination of low central venous pressure.
Nagdev AD, Merchant RC, Murphy MC. Ann Emerg Med. 2010 Mar;55(3):290-5

Assessment OF PRELOAD

In healthy subjects inspiration decreased IVC diameter by approx. 50%. This cyclic change is abolished in high volume status, right ventricular failure, cardiac tamponade. Applied Physiology in Intensive care Medicine. Pinsky, Mancebo. page 145

Could be affected by manner of respiration

Could be affected by raised IAP

Respiratory variation in VENACVAL DIAMETER

Assessment OF PRELOAD

POSITIVE PRESSURE VENTILATED PATIENTS

IVC distensibility index ( DDIVC) 12% predictive of increase in C.I. by at least 15%
Positive predictive value- 93 %, negative predictive value- 92% DDivc=(Dmax-Dmin)/ mean of 2 values

The respiratory variation in inferior venacava diameter as a guide to fluid therapy.

Feissel M, Michard F. Inten Car Med 2004;30:1834-7

IVC distensibility index (dIVC) 18% predictive of increase in C.I. of at least 15%
Sensitivity-90%, Specificity-90% divc=(Dmax-Dmin)/ Dmin

Respiratory changes in inferior venacava diameter are helpful in predicting fluid responsiveness in ventilated septic patients.
Barbier C, Jardin F. Inten Car Med 2004;30:1740-6

Respiratory variation in VENACVAL DIAMETER

Assessment OF PRELOAD

POSITIVE PRESSURE VENTILATED PATIENTS

Could be affected by raised IAP

Respiratory variation in VENACVAL DIAMETER

Assessment OF PRELOAD

POSITIVE PRESSURE VENTILATED PATIENTS

Could be affected by raised IAP

Assessment OF PRELOAD
Respiratory variation in VENACVAL DIAMETER

POSITIVE PRESSURE VENTILATED PATIENTS

SVC collapsibility index 36% identified preload responders.
Sensitivity- 90%, specificity- 100% dSVC= (Dmax-Dmin)/ Dmax

Superior venacaval collapsibility as a gauge of volume status in ventilated septic patients.

Vieillard Baron A, Chergui K, Rabiller A. Inten Care med 2004;30;1734-9 Not affected by raised IAP

Inspiratory fall in right atrial pressure

Assessment OF PRELOAD

Respiratory variation in RAP predicts the response to fluid challenge.

Magder S, Geoorgiadis G, Cheong T. J Crit Care 1992; 7:76-85

13 of 14 patients had no fall in RAPC.O. not increased with fluid challenge

16 of 19 patients who had a fall in RAP 1 mmHgC.O. increased by> 250 ml/ min with fluid challenge

Sufficient inspiratory effort to lower Ppaw by 2 mmHg

Assessment OF PRELOAD DEPENDENCE

FLUID CHALLENGE

PREDICTION BY PPV induced RESPIRATORY VARIATION IN C.I. RELATED PARAMETERS

Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow

Assessment OF PRELOAD DEPENDENCE

Response to FLUID CHALLENGE

change in filling pressures- CVP, RAP, Pawp change in perfusion markers- C.O., MAP, CFT, ABG, SCVO2, B. lactate

Disadvantages pulmonary edema excessive cumulative fluid balance

Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow

Assessment of PRELOAD DEPENDENCE

PREDICTION OF PRELOAD DEPENDENCE

Spontaneously breathing patients

PLR- stroke volume/ pulse pressure

Positive pressure ventilated patients

PLR- stroke volume/ pulse pressure Respiratory cycle induced change in parameters related to cardiac indexSPV, SVV, PPV, pulse oxymetry plathysmography waveform variation, Aortic blood flow velocity, aortic velocity time integral, aortic pre-ejection period Respiratory systolic variation test ( RSVT) end expiratory occlusion test

Assessment of PRELOAD DEPENDENCE

PREDICTION OF PRELOAD DEPENDENCE

PASSIVE LEG RAISING

Venous blood shift
(Rutlen et al. 1981, Reich et al. 1989) 1981,

45

Transient and reversible effect

Assessment of PRELOAD DEPENDENCE

PREDICTION OF PRELOAD DEPENDENCE

PLR

Passive leg raising predicts fluid responsiveness in the critically ill

Xavier Monnet, Mario Rienzo, David Osman, Nadia Anguel, C. Richard, Michael R. Pinsky, Jean-Louis Teboul, Crit Care Med 2006; 34:14021407

71 mechanically ventilated patients considered for volume expansion. 31 patients had spontaneous breathing activity and/or arrhythmias.

homodynamic status assessed at baseline, after PLR, after volume expansion (500 mL NaCl 0.9% infusion over 10 mins)

In both groups, PLR induced increase in aortic blood flow 10% predicted volume expansion induced increase in aortic blood flow 15% (sensitivity- 97%, specificity 94%)

Assessment of PRELOAD DEPENDENCE

PREDICTION OF PRELOAD DEPENDENCE- PLR

Immediate effect of PLR following induction of anesthesia for cardiac surgery in 18 patients
Baseline Cardiac output ( l/min) PAOP ( mmHg) SPV ( mmHg) dDown ( mmHg) PLR Change (%) 23 10 48 56

4.5 1.1 12.9 4.5 11.3 5.1 7.5 3.7

5.7 1.1 14.1 4.8 5.9 2.4 3.3 2

Functional hemodynamic monitoring. Pinsky and Payen, page 318

PREDICTION OF PRELOAD DEPENDENCE

Positive pressure ventilation induced change in parameters related to cardiac index

Paw Ppl
Transmural pressure
cardiac chambers/ great vesseles

PAlv Palv
Transpulmonary pressure
alveoli

Zone 3 to zone 2/1 formation

Filling gradient of LV no effect

Filling gradient of RV

PVR

RV preload

RV afterload

LV stroke volume

Pulmonary Transit time

RV stroke volume

Mainly responsible for change in stroke volume

Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow

PREDICTION OF PRELOAD DEPENDENCE

Positive pressure ventilation change in parameters related to cardiac index

Paw Ppl Palv

Transmural pressure
cardiac chambers

Transpulmonary pressure alveoli

alveolar vesseles

squeezing of blood out of

LV afterload

LV preload

LV stroke volume
Predominant mechanism in LV systolic dysfunction Predominant mechanism in hypervolemia

Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow

PREDICTION OF PRELOAD DEPENDENCE

Positive pressure ventilation induced change in parameters related to cardiac index

RV preload RV ejection Pleural pressure transpulmonary pressure RV afterload LV ejection LV afterload LV ejection LV preload Aortic velocity Stroke volume Systolic B.P. Pulse Pressure Aortic velocity Stroke volume Systolic B.P. Pulse Pressure
MAXIMUM AT END OF INSPIRATION

Pumonary transit time

LV preload

MINIMUM AT END OF EXPIRATION

Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow

PREDICTION OF PRELOAD DEPENDENCE

Respiratory cycle induced change in parameters related to cardiac index

SYSTOLIC PRESSURE VARIATION- SPV

PROPOSED BY COYLE IN 1983

dup inspiratory increase in systolic pressure: increased LV Stroke volumeincreased preload decreased afterload Increase in extramural aortic pressure

Ddown Expiratory decrease in systolic pressure: decrease in LV stroke volumedecrease in preload

PREDICTION OF PRELOAD DEPENDENCE

Respiratory cycle induced change in parameters related to cardiac index

SYSTOLIC PRESSURE VARIATION- SPV

Systolic pressure variation as a guide to fluid therapy in patients with sepsis induced hypotension
Taverneir B, Dupont J. Anesthesiology 1998, 89:1313-1321

ddown- threshold value of 5 mmHg was associated with Increase in stroke volume 15% Positive predictive value- 95%, Negative predictive value- 93%

dup- increase in hypervolemia and LVF ddown-not increased in RVF despite hypovolemia
In the presence of large dup, the PPV, SPV and SVV will be less effective in predicting fluid responsiveness

*cardiovascular monitoring Chapter 32, page 1327, Millers Anesthesia 7th edi

PREDICTION OF PRELOAD DEPENDENCE

Respiratory cycle induced change in parameters related to cardiac index

PULSE PRESSURE VARIATION- PPV

PPmax-PPmin PPV= PPmax+PPmin/2

PREDICTION OF PRELOAD DEPENDENCE

Respiratory cycle induced change in parameters related to cardiac index

PULSE PRESSURE VARIATION- PPV

Relation between Respiratory Changes in Arterial Pulse Pressure and Fluid Responsiveness in Septic Patients with Acute Circulatory Failure
F. MICHARD, S. BOUSSAT, D. CHEMLA, NADIA ANGUEL, MICHAEL R. PINSKY, and JEAN-LOUIS TEBOUL

Am J Respir Crit Care Med Vol 162. pp 134138, 2000

Baseline HR Pra Ppa CI

(beats/min)

VE 106 21 90 13 12 4 14 3 29 6 4.0 0.9 75 64 Threshold value of 13% was associated with increase in C.I. 15% in response to volume expansion Sensitivity- 94%, specificity96%

11o 22 69 13 93 10 3 24 6 3.6 0.9 14 10 96

MAP
(mmHg) (mmHg)

Pcwp

(mmHg)

(l/min/m2)

PPV SPV

(%) (%)

PREDICTION OF PRELOAD DEPENDENCE

Respiratory cycle induced change in parameters related to cardiac index

PULSE PRESSURE VARIATION- PPV

PREDICTION OF PRELOAD DEPENDENCE

Respiratory cycle induced change in parameters related to cardiac index

PULSE PRESSURE VARIATION- PPV

PPV better predictor than other SV derived variables

Inspiratory increase in pleural pressure increase in SPV Increase in extra-mural pressure Equal increase in Systolic pressure And Diastolic pressure no change in PPV

Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow

PREDICTION OF PRELOAD DEPENDENCE

Respiratory cycle induced change in parameters related to cardiac index

RESPIRATORY SYSTOLIC VARIATION TEST ( RSVT)

RSVT slope 0.24 mmHg/ cmH2O predicted change in CI of 15%

RSVT slope

Predicting fluid responsiveness in patients undergoing surgery: functional haemodynamic parameters including the Respiratory Systollic Variation Test and static preload indicators. Preisman S, Kogan S, Berkenstadt H, et al Br J Anaesth 2005;95:74655

since during critical illness maintenance of the cardiac output may depend upon right ventricular function, the clinician need to be able to discern the presence of right ventricular dysfunction
William Hurford, 1988

Presence of fluid responsiveness is not an indication by itself to administer fluids

It is commonly said that a teacher fails if he has not been surpassed by his students
-Edmond H. Fischer

o PPV
Pulse pressure depends on stroke volume and arterial compliance Change in compliance may affect degree of PPV induced by increase in stroke volume Elderly- stiff arteries--- small increase in stroke volume--- large PPV Young healthy adult- large increase in stroke volume relatively small PPV

CVP
o Effect of pleural pressure o Effect of PEEP on pleural pressure
less than half of PEEP is transmitted to the pleural space even less than that in pathological condition that require higher PEEP--- ARDS PEEP <=10 cm H2O = 8 mmHg----- change in pleural pressure2-3 mmHg
but at PEEP>10 changes in pleural pressure at end expiration become significant

o Effect of forced expiration on pleural pressure

Respiratory change in pleural pressure

o Respiratory change in Pcwp o Respiratory change in esophageal pressure

Fluid challenge
o Rapidity of fluid infusion is important- faster the fluid is given, lesser the amount to be given type of fluid- crystalloid or colloid does not matter Change in CVP and not the volume of infusion that is important Blood pressure is not a good guide as to whether C.O. increased with fluid infusion In patients in whom C.O. increased there was no increase in B.P. ( Bafaqeeh F, Magder S. CVP and volume responsiveness of cardiac output. Am J
Respir Crit Car Med 2004, 169: A 343

o o o

Role of echocardiography
Assessment of inadequate resuscitation:
o o Volume status and responsiveness fluid resuscitation Cardiac contractility -- ionotrope

Effect of Positive Pressure Mechanical Ventilation on Hemodynamics PULSE PRESSURE VARIATION- PPV

contribution of transmission of pleural pressure effect on both systolic as well as diastolic pressure equally
Determination of aortic pressure variation during positive pressure ventilation in man. Denault, Gasior, Pinsky, Gorscan, Mandarino. Chest 2000;116:176-186