HEMODYNAMIC MONITORIZATION

IN AWAKE PATIENTS

Melda Trkolu, MD, Assoc. Prof

Gazi University School of Medicine,
Medical Intensive Care UNit
Ankara, TURKEY, November 2015
meldaturkoglu@yahoo.com.tr
Shock Patients..

Does my patient need fluid therapy?

Does he response the fluid therapy?

Hypervolemia

Prolonged
Tissue andlength
organof MV
edema

Prolonged
Decubitus..ICU stay

ARDS
Increased ICU mortality
Hypovolemia.

Tissue hypoxia

Organ failure.

Mortality
What is fluid responsiveness?

Increase in stroke volume after fluid therapy.

Marik, et al. Annals of Intensive Care 2011; 1:1

FRANK STARLING law of the heart

Otto Frank Ernest Starling

...states that the stroke volume of the heart increases in

response to an increase in the volume of blood filling
the heart
 FRANK STARLING curve

Normal

Fluid
non-responsiveness

Stroke
Heart
Volume
Failure
Fluid responsiveness

Static indices

. Ventricular preload
Stroke volume variation in response to increase in ventricular preload

Stroke
Volume Fluid responsiveness

Dynamic indices

.
Fluid challenge...

Ventricular preload
Increase in preload without fluid challenge?

Mechanical Ventilation-Heart Lung Interactions

Passive Leg Raising

The End-Expiratory Occlusion Test

Mini Fluid Challenge

Increase in preload without fluid challenge?

Mechanical Ventilation-Heart Lung Interactions

Passive Leg Raising

The End-Expiratory Occlusion Test

Mini Fluid Challenge

Mechanical Ventilation-Heart Lung Interactions

. respiratuar variations of hemodynamic parameteres

induced by positive-pressure mechanical ventilation

Am J Respir Crit Care Med 2000; 162:134-8

 End End
Inspirium expirium
Am J Respir Crit Care Med 2000; 162:134-8
Dynamic indicis induced by respiratuar variation

Arterial Pressure Variation

Arterial catheter

Stroke Volume Variation

Arterial pressure waveform analysis

Aortic Blood Velocity Variation

Conventional echocardiography, esophageal doppler monitoring device

Vena Cava Diameter Variation

Conventional echocardiography, esophageal doppler monitoring device

Pulse Oxymetry Wave Variation

Masimo

Minerva Anestesiol 2008; 74: 123-35

Awake patients with spontenous breathing activity .

The variation in intrathoracic pressure is

not regular, neither in rate nor in
amplitude

The variation in stroke volume can

not relate to preload-dependency
Increase in preload without fluid challenge?

Mechanical Ventilation-Heart Lung Interactions

Not valuable in awake patients with spontaneos breathing activity

Passive Leg Raising

The End-Expiratory Occlusion Test

Mini Fluid Challenge

PASSIVE LEG RAISING.

The rescue therapy for hypotensive patients for years

150 ml blood is pomped to the heart during passive leg raising
 Stroke
Volume
b'
Fluid
responsiveness
a'

Self volume challenge

Rapid and short-lived

Maximum effect in 30 seconds

A B
PLR
Ventriculer preload
Lasting 30-90 seconds..
PASSIVE LEG RAISING.

Real-time cardiac output measurement is neccessary.

Cardiac output variation
Aortic blood flow variation
AUC: 0.91
PASSIVE LEG RAISING.
Cardiac output variation
Bioreactans
Endotracheal bioimpedance
cardiography
Pulse pressure variation
Pulse Counter analysis
Aortic blood flow variation
Esophageal Doppler Monitoring Device
Conventional Echocardiography
End-tidal carbondiokside variation
Capnography
Monnet X, Passive leg raising predicts fl uid responsiveness
in the critically ill. Crit Care Med 2006, 34:14021407.
Monnet X, Passive leg raising and end-expirat ory
occlusion tests perform better than pulse pressure variation
in patients with low respiratory system compliance. Crit
Care Med 2012, 40:15215
Biais M, Changes in stroke volume induced by passive leg
raising in spontaneously breathing patients: comparison
between echocardiography and Vigileo/FloTrac device. Crit
Care 2009, 13:R195.
Benomar B, Fluid responsiveness predicted by noninvasive
biorea ctance-based passive leg raise test. Intensive Care
Med 2010, 36:18751881
Fellahi JL, Canendotracheal bioimpedance cardiography
assess hemodynamic response to passive leg raising
following cardiac surgery? Ann Intensive Care 2012,2:26
Thiel SW, Non-invasive stroke volume measurement and
passive leg raising predict volume r esponsiveness in
medical ICU patients: an observational cohort study. Crit
Care 2009, 13:R111.
Monge Garcia MI, Non-inva sive assessment of fl uid
responsiveness by changes in partial end-tidal CO2 pressure
during a passive leg-raising maneuver. Ann Intensive Care
2012, 2:9..
.
.
Passive leg raising is also valuable in patients with spontanously breathing patients
Passive leg raising is also valuable in patients with spontanous breathing activity

34 shock patients, 68% of them have spontanous breathing

activity
! PASSIVE LEG
RAISING
Pulse pressure variation
 PPV (threshold: 12 %)

Pts fully adapted

to their ventilator Pts with
spontaneous
breathing
sensitivity

PPV

1 - specificity
Other important points.

When the mobilizing the patient is not possible

In the operating room, presence of head trauma.

Intraabdominal hypertension.
Increase in preload without fluid challenge?

Mechanical ventilation
Not valuable in awake patients with spontaneos breathing activity

Passive Leg Raising

Unless pulse pressure variation is not used

The End-Expiratory Occlusion Test

Mini Fluid Challenge

The End Expiratory Occlusion Test.

Cyclic impediment in
preload during inspirium

Cyclic increase in preload

with end expiratory
occlussion

Increase in preload in
patients with fluid
responsiveness
 34 Shock patients

68% receiving mechanical ventilation and have spontanous breathing activity

Measurements:
1. Base 0
2. PLR
3. Base 1
4. The End-Expiratory Occlusion (15sec expiratory pause, measurement in last 5sec)
5. Base 2
6. Post volme expansion (500 ml)
%5 Treshold for changes in cardiac index and pulse pressure varition
As effective as passive leg raising..
The End Expiratory Occlusion Test.

Effective independent of PEEP ve lung compliance

Not usable in operating room

Marked triggering activity interrupts the test

1: Silva S, Crit Care Med. 2013 Jul;41(7):1692-701.

2: Guinot PG,. Br J Anaesth. 2014 Jun;112(6):1050-4
3: Monnet X Crit Care Med. 2012 Jan;40(1):152-7.
Increase in preload without fluid challenge?

Mechanical ventilation
Not valuable in awake patients with spontaneos breathing activity

Passive Leg Raising

Unless pulse pressure variation is not used

The End-Expiratory Occlusion Test

Unless presence of marked triggering activity

Mini Fluid Challenge

Fluid Challenge.

300-500 mL fluid/colloid over 30 minutes

The most simple method
Irreversible
Hypervolemia in repeated challenges.

Mini fluid challenge.

100 mL colloid over 1 minute

The low risk for hyoervolemia in repeated challenges.
From: An Increase in Aortic Blood Flow after an Infusion of 100 ml Colloid over 1 Minute Can Predict Fluid
Responsiveness:The Mini-fluid Challenge Study
Anesthesiology. 2011;115(3):541-547. doi:10.1097/ALN.0b013e318229a500

small volumesmall changes in cardiac output

Figure Legend:
Fig. 4. Receiver operator characteristic (ROC) curves of variation of velocity time index (VTI) (cm) after infusion of 100 ml fluid over
1 min (VTI100), pulse pressure variation (PPV) (%), and central venous pressure (CVP) (mmHg) in 29 patients in whom VTI, PPV,
and CVP were measured.

Date of download: 11/5/2015 Copyright 2015 American Society of Anesthesiologists. All rights reserved.
Increase in preload without fluid challenge?

Mechanical ventilation
Not valuable in awake patients with spontaneos breathing activity

Passive Leg Raising

Unless pulse pressure variation is not used

The End-Expiratory Occlusion Test

Unless presence of marked triggering activity

Mini Fluid Challenge

Awake patients with spontenous breathing activity .

Mechanical ventilation/ heart lung interactions: not usefull

Passive leg raising: Valuable unless pulse pressure variation is not used

The End Expiratory Occlusion Test: Valuable unless presence of marked

triggering activity

Mini fluid challenge: Needs more study