1. No category

Accurate assessment of preload status in the ICU
Why and how?
h
dh ?
Prof. Jean‐‐Louis TEBOUL
Prof. Jean
Medical ICU
Bicetre Hospital
Bicetre Hospital
University Paris‐South
France
Conflicts of interest
Member of the Medical Advisory Board of Pulsion Accurate assessment of preload status in the ICU
Why
h and how?
dh ?
Prof. Jean‐‐Louis TEBOUL
Prof. Jean
Medical ICU
Bicetre Hospital
Bicetre Hospital
University Paris‐South
France
Critically ill patients often experience hemodynamic instability Clinicians are tempted to give fluid to restore adequate hemodynamic conditions
However, However
• often, patients patients have been
have been already resuscitated for several hours or days already resuscitated for several hours or days (see Rivers et al NEJM 2001)
• potential volume overload with
volume overload with subsequent risks of pulmonary edema
especially in this condition of increased lung permeability • positive positive cumulative
cumulative fluid balance
fluid balance: independent
: independent predictor of death
Critically ill patients often experience hemodynamic instability Clinicians are tempted to give fluid to restore adequate hemodynamic conditions
However, However
• often, patients have been already resuscitated for several hours or days (see Rivers et al NEJM 2001)
• potential volume overload with subsequent risks of pulmonary edema
especially in this condition of increased lung permeability • positive cumulative fluid balance: independent predictor of death
• no certainty of fluid responsiveness
CHEST 2002, 121:2000121:2000-8
Critically ill patients often experience hemodynamic instability Clinicians are tempted to give fluid to restore adequate hemodynamic conditions
However, However
• often, often, patients
patients have been have been already resuscitated
already resuscitated for several hours or days volume expansion volume
volume expansion benefit/risk
expansion
benefit/risk
ratio?
ratio? (see Rivers et al NEJM 2001)
Can help to choose the best fluid strategy
• potential volume overload
potential volume overload with subsequent risks of with subsequent risks of pulmonary edema
pulmonary edema
b
by avoiding
idi increased lung permeability
to fluid overload
fl id
l d
especially in this condition of especially in this condition of increased lung permeability
• positive positive cumulative cumulative fluid balance
fluid balance: independent : independent predictor of death
predictor of death
patients who would be fluid unresponsive
patients who would be fluid unresponsive
• no certainty of fluid responsiveness
markers of fluid responsiveness
fluid responsiveness/unresponsiveness unresponsiveness are required
markers of fluid responsiveness/unresponsiveness
Fluid infusion will increase LV stroke volume only if both ventricles both ventricles are
are preload responsive preload unresponsiveness
Stroke Volume
Fluid responsiveness
equivalent to
preload responsiveness
biventricular preload responsiveness
p
p
Ventricular preload
Accurate assessment of preload status in the ICU
Why and how
h
d how?
h ?
Prof. Jean‐‐Louis TEBOUL
Prof. Jean
Medical ICU
Bicetre Hospital
Bicetre Hospital
University Paris‐South
France
Patient with circulatory failure First, try to perform echocardiography echocardiography to assess cardiac function
Normal
cardiac function
Lung injury?
Lung injury
ABG, Chest X‐ray
no
basic monitoring
CVC
CVP
ScvO2
+
Art cath
AP PPV
Abnormal
cardiac function
The lower the CVP, the more likely the presence of preload responsiveness Stroke
Stroke Volume
preload preload
responsiveness
CVP
???
mmHg
responders
20
nonresponders pre‐‐infusion
pre
CVP
10
8
0
9
normal heart
Stroke volume
preload responsiveness
« static » measures of preload cannot reliably
li bl predict di failing heart
fluid responsiveness
p
preload unresponsiveness
Ventricular preload
Dynamic indices of preload responsiveness
Dynamic indices of
Dynamic indices preload responsiveness
normal heart
Stroke volume
preload responsiveness
failing heart
preload unresponsiveness
Ventricular preload
Patient with circulatory failure First, try to perform echocardiography echocardiography to assess cardiac function
Normal
cardiac function
Lung injury?
Lung injury
ABG, Chest X‐ray
no
basic monitoring
CVC
CVP
ScvO2
+
Art cath
AP PPV
Abnormal
cardiac function
Stroke volume
preload responsiveness
preload
unresponsiveness
A
B
Ventricular preload
PPmax ‐ PPmin
PPV =
(PPmax + PPmin) /2
PPmax
120 120
mmHg
40
PPmin
Arterial Pressure
Sensitivvity
PPV
CVP
PAOP
1 ‐ Specificity
Chest 2005;128;848-854
Anesth Analg 2011; 113:523‐8
Chest 2004, 126:1563-1568
PPV
Crit Care Med 2005;33:2534-9
M. Ca
Cannesson,
esso , J
J. S
Slieker,
e e ,O
O. Desebbe,
esebbe, F. Fahdi,O.
a d ,O Bastien,
ast e , JJ.
JJ Lehot
e ot
X. Monnet1,2*, L. Guerin1,2, M. Jozwiak1,2, A. Bataille1,2, F. Julien1,2, C. Richard1,2, J‐L. Teboul1,2
Limitations of PPV
Limitations of PPV • impossible to interpret in pts with spontaneous breathing activity
• impossible to interpret in pts with
spontaneous breathing activity
• impossible to interpret in patients with arrhythmias
• difficult to interpret if tidal volume is too low
• difficult to interpret if lung compliance is too low
• difficult to interpret in case of high frequency ventilation
• difficult to interpret in case of
high frequency ventilation
Patient with circulatory failure First, try to perform echocardiography echocardiography to assess cardiac function
Normal
cardiac function
Lung injury?
Lung injury
ABG, Chest X‐ray
no
basic monitoring
yes
onlyy
CVC
CVP
ScvO2
+
Art cath
AP PPV
considered valid
Abnormal
cardiac function
Patient with circulatory failure First, try to perform echocardiography echocardiography to assess cardiac function
Normal
cardiac function
Abnormal
cardiac function
Lung injury?
Lung injury
ABG, Chest X‐ray
no
basic monitoring
yes
no
uncalibrated
CO monitoring
onlyy
CVC
CVP
ScvO2
+
PPV/SVV
PPV
SVV
Art cath
AP PPV
CO response to:
considered valid
• PLR PLR t t
PLR test
Stroke
Stroke Volume
b'
preload PLR mimics fluid challenge
responsiveness
a'
preload b
Unlike fluid challenge,
no fluid is
infused,
unresponsiveness
a
and, the effects are reversible and transient
The hemodynamic response hemodynamic response to
toA PLR B
V ti l
Ventricular preload
l d
can predict the hemodynamic response to
hemodynamic response to volume infusion
PLR
The hemodynamic response
The hemodynamic response to to PLR
PLR
can predict the hemodynamic
can predict the hemodynamic response to to fluid infusion
fluid infusion
Real‐‐time Real
time CO response to PLR
PLR‐‐induced changes in CO
PLR
g
Study name
Study name sample size
sample size AUC AUC
Monnet CCM 2006 71 0.96
Lafanéchère CC 2006 22
0.95
Lamia ICM 2007
24
0.96
Maizel ICM 2007
34
0.89
Monnet CCM 2009
34
0.94
Thiel CC 2009
102
0.89
Biais CC 2009
30
0.96
Preau CCM 2010
34
0.94
351
0.95
PLR‐‐induced changes in PP
PLR
g
Study name
Study name sample size AUC
sample size AUC Monnet CCM 2006 71 0.75
Monnet CCM 2009
34
0.68
Preau CCM 2010
34
0.86
139
0.76
Patient with circulatory failure First, try to perform echocardiography echocardiography to assess cardiac function
Normal
cardiac function
Abnormal
cardiac function
Lung injury?
Lung injury
ABG, Chest X‐ray
no
basic monitoring
yes
no
uncalibrated
CO monitoring
onlyy
CVC
CVP
ScvO2
+
PPV/SVV
PPV
SVV
Art cath
AP PPV
CO response to:
considered valid
• PLR test
t t
• EEO EEO test
End‐‐expiratory occlusion End
expiratory occlusion test
test
Cyclic decrease in preload
y
p
Transient increase in p
preload and hence in CO in case of p
preload‐dependency
p
y
Fluid responders should be identified
by an increase of their CO during the
end‐expiration occlusion test Ê Systemic venous return
effects of end
end‐‐expiratory occlusion p
y
on Pulse contour CO
% 50
40
30
20
10
0
-10
NR
R
Patient with circulatory failure First, try to perform echocardiography echocardiography to assess cardiac function
Normal
cardiac function
Abnormal
cardiac function
Lung injury?
Lung injury
ABG, Chest X‐ray
yes
no
basic monitoring
CVC
CVP
ScvO2
+
yes
uncalibrated
CO monitoring
PPV/SVV
PPV
SVV
Art cath
AP PPV
no
CO response to:
considered valid
• PLR test
t t
• EEO test
advanced
monitoring
PAC
PiCCO2
CO
PAOP
PAP
SvO2
CO
GEDV, CFI, EVLW, PVPI PPV SVV
PVPI, PPV, SVV
ScvO2
GEDV
marker of cardiac preload
cardiac preload Chest 2003; 124:1900‐1908
%
*
*
14
*
10
Changes
g in CO
Changes in GEDV
6
GEDV behaves as a marker of marker of preload
preload
p
2
-2
fluid loading
dobutamine
Cardiac function index (CFI
Cardiac function index (CFI
CFI) = CO/GEDV
CFI) = CO
CO GEDV
CFI
Index off
cardiac systolic function
cardiac systolic function EVLW
quantitative measure measure
of f pulmonary edema 200 pts
D28 mortality: 54%
Multivariable stepwise logistic regression analysis with Day‐28 mortality as the dependant factor
Odds Ratio ( CI 95%)
p value
Maximal blood lactate 1.29
(1.14 ‐ 1.46)
0.0001
Mean PEEP
0.78
(0.67 – 0.91)
0.002
Minimal PaO2 / FiO2
0.98
(0.97 ‐ 0.99)
0.006
SAPS II
1.03
((1.01 ‐ 1.05))
0.02
EVLWmax
1.07
(1.02 02 ‐‐ 1.12
12))
0.007
(1 0001 1.0008)
(1.0001 –
1 0008)
0 02
0.02
M
Mean fluid balance
fl id b l
1 0004
1.0004
EVLW
Safety parameter
yp
during
fluid management
Cumulative fluid balance (L)
7
5
*
*
*
*
PAOP group
3
1
EVLW group
‐1
‐3
‐5
* p < 0.0001 vs temps 0
0
0 12 24 36 48 60 72
12
24
36
48
60
72
Time (hours)
25
20
15
*
*
10
5
0
MV days ICU days
PAOP group
EVLW group
PVPI = EVLW
= EVLW/Pulmonary
EVLW
blood volume
blood volume
PVPI
marker of
k
f
lung µvessels permeability PVPI
10
9
8
7
6
5
cut‐off cut‐
value
4
3
*
2
1
0
ALI/ARDS
Hydrostatic H
d t ti
pulmonary edema
= 3
Se = 85 %
Sp = 100 %
100
PVPI
p < 0.05
80
BNP
sensitiivity
60
40
20
0
0
20
40
60
100 ‐ specificity
80
100
Volumetric monitoring systems
Useful for guiding fluid management
especially in patients with lung injury
especially in patients with lung injury
lung injury and circulatory shock
and circulatory shock
circulatory shock
• SVV/PPV or
/
PLR or EEO test for
f predicting
d
volume responsiveness
l
• GEDV for checking that preload increases with fluid
• Pulse Contour CO for evaluating the actual response to fluid
• EVLW and
EVLW and PVPI for judging
PVPI for judging lung tolerance to fluid infusion
lung tolerance to fluid infusion
• SVV
SVV/PPV
/PPV, PLR
PLR, EEO
• GEDV
• CO
• EVLW/PVPI
• to start
decision
• to continue
• to stop
fluid infusion
Patient with circulatory failure First, try to perform echocardiography echocardiography to assess cardiac function
You can use these
three different
approaches
pp
because the situation can evolve
because
the situation
can evolve in a bad way
in
a bad way
Normal
cardiac function
Abnormal
cardiac function
depending on the
p
g
individual situation
yyou also can use a stepwise
p
approach
pp
Lung injury?
Lung injury
ABG, Chest X‐ray
yes
no
basic monitoring
CVC
CVP
ScvO2
+
yes
uncalibrated
CO monitoring
PPV/SVV
PPV
SVV
Art cath
AP
PPV
no
CO response to:
considered valid
• PLR test
PLR t t
• EEO test
advanced
monitoring
PAC
PiCCO2
CO
PAOP
PAP
SvO2
CO
GEDV, CFI, EVLW, PVPI PPV SVV
PVPI, PPV, SVV
ScvO2
Thank you