Professional Documents
Culture Documents
Fluid Responsiveness
Fluid Responsiveness
Erwin Pradian
Department of Anesthesiology & Intensive Care
Santosa Hospital Bandung Central
1
Kasus
• Pria 55 th, Decomp Cordis,
riwayat
– ICU, HHD. paru
edema
– Apatis-CM, ekst dingin, HR 120, RR 10 (SIMV 10, PS PEE 5,
FiO2 10, P
– Lab; BP 110/55, SGD;
50%),11,6/11.000/36/239. 37.8. Ronki
180, U/C+/+, kardiomegali
95/2.3
– Th/ lasik drip 10 mg/jam , NTG, lanoxin
– Oliguri (0.2 cc/kg/BB)
– AGD 7.48/46/81/+9.1/96% dgn 40% O2.
– Na 133, K 2.9 Cl 90, Alb 3.5
Can’t I look at my patient and
tell if they are OK?
3
Fluid responsiveness
• Definisi:
• Penilaian respon peningkatan curah
jantung setelah pemberian cairan.
4
Definisi Syok
• Suatu kondisi fisiologis yang
mengakibatkan perfusi organ dan
oksigenasi jaringan tidak adekuat
Gangguan Fungsi
IT IS NOT
LOW BLOOD
PRESSURE !!!
Gagal Organ
IT IS
HYPOPERFUSION…..
Kematian
5
Statement of the Problem
Endpoint Resuscitation
INADEQUATE OXYGENATION
Scalea TM, Maltz S, Yelon J, et al.
Crit Care Med 1994; 22:1610-1615
6
References
Inaccuracies of Physical Assessment
• Connors AF Jr, Dawson NV, Shaw PK, Montenegro HD, Nara AR, Martin L.
Hemodynamic status in critically ill patients with and without acute heart disease.
Chest. 1990 Nov;98(5):1200-6.
• Dawson NV, Connors AF Jr, Speroff T, Kemka A, Shaw P, Arkes HR. Hemodynamic
assessment in managing the critically ill: is physician confidence warranted? Med
Decis Making. 1993 Jul-Sep;13(3):258-66.
• Eisenberg PR, Jaffe AS, Schuster DP. Clinical evaluation compared to pulmonary
artery catheterization in the hemodynamic assessment of critically ill patients. Crit
Care Med. 1984 Jul;12(7):549-53.
• Iregui MG, Prentice D, Sherman G, Schallom L, Sona C, Kollef MH. Physicians'
estimates of cardiac index and intravascular volume based on clinical assessment
versus transesophageal Doppler measurements obtained by critical care nurses. Am
J Crit Care. 2003 Jul;12(4):336-42.
• Neath SX, Lazio L, Guss DA. Utility of impedance cardiography to improve physician
estimation of hemodynamic parameters in the emergency department. Congest
Heart Fail. 2005 Jan-Feb;11(1):17-20.
• Staudinger T, Locker GJ, Laczika K, et al. Diagnostic validity of pulmonary artery
catheterization for residents at an intensive care unit. J Trauma. 1998
May;44(5):902-6.
7
Are Physical Signs Early or Late
Indicators of Clinical Status?
Which signs are
Signs of similar with all
Hypoperfusion three?
LV dysfunction BP
Hypovolemia HR
Sepsis LOC
Urine output
8
Acute Hypoperfusion
↑ Blood Lactate
Imbalance between
O2 demand and O2 delivery
MOFS
9
10
Does CVP and PAOP tell us about
blood volume and flow?
• CVP and PAOP should never be used in
isolation
– Inconsistent in revealing information about volume
and flow
• Flow and pressure do not always correlate
– Marik et al. Based on the results of our
systematic review, we believe that CVP should no
longer be routinely measured in the ICU,
operating room, or emergency department.
Marik P, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness?
A Systematic Review ofthe Literature and the Tale of Seven Mares. Chest 2008;134;172-178
11
BP Measurement - Useful or
Misleading?
• Is BP is measured because it can be measured
• If BP increases, does blood flow increase?
– think of use of Vasopressor
• Blalock 1943, says:
“It is well known by those interested in this
subject that the blood volume and cardiac
output are usually diminished in traumatic
shock before the arterial blood pressure
declines significantly”
Blalock A, (1943) Surgery 14: 487-508
12
Blood Pressure and Blood
Flow
Do they equal each other?
13
Physiology Background
• Oxygen delivery components
– Cardiac output x oxygen saturation x hemoglobin
• Cardiac output components
– Stroke volume
• Preload
• Afterload (Systemic Vascular Resistance)
• Contractility
– Heart rate
• Primary methods to increase cardiac output
– Increase preload (volume expanders)
– Increase contractility (inotropes)
– Decrease afterload (vasodilators)
• Key point
– Administering volume may increase intravascular volume and preload but
not stroke volume and cardiac output
BP = CO x SVR
Stroke volume
Fluid responsiveness
Preload
Pulse pressure variation
Stroke volume variation
SVV = SV max – SV min / SV mean
Problems with PPV and SVV
HR HR HR HR
SV SV SV SV
VF VF VF VF
NT
Echocardiography to asses fluid status and responsiveness
• Static parameters
LVEDV
IVC
• Dynamic parameters
SVV with repeated SV measurements
Change in IVC/SVC diameter
septum position
• For assessment of
Heart lung interactions
Passive leg raising
Fluid challenge
Kesimpulan
Semoga Bermanfaat…..
Wass. Wr. Wb.
Is Cardiac Output Adequate?
Adequate Driving
Pump
intravascular pressure for
function ?
volume? venous return?
Is Cardiac Output Adequate?
We Should Know
The effects of
Left & right Preload &
respiration or
ventricular preload
mechanical
function responsiveness
ventilation
Stratification of perioperative monitoring tools
Calibrated PCM,
Less invasive ScvO2
Stroke
Volume
0
0
Preload
Role of fluids (and preload) in goal-directed therapy
DO2
(Outcome)
Fluids (ml)
Role of fluids (and preload) in goal-directed therapy
Optimal
DO2
Optimal preload
DO2
(Outcome)
Fluids (ml)
Role of fluids (and preload) in goal-directed therapy
Optimal
DO2
Optimal preload
DO2
(Outcome)
Hypovolemia
Fluids (ml)
Role of fluids (and preload) in goal-directed therapy
Optimal
DO2
Optimal preload
DO2
(Outcome)
Hypovolemia Oveload
Fluids (ml)
Role of fluids (and preload) in goal-directed therapy
DO2
(Outcome)
Hypovolemia Oveload
Fluids (ml)
Role of fluids (and preload) in goal-directed therapy
DO2
(Outcome)
Hypovolemia Oveload
Fluids (ml)
Role of fluids (and preload) in goal-directed therapy
Optimal
DO2
Safety margin
DO2
(Outcome)
Hypovolemia Oveload
Fluids (ml)
Role of fluids (and preload) in goal-directed therapy
CVP ? PAOP ?
Optimal Other ?
DO2
Safety margin
DO2
(Outcome)
Hypovolemia Oveload
Fluids (ml)
Preload: the first rule
Fluids are still administered during surgery according to pre-
determined “high volume” fluid regimens
(e.g., intra-abdominal surgery 5-15 ml/kg/h crystalloids),
based on the presumed “third space” fluid deficit.
52
Reliability of clinical monitoring to assess blood volume in
critically ill patients
PAOP
Factors and Pathologies affecting the PAOP
JJ Marini et al.PAOP: significance and clinical uses. In Functional Hemodynamic Monitoring - 2005
Pulmonary Artery Occlusion
& Central Venous Pressure
120 PPmax
mmHg
PPmin
Arterial
Pressure
40
PPV
PPV 5%
12 %
SVV
13% Preload-independence
PPV
Stroke
23 %
Volume
PPV
Preload-dependence
45 %
LVEDV (mL)
Preload
SVmax - SVmin
45
cmH2O ∆PP =
SVV 100
(SVmax + SVmin)/2
Airway
Pressure
mmHg
SVmax
SVmin
time (s)
Stroke Volume Variation
Starling Curve: fluid responsiveness
Normal heart
SVV
13% Preload-independence
Stroke
Volume
Preload-dependence
LVEDV (mL)
Preload
Evidence (10 RCTs) of Using SV as Endpoint
• Chytra I, Pradl R, Bosman R, Pelnar P, Kasal, Zidkova A. Esophageal Doppler-guided fluid management decreases blood
lactate levels in multiple-trauma patients: a randomized controlled trial. Critical Care 2007 Feb 22;11(1):1-9.
• Conway DH, Mayall R, Abdul-Latif MS, Gilligan S, Tackaberry C. Randomized controlled trial investigating the influence of
intravenous fluid titration using esophageal Doppler monitoring during bowel surgery. Anesthesia 2002 Sept;57(9):845-849.
• Gan TJ, Soppitt A, Maroof M, El-Moalem H, Robertson K, Moretti E, Dwane P, Glass PS. Goal-directed intra-operative fluid
administration reduces length of hospital stay after major surgery. Anesthesiology 2002;97:820-826.
• Mark JB, Steinbrook RA, Gugino LD, et al. Continuous noninvasive monitoring of cardiac output with esophageal Doppler during
cardiac surgery. Anesth Anlg 1986;61:1013-1020.
• McKendry M, McGloin H, Saberi D, Caudwell L, Brady AR, Singer M. Randomized controlled trial assessing the impact of a nurse
delivered, flow monitored protocol for optimization of circulatory status after cardiac surgery. BMJ 2004;329(7460):258 (31 July),
doi:10.1136/bmj.38156.767118.7C.
• Mythen MG, Webb AR. Peri-operative plasma volume expansion reduces the incidence of gut mucosal hypoperfusion during
cardiac surgery. Archives of Surgery 1995;130:423-429.
• Sinclair S, James S, Singer M. Intraoperative intravascular volume optimization and length of hospital stay after repair of
proximal femoral fracture: randomized controlled trial. BMJ 1997 October 11;315:909-912.
• Valtier B, Cholley BP, Belot JP, Coussay JE, Mateo J, Payen DM. Noninvasive monitoring of cardiac output in critically ill
patients using transesophageal Doppler. Am J Respir Crit Care Med. 1998;158:77-83.
• Venn R, Steele A, Richardson P, Poloniecki J, Grounds M, Newman P. Randomized controlled trial to investigate influence of
the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. British Journal of
Anesthesia 2002;88:65-71.
• Wakeling HG, McFall MR, Jenkins CS, Woods WGA, Miles WFA, Barclay GR, Fleming SC. Intraoperative esophageal Doppler
guided fluid management shortens postoperative hospital stay after major bowel surgery. Br J Anaesth. 2005 Nov;95(5):634-42.
63
64
Keys to management
• Treat underlying illness
• Supportive care
– Low tidal volume ventilation
– Nutrition
– Prevent ICU complications
• Stress ulcers
• DVT
• Nosocomial infections
• Pneumothorax
• No routine use of PA catheter
– Diuresis/avoidance of volume overload
• Give lungs time to recover
Fluid management
NEJM 2006;354:2564-75.
Survival and Long Term
Sequelae
• Traditionally mortality 40-60%
• May be improving, as mortality in more
recent studies in range 30-40%
• Nonetheless survivors report decreased
functional status and perceived health
• 79% of patients remember adverse
events in ICU
– 29.5% with evidence of PTSD
1 year after ARDS survival
• Lung Function:
– FEV1 and FVC were normal; DLCO minimally reduced
– Only 20% had mild abnormalities on CXR
• Functionally:
– Survivors’ perception of health was <70% of normals
in:
• Physical Role: Extent to which health limits physical activity
• Physical Functioning: Extent to which health limits work
• Vitality: Degree of energy patients have
– 6 minutes walk remained low
– Only 49% had returned to work