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?

NO! Physical Assessment is often inaccurate,

slow to change and difficult to interpret

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

Traditional Normalizatio Compensated

Marker n SHOCK
of Vital Sign
Urine Output

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

• CO = Stroke volume x heart rate

– decrease in SV causes increase in heart
rate
– decrease in CO causes increase in SVR
• Compensatory changes keep the BP
close to normal initially in shock states
• BP does not change until late due to
these compensatory responses
15
 Temporal order of events
(each event can take minutes to hours)

• Stroke volume falls

• Heart rate compensates to keep cardiac output
normal
– Many reasons for heart rate to increase
• Cardiac output falls
• Heart rate compensation fails
• Vasoconstriction (increase in SVR), BP remains
unchanged
• Increased oxygen extraction of
hemoglobin
• Peripheral initially (StO2)
• Central later (ScvO2)
• Blood pressure, urine output change
16
Fluid responsiveness is related to cardiac responsiveness
Cristalloids 500 – 1000 ml, or
Colloids 300 – 500 ml
Safety limit:
CVP of 15 mmHg !!
Cristalloids 500 – 1000 ml, or
Colloids 300 – 500 ml
Fluid responsiveness is related to cardiac responsiveness

Stroke volume

Fluid responsiveness

Preload
Pulse pressure variation
Stroke volume variation
SVV = SV max – SV min / SV mean
Problems with PPV and SVV

Spontaneously breathing patients

Arrhythmias
Significant tachycardia
Very low tidal volumes
Passive Leg Raising

Venous blood from legs and abdomen increases preload

İt is just like fluid challenge but it is reversible

Needs real time CO monitoring
 PLR compared with volume expansion
Post Volume
Baseline 1 PLR Baseline 2 expansion

HR HR HR HR
SV SV SV SV
VF VF VF VF

SPONTANEOUSLY BREATHİNG PATİENTS

500 ml colloid infusion
ALERT: Do not use PLR in patients with abdominal hypertension

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

• Pemberian cairan yang berlebihan akan menyebabkan

edema yang menyebabkan peningkatan morbiditas dan
mortalitas.
• Endothelial glycocalyx mempunyai peran yang sangat
penting dalam pengaturan shifting cairan tubuh, dan
glikokaliks ini selain oleh hipoksia, stress respon, dapat juga
dirusak oleh hipervolemia akut.
• Pengukuran status cairan secara dinamis lebih akurat
dibanding pengukuran secara statis.
 Selanjutnya…..

Semoga Bermanfaat…..
Wass. Wr. Wb.
Is Cardiac Output Adequate?

Is blood flow adequate to meet metabolic demands?

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

Level Conventional, ECG, NIBP,

1 non-invasive SpO2, EtCO2

Conventional, CVP, ABP

invasive

Level Minimally Oesoph Doppler,

2 invasive PCM, ScvO2

Calibrated PCM,
Less invasive ScvO2

Level Invasive PAC, SvO 2

3
 Frank-Starling Relationship

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

Low risk patients with

no cardio-respiratory disease = ASA 1-2
Optimal
DO2
Safety margin

DO2
(Outcome)

Hypovolemia Oveload

Fluids (ml)
Role of fluids (and preload) in goal-directed therapy

High risk patients with

major cardio-respiratory disease = ASA 3-4
Optimal
DO2
Safety margin

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.

The amount of fluid administered

should be individualized to the
patient’s needsand not
predetermined by some liberal or
restrictive regimen.
 Pulmonary Artery Occlusion
& Central Venous Pressure
• Preload : Panjang fibril pada akhir diastolik
( tdk dpt diukur )
• EDV → korelasi
• Compliance = Perubahan volume /
Perubahan Tekanan
 Factors and Pathologies affecting the CVP
Central venous blood volume • Venous return/cardiac output
• Total blood volume
• Regional vascular tone

Compliance of central compartment • Vascular tone

• Right ventricular compliance
- myocardial disease
- pericardial disease
- tamponade
Tricuspid valve disease • Stenosis
• Regurgitation
Cardiac rhythm • Junctional rhythm
• Atrial fibrillation
• A-V dissociation
Intrathoracic pressure • Respiration
• ippv
• peep
• pnx

Reference level of transducer • Positioning of the patient

Smith T et al. CVP: uses and limitation. In Functional Hemodynamic Monitoring - 2005
CHEST 2008; 134:172–178

52
Reliability of clinical monitoring to assess blood volume in
critically ill patients

Low Blood Volume

High CVP

High Blood Volume

Low CVP

Shippy CR and Shoemaker WC - Crit Care Med 1984

Crit Care Med 2005

PAOP
 Factors and Pathologies affecting the PAOP

Compliance of central compartment • Vascular tone

• Left ventricular compliance
- myocardial disease
- pericardial disease
- tamponade
Mitral valve disease • Stenosis
• Regurgitation
Cardiac rhythm • Junctional rhythm
• Atrial fibrillation
• A-V dissociation
Intrathoracic pressure • Respiration
• ippv
• peep
• pnx

Reference level of transducer • Positioning of the patient

JJ Marini et al.PAOP: significance and clinical uses. In Functional Hemodynamic Monitoring - 2005
Pulmonary Artery Occlusion
& Central Venous Pressure

Nilai “kecenderungan” (trend) dari

pengukuran ini lebih bermanfaat dari
nilai absolutnya, untuk memantau
respon terhadap intervensi terapetik.
 Pulmonary Artery Occlusion
& Central Venous Pressure

Seperti pada PAOP, nilai trend CVP

terhadap respon terapi mungkin lebih
bermakna.
 A variable is a predictor
of fluid responsiveness if
there is a relationship
between the baseline
value of that variable and
changes in SV after fluid
loading.
 PPmax - PPmin
45 ∆PP =
PPV 100
cmH2O
(PPmax + PPmin)/2
Airway
Pressure

120 PPmax
mmHg
PPmin

Arterial
Pressure

40

Pulse Pressure Variation

 Starling Curve: fluid responsiveness
Normal heart

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.
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 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

• 䇾Dry lungs are happy lungs䇿

• ARDSnet RCT of 1000 patients (FACTT),
Conservative vs liberal fluid strategy using CVP or
PAOP monitoring to guide, primary outcome:
death. Conservative fluids
– Improved oxygenation
– More ventilator-free days
– More days outside ICU
– No increase in shock or dialysis
– No mortality effects
ARDSnet 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

NEJM 2003: 348: 683-693

 Summary
• ARDS is a clinical syndrome characterized by
severe, acute lung injury, inflammation and scarring
• Significant cause of ICU admissions, mortality and
morbidity
• Caused by either direct or indirect lung injury
• Mechanical ventilation with low tidal volumes and
plateau pressures improves outcomes
• So far, no pharmacologic therapies have
demonstrated mortality benefit
• Ongoing large, multi-center randomized controlled
trials are helping us better understand optimal
management