1-BASIC-Fluid-Responsiveness-with-edits-AMHernandez.pptx

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1. Flui d Responsiveness

2. Learning Objectives To discuss the physiology of f luid r esuscitation To enumerate and discuss the different methods to predict f luid r esponsiveness

3. Fluid Responsiveness ability of the left ventricle to increase its Stroke Volume and Cardiac output in response to fluid administration Fluid responder = 10-15% increase in SV or cardiac output within 30 minutes of administration of a fluid challenge Hasanin A. (2015). Fluid responsiveness in acute circulatory failure.  Journal of intensive care ,  3 , 50. https:// doi.org /10.1186/s40560-015-0117-0

4. Goal of Fluid Resuscitation Question 1: How does fluid resuscitation improve circulation during a state of shock?

5. Goal of Fluid Resuscitation Question 1: How does fluid resuscitation improve circulation during a state of shock? Current (I) = Voltage(V) / Resistance(R)

6. Goal of Fluid Resuscitation Question 1: How does fluid resuscitation improve circulation during a state of shock?

7. Frank Starling Mechanism Ernest Starling and Otto Frank Marik , P., & Lemson , J. (2014, April). Fluid responsiveness: an evolution of our understanding. British Journal of Anaesthesia , 112(4), 617–620. https://doi.org/10.1093/bja/aet590

8. Fluid Responsiveness Question 2A: Does it infer that all patients who are fluid responders will benefit from fluid administration? Question 2B: Is the effect sustained? FCREV Study 2019: I mmediate response to fluid does not predict the persistence of fluid efficacy over time Widely recommended to assess fluid responsiveness at the end of fluid infusion Roger, C., Zieleskiewicz , L., Demattei , C., Lakhal , K., Piton, G., Louart , B., Constantin, J. M., Chabanne , R., Faure, J. S., Mahjoub , Y., Desmeulles , I., Quintard , H., Lefrant , J. Y., Muller, L., & AzuRea Group (2019). Time course of fluid responsiveness in sepsis: the fluid challenge revisiting (FCREV) study.  Critical care (London, England) ,  23 (1), 179. https:// doi.org /10.1186/s13054-019-2448-z

9. Boldt J. Seven misconceptions regarding volume therapy strategies-and their correction Br K Anaesth 2009; 103(2):147-51

10. Adverse Effects Risk of fluid overload as in cases of ARDS and distributive shock Organ edema causing hypoxemia due to diffusion block Hypernatremia after high volume fluid administration Maitland, K., Kiguli , S., Opoka , R. O., Engoru , C., Olupot-Olupot , P., Akech, S. O., Nyeko , R., Mtove , G., Reyburn , H., Lang, T., Brent, B., Evans, J. A., Tibenderana , J. K., Crawley, J., Russell, E. C., Levin, M., Babiker , A. G., Gibb, D. M., & FEAST Trial Group (2011). Mortality after fluid bolus in African children with severe infection.  The New England journal of medicine ,  364 (26), 2483–2495. https://doi.org/10.1056/NEJMoa1101549 Hawkins WA, Smith SE, Newsome AS, Carr JR, Bland CM, Branan TN. Fluid Stewardship During Critical Illness: A Call to Action. J Pharm Pract . 2020 Dec;33(6):863-873 Marik , P. E., Byrne, L., & van Haren , F. (2020). Fluid resuscitation in sepsis: the great 30 mL per kg hoax. Journal of Thoracic Disease, 12(S1), S37–S47. Malbrain MLNG, Rice T, Mythen M et al. (2018) It is time for improved fluid stewardship. ICU Management and Practice, 18(3): 158-162.

11. Adverse Effects FEAST Trial 2011 : Mortality after Fluid Bolus in African Children with Severe Infection Primary outcome: 48-hour mortality Secondary outcomes: pulmonary edema, increased ICP, mortality, neurologic sequelae at 4 weeks Maitland, K., Kiguli , S., Opoka , R. O., Engoru , C., Olupot-Olupot , P., Akech, S. O., Nyeko , R., Mtove , G., Reyburn , H., Lang, T., Brent, B., Evans, J. A., Tibenderana , J. K., Crawley, J., Russell, E. C., Levin, M., Babiker , A. G., Gibb, D. M., & FEAST Trial Group (2011). Mortality after fluid bolus in African children with severe infection.  The New England journal of medicine ,  364 (26), 2483–2495. https:// doi.org /10.1056/NEJMoa1101549

12. When to administer fluids? Pinsky, M. R., Teboul , J.-L., & Vincent, J. L. (2019). Hemodynamic monitoring . Springer : Brussels.

13. Variables that influence Fluid Resuscitation Pinsky, M. R., Teboul , J.-L., & Vincent, J. L. (2019). Hemodynamic monitoring . Springer : Brussels.

14. FACTT Trial in 2006: Comparison of Two Fluid-Management Strategies in Acute Lung Injury Primary outcome: death at 60 days (25.5% conservative vs 28.4% liberal) Secondary outcomes: ventilator-free days, organ failure-free days, lung physiology CLASSIC Trial in 2016: Restricting volumes of resuscitation fluid in adults with septic shock after initial management vs standard care REFRESH Trial in 2018: Restricted fluid resuscitation in suspected sepsis associated hypotension FRESH Trial in 2020: Personalized dynamic fluid responsiveness monitoring enhances appropriate resuscitation fluid and vasopressors administration and improves patient outcomes.

15. Predictors of Fluids Responsiveness

16. Passive Leg Raise Test

17. Passive Leg Raise Test Mimics hemodynamic effect of about 300 ml blood challenge AKA “Pseudo-fluid challenge” Real time hemodynamic assessment is required Poor results: HR, BP, Doppler femoral or carotid blood flow Good results Peripheral perfusion index (PI) Bioreactance-based CO monitor Capillary refill time

18. Peripheral Perfusion Index Peripheral perfusion index (PI) > 9% increase confers an increase in pulse contour CO (Sn 91%, Sp 79%, AUROC 0.89)

19. Peripheral Perfusion Index Peripheral perfusion index (PI) > 9% increase confers an increase in pulse contour CO (Sn 91%, Sp 79%, AUROC 0.89)

20. Peripheral Perfusion Index Peripheral perfusion index (PI) > 9% increase confers an increase in pulse contour CO (Sn 91%, Sp 79%, AUROC 0.89)

21. Bioreactance-based CO Monitor Phase shift > 10% confers an increase in pulse contour CO (AUROC 0.88)

22. Capillary Refill Time Decrease in CRT ~ 25% following fluid challenge conferred an increase in pulse contour CO. Issues: Dissociation between macro- hemodynamics and microcirculation

23. End Tidal CO2 Increase in > 5% predicted fluid responsiveness conferring an increase in pulse contour CI of > 15% Question 3: How does EtCO2 predict an increase in stroke volume during a passive leg raise test?

24. Passive Leg Raise Limitations Intraabdominal hypertension (AUROC 0.6) Head trauma / ICP issues DVT in the lower extremities Venous compression stockings Amputated leg

25. Heart Lung Interaction Indices Pulse pressure variation and Stroke volume variation Tidal volume challenge Respiratory variation of Vena Cava diameters End expiratory occlusion test Lung recruitment maneuvers Mini-Fluid Challenge

26. PPV and SVV

27. PPV and SVV PPV > 13% (preload dependence state) led to optimization of microcirculation and sublingual microcirculation Allows for an immediate correction of preload dependence to prevent reduced microcirculation Unreliable in spontaneous breathing, cardiac arrhythmias, doubtful in low tidal volume ventilation, low lung compliance and IAH

28. Tidal Volume Challenge Transiently increasing Vt to 8 ml/kg for 1 minute Increase of PPV at least 3.5% or SVV at least 2.5% during a tidal volume challenge predicted fluid responsiveness Applicable to prone and neurosurgical patients Not extensively studied in ARDS with low lung compliance

29. Respiratory Variation of VC Diameters IVC diameter - TTE Limitations: low lung compliance, IAH, low Vt Less accurate than SVV ?Cut-off 12-21% respiratory IVC variation in mechanically ventilated Note: IVCd (collapsibility index) in spontaneous breathing predicted responsiveness FAIRLY (AUROC 0.8) Deep inhalation and passive exhalation (standardized respiratory maneuver) IVCd >42% may predict increase in CO after fluid infusion ( Airapetian et. al. 2015)

30. Respiratory Variation of VC Diameters Moretti Study 2016 - IVC diameter as a predictor of fluid responsiveness in patients with subarachnoid hemorrhage (IVC Distensibility; AUROC 0.902, Cutoff >16%) Corl Study 2017 - IVC diameter detects fluid responsiveness among spontaneously breathing critically ill patients (IVC Collapsibility; AUROC 0.84, Cutoff ~ 25% Question 4: What is the difference between IVCd Collapsibility and IVCd Distensibility

31. Respiratory Variation of VC Diameters IVC diameter - TTE

32. Respiratory Variation of VC Diameters SVC diameter - TEE Confirmed for use in abdominal surgery (AUROC 0.85 cutoff 21%) and vascular surgery (AUROC 0.92 cutoff 37%) Poor results in ICU patients (AUROC 0.75)

33. End Expiratory Occlusion Test (EEOT)

34. End Expiratory Occlusion Test (EEOT)

35. Lung Recruitment Maneuvers Four sigh maneuvers at pressure support 0, 15, 25, 35 by noting the nadir hemodynamic variables at each step Negative slope of systolic arterial pressure = fluid responsive (AUROC 0.99, cutoff = –4.4 ) Further studies required Risk of lung overdistention

36. Mini Fluid Challenge Increase of 15% in CO after 250-500 ml over 30 minutes (highly variable practice) Measure CO to assess fluid responsiveness but cannot be used to predict (50% of patients are nonresponders ) Increase in CO after 1 st infusion NOT equal to improvement in CO after next boluses

37. Mini Fluid Challenge Mini-Fluid Challenge: 100-150ml crystalloid/colloid over a ~ 60-120 seconds Followed by measurement of response of CO or surrogates Low Vt ventilation = Increase in CO by 6% via pulse contour analysis after fluid challenge over 2 minutes is predictive better than PPV or use of 50 ml mini fluid challenge over 1 minute Attractive method when no other test can be used; No advantage over passive leg raise Best used with CO measures that are able to detect and catch small changes in cardiac output (like pulse contour analysis; caution with precision measures if LVOT VTI used)

38. Monnet Study in 2012: Passive leg-raising and end-expiratory occlusion tests perform better than pulse pressure variation in patients with low respiratory system compliance Feissel Study in 2001: Respiratory Changes in Aortic Blood Velocity as an Indicator of Fluid Responsiveness in Ventilated Patients With Septic Shock: Aortic blood flow analysis by TEE Respiratory changes in Vpeak and CI were measured Delta Vpeak 12% determined responders vs non-responders (Sensitivity 100%, Specificity 89%)

39. Summary Adequate selection for intended benefit Prevention of unnecessary infusion in non-responders Decision to administer fluids is not based on fluid responsiveness alone — balance between hemodynamic instability and absence of fluid overload risk

40. R Shui, X Monnet, and JL Teboul. Parameters of Fluid Responsiveness. Current Opinion. 2020. www. co-criticalcare.com

41. R Shui, X Monnet, and JL Teboul. Parameters of Fluid Responsiveness. Current Opinion. 2020. www. co-criticalcare.com

42. R Shui, X Monnet, and JL Teboul. Parameters of Fluid Responsiveness. Current Opinion. 2020. www. co-criticalcare.com

43. Thank you.