Part 2

QuesPon 3: The premature hump on the transpulmonary thermodiluPon curve is… 1. 
2. 
3. 
4. 
5. 
Crosstalk phenomenon Right-­‐to-­‐lep shunt Bolus mixing Wrong/false measurement I don't know 19/11/2011 Should I bother about Flow and Ebb phase 52 Premature hump = Hypovolemia GEDVi : 288 GEDVi : 537 Pulmonary Hypertension Before filling (at 8:40) aper filling with 500mL Voluven (at 9:02) Septic shock 100% FiO2 – PEEP 12 – extremely underfilled
19/11/2011 Should I bother about Flow and Ebb phase 53 DetecPon of right-­‐to-­‐lep intracardiac shunt CirculaPon 1954 using transpulmonary indicator diluPon EVLW RA RV PBV Special thanks to F Michard!
LA LV PEEP Our paPent became extremely hypotensive during recruitment 37,4
37,3
37,2
37,1
ZEEP 37,4
37,3
37,2
37,1
PEEP 37,4
37,3
Michard F et al. CCM 2004 Jan;32(1):308-­‐9. 37,2
37,1
• West Lung Zones ZONE 1: Palv > Part > Pven
Hypovolemia High PEEP ❶ ZONE 2: Part > Palv > Pven
❷ ❶ Right-­‐to-­‐Lep Shunt ZONE 3: Part > Pven > Palv
EvoluPon late apernoon D2 • 
• 
• 
• 
Urine output only 350 over 12 hours… FiO2 increased from 45% to 65% (P/F 200) Lactate increased from 1.6 to 2.6 CumulaPve FB +4L MAP 79 CI 5.4 P/F 205 CVP 8 GEF 23 IPAP 34 PPV 6 GEDVi 1080 PEEP 11 EVLWi 18 19/11/2011 Should I bother about Flow and Ebb phase 57 QuesPon 4: What is your treatment of choice? 1. 
2. 
3. 
4. 
5. 
19/11/2011 Norepinephrine Dobutamine Fluids bolus Dobu DiurePcs Norepi Other Normal Values:
PPV: <10 %
GEDVI: 600 – 850
GEF: 25-35%
EVLWI: 3 – 7
PVPI: 1 – 3
5 0.2 MAP 79 CI 5.4 P/F 205 CVP 8 GEF 23 IPAP 34 PPV 6 GEDVi 1080 PEEP 11 18 Flow and Ebb phase Should IEVLWi bother about 58 QuesPon 4: What is your treatment of choice? 1. 
2. 
3. 
4. 
5. 
19/11/2011 Norepinephrine Dobutamine Fluids bolus Dobu DiurePcs Norepi Other PEEP 18 Normal Values:
PPV: <10 %
GEDVI: 600 – 850
GEF: 25-35%
EVLWI:
3–7
3x200ml PVPI: 1 – 3
Hyper
Alb Haes 5 0.2 20% Lasix MAP 79 CI 5.4 P/F 205 CVP 8 GEF 23 IPAP 34 PPV 6 GEDVi 1080 PEEP 11 18 Flow and Ebb phase Should IEVLWi bother about 2x125ml 60mg/hr For 2hrs 10mg/hr 59 Chest X-­‐ray D3 2x200ml Dobu Lasix 3 Norepi 0.11 EVLWI 15 P/F 266 PVPI IPAP 34 PEEP 18 1.9 Alb 20% 40mg bolus Chest X-­‐ray D4 BUT… Dobu Norepi HFPV Evita When the going gets tough, STOP The tough get going 1 EVLWI 12 P/F 295 PVPI IPAP 30 PEEP 6 1.7 Chest X-­‐ray evoluPon D5 D6 HFPV PEEP 19 Lasix 10mg/hr conPnuously EVLWI 16 P/F 98 EVLWI 12 P/F 308 PVPI IPAP 30 PVPI IPAP 34 PEEP 6 PEEP 19 2.1 1.7 Chest X-­‐ray evoluPon D8 D7 EVLWI 10 P/F 355 EVLWI 8 P/F 358 PVPI IPAP 32 PVPI IPAP 26 PEEP 10 PEEP 6 1.5 1.3 D0 D1 D1 D2 D3 D4 38 26 18 12 D5 D6 D7 D8 16 12 10 8 D5 ICU day 38 EVLWI furosemide NIV Evita XL HFPV Daily and CumulaPve Fluid Balance Lasix Furosemide 5000 4000 3000 2000 1000 UO 0 -­‐1000 1 2 3 4 5 6 7 8 FB Cum FB -­‐2000 -­‐3000 -­‐4000 -­‐5000 -­‐6000 19/11/2011 Should I bother about Flow and Ebb phase 65 EVLWI-­‐GEDVI evoluPon 1400 40 1200 35 30 1000 GEDVi EVLWi CVD 25 800 20 600 15 400 10 200 5 0 0 Filling DiurePcs 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 19/11/2011 Should I bother about Flow and Ebb phase 66 For the Panel •  How do you explain the drop in EVLWI from 38 to 13 ml/kg PBW aper the iniPal resuscitaPon phase, while GEDVI increased from 757 to 921 ml/m2? 19/11/2011 Should I bother about Flow and Ebb phase 67 QUESTION 5: What is your opinion about a posiPve cumulaPve fluid balance in sepPc shock? 1.  It is just of cosmePc concern 2.  It is a biomarker of severity of illness 3.  It is harmful and an independent predictor for morbidity and mortality 4.  Fluid balance must be posiPve for a successful resuscitaPon of shock 5.  I don't care 19/11/2011 Should I bother about Flow and Ebb phase 68 Fluid Overload Meta-­‐Analysis 19/11/2011 Should I bother about Flow and Ebb phase 69 Murphy et al. Chest 2009;136;102-­‐109 RetrospecPve, N= 212 sepPc ALI paPents non-­‐survivors non-­‐survivors survivors survivors •  AIFR: adequate initial fluid resuscitation •  CLFM: conservaPve late fluid management Within 6 hrs from start pressors, fluids up to CVP> 8 mmHg
19/11/2011 Within 7 days aper start shock: neg FB on 2 consecuPve days Should I bother about Flow and Ebb phase 70 Summary of Findings: 40 studies • 
• 
• 
• 
• 
1 meta analysis 10 RCCT (4 blinded) 7 intervenPonal studies 28 observaPonal studies 4 case series •  A total of 23625 criPcally ill paPents •  In 23 studies IAP was measured 19/11/2011 Should I bother about Flow and Ebb phase 71 1 Fluid Balance and Outcome Non-­‐
survivors 2400 6982 9503 805 1782 6214 5994 56789&:;&
15875 10308 ()*+,&
2000 5410 17220 16100 Survivors SD n SD n delta FB 400 16 1700 20 Alsous 2000 Jun -­‐2350 "-###& 50 3419 7842 70 9875 44 Cordemans 2011 -­‐3563 7737 58 6910 65 Cordemans 2011 123 "####& 4971 -­‐4532 ''!'%$&
457 403 60 858 56 Goldstein 2005 -­‐348 668 16 750 15 Kuzkov 2006 Apr 18 -###& 893 -­‐889 !"#$%$&
1643 1500 192 2143 73 Malbrain 2005 Feb -­‐4571 3862 6904 314 7546 413 Malbrain META 2011 -­‐2132 #&
./012130.&625 434./012130.&
9250 125 1125 87 Murphy 2009 Jul -­‐6625 5154 769 159 1923 635 Rosenberg 2009 Jan-­‐Feb -­‐5154 (-###&
250 1600 43 2800 26 Schuller 1991 -­‐1750 880 2320 505 5050 134 Shum 2011 -­‐4530 ("####&
7500 4090 11 2045 26 Simmons 1986 -­‐9720 2100 3900 34 6400 49 Vidal 2008 Jun -­‐14000 mean Fluid Balance 3109,9 2981,4 1603,0 7737,9 3778,8 1643,0 -­‐4628,0 Standard Devia`on 2928,5 2848,3 5716,0 3011,1 3777,0 19/11/2011 Should I bother about Flow and Ebb phase 72 2 Fluid Balance and IntervenPon Interven
`on SD N control SD N Delta FB 126 8180 57 9902 5863 57 Cordemans 2011 -­‐9776 &),,,'
6857 1000 71 12286 2143 85 Balogh 2003 Jun -­‐5429 3240 2000 69 6888 4000 72 Brandstrup 2003 -­‐3648 &,,,,'
$!&$'
-­‐3300 1000 19 500 1000 18 Mar`n 2002 Oct -­‐3800 -­‐5480 4384 20 -­‐1490 5480 20 Mar`n 2005 Aug -­‐3990 ),,,'
2570 !"#$%&'
977 9 8242 714 11 Mc Ardle 2009 -­‐5672 142 3632 52 2239 3695 49 Mitchell 1992 -­‐2097 ,'
12300 9300 16 22100 12800 15 O'Mara 2005 May -­‐9800 -./0120.34.'
54./146'
706/8'9:'
14474 4202 14 23369 5393 22 Oda 2006 -­‐8895 (),,,'
8625 5162 130 10602 6216 133 Rivers 2001 Nov 8 -­‐1977 ()#*+%+'
-­‐4115 825 122 4651 917 122 Stewart 2009 -­‐8766 1633 2190 553 1732 2182 The SAFE Study 2004 (&,,,,'422 -­‐131 -­‐136 491 503 6992 502 497 Wiedemann 2006 -­‐7128 2748,1 3291,2 3272,0 8218,0 3881,2 3283,0 -­‐5469,9 mean Fluid Balance 6186,1 2884,5 7700,9 3415,6 Standard Devia`on 3202,3 19/11/2011 Should I bother about Flow and Ebb phase 73 2 Forest Plot (FB – Outcome) RestricPve 1443/6488 = 22.2% 19/11/2011 Liberal 1859/6384 = 29.1% Should I bother about Flow and Ebb phase 74 Fluid Overload 3 Hit Model Fluid Toxicity 19/11/2011 Should I bother about Flow and Ebb phase 75 Dilemma…
Dry lungs are happy lungs •  Patients don’t
die from
anasarca they
die from MOF…
A dry liver is A dead liver 76
Consequences of Fluid Overload… = ANASARCA 19/11/2011 Should I bother about Flow and Ebb phase 77 Anasarca = CosmePc? •  Pinsky M. Chest 2007;132;2020-­‐2029 •  Hemodynamic EvaluaPon and Monitoring in the ICU First Hit Acute inflammatory insult Trauma, InfecPon, Burns, Sepsis, Bleeding SIRS Sytemic proinflammatory cytokine release, acPvaPon RES, reacPve O2 species Mircocirculatory dysfuncPon, vasodilata-­‐
Pon, capillary leak, loss of autoregulaPon Distribu`ve shock: Ebb Phase Hypotension/hypovolemia/oliguria Myocardial depression IntersPPal edema formaPon Tissue hypoxia/increasing lactate levels FLUIDS Life saving TREATMENT Early Goal Directed MONITORING MAP, lactate, diuresis, ScvO2, PPV, SVV FLUID BALANCE Early adequate Second Hit Ischemia-­‐Reperfusion Organ DysfuncPon: MODS •  Acute Lung Injury →  PO2/FiO2↓, EVLWi↑ •  Acute Bowel Injury →  secondary IAH/ACS •  Acute Kidney Injury →  serum creaPnine↑, diuresis↓ •  Liver failure •  Nervous system failure FLUIDS Biomarker for criPcal illness TREATMENT ConservaPve fluid strategy MONITORING FuncPonal hemodynamics vs EVLWi, IAP FLUID BALANCE EquilibraPon EvoluPon TREATMENT of the iniPal insult and organ support Shock Reversal Systemic cytokine homeostasis Capillary leakage closure: CLI↓ Intravascular volume replePon Hemodynamic + renal recovery Flow Phase: fluid mobiliza`on Increased diuresis, edema clearance, EVLWi↓: weaning of venPlaPon Unresolved Shock Pro>AnP-­‐inflammatory cytokines Capillary leakage persistence: CLI↑, Increasing organ failure THIRD HIT Malbrain et al. ICM 2008;34(9):1565 - CCM 2009; 37:365
FLUIDS Third Hit Peripheral Edema Rhabdo ECS Toxic Cerebral Edema Global
Increased
Permeability
Syndrome
ICH Brain death Lung Edema Gut Edema AIPS Kidney Edema ALI IAH/ABI
AKI ARDS ACS/AIDS ATN TREATMENT Late Goal Fluid Removal MONITORING MAP, IAP, APP, EVLWi, Renal, PDR FLUID BALANCE NegaPve 2nd 3rd EVLWi IAP ICG-­‐PDR Fluids Life saving Bio-­‐
marker Toxic Goal EAGD LCFM LGFR FB + 0 -­‐ HIT 1st SVV, Monitor PPV, APP Fluid Overlad An Integrated Approach 19/11/2011 Should I bother about Flow and Ebb phase 85 PAL = your PAL ARDS
•  PEEP=IAP EVLWIá
–  Fluid from alveoli into IS •  ALBUMIN alb
–  Fluid from IS into capillaries – 
ARDS
PEEP
áPis =Pc âπis áπc Albumin 20% 200mL for serum levels at 30g/L •  LASIX lasix
–  Fluid out of paPent – 
Lasix 60mg/hr for 4 hrs followed by 10-­‐20mg/hr for UO> 2ml/kg/hr 19/11/2011 The Lungs are Should about low and Ebb phase I b other cleared by PFAL 86 PEEP (=IAP) + ALBUMINE + LASIX PEEP Cordemans C, Malbrain M et al. ESICM 2010 poster corner presentaPon Accepted for publicaPon in Annals of Intensive Care
N=114 MV paPents ALBUMIN IAP change
P/F change
EVLWi change
Cumulative FB
PAL Kaplan Meier curves SURVIVAL MECHANICAL VENTILATION PAL p = 0.037
p = 0.018
Impact of fluid kinePcs 80 Data on 180 patients
70 EA defined as fluid intake > 50ml/kg/1st 12-­‐24 hours n mortality LC defined as 2 negaPve daily FB within 1st week 60 50 40 30 20 10 0 EALC EALA ECLC ECLA Fluid Overload Wrap It Up 19/11/2011 Should I bother about Flow and Ebb phase 91 What I really need to know Œ When do I start giving fluids? SEE
GEF/GEDVi↓
benefit of fluid administration?
 When do I stop giving fluids? MORE
GEF/GEDVi↑
PLR-
PPV↓
risk of fluid administration?
Ž When do I start emptying? THAN
EVLW↑/PVPI↑
OTHERS
IAP↑/APP↓
FB+
benefit of fluid removal?
 When do I stop emptying? ICG-PDR↓
19/11/2011 PLR+
PPV↑
APP↓
ScvO2↓
FB--
risk of fluid removal?
Should I bother about Flow and Ebb phase 92 Moving Targets… 2nd HIT P/F, EVLWi, IAP 1st HIT MAP, SVV, PPV, ScvO2 3rd HIT PVPI, ICG-­‐
PDR Give the right fluid right Use the right monitor right EAGD LCFM Moving Goals… 19/11/2011 Should I bother about Flow and Ebb phase LGFR 93 Although… SomePmes it’s beher to have a lucky doctor than a smart doctor ! But… 19/11/2011 Should I bother about Flow and Ebb phase 94 However… It’s always beher trying to do something even if you don’t succeed than doing nothing and succeed 19/11/2011 Should I bother about Flow and Ebb phase 95 Therefore… Doing some kind of monitoring will preserve your knowledge basis 19/11/2011 Should I bother about Flow and Ebb phase 96 Therefore… Doing some kind of monitoring will preserve your knowledge basis 19/11/2011 Should I bother about Flow and Ebb phase 97 Relax WGAP
I only have Meeting
Friday March 23 9:30, Room 202
3 statements lep… rd
Places limited: only 350 lep… www.fluid-academy.org
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