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5/31/2014 1 Goal-Directed Fluid Resuscitation

Christopher G. Choukalas, MD, MS

Department of Anesthesia and Perioperative Care University of California, San Francisco

“Goal-Directed” Fluid Resuscitation

Christopher G. Choukalas, MD, MS

Department of Anesthesia and Perioperative Care University of California, San Francisco

Goal-Directed “Fluid Resuscitation”

Christopher G. Choukalas, MD, MS

Department of Anesthesia and Perioperative Care University of California, San Francisco

Goal-Directed Fluid Resuscitation

Christopher G. Choukalas, MD, MS

Department of Anesthesia and Perioperative Care University of California, San Francisco

5/31/2014 2

The case for why it matters

• Fluid balance a common concern
• Sepsis
• ALI/ARDS
• Sepsis PLUS ARDS!
• Patients with Sepsis who developed ALI
• 4 groups:

– Adequate initial + Conservative late fluids – Adequate initial only – Conservative late only – Neither

Murphry, CV , et al. 2009. Chest. 136(1)

It matters

• So how do we do it?

5/31/2014 3

I would posit two factors:

• Hemodynamic:

– Is the circulation adequate?

• Metabolic

– Are oxygen delivery and utilization adequate?

• Both have their own goals.

Hemodynamic Goals

• Blood pressure
• CVP
• Dynamic respiratory indices:

– Pulse pressure/systolic pressure/perfusion index variation

Hemodynamic Goals

• Blood pressure
• CVP
• Dynamic respiratory indices:

– Pulse pressure/systolic pressure/perfusion index variation

Blood pressure

• A proxy for flow, end organ perfusion
• Flow = pressure/resistance
• Do we ever really KNOW resistance?

5/31/2014 4

Wax, et al.

• Non-cardiac cases with both ABP and

NIBP.

• Compared SBP, DBP, and MAP btwn

technologies:

– A-line alone vs A-line + cuff

Randomized trials

• This used to be the 2nd joke of the talk

5/31/2014 5

Interesting review

• Reviewed 2 trials and 1 meta-analysis (13

studies)

– Target BP – Actual BP

• Dissociation

– BPs invariably higher than goal – Higher goal ranges permitted higher actual ranges:  pressors

The NEJM study

• Randomized to MAP 65 vs 85 (800 total)
• Norepinephrine
• Mortality
• AKI/RRT, stratified by HTN

5/31/2014 6

Blood pressure

• Necessary but not sufficient
• Goals are nebulous
• Supra-normal levels common, not helpful

Hemodynamic

• Blood pressure
• CVP
• Dynamic respiratory indices:

– Pulse pressure/systolic pressure/perfusion index variation

Concept: assumptions

Adequate DO2 Adequate contractility Optimal actin-myosin match Normal CVP

5/31/2014 7

The data

• Critical target in EGDT for sepsis
• Incorporated into SSC guidelines

Sepsis +  CVP = Death

• Retrospective analysis of VASST trial

– 778 pts w/ septic shock on NE

• CVP at 12 hrs did predict 28-d mortality in

patients:

Boyd, JH, et al. 2011. CCM. 39(2)

HR CVP < 8 0.61 CVP 8-12 0.76 CVP >12 1

Marik, PE, et al. 2008. Chest. 134(1)

5/31/2014 8

Fluid responsiveness and total blood volume

• Volume responsiveness
• Cardiac output before and after fluid

challenge

• 19 evaluated CVP and volume

responsiveness

Fluid responsiveness

• Calculated a Receiver Operating

Characteristic curve

• Likelihood that at any given point (CVP

level, score, etc) the true positives will exceed false positives.

• Higher = better discrimination

Volume responsiveness

Marik, PE, et al. 2008. Chest. 134(1)

Deja vu

• 43 studies, half ICU
• Same design

– AUC btwn CVP and ΔSV

• Same pooled AUC

– 0.56

• Same aggressive conclusion

5/31/2014 9

CVP

• Necessary?
• Certainly not sufficient
• Potentially misleading

Hemodynamic

• Blood pressure
• CVP
• Dynamic respiratory indices:

– Pulse pressure/systolic pressure/perfusion index variation

The Principles

Decreased RV SV

 RV Preload  RV Afterload

 LV Preload  LV SV

Applies to lots of measures

• Systolic pressure variation
• Pulse pressure variation
• Plethysmogram variation
• Outcome is “fluid responsiveness”

5/31/2014 10

Variations on a theme…

• A waveform…
• A peak and trough…
• And a proprietary algorithm:

The data

• Small studies
• Mostly OR

SVV, Vigileo 40% MORE fluid Lower lactate Fewer “complications” PVI, Masimo 1/3 LESS fluid Lower lactate

• 29 studies, 685 patients

– 9 ICU – 20 OR (15 in cardiac surgery)

• All included correlation/ROC between

SPV, PPV, or SVV and ΔSVI/CI after a fluid challenge.

Measure r AUC for ROC Threshold PPV 0.78 0.94 12.5% SVV 0.72 0.84 15.3% SPV 0.72 0.86 CVP 0.56

5/31/2014 11

A great review…

• Alphabet soup

– SVV, PPV, SPV, PVI – LidCO, PiCCO, esCCO, ProAQT

• Some require external calibration
• Some require specific catheters in specific

locations.

Now, keep in mind…

• Regular HR
• Sedated, mechanically ventilated
• Vt = 8 mL/kg
• Pressors?

PVI + NE = NEB

Monnet, et al Biais, et al Population 35 ICU patients on NE 35 ICU patients on NE Gold Standard TD PPV > 13% SensitivityFR 43 58 SpecificityFR 90 61 AUCROC 0.68 0.69 100 72 0.93 Monnet, et al Population 35 ICU patients on NE Gold Standard TD SensitivityFR 43 SpecificityFR 90 AUCROC 0.68

Hemodynamic goals

• Numerous
• State of the art: Dynamic indices

– PPV – SPV – PVI – VTI and esophageal doppler

• Necessary but not sufficient

5/31/2014 12

Metabolic

• Mental status, urine output
• Lactate
• S(c)vO2

Metabolic

• Mental status, urine output
• Lactate
• S(c)vO2

Metabolic

• Mental status, urine output
• Lactate
• S(c)vO2

Lactate

• The product of anaerobic respiration
• Presence implies inadequate oxygen

utilization, shock

• Easily, quickly measured in arterial blood

5/31/2014 13

Lactate: the data Two trials:

• JAMA: 300 patients, EGDT vs lactate

clearance

– Non-inferiority

• AJRCCM: 348 patients, EGDT vs lactate

clearance

– Improved mortality (multivariate) – Less time on vent, in ICU

How did they do it?

Jones, et al (JAMA) Jansen et al (AJRCCM) Monitoring interval 2 2 Goal 10% clearance 20% clearance Fluid totals (L) Control: 4.3 Intervention: 4.5ns Control: 2.2 Intervention: 2.7* Outcome Non-inferiority to EGDT Decreased time on vent, in ICU

The underpinnings…

5/31/2014 14

Metabolic

• Mental status, urine output
• Lactate
• S(c)vO2

How it’s used:

 ScvO2 attributed to:

 Supply (cardiac output)  Demand (hypermetabolism)

• In either case, treat by increasing DO2

– Volume, inotropes, RBCs

• But does it work?

DOGS

Humans w/ sepsis Humans w/ shock Changes in SvO2 and ScvO2

5/31/2014 15

But does it work?

• Conflicting data

The premise:

• Pts admitted to ICU w/ sepsis frequently

have NL ScvO2

• Many

– Still have evidence of hypoperfusion – Still die

EGDT ScvO2 > 70 Lactate NL Lactate High A-V(CO2) < 6 A-V(CO2) >6 ScvO2 < 70

• 50 such patients

– 26 Low gap – 24 High gap

• The same on many measures:

– SOFA, APACHE II, pressor use

• Over 24 hrs, High gap exhibited

hypoperfusion:

– Persistent lactate – Higher SOFA

5/31/2014 16

• Higher mortality

– 34% – 54% (ns)

• No specific therapy for gap
• Authors recommend augmenting CO

Metabolic goals

• Lactate and ScvO2

– Base deficit? – A-V (CO2) gradient? – A-V (CO2)cer gradient?

• Physiological rationale meets objective

data.

Does any of this…

• Save lives?
• Save money?
• Actually work?

5/31/2014 17

Subgroup Mortality Complications Jadad high

• +++

Jadad low +++ +++ 1980s-1990s +++ +++ 2000s

• +++

5/31/2014 18

• Randomized CT surgery patients to

– CVP and MAP – SVV, EDV index (PiCCO), EVLW

Counted up outcomes

• Less norepinephrine
• Higher CI, ScvO2
• Fewer post-op complications
• Left the ICU and hospital a full day sooner
• No difference in fluid totals, RBCs, UOP

– Timing of fluid: More in the OR.

5/31/2014 19

Putting it all together:

• Volume isn’t easy
• Volume is important
• Common conditions; competing goals
• Stepwise plan

– Hemodynamic – Metabolic

• It seems to work

The end

The End