2 nd iFAD 17/11/2012Should I bother about Ebb and Flow phase of shock Should I bother about Ebb and Flow phase of shock? (What did I learn last year) 17th

2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock

Should I bother about Ebb and Flow phase of shock?

(What did I learn last year)

17th November 20122nd iFAD– Interactive Case Discussion

Manu Malbrain


Disclosure• The speaker consults for the following

companies:– KCI– Pulsion Medical System– ConvaTec– Edwards– Fresenius- Kabi


Therapeutic Dilemma - ConflictKidney

Heart

Lung Liver


Today’s Agenda• The risks of fluid overload• Interactive Case Discussion• Meta-analysis• 3-hit model• Integrated approach• Wrap it up


Fluid Overload

The Risk of Fluids


What I really need to know is…

❶When do I start giving fluids?

❶When do I stop giving fluids?

❶When do I start emptying?

❶When do I stop emptying?

SEEMORETHANOTHERS

benefit of fluid administration?

risk of fluid administration?

benefit of fluid removal?

risk of fluid removal?


• Any measurement in the ICU stands or falls with its accuracy and reproducibility…

• No measurement has ever improved survival, only a good a protocol can…

Introduction

Hemodynamic treatment algorithms should follow physiology or they fail to improve

outcome. Malbrain Manu and Reuter Daniel – CCM 2012;40:2923


Example of a Poor Protocol…

Trof RJ et al. CCM 2012; 40

EVLWI < 10

Fluid Challenge

GEDVI < 850

We must NOT give a fluid challenge


788694

SURGICAL

SEPTIC

GEDVI < 850 ml/m2 is too high


Ebb Phase of SHOCK

“Ashen faces, a thready pulse and

cold clammy extremities…”

The Ebb Phase - Cuthbertson, Quart. J. Med.25:233,1932

Flow Phase of SHOCK

“The patient warms up, cardiac output increases and the

surgical team relaxes…”

The Flow Phase - Cuthbertson. Lancet 1:233, 1942

Fluid Guidance:MAP, SVV, PPV,

GEF/GEDVI, PLR, TEO

Fluid Guidance:Positive (Σ) Fluid

balance, IAP, EVLWI

EVLWI is NOT a trigger for Fluids


Septic Shock Patients (n=36)

Alsous et al. Chest 2000; 117: 1749-54


No excess extra-pulmonary organ failure

Better lung function:- LIS↓- FiO2/pO2

↑- Pplat ↓- PEEP ↓

RCCT, N=1000

Cum FB: -136±494 ml

Cum FB: 6992±502 ml


Case Study

From Ebb to Flow phase


LI, Male, 26 years old

• O2 debt during birth• CVA, left hemiparesis• Epilepsy

− Topamax, lamictal, tegretol• Cognitive deficit• Special daycare• Since age of 17 known with

ideopathic CMP (LVEF 52%)− Coversyl


Reason for admission

• General seizures− Different from previous

• Syncope• BP not palpable• On ED: VT?

− DC biphasic 200J• Transfer to ICU


Evolution Overnight• Hemodynamically stable• No seizures• Gradual increase in supplemental

O2-needs– From 2L via nasal cannula– To 15L with NRM

• Failure of NIV• ETT and MV


After ETT• Hemodynamically Unstable

– CVP 16 mmHg– MAP 51 mmHg

• On conventional MV– Evita XL FiO2 100%– 24 x 400 mL– PEEP 10– P/F ratio 74


Transthoracic Cardiac US

LVEF 30% MR 2 to 3/4


TT Cardiac US

• Dilated CMP (Left atrium 65mm)• CO: 6.2 L/min (CI 3.5)• LVEF: 30-35%, FAC: 28.5%• LVEDA: 28.7 cm2 – LVEDAi: 16.2 cm2• E/E’: 15 - LVEDP: 25 mmHg• MR 2 to ¾ (central + 2 eccentric jets)• VCI: 21 mm


Question 1: What is your treatment of choice?

1. Norepinephrine2. Dobutamine3. Fluids bolus4. Diuretics5. Other

MAP 59

CVP 16

CI 3.5

LVEDP

25

LVEF 30

LVEDA

28.7

P/F 74

IPAP 30

PEEP

10

Lactate 2.8


Further course…

• Norepinephrine was started– Swiftly increased to 0.4 y

• Dobutamine started at 3y• FiO2 was increased to 100%• PEEP set according to PV loop

– BPsys drop to 40 mmHg during recruitment

• Saturation poor at 88%• Switch to HFPV – VDR4


PiCCO catheter - TPTD• CI: 3.5• PPV: 19%• GEDVi: 757 ml/m2 – GEF: 13%• EVLWi: 38 ml/kg PBW – PVPI: 7.4• PLR = POSITIVE (15% increase in CI)

Normal Values:PPV: <10 %GEDVI: 600 – 850GEF: 25-35% EVLWI: 3 – 7 PVPI: 1 – 3


MAP 65

CVP 15

PPV 19

CI 3.5

GEF 13

GEDVi

757

EVLWi

38

P/F 57

IPAP 34

PEEP

15


HFPV30/10




Decision Tree..


General Question• How do you explain the relative discrepancy

between the volumetric (low normal – GEDVi 757) and barometric (high normal – CVP 14) preload indicators in this patient?

• Remember that the SSC guidelines state that CVP must be resuscitated towards 8-12 mmHg


• CVP: 8-12 mmHg• Chasing a CVP may

lead to:→ OVER resuscitation→ UNDER resuscitation

Surviving Sepsis GuidelinesIAP11


• Don’t trust traditional BAROmetric filling pressures (CVP or PAOP)

• Use Volumetric preload indicators (GEDVI: PiCCO/EV1000 or RVEDVI: PAC)

Barometric vs Volumetric preload?

Malbrain et al. Current Opinion Crit Care 2004; 10(2): 132-145

MV-IPPV(auto)PEEPPost CABGObesityIAH-ACS



Surviving Sepsis Guidelines


Crit Care Med 2008; 36:296-327[published correction in Crit Care Med 2008; 36:1394-1396]


Surviving Sepsis Guidelines


TT Cardiac US

• Small volume resuscitation (SVR): Hyperhaes 4ml/kg/15min

• 2x 500ml Volulyte

IVCCI= 50%


Next morning

Dobu 9

Norepi 0.4


Evolution overnight

• CI h

• GEDVI h

• EVLWI i

• MAP h

CVP decreased from 14 to 6 mmHg with filling


Respiratory Support overnight

HFPV NO(stand-by)

• pO2 h • P/F h• FiO2 i• IPAP h


P/F 157

IPAP 32

PEEP

11

EVLWI

13

PVPI 2

Next morning on Day 2


Therapeutic Dilemma…We gave fluids because:• PPV was high and PLR was positive• The GEDVI was relatively low (in relation

to GEF) despite the increased CVP, LVEDAI and high EVLWI…

• IVCCI was almost 50%


So,…What I really need to know:

• What is the Frank Starling curve of my patient?

• Where is my patient on the curve?


• When to use?

Solution: GEF-corrected GEDVi

Malbrain M. et al. AAS 2010; 54(5): 622-631


LVED area on TTE

LVEDA 34cm2 28cm2

?

After 30% blood loss of CBV


EF corrected volumes? GEF 0.15

GEF 0.25

GEF 0.35

Cardiac INDEX

GED

VI

Malbrain, Cheatham. Yearbook Intensive Care 2004


Pressures as preload?

ΔCVP ΔPCWP

ΔC

I

X


Volumes as preload?

ΔRVEDV

ΔGEDV

ΔC

I

X


Corrected volumes vs preload?

ΔcRVEDVΔcGED

V

ΔC

I ✓


Question 3: The premature hump on the transpulmonary thermodilution curve is…

1. Crosstalk phenomenon2. Bolus mixing3. Right-to-left shunt4. Wrong/false measurement5. I don't know


Premature hump = Hypovolemia

Septic shock 100% FiO2 – PEEP 12 – extremely underfilled

Pulmonary Hypertension Before filling (at 8:40)

after filling with 500mL Voluven (at 9:02)

GEDVi : 288 GEDVi : 537


Right-to-Left shunt on TPTD

RA LARV LVPBV

EVLW


ZEEP

PEEP

PEEP

Michard F et al. CCM 2004 Jan;32(1):308-9.

Our patient became extremely hypotensive during recruitment


•West Lung ZonesZONE 1: Palv > Part >

Pven

ZONE 2: Part > Palv > Pven

ZONE 3: Part > Pven > Palv

❶

❷

Hypovolemia

High PEEP

❶

Right-to-Left Shunt


Evolution late afternoon 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• Cumulative FB +4L

MAP 79

CVP 8

PPV 6

CI 5.4

GEF 23

GEDVi

1080

EVLWi

18

P/F 205

IPAP 34

PEEP

11




MAP 79

CVP 8

PPV 6

CI 5.4

GEF 23

GEDVi

1080

EVLWi

18

P/F 205

IPAP 34

PEEP

11

Dobu 5

Norepi 0.2


PEEP 18Alb 20%

Lasix

3x100mlHyperHaes

2x125ml

60mg/hrFor 2hrs10mg/hr


Chest X-ray D3

P/F 266

IPAP 34

PEEP

18

EVLWI

15

PVPI 1.9

Dobu 3

Norepi 0.11

Alb 20%

Lasix

2x100ml

40mg bolus


P/F 295

IPAP 30

PEEP

6

EVLWI

12

PVPI 1.7

Dobu 1

Norepi STOP

HFPV

When the going gets tough,The tough get going

BUT…Chest X-ray D4

Evita


Chest X-ray evolution

P/F 98

IPAP 30

PEEP

6

EVLWI

16

PVPI 2.1

P/F 308

IPAP 34

PEEP

19

EVLWI

12

PVPI 1.7

D5 D6

HFPV

PEEP 19

Lasix 10mg/hrcontinuously


Chest X-ray evolution

D7 D8

P/F 355

IPAP 32

PEEP

10

EVLWI

10

PVPI 1.5

P/F 358

IPAP 26

PEEP

6

EVLWI

8

PVPI 1.3


General Question• How do you explain the drop in EVLWI from 38

to 13 ml/kg PBW after the initial resuscitation phase, while GEDVI increased from 757 to 921 ml/m2?


QUESTION 5: What is correct regarding a positive cumulative fluid balance in septic shock?

1. Peripheral edema may look frightening for the relatives but it is just of cosmetic concern

2. Fluid balance must initially always be positive for a successful resuscitation of shock

3. Patients don’t die form anasarc edema they only die from organ failure

4. A cumulative fluid balance is always a biomarker of severity of illness

5. A positive fluid balance is harmful and an independent predictor for morbidity and mortality.

6. None of the above


D7D5 D6

D4D2D1

D0

D3

D1

122638 18

81216 10

D8

NIVEvita XLHFPV

D5

38

ICU day

EVLWIfurosemide


Daily and Cumulative Fluid Balance

Lasix Furosemide


EVLWI-GEDVI evolution

Filling

Diuretics


Fluid Overload

Meta-Analysis


• AIFR: adequate initial fluid resuscitationWithin 6 hrs from start pressors, fluids up to CVP> 8 mmHg

Murphy et al. Chest 2009;136;102-109

survivors

non-survivors

non-survivors

survivors

• CLFM: conservative late fluid management Within 7 days after start shock: neg FB on 2 consecutive days

Retrospective, N= 212 septic ALI patients



Summary of Findings: 40 studies• 1 meta analysis• 10 RCCT (4 blinded)• 7 interventional studies• 28 observational studies• 4 case series• A total of 23625 critically ill patients• In 23 studies IAP was measured


1 Fluid Balance and OutcomeSurvivor

s SD n

Non-survivor

s SD n delta FBAlsous 2000 Jun 50 400 16 2400 1700 20 -2350Cordemans 2011 3419 7842 70 6982 9875 44 -3563Cordemans 2011 123 4971 7737 58 9503 6910 65 -4532Goldstein 2005 457 403 60 805 858 56 -348Kuzkov 2006 Apr 18 893 668 16 1782 750 15 -889Malbrain 2005 Feb 1643 1500 192 6214 2143 73 -4571Malbrain META 2011 3862 6904 314 5994 7546 413 -2132Murphy 2009 Jul 9250 625 125 15875 1125 87 -6625Rosenberg 2009 Jan-Feb

5154 769 159 10308 1923 635-5154

Schuller 1991 250 1600 43 2000 2800 26 -1750Shum 2011 880 2320 505 5410 5050 134 -4530Simmons 1986 7500 4090 11 17220 2045 26 -9720Vidal 2008 Jun 2100 3900 34 16100 6400 49 -14000mean Fluid Balance 3109,9 2981,4 1603,0 7737,9 3778,8 1643,0 -4628,0Standard Deviation 2928,5 2848,3 5716,0 3011,1 3777,0


2 Fluid Balance and InterventionInterven

tion SD N control SD N Delta FBCordemans 2011 126 8180 57 9902 5863 57 -9776Balogh 2003 Jun 6857 1000 71 12286 2143 85 -5429Brandstrup 2003 3240 2000 69 6888 4000 72 -3648Martin 2002 Oct -3300 1000 19 500 1000 18 -3800Martin 2005 Aug -5480 4384 20 -1490 5480 20 -3990Mc Ardle 2009 2570 977 9 8242 714 11 -5672Mitchell 1992 142 3632 52 2239 3695 49 -2097O'Mara 2005 May 12300 9300 16 22100 12800 15 -9800Oda 2006 14474 4202 14 23369 5393 22 -8895Rivers 2001 Nov 8 8625 5162 130 10602 6216 133 -1977Stewart 2009 -4115 825 122 4651 917 122 -8766The SAFE Study 2004 422 1633 2190 553 1732 2182 -131Wiedemann 2006 -136 491 503 6992 502 497 -7128mean Fluid Balance 2748,1 3291,2 3272,0 8218,0 3881,2 3283,0 -5469,9

Standard Deviation 6186,1 2884,5 7700,9 3415,6 3202,3


2 Forest Plot (FB – Outcome)

Restrictive1443/6488 =

22.2%

Liberal1859/6384 =

29.1%

P<0.0001


Fluid Overload

3 Hit ModelFluid Toxicity


Dilemma…

• Patients don’t die from anasarca they die from MOF…

Dry lungs are happy lungs

A dry liver isA dead liver


• Pinsky M. Chest 2007;132;2020-2029• Hemodynamic Evaluation and Monitoring in the ICU

Anasarca = Cosmetic?


First Hit FLUIDSLife saving

TREATMENTEarly Goal Directed

MONITORINGMAP, lactate,

diuresis, ScvO2, PPV, SVV

FLUID BALANCEEarly adequate

Acute inflammatory insultTrauma, Infection, Burns, Sepsis, Bleeding

SIRSSytemic proinflammatory cytokine release,

activation RES, reactive O2 species

Mircocirculatory dysfunction, vasodilata-tion, capillary leak, loss of autoregulation

Distributive shock: Ebb PhaseHypotension/hypovolemia/oliguria

Myocardial depressionInterstitial edema formation

Tissue hypoxia/increasing lactate levels

EBB = dangerous


Second HitFLUIDS

Biomarker for critical illness

TREATMENTConservative fluid

strategy

MONITORINGFunctional

hemodynamics vs EVLWi, IAP

FLUID BALANCEEquilibration

Ischemia-ReperfusionOrgan Dysfunction: MODS• Acute Lung Injury

→ PO2/FiO2↓, EVLWi↑• Acute Bowel Injury

→ secondary IAH/ACS• Acute Kidney Injury

→ serum creatinine↑, diuresis↓• Liver failure• Nervous system failure


EvolutionTREATMENT

of the initial insult and organ support

Shock ReversalSystemic cytokine homeostasisCapillary leakage closure: CLI↓Intravascular volume repletionHemodynamic + renal recovery

Flow Phase: fluid mobilization

Increased diuresis, edema clearance, EVLWi↓: weaning of

ventilation

Unresolved ShockPro>Anti-inflammatory cytokines

Capillary leakage persistence: CLI↑, Increasing organ failure

THIRD HITMalbrain et al. ICM 2008;34(9):1565 - CCM

2009; 37:365


Third Hit FLUIDSToxic

TREATMENTLate Goal Fluid

Removal

MONITORINGMAP, IAP, APP,

EVLWi, Renal, PDR

FLUID BALANCENegative

Lung Edema

Gut EdemaAIPS

Kidney Edema

ALI IAH/ABI AKI

ARDS ACS/AIDS ATN

Peripheral Edema

Cerebral Edema

Rhabdo

ECS

ICH

Brain death

GlobalIncreased

PermeabilitySyndrome

FLOW = hazardous


HIT

Monitor

Fluids

Goal

FB


Fluid Overlad

An Integrated Approach


PALPAL

PEEP ALBUMIN

N=114 MV patients


PAL

IAP change

PAL

P/F change

PAL

EVLWi change

PAL

Cumulative FB


Kaplan Meier curves

PAL

PAL

SURVIVAL MECHANICAL VENTILATION


Impact of fluid kineticsData on 180

patientsEA defined as fluid intake > 50ml/kg/1st 12-24 hours

LC defined as 2 negative daily FB within 1st week


Fluid Overload

Wrap It Up


What I really need to know

❶When do I start giving fluids?

❶When do I stop giving fluids?

❶When do I start emptying?

❶When do I stop emptying?

SEEMORETHANOTHERS

benefit of fluid administration?

risk of fluid administration?

benefit of fluid removal?

risk of fluid removal?

GEF/GEDVi↓ PPV↑ PLR+

GEF/GEDVi↑ PPV↓ PLR-

EVLW↑/PVPI↑ IAP↑/APP↓ FB+

ICG-PDR↓ APP↓ ScvO2↓ FB--


Moving Targets…

1st HITMAP, SVV, PPV, ScvO2

2nd HITP/F, EVLWi,

IAP3rd HIT

PVPI, ICG-PDR

Moving Goals…EAGD LGFR

LCFM

Give the right fluid rightUse the right monitor right


Although…

Sometimes it’s better to have a lucky doctor than a smart doctor !

But…


It’s always better trying to do something

even if you don’t succeed than doing

nothing and succeed

However…


Doing some kind of monitoring will preserve your

knowledge basis

Therefore…

RELAX I only have 3 statements left…


Therefore…

RELAX I only have 3 statements left…


XAVIER!

Once upon a time in Paris…


WGAP Meeting at ESICMACS Workshop at ISICEM


3rdMARK THE DATE!

FRIDAY AND SATURDAY NOV 29TH-30TH 2013 / ANTWERP BELGIUM

A CONCISE BUT COMPLETE 2 DAY SYMPOSIUM ON FLUID MANAGEMENT AND MONITORING IN THE CRITICALLY ILL

INTERACTIVE VOTING SYSTEM / POSTER SESSIONS / WORKSHOPS / ACADEMY PRIZE AWARD / NURSING SESSION / CASE DISCUSSIONS / STATE OF THE ART LECTURES / FLUID MANAGEMENT /

HEMODYNAMIC MONITORING / ORGAN SUPPORT AND MONITORING / ROUND TABLE DISCUSSIONS /

[email protected] WWW.FLUID-ACADEMY.ORGFOLLOW US ON:ORGANIZED BY THE INTERNATIONAL FLUID ACADEMY


1st IFAD huge succes: 450 att

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Documents

2 nd iFAD 17/11/2012Should I bother about Ebb and Flow phase of shock Should I bother about Ebb and Flow phase of shock? (What did I learn last year) 17th