Use the right tool for the right job! Assessment of fluid therapy Use the right tool for the right job! Prof. Xavier MONNET Medical Intensive Care Unit Bicêtre Hospital Assistance publique – Hôpitaux de Paris FRANCE

Conflict of interest Pulsion Medical Systems

Use the right tool for the right job! Assessment of fluid therapy Use the right tool for the right job! Prof. Xavier MONNET Medical Intensive Care Unit Bicêtre Hospital Assistance publique – Hôpitaux de Paris FRANCE

?   Differents monitoring devices Different indications AP CVP PAC PiCCO Nexfin ProAQT/PulsioFlex Esophageal Doppler FloTrac/Vigileo Echo  Differents monitoring devices ?  Different indications

Peri-op monitoring   Peri-op monitoring ICU monitoring

Peri-op monitoring Context High-risk surgical patients (except cardiac surgery) Goals of monitoring to detect hemodynamic deterioration to guide volume expansion Improves prognosis

Peri-op monitoring Improves prognosis with esophageal Doppler 60 patients hip replacement  hospital length of stay 100 high-risk surgical patients  hospital length of stay 174 patients post cardiac surgery  hospital length of stay 162 multiple trauma patients after surgery hospital length of stay ICU length of stay lactate level

Peri-op monitoring Improves prognosis with LidCO 60-risk general surgical patients Goal directed therapy vs. conventional treatment Post-operative phase  number of complications  hospital length of stay 120 high-risk abdominalsurgery patients SVV-directed therapy vs. conventional treatment Per-operative phase LidCO monitoring  number of complications  hospital length of stay

Peri-op monitoring Improves prognosis with Flotrac/Vigileo 40 patients with hip replacement under regional anesthesia Goal directed therapy vs. conventional treatment  number of complications

Peri-op monitoring LidCOrapid Vigileo Pulsioflex Eso Doppler continuous cardiac output continuous cardiac output continuous cardiac output continuous cardiac output (AP curve analysis) (AP curve analysis) (AP curve analysis) (cardiac output) preload dependance (VVE and Δ PP) preload dependance (VVE and Δ PP) preload dependance (VVE and Δ PP) preload dependance (Δ aortic blood flow) preload (FTc)

  OR monitoring ICU monitoring Basic monitoring Advanced monitoring Arterial pressure CVP Esophageal Doppler Flotrac/Vigileo Pulsioflex LidCOrapid PiCCO EV 1000 PA catheter

Basic ICU monitoring  Context initial phase of shock after the ER Objectives of monitoring assess the hemodynamic profile (type of shock) guide initial therapy fix some therapeutic goals  Which basic monitoring?

Basic ICU monitoring

Basic ICU monitoring CVP Arterial pressure DAP PPV MAP Helps for: determining the type of shock (preload) deciding to give vasopressors guiding fluid responsiveness (preload) deciding to give fluid (if ventilated) PPV MAP fixing some therapeutic goals

  ? ? OR monitoring ICU monitoring Basic monitoring Advanced monitoring Arterial pressure ? CVP ? Esophageal Doppler Flotrac/Vigileo Pulsioflex LidCOrapid PiCCO EV 1000 PA catheter

Advanced ICU monitoring Context critically ill patients when shock persists after initial fluid therapy The only arterial pressure and CVP monitoring is not sufficient anymore because patients receive vasopressors

Advanced ICU monitoring 228 pts receiving volume expansion 145 patients with increase of NE * r = 0.56 n = 228 r = 0.21 n = 145 -50 50 100 150 200 250 300 Changes in CI induced by VE (%) Changes in PP induced by VE (%) -50 50 100 150 200 250 300 Changes in CI induced by NE (%) Changes in PP induced by NE (%)

Advanced ICU monitoring 228 pts receiving volume expansion 145 patients with increase of NE -20 20 40 60 80 100 non responders responders changes in CI (%) -20 20 40 60 80 100 non responders responders changes in PP (%) 6% false + +15% 22% false -

Advanced ICU monitoring LidCOrapid Vigileo Pulsioflex Eso Doppler continuous cardiac output AP curve analysis uncalibrated continuous cardiac output continuous cardiac output AP curve analysis uncalibrated continuous cardiac output continuous cardiac output AP curve analysis uncalibrated continuous cardiac output continuous cardiac output (AP curve analysis) (AP curve analysis) (AP curve analysis) (cardiac output) preload dependance (VVE and Δ PP) preload dependance (VVE and Δ PP) preload dependance (VVE and Δ PP) preload dependance (Δ aortic blood flow) preload (FTc)

? Advanced ICU monitoring Which device for advanced monitoring? Uncalibrated devices 20 40 60 80 100 120 estimate SV from the arterial pressure curve estimate arterial compliance by analysing the arterial waveform = k . SV still valuable when the properties of the arterial curve change in a large extent (sepsis, vasopressors) ?

arterial pressure curve Advanced ICU monitoring Which device for advanced monitoring? PiCCO and EV1000 devices measure cardiac output by arterial pressure curve analysis 3.5 L/min

arterial pressure curve Advanced ICU monitoring Which device for advanced monitoring? PiCCO and EV1000 devices measure cardiac output by arterial pressure curve analysis cold bolus calibrated by transpulmonary thermodilution inj Blood temperature (Ts) Ttm

Advanced ICU monitoring Which device for advanced monitoring? Ability to track calibrated cardiac index changes induced by volume expansion (40 patients) PiCCO changes induced by norepinephrine (40 patients) Vigileo2 uncalibrated cardiac index

Advanced ICU monitoring Which device for advanced monitoring? Changes induced by volume expansion -15 15 30 45 60 75 D CItd (%) r = 0.78 p < 0.05 PiCCO r = -0.03 p = NS 90 105 120 Vigileo2 Changes induced by norepinephrine PiCCO r = 0.72 p < 0.05 -15 15 30 45 60 75 90 105 120 D CIpc (%) DCItd (%) Vigileo2 r = 0.33 CIpw (%) CItd (%)  

Advanced ICU monitoring Which device for advanced monitoring? 51 pts, 401 measurements Vigileo2 vs.Vigileo3 vs. PAC Vigileo3 is more accurate and as precise than Vigileo2

Advanced ICU monitoring Which device for advanced monitoring? 33 patients Vigileo3 vs. esophageal Doppler Hemodynamic challenges by phenylephrine, ephedrine and whole-body tilting

Advanced ICU monitoring Which device for monitoring cardiac output? PA catheter PiCCO EV 1000 cardiac output cardiac output cardiac output

Advanced ICU monitoring Context critically ill patients when shock persists after initial fluid therapy Goals of monitoring precisely monitor the effects of therapy fix some therapeutic goals predict fluid responsiveness assess the risk of fluid expansion

Advanced ICU monitoring How to assess the need for fluid? PA catheter PiCCO EV 1000 cardiac output cardiac output cardiac output SvO2 ScvO2 ScvO2

Advanced ICU monitoring Context critically ill patients when shock persists after initial fluid therapy Goals of monitoring precisely monitor the effects of therapy fix some therapeutic goals predict fluid responsiveness assess the risk of fluid expansion

Advanced ICU monitoring How to assess the need for fluid? PA catheter PiCCO EV 1000 cardiac output cardiac output cardiac output PAOP PPV, SVV, PLR test, EEO test PPV, SVV, PLR test, EEO test SvO2 ScvO2 ScvO2

Advanced ICU monitoring How to assess the need for fluid?

Advanced ICU monitoring How to assess the need for fluid? PA catheter PiCCO EV 1000 cardiac output cardiac output cardiac output continuous continuous PAOP PPV, SVV, PLR test, EEO test PPV, SVV, PLR test, EEO test SvO2 ScvO2 ScvO2

Advanced ICU monitoring How to assess the need for fluid? venous return

Advanced ICU monitoring How to assess the need for fluid? Effects of end-expiratory pause on cardiac index 34 patients with acute circulatory failure monitored by PiCCO device 50 40 30 20 increase  5% Se = 91% Sp = 100 % 10 -10 NR R

Advanced ICU monitoring How to assess the need for fluid?

Advanced ICU monitoring Context critically ill patients when shock persists after initial fluid therapy Goals of monitoring precisely monitor the effects of therapy fix some therapeutic goals predict fluid responsiveness assess the risk of fluid expansion

Advanced ICU monitoring How to assess the risk of volume expansion? PA catheter PiCCO EV 1000 cardiac output cardiac output cardiac output PAOP PPV, SVV, PLR test, EEO test PPV, SVV, PLR test, EEO test SvO2 ScvO2 ScvO2 lung water and lung permeability lung water and lung permeability

Advanced ICU monitoring How to assess the risk of volume expansion? Lung permeability lung water very high permeability normal permeability high permeability lung water Pcap Pcap

Advanced ICU monitoring Lung water for estimating the risk of volume expansion? Lung permeability Lung water very high permeability normal permeability high permeability lung water lung water Pcap Pcap

Advanced ICU monitoring Lung water for estimating the risk of volume expansion? Cold bolus PiCCO EV1000

Advanced ICU monitoring Lung water for estimating the risk of volume expansion? 30 pts EVLW measured by TPTD and by postmortem gravimetry First validation of EVLW-TPTD evaluation in humans → validation in human beings

Advanced ICU monitoring Lung water for estimating the risk of volume expansion?

Advanced ICU monitoring Lung water for estimating the risk of volume expansion? Extra-vascular lung water and pulmonary vascular permeability index are independent prognostic factors in patients with acute respiratory distress syndrome Jozwiak M, Silva S, Persichini R, Anguel N, Osman D, Richard C, Teboul JL, Monnet X submitted 200 pts with ARDS EVLW measured by PiCCO device 20 40 60 80 100 EVLWImax > 21 mL/kg EVLWImax ≤ 21 mL/kg 70% 42% p = 0.0001 Day-28 mortality (%) p value Maximal blood lactate 0.81 (0.71 - 0.93) 0.002 Mean PEEP 1.25 (1.07 - 1.47) 0.005 EVLWI max 0.94 (0.87 - 0.98) 0.01 SAPS II 0.97 (0.95 - 0.99) 0.02 Mean fluid balance 0.9996 ( 0.9993 - 0.9999) Minimal P/F ratio 1.01 (1.00 - 1.02) Minimal pH 35.97 (0.47 - 2769.52) 0.10 Odds Ratio ( CI 95%)

Advanced ICU monitoring Lung water for estimating the risk of volume expansion? Cumulative fluid balance (input - output; L) 7 * * PAOP group * 5 * 3 1 EVLW group -1 -3 * p < 0.0001 vs time 0 -5 0 12 24 36 48 60 72 Time (hours) 101 ARDS patients randomized to EVLW-guided management vs. PAOP-guided management Mitchell JP et al., Am Rev Respir Dis 1992

Advanced ICU monitoring Lung water for estimating the risk of volume expansion?  functional benefit of lung water monitoring 25 20 15 Management of fluid therapy with : * * 10 PAOP Group 5 EVLW Group Ventilation days ICU days 101 ARDS patients randomized to EVLW-guided management vs. PAOP-guided management Mitchell JP et al., Am Rev Respir Dis 1992

Advanced ICU monitoring Lung water for estimating the risk of volume expansion Lung permeability Lung water very high permeability normal permeability high permeability lung water lung water Pcap Pcap

pulmonary blood volume Advanced ICU monitoring Lung permeability for estimating the risk of volume expansion? PVPI lung water pulmonary vascular permeability index = pulmonary blood volume cold bolus PiCCO EV1000

Advanced ICU monitoring Lung permeability for estimating the risk of volume expansion? PVPI 1 2 3 4 5 6 7 8 9 10 48 patients with pulmonary edema inflammatory vs. hydrostatic discriminated by experts PVPI by the PiCCO device Cut-off : 3 Se = 85 % Sp = 100 % * ALI/ARDS Hydrostatic pulmonary edema

Advanced ICU monitoring Lung permeability for estimating the risk of volume expansion? ARDS AP = 90 / 40 mmHg Cardiac index = 2.0 L/min/m2 PaO2/FiO2 = 180 mmHg PLR test : positive ARDS AP = 90 / 40 mmHg Cardiac index = 2.0 L/min/m2 PaO2/FiO2 = 180 mmHg PLR test : positive PVPI = 4 PVPI= 7 volume expansion volume expansion vasopressors?

Advanced ICU monitoring Lung permeability for estimating the risk of volume expansion? PA catheter PiCCO EV 1000 cardiac output cardiac output cardiac output PAOP PPV, VVE, PLR test, EEO test PPV, VVE, PLR test, EEO test SvO2 ScvO2 ScvO2 lung water and lung permeability lung water and lung permeability

!   Differents monitoring devices Different indications AP CVP PAC PiCCO Nexfin ProAQT/PulsioFlex Esophageal Doppler FloTrac/vigileo Echo  Differents monitoring devices !  Different indications

  OR monitoring ICU monitoring Basic monitoring Advanced monitoring Arterial pressure CVP Esophageal Doppler Flotrac/Vigileo Pulsioflex LidCOrapid PiCCO EV 1000 PA catheter