Prof.Mehdi H MUMTAZ

FLUID THERAPY ;It is the first weapon in the armoury of physcian to counter hypovolaemia or shock; ;Uncorrected hypovolaemia with use of vasopressors may lead to critical organ hypoperfusion and ultimately ischaemia;

WHY FLUIDS ? BALANCE O 2 Delivery O 2 Demand By making adjustments Cardiac preload After load M.contractility Confirm;- MVO 2, Lactate,Base deficit

FLUID THERAPY CELL CAPILLARY EG OSMOLALITY Na + COP INTRACELLULARINTERSTITIAL VASCULAR

FLUIDS IVSISSICS 1L 5% Dextros 5/42 X 1000 = 120ml 14/42 X 1000 = 333ml 23/42 X 1000 = 547ml 1L Nacl 0.9% 5/19 X 1000 = 263ml 14/19 X 1000 = 737ml - 1L Colloid containing solution 5/5 X 1000 = 1000ml --

PHYSIOLOGICAL PRINCIPLES ;Frank – Starling principle; Preload Left ventricular SV Overlap of actin and myosin myofibrils

Increasing Preload Increasing Contractility Preload decrease Induced by mechanical inspiration Resulting PPV PRELOAD Stroke volume or pressure

Heart-Lung Interactions IPPV RV Preload Cyclic changes After load LV In loading conditions

Blood Pulmonary Transit Time Systolic Pressure Pulse Pressure Aortic Blood Velocity minimum during the expiratory period Systolic Pressure Pulse Pressure Aortic Blood Velocity Maximum at the end of inspiratory period RV Preload RV Afterload LV Afterload RV Ejection LV Ejection Pleural Pressure LV Preload Trans- pulmonary Pressure LV Preload LV Ejection

WHAT ARE THE TECHNOLGIES ?  CLINICAL ASSESSMENT  CVP Catheterisation  SWAN GANZ Catheterisation  TRANS-OESOPHAGEAL DOPPLER ( TOD)  LiDCO  PiCCO

What are the Parameters ? Static ParametersDynamic Parameters  CVP  PAOP  LVEDA  IVC Diameter  ITBV, GEDV  SVV and PPV  Pulse oximeter pleth wave  Dynamic changes in aortic flow velocity/stroke volume  SVC Collapsibility index

STATIC Parameters, CENTRAL VENOUS Pressure ;Traditional guide; ;Marker of RV Pre-load; ;Also marker of LV preload if no dissociation between RV and LV. ;No good if on CMV

STATIC PARAMETERS  CENTRAL VENOUS PRESSURE Blood brought to Heart 1 C.contractility 3 Venous tone 2 Absolute B.V.

Static PARAMETERS CENTRAL VENOUS PRESSURE Normal Low High BP N Low hyper volaemia HR N High increased T.V. TEMP N Cold Decreased M.Contra.

STATIC PARAMETERS CENTRAL VENOUS PRESSURE VENOUS TONE INTRATHORACIC PRESSURE R & L Ventricular compliance& Geometry Relationship between CVP & RVEDV less accurate CVP Still used widely,even in guidelines for SSC bundles

STATIC PARAMETERS 2, PULMONARY ARTERY OCCLUSION P ( PAOP) Indicator of LV Preload Limitations like CVP Measure LVEDP not LVEDV Shows overestimate transmural P in; a,Ventilated with PEEP b,Who generate PEEPi

STATIC PARAMETERS 3.LEFT VENTRICULAR END-DIASTOLIC AREA (LVEDA) ; Measured by TOE ; Assess LV dimensions ; Corelates with LVEDV and as such LV Preload ; Single use TOE probe for 72 hours

STATIC PARAMETERS 4.INFERIOR VENA CAVA DIAMETER ; Measured by subcostal ECHO ;Indirect indicator of CVP ;Limitations of CVP ;Collapsibility index= IVC D at end inspiration –IVC D end expiration ________________________________________ IVC D at end expiration Values above 18% predicts efficacy of volume expansion with 90% sensitivity and 90% specificity

WHAT about IVC D limitations 1, IPPV Maximum D during inspiration Minimum D during expiration 2, In surgical patients with raised IAP 3, Obese patients 4, Major abdominal surgery

STATIC PARAMETERS Intrathoracic Blood Volume (ITBV) Global endiastolic volume (GEDV) PiCCO used for assessment Mathematical analysis of transpulmonay thermodilution curve,ITBV INDEX,GEDV INDEX Good estimate of I/V volume & preload

LiDCO Technology Haemodynamics

PiCCO Technology Measure all the parameters

What is PiCCO Technology? Combination of two techniques for; Adnanced haemodynamic management Volumetric management 1, Transpulmonary Thermodilution 2,Arterial pulse contour analysis

Advantages of Technique ? Thermodilution parameters CO GEDV ITBV EVLW Pulse contour parameters PCCO SVR SVV

PiCCO Technology

B DYNAMIC PARAMETERS 1, Pulse pressure variation (PPV) Stroke volume variation (SVV) Measured by LiDCO or PiCCO Pulse Pressure (SP—DP ) LV Stroke VOL Arterial compliance

DYNAMIC PARAMETERS PPV / SVV ;Predicts individual patients position on starling curve; This is independent of ;- 1 Ventricular function 2 Compliance of lung 3 Pulmonary pressures

DYNAMIC PARAMETER 2 Pulse Oximeter Plethysmographic Waveform :This wave form differs from Arterial wave form by measuring wave volume rather than pressue changes in both arteries and veins; Respiratory variations corelate with those of PPV,and can predict fluid responsiveness PVI as accurate as SVV

DYNAMIC PARAMETERS 3. Dynamic changes in aortic blood flow velocity/stroke volume assessed by ECHO ; Assuming aortic annulus diameter is constant over the respiratory cycle,the changes in the aortic blood flow should reflect changes in left ventricular stroke volume,so fluid responsiveness is predictable; TOE; trained person,continous use, draw back;Oessophageal stricture,upper GIT surgery

DYNAMIC PARAMETERS 4, Superior vena cava collapsibility index Measured by TOE ;SVC collapsibility index more reliable IVC distensibility index;

ASSESSMENT OF VOLUME OVERLOAD  CLINICAL  X-Ray Chest  EVLW  Dynamic observation, :Triad: EVLW Preload Offers accuracy Preload responsiveness

CONCLUSION  Dynamic parameters are superior to static parameters.  PPV/SVV appears to be ideal tool to guide fluid management in ICU,Pt on CMV.  Studies are required to define protocols for peri operative fluid management.  Studies are required to assess the benefits of these tools in spontaneous breathing Pts.  Our target;Balance O2 supply & O2 demand.

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