1. 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

2. Conflict of interest
Pulsion Medical Systems

3. 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

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

6. Peri-op monitoring  
Peri-op monitoring
ICU monitoring

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

8. 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

9. 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

10. 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

11. 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)

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

13. 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?

14. Basic ICU monitoring

15. 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

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

17. 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

18. 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 (%)

19. 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 -

20. 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)

21. ? 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) ?

22. 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

23. 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

24. 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

25. 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 (%)  

26. 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

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

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

29. 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

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

31. 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

32. 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

33. Advanced ICU monitoring
How to assess the need for fluid?

34. 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

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

36. 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

37. Advanced ICU monitoring
How to assess the need for fluid?

38. 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

39. 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

40. 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

41. 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

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

43. 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

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

45. 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 =
Day-28 mortality (%)
p value
Maximal blood lactate
0.81
( )
0.002
Mean PEEP
1.25
( )
0.005
EVLWI
max
0.94
( )
0.01
SAPS II
0.97
( )
0.02
Mean fluid balance
0.9996
( )
Minimal P/F ratio
1.01
( )
Minimal pH
35.97
( )
0.10
Odds Ratio ( CI 95%)

46. 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 < vs time 0 -5
Time (hours)
101 ARDS patients
randomized to EVLW-guided management vs.
PAOP-guided management
Mitchell JP et al., Am Rev Respir Dis 1992

47. 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

48. 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

49. 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

50. 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

51. 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?

52. 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

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

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