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Hemodynamic MonitoringTo Guide Volume Resuscitation

Nick Johnson, MDActing Assistant Professor

Division of Emergency MedicineAttending Physician, Medical & Neuro-Intensive Care Units

Harborview Medical Center

No Conflicts of Interest

Objectives

1. To highlight a key challenge: excess volume can hurt patients, but so can tissue hypoperfusion.

2. To discuss the challenges of evaluating hemodynamic monitoring tools when there is no gold standard.

3. To review several endpoints for volume resuscitation and discuss their utility.

4. To discuss three interesting hemodynamic monitoring tools, which can be used in a variety of clinical settings.

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The Problem

Boyd CCM 2011 Sadaka J Int Care Med 2014

FACCT NEJM 2006

Elofson J Crit Care 2015 Shim J Crit Care 2014 Payan Crit Care 2008

Goldilocks Principle

The Gold Standard Conundrum

SUPPORT JAMA 1996Sandham et al. NEJM 2003Richard et al. JAMA 2003

PAC-Man Lancet 2005FACCT NEJM 2006

Cochrane Review 2013

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Preload

CardiacOutput

Yes

Responsiveness

Preload

CardiacOutput

Yes

No

Responsiveness

Endpoints

Tolerance

Responsiveness

Organ Perfusion

Patient-Centered Outcomes

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Upstream:IVC ultrasound

Downstream:End-tidal CO2

Mid-Stream:Pulse pressure variation

Point-of-Care Ultrasound (POCUS)

Spontaneously breathing

Gestalt

Mechanicallyventilated

“The IVC looks full or empty”

IVC Diameter or Percent Collapse

Estimate CVP

IVC collapse index or ∆IVC

VolumeResponsive

Spontaneously Breathing

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Spontaneously Breathing

Rudski et al. J Am Soc Echo. 2010.

IVC Size(cm)

Respiratory Change CVP (cmH20)

<1.5 Total collapse 0-5

1.5-2.5 >50% collapse 6-10

1.5-2.5 <50% collapse 11-15

>2.5 <50% collapse 16-20

>2.5 No change >20

Mechanically Ventilated

Barbier ICM 2004, Feissel ICM 2004

dIVC = Max-Min ≥ 18%Min

∆DIVC = Max-Min ≥ 12%Mean

All patients had tidal volume > 8 ml/kg

Pulse Pressure Variation

>12-15% ~ Fluid responsive

Musts:Mechanically ventilatedControlled modeNot triggeringTidal volume > 8ml/kgSinus rhythm

Michard AJRCC 2010, Michard Chest 2002, Lanspa Shock 2013

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Pulse Pressure VariationFlotrac/Vigileo

LiDCO Rapid with CNAP module

PiCCO

Pleth Variability

Feissel et al. Int Care Med 2007. Feissel et al. J Crit Care 2013. Natalini et al. Anesth Analg 2006. Cannesson et al. Anesthesiology 2007.

Pleth Variability

Feissel et al. Int Care Med 2007. Feissel et al. J Crit Care 2013. Natalini et al. Anesth Analg 2006. Cannesson et al. Anesthesiology 2007.

Respiratory variation > 12-15%

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End-Tidal CO2

Monnet ICM 2013

End-Tidal CO2

Monnet ICM 2013

Cardiac Index

Arterial pulse pressure

EtCO2

100-Specificity

Sen

sitiv

ity

End-Tidal CO2

Monnet ICM 2013

Cardiac Index

Arterial pulse pressure

EtCO2

100-Specificity

Sen

sitiv

ity Passive leg raise →

↑ EtCO2 ≥ 5% ~

↑ Cardiac index ≥15%

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Summary

1. Give the right amount of fluid, but not a drop more.

2. There is no gold standard hemodynamic monitor.

3. Endpoints: tolerance, responsiveness, perfusion, mortality?

4. A variety of monitoring tools exist, each with limitations. Use multiple tools along with your clinical judgement.

Thank you!

Nick Johnson, MDnickj45@uw.edu

@NickJohnsonMD

Additional References• Flotrac

– Review of 45 published studies:• Marik PE. J Cardiothorac Vasc Anesth 2013;27(1):121–34.

– 1st & 2nd generation devices• Slagt C, et al. Eur J Anaesthesiol 2015;32(1):5–12.• Compton FD, et al. Br J Anaesth 2008;100(4):451–6.• Hadian M, et al. Crit Care 2010;14(6):R212.• De Backer D, et al. Intensive Care Med 2011;37(2):233–40.• Monnet X, et al. Critical Care 2010;14(3):R109.

– 3rd generation devices• Machare-Delgado E, et al. J Intensive Care Med 2011;26(2):116–24.• Monnet X, et al. Br J Anaesth 2012;108(4):615–22.• Monnet X, Lahner D. Care Med 2011;37(2):183–5.

– OR setting• Benes J, et al. Crit Care 2010;14(3):R118.

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Additional References

• CNAP– Jeleazcov C, et al British Journal of Anaesthesia

2010;105(3):264-272.– Ilies C, et al. British Journal of Anaesthesia 2012;108

(2): 202–10– Jagadeesh A, et al. Ann. Card. Anaesth

2012;15(3):180-4..– Siebig S, et al. International Journal of Medical

Sciences 2009;6(1): 37-42– Ilies, H. et al. British Journal of Anaesthesia

2012;109(3): 413–19– Monnet X, et al . British Journal of Anaesthesia

2012Sep;109(3):330-8

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