CHƯƠNG TRÌNH TỐI ƯU HÓA SINH LÍ SỬ DỤNG SVV & SI

measures of volume responsiveness Stroke Volume Variation SVV and Pulse Pressure. Variation PPV[r]

Fluid therapy!!



The Volume prescription Rx for the

Critically Ill and Injured

William T McGee, M.D., M.H.A

FCCM, FCCP

Intensivist Baystate Medical Center, Springfield, MA Associate Professor of Medicine and Surgery

Tufts University School of Medicine

Boston, MA

Relevant Disclosures

Edwards Lifesciences FloTrac/Vigileo/EV1000/ Clear

Sight

My cases; POPtm (free)

PICCOLIDCOEchoEsophageal DopplerRespirophasic change in SV

(SVV)SV

Important Disclosure

What I won’t be able to do in

25 minutes …

Hospital mortality according to whether or not patients achieved AIFR, CLFM, both, or neither.

Murphy C V et al Chest 2009;136:102-109

©2009 by American College of Chest

1 Volume management is the most

important part of care of the critically ill (volume management is important )

2 POP provides a simple physiology based

A critique of fluid bolus

resuscitation in severe sepsis

Andrew K Hilton & Rinaldo Bellomo

Critical Care 2012, 16:302

BAD Fluids!

Anything other than good for many of our sickest, most vulnerable patients

•The Question we ask on rounds every

day…

•Do we want to give more IVF?!?!?!?!?

•Is the patient fluid responsive?!?!?!?!?

Fundamentally, will fluid increase the

patient’s stroke volume and therefore

increase oxygen delivery?

Med Student Perspective

Fluid ?

Pressor ?

Diuretic ?

Nurse Perspective

DO2 = CO (CaO2)

What percentage of ICU patients are volume depleted

Volume therapy critical care

perspective: 1 question

What is the impact on cardiac performance? Requires a cardiac performance measure!

regarding Organ perfusion and function

Answer: Physiologic Optimization Program

(POP)

Is Volume Management

Important?

Do we need to get the volume

prescription right?

Goal

Relationship of Morbidity/Mortality toVolume Status for High-Risk Patients

Functional Hemodynamics

The Study and use of the cardiopulmonary interaction to assess physiology  Dynamic measures of volume responsiveness Stroke Volume Variation SVV and Pulse Pressure

Variation PPVChallenges, volume, PLR

Physiologic Basis of

Functional Hemodynamics

Ancient Chinese physicians

would assess a patient's pulse

for hours at a time to establish a

They could recognize more

than 200 different variations of

pulse based on volume,

strength, and regularity.

Pulse-doctrine

The increase of preload volume is equal: ∆ EDV 1 = ∆ EDV 2

starting point is not ∆ SV 1 >> ∆ SV 2

SV – SVV Mirrors Frank-Starling EDV – SV Relationship

Preload Increases from A to B

More variability SVV high

Preload

Sweet spot Goal

Less variability SVV low

SV/SVV pairs determine an individual’s position on their Starling Curve

Sweet spot: max benefit from preload s volume

overload!

Provides a Goal for volume therapy

A

B deresuscitation

For patients clinically diagnosed with

ARDS/ALI, what percentage have

hydrostatic; PCWP, pulmonary edema as

a contributing factor to their chest x-ray picture and A-a gradient (oxygenation

Distribution of Pulmonary-Artery–Occlusion Pressure (Panel A) and Central

Venous Pressure (Panel B) before Receipt of the First Protocol-Mandated

Instruction on Fluid Management.

The National Heart, Lung, and Blood Institute Acute Respiratory Distress

Syndrome (ARDS) Clinical Trials Network N Engl J Med 2006;354:2213-2224.

Many had hydrostatic pulmonary edema (30%) Likely preventable; CI≥nl 97%

PCWP ≥ 18

POP: Goals vs.

No Goals (Chaos)

● Simulation/standardization

● Practice and rehearsal!

● Athletes and musicians

PHYSIOLOGIC OPTIMIZATION PROGRAM USING SVV & SV

Assess impact on DO2

SI Normal: Pressor

Vasodilation, severe sepsis or septic shock

SI Low: Inotrope/Vasodilator

Low output state Echo?

SI High: Diuretic

Acute lung injury, ARDS, or previous massive resuscitation (wet lungs)

The clinical impression of non-volume

responsive patients along with the

stroke index directs therapy

When SVV doesn’t help

When SVV is not useful

Cardiac performance SV/CO

∆ CO/SV

SVV provides additional

information about volume

responsiveness limitations!

Give Fluids Assess Change in

May be problematic:

Renal FailureALI/ARDS

Passive leg-raising test consists of measuring the hemodynamic effects: ΔSV/CO of a leg

elevation up to 45o

45 o

Responders get fluid

Non responders don’t! Improvement in SV requires

other therapy

Teboul J-L and Monnet X Prediction of volume responsiveness in critically ill patients

with spontaneous breathing activity Curr Opin Crit Care 2008:14(3);337

45 o

Assessing DO2 adequacy

• SV cardiac performance measure: DO2

Individually assessed “adequate” baseline (OR)

or normal

• SVV volume responsiveness; α slope of F-S Curve: if actively giving fluids goal

Target: < 10-15% (13%)

CONCLUSION 2017 SVV/SV

Optimization of volume therapy saves lives! Manage volume therapy using physiology in both directions

SV

More variability SVV is high

Less variability SVV is low

Preload

Sweet spot GDT

No DO2 change Assess downsloping F-S curve