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Whatisthe best surrogatemarker for adequate volemic ... · Microsoft PowerPoint - Julien Maizel -...
Transcript of Whatisthe best surrogatemarker for adequate volemic ... · Microsoft PowerPoint - Julien Maizel -...
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What is the best surrogate marker
for adequate volemic ressuscitation?for adequate volemic ressuscitation?
Porto, 2010
Maizel Julien
Medical ICU, Amiens, France
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Right ventricule
Left ventricule
Absolute hypovolemia Relative hypovolemia
Always decreased preload and stroke volume
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Septic shock
Septic shock = relative hypovolemia
≠ absolute hypovolemia
Always LV preload and stroke volume decreased
Volume expension
Always LV preload and stroke volume decreased
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When do i stop volume
resuscitation?resuscitation?
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SSC, CCM 2008
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Volemia
≠
Fluid responsiveness
Does volume expension will provoke an increase of stroke volume ?
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How to explore fluid
responsiveness?
• Clinical findings
• Biology• Biology
• Echocardiography•Static parameters•Dynamic parameters
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Clinical findings
YesConscious patient: tachycardia, postural dizziness (tilt), Hypotension + clinical context (trauma, blood loss)
Mc Gee, JAMA 1999
NoPatient intubatedProbability of 50% to predict fluid responsiveness based on clinical and static preload parametersHypoprotidemia, hepatopathy, right heart failure.
Teboul, Chest 2000
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CHEST 2002, 121:2000CHEST 2002, 121:2000--8 8
R / NRR / NR R R (%)(%)
Calvin Calvin (Surgery 81)(Surgery 81) 20 / 820 / 8 71 71 %%Schneider Schneider (Am Heart J 88)(Am Heart J 88) 13 / 513 / 5 72 72 %%ReuseReuse (Chest 90)(Chest 90) 26 / 1526 / 15 63 63 %%Magder Magder (J Crit Care 92)(J Crit Care 92) 17 / 1617 / 16 52 52 %%
MeanMean 211 / 195211 / 195 52 52 %%
Magder Magder (J Crit Care 92)(J Crit Care 92) 17 / 1617 / 16 52 52 %%Diebel Diebel (Arch Surgery 92)(Arch Surgery 92) 13 / 913 / 9 59 59 %%Diebel Diebel (J Trauma 94)(J Trauma 94) 26 / 3926 / 39 40 40 %%Wagner Wagner (Chest 98)(Chest 98) 20 / 1620 / 16 56 56 %%Tavernier Tavernier (Anesthesio 98)(Anesthesio 98) 21 / 1421 / 14 60 60 %%Magder Magder (J Crit Care 99)(J Crit Care 99) 13 / 1613 / 16 45 45 %%Tousignant Tousignant (A Analg 00)(A Analg 00) 16 / 2416 / 24 40 40 %%Michard Michard (AJRCCM 00)(AJRCCM 00) 16 / 2416 / 24 40 40 %%Feissel Feissel (Chest 01)(Chest 01) 10 / 910 / 9 53 53 %%
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Chakko S, Am J Med 1991
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Biology
Renal functionHaemoglobinProtidemiaHaematocrite
Poor diagnostic value
Haematocrite
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Anguel, ICM 2008
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Before weaningPAOP 14
Spontaneous breathing trialPAOP 24
H+1 after reventilationPAOP 12
Protidemia 58 Protidemia 66 Protidemia 60
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Biology
Renal functionHaemoglobinProtidemiaHaematocrite
Poor diagnostic value
BNP ?
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Pirrachio, CCM 2008
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Pirrachio, CCM 2008
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Clinical + Bio + Radio
Fluid responsiveness ?
Uncertain
Hemodynamic parameter
Certain
Fluid challengeVolume expension
Improvement WorsenedNo effect
Evaluation
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Predictive factors of fluid
responsiveness
Static parameterMeasured under a single ventricular loading condition
Dynamic parameterTry to detect a stroke volume variation under two different ventricular loading condition
Presumed to reliably estimate the preload
Assuming that lower preload increases the probability of FR
variation under two different preload condition.
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Stroke volumeStroke volume
PreloadPreload unresponsivenessunresponsiveness
PreloadPreload responsivenessresponsiveness
VentricularVentricular preloadpreload
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CVPCVPCVPCVP
Michard et al. Predicting fluid responsiveness in ICU patients. Chest 2002; 121: 2000Michard et al. Predicting fluid responsiveness in ICU patients. Chest 2002; 121: 2000--88
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Michard et al. Predicting fluid responsiveness in ICU patients. Chest 2002; 121: 2000Michard et al. Predicting fluid responsiveness in ICU patients. Chest 2002; 121: 2000--88
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1212
1414
1616
LVEDALVEDABefore volume expensionBefore volume expension
LVEDALVEDA
44
66
88
1010
1212
répondeursrépondeurs non répondeursnon répondeurs
(cm(cm22/m/m22))
Feissel M et coll, Chest 2001
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NormalNormal
PreloadPreload--responsivenessresponsiveness
SVSV
Why static parameters are not predictive of fluid responsiveness?
PreloadPreload--unresponsivenessunresponsiveness
VentricularVentricular preloadpreload
Heart failure
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Stroke volumeStroke volume
Dynamic parameters
VentricularVentricular preloadpreload
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InsuflationInsuflation
Mechanical ventilationMechanical ventilation
Intrathoracic pressureIntrathoracic pressure
?
SVC collapsibility IVC Distensibility
?
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SVC
Vieillard Baron ICM 2005
(VCImax – VCImin) / VCImin
>36%
IVC
Vieillard Baron ICM 2005
Feissel CCM2005
(VCImax – VCImin) / VCImin
>18%
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InsuflationInsuflation RV preloadRV preload
RV EjectionRV Ejection
Mechanical ventilationMechanical ventilation
RV EjectionRV Ejection
LV LV preloadpreload
2 to 3 cardiac cycles later2 to 3 cardiac cycles later
PulmonaryPulmonary transittransitinspirationinspiration
SedatedAdapted to ventilatorSinusalVt>7ml/KgSta > 0.15m/sec
Stroke volume variation ?
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(PPmax – PPmin) / PPmean >12%
Michard AJRCCM 200
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Après remplissage vasculaire
Avant remplissage vasculaire
DAM = 3.92 L/min
DAM = 2.30
30 L/min
30 L/min
1 sec
Oesophageal Doppler
Plethysmography
L/min∆DAM = 13%
L/min∆DAM = 39%
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A
(Max – Min) / Mean > 12% (Vmax Ao) and > 20% (VTI Ao)
B
Slama AJPHCP 2002Feissel Chest 2001
(Max – Min) / Mean > 12% (Vmax Ao) and > 20% (VTI Ao)
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Spontaneous breathing
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InsuflationInsuflation RV preloadRV preload
RV EjectionRV EjectionRV EjectionRV Ejection
LV LV preloadpreload
2 to 3 cardiac cycles later2 to 3 cardiac cycles later
PulmonaryPulmonary transittransitinspirationinspiration
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(Max – Min) / Mean ≥ 50% predict a RAP <10mmHg
Kircher Am J Cardio, 1990
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Lever de jambe passif
Maizel, ICM 2007
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•Dynamic > static
Conclusion
•Dynamic > static
•Non invasive > invasive
•Feasibility