2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Should I bother about Ebb and Flow phase of shock?
(What did I learn last year)
17th November 20122nd iFAD– Interactive Case Discussion
Manu Malbrain
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Disclosure• The speaker consults for the following
companies:– KCI– Pulsion Medical System– ConvaTec– Edwards– Fresenius- Kabi
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Therapeutic Dilemma - ConflictKidney
Heart
Lung Liver
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Today’s Agenda• The risks of fluid overload• Interactive Case Discussion• Meta-analysis• 3-hit model• Integrated approach• Wrap it up
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Fluid Overload
The Risk of Fluids
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
What I really need to know is…
❶When do I start giving fluids?
❶When do I stop giving fluids?
❶When do I start emptying?
❶When do I stop emptying?
SEEMORETHANOTHERS
benefit of fluid administration?
risk of fluid administration?
benefit of fluid removal?
risk of fluid removal?
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
• Any measurement in the ICU stands or falls with its accuracy and reproducibility…
• No measurement has ever improved survival, only a good a protocol can…
Introduction
Hemodynamic treatment algorithms should follow physiology or they fail to improve
outcome. Malbrain Manu and Reuter Daniel – CCM 2012;40:2923
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Example of a Poor Protocol…
Trof RJ et al. CCM 2012; 40
EVLWI < 10
Fluid Challenge
GEDVI < 850
We must NOT give a fluid challenge
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
788694
SURGICAL
SEPTIC
GEDVI < 850 ml/m2 is too high
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Ebb Phase of SHOCK
“Ashen faces, a thready pulse and
cold clammy extremities…”
The Ebb Phase - Cuthbertson, Quart. J. Med.25:233,1932
Flow Phase of SHOCK
“The patient warms up, cardiac output increases and the
surgical team relaxes…”
The Flow Phase - Cuthbertson. Lancet 1:233, 1942
Fluid Guidance:MAP, SVV, PPV,
GEF/GEDVI, PLR, TEO
Fluid Guidance:Positive (Σ) Fluid
balance, IAP, EVLWI
EVLWI is NOT a trigger for Fluids
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Septic Shock Patients (n=36)
Alsous et al. Chest 2000; 117: 1749-54
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
No excess extra-pulmonary organ failure
Better lung function:- LIS↓- FiO2/pO2
↑- Pplat ↓- PEEP ↓
RCCT, N=1000
Cum FB: -136±494 ml
Cum FB: 6992±502 ml
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Case Study
From Ebb to Flow phase
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
LI, Male, 26 years old
• O2 debt during birth• CVA, left hemiparesis• Epilepsy
− Topamax, lamictal, tegretol• Cognitive deficit• Special daycare• Since age of 17 known with
ideopathic CMP (LVEF 52%)− Coversyl
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Reason for admission
• General seizures− Different from previous
• Syncope• BP not palpable• On ED: VT?
− DC biphasic 200J• Transfer to ICU
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Evolution Overnight• Hemodynamically stable• No seizures• Gradual increase in supplemental
O2-needs– From 2L via nasal cannula– To 15L with NRM
• Failure of NIV• ETT and MV
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
After ETT• Hemodynamically Unstable
– CVP 16 mmHg– MAP 51 mmHg
• On conventional MV– Evita XL FiO2 100%– 24 x 400 mL– PEEP 10– P/F ratio 74
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Transthoracic Cardiac US
LVEF 30% MR 2 to 3/4
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
TT Cardiac US
• Dilated CMP (Left atrium 65mm)• CO: 6.2 L/min (CI 3.5)• LVEF: 30-35%, FAC: 28.5%• LVEDA: 28.7 cm2 – LVEDAi: 16.2 cm2• E/E’: 15 - LVEDP: 25 mmHg• MR 2 to ¾ (central + 2 eccentric jets)• VCI: 21 mm
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Question 1: What is your treatment of choice?
1. Norepinephrine2. Dobutamine3. Fluids bolus4. Diuretics5. Other
MAP 59
CVP 16
CI 3.5
LVEDP
25
LVEF 30
LVEDA
28.7
P/F 74
IPAP 30
PEEP
10
Lactate 2.8
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Further course…
• Norepinephrine was started– Swiftly increased to 0.4 y
• Dobutamine started at 3y• FiO2 was increased to 100%• PEEP set according to PV loop
– BPsys drop to 40 mmHg during recruitment
• Saturation poor at 88%• Switch to HFPV – VDR4
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
PiCCO catheter - TPTD• CI: 3.5• PPV: 19%• GEDVi: 757 ml/m2 – GEF: 13%• EVLWi: 38 ml/kg PBW – PVPI: 7.4• PLR = POSITIVE (15% increase in CI)
Normal Values:PPV: <10 %GEDVI: 600 – 850GEF: 25-35% EVLWI: 3 – 7 PVPI: 1 – 3
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
MAP 65
CVP 15
PPV 19
CI 3.5
GEF 13
GEDVi
757
EVLWi
38
P/F 57
IPAP 34
PEEP
15
1. Norepinephrine2. Dobutamine3. Fluids bolus4. Diuretics5. Other
HFPV30/10
Question 2: What is your treatment of choice?
Normal Values:PPV: <10 %GEDVI: 600 – 850GEF: 25-35% EVLWI: 3 – 7 PVPI: 1 – 3
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Decision Tree..
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
General Question• How do you explain the relative discrepancy
between the volumetric (low normal – GEDVi 757) and barometric (high normal – CVP 14) preload indicators in this patient?
• Remember that the SSC guidelines state that CVP must be resuscitated towards 8-12 mmHg
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
• CVP: 8-12 mmHg• Chasing a CVP may
lead to:→ OVER resuscitation→ UNDER resuscitation
Surviving Sepsis GuidelinesIAP11
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
• Don’t trust traditional BAROmetric filling pressures (CVP or PAOP)
• Use Volumetric preload indicators (GEDVI: PiCCO/EV1000 or RVEDVI: PAC)
Barometric vs Volumetric preload?
Malbrain et al. Current Opinion Crit Care 2004; 10(2): 132-145
MV-IPPV(auto)PEEPPost CABGObesityIAH-ACS
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Surviving Sepsis Guidelines
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Crit Care Med 2008; 36:296-327[published correction in Crit Care Med 2008; 36:1394-1396]
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Surviving Sepsis Guidelines
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
TT Cardiac US
• Small volume resuscitation (SVR): Hyperhaes 4ml/kg/15min
• 2x 500ml Volulyte
IVCCI= 50%
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Next morning
Dobu 9
Norepi 0.4
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Evolution overnight
• CI h
• GEDVI h
• EVLWI i
• MAP h
CVP decreased from 14 to 6 mmHg with filling
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Respiratory Support overnight
HFPV NO(stand-by)
• pO2 h • P/F h• FiO2 i• IPAP h
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
P/F 157
IPAP 32
PEEP
11
EVLWI
13
PVPI 2
Next morning on Day 2
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Therapeutic Dilemma…We gave fluids because:• PPV was high and PLR was positive• The GEDVI was relatively low (in relation
to GEF) despite the increased CVP, LVEDAI and high EVLWI…
• IVCCI was almost 50%
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
So,…What I really need to know:
• What is the Frank Starling curve of my patient?
• Where is my patient on the curve?
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
• When to use?
Solution: GEF-corrected GEDVi
Malbrain M. et al. AAS 2010; 54(5): 622-631
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
LVED area on TTE
LVEDA 34cm2 28cm2
?
After 30% blood loss of CBV
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
EF corrected volumes? GEF 0.15
GEF 0.25
GEF 0.35
Cardiac INDEX
GED
VI
Malbrain, Cheatham. Yearbook Intensive Care 2004
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Pressures as preload?
ΔCVP ΔPCWP
ΔC
I
X
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Volumes as preload?
ΔRVEDV
ΔGEDV
ΔC
I
X
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Corrected volumes vs preload?
ΔcRVEDVΔcGED
V
ΔC
I ✓
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Question 3: The premature hump on the transpulmonary thermodilution curve is…
1. Crosstalk phenomenon2. Bolus mixing3. Right-to-left shunt4. Wrong/false measurement5. I don't know
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Premature hump = Hypovolemia
Septic shock 100% FiO2 – PEEP 12 – extremely underfilled
Pulmonary Hypertension Before filling (at 8:40)
after filling with 500mL Voluven (at 9:02)
GEDVi : 288 GEDVi : 537
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Right-to-Left shunt on TPTD
RA LARV LVPBV
EVLW
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
ZEEP
PEEP
PEEP
Michard F et al. CCM 2004 Jan;32(1):308-9.
Our patient became extremely hypotensive during recruitment
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
•West Lung ZonesZONE 1: Palv > Part >
Pven
ZONE 2: Part > Palv > Pven
ZONE 3: Part > Pven > Palv
❶
❷
Hypovolemia
High PEEP
❶
Right-to-Left Shunt
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Evolution late afternoon D2• Urine output only 350 over 12 hours…• FiO2 increased from 45% to 65% (P/F 200)• Lactate increased from 1.6 to 2.6• Cumulative FB +4L
MAP 79
CVP 8
PPV 6
CI 5.4
GEF 23
GEDVi
1080
EVLWi
18
P/F 205
IPAP 34
PEEP
11
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Question 4: What is your treatment of choice?
1. Norepinephrine2. Dobutamine3. Fluids bolus4. Diuretics5. Other
MAP 79
CVP 8
PPV 6
CI 5.4
GEF 23
GEDVi
1080
EVLWi
18
P/F 205
IPAP 34
PEEP
11
Dobu 5
Norepi 0.2
Normal Values:PPV: <10 %GEDVI: 600 – 850GEF: 25-35% EVLWI: 3 – 7 PVPI: 1 – 3
PEEP 18Alb 20%
Lasix
3x100mlHyperHaes
2x125ml
60mg/hrFor 2hrs10mg/hr
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Chest X-ray D3
P/F 266
IPAP 34
PEEP
18
EVLWI
15
PVPI 1.9
Dobu 3
Norepi 0.11
Alb 20%
Lasix
2x100ml
40mg bolus
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
P/F 295
IPAP 30
PEEP
6
EVLWI
12
PVPI 1.7
Dobu 1
Norepi STOP
HFPV
When the going gets tough,The tough get going
BUT…Chest X-ray D4
Evita
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Chest X-ray evolution
P/F 98
IPAP 30
PEEP
6
EVLWI
16
PVPI 2.1
P/F 308
IPAP 34
PEEP
19
EVLWI
12
PVPI 1.7
D5 D6
HFPV
PEEP 19
Lasix 10mg/hrcontinuously
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Chest X-ray evolution
D7 D8
P/F 355
IPAP 32
PEEP
10
EVLWI
10
PVPI 1.5
P/F 358
IPAP 26
PEEP
6
EVLWI
8
PVPI 1.3
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
General Question• How do you explain the drop in EVLWI from 38
to 13 ml/kg PBW after the initial resuscitation phase, while GEDVI increased from 757 to 921 ml/m2?
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
QUESTION 5: What is correct regarding a positive cumulative fluid balance in septic shock?
1. Peripheral edema may look frightening for the relatives but it is just of cosmetic concern
2. Fluid balance must initially always be positive for a successful resuscitation of shock
3. Patients don’t die form anasarc edema they only die from organ failure
4. A cumulative fluid balance is always a biomarker of severity of illness
5. A positive fluid balance is harmful and an independent predictor for morbidity and mortality.
6. None of the above
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
D7D5 D6
D4D2D1
D0
D3
D1
122638 18
81216 10
D8
NIVEvita XLHFPV
D5
38
ICU day
EVLWIfurosemide
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Daily and Cumulative Fluid Balance
Lasix Furosemide
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
EVLWI-GEDVI evolution
Filling
Diuretics
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Fluid Overload
Meta-Analysis
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
• AIFR: adequate initial fluid resuscitationWithin 6 hrs from start pressors, fluids up to CVP> 8 mmHg
Murphy et al. Chest 2009;136;102-109
survivors
non-survivors
non-survivors
survivors
• CLFM: conservative late fluid management Within 7 days after start shock: neg FB on 2 consecutive days
Retrospective, N= 212 septic ALI patients
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Summary of Findings: 40 studies• 1 meta analysis• 10 RCCT (4 blinded)• 7 interventional studies• 28 observational studies• 4 case series• A total of 23625 critically ill patients• In 23 studies IAP was measured
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
1 Fluid Balance and OutcomeSurvivor
s SD n
Non-survivor
s SD n delta FBAlsous 2000 Jun 50 400 16 2400 1700 20 -2350Cordemans 2011 3419 7842 70 6982 9875 44 -3563Cordemans 2011 123 4971 7737 58 9503 6910 65 -4532Goldstein 2005 457 403 60 805 858 56 -348Kuzkov 2006 Apr 18 893 668 16 1782 750 15 -889Malbrain 2005 Feb 1643 1500 192 6214 2143 73 -4571Malbrain META 2011 3862 6904 314 5994 7546 413 -2132Murphy 2009 Jul 9250 625 125 15875 1125 87 -6625Rosenberg 2009 Jan-Feb
5154 769 159 10308 1923 635-5154
Schuller 1991 250 1600 43 2000 2800 26 -1750Shum 2011 880 2320 505 5410 5050 134 -4530Simmons 1986 7500 4090 11 17220 2045 26 -9720Vidal 2008 Jun 2100 3900 34 16100 6400 49 -14000mean Fluid Balance 3109,9 2981,4 1603,0 7737,9 3778,8 1643,0 -4628,0Standard Deviation 2928,5 2848,3 5716,0 3011,1 3777,0
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
2 Fluid Balance and InterventionInterven
tion SD N control SD N Delta FBCordemans 2011 126 8180 57 9902 5863 57 -9776Balogh 2003 Jun 6857 1000 71 12286 2143 85 -5429Brandstrup 2003 3240 2000 69 6888 4000 72 -3648Martin 2002 Oct -3300 1000 19 500 1000 18 -3800Martin 2005 Aug -5480 4384 20 -1490 5480 20 -3990Mc Ardle 2009 2570 977 9 8242 714 11 -5672Mitchell 1992 142 3632 52 2239 3695 49 -2097O'Mara 2005 May 12300 9300 16 22100 12800 15 -9800Oda 2006 14474 4202 14 23369 5393 22 -8895Rivers 2001 Nov 8 8625 5162 130 10602 6216 133 -1977Stewart 2009 -4115 825 122 4651 917 122 -8766The SAFE Study 2004 422 1633 2190 553 1732 2182 -131Wiedemann 2006 -136 491 503 6992 502 497 -7128mean Fluid Balance 2748,1 3291,2 3272,0 8218,0 3881,2 3283,0 -5469,9
Standard Deviation 6186,1 2884,5 7700,9 3415,6 3202,3
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
2 Forest Plot (FB – Outcome)
Restrictive1443/6488 =
22.2%
Liberal1859/6384 =
29.1%
P<0.0001
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Fluid Overload
3 Hit ModelFluid Toxicity
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Dilemma…
• Patients don’t die from anasarca they die from MOF…
Dry lungs are happy lungs
A dry liver isA dead liver
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
• Pinsky M. Chest 2007;132;2020-2029• Hemodynamic Evaluation and Monitoring in the ICU
Anasarca = Cosmetic?
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
First Hit FLUIDSLife saving
TREATMENTEarly Goal Directed
MONITORINGMAP, lactate,
diuresis, ScvO2, PPV, SVV
FLUID BALANCEEarly adequate
Acute inflammatory insultTrauma, Infection, Burns, Sepsis, Bleeding
SIRSSytemic proinflammatory cytokine release,
activation RES, reactive O2 species
Mircocirculatory dysfunction, vasodilata-tion, capillary leak, loss of autoregulation
Distributive shock: Ebb PhaseHypotension/hypovolemia/oliguria
Myocardial depressionInterstitial edema formation
Tissue hypoxia/increasing lactate levels
EBB = dangerous
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Second HitFLUIDS
Biomarker for critical illness
TREATMENTConservative fluid
strategy
MONITORINGFunctional
hemodynamics vs EVLWi, IAP
FLUID BALANCEEquilibration
Ischemia-ReperfusionOrgan Dysfunction: MODS• Acute Lung Injury
→ PO2/FiO2↓, EVLWi↑• Acute Bowel Injury
→ secondary IAH/ACS• Acute Kidney Injury
→ serum creatinine↑, diuresis↓• Liver failure• Nervous system failure
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
EvolutionTREATMENT
of the initial insult and organ support
Shock ReversalSystemic cytokine homeostasisCapillary leakage closure: CLI↓Intravascular volume repletionHemodynamic + renal recovery
Flow Phase: fluid mobilization
Increased diuresis, edema clearance, EVLWi↓: weaning of
ventilation
Unresolved ShockPro>Anti-inflammatory cytokines
Capillary leakage persistence: CLI↑, Increasing organ failure
THIRD HITMalbrain et al. ICM 2008;34(9):1565 - CCM
2009; 37:365
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Third Hit FLUIDSToxic
TREATMENTLate Goal Fluid
Removal
MONITORINGMAP, IAP, APP,
EVLWi, Renal, PDR
FLUID BALANCENegative
Lung Edema
Gut EdemaAIPS
Kidney Edema
ALI IAH/ABI AKI
ARDS ACS/AIDS ATN
Peripheral Edema
Cerebral Edema
Rhabdo
ECS
ICH
Brain death
GlobalIncreased
PermeabilitySyndrome
FLOW = hazardous
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
HIT
Monitor
Fluids
Goal
FB
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Fluid Overlad
An Integrated Approach
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
PALPAL
PEEP ALBUMIN
N=114 MV patients
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
PAL
IAP change
PAL
P/F change
PAL
EVLWi change
PAL
Cumulative FB
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Kaplan Meier curves
PAL
PAL
SURVIVAL MECHANICAL VENTILATION
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Impact of fluid kineticsData on 180
patientsEA defined as fluid intake > 50ml/kg/1st 12-24 hours
LC defined as 2 negative daily FB within 1st week
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Fluid Overload
Wrap It Up
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
What I really need to know
❶When do I start giving fluids?
❶When do I stop giving fluids?
❶When do I start emptying?
❶When do I stop emptying?
SEEMORETHANOTHERS
benefit of fluid administration?
risk of fluid administration?
benefit of fluid removal?
risk of fluid removal?
GEF/GEDVi↓ PPV↑ PLR+
GEF/GEDVi↑ PPV↓ PLR-
EVLW↑/PVPI↑ IAP↑/APP↓ FB+
ICG-PDR↓ APP↓ ScvO2↓ FB--
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Moving Targets…
1st HITMAP, SVV, PPV, ScvO2
2nd HITP/F, EVLWi,
IAP3rd HIT
PVPI, ICG-PDR
Moving Goals…EAGD LGFR
LCFM
Give the right fluid rightUse the right monitor right
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Although…
Sometimes it’s better to have a lucky doctor than a smart doctor !
But…
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
It’s always better trying to do something
even if you don’t succeed than doing
nothing and succeed
However…
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Doing some kind of monitoring will preserve your
knowledge basis
Therefore…
RELAX I only have 3 statements left…
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
Therefore…
RELAX I only have 3 statements left…
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
XAVIER!
Once upon a time in Paris…
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
WGAP Meeting at ESICMACS Workshop at ISICEM
2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
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2nd iFAD 17/11/2012 Should I bother about Ebb and Flow phase of shock
1st IFAD huge succes: 450 att
3rd
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