prof. xavier monnet

Prof. Xavier MONNET

Medical Intensive Care UnitBicêtre Hospital

Assistance publique – Hôpitaux de ParisFRANCE

Assessment of fluid therapy

Use the right tool for the right job!

Conflict of interest

Pulsion Medical Systems

Prof. Xavier MONNET

Medical Intensive Care UnitBicêtre Hospital

Assistance publique – Hôpitaux de ParisFRANCE

Assessment of fluid therapy

Use the right tool for the right job!

APCVP

PiCCO

EsophagealDoppler

Echo

ProAQT/PulsioFlex

PAC

FloTrac/Vigileo

Nexfin

Differents monitoring devicesDifferent indications ?

Peri-op monitoring

ICU monitoring

Pe

ri-op

mon

itorin

g

Context

Goals of monitoring

Improves prognosis

to detect hemodynamic deterioration

to guide volume expansion

High-risk surgical patients (except cardiac surgery)

Peri-

op m

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60 patients hip replacement

hospital length of stay

100 high-risksurgical patients

hospital length of stay

174 patients post cardiac surgery

hospital length of stay

162 multiple trauma patientsafter surgery

hospital length of stay ICU length of stay lactate levelPe

ri-op

mon

itorin

g Improves prognosis with esophageal Doppler

60-risk general surgical patientsGoal directed therapy vs. conventional treatmentPost-operative phase

Peri-

op m

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number of complications hospital length of stay

120 high-risk abdominalsurgery patientsSVV-directed therapy vs. conventional treatmentPer-operative phaseLidCO monitoring

number of complications hospital length of stay

Improves prognosis with LidCO

40 patients with hip replacement under regional anesthesiaGoal directed therapy vs. conventional treatment

Peri-

op m

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number of complications

Improves prognosis with Flotrac/Vigileo

Vigileo Eso Doppler

preloaddependance

(Δ aortic blood flow)

preload(FTc)

Pulsioflex

preloaddependance

(VVE and Δ PP)

preloaddependance

(VVE and Δ PP)

LidCOrapid

preloaddependance

(VVE and Δ PP)

continuouscardiac output

continuouscardiac output(cardiac output)(AP curve

analysis)

continuouscardiac output(AP curve analysis)

continuouscardiac output(AP curve analysis)

Peri-

op m

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ring

Arterial pressure

Esophageal Doppler

Flotrac/VigileoPulsioflex

LidCOrapid

PA catheter

CVP

PiCCOEV 1000

ICU monitoringOR monitoring

Basic monitoring Advanced monitoring

Context

Objectives of monitoring

initial phase of shock

after the ER

assess the hemodynamic profile (type of shock)

guide initial therapy

fix some therapeutic goals

Which basic monitoring?Basic

ICU

mon

itorin

g

Basic

ICU

mon

itorin

g

Helps for :Helps for:

determining the type of shock(preload)

guiding fluid responsiveness(preload)

CVP Arterial pressure

deciding to give vasopressors

deciding to give fluid(if ventilated)

fixing some therapeutic goals

Basic

ICU

mon

itorin

g

DAP

PPV

MAP

Arterial pressure

Esophageal Doppler

Flotrac/VigileoPulsioflex

LidCOrapid

PA catheter

CVP

PiCCOEV 1000

ICU monitoring

OR monitoring

Basic monitoring Advanced monitoring

?

?

The only arterial pressure and CVP monitoring is not sufficient anymore

critically ill patients

Context

because patients receive vasopressors

Adva

nced

ICU

mon

itorin

g

when shock persists after initial fluid therapy

r = 0.56n = 228

r = 0.21n = 145

*

-50 0 50 100 150 200 250 300-50

0

50

100

150

200

250

300

Changes in CI induced by VE (%)

Changes in PPinduced by VE (%)

-50 0 50 100 150 200 250 300-50

0

50

100

150

200

250

300

Changes in CI induced by NE (%)

Changes in PPinduced by NE (%)

228 pts receiving volume expansion145 patients with increase of NE

Adva

nced

ICU

mon

itorin

g

-20

0

20

40

60

80

100

non responders responders

changes in CI (%)

-20

0

20

40

60

80

100

non responders responders

changes in PP (%)

+15%

6% false +

228 pts receiving volume expansion145 patients with increase of NE

22% false -

Adva

nced

ICU

mon

itorin

g

Adva

nced

ICU

mon

itorin

gVigileo Eso Doppler

preloaddependance

(Δ aortic blood flow)

preload(FTc)

Pulsioflex

preloaddependance

(VVE and Δ PP)

preloaddependance

(VVE and Δ PP)

LidCOrapid

preloaddependance

(VVE and Δ PP)

continuouscardiac output

continuouscardiac output(cardiac output)(AP curve

analysis)

continuouscardiac output(AP curve analysis)

continuouscardiac output(AP curve analysis)

continuouscardiac output

AP curve analysis

uncalibrated

continuouscardiac output

AP curve analysis

uncalibrated

continuouscardiac output

AP curveanalysis

uncalibrated

20

40

60

80

100

120

0

= k . SV

Uncalibrated devices

estimate SV from the arterial pressure curve

estimate arterial compliance by analysing the arterial waveform

?still valuable when the properties of the arterial curve

change in a large extent (sepsis, vasopressors)

Which device for advanced monitoring?Ad

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3.5 L/min

PiCCO and EV1000 devices measure cardiac output by

arterial pressure curveanalysis

Which device for advanced monitoring?Ad

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PiCCO and EV1000 devices measure cardiac output by

inj

Blood temperature (Ts)

Ttm

cold bolus

calibrated by

transpulmonarythermodilution

arterial pressure curveanalysis

Which device for advanced monitoring?Ad

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Vigileo2

PiCCO

calibratedcardiac index

uncalibratedcardiac index

changes induced byvolume expansion (40 patients)

changes induced bynorepinephrine (40 patients)

Ability to track

Which device for advanced monitoring?Ad

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-15 0 15 30 45 60 75

-15

0

15

30

45

60

75

D CItd (%)

r = 0.78p < 0.05

PiCCO

r = -0.03p = NS

-15 0 15 30 45 60 75 90 105 120

-15

0

15

30

45

60

75

90

105

120

D CItd (%)

Vigileo2

Changes induced by

norepinephrine

Changes induced by

volume expansion

PiCCO

r = 0.72p < 0.05

-15 0 15 30 45 60 75 90 105 120

-15

0

15

30

45

60

75

90

105

120

D CIp

c (%

)

DCItd (%)

Vigileo2

r = 0.33p < 0.05

-15 0 15 30 45 60 75 90 105120

-15

0

15

30

45

60

75

90

105

120

D CIp

w (%

)

D CItd (%)

Which device for advanced monitoring?Ad

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51 pts, 401 measurementsVigileo2 vs.Vigileo3 vs. PAC

Vigileo3 is more accurate and as precise than Vigileo2

Which device for advanced monitoring?Ad

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33 patientsVigileo3 vs. esophageal DopplerHemodynamic challenges by phenylephrine, ephedrine and whole-body tilting

Which device for advanced monitoring?Ad

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ed IC

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PA catheter

Which device for monitoring cardiac output?

PiCCO EV 1000

cardiac output cardiac output cardiac output

Adva

nced

ICU

mon

itorin

g

Context

Goals of monitoring

predict fluid responsiveness

precisely monitor the effects of therapy

fix some therapeutic goals

when shock persists after initial fluid therapy

assess the risk of fluid expansion

critically ill patients

Adva

nced

ICU

mon

itorin

g

PA catheter PiCCO EV 1000

cardiac output cardiac output cardiac output

SvO2ScvO2 ScvO2

How to assess the need for fluid?Ad

vanc

ed IC

U m

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ring

Context

Goals of monitoring

predict fluid responsiveness

precisely monitor the effects of therapy

fix some therapeutic goals

when shock persists after initial fluid therapy

assess the risk of fluid expansion

critically ill patients

Adva

nced

ICU

mon

itorin

g

PA catheter PiCCO EV 1000

cardiac output cardiac output cardiac output

PAOP

SvO2ScvO2 ScvO2

How to assess the need for fluid?

PPV, SVV,PLR test, EEO test

PPV, SVV,PLR test, EEO test

Adva

nced

ICU

mon

itorin

g

How to assess the need for fluid?Ad

vanc

ed IC

U m

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EV 1000PA catheter PiCCO

cardiac output cardiac output cardiac output

PAOP

SvO2ScvO2 ScvO2

How to assess the need for fluid?

PPV, SVV,PLR test, EEO test

PPV, SVV,PLR test, EEO test

continuous continuous

Adva

nced

ICU

mon

itorin

g

venous return

How to assess the need for fluid?Ad

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34 patients with acute circulatory failuremonitored by PiCCO device

-10

0

10

20

30

40

50

Effects of end-expiratory pause

on cardiac index

increase 5%Se = 91%Sp = 100 %

How to assess the need for fluid?Ad

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ed IC

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RNR

How to assess the need for fluid?Ad

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ed IC

U m

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Context

Goals of monitoring

predict fluid responsiveness

precisely monitor the effects of therapy

fix some therapeutic goals

when shock persists after initial fluid therapy

assess the risk of fluid expansion

critically ill patients

Adva

nced

ICU

mon

itorin

g

EV 1000PA catheter PiCCO

cardiac output cardiac output cardiac output

PAOP

SvO2ScvO2 ScvO2

PPV, SVV,PLR test, EEO test

PPV, SVV,PLR test, EEO test

lung waterand lung permeability

lung waterand lung permeability

How to assess the risk of volume expansion?Ad

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ed IC

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Pcap

lung water

normal permeability

very high permeability

Pcap

lungwater

How to assess the risk of volume expansion?

high permeability

Adva

nced

ICU

mon

itorin

g

Lung permeability

Lung water for estimating the risk of volume expansion?

Pcap

Lung water

normal permeability

very high permeability

Pcap

lungwater

lungwater

high permeability

Lung permeability

Adva

nced

ICU

mon

itorin

g

Cold bolus

PiCCO EV1000

Lung water for estimating the risk of volume expansion?Ad

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ed IC

U m

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validation in human beings→

Lung water for estimating the risk of volume expansion?

30 ptsEVLW measured by TPTD and by postmortem gravimetry

First validation of EVLW-TPTD evaluation in humans

Adva

nced

ICU

mon

itorin

g

Lung water for estimating the risk of volume expansion?Ad

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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

0

20

40

60

80

100

EVLWImax > 21 mL/kg EVLWImax ≤ 21 mL/kg

70%

42%

p = 0.0001

Day-28 mortality (%)

p value

Maximal blood lactate 0.81 (0.71 - 0.93) 0.002Mean PEEP 1.25 (1.07 - 1.47) 0.005

EVLWI max 0.94 (0.87 - 0.98) 0.01

SAPS II 0.97 (0.95 - 0.99) 0.02Mean fluid balance 0.9996 ( 0.9993 - 0.9999) 0.02Minimal P/F ratio 1.01 (1.00 - 1.02) 0.02Minimal pH 35.97 (0.47 - 2769.52) 0.10

Odds Ratio ( CI 95%)

200 pts with ARDSEVLW measured by PiCCO device

Lung water for estimating the risk of volume expansion?

submitted

Adva

nced

ICU

mon

itorin

g

PAOP group

EVLW group

Time (hours)

Cumulative fluid balance (input - output; L)7

3

1

5

-1

-3

-50 12 24 36 48 60 72

***

*

* p < 0.0001 vs time 0

Mitchell JP et al., Am Rev Respir Dis 1992

101 ARDS patientsrandomized to EVLW-guided management vs.PAOP-guided management

Lung water for estimating the risk of volume expansion?Ad

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0

5

10

15

20

25

Ventilation days ICU days

PAOP Group

EVLW Group

* * Management of fluid therapy with :

functional benefit of lung water monitoring

Mitchell JP et al., Am Rev Respir Dis 1992

101 ARDS patientsrandomized to EVLW-guided management vs.PAOP-guided management

Lung water for estimating the risk of volume expansion?Ad

vanc

ed IC

U m

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Lung water for estimating the risk of volume expansion

Pcap

Lung water

normal permeability

very high permeability

Pcap

lungwater

lungwater

high permeability

Lung permeability

Adva

nced

ICU

mon

itorin

g

lung water

cold bolus pulmonary blood volume

pulmonary vascularpermeability index =PVPI

PiCCO EV1000

Lung permeability for estimating the risk of volume expansion?Ad

vanc

ed IC

U m

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0123456789

10PVPI

ALI/ARDS Hydrostaticpulmonary edema

*

Cut-off : 3

Se = 85 %

Sp = 100 %

48 patients with pulmonary edemainflammatory vs. hydrostatic discriminated by expertsPVPI by the PiCCO device

Lung permeability for estimating the risk of volume expansion?Ad

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PVPI = 4 PVPI= 7

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

volume expansion volume expansion

vasopressors?

Lung permeability for estimating the risk of volume expansion?Ad

vanc

ed IC

U m

onito

ring

PA catheter PiCCO EV 1000

cardiac output cardiac output cardiac output

PAOP

SvO2ScvO2 ScvO2

PPV, VVE,PLR test, EEO test

PPV, VVE,PLR test, EEO test

lung waterand lung permeability

lung waterand lung permeability

Lung permeability for estimating the risk of volume expansion?Ad

vanc

ed IC

U m

onito

ring

APCVP

PiCCO

EsophagealDoppler

Echo

ProAQT/PulsioFlex

PAC

FloTrac/vigileo

Nexfin

Differents monitoring devicesDifferent indications !

Arterial pressure

Esophageal Doppler

Flotrac/VigileoPulsioflex

LidCOrapid

PA catheter

CVP

PiCCOEV 1000

ICU monitoring

OR monitoring

Basic monitoring Advanced monitoring