Nurse Driven Fluid Optimization Using Dynamic Assessments

2016

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WHAT WE BELIEVE

We believe that clinicians make vital fluid and drug decisions every day with limited and inconclusive information

Cheetah believes that with a complete hemodynamic profile, clinicians are empowered to make decisions better…leading to improved outcomes

We believe Cheetah’s accurate, precise and non-invasive technology can help you optimize your patients fluid and perfusion status

2 Decisions Made Better

Careful management of intraoperative fluids can greatly enhance patient outcomes4

Volume overload in septic patients is associated with an increased risk of mortality1,2

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WHY VOLUME MATTERS

FLUID IMBALANCE CAN LEAD TO SERIOUS CONSEQUENCES Every patient has unique and constantly changing hemodynamic needs Understanding a patient’s volume status throughout their care is a challenge clinicians face every day Serious complications are associated with both under- and over-resuscitation of a patient, including

organ failure and death

SEPSIS / SHOCK

SURGERY (ERAS)

References:1. Shoemaker W et al. Tissue oxygen debt as a determinant of lethal and nonlethal postoperative organ failure. Crit Care Med 1988; 16:1117-1120.2. Vermeulen H et al. Intravenous fluid restriction after major abdominal surgery: A randomized blinded clinical trial. Trials 2009; 10:50.3. Rivers E et al. Early goal directed therapy in the treatment of severe sepsis and septic shock. NEJM 2001; 345:1368-1377.4. Gustafsson UO et al. Enhanced Recovery after Surgery Society. Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations. Clin Nutr. 2012; 31:783-800.5. Corcoran T et al. Perioperative Fluid Management Strategies in Major Surgery: A stratified meta-analysis. Anesth Analg 2012; 114:640-651.6. Boyd J et al. Vasopressin in Septic Shock Trial (VASST). Critical Care Medicine 2011; 39:259-265.7. Vincent JL et al. Sepsis in European ICU: Results of the SOAP Study. Critical Care Med 2006; 34:344-353.8. Kelm D et al. Fluid overload in patients with severe sepsis and septic shock treated with early goal directed therapy is associated with increased acute need for fluid-related medical interventions and hospital death. Shock 2015; 43:680-73.

Too Little Fluid1,2,3

[Hypovolemia]Tissue HypoperfusionTissue HypoxiaOrgan FailureInsufficient Perfusion

Too Much Fluid4,5,6,7,8

[Hypervolemia]Tissue EdemaOrgan FailureIncreased ICU/Ventilator DaysIncreased Mortality

HEMODYNAMICS – THE SCIENCE OF BLOOD FLOW

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HEMO BloodDYNAMICS Flow

Optimized Hemodynamics Enables Perfusion

Perfusion is critical for life –delivery of oxygen, nutrients, and

toxin removal at tissue level

#1 Driver TissuePerfusion

HOW DO WE CURRENTLY MEASURE PERFUSION?

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Physiology

O2 Delivery

SvO2

Blood Pressure

MAP > 65SBP > 90

Urine Output

BioMarkers

Critical Care Is About Optimizing Hemodynamics

DRAWBACKS TO USING PRESSURE TO ASSESS VOLUME

Pulmonary Wedge Pressure

Central Venous Pressure

Δ Pressure * Compliance = Δ Volume

For pressure to accurately reflect volume …… compliance must remain constant

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OPTIMIZING HEMODYNAMICS

IV FluidPRELOAD

InotropesCONTRACTILITY

VasopressorsVasodilatorsAFTERLOAD

Cardiac Function

Volume

Peripheral Resistance

Adequate Perfusion

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BREAKTHROUGH TECHNOLOGY MAKES THE DIFFERENCE

4 non-invasive sensor pads are applied to the thorax, creating a ‘box’ around the heart

A small electric current of known frequency (75kHz) is applied across the thorax between the outer pair of sensors

A voltage signal is recorded between the inner pair of sensors

The flow of blood in the thorax introduces a time delay or phase shift in our signal

We have correlated these signal changes to known thermodilution cardiac output

– 65,000 patient samples in multiple clinical settings (ICU/OR/Cath Lab)

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Phase Shift

DYNAMIC ASSESSMENTS

WHAT ARE THEY?

– Directly challenging the heart with volume to see the response

– Ideal for assessing fluid responsiveness

– Provides continuous feedback of volume response after an intervention

– May answer the following key questions regarding your patient:

“Will additional IV fluid increase cardiac output?”

“Will additional IV fluid optimize perfusion?”

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ASSESSING FLUID RESPONSIVENESS

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Passive Leg Raise Bolus Challenge Trending Therapy

METHODS OF FLUID BOLUS

Before Therapy During Therapy

FRANK-STARLING LAW

METHODS TO ASSESS VOLUME – DYNAMIC ASSESSMENT

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Reversible challenge ~ 300cc of acute volume High sensitivity & specificity Positive change in SVI of ≥ 10% is predictive of an increase in

Cardiac Output Pro: Reversible Con: Contraindicated in certain patient populations

Passive Leg Raise

Will Fluid Increase Stroke Volume?

METHODS TO ASSESS VOLUME – DYNAMIC ASSESSMENT

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Bolus Challenge

Reliable Rapid infusion of 250cc over 3-5 minutes High sensitivity /specificity Positive change in SVI of 10% or greater is predictive of an

increase in CO and therefore flow Pro: Reliable Con: Irreversible

Will Fluid Increase Stroke Volume?

METHODS TO ASSESS VOLUME

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Trending Therapy

Minute-to-minute Information Assess Therapeutic Response Identify Early Trends Pro: Real Time / Continuous Con: None!

Will Fluid Increase Stroke Volume?

WHO IS A CHEETAH PATIENT?

Shock States:Severe Sepsis/Septic ShockHypovolemicCardiogenicNeurogenic

Other Conditions characterized by hemodynamic instabilityCongestive Heart Failure (CHF)Acute Respiratory Distress Syndrome (ARDS)Acute Kidney Injury/Renal Insufficiency (AKI)Subarachnoid Hemorrhage (SAH)

Care Pathways and ProtocolsERAS & Perioperative Goal Directed Fluid TherapyCMS Severe Sepsis and Septic Shock Bundle (NQF #0500, SEP-1)Surviving Sepsis CampaignEmergency/Trauma

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Any patient where you ask yourself:

“Will additional IV fluid increase cardiac output and optimize perfusion?

CHEETAH SCENARIO – SEPTIC PATIENT

42 year old male, paraplegic with large wound to coccyx, admitted

with septic shock

Pt had already received 6L fluid over night, however remained on

low-dose Levophed that was unable to be weaned down further

CVP reading 8-10, UOP >30mL/hr, MAP 55-60

Cheetah monitor placed on patient to assess if more volume is

needed as they were unable to wean the Levophed

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Time

SVI (ml/m2/beat)

Patient placed back

in semi-recumbent

position

Start of PLR

STROKE VOLUME INDEX CHANGE

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Passive Leg Raise #1

≥ 10% change in SVI, patient is likely fluid responsive

PLR indicated patient was likely fluid responsive. 1 Liter LR was ordered to be given and PLR to be repeated after

infusion complete.

Notice that CI increases with PLR (this is not always the case!)

RESULTS AND ORDERS

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1:23:21 PM1:24:21 PM1:25:21 PM1:26:21 PM1:28:11 PM1:29:11 PM1:30:11 PM1:32:07 PM1:33:07 PM1:34:07 PM1:35:08 PM1:36:08 PM1:37:08 PM

Time

SVI (ml/m2/beat)

Passive Leg Raise #2

Patient placed back in semi-recumbent position

Start of PLR

REPEAT PASSIVE LEG RAISE

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Passive Leg Raise #2

< 10% change in SVI, patient unlikely to be fluid responsive

PLR indicated patient was unlikely fluid responsive. Pt was able to be weaned off of Levophed following the 1 Liter LR infusion.

Minimal change in CI compared to previous test (11.3%)

RESULTS AND OUTCOME

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SUMMARY

Volume matters

Perform guided fluid resuscitation to optimize organ perfusion, oxygenation and prevention of organ failure

Determine fluid responsiveness by means of simple, nurse-driven dynamic assessments

Use of hemodynamics at the bedside by nurses can help to drive differential diagnosis and treatment of shock states

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