What is the best surrogate marker

for adequate volemic ressuscitation?for adequate volemic ressuscitation?

Porto, 2010

Maizel Julien

Medical ICU, Amiens, France

Right ventricule

Left ventricule

Absolute hypovolemia Relative hypovolemia

Always decreased preload and stroke volume

Septic shock

Septic shock = relative hypovolemia

≠ absolute hypovolemia

Always LV preload and stroke volume decreased

Volume expension

Always LV preload and stroke volume decreased

When do i stop volume

resuscitation?resuscitation?

SSC, CCM 2008

Volemia

≠

Fluid responsiveness

Does volume expension will provoke an increase of stroke volume ?

How to explore fluid

responsiveness?

• Clinical findings

• Biology• Biology

• Echocardiography•Static parameters•Dynamic parameters

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

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 %%

Chakko S, Am J Med 1991

Biology

Renal functionHaemoglobinProtidemiaHaematocrite

Poor diagnostic value

Haematocrite

Anguel, ICM 2008

Before weaningPAOP 14

Spontaneous breathing trialPAOP 24

H+1 after reventilationPAOP 12

Protidemia 58 Protidemia 66 Protidemia 60

Biology

Renal functionHaemoglobinProtidemiaHaematocrite

Poor diagnostic value

BNP ?

Pirrachio, CCM 2008

Pirrachio, CCM 2008

Clinical + Bio + Radio

Fluid responsiveness ?

Uncertain

Hemodynamic parameter

Certain

Fluid challengeVolume expension

Improvement WorsenedNo effect

Evaluation

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.

Stroke volumeStroke volume

PreloadPreload unresponsivenessunresponsiveness

PreloadPreload responsivenessresponsiveness

VentricularVentricular preloadpreload

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

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

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

NormalNormal

PreloadPreload--responsivenessresponsiveness

SVSV

Why static parameters are not predictive of fluid responsiveness?

PreloadPreload--unresponsivenessunresponsiveness

VentricularVentricular preloadpreload

Heart failure

Stroke volumeStroke volume

Dynamic parameters

VentricularVentricular preloadpreload

InsuflationInsuflation

Mechanical ventilationMechanical ventilation

Intrathoracic pressureIntrathoracic pressure

?

SVC collapsibility IVC Distensibility

?

SVC

Vieillard Baron ICM 2005

(VCImax – VCImin) / VCImin

>36%

IVC

Vieillard Baron ICM 2005

Feissel CCM2005

(VCImax – VCImin) / VCImin

>18%

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 ?

(PPmax – PPmin) / PPmean >12%

Michard AJRCCM 200

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%

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)

Spontaneous breathing

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

(Max – Min) / Mean ≥ 50% predict a RAP <10mmHg

Kircher Am J Cardio, 1990

Lever de jambe passif

Maizel, ICM 2007

•Dynamic > static

Conclusion

•Dynamic > static

•Non invasive > invasive

•Feasibility