Goal - Directed Fluid Resuscitation Goal-Directed Fluid - PDF document

5/31/2014 “Goal - Directed” Fluid Resuscitation Goal-Directed Fluid Resuscitation Christopher G. Choukalas, MD, MS Christopher G. Choukalas, MD, MS Department of Anesthesia and Perioperative Care Department of Anesthesia and Perioperative Care University of California, San Francisco University of California, San Francisco Goal- Directed “Fluid Resuscitation” Goal-Directed Fluid Resuscitation Christopher G. Choukalas, MD, MS Christopher G. Choukalas, MD, MS Department of Anesthesia and Perioperative Care Department of Anesthesia and Perioperative Care University of California, San Francisco University of California, San Francisco 1

5/31/2014 The case for why it matters • Fluid balance a common concern • Patients with Sepsis who developed ALI • Sepsis • 4 groups: – Adequate initial + Conservative late fluids • ALI/ARDS – Adequate initial only • Sepsis PLUS ARDS! – Conservative late only – Neither It matters • So how do we do it? Murphry, CV , et al. 2009. Chest. 136(1) 2

5/31/2014 I would posit two factors: Hemodynamic Goals • Hemodynamic: • Blood pressure – Is the circulation adequate? • CVP • Metabolic • Dynamic respiratory indices: – Are oxygen delivery and utilization adequate? – Pulse pressure/systolic pressure/perfusion • Both have their own goals. index variation Hemodynamic Goals Blood pressure • Blood pressure • A proxy for flow, end organ perfusion • CVP • Flow = pressure/resistance • Dynamic respiratory indices: • Do we ever really KNOW resistance? – Pulse pressure/systolic pressure/perfusion index variation 3

5/31/2014 Wax, et al. • Non-cardiac cases with both ABP and NIBP. • Compared SBP, DBP, and MAP btwn technologies: – A-line alone vs A-line + cuff Randomized trials • This used to be the 2 nd joke of the talk 4

5/31/2014 Interesting review • Reviewed 2 trials and 1 meta-analysis (13 studies) – Target BP – Actual BP • Dissociation – BPs invariably higher than goal – Higher goal ranges permitted higher actual ranges:  pressors The NEJM study • Randomized to MAP 65 vs 85 (800 total) • Norepinephrine • Mortality • AKI/RRT, stratified by HTN 5

5/31/2014 Blood pressure • Necessary but not sufficient • Goals are nebulous • Supra-normal levels common, not helpful Hemodynamic Concept: assumptions • Blood pressure Normal CVP • CVP • Dynamic respiratory indices: Optimal actin-myosin match – Pulse pressure/systolic pressure/perfusion index variation Adequate contractility Adequate DO 2 6

5/31/2014 The data • Critical target in EGDT for sepsis • Incorporated into SSC guidelines Sepsis +  CVP = Death • Retrospective analysis of VASST trial – 778 pts w/ septic shock on NE • CVP at 12 hrs did predict 28-d mortality in patients: HR CVP < 8 0.61 CVP 8-12 0.76 CVP >12 1 Marik, PE, et al. 2008. Chest. 134(1) Boyd, JH, et al. 2011. CCM. 39(2) 7

5/31/2014 Fluid responsiveness and total Fluid responsiveness blood volume • Calculated a Receiver Operating • Volume responsiveness Characteristic curve • Cardiac output before and after fluid • Likelihood that at any given point (CVP challenge level, score, etc) the true positives will • 19 evaluated CVP and volume exceed false positives. responsiveness • Higher = better discrimination Volume responsiveness Deja vu • 43 studies, half ICU • Same design – AUC btwn CVP and ΔSV • Same pooled AUC – 0.56 • Same aggressive conclusion Marik, PE, et al. 2008. Chest. 134(1) 8

5/31/2014 CVP Hemodynamic • Necessary? • Blood pressure • Certainly not sufficient • CVP • Potentially misleading • Dynamic respiratory indices: – Pulse pressure/systolic pressure/perfusion index variation The Principles Applies to lots of measures • Systolic pressure variation • Pulse pressure variation • Plethysmogram variation • Outcome is “fluid responsiveness”  LV Preload  LV SV Decreased RV SV  RV Preload  RV Afterload 9

5/31/2014 Variations on a theme… The data • A waveform… • Small studies • A peak and trough… • Mostly OR • And a proprietary algorithm: SVV, Vigileo PVI, Masimo 40% MORE fluid 1/3 LESS fluid Lower lactate Lower lactate Fewer “complications” • 29 studies, 685 patients – 9 ICU Measure r AUC for ROC Threshold – 20 OR (15 in cardiac surgery) PPV 0.78 0.94 12.5% • All included correlation/ROC between SVV 0.72 0.84 15.3% SPV, PPV, or SVV and ΔSVI/CI after a SPV 0.72 0.86 CVP 0.56 fluid challenge. 10

5/31/2014 A great review… Now, keep in mind… • Alphabet soup • Regular HR – SVV, PPV, SPV, PVI • Sedated, mechanically ventilated – LidCO, PiCCO, esCCO, ProAQT • Vt = 8 mL/kg • Some require external calibration • Pressors? • Some require specific catheters in specific locations. PVI + NE = NEB Hemodynamic goals • Numerous • State of the art: Dynamic indices – PPV – SPV Monnet, et al Monnet, et al Biais, et al – PVI Population Population 35 ICU patients on NE 35 ICU patients on NE 35 ICU patients on NE – VTI and esophageal doppler Gold Standard Gold Standard TD TD PPV > 13% Sensitivity FR Sensitivity FR 43 43 58 100 • Necessary but not sufficient Specificity FR Specificity FR 90 90 61 72 AUC ROC AUC ROC 0.68 0.68 0.69 0.93 11

5/31/2014 Metabolic Metabolic • Mental status, urine output • Mental status, urine output • Lactate • Lactate • S(c)vO2 • S(c)vO2 Metabolic Lactate • Mental status, urine output • The product of anaerobic respiration • Lactate • Presence implies inadequate oxygen • S(c)vO2 utilization, shock • Easily, quickly measured in arterial blood 12

5/31/2014 Lactate: the data Two trials: • JAMA: 300 patients, EGDT vs lactate clearance – Non-inferiority • AJRCCM: 348 patients, EGDT vs lactate clearance – Improved mortality (multivariate) – Less time on vent, in ICU The underpinnings… How did they do it? Jones, et al (JAMA) Jansen et al (AJRCCM) Monitoring interval 2 2 Goal 10% clearance 20% clearance Fluid totals (L) Control: 4.3 Control: 2.2 Intervention: 4.5 ns Intervention: 2.7 * Outcome Non-inferiority to EGDT Decreased time on vent, in ICU 13

5/31/2014 Metabolic • Mental status, urine output • Lactate • S(c)vO2 How it’s used: DOGS  ScvO 2 attributed to:  Supply (cardiac output)  Demand (hypermetabolism) Changes in SvO2 and ScvO2 • In either case, treat by increasing DO 2 Humans w/ shock – Volume, inotropes, RBCs • But does it work? Humans w/ sepsis 14

5/31/2014 But does it work? The premise: • Conflicting data • Pts admitted to ICU w/ sepsis frequently have NL ScvO2 • Many – Still have evidence of hypoperfusion – Still die • 50 such patients – 26 Low gap Lactate – 24 High gap NL ScvO2 > A-V(CO2) 70 < 6 • The same on many measures: Lactate EGDT High – SOFA, APACHE II, pressor use ScvO2 < A-V(CO2) 70 >6 • Over 24 hrs, High gap exhibited hypoperfusion: – Persistent lactate – Higher SOFA 15

5/31/2014 Metabolic goals • Higher mortality • Lactate and ScvO 2 – 34% – Base deficit? – 54% (ns) – A-V (CO 2 ) gradient? – A-V (CO 2 ) cer gradient? • No specific therapy for gap • Physiological rationale meets objective • Authors recommend augmenting CO data. Does any of this… • Save lives? • Save money? • Actually work? 16

5/31/2014 Subgroup Mortality Complications Jadad high --- +++ Jadad low +++ +++ 1980s-1990s +++ +++ 2000s --- +++ 17

5/31/2014 Counted up outcomes • Randomized CT surgery patients to • Less norepinephrine – CVP and MAP • Higher CI, S cv O2 – SVV, EDV index (PiCCO), EVLW • Fewer post-op complications • Left the ICU and hospital a full day sooner • No difference in fluid totals, RBCs, UOP – Timing of fluid: More in the OR. 18

5/31/2014 Putting it all together: The end • Volume isn’t easy The End • Volume is important • Common conditions; competing goals • Stepwise plan – Hemodynamic – Metabolic • It seems to work 19