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Hemodynamic MonitoringTo Guide Volume Resuscitation

Nick Johnson, MDActing Assistant Professor

Division of Emergency MedicineAttending Physician, Medical & Neuro-Intensive Care Units

Harborview Medical Center

Disclosures

No financial conflicts of interest

No industry relationships

Funding from NIH &Medic One Foundation

Disclosures

Objectives

1. Understand a conundrum: hypoperfusion can hurt patients, but so can excess volume.

2. Discuss the challenges of evaluating hemodynamic monitoring tools when there is no gold standard.

3. Review several endpoints for volume resuscitation and discuss their utility.

4. Highlight a few interesting hemodynamic monitoring tools that can be used in a variety of clinical settings.

Objectives

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The Problem

The Problem

Boyd CCM 2011 Sadaka J Int Care Med 2014

FACCT NEJM 2006

Elofson J Crit Care 2015 Shim J Crit Care 2014 Payan Crit Care 2008

Goldilocks PrincipleGoldilocks Principle

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The Gold Standard ConundrumThe Gold Standard Conundrum

The Gold Standard Conundrum

SUPPORT JAMA 1996Sandham et al. NEJM 2003Richard et al. JAMA 2003

PAC-Man Lancet 2005FACCT NEJM 2006

Cochrane Review 2013

The Gold Standard Conundrum

Endpoints

Tolerance

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Endpoints

Tolerance

Responsiveness

Preload

CardiacOutput

Yes

Responsiveness

Preload

CardiacOutput

Yes

No

Responsiveness

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Endpoints

Tolerance

Responsiveness

Organ Perfusion

Endpoints

Tolerance

Responsiveness

Organ Perfusion

Patient-Centered Outcomes

Upstream:Point-of-care ultrasound

Downstream:End-tidal CO2

Tissue O2 Saturation

Mid-Stream:Pulse waveform analysis

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Point-of-Care Ultrasound: Holistic Approach

Pre-test probability(history & exam)

UltrasoundHeart

Chamber size & function

LungB-lines

IVCTolerance

Post-test probability(Volume: yes/no)

Bedside Ultrasound: Cardiac

Strumwasser J Trauma ACS 2016.

Phenotype Parameters

Vasodilated/High-Output EF >70%, CI >3.5, LV/RV fullIVCd < 2cm, IVC∆ 25-50%

Hypovolemic“Hummingbird Heart”

EF >55%, CI <3.5LV/RV small IVCd <2cm, IVC∆ >50%

Normal x 3Function, Volume, Resistance

EF 55-70%, CI <2.5-4, LV/RV fullIVCd 1-2cm, IVC∆ 25-50%

Dysfunctional Heart EF ≤40%, CI <3LV/RV fullIVCd >2cm, IVC∆ <50%,

Lung UltrasoundLung Ultrasound: B-lines

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IVC: Spontaneously Breathing

IVC Ultrasound

Spontaneously breathing

Gestalt

Mechanicallyventilated

“The IVC looks full or empty”

IVC Diameter or Percent Collapse

Estimate CVP

Tolerance

Responsive

IVC distensabilityindex or ∆IVC

VolumeResponsive

IVC: Mechanically Ventilated

Barbier ICM 2004, Feissel ICM 2004

dIVC = Max-Min ≥ 18%Min

∆DIVC = Max-Min ≥ 12%Mean

All patients had tidal volume > 8 ml/kg

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Bedside Ultrasound: Holistic Approach

A-lines B-lines

Lee. J Crit Care 2016.

Upstream:Point-of-care ultrasound

Downstream:End-tidal CO2

Tissue O2 Saturation

Mid-Stream:Pulse waveform analysis

Pulse Waveform Analysis

Strumwasser J Trauma ACS 2016.

Pulse Waveform Analysis

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Pulse Waveform Analysis

Flotrac/VigileoLiDCO Rapid

Upstream:Point-of-care ultrasound

Downstream:End-tidal CO2

Tissue O2 Saturation

Mid-Stream:Pulse waveform analysis

End-Tidal CO2

Monnet ICM 2013

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End-Tidal CO2

Monnet ICM 2013

Cardiac Index

Arterial pulse pressure

EtCO2

100-Specificity

Sen

sitiv

ity Passive leg raise →

↑ EtCO2 ≥ 5% ~

↑ Cardiac index ≥15%with volume challenge

Tissue Oxygen Saturation

Cohn et al 2007, Moore et al 2008, Guyette et al. 2012, Beekley et al 2012, Vorwerk et al 2012

Inspectra StO2

Tissue Oxygen Saturation

Sen

sitiv

ity

1 - Specificity

Cohn et al 2007

Systolic Blood PressureStO2

Base Deficit

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Summary

1. Give the right amount of volume, but not a drop more.

2. There is no gold standard hemodynamic monitor.

3. Endpoints: tolerance, responsiveness, perfusion, mortality?

4. A variety of monitoring tools exist, each with limitations. Use multiple tools along with your clinical judgement.

Thank you!

Nick Johnson, MDnickj45@uw.edu

@NickJohnsonMD

Additional References• Flotrac

– Review of 45 published studies:• Marik PE. J Cardiothorac Vasc Anesth 2013;27(1):121–34.

– 1st & 2nd generation devices• Slagt C, et al. Eur J Anaesthesiol 2015;32(1):5–12.• Compton FD, et al. Br J Anaesth 2008;100(4):451–6.• Hadian M, et al. Crit Care 2010;14(6):R212.• De Backer D, et al. Intensive Care Med 2011;37(2):233–40.• Monnet X, et al. Critical Care 2010;14(3):R109.

– 3rd generation devices• Machare-Delgado E, et al. J Intensive Care Med 2011;26(2):116–24.• Monnet X, et al. Br J Anaesth 2012;108(4):615–22.• Monnet X, Lahner D. Care Med 2011;37(2):183–5.

– OR setting• Benes J, et al. Crit Care 2010;14(3):R118.

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Additional References

• CNAP– Jeleazcov C, et al British Journal of Anaesthesia

2010;105(3):264-272.– Ilies C, et al. British Journal of Anaesthesia 2012;108

(2): 202–10– Jagadeesh A, et al. Ann. Card. Anaesth

2012;15(3):180-4..– Siebig S, et al. International Journal of Medical

Sciences 2009;6(1): 37-42– Ilies, H. et al. British Journal of Anaesthesia

2012;109(3): 413–19– Monnet X, et al . British Journal of Anaesthesia

2012Sep;109(3):330-8

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Additional References

• Bioreactance– Squara P, et al. Intensive Care Med

2007;33(7):1191–4.

– Marik PE, et al. Chest 2013;143(2):364–70. – Saugel B, et al. Br J Anaesth 2015;114(4):562–

75. – Fagnoul D, et al. Crit Care 2012;16(6):460. – Han S, et al. PLoS ONE 2015;10(5):e0127981.

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