Making the Case for Stroke Volume Variation:

A Tool for Fluid Optimization

Jan M. Headley, RN, BSDirector, Strategic Alliances &

Professional EducationEdwards Lifesciences

Irvine , Ca

Does this Patient NEED Fluid??

ScvO2

CCO

WE Have a Problem…

Identified Problem• Volume expansion 1st line of therapy.• Only ½ of patients show an increase in CO as a

response to fluid therapy. (Defined as responders)

• Need a reliable means to be able to determine the patients ability to respond to fluid.

Teboul 2003:

An Editorial Review

Pressure Based Parameters• Issues: CVP and PAOP poor predictors of fluid

statusKumar CCM 2004

Pressures do not predict fluid responsiveness

• Osman, et al. CCM 2007 • Cardiac filling pressures

did not predict fluid responders from non-responders.

Dynamic Preload Predicting Parameters

• Dynamic preload parameters such as SPV and its delta up or down, PPV and SVV are better predictors of preload responsivenessthan static indices.

Teboul

SPV, PPV, SVV Defined • All measure the difference between the

maximum and minimum values over a full respiratory cycle. – SPV: Systolic Pressure Variation (mmHg):

• SPMax – SPMin Normal < 10 mmHg– PPV: Pulse Pressure Variation (%):

• PPMax – PPmin/ PP mean Normal <13%– SVV: Stroke Volume Variation (SVV%):

measured over the 20 second cycle. • SVMax – SVMin/SV mean Normal < 15 %

JMHeadley 2007 AACN NTI News

SVV: The Basic Formula

Preload Responsiveness: SVV

Predicting SVI changes >= 5%, CI > 15% Michard 1999 & Cannesson 2009

Pulsus Paradoxus: The Origin of SVV

• Pulsus Paradoxus is the origin of SVV value.– Occurs with spontaneously

breathing patients.• Reverse Pulsus Paradoxus

– Occurs during positive pressure ventilation.

• Clinical use of this phenomenon remains “marginal”.

Michard Anesthesiology 2005

Dynamic Response to Preload

• During each respiratory cycle a “virtual” preload challenge occurs.

• Therefore, variations in the tidal volumes during a breath can impact the next systolic pressure.Parry-Jones

Stro

ke V

olum

e

Preload

P

SV

SVV 28%

SVV 10%

SVV 8%

Patient A

Patient B

F- S Curve for Preload Responsiveness

• Patient A is preload responsive– On steep portion of the curve– Fluid bolus produces large

increase in SV– SVV > 10 – 15 %

• Patient B is not preload responsive – On flat portion of the curve– Fluid bolus does not produce

the same amount of increase in SV

– SVV < 10 – 15%

Modified Concepts from Parry-Jones, Michard, et al.

Patient B

Patient A

Two Major Indications of SVV:• 1. evaluate the response to fluid

interventions

• 2. determine or predict the patient’s potential response to fluid therapy

• If variability is low, need for fluid low• If variability is high, need for fluid is high

Michard 2005, Teboul 2003

Fluid Responsive??

Parameter Normal Fluid Responsive

SPV mmHg 5 mmHg >10 mmHg

PPV % < 13% >13%

SVV % <10 % > 10 - 15%

Useful but has some limitations

• Some potential limitations:– Arrhythmias– Spontaneous breathing– Varied ventilator

delivered tidal volumes • “However, this does not

represent a true limitation of the interpretation of large SVV as an indicator of fluid responsiveness”Teboul

Chest 2002;121;1245-1252

PLR??

PassiveLeg Raising45 °

PassiveLeg Raising45 °

• 150 – 300 ml volume• Effects < 30 sec.. Not more than 4 minutes

• Self-volume challenge• Reversible

PLR Effects on Starling Curve

• If the increase in cardiac preload induced by PLR induces significant changes in SV (a to b), the patient will likely be fluid responsive

• If the same changes in cardiac preload during PLR do not significantly change SV (a’ to b’), the heart is likely preload independent and should not be administered

Monnet 2007

How to Perform a PLR

• Pivot bed automatically (in some beds) •Trunk is tilted supine, lower limbs raised to 45° angle •Angle between the trunk and lower limbs remains unchanged (135°)

PassiveLeg Raising45 °

Semi-Fowler’s Passive

Leg Raising45 °

Semi-Fowler’s

Monnet 2007, artwork from www.medtrng.com

Time 2 pm

Temp 36.8HR 88 MAP 90CVP 10CCI 2.5Hb 10.4SaO2 100%SV 44SVV 18%

62 y/o female, Post AoVR

Is the SV Adequate?

SV – SVV F-S Curve

High values SVV (PLR) Low values

4418%

High values

SV

Low values

Time 2 pm 2:15 pm

Temp 36.8 36.4HR 88 81MAP 90 86CVP 10 12CCI 2.5 3.2Hb 10.4 10.4SaO2 100% 100%SV 44 55SVV 18% 13%

62 y/o female, Post AoVR Post Fluid Bolus

Is the SV Adequate?

SV – SVV F-S Curve

High values SVV (PLR) Low values

4418%

5513%

High values

SV

Low values

Time 2 pm 2:15 pm 2:45 pm

Temp 36.8 36.4 36.5HR 88 81 80MAP 90 86 85CVP 10 12 11CCI 2.5 3.2 3.4Hb 10.4 10.4 10.4SaO2 100% 100% 100%SV 44 55 62SVV 18% 13% 11%

62 y/o female, Post AoVR Post Fluid Bolus

Is the SV Adequate?

SV – SVV F-S Curve

High values

SV

Low values

High values SVV (PLR) Low values

4418%

5513%

6211%

SVV: Pre PLR

SVV 22%SV/SVI 46/22CO/CI 3.9/2.1

Simulated data

SVV: Post PLR

• SVV 14% • SV/SVI 63/35• CO/CI 4.8/2.8

Simulated data

So did this patient need fluid?

JMHeadley 2007 AACN NTI News

Making the Case for Stroke Volume Variation: A Tool for Fluid Optimization

CAUTION: Federal (United States) law restricts this device to sale by or on the order of a physician. See instructions for use for full prescribing information, including indications, contraindications, warnings, precautions and adverse events.

Jan Headley is an employee of Edwards Lifesciences. Any quotes used in this material are taken from independent third-party publications and are not intended to imply that such third party received or endorsed any of the products of Edwards Lifesciences.

As a member of the Advanced Medical Technology Association ("AdvaMed"), Edwards Lifesciences strictly adheres to the requirements of the AdvaMed Code of Ethics regarding interactions with health care professionals. Edwards Lifesciences wishes to disclose that all speakers, instructors and panel members will receive compensation and reimbursement of reasonable travel expenses from Edwards Lifesciences for their services in full compliance with all applicable laws, rules and regulations, including the AdvaMed Code of Ethics.

Edwards, Edwards Lifesciences, the stylized E logo, FloTrac and Vigileo are trademarks of Edwards Lifesciences Corporation. All other trademarks are the property of their respective owners.

EV1000 clinical platform currently available in the US exclusively for clinical investigation.

©2011 Edwards Lifesciences Corporation. All rights reserved. AR06193