Noninvasive and Continuous Fluid Responsiveness Monitoring

with Pleth Variability Index (PVI)

PVI Overview

• Physiology

• Fluid administration challenges

• PVI method

• PVI clinical evidence

Physiology Background• Oxygen delivery components

• Cardiac output x oxygen saturation x hemoglobin

• Cardiac output components• Stroke volume

• Preload • Afterload (Systemic Vascular Resistance)• Contractility

• Heart rate

• Primary methods to increase cardiac output• Increase preload (volume expanders)• Increase contractility (inotropes)

• Decrease afterload (vasodilators)

• Key point• Administering volume may increase intravascular volume and

preload but not stroke volume and cardiac output

Preload

Stroke Volume

00

Frank-Starling RelationshipFrank-Starling Relationship

1 Perel A. Anesth Analg. 2008; 106 (4):1031-33 2 Bundgaard-Nielsen M et al. Acta Anaesthesiol Scand. 2007; 51(3):331-403 Michard F et al. Chest. 2002; 121(6):2000-08 4 Joshi G et al. Anesth Analg. 2005; 101:601-5

Fluid Administration Challenges

• Fluid administration is critical to optimizing oxygen delivery by optimizing cardiac output 1

• Unnecessary fluid administration may be harmful2

• Traditional methods to guide fluid administration often fail to predict fluid responsiveness• Accurate only 50-60% of time 3

• Newer dynamic methods that can predict fluid responsiveness are invasive, complex, and/or costly 4

• Many patients are not candidates for this level of monitoring

Pleth Variability Index (PVI)

• Masimo PVI is clinically proven to help clinicians assess fluid responsiveness and improve fluid management to reduce patient risk.1,2

• Once your Masimo Pulse CO-Oximeter is enabled with PVI-monitoring capability, PVI is automatically displayed for every patient receiving pulse oximetry monitoring

1 Cannesson M et al. Br J Anaesth. 2008;101(2):200-6. 2 Forget P et al. Anesth & Anal. 2010;111(4):910-4.

Pulse Pressure Variation and Changes in PPW During Ventilation

Ventilatory Cycle

Adapted from: Cannesson M et al

PPWmax

PPWmin

Arterial Pulse Pressure Variation

PPmax- PPmin

(PPmax + PPmin) ÷ 2

ΔPP =

Pleth Waveform Variation

PPWmax – PPWmin

(PPWmax + PPWmin) ÷ 2ΔPPW =

• Automated measurement• Changes in plethysmographic waveform amplitude over the

respiratory cycle• PVI is a percentage from 1 to 100%:

• 1 - no pleth variability • 100 - maximum pleth variability

PVI Calculation

2011 Radical-7

Preload

Stroke Volume

00

Higher PVI = More likely to respond to fluid administration24 %

10 % Lower PVI = Less likely to respond

to fluid administration

PVI to Help Clinicians Optimize Preload / Cardiac Output

Maxime Cannesson, MD, PhD

PVI to Help Clinicians Assess Fluid Responsiveness During Surgery: Similar to Arterial Pulse Pressure /

Superior to CI, PCWP, CVP

Adapted from Cannesson M. et. al. Br J Anesth 2008;101(2):200-206

PVI to Help Clinicians Assess Fluid Responsiveness During Surgery:Similar to Stroke Volume Variation / Superior to CVP

Zimmermann M, et al. Eur J Anaesthesiol. 2010;27(66):555-561.

CO

PPV

PVI

PVI to Assess Fluid Responsiveness in the ICUSimilar to Pulse Pressure Variation / Superior to Cardiac

Output

Loupec T et al. Crit Care Med 2011 Vol. 39, No. 2

PVI to Help Clinicians Predict Hypotension During Surgery

Tsuchiya M et al. Acta Anaesthesiol Scand. 2010.

PVI to Help Clinicians Predict Hemodynamic Instability by PEEP

Desebbe O et al. Anesth Analg 2010;110:792–798.

PVI to Help Clinicians Improve Fluid Management and Reduce Patient Risk

Forget P et al. Anesth Analg 2010.

Overall Conclusions: Clinical Utility of PVI

• Fluid administration is critical to optimizing patient status• Traditional methods to guide fluid administration are not

sensitive or specific 1

• Newer methods to improve fluid administration may improve patient outcomes but are impractical, invasive, or costly 2

• PVI is noninvasive and proven to predict fluid responsiveness in mechanically ventilated patients in the OR and ICU 3,4

• PVI improves fluid management and reduces patient risk as evidenced by lower lactate levels 5

1 Michard F, Teboul JL. Chest. 2002 Jun;121(6):2000-8. 2 Joshi G. et al. Anesth Analg. 2005; 101:601. 3 Cannesson M et al. Br J Anaesth. 2008 Aug;101(2):200-6. 4 Feissel M et al. Critical Care. 2009;13(1):P219. 5 Forget P et.al. Critical Care. 2009; 13(1):P204.

Reference Slides

Cannesson M et al. Br J Anaesth. 2008 Aug;101(2):200-6

PVI to Assess Fluid Responsiveness During Surgery: Summary

• Methods• 25 surgical patients under general anesthesia• Recorded CVP, PCWP, cardiac index, delta PP, PVI

• Before and after volume expansion (500 ml of hetastarch 6%)• Fluid responsiveness was defined >15% increase in cardiac index

• Results• Response to volume expansion

• Cardiac index increase from 2.0 to 2.5 l/min/m2

• PVI decrease of 14 to 9• PVI >14% before volume expansion

• Discriminated between responders and non-responders with 81% sensitivity and 100% specificity

• Significant relationship between PVI before volume expansion and change in cardiac index after volume expansion (R=0.67; P<0.01)

• Conclusion• PVI can predict fluid responsiveness non-invasively in mechanically

ventilated patients during general anesthesia

• Method• 20 patients scheduled for elective major abdominal surgery• After induction of anesthesia, all hemodynamic variables were recorded

immediately before (T1) and subsequent to volume replacement (T2) by infusion

• Results• The volume-induced increase in SVI was at least 15% in 15 patients

(responders) and less than 15% in five patients (non-responders).• Baseline SVV correlated significantly with changes in SVI as did baseline

PVI whereas baseline values of central venous pressure showed no correlation to DSVI

• No significant difference between the area under the receiver operating characteristic curve for SVV (0.993) and PVI (0.973)

• The best threshold values to predict fluid responsiveness were more than 11% for SVV and more than 9.5% for PVI

• Conclusion• SVV and PVI can serve as valid indicators of fluid responsiveness in

mechanically ventilated patients undergoing major surgery

Zimmermann M, et al. Eur J Anaesthesiol. 2010;27(66):555-561.

PVI to Help Clinicians Assess Fluid Responsiveness During Surgery: Summary

• Method• Forty mechanically ventilated patients with circulatory insufficiency • Fluid challenge with 500 mL of 130/0.4 hydroxyethyl-starch if

respiratory variations in arterial pulse pressure were >13% or with passive leg raising if variations in arterial pulse pressure were <13%

• Results• 21 were responders and 19 were non-responders.• Differences in responders vs. non-responders

• PVI 28 + 13% vs. 11 + 4% (p<0.05)

• Arterial pulse pressure variation 22 + 11% vs. 5 + 2% (p<0.05)• PVI correlation with change in cardiac output after fluid challenge

(0.72, p<0.0001)• Values at baseline were significantly higher in responders than in

non-responders• Conclusion

• PVI can predict fluid responsiveness noninvasively in intensive care unit patients under mechanical ventilation

PVI to Assess Fluid Responsiveness in the ICU: Summary

Loupec T et al. Crit Care Med 2011 Vol. 39, No. 2

PVI to Help Clinicians Predict Hypotension During Surgery: Summary

• Method• Measured PVI, HR, SBP, DBP, and MAP in 76 adult healthy patients under

light sedation with fentanyl to obtain pre-anesthesia control values• Anesthesia induced w/bolus administrations of 1.8 mg/kg propofol and 0.6

mg/kg rocuronium • During the 3-min period from the start of propofol administration, HR, SBP,

DBP, and MAP were measured at 30-s intervals

• Results• HR, SBP, DBP, and MAP were significantly decreased after propofol

administration by 8.5%, 33%, 23%, and 26%, respectively, as compared with the pre-anesthesia control values

• Linear regression analysis that compared pre-anesthesia PVI with the decrease in MAP yielded an r value of -0.73

• Conclusion• PVI can predict a decrease in MAP during anesthesia induction with

propofol. Its measurement may be useful to identify high-risk patients for developing severe hypotension during anesthesia induction

Tsuchiya Acta Anaesthesiol Scand. 2010.

PVI to Help Clinicians Predict Hemodynamic Instability by PEEP: Summary

• Method• 21 mechanically ventilated and sedated patients in the

postoperativeperiod after coronary artery bypass grafting

• Patients were monitored with a pulmonary artery catheter and a pulse oximeter sensor attached to the index finger

• Cardiac index [CI], PVI, pulse pressure variation, central venous pressure) were recorded at 3 successive tidal volumes

• Results• PEEP induced changes in CI and PVI for VT of 8 and 10 mL/kg.• For VT of 8 mL/kg, a PVI threshold value of 12% during ZEEP

predicted hemodynamic instability with a sensitivity of 83% and a specificity of 80% (area under the receiver operating characteristic curve 0.806; P 0.03)

• Conclusion• PVI may be useful in automatically and noninvasively detecting the

hemodynamic effects of PEEP

Desebbe O et al. Anesth Analg 2010;110:792–798.

Optimization of Fluid Management by PVI: Summary

• Methods• Randomized Clinical Trial

• Intra-operative PVI-directed fluid management vs. standard care

• Abdominal surgery patients

• PVI Group – 41 patients• 500 ml crystalloids followed by 2ml/kg/hr• Colloids added at 250ml for PVI values between 10-13

• Control Group – 41 patients• 500 ml crystalloids followed by standard fluid management care

(challenges and CVP)

• Outcomes• Primary: Perioperative lactate levels• Secondary: Hemodynamic data and post-op complications

Forget P et al. Anesth Analg 2010.

Optimization of Fluid Management by PVI: Summary Cont.

• Results• PVI group had lower lactate levels

• Max intraoperative (1.2 vs. 1.6, p<0.05)• 24 hours (1.4 vs. 1.8, p<0.05)• 48 hours (1.2 vs. 1.4, p<0.05)

• PVI group received lower amounts of intra-operative crystalloids• 1363 vs. 1818 mL (p<0.01)

• No significant differences in morbidity or mortality

• Conclusion• PVI-based goal-directed fluid management reduced the volume

of intraoperative fluid infused and reduced intraoperative and postoperative lactate levels

Forget P et al. Anesth Analg 2010.