Prof. Xavier MONNET
Medical Intensive Care UnitBicêtre Hospital
Assistance publique – Hôpitaux de ParisFRANCE
Assessment of fluid therapy
Use the right tool for the right job!
Conflict of interest
Pulsion Medical Systems
Prof. Xavier MONNET
Medical Intensive Care UnitBicêtre Hospital
Assistance publique – Hôpitaux de ParisFRANCE
Assessment of fluid therapy
Use the right tool for the right job!
APCVP
PiCCO
EsophagealDoppler
Echo
ProAQT/PulsioFlex
PAC
FloTrac/Vigileo
Nexfin
Differents monitoring devicesDifferent indications ?
Peri-op monitoring
ICU monitoring
Pe
ri-op
mon
itorin
g
Context
Goals of monitoring
Improves prognosis
to detect hemodynamic deterioration
to guide volume expansion
High-risk surgical patients (except cardiac surgery)
Peri-
op m
onito
ring
60 patients hip replacement
hospital length of stay
100 high-risksurgical patients
hospital length of stay
174 patients post cardiac surgery
hospital length of stay
162 multiple trauma patientsafter surgery
hospital length of stay ICU length of stay lactate levelPe
ri-op
mon
itorin
g Improves prognosis with esophageal Doppler
60-risk general surgical patientsGoal directed therapy vs. conventional treatmentPost-operative phase
Peri-
op m
onito
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number of complications hospital length of stay
120 high-risk abdominalsurgery patientsSVV-directed therapy vs. conventional treatmentPer-operative phaseLidCO monitoring
number of complications hospital length of stay
Improves prognosis with LidCO
40 patients with hip replacement under regional anesthesiaGoal directed therapy vs. conventional treatment
Peri-
op m
onito
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number of complications
Improves prognosis with Flotrac/Vigileo
Vigileo Eso Doppler
preloaddependance
(Δ aortic blood flow)
preload(FTc)
Pulsioflex
preloaddependance
(VVE and Δ PP)
preloaddependance
(VVE and Δ PP)
LidCOrapid
preloaddependance
(VVE and Δ PP)
continuouscardiac output
continuouscardiac output(cardiac output)(AP curve
analysis)
continuouscardiac output(AP curve analysis)
continuouscardiac output(AP curve analysis)
Peri-
op m
onito
ring
Arterial pressure
Esophageal Doppler
Flotrac/VigileoPulsioflex
LidCOrapid
PA catheter
CVP
PiCCOEV 1000
ICU monitoringOR monitoring
Basic monitoring Advanced monitoring
Context
Objectives of monitoring
initial phase of shock
after the ER
assess the hemodynamic profile (type of shock)
guide initial therapy
fix some therapeutic goals
Which basic monitoring?Basic
ICU
mon
itorin
g
Basic
ICU
mon
itorin
g
Helps for :Helps for:
determining the type of shock(preload)
guiding fluid responsiveness(preload)
CVP Arterial pressure
deciding to give vasopressors
deciding to give fluid(if ventilated)
fixing some therapeutic goals
Basic
ICU
mon
itorin
g
DAP
PPV
MAP
Arterial pressure
Esophageal Doppler
Flotrac/VigileoPulsioflex
LidCOrapid
PA catheter
CVP
PiCCOEV 1000
ICU monitoring
OR monitoring
Basic monitoring Advanced monitoring
?
?
The only arterial pressure and CVP monitoring is not sufficient anymore
critically ill patients
Context
because patients receive vasopressors
Adva
nced
ICU
mon
itorin
g
when shock persists after initial fluid therapy
r = 0.56n = 228
r = 0.21n = 145
*
-50 0 50 100 150 200 250 300-50
0
50
100
150
200
250
300
Changes in CI induced by VE (%)
Changes in PPinduced by VE (%)
-50 0 50 100 150 200 250 300-50
0
50
100
150
200
250
300
Changes in CI induced by NE (%)
Changes in PPinduced by NE (%)
228 pts receiving volume expansion145 patients with increase of NE
Adva
nced
ICU
mon
itorin
g
-20
0
20
40
60
80
100
non responders responders
changes in CI (%)
-20
0
20
40
60
80
100
non responders responders
changes in PP (%)
+15%
6% false +
228 pts receiving volume expansion145 patients with increase of NE
22% false -
Adva
nced
ICU
mon
itorin
g
Adva
nced
ICU
mon
itorin
gVigileo Eso Doppler
preloaddependance
(Δ aortic blood flow)
preload(FTc)
Pulsioflex
preloaddependance
(VVE and Δ PP)
preloaddependance
(VVE and Δ PP)
LidCOrapid
preloaddependance
(VVE and Δ PP)
continuouscardiac output
continuouscardiac output(cardiac output)(AP curve
analysis)
continuouscardiac output(AP curve analysis)
continuouscardiac output(AP curve analysis)
continuouscardiac output
AP curve analysis
uncalibrated
continuouscardiac output
AP curve analysis
uncalibrated
continuouscardiac output
AP curveanalysis
uncalibrated
20
40
60
80
100
120
0
= k . SV
Uncalibrated devices
estimate SV from the arterial pressure curve
estimate arterial compliance by analysing the arterial waveform
?still valuable when the properties of the arterial curve
change in a large extent (sepsis, vasopressors)
Which device for advanced monitoring?Ad
vanc
ed IC
U m
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3.5 L/min
PiCCO and EV1000 devices measure cardiac output by
arterial pressure curveanalysis
Which device for advanced monitoring?Ad
vanc
ed IC
U m
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PiCCO and EV1000 devices measure cardiac output by
inj
Blood temperature (Ts)
Ttm
cold bolus
calibrated by
transpulmonarythermodilution
arterial pressure curveanalysis
Which device for advanced monitoring?Ad
vanc
ed IC
U m
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Vigileo2
PiCCO
calibratedcardiac index
uncalibratedcardiac index
changes induced byvolume expansion (40 patients)
changes induced bynorepinephrine (40 patients)
Ability to track
Which device for advanced monitoring?Ad
vanc
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-15 0 15 30 45 60 75
-15
0
15
30
45
60
75
D CItd (%)
r = 0.78p < 0.05
PiCCO
r = -0.03p = NS
-15 0 15 30 45 60 75 90 105 120
-15
0
15
30
45
60
75
90
105
120
D CItd (%)
Vigileo2
Changes induced by
norepinephrine
Changes induced by
volume expansion
PiCCO
r = 0.72p < 0.05
-15 0 15 30 45 60 75 90 105 120
-15
0
15
30
45
60
75
90
105
120
D CIp
c (%
)
DCItd (%)
Vigileo2
r = 0.33p < 0.05
-15 0 15 30 45 60 75 90 105120
-15
0
15
30
45
60
75
90
105
120
D CIp
w (%
)
D CItd (%)
Which device for advanced monitoring?Ad
vanc
ed IC
U m
onito
ring
51 pts, 401 measurementsVigileo2 vs.Vigileo3 vs. PAC
Vigileo3 is more accurate and as precise than Vigileo2
Which device for advanced monitoring?Ad
vanc
ed IC
U m
onito
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33 patientsVigileo3 vs. esophageal DopplerHemodynamic challenges by phenylephrine, ephedrine and whole-body tilting
Which device for advanced monitoring?Ad
vanc
ed IC
U m
onito
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PA catheter
Which device for monitoring cardiac output?
PiCCO EV 1000
cardiac output cardiac output cardiac output
Adva
nced
ICU
mon
itorin
g
Context
Goals of monitoring
predict fluid responsiveness
precisely monitor the effects of therapy
fix some therapeutic goals
when shock persists after initial fluid therapy
assess the risk of fluid expansion
critically ill patients
Adva
nced
ICU
mon
itorin
g
PA catheter PiCCO EV 1000
cardiac output cardiac output cardiac output
SvO2ScvO2 ScvO2
How to assess the need for fluid?Ad
vanc
ed IC
U m
onito
ring
Context
Goals of monitoring
predict fluid responsiveness
precisely monitor the effects of therapy
fix some therapeutic goals
when shock persists after initial fluid therapy
assess the risk of fluid expansion
critically ill patients
Adva
nced
ICU
mon
itorin
g
PA catheter PiCCO EV 1000
cardiac output cardiac output cardiac output
PAOP
SvO2ScvO2 ScvO2
How to assess the need for fluid?
PPV, SVV,PLR test, EEO test
PPV, SVV,PLR test, EEO test
Adva
nced
ICU
mon
itorin
g
How to assess the need for fluid?Ad
vanc
ed IC
U m
onito
ring
EV 1000PA catheter PiCCO
cardiac output cardiac output cardiac output
PAOP
SvO2ScvO2 ScvO2
How to assess the need for fluid?
PPV, SVV,PLR test, EEO test
PPV, SVV,PLR test, EEO test
continuous continuous
Adva
nced
ICU
mon
itorin
g
venous return
How to assess the need for fluid?Ad
vanc
ed IC
U m
onito
ring
34 patients with acute circulatory failuremonitored by PiCCO device
-10
0
10
20
30
40
50
Effects of end-expiratory pause
on cardiac index
increase 5%Se = 91%Sp = 100 %
How to assess the need for fluid?Ad
vanc
ed IC
U m
onito
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RNR
How to assess the need for fluid?Ad
vanc
ed IC
U m
onito
ring
Context
Goals of monitoring
predict fluid responsiveness
precisely monitor the effects of therapy
fix some therapeutic goals
when shock persists after initial fluid therapy
assess the risk of fluid expansion
critically ill patients
Adva
nced
ICU
mon
itorin
g
EV 1000PA catheter PiCCO
cardiac output cardiac output cardiac output
PAOP
SvO2ScvO2 ScvO2
PPV, SVV,PLR test, EEO test
PPV, SVV,PLR test, EEO test
lung waterand lung permeability
lung waterand lung permeability
How to assess the risk of volume expansion?Ad
vanc
ed IC
U m
onito
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Pcap
lung water
normal permeability
very high permeability
Pcap
lungwater
How to assess the risk of volume expansion?
high permeability
Adva
nced
ICU
mon
itorin
g
Lung permeability
Lung water for estimating the risk of volume expansion?
Pcap
Lung water
normal permeability
very high permeability
Pcap
lungwater
lungwater
high permeability
Lung permeability
Adva
nced
ICU
mon
itorin
g
Cold bolus
PiCCO EV1000
Lung water for estimating the risk of volume expansion?Ad
vanc
ed IC
U m
onito
ring
validation in human beings→
Lung water for estimating the risk of volume expansion?
30 ptsEVLW measured by TPTD and by postmortem gravimetry
First validation of EVLW-TPTD evaluation in humans
Adva
nced
ICU
mon
itorin
g
Lung water for estimating the risk of volume expansion?Ad
vanc
ed IC
U m
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ring
Extra-vascular lung water and pulmonary vascular permeability index are independent prognostic factors in patients with acute respiratory distress syndrome
Jozwiak M, Silva S, Persichini R, Anguel N, Osman D, Richard C, Teboul JL, Monnet X
0
20
40
60
80
100
EVLWImax > 21 mL/kg EVLWImax ≤ 21 mL/kg
70%
42%
p = 0.0001
Day-28 mortality (%)
p value
Maximal blood lactate 0.81 (0.71 - 0.93) 0.002Mean PEEP 1.25 (1.07 - 1.47) 0.005
EVLWI max 0.94 (0.87 - 0.98) 0.01
SAPS II 0.97 (0.95 - 0.99) 0.02Mean fluid balance 0.9996 ( 0.9993 - 0.9999) 0.02Minimal P/F ratio 1.01 (1.00 - 1.02) 0.02Minimal pH 35.97 (0.47 - 2769.52) 0.10
Odds Ratio ( CI 95%)
200 pts with ARDSEVLW measured by PiCCO device
Lung water for estimating the risk of volume expansion?
submitted
Adva
nced
ICU
mon
itorin
g
PAOP group
EVLW group
Time (hours)
Cumulative fluid balance (input - output; L)7
3
1
5
-1
-3
-50 12 24 36 48 60 72
***
*
* p < 0.0001 vs time 0
Mitchell JP et al., Am Rev Respir Dis 1992
101 ARDS patientsrandomized to EVLW-guided management vs.PAOP-guided management
Lung water for estimating the risk of volume expansion?Ad
vanc
ed IC
U m
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0
5
10
15
20
25
Ventilation days ICU days
PAOP Group
EVLW Group
* * Management of fluid therapy with :
functional benefit of lung water monitoring
Mitchell JP et al., Am Rev Respir Dis 1992
101 ARDS patientsrandomized to EVLW-guided management vs.PAOP-guided management
Lung water for estimating the risk of volume expansion?Ad
vanc
ed IC
U m
onito
ring
Lung water for estimating the risk of volume expansion
Pcap
Lung water
normal permeability
very high permeability
Pcap
lungwater
lungwater
high permeability
Lung permeability
Adva
nced
ICU
mon
itorin
g
lung water
cold bolus pulmonary blood volume
pulmonary vascularpermeability index =PVPI
PiCCO EV1000
Lung permeability for estimating the risk of volume expansion?Ad
vanc
ed IC
U m
onito
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0123456789
10PVPI
ALI/ARDS Hydrostaticpulmonary edema
*
Cut-off : 3
Se = 85 %
Sp = 100 %
48 patients with pulmonary edemainflammatory vs. hydrostatic discriminated by expertsPVPI by the PiCCO device
Lung permeability for estimating the risk of volume expansion?Ad
vanc
ed IC
U m
onito
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PVPI = 4 PVPI= 7
ARDS
AP = 90 / 40 mmHg
Cardiac index = 2.0 L/min/m2
PaO2/FiO2 = 180 mmHg
PLR test : positive
ARDS
AP = 90 / 40 mmHg
Cardiac index = 2.0 L/min/m2
PaO2/FiO2 = 180 mmHg
PLR test : positive
volume expansion volume expansion
vasopressors?
Lung permeability for estimating the risk of volume expansion?Ad
vanc
ed IC
U m
onito
ring
PA catheter PiCCO EV 1000
cardiac output cardiac output cardiac output
PAOP
SvO2ScvO2 ScvO2
PPV, VVE,PLR test, EEO test
PPV, VVE,PLR test, EEO test
lung waterand lung permeability
lung waterand lung permeability
Lung permeability for estimating the risk of volume expansion?Ad
vanc
ed IC
U m
onito
ring
APCVP
PiCCO
EsophagealDoppler
Echo
ProAQT/PulsioFlex
PAC
FloTrac/vigileo
Nexfin
Differents monitoring devicesDifferent indications !
Arterial pressure
Esophageal Doppler
Flotrac/VigileoPulsioflex
LidCOrapid
PA catheter
CVP
PiCCOEV 1000
ICU monitoring
OR monitoring
Basic monitoring Advanced monitoring