Solving therapeutic conflicts in ARDS - PULSION Medical Systems SE

Solving therapeutic conflicts
i in ARDS
ARDS
Azriel Perel
Perel
Professor and Chairman
Department of Anesthesiology and Intensive Care
Sheba Medical Center, Tel Aviv University
Israel
Lisbon 2012

Disclosure
The The speaker speaker cooperates with the following companies
BMEYE
Pulsion
perelao@shani.net

A A few statements about therapeutic conflicts
�� �� A therapeutic conflict is a situation where each
of the possible therapeutic decisions carries
some potential potential harm harm.
�� A therapeutic conflict is often encountered in
patients who have more than one failing organ
system or have significant co co-morbidities.
morbidities.
�� Therapeutic conflicts present a great challenge
for protocolized cardiovascular management.
management.
�� A therapeutic conflict is where our decisions
can make k th the most t diff difference.

Fluid management g in
patients with ARDS
presents one of the most
common and most important
therapeutic conflict
f
i in the th ICU
ICU

Many of these conditions
are associated with
hemodynamic instability
including possible
h hypovolemia
l i

The initial hemodynamic resuscitation
according to the SSC guidelines
Dellinger RP, et al. Crit Care Med 2004;32:858-73
2004;32:858 73
Requirements for fluid infusion
are not not easily easily determined so
so
that t at repeated epeated fluid u d c challenges a e ges
should be performed.

�� Patients with sepsis-induced sepsis induced ALI had greater
ill illness severity it and d organ dysfunction d f ti at t ALI
ALI
diagnosis and higher crude in in-hospital hospital mortality
rates compared with non non-sepsis non non-sepsis sepsis ALI ALI patients. patients
�� Patients with sepsis-induced sepsis p induced ALI had a more
positive net fluid balance in the first week after
ALI diagnosis.

High g tidal volume and positive p fluid balance are
associated with worse outcome in ALI
Sakr Y and the SOAP Investigators. Chest 2005; 128: 3098-108
Sepsis in European intensive care units:
results of the SOAP study.
Vi Vincent t JL, JL et t al; l SSepsis i OOccurrence iin AAcutely t l Ill Patients P ti t Investigators.
I ti t
Crit Care Med. 2006 Feb;34(2):344-53
�� A positive fluid balance is associated with a
worse outcome t in i ALI/ARDS ALI/ARDS and d in i acute t kidney kid
injury.
��A A threshold may exist beyond which, after
acute resuscitation, , additional fluid therapy py may y
cause harm.

A conservative strategy of fluid management
improved lung function and shortened the
duration of of mechanical mechanical ventilation ventilation and
and
intensive care without increasing nonpulmonary
pulmonary-organ pulmonary organ failures.
failures

�� Background: Recent studies have suggested that
early goal goal-directed directed resuscitation of patients with septic
shock and conservative fluid management of patients
with acute acute lung lung injury injury (ALI) (ALI) can can improve improve outcomes. outcomes
�� �� Because these may be seen as potentially conflicting
practices, we set out to determine the influence of fluid
management on the outcomes of patients with septic
shock complicated by ALI.

�� Mortality in 212 patients with ALI complicating septic
shock was lowest for those achieving both Adequate
Initial Fluid Resuscitation (AIFR, fluid bolus to a CVP > 8
mm Hg) and Conservative Late Fluid Management
(CLFM (CLFM, even even-to to to-negative negative fluid balance for at least 2
consecutive days).
�� �� M Mortality t lit was hi higher h for f those th achieving hi i only l AIFR AIFR or
CLFM or neither.
�� �� B Both th early l and d late l t fluid fl id management t of f septic ti shock h k
complicated by ALI can influence patient outcomes.

Was the amount of fluids adequate or excessive?
Survivors
NNon-survivors i
Was fluid removal adequate or excessive?
Survivors

YES NO
We need to
We need to
stabilize the
prevent
hemodynamic
respiratory
status
deterioration
The conflict in administering fluids
to t tto a patient ti t with ith ARDS
ARDS

A Accurate t h hemodynamic d i
assessment is absolutely
necessary in order to
correctly solve solve a
therapeutic conflict
conflict

Practice parameters for hemodynamic support of sepsis
in adult patients. p 2004 update. p
Hollenberg S et al. Crit Care Med 2004; 32:1928-48
PPulmonary l edema d may occur as a
complication of fluid resuscitation
and necessitates monitoring of
arterial oxygenation.

Singer M, Critical Care and Resuscitation 2006, 8:244-5
Would anyone argue that iatrogenic fluid
overload is safe?
Would it it be be more more sensible sensible to to give give guidelines
as to when to use more sophisticated
hemodynamic monitoring monitoring to to better better titrate titrate fluid
input, rather than react post post-drowning?
drowning?

Clinical examination, vital signs, urine output, Hb, lactate...
EVLW
(PVPI)
Liver function
Preload &
Fluid Fluid responsiveness
responsiveness
ScvO 2
Cardiac Output p
(dP/dT, CFI, GEF)
Intra Intra-abdominal abdominal PP.

�� The desired effect of fluid administration is an
increase in CO.
�� In the absence of such an increase, it is time to
stop giving fluids.
�� �� Hence, fluid fluid should should not not be be administered administered when
there is no fluid fluid-responsiveness.
responsiveness.
CO
Preload

The majority of the parameters
that we routinely use to guide
X
fluid administration are poor
X indicators of when to stop
giving fluids!
X
X
X
X
V
V V-
X
VV
X V
X
X

�� �� We recommend a a fluid challenge to
predict fluid responsiveness (with a goal
of obtaining a rise in CVP CVP of at least 2
mmHg).

Overall, only 56 56% of the 803
patients included in 24 studies
responded to a fluid challenge.

A volume change, as a primary diagnostic approach
in hemodynamically unstable patients patients, has important
clinical drawbacks:
�� OOnly l half h lf of f all ll hemodynamically h d i ll unstable t bl
patients are preload responsive.
�� It delays d l primary i therapy th in i a setting tti where h
delayed appropriate treatment has
consequences for survival. survival
� A volume challenge in an unresponsive patient
may worsen or precipitate pulmonary edema or
cor pulmonale.

Th The value l of f bedside b d id
measurement of
extra extra-vascular vascular lung water
(EVLW) in in solving
solving
therapeutic conflicts
conflicts

At the present time, technology to measure
EVLW is is relatively relatively costly costly, invasive invasive, not widely
available, and has significant methodological
li limitations, i i so we did did not include i l d it i in i the h
definition.

�� More than half of the patients p with severe sepsis p
but without ARDS had increased EVLW, possibly
representing sub sub-clinical clinical lung injury.
�� 25 25% % of ARDS patients had normal EVLW.
�� EVLW may improve both risk stratification and
management g of patients p with severe sepsis. p

New criteria for ARDS
Schuster, Intensive Care Med, 1997
�� Diffuse alveolar edema (EVLW> (EVLW>7ml/kg) ml/kg)
�� �� Increased lung vascular vascular permeability
�� Diffuse Alveolar Damage pathologically

Michard, Fernandez-Mondejar, Kirov, Malbrain, Tagami.

In 21% of patients fluid loading
was associated with an
an
increase in EVLW of > 10%.

The patient with ARDS is more
susceptible to develop pulmonary
edema following fluid resuscitation

(Crit Care Med 2010; 38: 000)
�� Increased EVLW is a feature of early ARDS and
appears to be reliably measured even with extremely
elevated VD/V D T. T
� The measurement of EVLW may help to better
characterize ARDS and to guide g future therapeutic p
interventions.

�� EVLWI may reflect a higher fluid balance, which is
an i independent d d t determinant d t i t of f mortality t lit and d is i
associated with worse oxygenation and lower
compliance
compliance.
�� The lack of correlation with other oxygenation
yg
parameters and compliance suggests that EVLW may
provide additional information not available in other
parameters.
t

�� �� Elevated EVLW EVLW is a feature of early ALI and
discriminates between those with ALI and those
without.
�� EVLW predicts progression to ALI in patients
with risk risk factors factors for development of of ALI ALI 2.6 6 ± 0.3 3
days before the patients meet the Consensus
criteria for it.
�� These 2.6 6 days may then represent missed
opportunity for therapeutic intervention and
improved outcome.

�� �� There was a trend toward higher fluid balance in
in
the group in whom ALI developed.
�� It is unlikely that the individuals who had ALI
develop received more fluid because they were
“sicker “sicker,” ” beca because se the the APACHE APACHE II and SAPS scores
were not different between the two groups.
�� This, perhaps, suggests that using a fluid-
restrictive strategy earlier may have been
beneficial.

YES NO
We can
We may
improve
destabilize
respiratory
hemodynamic
function
status
The conflict in removing fluids
in i iin a patient ti t with ith ARDS
ARDS

At least 1 day of negative fluid balance
(< 2500 mL) L) achieved hi d bby th the third thi d day d of f
treatment may be a good independent
predictor of survival in patients with
septic p
shock.

Management by target EVLW vs. target PAOP
n=101
22 days y
Mitchell et al, Am Rev Resp Dis 145: 990-998, 1992
* *
9 days
15 days y
7 days
RHC group EVLW group RHC group EVLW group
Ventilation days ICU days

Survivors

Aggressive attempts to achieve
negative fluid balance should be
constantly t tl done
d

�� �� Quantification of EVLW led led to to important
modifications in fluid and vasoactive therapy.
�� �� These changes changes generally generally resulted resulted in in a a lower
lower
volume loading and a positive outcome for the
patient patient.

YES NO
We can
We may
improve
destabilize
respiratory
hemodynamic
function
status
The conflict of applying or
i increasing i PEEP PEEP level
l l

The lack of significant respiratory
variations is a strong indicator that
the patient may may tolerate aggressive
aggressive
fluid withdrawal and or tolerate high
levels of PEEP.

�� �� Baseline PPV PPV values values accurately accurately predicted
the fluid responsiveness in early ARDS
patients patients.
�� �� A baseline PPV > 12 12% 12 12% % is associated with a
a
significantly increase in cardiac index after
the end of volume volume expansion.
expansion

When presented with a
therapeutic conflict, f choose the
l least t harmful h f l option, ti should h ld
your decision decision prove prove to be the
wrong wrong one!

RIGHT WRONG WRONG RIGHT
≤≥
A B

An old patient with with chronic chronic heart failure, failure
sepsis, severe respiratory failure and
h hemodynamic d i instability. i t bilit
CO 1.8 l/min Low
ITBVi 600 ml/m 2 Low
EVLWi 15 ml/kg High
SVV 25-30% 25 30% High

Question Q QQuestion ti 4: 4 What Wh t would ld you do d now? ?
A. Fluids
B. Inotropes
CC. Vasopressors
D. Diuretics
E. I need more information

Persistent
ti tissue
hypoperfusion
≥
Worsening of
pulmonary l
edema
RIGHT RIGHT
Inotropes X
Fluids
EVLW

A 63 years old male patient who developed
fulminant pulmonary edema and hemodynamic
instability during re re-total total hip replacement.
Parameter
Normal
range
Interpretation
CI 1 9 l/m2 CI 1.9 l/m 35- 3.5 50 5.0 Low CO
ITBVI 779 ml/m2 ITBVI 779 ml/m 850 -1000 1000 Low preload
SVV 22 %

PACU
Fluid Postop Postop
loading Day 1 Day 2
CI (l/m2 CI (l/m ) 19 375 289 347
2 ) 1.9 3.75 2.89 3.47
ITBVI (ml/m 2 ) 779 1444 !!! 972 1093
SVV % 22 15 8 7
EVLW ( (ml/kg) l/k ) 23 15 5 4
EVLW /
ITBV
1.82 0.73 0.36 0.26

A considerable number of patients
with ith pulmonary l edema d may be b
hypovolemic!

34 yr f female; l V Very severe respiratory i t f failure; il
Hemodynamic collapse; on noradrenaline.
BP 113 / 67 mmHg CI 2 7 l/min/m2 BP 113 / 67 mmHg CI 2.7 l/min/m
HR 91 bpm p
ITBVi 578 ml/m 2
SaO 2 86% !!! EVLWi 20 ml/kg

In patients with severe ARDS and
low preload, preload consider consider the the use use of
inotropes p before “normalizing” g
parameters of preload with fluids.

In a situation where
fluid overload may be
particularly
deleterious, only
higher higher-than than-normal normal
PPV values should
serve as indication for
fluid administration.

Conclusions
�� �� Fl Fluid id management t of f patients ti t with ith ARDS is i
very often associated with a therapeutic
conflict conflict.
�� Such therapeutic conflicts should be best
handled by choosing the least harmful
therapeutic option.
�� A multi-parametric multi parametric hemodynamic monitoring
approach which which includes includes EVLW EVLW increases increases the
the
chance of correct conflict solution.
Thank you for your attention!
perelao@shani.net