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How to monitor fluid therapy – A clinical case (continuation) Question 3: What do you do now? 60 50 40 30 20 10 0 Nothing more Administer fluids first Increase the dose of norepinephrine *Results (in%) of the votes of an interactive session (audience 300) during ISICEM, 2012 Because of the high EVLWI it was decided to ” increase the dose of norepinephrine rather than give fluids to increase the arterial pressure. The lung water and permeability were monitored closely over the coming hours. Knowing when to stop giving fluids, as stated before, is very important. A high cumulative fluid balance is an independent predictor of intensive care mortality (4). Excessive fluid administration is deleterious in septic shock patients (5). Question 4: Which statement seems appropriate at this stage? 60 50 40 30 20 10 0 One can rely on PAOP for assessing the risk of fluid administration One can rely on tlung water for assessing the risk of fluid administration The value of PAOP is a predictor of mortality in such a patients The value of lung water is a predictor of mortality in such a patient Re-estimate the lung water and premeability in the coming hours The measurement of lung water is reliably estimated by transpulmonary thermodilution, it can be relied upon for assessing the risk of fluid administration and a high lung water is a predictor of mortality. Fluids should be stopped when there is lack of fluid responsiveness as indicated by the PPV / SVV (if appropriate), PLR or EEO, but also when the relationship between lung water and the pressure in the capillaries increases with volume expansion to the point where the fluid goes extravascularly instead of staying intravascularly. Lung water estimation by transpulmonary thermodilution is reliable and is an independent predictor of mortality in ARDS patients. This depends on the permeability of the lungs where (for example, in sepsis), increased permeability means that it takes less volume to increase the pressure in the capillaries and therefore increase the lung water to harmful levels. On the ” other hand, the pulmonary artery occlusion pressure (PAOP) physiologically cannot estimate the risk of fluid infusion in cases of ARDS. Knowing when to stop giving fluids, as stated before, is very important. Transpulmonary thermodilution reliably estimates lung water *Results (in%) of the votes of an interactive session (audience 300) during ISICEM, 2012 EVLW from the PiCCO has been independently validated against the gravimetry method in humans (6). In addition EVLW and the pulmonary vascular permeability index have been shown to be independent prognostic factors for patients with ARDS or Acute Lung Injury (ALI) demonstrating that lung water measured by TPTD has real physiological significance for the patient (Jozwiak et al. submitted 2012). Therefore in most instances the presence of high lung water may well signify that fluid administration should maybe cease or be given more judiciously. It has also been shown that using EVLW to guide your treatment may also result in lower cumulative fluid balance, less days on the ventilator and less days in ICU (7). PVPI is calculated from advanced analysis of the thermodilution curve when lung water is divided by pulmonary blood volume. It has been shown to discriminate between raised lung water caused by sepsis or raised lung water caused by hydrostatic factors. Values above 3 usually mean the raised lung water is a result of increased permeability caused by sepsis (8). With the increase in norepinephrine to 0.55µg/kg/min the patients arterial pressures improved (91/40/57 to 110/50/70), CI increased from 2.9 – 3.4L/min/m 2 and PLR fell to CI+10%.
KEY MESSAGES: • Cardiac output needs to be directly measured in complex patients receiving vasopressors • Real time measurement of cardiac output is required for predicting fluid responsiveness when PPV / SVV cannot be used • Lung water estimation by transpulmonary thermodilution is reliable and is an independent predictor of mortality in ARDS patients • Lung water and lung permeability are useful in the decision making process for avoiding fluid overload in cases of ARDS When to administer fluid? spont. breath, arrhythmias, ARDS? no yes PPV, SVV PLR EEO + PLR EEO Is fluid threapy effective? ↑ preload ↑ cardiac index Acute circulatory failure References PULSION Abstract Book - ISICEM Brussels 2012 page 19 1. Antonelli M, Levy M et al. Hemodynamic monitoring in shock and implications for management : International Consensus Conference, Paris, France, 27-28 April 2006. Intensive Care Med 2007; 33(4): 575-90.2 2. Monnet X, Jabot J, Maizel J, Richard C, Teboul JL. Norepinephrine increases cardiac preload and reduces preload dependency assessed by passive leg raising in septic shock patients (R3). Crit Care Med 2011; 39(4): 689-94 3. Monnet X, Osman D, Ridel C, Lamia B, Richard C, Teboul JL. Predicting volume responsiveness by using the end-expiratory occlusion in mechanically ventilated intensive care unit patients. Crit Care Med 2009; 37(3): 951-6 4. Vincent JL, Sakr Y et al. Sepsis in European intensive care units: results of the SOAP study. Crit Care Med 2006; 34(2): 344-53. 5. Boyd JH, Forbes J, Nakada TA, Walley KR, Russell JA. Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med 2011; 39(2): 259-65 6. Tagami T, Kushimoto S et al. Validation of extravascular lung water measurement by single transpulmonary thermodilution: human autopsy study. Crit Care 2010; 14(5): R162 7. Mitchell JP, Schuller D, Calandrino FS, Schuster DP. Improved outcome based on fluid management in critically ill patients requiring pulmonary artery catheterization. Am Rev Respir Dis 1992; 145(5): 990-8 8. Monnet X, Anguel N, Osman D, Hamzaoui O, Richard C, Teboul JL. Assessing pulmonary permeability by transpulmonary thermodilution allows differentiation of hydrostatic pulmonary edema from ALI/ARDS. Intensive Care Med 2007; 33(3): 448-53. When to stop fluid? lack of fluid responsiveness as indicated by PPV/SVV high lung water high lung permeability
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