How to assess fluid responsiveness?

[Music] [Music] states [Music] [Applause] [Music] [Applause] [Music] common fair [Music] [Music] and what scares me is that making those decisions and making those wrong decisions and the realization that that decision uh of that decision in three four weeks time where you end up having a patient who in effect can be crippled by life-sustaining therapy um which may not have been in their best interests or their family's best interests and that still scares me and i think it scares a lot of colleagues but um intense care is much more multidisciplinary now and i think that has helped our decision making and has reduced that fear factor honesty and humility go a long way and most patients and relatives understand that we're also human and mistakes can happen and should be openly discussed [Music] [Applause] [Music] together with my colleagues in particular the nursing colleagues we arranged a wedding for a patient who was at the end of his life and had decided to marry his long-term partner before he later died and it was very moving to be part of this very special event in the intensive care unit it's a real privilege to be able to support a patient and their family through that what i hope is the worst thing that ever happens to them in their lives to to be able to support them through that hopefully to recovery or to support them um through managing a dignified death foreign [Music] [Music] intensive care medicine allows me to learn something new every day so every day i need colleagues and i hear of their new technologies new advances and progress in their particular specialty but most importantly every day is a different day with new challenges and i enjoy the interaction with my colleagues and most importantly with patients and their relatives so it is a provides a great variety it's different every day and it's a specialty where progress is made on a on a regular basis is [Music] [Applause] [Music] uh [Music] good afternoon everybody i'm olfam devi i'm intensivist and intensive care antoine beckley hospital from parisecla university hospitals and a member of the cardiovascular session in es icm i'm very pleased to share this webinar from this icm supported by ge healthcare around fluid responsiveness and as you know in critically ill patients the decisions to give fluids is a big issue at the bedside for all the physicians who try every day to find the good balance between in one hand not inducing fluid overload on the other hand not missing hypoperfusion due to a real need of fluids the decision to give or not fluids should not be taken lightly and i'm sure that after this webinar you will have the right keys for this daily deal in this webinar we will have the opportunity with our international experts to discuss firstly how to differ differentiate between the need of fluids and fluid responsiveness and secondly the appropriate use of non-invasive method to assess fluid responsiveness so you can send your questions directly on the esicn tv or via a facebook and youtube account and we will have time to answer them after the two talks of our experts so first i have the great pleasure and a big honor to introduce one among the most recognized experts in this field professor xavier monet professor xavier monet is professor of intensive care in the medical intensive care of biset hospital from paris sacre university hospitals in france he is also the chair of the cardiovascular session of the esicm and we will talk about he will talk about the need of fluids versus fluid responsiveness so please thank you very much anfa for your very nice and kind introduction and before starting i disclose my collaboration with falchion medical systems getting and with um baxter you're right it's not a light question but what are we speaking about exactly let's think about the patient for instance with septic shock on community acquired pneumonia on day one in this patients the pf ratio is low the blood pressure is low the beep is elevated and the patient has already received one liter and a half saline and is under norepinephrine blood pressure is too low should we give fluid to this patient or not this is you will agree the daily question the first issue we have with this treatment is that all the patients do not respond to fluid administration through the expected increase in cardiac output initially this was totally ignored but when colleagues started to measure cardiac put at the time with the pulmonary artery catheter in the 18s they observed that some patients had no increase in stroke volume this is the first study i think showing that after fluid administration and after this first study of convenient co-workers many of them and many since this first study reviewed here 20 years ago many studies confirmed that half of the patients only respond to fluid administration through a significant increase in cardiac output unlikely you know that and the main reason is basically physiology as if we give fluid administration actually we expect that stroke volume and correct output increase in this way we use the cardiac output relationship the frank stelling curve at the bedside but basically you know from your first years in at medical school that the slope of the frank selling curve basically depends on the ventricular function and this explains why the same fluid administration with the same volume of fluid may lead to a significant or a negligible increase in cardiac output it means that fluids is are not fluid responsiveness these are totally different concepts it's not because you give fluid that your patient will respond to fluid is that really an important issue for years it was not that sure but today we know all the drawbacks all the adverse effects of fluid administration in our icu patients unlikely in the operating room patients as well the effects of fluid are not constant and even more when you give fluid and that it does not increase cocaine but it has only adverse effects mainly it increases lung water it increases lymphedema it promotes in trap abdominal hypertension it reduces homo delusion it promotes also right ventricular failure etc and more than theory we know that's been clearly demonstrated today just to show you one study the first that's been clearly showing that in septic patients the sub-analysis of the soap study definitely the total amount of fluid administered the cumulative fluid balance is an independent predator of mortality in this patients the more fluid you give to these patients the more they die and so we are left with these two issues in constant effect and potential harmfulness which means by the way and confirms by the way that fluids are drug we should logically predict fluid responsiveness before giving fluids just as antibiotics fluids are drugs with several adverse effects and an inconstant efficacy if you try to predict before giving antibiotics whether they will be effective or not on the germ you want to treat the same you should test fluid responsiveness before giving fluid to your patient in fact in our mind we are drawing this very simple algorithm is cardic outputs too low urine output is low lactoid is elevated should i give fluid there are two cases in the minority of cases you know that the patient will be fluid responsive because fluid losses are obvious because it's the very early phase of septic shock with obvious relative hypovolemia in this in these cases definitely you should not try to predict fluid and responsiveness because it is likely in this cases you should give fluid and that's all but in the majority of cases in all the other cases you know that only half of the patients will respond positively to fluid administration it means you should look at indices that will tell you before starting fluid infusion that the patient will very likely be fluid responsible and as you know for this purpose static markers of cardiac preload as central venous pressure for instance are not valuable at all and we should look for dynamic indices what are we speaking about this concept of dynamic prediction of fluid responsiveness is in fact very very easy it's a way to assess the slope of the cardiac function curve at the bedside i mean you change preload or you observe spontaneous changes in preload for instance fluid administration effects of ventilation etc and you look at the changes in cardiac output stroke volume or surrogates if the change is significant then you can give fluid being sure that the patient will respond to fluid positively otherwise otherwise you refrain from fluid administration and during the last um during the last 20 years several indices were developed to predict fluid responsiveness in a dynamic way and i suggest that together in the next minutes we review all these indices methods and that we together consider their advantages and drawbacks definitely the most the easiest way to assess fluid responsiveness is just to give fluid and look at the response it means a fluid challenge give three or five hundred milliliters to your patient and see how he or she responds it's very easy to do two main drawbacks the first one is that bear in mind that to correctly assess the response of fluid to during a fluid challenge you must measure cortical if you look just at pulse pressure arterial pressure it is not reliable enough you need to directly measure cardiac effort but even more importantly inherently fluid challenges that perhaps many of you like a lot induces fluid overload this is inherent to the method you use why because it is not a challenge it's the treatment itself i mean that you give fluid to a patient and if the patient does not respond you go on with the next policy etc until the last policy that does not increase correct britain's growth volume anymore and then you stop fluid administration this is basically the fluid channel let's imagine a patient's as the one we we spoke about in the beginning septic shock with ars on thursday you will agree with me your patient will experience perhaps five six episodes of hypertension which means that obviously this induces fluid you cannot remove the fluids you've given to your patient and definitely the fluid challenge is not a challenge it's the treatment itself this is why the concept of giving small amounts of fluid 100 150 milliliters the many fluid challenge might be interesting and we now have some positive studies my point regarding many fluid challenges that it requires a precise measurement of cardiac output what do i mean this is the first study of some french showing the interests of this of this mini fluid challenge one milliliter of starch and those patients could discriminate responders from non-respondents nevertheless small amounts of fluid can only induce small changes in cardiac prelims that can only induce small changes in cardiac output and in this study these small changes were detected by echocardiography we will speak about that slightly later with the doctors in philippi but is cardiac echo reliable enough precise enough to detect so small changes in codec output likely not i'm even sure that it's not the case because the smallest change that you may trust with a cocariography in the velocity time integral in this estimation of stroke volume is ten percent only smaller changes you're not sure that it will that it will be detectable with accuracy that's why for this mini fluid challenge i would much better rely on some more precise techniques for measuring cardiac with cardiac index as for instance post-contour analysis or other continuous methods and for instance in this study by the team of die in bordeaux they shared that pulse control analysis detected the many fluid challenge effects look at the change in stroke volume less than ten percent six percent which is compatible with the precision of post contour analysis not of echocardiography anyway it still requires to give fluid to the patient that you cannot remove as all of you know pulse pressure stroke volume variations that have been developed 20 years ago are very reliable indices of fluid responsiveness but on the other side we can use them in a minority of patients and the main circumstances situations where we cannot use these indices because they are not valuable anymore are cardiac arrhythmias spontaneous breathing even in an antibated patient spontaneous uh ventilation and ars because of flank compliance low land compliance and low tidal volume and the problem is that it's likely at a large proportion of our icu patients where we cannot use ppv and svp nevertheless we can say that there might be a solution in the specific case of ars with the low tide and volume which is that tidal volume challenge that's been developed four years ago by dr mayatra and some other indian colleagues and the principle is very simple no need to measure cardiac output you just increase the tidal volume from for instance six to eight millimeters per kilogram and look at the induced changes in pulse pressure variation and if ppv ppv i'm sorry if pulse pressure variation increases by more than a given threshold it's very likely your patient is fluid responsible in this first study we showed that the threshold was a 3.5 percent increase in ppv nevertheless some other studies found smaller smaller thresholds as the one we just published in in critical care where we show that the threshold was a one percent increase only so i think that further studies and should try to refine the threshold of the time volume change the changes in the diameter of inferior ivc superior spc vena cava are very popular indices i think that many colleagues like it a lot actually you don't need to measure curricula or vti or stroke volume just look at the changes in the diameter of the vena cava first drawback you must know how to do that nevertheless it's very easy to assess it at least the ivc svc is much more complicated you need tee it's not easy but ivc definitely it is it is very easy my point here is that keep in mind that these are the less reliable indices of fluid responsiveness we have it's today very clear many small sized studies showed that and many meta analysis of this study confirmed that even more we have a two um twenty thousand [Music] seven large french negative study look in that study the ability of the changes in the ivc to predict to detect prelude responsiveness was very low the area under the rack curve was only 0.65 which is very low so it is well demonstrated and likely it can be explained why why does for instance the ivc changed with ventilation in fluid responsive or preload responsive patients did you think about that already it's not only due to the slope of the frank styling curve i mean that if it changes it's likely because yes the intramural pressure the cvp changes in case of prelude responsiveness but the change also depends on other factors the compliance of the ivc the intra-abdominal pressure and so the transmission the degree of transmission between the thoracic and the abdominal pressure it's not only related to pre-load responsiveness and i think it is the reason why it has a so low predictive ability in addition these changes in vena cava diameter share most of the limitations of pbv and svv do not use it in patients with low tidal volume and spontaneous breathing and expiratory occlusion i have used perhaps you've heard about that about that test that we developed uh years ago with jean-luc in this study the principle is very easy it's all about heart lung interactions indeed in a patient with mechanical ventilation you agree that each insufflation tends to impede venous return it decreases cardiac preload and then the next cycle stops the cycle stops preload increases next insufflation preload decreases etc etc and so the principle of the test is that it shifts if you stop mechanical ventilation for a few seconds for instance 15 seconds you increase cardiac preload for a few seconds and if in turn stroke volume increases it means that both ventricles are preload dependent the duration must be at least 15 seconds or 12 seconds because the the the prelude ballast must cross the pulmonary circulation and also the cardiac output monitors we use must average this change in cardiac output and today we have several studies showing that there is a good uh level of reliability which performed this analysis as you a month ago with a francesco gavelli you see the threshold is a five percent increase and look at the area under the rocket or 0.95 compared to ivc changes it's totally different it's very easy if you have a direct display of cardiac output under your eyes for instance with pulse contour analysis again or any other technique with echocardiography it is possible but since the threshold is low and because of the precision of echocardiography we showed in this study that you need to add to the end expiratory occlusion and and inspiratory occlusion that will that will enlarge the induced changes with a higher threshold but that will make the changes in cardiac output induced by the test detectable by echo cardiography of course it's not possible to use it in patients with a strong respiratory efforts the interrupts the the infusion and again you need something that measures cardiac output it's difficult to measure with blood pressure only let's end up with the passive leg raising tears that likely you know many studies have shown that it is a reversible preload challenge on average the volume is 300 meters of blood but it's very variable from one patient to another but it's a pseudo fluid challenge i would like to insist on two points two last points regarding the passive leg raising type the first is that you need something that measures cardiac output to perform the test unfortunately if you use arterial pressure and especially under your pulse pressure it's not very reliable then you need something that measures cardiac output and many studies have looked at um reliable ways to perform the test in a non-invasive way because of course you can use pulse contour analysis but of course all all the patients are not equipped with such systems the softgel dapper not easy in the icu echocardiography you look for an increase in the vti by more than 10 percent capnography i don't have time to show that but it's interesting bioreactance is likely is reliable changes in carotid flow i think it is not reliable that again no time to insist on that because i'd like to speak about platysmography spo2 to assess the effects of passive leg raising this plaque signal that we have under our eyes every day in fact is made of two parts there is a pulsatile systolic part of the signal and a non-versatile portion that you don't see on your screen and the ratio between both is called the pr the perfusion index and you can easily understand that it has two determinants the first one is vasometer tone of course if the patient is vasoconstricted the pi is low but also strong volume because it will increase the volatility of spo2 so is it possible to use that amplitude of aspirator to assess the effects of for instance passive leg raising or a fluid challenge i don't show all the details of this study that we performed but look the changes in this pi were able to detect to detect i'm sorry the changes in cardiac output interest by passive leg raising and volume expansion and for instance in this fluid with non-responder here there was no change neither in cardiac index nor in the fusion index so spo2 to detect changes in cardiac output during passive leg raising be careful we had to exclude some patients because the signal was very unstable we showed recently that the pi can also detect the change detect i'm sorry the changes in the end expert occlusion test we need some confirmation but likely a way which is costless non-invasive and widely available to assess changes in kartika but in these tests finally you may you may use just ppv which is displayed on your screens for instance during passive leg raising as we showed recently finally less reliable in case of intra-abdominal hypertension likely there is less volume in the abdomen less possibility to less volume to mobilize during the test it's been suspected for years that it may induce some false negatives and we confirmed it in this study published two years ago in patients with intra-abdominal hypertension fluid increased volume expansion increased cardiac index passive leg raising to a lesser extent meaning that there might be some not all but some false negatives in this case so i think the best dynamic ways to assess fluid responsiveness might be the many fluid challenge the end expiratory occlusion test and passive leg grading thank you very much for your kind attention thank you xavier for your as usual your a brilliant presentation and i'm sure that you will have a lot of question after and we'll try to have some time for the question and now let us move to the second speaker who is one of among our brilliant experts in ecocardiography and he is a part of the ac group for advanced eco accreditation the edec program dr philippe philippo is a consultant in anaesthesia and intensive care at the poly clinical university hospital in catania and he will be talking about non-invasive assessment of fluid responsiveness so please philippa thank you very much for the introduction thank you for the invitation it's such a privilege uh i hope this is running the presentation [Music] yeah it's okay sorry okay thank you very much again for the invitation and the presentation it's an honorable privilege i have no conflict of interest and in the agenda what i put is a couple of thoughts on what he's not invested intel in the intensive care and then of course we talked about psycho-cardiography point of view ultrasound and a few other considerations on non-invasive assessment for fluid responsiveness when i was given the title the first thought was okay i'm gonna speak about uh ultrasound for sure but uh before that i thought what is truly non-invasive in the intensive care and uh certainly most of our patients are have got an arterial line capital in situ so in this case uh monitoring advances cardiac output with also control method analysis or other approaches it doesn't mean adding any embarrassing or risk towards the patient so echo is not mutually exclusive with this other monitoring tool and before moving to the approaches to uh defined with responsiveness with non-invasive uh methods i would like to remind about the tunisian study led by our president which showed that most of the fluid challenges were given without a variable use and when a variable was used people used mainly uh static variables while dynamic variables were used only in 22 percent and if we look in green uh at the bottom of the screen the echo variables these were used very rarely um echocardiography and point of care with the sound variable are based mainly on dynamic evaluation and rather than measurement and during this presentation we try to cover uh assessment of fluid responses using the heart of the veins and the arteries so from the art perspective as mentioned already by professor monet we evaluate the variation of soft polymer and chronic output and how these uh changes over time with either preload redistributing maneuvers as positive leg raising or with ventilation in using chains the calculation of stock volume kind of output i'm sure most of the people are aware his performance with echocardiography calculating the diameter of the lbot and then to get the pathway doctor analysis of the flow in the lvlc with an ethical five-chamber view professor monet has already discussed the limitation of echocardiography measurement in italic output with [Music] inter and the intro server variability of course and in this regards uh some help may be given but needs a research study but this new software that allows automated tracing of the dti as you can see in this example where the lvc diameter was 2.2 centimeter and the machine already calculated the vtr and gave us number of stock volume and targets [Music] of course it can be calculated also with chances of ideal echo cardiology the principle behind are the same just the views are different i'll move now to the bigger part of the presentation which is the use of the venus district to assess fluid responsiveness and certainly the interior vena cava is the most studied parameter where in order to understand the fluid responses we evaluate changes in the diameter of the vena cava and this is performed according to the change in the pressure into the chest during either spontaneous or invasive mechanical ventilation uh now the pioneer uh where our french friends and in particular in 2004 we have two uh important paper by the group of professor john little and the group of professors where the authors found a different cutoff for fluid responsiveness but please note how they use the different formula while the group of table did divide the the the variation of the mc diameter over the icy ibc mean the emitter and founded 12 percent cut off to predict fluid responsiveness the group of professor antoinville baron divided the variation of the ldc by the uh ibc minimum diameter and that they found that 18 the last formula is probably the one that is more commonly used and is called the iec distance ability index and this is important from dictionary perspective because the term refers to the increase in size during the inspection uh we have also studies that were performed later on by other groups and uh in the patient with spontaneous intellect in this case all the groups have used the idc collapsibility index where the variation of the idc diameter is uh divided by the idc maximum diameter and the outputs of these studies found that good cutoff or fluid responsiveness are around 40 to 48 percent however as already mentioned by prof monet uh the group of professor philippe vignon from france performed a much bigger studies than the other one where they found lower sensitivity and specificity and in these regards then i think it's fair to show you uh the polar results from meta-analysis and what we can take from the ivc so there are several meta-analysis and one of these in 2017 started to introduce the concept that fluid responsiveness using the ibc variation can be better predicted if we use it in mechanically ventilated patients as you can see where the area under the curve decreases slightly in the patient not ventilation but what i find very interesting is these other methodologies in there published in anesthesia and november 18 where the authors identify the 12 big studies in evaluating the ivc variation for fluid responsiveness and they identified that ventilator settings were a source of significant detergent and therefore the elders decided to divide studies according to the way patients were ventilated therefore we have six studies where patients were ventilated with at least 8 ml per kg of tidal volume and with a heap of 5 centimeter of water or below while the other 6 studies were performed in patient with lower tidal volume and or higher heat level what the outers found that the area under the tube was much bigger and reliable when the patients were ventilated with bigger tidal volume and lower heat rather than when patients were ventilated with low tide environment higher so this is a take-home message uh recently it's in 2021 the group of brothers published their metallics looking at predictors of fluid responsibility in patient ventilation at low tidal volume and if we look the results of the ivc we can see that the area under the cube is 0.86 which is a bit lower than others but not so lower as mentioned by monet there are lots of situations where the idc cannot be reliable and this is a nice review by gabrielle and among others i would like to mention the rv failure cycle speed regulation component and as mentioned by pro money also inter abdominal like attention there are several reasons when and conditions and scenario where the idc is not reliable and i would like to uh continue a bit on the idc with a couple of news first of all the use of artificial intelligence which seems promising in this study the algorithm of artificial intelligence was a good argument with the point of care which was on experts for evaluating their dc collapsibility and the use of as you can see in these images of software for automatic border detection or the abc can be helpful also in decreasing the time of data collection space and allowing repeated measurement the other concept that i would like to introduce on the idc is uh the possibility to use another uh window to look at the ibc as you can see here uh it can be uh imaged through the liver basically using the trance of attitude the first study was conducted by our indian colleagues and the authors found that while the diameters were not reliable comparing the standard and the transavatic view the limits of argument were acceptable when they looked at the percentage variation so this could be an option when you have a patient with chest pain like in this study by the group of massimiliano where they performed the same concept studying the [Music] postoperative period of target but also when we have patients with a laparotomy or with difficult uh views for uh looking at the idc from the subcostal approach [Music] so again of course the automated border detection can be helpful and uh this is an example where collapsibility index was 26 percent in the subcostal and 23 percent in the trans-epidemic let's move now to the superior vena cava where uh of course as mentioned by bob monet is performed in mechanically ventilated patients it requires much more skills than the use of transesophageal echocardiography which is not everywhere available the pioneer group in this regard is the group of professor antoine villavaron where they calculated the svc collapsibility index because of the collapse of the sbc during inspiration and the others found that 36 percent cut off predicted with 100 percent accuracy the patient with an increase in cardiac index after volume expansion with a 90 percent specificity in patients that didn't respond to foreign [Music] how does the superior vena cava perform as compared to the ivc uh it seems to perform better according to this study where the outers found that the catapult 35 which is very similar to the 36 and much better specificity and sensitivity as compared to the ibc distance another option is to use the miniaturized the te probe which is available in some units and in this study in facial undergoing open major vascular structure the authors compared the spc collapsibility index with stock volume variation and what they found is that both indexes are at a good productivity around 0.9 percent and again that echo was very similar to the one used by the group of uh professor bill barron uh one uh concept that must be clear is of course that with hd there is no only plane and the spc is uh identified in short access view while in the transits of ideal echocardiography we use it in longer access [Music] let's move now to uh other parts of the venus district which i call those non-vena cava veins and several districts have been evaluated for through response press subtraction internal jugular femoral femoral and there are these two studies by dr uh kent which i will summarize in this table to make it easier so uh in the first study the elders evaluated the ivc as compared to the subdragon name with 94 faded measurements and in the second one they evaluated the internal jugular vein or the femoral vein as compared to games what's the authors found is that time to data acquisition is shortened for the three uh other districts as compared to the idc however the subclavian vein and the internal jugular vein and another estimation of 3.2 to 3.5 percent while the femoral vein had a 3.8 percent underestimation more importantly the correlation was acceptable for the day but wasn't that good for the ijb or the femoral pain also a patrick vein and in particular the middle hepatic vein had been studied in this regard it's a bit more complex the analysis of a pathway daughter but one of the most important uh parameters in this pattern is the change in the diastole diastolic flow and this is a study from our chinese colleague that found a very good area under the tube by the changes in the d wave calculated with echocardiogram [Music] so sorry with point of care ultrasound of course my summary on the use of non-being a campaign for fluid responsiveness is that they are interesting they are targets that most of the time are accessible and easier to perform but people must be aware of the measurement bias the different cutoff for each index and the correlation anyway is never really strong with uh the idc and more importantly we know that there are factors interfering with the idc and the sdc diameter and the and there is no reason to why this shouldn't affect also the flow upstream let's move now to the arteries and uh regarding the arteries is the ascending art has been used mainly in children with echocardiography but the carotid artery is another interesting target that i will discuss uh one of the most common indexes that have been studied is the correctly corrected current inflow time where the operator evaluates the time between the systolic peak to the [Music] and as a rule of thumb the lower the time the most likely the patient will be through the responder of course it needs to be corrected for the heart rate and this is why we call it corrected proton another one is the carotid blood flow which essentially has the same principle behind the calculation of cardiac output so we measure the diameter of the artery and the vti with translate analysis um there are several studies on the corrected carotid flow time and i will show you this one from the group of maxim cancer where patient with undifferentiated shock had a good area under the tube when the corrected carotid flow time variation after possible advancing was used to identify fluid responders however there are also studies that were not able to identify a top point on the use of carotid protein my summary on carotid flow timing is that certainly the easy identification of the artery is a good point but the analysis can be challenging because it needs some angle correction because the measurement is in milliseconds and therefore it's more prone to measurement errors and the identification of the necrotic notch may be more challenging especially in very satisfaction there are completing findings between studies and the last point is that carotid blood flow could be a better alternative at least as shown by the group of iodine where a measurement of carotid blood flow was a better marker of fluid responsiveness and as compared to the carotid corrected [Music] there are several other non-invasive assessment of fluid responsiveness with non-ultrasound and the non-arterial line methods [Music] has shown you about the separation waveform analysis but again prof mode has conducted several studies also on entitled co2 variation after passive neglect for pre-responses um before concluding my presentation i would like to stress that fluid may be harmful to the patient and therefore we need to collect as many information as possible as is and the risk for the patient comes not only during information acquisition so when we use invasive best non-invasive methods but also when we collect information that may be not accurate or precise and therefore we could make wrong clinical diseases [Music] the non-invasive tool for fluid responsiveness can be associated also to other non-invasive tools to evaluate whether the patient needs fluid and the center in these regards the use of language of sound or their biggest congestion score by liprolla could be really promising tool that are under investigation in conclusion uh there is certainly no holy grail or non-invasive assessment of good responsibilities and echocardiography and point of care ultrasound are invaluable too but not only for fluid responses for the assessment of patients in shock and so on there are issues on training their resources of course as well and clinicians should combine all the information to decide whether administration is a project and finally let me mention that there is no reason why the future intensities shouldn't be competent in uh echocardiography and point of care ultrasound so please do consider the european diploma by our society and also to join our congress annual congress that will start in less than one month thank you very much for your attention thank you thank you dr philippus of philippu for this nice and complete presentation about the non-invasive devices for fluid assessing fluid responsiveness and they have we have just 10 minutes for question i have some question for the moment for xavier but probably we should have some other question for you filippo so the first question is that can we use the ppv and svv in the following situation the first situation when patient has intercostal tube chest tube or abdominal drains because there is probable disruption of the pressure transmission and the second part for the situation is can we use these parameters when we have long femoral access for rrt so thank you for the question chest tubes and abdominal drainage abdominal drainage it's not i think it's not been uh investigated alpha do you know any study about it abdominal drainage test tubes likely it is less reliable because of course some of the pressure induced by ventilation is uh escapes out of the lungs less reliable and false negatives regarding renal replacement therapy and fungal artery ppv and suv keeps its reliability and it's not um i mean that of course it may detect hypovolemia induced by priming of the circuit by um ultra filtration by the circuit etc but of course the uh the altean line must not be in contact just uh with the uh with the um [Music] there must not be a how may i say of course it should not be in a fistula okay it's of course if renal replacement therapy is performed in a vein and ppv is measured in an artery artery that's very circulation okay xavier the second question is regarding the end expiratory occlusion test how practicable to induce breath hold for 12 seconds in icu i think you have a quick answer exactly as you do for a measuring the intrinsic peak you know you have a button on the ventilator you click on it and you wait until 15 seconds in some ventilators by the way it stops automatically at 15 seconds for avoiding too long ventilatory poses so just by click on the button and look at the patient if there is no breathe spontaneous breathe if the patient is totally awake for instance then the test is valid and at the same time you look at the value of correct output or with a co-cardiac with here's vti or sp2 etc etc so it is just by clicking on the button again the time is is uh is a bit long i i repeats the cross of the pulmonary circulation and the fact that you have to average several values of correctly good so to keep the max value to catch the max value you need to have a quite long and expiration inclusion but five seconds definitely it's too short you will see nothing on correct and xavier as you said also if the patient has a lot of inspiratory effort spontaneous inspire it's not possible to do that but it's not very frequent in your practice it's it's not that frequent because in the icu many patients have a low level sedations or spontaneously do not breathe that much but it's true that in some patients it is not possible to study with the formed we we found that i think it was in 10 or 15 percent of common icu patients that definitely it's not possible so it's not a majority of the patients it's a minority of them okay i still with you xavier and i will read integrally the the question hi xavier in 2016 you published a study my patient received fluids in which you underline the side effects of fluid administration in view of this should we redefine the term of fluid responder not only for cardiac output increase but also tissue oxygenation without increasing cvp and or intra-abdominal pressure extra vascular lung water no high-moderation no rv impairment a new definition uh i thank our friend for that long question then my our point in this review is to say that it's not give it's not just give fluid and and go away now you should really look at the response to fluids of course you measured preload responsiveness you assassinated with some concepts before but after fluid infusion do not leave the room did cardiac output actually increase did tissue oxygenation increase and it improved and it's not in other patients with increasing cardiac output did you induce some adverse effects of fluid administration increase in cbp in lung water etc so it is not just assessing preload responsiveness but also the response positive and negative response to fluid administration okay thank you xavier a last question for you xavier and then after for uh filippo uh is ppv and spp useful in patients with heart rate more than 140 beats per minute likely not there have been one study at least one i know by the team of danielle debecker showing that if heart rate is too um is too high ppv has no time to vary in fact but of course for this you really need a very uh rapid event no i answer it is with rapid ventilation so if the rate of rate of ventilation of a heart rate is is very high then you cannot use it i think it's only for exceptional values actually but it may happen okay it happens for respiratory rates more than 40 breaths per minute regarding heart rate itself so tachycardia there is no reason because they it works even for higher heart rates even more because ventilation if ventilation is slow slow enough you will see variations whatever the number of cardiac cycles so tachycardia no problem very rapid ventilation it might be a problem with false negatives in case of very very rapid ventilation of course and uh when it is techy arrhythmia of course it's not applicable and it's not valid very good point you're right of course to mention that so philippo we have some question for you uh i will read it also integrity because it's um it's a nice uh a nice question thank you so much for that brilliant presentation i would like to know if i can use vti variation and the mechanical ventilation to assess fluid responsiveness [Music] okay thank you for the question yes i mean uh vti variations are calculated with a pathway doctor and can be used and i would suggest to couple it with maneuvers that change reload uh to the patient let's say passive leg raising of course also with the variation in the ventilation okay so you measure the biggest and the smallest ppi but as you phrase it there is a risk of also um errors and as mentioned by uh there is a i variability inter observer and the income server variability so then when you when you measure it and you have a a big big variation then it will be clear that your patient is possibly fluid responder but for smaller variation then on its own could be less evident i would suggest to calculate with the plastic leg raising the variation or with an expiratory occlusion test and so on uh the technical uh issue is that you need to stay still with your problem you need advanced skills from echocardiography perspective and so on and we know also how it can be challenging to gather uh apical five chamber view in patient uh ventilated in the intensive care so also the feasibility of it is an option it's a it's an issue that can be taken on board okay so uh sorry can you go very briefly on the first question received by prof uh agree that there are no studies on the chest tube and how they influence variation or other indexes but if the chess cube is there not for a big pneumothorax and with the risk of accumulation the chest tube can be trampled for few seconds during the assessment so this is an option that can be considered several it doesn't expose the patient to [Music] risk okay so what about the ivc diameter usage in femoral venous excess for crrt what about the oh okay the ivc and the in the venus uh access the tour i mean it's we are still in the pioneer uh era for the venus axis ultrasound and um i would first consider if the patient is fluid responder and then if the operator is skilled to use texas or lang ultrasound then of course take this information on board if you use it during a crrt i'm not aware there are studies evaluating uh we still need studies on boxes and then of course on the limitation of the exercise let's say like uh patient undergoing uh crt so i'm not aware of any study in these regards and it may influence of course but it needs to be properly studied and addressed from scientific perspective to continue with the vexes i have a question what is your cutoff point of fluid therapy uh i personally must admit that i am i don't use vectors frequently it's still something that needs to be studied and i think we still need evidence before we introduce in clinical practice we don't we don't need to be over enthusiastic with echo as with any other tool uh we just need to evaluate scientifically all this and see whether they can help to distinguish patients that may need or may not need food i think lexus will have a lot of space during the recovery of the patient the critical impression when we will use it uh to understand uh how much intervenors congested and how much we need to push on fluid removal and there are studies uh by manu my brain and other experts implementing also crt during recovery of the patient for uh speeding up the fluid removal as we are still at early stages okay xavier we have a last question and then we finish increasing cardiac output doesn't assure increasing blood pressure do you think you could be satisfied with only increasing cardiac output uh it depends for which test um if we speak about fluid challenge or passive leg raising which is like a fluid challenge then it must increase cartilage but basically fluid should increase cardiac output and blood pressure is only a side effect and it does not always in all the cases so basically that's why for these tests you need to measure correct output or estimate it in a way but you can unfortunately you cannot rely just on blood pressure so definitely what you must look for fluid tests of fluid responsiveness basically it is for an increase in cardiac output or a surrogate okay thank you xavier thank you philippu we thank all the audience and the esi cmg healthcare for this nice webinar and i say to you just good evening everybody and thank you alfa thank you very much for your moderation [Music] uh [Music] [Music] you

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Length: 81min 20sec (4880 seconds)

Published: Tue Sep 07 2021