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FluidChallengeRevisitedBinDu,MDMedicalICU,PekingUnionMedicalCollegeHospitalWhyFluidChallengeacutelyillpatientsfrequentlyrequirefluidrepletionhypovolemiaexternalloss:bleeding,gastrointestinal,urinarytracts,skininternalloss:extravasationofblood,exudation/transudationoffluidsRelativehypovolemia:increasesvenouscapacitancesepsis,drugsvolumerepletionessentialrestorecriticallevelsofcardiacoutputandarterialpressure,morenormalperfusionofvitalorgansandtissuesWhyFluidChallengeWhyFluidChallengeClinicalexamination:limitedsensitivity&specificityhistoryphysicalsignsroutinelaboratorytestsAnygivenleveloffillingpressure↓→morelikelyhypovolemia↑→morelikelyright/leftheartfailureneithersufficientlyreliableCVP&PAOPOsmanD,RidelC,RayP,etal.Cardiacfillingpressuresarenotappropriatetopredicthemodynamicresponsetovolumechallenge.CritCareMed2007;35:64-68FluidChallenge:WhenExtravascularvolumedeficitsdonotbecomeclinicallyapparentuntiltheyexceed10%ofbodyweightCO=SVXHRnonspecificsignLackofreliabilitybasedonastaticmeasurementFluidChallenge:WhenAmbulatorypatientFunctionalHemodynamicsSystolicpressurevariation(SPV)Strokevolumevariation(SVV)Pulsepressurevariation(PPV)Respiratorysystolicvariationtest(RSVT)Respiratory-inducedIVCdiameterchangereliablymeasuredonlyduringCMVtidalvolumedependentunreliablymeasuredduringarrhythmiaaffectedbydecreasedchestwallcompliancemisleadingduringrightheartfailureWhoNeedFluidChallengeMichardF,TeboulJL.PredictingfluidresponsivenessinICUpatients.Acriticalanalysisoftheevidence.Chest2002;121:2000-2008FluidChallenge:WhatFluidColloid:4%gelatin6%hetastarch5%albuminCrystalloid:0.9%normalsalinevs.vanderHeijdenVerheijJ,vanNieuwAmerongenGP,etal.Crystalloidorcolloidfluidloadingandpulmonarypermeability,edema,andinjuryinsepticandnonsepticcriticallyillpatientswithhypovolemia.CritCareMed2009;37:1275-1281FluidChallenge:WhatFluidvanderHeijdenVerheijJ,vanNieuwAmerongenGP,etal.Crystalloidorcolloidfluidloadingandpulmonarypermeability,edema,andinjuryinsepticandnonsepticcriticallyillpatientswithhypovolemia.CritCareMed2009;37:1275-1281FluidChallenge:WhatFluidvanderHeijdenVerheijJ,vanNieuwAmerongenGP,etal.Crystalloidorcolloidfluidloadingandpulmonarypermeability,edema,andinjuryinsepticandnonsepticcriticallyillpatientswithhypovolemia.CritCareMed2009;37:1275-1281FluidChallenge:WhatFluidvanderHeijdenVerheijJ,vanNieuwAmerongenGP,etal.Crystalloidorcolloidfluidloadingandpulmonarypermeability,edema,andinjuryinsepticandnonsepticcriticallyillpatientswithhypovolemia.CritCareMed2009;37:1275-1281conclusionpulmonaryedemaandLISnotaffectedbythetypeoffluidloadinginthesteeppartofthecardiacfunctioncurveinsepticandnonsepticpatientspulmonarycapillarypermeabilityasasmallerdeterminantofpulmonaryedemathanCOPandCVPFluidChallenge:HowMuchTheamountoffluidtobeadministeredoveradefinedintervalVincentJL,WeilMH.Fluidchallengerevisited.CritCareMed2006;34:1333-1337FluidChallenge:HowMuchFluidChallenge:HowMuchOriginaltechnique600-1000ml/hrOtherstudies(mostlyfromTeboulJLetalaboutPLR)500ml/10-30minSurvivingSepsisCampaignGuidelineCrystalloid500-1000ml/30minColloid300-500ml/30minVincentJL,WeilMH.Fluidchallengerevisited.CritCareMed2006;34:1333-1337DellingerRP,CarletJM,MasurH,etal:SurvivingSepsisCampaignguidelinesformanagementofseveresepsisandsepticshock.CritCareMed2004;32:858-873FluidChallenge:WhereMateerJR,etal.Rapidfluidresuscitationwithcentralvenouscatheters.AnnEmergMed1983;12:149-52.PeripheralvenouscatheterCentralvenouscatheterWhatParameterstoMonitorWhenCO/CI/SVcanbemeasured...PACPiCCOFlowTrac...WhenCO/CI/SVcannotbemeasured...SAP/DAP/MAPPP...IfCO/CI/SVisAvailable...volumeexpansion-inducedchangesinstrokevolume(?SV)>0%Calvin,Schneider>10%Wagner&Leatherman>15%Tavernier>20%Tousignantvolumeexpansion-inducedchangesincardiacoutput(?CO)>250ml/minMagder>0%Reuse>10%Diebel>15%Michard,Feissel>20%DiebelIfCO/CI/SVisnotAvailable...volumeexpansion-inducedfillingpressurechangeCVP2-5rulePAOP3-7rulevolumeexpansion-inducedbloodpressurechangeMAP/SAP/DAPpulsepressureCVP2-5RuleWeilMH,HenningRJ.Newconceptsinthediagnosisandfluidtreatmentofcirculatoryshock.AnesthAnalg1979;58:124-132CVP2-5RuleWeilMH,HenningRJ.Newconceptsinthediagnosisandfluidtreatmentofcirculatoryshock.AnesthAnalg1979;58:124-132?CVP?CVPCVP2-5RuleDataonfile,MedicalICU,PUMCHIfCO/CI/SVisnotAvailable...PreauS,SaulnierF,DewavrinF,etal.Passivelegraisingispredictiveoffluidresponsivenessinspontaneouslybreathingpatientswithseveresepsisoracutepancreatitis.CritCareMed2010;38:819-825IfCO/CI/SVisnotAvailable...PreauS,SaulnierF,DewavrinF,etal.Passivelegraisingispredictiveoffluidresponsivenessinspontaneouslybreathingpatientswithseveresepsisoracutepancreatitis.CritCareMed2010;38:819-825IfCO/CI/SVisnotAvailable...VolumeExpansionInfluenceofCardiacFunction18cardiacsurgicalpatientsPreoperativeLVEF%Group1:59.3(5.3)Group2:33.1(5.3)Volumeloadingsteps2consecutiveVLSperformed250mlHaemaccelgivenover5to7minutesPreismanS,KoganS,BerkenstadtH,etal.Predictingfluidresponsivenessinpatientsundergoingcardiacsurgery:functionalhaemodynamicparametersincludingtherespiratorysystolicvariationtestandstaticpreloadindicators.BrJAnaesth2005;95:746-755InfluenceofCardiacFunctionpatientsscheduledforelectiveCABGgeneralhaemodynamicHR,MAP,CVPPAC/PiCCOPAOP,pulsecontourSV,SVVTEELVEDA,LVESA,LVEFvolumeloadinghetastarch130kD6%10ml.m2/kgxBMIover5mins?SV>5%respondernonresponderSTOPReuterDA,KirchnerA,FelbingerTW,etal.Usefulnessofleftventricularstrokevolumevariationtoassessfluidresponsivenessinpatientswithreducedcardiacfunction.CritCareMed2003;31:1399-1404YesNoInfluenceofCardiacFunctionReuterDA,KirchnerA,FelbingerTW,etal.Usefulnessofleftventricularstrokevolumevariationtoassessfluidresponsivenessinpatientswithreducedcardiacfunction.CritCareMed2003;31:1399-1404meannumberofVLSperpatientmeanvolumeofVLSperpatient2.5637mL2.8809mLIfYouDoWorryaboutCardiacFunction...45°?45°?PassiveLegRaisingvenousbloodshift(Rutlenetal1981,Reichetal1989)increaseinrightventricularpreload(Thomasetal1965)increaseinleftventricularpreload(Rocha1987,Takagi1989)transienthemodynamiceffect(Gaffney1982)HowtoPerformPassiveLegRaising(PLR)JabotJ,TeboulJL,RichardC,etal.Passivelegraisingforpredictingfluidresponsiveness:importanceoftheposturalchange.IntensiveCareMed2009;35:85-9045°?45°?45°?45°?PLRSEMIRECPLRSUPINETimeFrame(2min)HowtoPerformPassiveLegRaising(PLR)JabotJ,TeboulJL,RichardC,etal.Passivelegraisingforpredictingfluidresponsiveness:importanceoftheposturalchange.Intensiv