should I bother with the ebb and flow phases of

should I bother with the ebb and flow phases of

32nd ISICEM 2012 – Brussels, Belgium
Should I bother about Ebb and Flow phase of shock? 22 March 2012 32nd ISICEM – Pulsion session Manu Malbrain 19/11/2011 Should I bother about Flow and Ebb phase 1 Manu Malbrain? •  ICU and HC Burn Unit Director ZNA STER •  Past President, treasurer WSACS (www.wsacs.org) •  EducaPonal Grant: 2003 ESICM Chris Stoutenbeek Award •  Member Medical Advisory Board Pulsion Medical Systems My biggest bias = WSACS
→  KCI Benelux →  Spiegelberg World
Society on Abdominal Compartment
→  Convatec and Holtech Medical → 
Syndrome
•  European Patent Holder CiMON (PMS) •  Research Project: Draeger, Edwards, Bard, Wolfe Tory •  Fees -­‐ Honoraria: GSK, MSD WSACS Executive Committee 2007-2011: Your Humble Servants…
WSACS Founded 2004 in
NOOSA, AUS
Zsolt Balogh, AUS
Secretary WCACS
Jan De Waele, B
19/11/2011 CTWG
Manu Malbrain, B
Founding President
Treasurer
Mike Cheatham, USA
President
Michael
Sugrue,
AUS
Rao Ivatury, USA
Should I bother about Flow and Ebb phase Past President
Vice-President
3 In Medicine as in Real Life… Things are Seldom what they Seem • Q1-­‐ What is the highest? A. Mr Bean
C. Atomium B. Manneken Pis D. Town Hall 32nd ISICEM – PULSION SESSION Manu Malbrain, MD, PhD • Q1-­‐ What is the highest? A. Mr Bean (1.81m) C. Atomium (108m) B. Manneken Pis (0.45m) D. Town Hall (96m) 32nd ISICEM – PULSION SESSION Manu Malbrain, MD, PhD • Q2-­‐ What has the most alcohol? A. Stella C. Trappist Westvleteren B. Leffe D. Duvel 32nd ISICEM – PULSION SESSION Manu Malbrain, MD, PhD medisch-financieel overleg
• Q2-­‐ What has the most alcohol? A. Stella (5.5%) C. Westvleteren (10.2%) B. Leffe (9%)
D. Duvel (8.5%) 32nd ISICEM – PULSION SESSION Manu Malbrain, MD, PhD • TherapeuPc Dilemmas 32nd ISICEM – PULSION SESSION Manu Malbrain, MD, PhD Today’s Agenda •  The risks of fluid overload •  InteracPve Case Discussion •  Meta-­‐analysis •  A 3 hit model of shock •  An integrated approach •  Wrap it up 19/11/2011 Should I bother about Flow and Ebb phase 10 Fluid Overload The Risk of Fluids 19/11/2011 Should I bother about Flow and Ebb phase 11 What I really need to know is… SEE
MORE
Œ When do I start giving fluids? benefit of fluid administration?
 When do I stop giving fluids? risk of fluid administration?
THAN
Ž When do I start emptying? benefit of fluid removal?
OTHERS
 When do I stop emptying? risk of fluid removal?
19/11/2011 Should I bother about Flow and Ebb phase 12 SepPc Shock PaPents (n=36) 19/11/2011 Alsous Should et al.I bChest
2000;
117:
other about Flow and E1749-54
bb phase 13 Beher lung funcPon: -­‐ LIS↓ -­‐ FiO2/pO2 ↑ -­‐ Pplat ↓ -­‐ PEEP ↓ Cum FB: 6992±502 ml Cum FB: -­‐136±494 ml No excess extra-­‐
pulmonary organ failure RCCT, N=1000 19/11/2011 Should I bother about Flow and Ebb phase 14 IntroducPon •  Any measurement in the ICU stands or falls with its accuracy and reproducibility… •  No measurement has ever improved survival, only a good a protocol can… Example of a Poor Protocol… Trof RJ et al. CCM 2012; 40
Example of a Poor Protocol… Fluid Challenge
EVLWI < 10
GEDVI < 850
Trof RJ et al. CCM 2012; 40
Example of a Poor Protocol… Fluid Challenge
EVLWI < 10
GEDVI < 850
We must NOT give a fluid challenge Trof RJ et al. CCM 2012; 40
SEPTIC
SURGICAL
694 788 GEDVI < 850 ml/m2 is too high Ebb Phase of SHOCK Fluid Guidance:
MAP, SVV, PPV,
GEF/GEDVI,
PLR, TEO Flow Phase of SHOCK Fluid Guidance:
Positive (Σ) Fluid
balance, IAP,
EVLWI EVLWI is NOT a trigger Fluids The pfor aPent warms Ashen faces, a thready pulse and cold clammy extremiPes… up, cardiac output increases and the surgical team relaxes… The Flow Phase -­‐ Cuthbertson. The Ebb Phase -­‐ Cuthbertson, Lancet 1:233, 1942 Should I bother about Flow and Ebb phase 19/11/2011 Quart. J. Med.25:233,1932 21 Case Study From Ebb to Flow phase 19/11/2011 Should I bother about Flow and Ebb phase 22 LI, Male, 26 years old •  O2 debt during birth •  CVA, lep hemiparesis •  Epilepsy −  Topamax, lamictal, tegretol •  CogniPve deficit •  Special daycare •  Since age of 17 known with ideopathic CMP (LVEF 52%) −  Coversyl Reason for admission •  General seizures −  Different from previous •  Syncope •  BP not palpable •  On ED: VT? −  DC biphasic 200J •  Transfer to ICU EvoluPon Overnight •  Hemodynamically stable •  No seizures •  Gradual increase in supplemental O2-­‐needs –  From 2L via nasal cannula –  To 15L with NRM •  Failure of NIV •  ETT and MV Aper ETT •  Hemodynamically Unstable –  CVP 16 mmHg –  MAP 51 mmHg •  On convenPonal MV –  Evita XL FiO2 100% –  24 x 400 mL –  PEEP 10 –  P/F raPo 74 Transthoracic Cardiac US LVEF 30% MR 2 to 3/4 TT Cardiac US • 
• 
• 
• 
• 
• 
• 
Dilated CMP (Lep atrium 65mm) CO: 6.2 L/min (CI 3.5) LVEF: 30-­‐35%, FAC: 28.5% LVEDA: 28.7 cm2 – LVEDAi: 16.2 cm2 E/E’: 15 -­‐ LVEDP: 25 mmHg MR 2 to ¾ (central + 2 eccentric jets) VCI: 21 mm QuesPon 1: What is your treatment of choice? 1. 
2. 
3. 
4. 
5. 
Norepinephrine Dobutamine Fluids bolus DiurePcs Other MAP 59 CI CVP 16 3.5 Lactate 2.8 P/F 74 LVEDP 25 IPAP 30 LVEF PEEP 10 30 LVEDA 28.7 Further course… •  FiO2 was increased to 100% •  PEEP set according to PV loop –  BPsys drop to 40 mmHg during recruitment •  Norepinephrine was started –  Swiply increased to 0.4 y •  Dobutamine started at 3y •  SaturaPon poor at 88% •  Switch to HFPV – VDR4 19/11/2011 Should I bother about Flow and Ebb phase 30 !"##$%&!'(")*(+'(',-'../-(
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Should I bother about Flow and Ebb phase 31 QuesPon 2: What is your treatment of choice? 1. 
2. 
3. 
4. 
5. 
Normal Values:
PPV: <10 %
GEDVI: 600 – 850
GEF: 25-35%
EVLWI: 3 – 7
PVPI: 1 – 3
Norepinephrine Dobutamine Fluids bolus DiurePcs Other HFPV 30/10 MAP 65 CI 3.5 P/F 57 CVP 16 GEF 13 IPAP 34 PPV 19 GEDVi 757 PEEP 15 EVLWi 38 Decision Tree.. 19/11/2011 Should I bother about Flow and Ebb phase 33 For the Panel •  How do you explain the relaPve discrepancy between the volumetric (low normal – GEDVi 757) and barometric (high – CVP 16) preload indicators in this paPent? •  Remember that the SSC guidelines state that CVP must be resuscitated towards 8-­‐12 mmHg 19/11/2011 Should I bother about Flow and Ebb phase 34 Barometric vs Volumetric preload? 20
15
•  Don’t trust tradiPonal BAROmetric filling pressures (CVP or PAOP) •  Use Volumetric preload indicators (GEDVI – PiCCO or RVEDVI – Swan) GEDVI (BL)
1200
CVP (BL)
GEDVI (IAH)
1000
CVP (60min)
MV-IPPV
(auto)PEEP
Post CABG
Obesity
IAH-ACS
800
600
10
400
5
200
0
0
Malbrain
Hering
Schachtrupp
Malbrain
Hering
Malbrain et al. Current Opinion Crit Care 2004; 10(2): 132-­‐145 Schachtrupp Hachenberg
Surviving Sepsis Guidelines IAP 11 •  CVP: 8-­‐12 mmHg •  Chasing a CVP may lead to: →  OVER resuscitaPon →  UNDER resuscitaPon 19/11/2011 Should I bother about Flow and Ebb phase 37 Crit Care Med 2008; [published correc`on appears in Crit Care Med 2008; 36:1394-­‐1396] 36:296-­‐327 19/11/2011 Should I bother about Flow and Ebb phase 38 Surviving Sepsis Guidelines 19/11/2011 Should I bother about Flow and Ebb phase 39 TT Cardiac US IVCCI= 50% •  Small volume resuscitaPon (SVR): Hyperhaes 4ml/kg/15min •  2x 500ml Volulyte Next morning Dobu 9 Norepi 0.4 19/11/2011 Should I bother about Flow and Ebb phase 41 EvoluPon overnight •  CI h
•  GEDVI h •  EVLWI i •  MAP h CVP decreased from 16 to 6 mmHg with filling 19/11/2011 Should I bother about Flow and Ebb phase 42 Respiratory Support overnight HFPV NO (stand-­‐by) • 
• 
• 
• 
19/11/2011 Should I bother about Flow and Ebb phase pO2 h
P/F h FiO2 i IPAP h 43 Next morning on Day 2 EVLWI 13 P/F 157 PVPI IPAP 32 PEEP 11 2 TherapeuPc Dilemma… We gave fluids because: •  PPV was high and PLR was posiPve •  The GEDVI was relaPvely low (in relaPon to GEF) despite the increased CVP, LVEDAI and high EVLWI… •  (IVCCI was almost 50%) 19/11/2011 Should I bother about Flow and Ebb phase 45 So,… What I really need to know: •  What is the Frank Starling curve of my paPent? •  Where is my paPent on the curve? 19/11/2011 Should I bother about Flow and Ebb phase 46 SoluPon: GEF-­‐corrected GEDVi •  When to use? Malbrain M. et al. AAS 2010; 54(5): 622-­‐631 EF corrected volumes? GEF 0.15 GEDVI GEF 0.25 GEF 0.35 Cardiac INDEX Malbrain, Cheatham. Yearbook Intensive Care 2004 ΔCI
Pressures as preload? ΔCVP
19/11/2011 ΔPCWP
Should I bother about Flow and Ebb phase 49 ΔCI
Volumes as preload? ΔRVEDV
19/11/2011 ΔGEDV
Should I bother about Flow and Ebb phase 50 ΔCI
Corrected volumes vs preload? ΔcRVEDV
19/11/2011 ΔcGEDV
Should I bother about Flow and Ebb phase 51