Sink or Swim: New Waves in
Fluid Resuscitation
Mike McEvoy, PhD, RN, CCRN, NRP
Chair – Resuscitation Committee – Albany
Medical Center, NY
Sr. Staff RN – CTICU – Albany Medical Center
EMS Coordinator – Saratoga County, NY
Learning Objectives
1. Recall the incidence of patients who fail to respond to
fluid boluses in the ICU
2. Discuss current controversies in fluid volume
management
3. Recognize the value of measuring patient response to
fluid administration
www.mikemcevoy.com
S/P Open AAA
> BP 80/40 (MAP 58), CVP 4, HR 86, UO 5
> BP 82/38 (MAP 60), CVP 4, HR 82, UO 10
> BP 84/36 (MAP 59), CVP 4, HR 88, UO 8
3 Shock States:
1. Hypovolemic
2. Distributive
3. Cardiogenic
Is there danger in the water?
Permissive Hypotension in Trauma Resus
IV fluids in hypovolemic shock:
> No  survival, some  mortality
Theories on IVF in trauma:
1.  BP dislodges clots
2.  BP =  bleeding
3. IVF hemodilutes clotting factors
EMS/ED: allow SBP 90, MAP 50-60
Duchesne JC et al. Damage Control Resuscitation: From Emergency Department to the Operating
Room. The Amer Surgeon. 2011; 77: 201-206.
Permissive Hypotension Limits
SBP 90 (MAP 50 – 60 mmHg):
1. Bleeding controlled, no shock = no IVF
2. Bleeding controlled, shock  500 ml IVF (may
repeat X 1)
3. Bleeding uncontrolled = no IVF
Ideal permissive hypotension < 90 min.
Severe damage when > 120 min.
Li T, et al. Ideal Permissive Hypotension to Resuscitate Uncontrolled Hemorrhagic Shock and the
Tolerance Time in Rats. Anesthesiology. 2011; 114 (1): 111-119.
More than 50% of patients in which fluid loading
was “clinically indicated” are non-responders and
are being loaded with fluids unnecessarily!
The Volume Problem
> Volume expansion 1st line
of therapy.
> Only ½ of patients show an
increase in CO as a
response to fluid therapy
(Defined as responders).
> Need a reliable means to
determine patient ability to
respond to fluids.
Crit Care Med – Jan 2013
Crit Care Med 2013; 41:34–40
Crit Care Med – Jan 2013
•
•
•
•
•
•
27,022 simultaneous NIBP & A-line BPs
4,957 patients
University teaching hospital ICU
NIBP overestimated SBP in hypotension
Mean from NIBP and A-line consistent
MAP < 60 associated with AKI & death
Crit Care Med 2013; 41:34–40
AKI: aline versus cuff
Acute Kidney Injury: MAP
Can We Use BP Alone?
Bland, Shoemaker
J Surg Obst 1978:
 74 % of survivors
achieved normal values
 76% of NONSURVIVORS achieved
normal vital signs
2001: Rivers Calls for EGDT
System-based Approaches to sepsis
Early-Goal Directed Therapy
INCLUSION = Sepsis AND [BP < 90 after fluid OR Lactate > 4]
Control
Intervention
EGDT
CVP 8-12
Fluids
CVP 8-12
MAP > 65
Vasopressors
MAP > 65
Transfusions
Dobutamine
ScvO2 > 70%
49% mortality
33% mortality
LOS 4 less days
$13-16,000 savings
Rivers, E., Nguyen, B., Havstad, S., Ressler, J., Muzzin, A., Knoblich, B., Peterson, E., et al. (2001). Early goal-directed therapy in the treatment
of severe sepsis and septic shock. New England Journal of Medicine, 345(19), 1368–1377.
System-based Approaches to sepsis
Going forward after the study…
Control
EGDT
49% mortality
33% mortality
...treated at clinician discretion
according
to a protocol
Do what
you for
hemodynamic support, with
normally
do. We’ll
critical-care consultation,
and
admitted
for inpatientyou.
care as
be watching
soon as possible...
...treated in the emergency
Use
a rigid protocol
department (by ED attending, 2
residents,
according
with3 nurses)
multiple
to a protocol for early goaldedicated
team
directed
therapy...for
at least
six hours...
members
Rivers, E., Nguyen, B., Havstad, S., Ressler, J., Muzzin, A., Knoblich, B., Peterson, E., et al. (2001). Early goal-directed therapy in the treatment
of severe sepsis and septic shock. New England Journal of Medicine, 345(19), 1368–1377.
Hospital-wide impact of a standardized order set for
the management of bacteremic severe sepsis
After
Before
Thiel, S. W., Asghar, M. F., Micek, S. T., Reichley, R. M., Doherty, J. A., & Kollef, M. H. (2009). Hospital-wide impact of a standardized
order set for the management of bacteremic severe sepsis*. Critical Care Medicine, 37(3), 819–824.
doi:10.1097/CCM.0b013e318196206b
Summary of Trials
Rivers 2001
RCT
Sebat 2005
Before-After
Nguyen 2007
Complete or
Not
Goals
CVP >8
MAP > 65
ScVO2 >70%
HCT >30
MAP > 70
SaO2 > 92
UOP > 30ml/h
SvO2 > 60
CI > 2.5
Specific
Interventions
Fluids, Blood,
Pressors
ABX, Fluids
Pressors
Screening,
System
ED-based Sepsis
Education, Shock
Team
Interventions
Team, Protocols
Absolute
Change in
Mortality
-16%
-12%
Thiel 2009
Before-After
Levy 2011
Before-After
ABX in 4 h
CVP > 8, MAP >
65, ScVO2 >
70%, HCT > 30
Check Lactate
Steroids
Appropriate ABX
in 4 h, CVP > 8,
MAP > 65,
ScVO2 > 70%
Early ABX, Blood
Cultures,
Appropriate ABX,
CVP > 8, MAP >
65,
SvO2 > 70%
ABX, Fluids,
Blood, Pressors
ABX, Fluids, Pressors,
Steroids, Xigris, Other
Supportive Care
ABX, Fluids, Pressors,
Steroids, Xigris, Other
Supportive Care
Education, Inservices,
Protocols
Education, Inservices, Order
Set, Protocols
Screening,
Education, Order
Sets
-19%
-16%
-7%
Sepsis Guidelines 2012
Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: International Guidelines for Management
of Severe Sepsis and Septic Shock: 2012. Critical Care Medicine 2013;41(2):580–637.
Sepsis Guidelines 2012
Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: International Guidelines for Management
of Severe Sepsis and Septic Shock: 2012. Critical Care Medicine 2013;41(2):580–637.
During the first 6 hrs of resuscitation, the goals of initial
resuscitation of sepsis-induced hypoperfusion should
include all of the following as a part of a treatment
protocol (grade 1C):
Drilling into Surviving Sepsis 2012
Strong evidence exists only for:
1. Quickly restoring perfusion
2. Early blood cultures
Bundles
 A bottle of wine makes for a good evening?
 5 beers make for a good evening?
 A fine scotch makes for a good evening?
Wine + 5 Beers + fine scotch = a GREAT evening?
2012 Meta-Analysis of Fluid Bolus in Kids:
Conclusions: “…fluid boluses were harmful compared to no
bolus. Simple algorithms are needed to…determine who
could potentially be harmed by the provision of bolus fluids,
and who will benefit.”
Ford N, Hargreaves S, Shanks L (2012) Mortality after Fluid Bolus in Children with Shock Due to Sepsis or Severe
Infection: A Systematic Review and Meta-Analysis. PLoS ONE 7(8): e43953. doi:10.1371/journal.pone.0043953
Forest plot for the outcome of mortality: no bolus versus bolus
Continuous cardiac output monitoring is
the gold standard to monitor the
response to a fluid challenge.
Arterial Pulse Cardiac Output (APCO)
Pulse Pressure Relationship to Stroke Volume
>
Fluctuations of blood pressure
around a mean value result
from the volume of blood
forced into the arterial circuit
during systole
>
Magnitude of change in
pressure – i.e., pulse pressure,
is a function of the magnitude
of the change in stroke volume
>
One factor of importance is
compliance of the arterial walls
Limitation: Heart Rate Variability
47
SVV
Arterial Pressure Based Technologies
> Technologies that use
the arterial pressure
to determine cardiac
output can be
affected by the quality
of the arterial
pressure tracing.
> Note the impact of an
overdamped tracing
on the LiDCO cardiac
output value.
Jansen & van den Berg 2005
“There is growing evidence that the pulse
contour method is not the solution to
providing reliable CO monitoring at the
bedside.”
Does Respiration Affect Pressure Waveforms?
SPV, PPV, SVV Defined
All measure the difference between the maximum and
minimum values over a full respiratory cycle:

SPV: Systolic Pressure Variation (mmHg):


PPV: Pulse Pressure Variation (%):


SPMax – SPMin Normal < 10 mmHg
PPMax – PPmin/ PP mean Normal <13%
SVV: Stroke Volume Variation (SVV%)
measured over a 20 second cycle:

SVMax – SVMin/SV mean Normal < 10 – 15 %
SPV, PPV, SVV Dynamic Parameters
Pleth Waveform
SVV or PVI and Fluid Status
> High variability = volume depletion (“high is dry”)
 Ability to observe and intervene in real time
> 50% of patients are fluid non-responders
 The ventricle more
sensitive to respiratory
changes is more
responsive to preload
1. Who needs fluid
2. Who will respond
Clinical Evidence:
Predicting Fluid Nonresponders
Invasive
-Maxime Cannesson, M.D., Louis Pradel Hospital , Lyon, France
Lactate (Lactic Acid)




Hypoperfusion
severity index
NL < 2, concerned
when > 4
> 15 often fatal
More helpful as
trend (q 6 hours)
Chest 2002;121;1245-1252
PLR??
SemiFowler’s
>
>
>
>
45 °
Passive
Leg Raising
150 – 300 ml volume
Effects < 30 sec., not > than 4 minutes
Self-volume challenge
Reversible
InSpectraTM StO2 Systems
Ardolic, Ann Emerg Med. 2010;56:S131.
Cohn, J Trauma. 2007;62:44.
Moore, Int Proc TSIS 2007;111.
What is StO2?
StO2 = hemoglobin oxygen saturation of the microcirculation
SaO2 and
SpO2
measure O2
saturation in
the arteries.
ScvO2 measures
O2 saturation in
the superior vena
cava.
SaO2
SpO2
ScvO2 SvO2 measures
SvO2 O2 saturation in
InSpectra StO2
StO2 measures O2 saturation in the
microcirculation where O2 diffuses to tissue cells. StO2 is a
measure of tissue oxygenation and is a sensitive indicator of
tissue perfusion status.
Cohn, J Trauma. 2007;62:44.
the pulmonary
artery.
Intensive Care Med. 2013 Jan;39(1):93-100
What hemodynamic
monitoring do you
routinely use for the
management of high-risk
surgery patients?
What are your indicators for volume expansion
in patients undergoing high-risk surgery?
While only 47% of intensivists
believed that CVP should guide
resuscitation, 86% used it
because of the Surviving Sepsis
Campaign Guidelines.
How should we monitor preload and
fluid responsiveness in shock?
Why, why, why?
Crit Care Med Apr 2013; 41:972–981
Why, why, why?
• Lactic acidosis results from the effects of
Care Med 2013; 41:972–981
the organisms, notCrit
hypovolemia
• Liberal fluid administration has little effect
and does not improve lactic acidosis or
renal function
• Pulonary edema is common and
exacerbated by fluid loading
• Liberal fluid replacement should be avoided
Fluid Resuscitation
 Give fluids only when needed, and no more
than needed (Could 2 liters be the limit?)

No value in non-responders, likely harmful
 Crystalloids are favored as the initial fluid
 Hydroxyethyl starches are likely harmful
 Albumin may have a role, particularly if a
lot of fluid is given
 A lower Hb target (~7) is generally accepted
Summary
> We need to rethink why we’re giving fluids

Important to identify who will benefit
> Restoration of circulation is the goal


Assess cardiac function and perfusion markers
When fluids are not immediately effective – use pressors
> Standardized approaches improve outcomes

Continual attention to effects of individual interventions
Questions?