Prof. Xavier MONNET

1. Assessment of fluidtherapy Use the right tool for the right job! Prof. Xavier MONNET Medical Intensive Care Unit Bicêtre Hospital Assistance publique – Hôpitaux de Paris FRANCE

2. Conflict of interest Pulsion Medical Systems

3. Assessment of fluidtherapy Use the right toolfor the right job! Prof. Xavier MONNET Medical Intensive Care Unit Bicêtre Hospital Assistance publique – Hôpitaux de Paris FRANCE

4. AP CVP PAC PiCCO ProAQT/PulsioFlex Nexfin Esophageal Doppler FloTrac/Vigileo Echo  Differents monitoring devices ?  Different indications

6.   Peri-op monitoring ICU monitoring Peri-op monitoring

7. Context High-risksurgical patients (exceptcardiacsurgery) Goals of monitoring Peri-op monitoring to detecthemodynamicdeterioration to guide volume expansion Improvesprognosis

8. Improvesprognosis withesophageal Doppler 60 patients hip replacement  hospital length of stay Peri-op monitoring 100 high-risk surgical patients  hospital length of stay 174 patients post cardiac surgery  hospital length of stay 162 multiple trauma patients after surgery • hospitallength of stay • ICU length of stay • lactate level

9. Improvesprognosis withLidCO 60-riskgeneralsurgical patients Goal directedtherapy vs. conventionaltreatment Post-operativephase  number of complications  hospital length of stay Peri-op monitoring 120 high-riskabdominalsurgery patients SVV-directedtherapy vs. conventionaltreatment Per-operative phase LidCO monitoring  number of complications  hospital length of stay

10. Improvesprognosis with Flotrac/Vigileo 40 patients with hip replacement underregionalanesthesia Goal directedtherapy vs. conventionaltreatment  number of complications Peri-op monitoring

11. Vigileo Pulsioflex Eso Doppler LidCOrapid continuous cardiac output continuous cardiac output continuous cardiac output continuous cardiac output Peri-op monitoring (AP curve analysis) (AP curve analysis) (cardiac output) (AP curve analysis) preload dependance (VVE and Δ PP) preload dependance (VVE and Δ PP) preload dependance (Δ aortic blood flow) preload dependance (VVE and Δ PP) preload (FTc)

12.   OR monitoring ICU monitoring Advanced monitoring Basic monitoring Arterial pressure CVP Esophageal Doppler Flotrac/Vigileo Pulsioflex LidCOrapid PiCCO EV 1000 PA catheter

13. Context initial phase of shock after the ER Basic ICU monitoring Objectives of monitoring assess the hemodynamic profile (type of shock) guide initial therapy fixsometherapeutic goals  Which basic monitoring?

14. Basic ICU monitoring

15. CVP Arterial pressure Helps for: Helps for : DAP Basic ICU monitoring deciding to give vasopressors determining the type of shock (preload) guiding fluid responsiveness (preload) deciding to give fluid (if ventilated) PPV MAP fixing some therapeutic goals

16.   OR monitoring ICU monitoring Advanced monitoring Basic monitoring Arterial pressure ? CVP ? Esophageal Doppler Flotrac/Vigileo Pulsioflex LidCOrapid PiCCO EV 1000 PA catheter

17. Context criticallyill patients whenshockpersistsafter initial fluidtherapy The onlyarterialpressure and CVP monitoring is not sufficientanymore Advanced ICU monitoring because patients receivevasopressors

18. Changes in PP induced by NE (%) 228 pts receiving volume expansion 145 patients withincrease of NE 300 Changes in PP induced by VE (%) * 250 300 200 r = 0.56 n = 228 r = 0.21 n = 145 Advanced ICU monitoring 250 150 200 100 150 50 100 0 50 -50 -50 0 50 100 150 200 250 300 0 Changes in CI induced by NE (%) -50 -50 0 50 100 150 200 250 300 Changes in CI induced by VE (%)

19. changes in CI (%) changes in PP (%) 100 100 228 pts receiving volume expansion 145 patients withincrease of NE 80 80 60 60 40 40 Advanced ICU monitoring 20 20 0 0 6% false + -20 -20 non responders non responders responders responders +15% 22% false -

20. Vigileo Pulsioflex Eso Doppler LidCOrapid continuous cardiac output continuous cardiac output continuous cardiac output continuous cardiac output continuous cardiac output continuous cardiac output continuous cardiac output Advanced ICU monitoring AP curve analysis uncalibrated AP curve analysis uncalibrated AP curve analysis uncalibrated (AP curve analysis) (AP curve analysis) (cardiac output) (AP curve analysis) preload dependance (VVE and Δ PP) preload dependance (VVE and Δ PP) preload dependance (Δ aortic blood flow) preload dependance (VVE and Δ PP) preload (FTc)

21. Whichdevice for advanced monitoring? Uncalibrateddevices 120 100 estimate SV from the arterial pressure curve 80 Advanced ICU monitoring 60 estimatearterialcompliance by analysing the arterialwaveform = k . SV 40 20 0 stillvaluablewhen the properties of the arterialcurve change in a large extent (sepsis, vasopressors) ?

22. 3.5 L/min Whichdevice for advanced monitoring? PiCCO and EV1000 devices measure cardiac output by Advanced ICU monitoring arterial pressure curve analysis

23. Blood temperature (Ts) inj Ttm Whichdevice for advanced monitoring? PiCCO and EV1000 devices measure cardiac output by arterial pressure curve analysis cold bolus calibrated by Advanced ICU monitoring transpulmonary thermodilution

24. PiCCO Vigileo2 Whichdevice for advanced monitoring? Ability to track calibrated cardiac index Advanced ICU monitoring changes induced by volume expansion (40 patients) changes induced by norepinephrine (40 patients) uncalibrated cardiac index

25. Whichdevice for advanced monitoring? Changes induced by norepinephrine Changes induced by volume expansion r = 0.72 p < 0.05 120 r = 0.78 p < 0.05 105 75 90 60 75   45 60 Advanced ICU monitoring PiCCO PiCCO CIpc (%) 45 30 D 30 15 15 0 0 -15 -15 -15 0 15 30 45 60 75 90 105 120 DCItd (%) -15 0 15 30 45 60 75 D CItd (%) 120 r = 0.33 p < 0.05 r = -0.03 p = NS 120 105 105 90 90 75 75  60 60 Vigileo2 Vigileo2 CIpw (%) 45 45 30 D 30 15 15 0 0 -15 -15 -15 0 15 30 45 60 75 90 105 120 -15 0 15 30 45 60 75 90 105 120 D CItd (%) D CItd (%)

26. Whichdevice for advanced monitoring? 51 pts, 401 measurements Vigileo2 vs.Vigileo3 vs. PAC Vigileo3 is more accurate and as precise than Vigileo2 Advanced ICU monitoring

27. Whichdevice for advanced monitoring? 33 patients Vigileo3 vs. esophagealDoppler Hemodynamic challenges by phenylephrine, ephedrine and whole-body tilting Advanced ICU monitoring

28. Whichdevice for monitoring cardiac output? PiCCO PA catheter EV 1000 cardiac output cardiac output cardiac output Advanced ICU monitoring

29. Context criticallyill patients whenshockpersistsafter initial fluidtherapy Goals of monitoring Advanced ICU monitoring precisely monitor the effects of therapy fixsometherapeutic goals predictfluidresponsiveness assess the risk of fluid expansion

30. How to assess the need for fluid? PiCCO PA catheter EV 1000 cardiac output cardiac output cardiac output Advanced ICU monitoring ScvO2 ScvO2 SvO2

31. Context criticallyill patients whenshockpersistsafter initial fluidtherapy Goals of monitoring Advanced ICU monitoring precisely monitor the effects of therapy fixsometherapeutic goals predictfluidresponsiveness assess the risk of fluid expansion

32. How to assess the need for fluid? PiCCO PA catheter EV 1000 cardiac output cardiac output cardiac output Advanced ICU monitoring PPV, SVV, PLR test, EEO test PPV, SVV, PLR test, EEO test PAOP ScvO2 ScvO2 SvO2

33. How to assess the need for fluid? Advanced ICU monitoring

34. How to assess the need for fluid? PiCCO PA catheter EV 1000 cardiac output cardiac output cardiac output Advanced ICU monitoring continuous continuous PPV, SVV, PLR test, EEO test PPV, SVV, PLR test, EEO test PAOP ScvO2 ScvO2 SvO2

35. How to assess the need for fluid? Advanced ICU monitoring • venous return

36. How to assess the need for fluid? Effects of end-expiratory pause on cardiac index 34 patients with acute circulatory failure monitored by PiCCO device 50 Advanced ICU monitoring 40 30 20 increase  5% Se = 91% Sp = 100 % 10 0 NR -10 R

37. How to assess the need for fluid? Advanced ICU monitoring

38. Context criticallyill patients whenshockpersistsafter initial fluidtherapy Goals of monitoring Advanced ICU monitoring precisely monitor the effects of therapy fixsometherapeutic goals predictfluidresponsiveness assess the risk of fluid expansion

39. How to assess the risk of volume expansion? PiCCO PA catheter EV 1000 cardiac output cardiac output cardiac output Advanced ICU monitoring PPV, SVV, PLR test, EEO test PPV, SVV, PLR test, EEO test PAOP ScvO2 ScvO2 SvO2 lung water and lung permeability lung water and lung permeability

40. veryhighpermeability normal permeability Lung permeability lung water Pcap How to assess the risk of volume expansion? lung water highpermeability Advanced ICU monitoring Pcap

41. veryhighpermeability normal permeability lung water Lung permeability lung water Pcap Lung water for estimating the risk of volume expansion? Lung water highpermeability Advanced ICU monitoring Pcap

42. Lung waterfor estimating the risk of volume expansion? Cold bolus Advanced ICU monitoring EV1000 PiCCO

43. Lung waterfor estimating the risk of volume expansion? 30 pts EVLW measured by TPTD and by postmortemgravimetry First validation of EVLW-TPTD evaluation in humans Advanced ICU monitoring → validation in humanbeings

44. Lung waterfor estimating the risk of volume expansion? Advanced ICU monitoring

45. Day-28 mortality (%) 100 p = 0.0001 80 70% 60 40 42% 20 0 EVLWImax > 21 mL/kg EVLWImax ≤ 21 mL/kg Lung waterfor estimating the risk of volume expansion? Extra-vascular lung water and pulmonary vascular permeability index are independent prognostic factors in patients with acute respiratory distress syndrome Jozwiak M, Silva S, Persichini R, Anguel N, Osman D, Richard C, Teboul JL, Monnet X submitted 200 pts with ARDS EVLW measured by PiCCO device Advanced ICU monitoring Odds Ratio ( CI 95%) p value Maximal blood lactate 0.81 (0.71 - 0.93) 0.002 Mean PEEP 1.25 (1.07 - 1.47) 0.005 EVLWI 0.94 (0.87 - 0.98) 0.01 max SAPS II 0.97 (0.95 - 0.99) 0.02 Mean fluid balance 0.9996 ( 0.9993 - 0.9999) 0.02 Minimal P/F ratio 1.01 (1.00 - 1.02) 0.02 Minimal pH 35.97 (0.47 - 2769.52) 0.10

46. Lung waterfor estimating the risk of volume expansion? Cumulative fluid balance (input - output; L) * 7 PAOP group * * 5 * 3 1 Advanced ICU monitoring EVLW group -1 -3 * p < 0.0001 vs time 0 -5 0 12 24 36 48 60 72 Time (hours) 101 ARDS patients randomized to EVLW-guided management vs. PAOP-guided management Mitchell JP et al., Am Rev Respir Dis 1992

47. Lung waterfor estimating the risk of volume expansion?  functional benefit of lung water monitoring 25 20 Advanced ICU monitoring 15 Management of fluid therapy with : * * 10 PAOP Group 5 EVLW Group 0 Ventilation days ICU days 101 ARDS patients randomized to EVLW-guided management vs. PAOP-guided management Mitchell JP et al., Am Rev Respir Dis 1992

48. veryhighpermeability normal permeability lung water Lung permeability lung water Pcap Lung water for estimating the risk of volume expansion Lung water highpermeability Advanced ICU monitoring Pcap

49. Lung permeability for estimating the risk of volume expansion? PVPI lung water pulmonary vascular permeability index = pulmonary blood volume cold bolus Advanced ICU monitoring EV1000 PiCCO

50. 10 9 8 7 6 5 4 3 * 2 1 0 Lung permeability for estimating the risk of volume expansion? PVPI 48 patients with pulmonary edema inflammatory vs. hydrostatic discriminated by experts PVPI by the PiCCO device Advanced ICU monitoring Cut-off : 3 Se = 85 % Sp = 100 % ALI/ARDS Hydrostatic pulmonary edema