Fluid Challenge Revisited

Jean-Louis Vincent, MD, PhD, FCCM Max Harry Weil, MD, PhD, ScD (Hon), FCCM Crit Care Med 2006; 34:13331337
Presented by Resident Dr. Toh Han Siong Supervised by VS Dr. Hsiu-Nien Shen Department of Intensive Care, Chi-Mei Medical Center, ROC, Taiwan

Introduction
Acutely ill patients frequently require fluid repletion
Hypovolemia: external loss & internal loss Relative Hypovolemia: increases venous capacitance

Volume repletion may be essential

Restore critical levels of cardiac output and arterial pressure More normal perfusion of vital organs and tissues

Introduction
Hemorrhage: Benefit / risk of fluid repletion must be assessed
Benefits of delayed resuscitation Large volume of fluid red cell deficit oxygen deficit

Persistent hypovolemia will result in MODS

Fluid repletion is typically more effective during hypovolemic states but is less effective in later stages.

Introduction
A method for guiding volume repletion has been
available for 25 yrs based on measurements of the patients response to a fluid load.

Current role of fluid challenge as a method

of assessing response to fluid infusion.

In the absence of overt hypovolemia, which patient is likely to respond favorably to fluid administration?

In the absence of overt hypovolemia, which patient is likely to respond favorably to fluid administration?

Clinical examination: limited sensitivity & specificity

History Physical signs Routine laboratory tests

Any given level of filling pressure:

more likely hypovolemia more likely right / left heart failure Neither is sufficiently reliable

Extravascular volume deficits do not Lack of reliability based on become clinically apparent until they a static measurement exceed 10% of body weight.
CO = SV x HR

Nonspecific sign

Dynamic Evaluation ?
Ambulatory patient

Sedated and paralyzed

Provocative test Fluid is given over defined interval Effect on right-sided filling pressures

Misconceptions 1

Fluid administration should be withheld because the central venous pressure is high.
Any

given level of filling pressure: not reliable !!!

Filling

pressures may paradoxically decline during volume repletion, presumably as a result of decreased sympathetic stimulation.

Misconceptions 2

Fluid administration should be withheld because there is evidence of lung edema on the chest roentgenogram.
Pulmonary Pulmonary

edema Contraindication to fluids edema Volume overload

May also be the cause of hypovolemia ! Acute cardiogenic pulmonary edema Extravasation of fluid into the interstitium and alveoli Reduces plasma volume and total blood volume Graded fluid administration reverse hypovolemia (shock)

Misconceptions 3

Fluid administration should be withheld because the patient has already received a large volume in a short time interval.

Was amount of fluid already given insufficient or excessive? The patients objective response to fluid administered over a defined interval, representing the fluid challenge, rather than quantity previously administered is likely to resolve this issue.

Misconceptions 4

Tachycardia is due to fluid deficit and should prompt increases in fluid administration.
Tachycardia has diverse causes !!! Stress, high environmental temperatures, intrinsic heart disease, effects of medications (esp. -agonists) If

there is a fluid deficit, prompt intervention is appropriate and the fluid challenge is likely to reduce the heart rate.

Misconceptions 5

I gave fluids to increase the central venous pressure to 12 mm Hg to exclude an underlying hypovolemia.

NOT SO!

Variable zero reference, the effects of afterload, and increases in intrathoracic pressure (esp. positive pressure ventilation)
Relationships between intravascular volume and filling pressures

Intravascular volume may be insufficient or excessive !!!

What is a Fluid Challenge?

Distinguished from conventional fluid administration Fluid replacement to patients with cardiorespiratory failure The fluid challenge is reserved for hemodynamically unstable patients and offers three major advantages:
1.

Quantitation of the cardiovascular response during volume infusion.

Prompt correction of fluid deficits. Minimizing the risk of fluid overload and its potentially adverse effects, especially on the lungs.

1.

1.

What kind of Measurement does it suppose?

Filling pressures Preload

Net effect of preload, ventricular compliance, and afterload Frank-Starling principle:

Fluid infusion SV filling pressure

Dual end points:

Filling pressures

filling pressure levels at which stroke volumes are increased

Blood flow: related to arterial pressure & urine output

vital organ blood flow is preserved

Initial Fluid Challenge Technique

Weil and Henning, 1979:
25 rule for central venous pressure (CVP) 37 rule for pulmonary artery occlusion pressure (PAOP) Filling pressure was measured at 10-min intervals Change 3mmHg for PAOP or 2 for CVP:
infusion was continued Change 37 mmHg for PAOP or 25 mmHg for CVP: infusion was interrupted and reevaluated after a 10-min wait Change 7mm Hg for PAOP or 5 mmHg for CVP: infusion was stopped

The protocol may be updated and even simplified.

Modified Fluid Challenge Technique

Type of Fluid Rate of Fluid Administration Goal to be Achieved Safety Limits

Type of Fluid
Crystalloids or Colloids can be used Fluid challenges with colloids allow for more rapid
completion of challenge.

Crystalloid:
Physiologic (0.9%) salt solution (saline)
May increase serum chloride concentrations

Balanced salt solutions (Ringers lactate / Hartmanns solution)

Mildly hypotonic, may exacerbate cerebral edema

Type of Fluid
SAFE study: albumin vs crystalloid solution
Mortality rate was identical

Hypoalbuminemia is associated with higher morbidity Vincent JL et al, Ann Surg 2003; 237:319334: meta-analysis
Albumin administration may reduce complications in critically ill patients

SAFE trial:
Improved survival with albumin in patients with sepsis who are often
hypoalbuminemia (relative risk of death, 0.87; 95% CI, 0.74 1.02; p 0.06) Albumin may be beneficial in this subset of critically ill patients

Type of Fluid
Synthetic colloid solution:
Hydroxyethyl starch solutions:
Less expensive, adverse effects on blood clotting

Gelatins:
Smaller MW, less effective plasma expanders, low cost

Type of Fluid
No intravenous fluid solution that is ideal in all clinical settings No secure data support a preference for one over another
The choice is best made contingent on:
the underlying disease the type of fluid that has been lost

the severity of circulatory failure

the serum albumin concentration of the patient the risk of bleeding.

Rate of Fluid Administration

Amount of fluid to be administered over a defined interval
Original fluid challenge technique:
Infusion pump that allowed close control of the rate of infusion Pump rate: 600 or 999 mL/hr

Guidelines of the Surviving Sepsis Campaign:

5001000 mL of crystalloids over 30 mins 300500 mL of colloids over 30 mins

Goal to be Achieved
Identify and Quantitate primary defect Defects that prompt the fluid challenge
Hypotension & tachycardia: most common Oliguria: organ perfusion Skin perfusion (esp. limbs): toe temperature, sublingual CO2

Lactate: A good measure of

Anaerobic metabolism Severity of perfusion failure

Fails to reverse rapidly enough to serve as a real-time indicator

Safety Limits
Pulmonary edema due to congestive heart failure
Most serious complication of fluid infusion PAOP is a more direct indicator than CVP Regard CVP as acceptable in patients who do not have intrinsic heart /
lung disease

Time interval for measurements of cardiac filling pressures

Every 10 mins for a define fluid load of 100 or 200 mL

Availability of continuous and simultaneous infusion and

measurements, the intervals may be extended (i.e., larger volumes with correspondingly larger intervals are possible).

What Are the Advantages?

Proposed protocol:
Concurrent measurement of monitoring MAP & HR, even CO Safety limits based on filling pressures

Safety limit can be increased

What Are the Advantages?

1. Quantitative goals & limits

Lets see what happens and call me if youre in doubt Can be employed equally by experienced clinicians and trainees Exposes mechanisms and, especially, limited cardiac competence
at one extreme and directs the clinician to search for causes of perfusion failure other than hypovolemia on the other.

It supports the team approach. Physicians, and especially nurses, appreciate the clear end points.

What Are the Advantages?

2. Fluid deficits are more rapidly corrected in contrast to a protracted infusion over 12 or even 24 hrs, with lesser durations of hypovolemia and, therefore, less ischemic injury and multiple organ failure.
3. After goals are achieved, there is more predictable completeness of fluid repletion. Fears of large volumes are minimized.

What Are the Limitations and Risks?

The technique identifies cardiac failure early, based on early
increases in filling pressures to threshold levels.

Failure of renal elimination of fluids: esp. resorption of edema

Renal function is protected: fluid challenge restores hemodynamic stability. If there is renal failure, we now have effective renal replacement therapies

Neurologically impaired patients in whom fluids may increase

intracranial pressure and adversely affect intracranial disease or traumatic brain injuries or in patients with diabetes insipidus.

Conclusion
Fluid challenge strategy: not new or complex bedside technique
One of the most useful, basic interventions for management of critically ill
and injured patients

Updated protocol outlined above:

Types of fluid selected Rates of administration Objective goals and limits for volumes and rates of infusion

A procedure that facilitates diagnosis in the routine management

of critically ill and injured patients