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FluidChallengeRevisited BinDu MDMedicalICU PekingUnionMedicalCollegeHospital WhyFluidChallenge acutelyillpatientsfrequentlyrequirefluidrepletionhypovolemiaexternalloss bleeding gastrointestinal urinarytracts skininternalloss extravasationofblood exudation transudationoffluidsRelativehypovolemia increasesvenouscapacitancesepsis drugsvolumerepletionessentialrestorecriticallevelsofcardiacoutputandarterialpressure morenormalperfusionofvitalorgansandtissues WhyFluidChallenge WhyFluidChallenge Clinicalexamination limitedsensitivity specificityhistoryphysicalsignsroutinelaboratorytestsAnygivenleveloffillingpressure morelikelyhypovolemia morelikelyright leftheartfailureneithersufficientlyreliable CVP PAOP OsmanD RidelC RayP etal Cardiacfillingpressuresarenotappropriatetopredicthemodynamicresponsetovolumechallenge CritCareMed2007 35 64 68 FunctionalHemodynamics Systolicpressurevariation SPV Strokevolumevariation SVV Pulsepressurevariation PPV Respiratorysystolicvariationtest RSVT Respiratory inducedIVCdiameterchangereliablymeasuredonlyduringCMVtidalvolumedependentunreliablymeasuredduringarrhythmiaaffectedbydecreasedchestwallcompliancemisleadingduringrightheartfailure WhoNeedFluidChallenge MichardF TeboulJL PredictingfluidresponsivenessinICUpatients Acriticalanalysisoftheevidence Chest2002 121 2000 2008 FluidChallenge WhatFluid Colloid 4 gelatin6 hetastarch5 albumin Crystalloid 0 9 normalsaline vs vanderHeijdenVerheijJ vanNieuwAmerongenGP etal Crystalloidorcolloidfluidloadingandpulmonarypermeability edema andinjuryinsepticandnonsepticcriticallyillpatientswithhypovolemia CritCareMed2009 37 1275 1281 FluidChallenge WhatFluid vanderHeijdenVerheijJ vanNieuwAmerongenGP etal Crystalloidorcolloidfluidloadingandpulmonarypermeability edema andinjuryinsepticandnonsepticcriticallyillpatientswithhypovolemia CritCareMed2009 37 1275 1281 FluidChallenge WhatFluid vanderHeijdenVerheijJ vanNieuwAmerongenGP etal Crystalloidorcolloidfluidloadingandpulmonarypermeability edema andinjuryinsepticandnonsepticcriticallyillpatientswithhypovolemia CritCareMed2009 37 1275 1281 FluidChallenge WhatFluid vanderHeijdenVerheijJ vanNieuwAmerongenGP etal Crystalloidorcolloidfluidloadingandpulmonarypermeability edema andinjuryinsepticandnonsepticcriticallyillpatientswithhypovolemia CritCareMed2009 37 1275 1281 conclusionpulmonaryedemaandLISnotaffectedbythetypeoffluidloadinginthesteeppartofthecardiacfunctioncurveinsepticandnonsepticpatientspulmonarycapillarypermeabilityasasmallerdeterminantofpulmonaryedemathanCOPandCVP FluidChallenge HowMuch Theamountoffluidtobeadministeredoveradefinedinterval VincentJL WeilMH Fluidchallengerevisited CritCareMed2006 34 1333 1337 FluidChallenge HowMuch FluidChallenge HowMuch Originaltechnique600 1000ml hrOtherstudies mostlyfromTeboulJLetalaboutPLR 500ml 10 30minSurvivingSepsisCampaignGuidelineCrystalloid500 1000ml 30minColloid300 500ml 30min VincentJL WeilMH Fluidchallengerevisited CritCareMed2006 34 1333 1337DellingerRP CarletJM MasurH etal SurvivingSepsisCampaignguidelinesformanagementofseveresepsisandsepticshock CritCareMed2004 32 858 873 FluidChallenge Where MateerJR etal Rapidfluidresuscitationwithcentralvenouscatheters AnnEmergMed1983 12 149 52 Peripheralvenouscatheter Centralvenouscatheter WhatParameterstoMonitor WhenCO 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 Diebel IfCO CI SVisnotAvailable volumeexpansion inducedfillingpressurechangeCVP2 5rulePAOP3 7rulevolumeexpansion inducedbloodpressurechangeMAP SAP DAPpulsepressure CVP2 5Rule WeilMH HenningRJ Newconceptsinthediagnosisandfluidtreatmentofcirculatoryshock AnesthAnalg1979 58 124 132 CVP2 5Rule WeilMH HenningRJ Newconceptsinthediagnosisandfluidtreatmentofcirculatoryshock AnesthAnalg1979 58 124 132 CVP CVP CVP2 5Rule Dataonfile MedicalICU PUMCH IfCO CI SVisnotAvailable PreauS SaulnierF DewavrinF etal Passivelegraisingispredictiveoffluidresponsivenessinspontaneouslybreathingpatientswithseveresepsisoracutepancreatitis CritCareMed2010 38 819 825 IfCO CI SVisnotAvailable PreauS SaulnierF DewavrinF etal Passivelegraisingispredictiveoffluidresponsivenessinspontaneouslybreathingpatientswithseveresepsisoracutepancreatitis CritCareMed2010 38 819 825 IfCO CI SVisnotAvailable VolumeExpansion InfluenceofCardiacFunction 18cardiacsurgicalpatientsPreoperativeLVEF Group1 59 3 5 3 Group2 33 1 5 3 Volumeloadingsteps2consecutiveVLSperformed250mlHaemaccelgivenover5to7minutes PreismanS KoganS BerkenstadtH etal Predictingfluidresponsivenessinpatientsundergoingcardiacsurgery functionalhaemodynamicparametersincludingtherespiratorysystolicvariationtestandstaticpreloadindicators BrJAnaesth2005 95 746 755 InfluenceofCardiacFunction patientsscheduledforelectiveCABG generalhaemodynamicHR MAP CVPPAC PiCCOPAOP pulsecontourSV SVVTEELVEDA LVESA LVEF volumeloadinghetastarch130kD6 10ml m2 kgxBMIover5mins SV 5 responder nonresponder STOP ReuterDA KirchnerA FelbingerTW etal Usefulnessofleftventricularstrokevolumevariationtoassessfluidresponsivenessinpatientswithreducedcardiacfunction CritCareMed2003 31 1399 1404 Yes No InfluenceofCardiacFunction ReuterDA KirchnerA FelbingerTW etal Usefulnessofleftventricularstrokevolumevariationtoassessfluidresponsivenessinpatientswithreducedcardiacfunction CritCareMed2003 31 1399 1404 meannumberofVLSperpatientmeanvolumeofVLSperpatient 2 5637mL 2 8809mL IfYouDoWorryaboutCardiacFunction 45 45 PassiveLegRaising venousbloodshift Rutlenetal1981 Reichetal1989 increaseinrightventricularpreload Thomasetal1965 increaseinleftventricularpreload Rocha1987 Takagi1989 transienthemodynamiceffect Gaffney1982 HowtoPerformPassiveLegRaising PLR JabotJ TeboulJL RichardC etal Passivelegraisingforpredictingfluidresponsiveness importanceoftheposturalchange IntensiveCareMed2009 35 85 90 45 45 45 45 PLRSEMIREC PLRSUPINE TimeFrame 2min HowtoPerformPassiveLegRaising PLR JabotJ TeboulJL RichardC etal Passivelegraisingforpredictingfluidresponsiveness importanceoftheposturalchange IntensiveCareMed2009 35 85 90 HowtoPerformPassiveLegRaising PLR JabotJ TeboulJL RichardC etal Passivelegraisingforpredictingfluidresponsiveness importanceoftheposturalchange IntensiveCareMed2009 35 85 90 HowtoPerformPassiveLegRaising PLR JabotJ TeboulJL RichardC etal Passivelegraisingforpredictingfluidresponsiveness importanceoftheposturalchange IntensiveCareMed2009 35 85 90 45 45 PLRSEMIREC ConclusionPLRsemirecinduceslargerincreaseincardiacpreloadthanPLRsupineandmaybepreferredforpredictingfluidresponsiveness IfCO CI SVisnotAvailable JabotJ TeboulJL RichardC etal Passivelegraisingforpredictingfluidresponsiveness importanceoftheposturalchange IntensiveCareMed2009 35 85 90 IfCO CI SVisnotAvailable PassiveLegRaising VolumeExpansionvs PLR FluidChallenge WhatAfter Map SBP DBP CVP mmHg OtherThingstoConsider nochangeinvasopressordosenochangeinventilatorsettingspresenceofspontaneousbreathingpresenceofarrhythmia NoChangeinVasopressorDose NouiraS ElatrousS DimassiS etal Effectsofnorepinephrineonstaticanddynamicpreloadindicatorsinexperimentalhemorrhagicshock CritCareMed2005 33 2339 2343 NoChangeinVasopressorDose NouiraS ElatrousS DimassiS etal Effectsofnorepinephrineonstaticanddynamicpreloadindicatorsinexperimentalhemorrhagicshock CritCareMed2005 33 2339 2343 NoChangeinVasopressorDose NouiraS ElatrousS DimassiS etal Effectsofnorepinephrineonstaticanddynamicpreloadindicatorsinexperimentalhemorrhagicshock CritCareMed2005 33 2339 2343 ConclusionsuperiorityofdynamicvariablesoverstaticvariablesinassessingcardiacpreloadchangesinhemorrhagicshockPPV SPV RAP PAOPnorepinephrinecouldsignificantlyreducethevalueofthesedynamicvariables NoChangeinVentilato