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Nurse Driven Fluid Optimization Using Dynamic Assessments
2016
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WHAT WE BELIEVE
We believe that clinicians make vital fluid and drug decisions every day with limited and inconclusive information
Cheetah believes that with a complete hemodynamic profile, clinicians are empowered to make decisions better…leading to improved outcomes
We believe Cheetah’s accurate, precise and non-invasive technology can help you optimize your patients fluid and perfusion status
2 Decisions Made Better
Careful management of intraoperative fluids can greatly enhance patient outcomes4
Volume overload in septic patients is associated with an increased risk of mortality1,2
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WHY VOLUME MATTERS
FLUID IMBALANCE CAN LEAD TO SERIOUS CONSEQUENCES Every patient has unique and constantly changing hemodynamic needs Understanding a patient’s volume status throughout their care is a challenge clinicians face every day Serious complications are associated with both under- and over-resuscitation of a patient, including
organ failure and death
SEPSIS / SHOCK
SURGERY (ERAS)
References:1. Shoemaker W et al. Tissue oxygen debt as a determinant of lethal and nonlethal postoperative organ failure. Crit Care Med 1988; 16:1117-1120.2. Vermeulen H et al. Intravenous fluid restriction after major abdominal surgery: A randomized blinded clinical trial. Trials 2009; 10:50.3. Rivers E et al. Early goal directed therapy in the treatment of severe sepsis and septic shock. NEJM 2001; 345:1368-1377.4. Gustafsson UO et al. Enhanced Recovery after Surgery Society. Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations. Clin Nutr. 2012; 31:783-800.5. Corcoran T et al. Perioperative Fluid Management Strategies in Major Surgery: A stratified meta-analysis. Anesth Analg 2012; 114:640-651.6. Boyd J et al. Vasopressin in Septic Shock Trial (VASST). Critical Care Medicine 2011; 39:259-265.7. Vincent JL et al. Sepsis in European ICU: Results of the SOAP Study. Critical Care Med 2006; 34:344-353.8. Kelm D et al. Fluid overload in patients with severe sepsis and septic shock treated with early goal directed therapy is associated with increased acute need for fluid-related medical interventions and hospital death. Shock 2015; 43:680-73.
Too Little Fluid1,2,3
[Hypovolemia]Tissue HypoperfusionTissue HypoxiaOrgan FailureInsufficient Perfusion
Too Much Fluid4,5,6,7,8
[Hypervolemia]Tissue EdemaOrgan FailureIncreased ICU/Ventilator DaysIncreased Mortality
HEMODYNAMICS – THE SCIENCE OF BLOOD FLOW
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HEMO BloodDYNAMICS Flow
Optimized Hemodynamics Enables Perfusion
Perfusion is critical for life –delivery of oxygen, nutrients, and
toxin removal at tissue level
#1 Driver TissuePerfusion
HOW DO WE CURRENTLY MEASURE PERFUSION?
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Physiology
O2 Delivery
SvO2
Blood Pressure
MAP > 65SBP > 90
Urine Output
BioMarkers
Critical Care Is About Optimizing Hemodynamics
DRAWBACKS TO USING PRESSURE TO ASSESS VOLUME
Pulmonary Wedge Pressure
Central Venous Pressure
Δ Pressure * Compliance = Δ Volume
For pressure to accurately reflect volume …… compliance must remain constant
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OPTIMIZING HEMODYNAMICS
IV FluidPRELOAD
InotropesCONTRACTILITY
VasopressorsVasodilatorsAFTERLOAD
Cardiac Function
Volume
Peripheral Resistance
Adequate Perfusion
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BREAKTHROUGH TECHNOLOGY MAKES THE DIFFERENCE
4 non-invasive sensor pads are applied to the thorax, creating a ‘box’ around the heart
A small electric current of known frequency (75kHz) is applied across the thorax between the outer pair of sensors
A voltage signal is recorded between the inner pair of sensors
The flow of blood in the thorax introduces a time delay or phase shift in our signal
We have correlated these signal changes to known thermodilution cardiac output
– 65,000 patient samples in multiple clinical settings (ICU/OR/Cath Lab)
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Phase Shift
DYNAMIC ASSESSMENTS
WHAT ARE THEY?
– Directly challenging the heart with volume to see the response
– Ideal for assessing fluid responsiveness
– Provides continuous feedback of volume response after an intervention
– May answer the following key questions regarding your patient:
“Will additional IV fluid increase cardiac output?”
“Will additional IV fluid optimize perfusion?”
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ASSESSING FLUID RESPONSIVENESS
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Passive Leg Raise Bolus Challenge Trending Therapy
METHODS OF FLUID BOLUS
Before Therapy During Therapy
FRANK-STARLING LAW
METHODS TO ASSESS VOLUME – DYNAMIC ASSESSMENT
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Reversible challenge ~ 300cc of acute volume High sensitivity & specificity Positive change in SVI of ≥ 10% is predictive of an increase in
Cardiac Output Pro: Reversible Con: Contraindicated in certain patient populations
Passive Leg Raise
Will Fluid Increase Stroke Volume?
METHODS TO ASSESS VOLUME – DYNAMIC ASSESSMENT
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Bolus Challenge
Reliable Rapid infusion of 250cc over 3-5 minutes High sensitivity /specificity Positive change in SVI of 10% or greater is predictive of an
increase in CO and therefore flow Pro: Reliable Con: Irreversible
Will Fluid Increase Stroke Volume?
METHODS TO ASSESS VOLUME
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Trending Therapy
Minute-to-minute Information Assess Therapeutic Response Identify Early Trends Pro: Real Time / Continuous Con: None!
Will Fluid Increase Stroke Volume?
WHO IS A CHEETAH PATIENT?
Shock States:Severe Sepsis/Septic ShockHypovolemicCardiogenicNeurogenic
Other Conditions characterized by hemodynamic instabilityCongestive Heart Failure (CHF)Acute Respiratory Distress Syndrome (ARDS)Acute Kidney Injury/Renal Insufficiency (AKI)Subarachnoid Hemorrhage (SAH)
Care Pathways and ProtocolsERAS & Perioperative Goal Directed Fluid TherapyCMS Severe Sepsis and Septic Shock Bundle (NQF #0500, SEP-1)Surviving Sepsis CampaignEmergency/Trauma
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Any patient where you ask yourself:
“Will additional IV fluid increase cardiac output and optimize perfusion?
CHEETAH SCENARIO – SEPTIC PATIENT
42 year old male, paraplegic with large wound to coccyx, admitted
with septic shock
Pt had already received 6L fluid over night, however remained on
low-dose Levophed that was unable to be weaned down further
CVP reading 8-10, UOP >30mL/hr, MAP 55-60
Cheetah monitor placed on patient to assess if more volume is
needed as they were unable to wean the Levophed
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Time
SVI (ml/m2/beat)
Patient placed back
in semi-recumbent
position
Start of PLR
STROKE VOLUME INDEX CHANGE
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Passive Leg Raise #1
≥ 10% change in SVI, patient is likely fluid responsive
PLR indicated patient was likely fluid responsive. 1 Liter LR was ordered to be given and PLR to be repeated after
infusion complete.
Notice that CI increases with PLR (this is not always the case!)
RESULTS AND ORDERS
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1:23:21 PM1:24:21 PM1:25:21 PM1:26:21 PM1:28:11 PM1:29:11 PM1:30:11 PM1:32:07 PM1:33:07 PM1:34:07 PM1:35:08 PM1:36:08 PM1:37:08 PM
Time
SVI (ml/m2/beat)
Passive Leg Raise #2
Patient placed back in semi-recumbent position
Start of PLR
REPEAT PASSIVE LEG RAISE
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Passive Leg Raise #2
< 10% change in SVI, patient unlikely to be fluid responsive
PLR indicated patient was unlikely fluid responsive. Pt was able to be weaned off of Levophed following the 1 Liter LR infusion.
Minimal change in CI compared to previous test (11.3%)
RESULTS AND OUTCOME
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SUMMARY
Volume matters
Perform guided fluid resuscitation to optimize organ perfusion, oxygenation and prevention of organ failure
Determine fluid responsiveness by means of simple, nurse-driven dynamic assessments
Use of hemodynamics at the bedside by nurses can help to drive differential diagnosis and treatment of shock states
20R-MRK-062
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