Goal Directed Perfusion: theory, clinical results, and key rules

Transcription

1 Goal Directed Perfusion: theory, clinical results, and key rules M. Ranucci Director of Clinical Research Dept of Cardiothoracic and Vascular Anesthesia and Intensive Care IRCCS Policlinico S.Donato Ranuuci, M et al. 2005

2 Outline Theory: postoperative organ dysfunction and oxygen dependency Clinical results: the hypothesis generated by retrospective data Key rules: the GDP laws

3 Outline Theory: postoperative organ dysfunction and oxygen dependency Clinical results: the hypothesis generated by retrospective data Key rules: the GDP laws

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5 Performing perioperative optimization of the high-risk surgical patients. If this debt is paid back within 8 hours, the incidence of postoperative complications decreases, and if it is never paid then cell dysfunction and death occur. BJA 2006;97:4-11

6 Lactate

7 Hemodynamic optimization Cardiac Index > 4,5 L/min/m2 O 2 delivery > 600 ml/min /m2 O 2 consumption > 170 ml/min/m2 Control PAC control PAC hemodynamic optimization

8 FROM NON-CARDIAC SURGERY TO CPB-CARDIAC OPERATIONS

9 THE ASSOCIATION BETWEEN ORGAN FAILURE AND LOW OXYGEN CONTENT/ DELIVERY Low HCT levels on CPB have been associated with: AKI Stroke Low cardiac output

10 THE ASSOCIATION BETWEEN ORGAN FAILURE AND LOW OXYGEN CONTENT/ DELIVERY Low HCT levels on CPB have been associated with: KIDNEY BRAIN HEART

11 Cardiac Output Preload Chang MC. New Horizons 1999;7:35-45

12 THE ASSOCIATION BETWEEN ORGAN FAILURE AND LOW OXYGEN CONTENT/ DELIVERY Low HCT levels on CPB have been associated with: KIDNEY BRAIN HEART

13 Crude risk of Low Output Failure (LOF) by Nadir Hematocrit during CPB. Surgenor SD, et al. Circulation 2006;114(Suppl):43 8i.

14 THE ASSOCIATION BETWEEN ORGAN FAILURE AND LOW OXYGEN CONTENT/ DELIVERY Low HCT levels on CPB have been associated with: KIDNEY BRAIN HEART

15 Possible perfusion-related risk factors CPB itself Perfusion pressure Perfusion flow Loss of pulsatility Severe hemodilution Poor oxygen delivery Hemolysis

16 PRESSURE

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21 FLOW

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23 OXYGEN CONTENT OXYGEN DELIVERY

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25 STRUCTURE OF THE KIDNEY(after A.Despopoulos & S.Silbernagl, Color Atlas of Physiology, 2003)

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28 Kidney and oxygen supply Renal medulla is chronically hypoxemic A low oxygen content (hemodilution) further worsen kidney hypoxia Low blood flow is a major determinant of reduced oxygen supply

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30 12%

31 0.3 16,000 consecutive patients at the IRCCS PSD Riskof AKI stage % Nadir HCT (%) on CPB

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36 HCT DO 2 VCO 2 DO 2 /VCO 2 AKI (creatinine change within first 48h)

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38 DO 2 262ml/min/m 2 DO 2 /VCO Hct 23.5%

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40 Measurements and calculations PA-catheter: Systemic haemodynamics Renal vein catheter: Renal blood flow (RBF) Renal oxygen extraction (SaO 2 -SrvO 2 ) / SaO 2 Filtration fraction (FF), the renal extraction of Cr 51 -EDTA Calculations: Glomerular Filtration Rate (GFR) = FF x RBF x (1-Hct) Renal Oxygen Consumption (RVO 2 ) = RBF x (CaO 2 - CvO 2 ) Renal Oxygen Delivery (RDO 2 ) = RBF x CaO 2 Urinary excretion of NAG (every 30 minutes) Lukas lannemyr, M D, Dpt of Cardiothoracic anaesthesia and intensive care, Sahlgrenska University Hospital, Gothenburg, Sweden

41 g/l mmhg 3 2,5 Results Systemic variables Cardiac Index *** *** ** Mean Arterial Pressure Pre CPB 30' CPB 60' Post CPB * L/min/m 2 2 1,5 1 0, Haemoglobin *** *** *** 0 Pre CPB 30' CPB 60' Post CPB * p < 0.05, ** p < 0.01, ** p < Pre CPB 30' CPB 60' Post CPB

42 ml/min ml/min mmhg/ml/min ml/min Results Renal variables Renal blood flow Pre CPB 30' CPB 60' Post CPB *** p < Glomerular filtration rate Pre CPB 30' CPB 60' Post CPB 0,2 0,15 0,1 0, Renal vascular resistance Pre CPB 30' CPB 60' Post CPB Renal oxygen consumption *** Pre CPB 30' CPB 60' Post CPB

43 RDO 2 ml/min Systemic and renal oxygen delivery * * DO 2 I ml/min/m DO2I RDO2 * ** * * p < 0.05, ** p < 0.01 vs Pre Pre CPB CPB 30' CPB 60' Post CPB 0

44 0,2 0,15 Renal oxygen extraction - oxygen supply demand relationship *** * * 0,1 0,05 0 Pre CPB 30' CPB 60' Post CPB * p < 0.05, *** p < vs Pre

45 ml/min NAG excretion 14 NAG/U-creatinine *** *** * Pre CPB CPB 30' CPB 60' CPB 120' Post CPB30' Post CPB60' 24 hpost CPB * * p < 0.05, *** p < vs Pre

46 BEFORE CPB DO2 600 ml/min DO2 85 ml/min (14%) O2ER 10%

47 ON CPB DO2 680 ml/min DO2 68 ml/min (10%) O2ER 15%

48 AFTER CPB DO2 610 ml/min DO2 76 ml/min (12%) O2ER 17%

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53 Outline Theory: postoperative organ dysfunction and oxygen dependency Clinical results: the hypothesis generated by retrospective data Key rules: the GDP laws

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56 SvO2 not sensitive

57 Single center retrospective cohort study non congenital adult patients undergone cardiac surgery on pump from 2000 to december (4,7%) AKI stage 2/3 in postop (increasing serum creatinine more than 200%)

58 Nadir Hct value during CPB was confirmed as an indipendent determinant of AKI (increase of 7% per 1% point of nadir Hct value

59 Some factors (egfr and EF) have been improving in the last period Others (diabetes, redo and nonelective operations, non isolated CABG, peoperative use of IABP and duration CPB) show a significantly higher severity.

60 AKI rate significantly increased until 2005, despite no significant change in RRS Starting 2006 AKI rate decline, despite the increase in the RRS

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62 7.7% 7.5% CENTRIFUGAL PUMPS

63 4.8% 3.7% NO ANGIOGRAPHY ON THE DAY OF SURGERY P=0.028

64 5.8% 3.1% GOAL DIRECTED PERFUSION P=0.001

65 Effect of Goal Directed Perfusion

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68 Outline Theory: postoperative organ dysfunction and oxygen dependency Clinical results: the hypothesis generated by retrospective data Key rules: the GDP laws

69 Gas flow temperature GDP monitor Pump flow measured Low prime oxygenators Same old perfusionist as in the 90 s

70 THE FIVE GDP LAWS 1. Limit hemodilution on CPB 0.25 AKI rate (% with 95% CI) Nadir HCT on CPB (%)

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72 THE FIVE GDP LAWS 2. Always stay at a DO2 > 270 ml/min/m2

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74 THE FIVE GDP LAWS 3. Increase the DO2 by acting on pump flow, PaO2

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76 Perfusion Jul 23. pii: [Epub ahead of print] The effects of hyperoxaemia on tissue oxygenation in patients with a nadir haematocrit lower than 20% during cardiopulmonary bypass. Sevuk U(1), Altindag R(2), Baysal E(2), Yaylak B(2), Adiyaman MS(2), Akkaya S(2), Ay N(3), Alp V(3). Excessive haemodilution and the resulting anaemia during CPB is accompanied by a decrease in the total arterial oxygen content, which may impair tissue oxygen delivery. Hyperoxic ventilation has been proven to improve tissue oxygenation in different pathophysiological states of anaemic tissue hypoxia. The aim of this study was to examine the influence of arterial hyperoxaemia on tissue oxygenation during CPB. Records of patients undergoing isolated CABG with CPB were retrospectively reviewed. Patients with nadir haematocrit levels below 20% during CPB were included in the study. Tissue hypoxia was defined as hyperlactataemia (lactate >2.2 mmol/l) coupled with low ScVO2 (ScVO2 <70%) during CPB. One hundred patients with normoxaemia and 100 patients with hyperoxaemia were included in the study. Patients with hyperoxaemia had lower tissue hypoxia incidence than patients with normoxaemia (p<0.001). Compared with patients without tissue hypoxia, patients with tissue hypoxia had significantly lower PaO2 values (p<0.001) and nadir haematocrit levels (p<0.001). Nadir haematocrit levels <18% (OR: 5.3; 95% CI: ; p<0.001) and hyperoxaemia (OR: 0.28; 95% CI: ; p<0.001) were independently associated with tissue hypoxia.conclusions: Hyperoxaemia during CPB may be protective against tissue hypoxia in patients with nadir haematocrit levels <20%.

77 THE FIVE GDP LAWS 4. Transfuse RBC based on SvO2 and O2ER rather than HCT

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79 THE FIVE GDP LAWS 5. Avoid the anaerobic zone by checking lactates and VCO2

80 DO 2, VO 2, SvO 2, and Lactates...and VCO2 VCO 2 VO (ml/min) 2 (ml/min) OXYGEN DEBT Critical DO 2 SvO 2 (%) Lac (mmol/l) ,000 DO 2 (ml/min)

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83 THE GDP CONCEPT: VCO 2 VO (ml/min) 2 (ml/min) OXYGEN DEBT Critical DO 2 WE WANT THE PATIENT IN THIS ZONE SvO 2 (%) Lac (mmol/l) ,000 DO 2 (ml/min)

84 AKI 2 rate (%) KEEP THE PATIENT HERE Lowest HCT on CPB

85 Peak Arterial Blood Lactate (mmol/l) 3,0 Critical DO2 2,5 2,0 GDP: KEEP THE PATIENT HERE 1,5 1, Lowest Oxygen Delivery (ml/min/mq)

86 KEEP THE PATIENT HERE

87 H E R E HERE

88 AKI 2 rate (%) Same HCT Higher Pump Flow GDP in years of CPB technologies improvements Centrifugal vs roller pumps Biocompatible circuits Flow monitoring Less transfusions Lowest HCT on CPB