Role of PoCT in Goal-Directed Therapy in Critical Care Settings
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1 Role of PoCT in Goal-Directed Therapy in Critical Care Settings Alessandro Protti Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico Milan, Italy Sponsored by Instrumentation Laboratory
2 Contents What is Goal-Directed Therapy? What are the targets of Goal-Directed Therapy? Which PoCT for Goal-Directed Therapy? Does Goal-Directed Therapy improve outcome? Is PoCT better than central laboratory setting?
3 762 critically ill patients, 56 Intensive Care Units High Postoperative Risk Septic shock Acute Respiratory Failure Massive blood loss Sepsis Syndrome COPD
4 1818 critically ill patients, 100 Intensive Care Units Severe Sepsis Septic Shock
5 What is Critical Care? Prevention or reversal of cellular energetic deficits that can limit the function of one or more vital organs.
6 What is Goal-Directed Therapy? Protocol-based (or quantitative) strategy to prevent or reverse cellular energetic deficits. Monitoring Interventions
7 Why do we need monitors? Physiological variables cannot be accurately predicted based solely on clinical evaluation. Correct prediction (%) Pulmonary Occlusion Pressure 30 Cardiac Output 51 Systemic Vascular Resistances 44 Central venous pressure 55 Direct measurement of physiological variables lead to changes in therapy in 58% of the cases. Eisenberg, Crit Care Med 1984
8 No monitoring device can improve outcome by itself Monitoring technique Accurate and relevant data Correct interpretation Beneficial intervention Improved outcome Vincent, Crit Care 2011
9 How can we assess cellular energy metabolism? 1. Evaluate adequacy of oxygen delivery: CENTRAL VENOUS OXYGEN SATURATION (ScvO 2 ) 2. Evaluate adequacy of aerobic energy production: BLOOD LACTATE LEVEL
10 What is ScvO 2? Hemoglobin oxygen saturation of blood drawn from the superior vena cava or right atrium ( central venous oxygen content).
11 What does low ScvO 2 mean? ScvO 2 <70% reveals an imbalance between oxygen delivery and demand (impending or actual hypoxia). Low cardiac output Hypoxemia Anemia Fever Anxiety Exercise
12 What is ScvO 2? R ScvO 2 (%) Oxygen delivery (ml/min) Gattinoni, N Engl J Med 1995
13 What is ScvO 2? R ScvO 2 (%) Oxygen consumption (ml/min) Gattinoni, N Engl J Med 1995
14 What is ScvO 2? R ScvO 2 (%) Oxygen delivery / Oxygen consumption Gattinoni, N Engl J Med 1995
15 ScvO 2 <70% ScvO 2 70% p n (%) 557 (35) 1043 (65) Heart rate (bpm) Mean arterial pressure (mmhg) Central venous pressure (cmh 2 O) Urine output (ml/h) 107 (92-120) 70 (60-82) 10 (6-13) 50 (20-100) 105 (93-120) 73 (63-83) 10 (7-13) 60 (30-100) < < day mortality (%) day mortality (%) Median (IQR); Mann-Whitney rank sum and Chi-square tests Caironi, N Engl J Med 2014
16 What is lactate? It is a product of anaerobic, extra-mitochondrial, cellular metabolism.
17 What does high lactate level mean? Hyperlactatemia (> 2mmol/L) reveals an imbalance between lactate production and clearance. Low oxygen provision Impaired oxygen use (mitochondrial damage) Fever Anxiety Exercise
18 Lactate 2 mmol/l Lactate >2 mmol/l n (%) 1015 (58) 726 (42) Heart rate (bpm) Mean arterial pressure (mmhg) Central venous pressure (cmh 2 O) Urine output (ml/h) 100 (85-113) 76 (66-87) 10 (7-12) 69 (32-100) 110 (96-123) 70 (60-80) 10 (6-13) 50 (17-100) p <0.001 < < day mortality (%) < day mortality (%) <0.001 Median (IQR); Mann-Whitney rank sum and Chi-square tests Caironi, N Engl J Med 2014
19 How can we measure ScvO 2 and lactate at the bedside? (Cartridge-type) Blood gas analyzer Clinically acceptable and immediately available results Ease to use Low maintenance time Beneteau-Burnat, Clin Chem Lab Med 2008; De Koninck, Clin Chem Lab Med 2013
20 ScvO 2 70% In-hospital mortality from 41% to 31% (p=0.009) Rivers, NEJM 2001
21 Early normalization of ScvO 2 decreases mortality 28-day mortality 26% ScvO 2 (%) 28-day mortality 40% Enrollment 6-h later Caironi, N Engl J Med 2014
22 6-h lactate clearance 10% ScvO 2 70% In-hospital mortality from 23% to 17% (NS) Jones, JAMA 2010
23 Early normalization of lactatemia decreases mortality 28-day mortality 39% Lactate (mmol/l) 28-day mortality 24% Enrollment 1-day later Caironi, N Engl J Med 2014
24 ScvO 2 70% ScvO 2 <70% 2-h lactate clearance 20% In-hospital mortality from 44% to 34% (p=0.067) Jansen, AJRCCM 2010
25 Early Late Favors Goal-Directed Therapy Favors Controls Jones, Crit Care Med 2008
26 Is PoCT better than central laboratory testing? Evidence-based practice for PoCT, National Academy of Clinical Biochemistry (2006)
27 Is PoCT better than central laboratory testing? Evidence-based practice for PoCT, National Academy of Clinical Biochemistry (2006)
28 Take home messages Goal-Directed Therapy is a protocol-based approach to reverse cellular energetic deficit ScvO 2 and lactate are useful markers of the balance between cellular energy production and demand Central venous blood gas analysis is the most important test to guide therapy Early Goal-Directed Therapy improves outcome of critically ill patients PoCT may be better than central laboratory testing
29 Acknowledgements Prof. Luciano Gattinoni Prof. Mervyn Singer Alfredo Lissoni Giuseppe Breda Daniela Tubiolo Nicola Bottino Mauro Panigada Davide Chiumello Stefania Crotti Alberto Sicignano Monica Savioli Riccarda Russo Federico Polli Pietro Caironi Medical students, Fellows and Nurses working with me
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