Mon patient a une bonne pression artérielle il a a donc un bon débit cardiaque! seminaires iris. Daniel De Backer
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1 Mon patient a une bonne pression artérielle il a a donc un bon débit cardiaque! Daniel De Backer Head Dept Intensive Care, CHIREC hospitals, Belgium Professor of Intensive Care, Université Libre de Bruxelles Past-President European Society of Intensive Care Medicine
2 Pression artérielle = Débit cardiaque x SVR
3
4 Flow and pressure are often dissociated 61 high risk trauma patients in ED 163 high risk surgery pts admitted to ICU Wo-C et al CCM 21:218;1993
5 Flow and pressure are often dissociated 61 high risk trauma patients in ED 163 high risk surgery pts admitted to ICU Wo-C et al CCM 21:218;1993
6 Flow and heart rate are often dissociated 61 high risk trauma patients in ED 163 high risk surgery pts admitted to ICU Wo-C et al CCM 21:218;1993
7 Flow and pressure are often dissociated Cardiac index, L/min.m² 10,0 9,0 8,0 7,0 6,0 5,0 4,0 3,0 2,0 1,0, Simulatenous measurements of CI and MAP in 252 pts with sepsis De Backer et al unpublished MAP, mmhg
8 Fluids have variable effects on MAP and CO in patients with sepsis Pierrakos et al ICM 38:422;2012
9 Arterial pressure and cardiac output
10 Marques et al Crit Care Med 2008
11
12
13 What is the link between stroke volume and arterial pressure? DDB
14 What is the link between stroke volume and arterial pressure? P fem Aortic compliance (elastance)
15 Factors influencing arterial pressure Aortic elastance Stroke volume
16 Changes in pulse pressure poorly track changes in stroke volume Fluids Norepi Monnet X et al CCM 2011 N=228 N=145
17 Changes in pulse pressure poorly track changes in stroke volume N=228 -X Fluids Monnet X et al CCM 2011
18 Arterial pressure Stiff artery Stroke volume Volume Normal artery
19 The role of Reflected waves in arterial pressure waveform morphology
20 Distortion of the signal by reflected waves Femoral artery Wang J et al AJP 284:1358;2003 Aortic root
21 Influence of vascular tone on wave reflection CTRL Constrict Dilate Berger D et al AJP 264:269;1993
22 Homme 55 ans Pneumonie ATCD: infarctus du myocarde-fevg 40% PA 98/35 mmhg FC 104 bpm T 38.8 C GDS: 7.21 / 34 / 71 / 94 CPPV 560 ml 15x PEEP Lactate 4.6 meq/l Oligurie Quel type de choc? Hypovolemique Cardiogenique Septique Obstructif Quels éléments nous indiquaient déjà la solution?
23 Pression artérielle = volume éjecté x tonus vasculaire Cardiogénique hypovolémique Normal Septique
24 Can physicians estimate cardiac output based on clinical examination?
25 Connors-A et al NEJM 308:263;1983 Prediction of hemodynamic values before PAC insertion 56 ICU pts
26 Connors-A et al NEJM 308:263;1983 Prediction of hemodynamic values before PAC insertion 56 ICU pts
27 Very little agreement between clinical evaluation and: initial CO (K ) 2-hour CO (K Initial SVR (K ) 2-hour SVR (K ) 40 ED pts Dyspnea n=18 Stroke n=11 Sepsis n=3 Other n=8
28
29
30 Is it useful to measure cardiac output? CO measurements are useful: As index of tissue perfusion As an index of cardiovascular function To evaluate response to therapy
31 The determinants of cardiac output
32 - HEART RATE CONTRACTILITY DIASTOLE VOLEMIA AFTERLOAD PRELOAD CARDIAC OUTPUT - EJECTED VOLUME
33 CARDIAC OUTPUT: How to measure?
34 How can cardiac output be measured? Thermodilution Arterial waveform analysis Echocardiography Esophageal Doppler Bioimpedance / Bioreactance.
35 Hemodynamic devices SvO2/ScvO2 Cardiac output Intravascular pressures Intravascular volumes Extravascular lung water The choice of the hemodynamic device should be based on its reliability / cost / invasiveness / need for additional measurements
36 CARDIAC OUTPUT: how to interpret? Physiologically, cardiac output is an adaptative variable. Accordingly, it should always be analyzed in conjunction with its covariates.
37 Is cardiac output adequate? O2 DEMAND O2 DELIVERY SvO2 Cardiac output Hb SaO2 DDB USI
38 Adapted cardiac output Artery SaO2 95% Hb 10 Flow In: O2 600 ml/min NB: O2 flow in = flow out Hb in = Hb out VO2 150 ml/min Tissue Vein SvO2 75% Hb 10 Out: O2 450 ml/min
39 low cardiac output Artery SaO2 95% Hb 10 Flow In: O2 300 ml/min O2 VO2 150 ml/min Tissue Vein SvO2 50% Hb 10 Out: O2 150 ml/min NB: flow in = flow out
40 VO2 DO2
41 VO2 VO2crit EO2crit DO2crit O2 Extraction SvO2 DO2
42 VO2 Lactate DO2crit DO2
43 O2 CONSUMPTION SvO2 O2 DEMAND O2 CONSUMPTION O2 DELIVERY Lactate DDB USI
44 Is cardiac output adequate? Cardiac output Hb / SaO2 SvO2/ScvO2 O2 delivery O2 consumption O2 needs Lactate
45 Zhang H et al Shock 5:349;1996 dogs
46 SvO2 How to evaluate adequacy of DO2 to VO2? VO2/DO2 Lactate relationships Pv-aCO2
47 HEMODYNAMIC ALTERATIONS IN SEPTIC SHOCK Factors independently associated with poor outcome Varpula et al ICM 31:1066;2005 Continuous hemodynamic measurements during the first 48h of shock (111 consecutive patients)
48 Squara P et al ICM 33:1191; SvO2 measurements ICU pts
49 All pts -ScvO2 <60% n=38 (14%) -ScvO2 <50% n=14 (5%) Sepsis -ScvO2 <60% n=8 (6%) -ScvO2 <50% n=1 (1%) Crit Care 2008
50 Major differences in mortality in control arm Rivers et al PROCESS ARISE PROMISE ScvO2 % Rivers et al NEJM 2001 Angus D et al NEJM 2014 Peake S et al NEJM 2014 Mouncey P et al NEJM 2015 Inclusion: refractory hypotension and/or lactate 4 (despite fluids)
51 Mortality, % ScvO2 and outcome ScvO2 <70% 70-90% Pope J et al Ann Emerg Med 15:40; pts severe sepsis (ED)
52 Limits in the interpretation of SvO2 A high SvO2 can be abnormal (microciculatory alterations and/or mitochondrial dysfunction)
53 Mortality, % ScvO2 <70% 70-90% >90% 619 pts severe sepsis (ED) Pope J et al Ann Emerg Med 15:40;2010
54 Textoris J et al Crit Care 15:R176; pts septic shock (ICU)
55 Textoris J et al Crit Care 15:R176; pts septic shock (ICU)
56 SvO2: key messages SvO2 reflects the balance between O2 consumption and O2 delivery A low SvO2 is abnormal in most cases. A normal SvO2 cannot rule out zones of tissue hypoperfusion (especially in sepsis). A low SvO2 does not mandate to increase cardiac output (or other components of O2 delivery).
57 Vincent JL and De Backer D NEJM 369:1726; 2013
58 Prognostic value of lacate and impact of time from diagnosis Casserly B et al CCM 43:567; pts / 218 sites / SSC database
59 9190 pts with sepsis Liu V et al Annals ATS 2013
60 Janssens T et al AJRCCM 2010 Lactate guided therapy
61 Lactate guided therapy (-20%/2h for 8h) Janssens T et al AJRCCM 2010 N=348
62 Lactate guided therapy (-20%/2h for 8h) Janssens T et al AJRCCM 2010 N=348
63
64 LACTATE AND PYRUVATE IN ICU PATIENTS On admission Rimachi R et al Anaesth Inten Care 40:427:2012 At 24h 39 pts with septic or cardiogenic shock Serial measurement over 24h
65 Veno-arterial difference in PCO2 Applications
66 Evolution of veno-arterial PCO2 gradient Vallée F et al CHEST 2010 Septic shock (n=46)
67 Evolution of veno-arterial PCO2 gradient Low PvaCO2 6 mmhg High PvaCO2 Ospina-Tascon G et a Crit Care 2013 Septic shock (n=85)
68 Evolution of veno-arterial PCO2 gradient Ospina-Tascon G et a Crit Care 2013 Low PvaCO2 6 mmhg High PvaCO2 Septic shock (n=85)
69 Veno-arterial differences in PCO2: -Flow -Anaerobic metabolism? DDB USI
70 Veno-arterial PCO2 gradient Van Beest et al ICM 2013 Septic shock (n=53)
71
72 PvaCO2 and microcirculatory perfusion Ospina-Tascon G et al ICM pts septic shock
73 Changes in PvaCO2 track changes in microvascular perfusion Ospina-Tascon G et al ICM pts septic shock
74 PvCO2-PaCO2 CaO2 CvO2 ~ RQ
75 Veno-arterial PCO2 / Arterio-venous O2 gradients? Mekontso-Dessap A et a ICM 28:272; 2002 PvCO2-PaCO2 CaO2 CvO2 ~ RQ 89 ICU pts
76 Veno-arterial PCO2 / Arterio-venous O2 gradients? 51 pts with shock / 25 fluid responders Monnet X et al CCM 41:1412; 2013 Lac 2.3 meq/l ScvO2 64 % PVACO2 5.9 mmhg PVACO2/AVO2 1.3 mmhg/ml Lac 5.5 meq/l ScvO2 70 % PVACO2 8.5 mmhg PVACO2/AVO2 2.3 mmhg/ml
77 Impact of SO2 on the relationship between PCO2 and CO2 content (Haldane effect) METHODOLOGICAL ASPECTS OF MUCOSAL CAPNOMETRY [CO2] HALDANE EFFECT mm/l PCO2 Hb 100% HbO2 100% mmhg
78 CvCO2-CaCO2 CaO2 CvO2 = RQ
79 PCO2 gradient combined to lactate Ospina-Tascon G et al ICM 2015 Lactate <2.0 mmol/l and Cv-aCO 2 /Da-vO 2 ratio 1.0 Lactate <2.0 mmol/l and Cv-aCO 2 /Da-vO 2 ratio > 1.0 Lactate 2.0 mmol/l and Cv-aCO 2 /Da-vO 2 ratio 1.0 Lactate 2.0 mmol/l and Cv-aCO 2 /Da-vO 2 ratio >1.0 N= 135
80 Interpretation of venous arterial PCO2 gradients Perner and De Backer ICM 2016 Anemic/hypoxic hypoxia
81 Your patient is in shock But what is the type of shock?
82
83 The four types of shock Vincent JL and De Backer D NEJM 369:1726; 2013
84 Tamponade Low Hypovolic Low DIAGNOSTIC APPROACH Pressures/volumes Cardiac output High Cardiogenic Obstructive High Distributive Sepsis Anaphyl.
85 Vincent JL and De Backer D NEJM 369:1726; 2013
86 Ultrasounds in shock Time to diagnosis: 4.9±1.3 min 108 hypotensive patients in ED Volpicelli et al ICM 2013
87
88 CVP ScvO2 PvaCO2 Central line Rapid improvement Expect and reevaluate CIRCULATORY FAILURE ECHO Arterial line No improvement Complex cases EVLW GEDV PAC TPTD AP PPV Lactate PAP PAOP
89 DIAGNOSTIC APPROACH Low PAOP/CVP low Pressures Cardiac output CVP PAOP Hypovolic RV failure High Distributive Sepsis Anaphyl. PAOP = CVP = PAPd Tamponade PAOP >CVP LV failure
90 DIAGNOSTIC APPROACH (TPTD) GEDV SVV Hypovolic Low Volumes Cardiac output GEDV GEF RV/LV failure High Distributive Sepsis Anaphyl. GEDV SVV Tamponade
91 What to do with the measured variables?
92 Protocols??
93 Individualized medicine??
94 Signs of tissue hypoperfusion? no yes Expect Cardiac output low or inadapted? no Other intervention yes Hemodynamic intervention
95
96 Integrate several variables in your decision process
97 THERAPEUTIC APPROACH Inadequate Preload responsiveness LV function Inotropes Cardiac output Volume Vasopressors (vasodilators) RV function Adapted Adjust ventilator ino/
98 Echographic evaluation of LVEF in patients with septic shock Vieillard-Baron et al AJRCCM 168:1270;2003 => Inotropic agents should not be used to correct a low EF
99 Pay attention to the response of the patient
100 ICM 2015 N = 2213
101
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