Functional Hemodynamic Monitoring and Management A practical Approach
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1 Functional Hemodynamic Monitoring and Management A practical Approach Daniel A. Reuter Center of Anesthesiology and Intensive Care Medicine Hamburg-Eppendorf University Hospital Hamburg, Germany Euronaesthesia 2006, Madrid, June 4
2 Early Optimization of Hemodynamics improves outcome Kern JW and Shoemaker WC Crit Care Med 30: , 2002 Metaanalysis of hemodynamic optimizaton in high risk patients Rivers et al., N Engl J Med 345: , 2001 Early goal-directed therapy in the treatment of severesepsis and septic shock
3 Goals of hemodynamic Management 1. Optimizing Stroke volume /Cardiac Output: Measurement of SV/CO 2. Optimizing Preload: Measurement of Preload Assessing Fluid Responsiveness 3. Avoiding Fluid Overload Assessing Pulmonary Edema
4 Preload Optimizitation as primary Step to optimize SV/CO Preload low (too) high CO?? Macrocirculatory Dysfunctions? Microzirculatory Dysfunctions? Organ Failure CO??? (Macrozirculatory Dysfunctions)? Formation of Edema? Microzirculatory Dysfunctions? Organ Failure
5 Ventricular Function Curve Stroke volume Preload
6 Stepwise Fluid Loading to optimize SV
7 Stepwise Fluid Loading to optimize SV
8 CVP and PAOP do not allow quantitative Assessment of Preload CVP PAOP Kumar et al; Crit Care Med ; 2005
9 Ventricular function curve Stroke volume Preload Volume
10 Volumetric preload monitoring Transesophageal Echocardiography LVEDA
11 Volumetric Preoad Monitoring Injection of Indicator (cv-line) EVLW arterial Catheter (PiCCO) RAEDV RVEDV PBV LAEDV LVEDV ITBV: GEDV: intrathoracic Blood Volume global end-diastolic Volume
12 Volumetric Preload Monitoring Michard F et al; Chest 125: ; 2003
13 How to define best Preload? stroke volume volume dependency volume independency preload volume
14 Fluid Responsiveness: CVP r² = 0.08 p > 0.05 CVP baseline [mmhg] r² = p > CI [%] Reuter DA et al. Intensive Care Med 2002; 28:
15 Heart-Lung-Interactions during MV P intrathoracic venous Return to RV/LV fl LV Preload fl LVSV fl
16 Stroke Volume Variation by arterial Pulse Contour Analysis Stroke Volume Variation (SVV) 80 ml 50 ml SVV = (SV max - SV min ) / SV mean
17 SVV - Mechanism - SV SVV SVV Preload (Volume)
18 Prediction of fluid responsiveness: SVV SVV SVV baseline [%] DCI [%] r² = 0.55 r² 0.55 p < 0.05 CVP Reuter DA et al. Intensive Care Med 2002; 28: Berkenstadt H, et al: Anesth Analg 92: , 2001
19 Early hemodynamic Goals optimized SV Organ Function optimized preload prevent pulm. edema
20 Avoiding Fluid Overlad
21 Chest X-Ray vs. EVLW Eisenberg PR et al., CritCare Med 5: ,1984
22 EVLW in ARDS : The Mitchell-Study Probability of requiring mech. vent EVLW (n=40) WP (n=42) days on mechanical ventliation Probability of still being in ICU EVLW (n=52) WP (n=49) days in ICU Mitchell JP, et al., Am Rev Respir Dis, 1992
23 Transcardiopulmonary Thermodilution: Extravascular Lung Water (EVLW) Injection of Indicator (cv-line) EVLW arterial Catheter (PiCCO) RAEDV RVEDV PBV LAEDV LVEDV EVLW: extravascular Lung Water
24 Experimental Validation EVLW by Thermodilution Kirov MY et al; J Crit Care 2004
25
26
27 Preload-directed Therapy CO, GEDV, ITBV, EVLW The Practical Approach
28 Preload-directed Therapy 80 cardiac surgery patients (CABG) Study group: n = 40 Controls: n = 40 (matched pairs) Studyperiod: start of surgery 48 h post op
29 Treatment Algorithm CO / GEDV / EVLW yes GEDVI > 640? CI > 2.5? MAP > 70? no no no EVLWI >10? GEDVI > 800? no no EVLWI >10? yes yes yes GEDVI > 800? no EVLWI >10? yes yes GOOD!! no no give Volume until GEDVI >640 give Volume until GEDVI > 800 give catecholamines until CI > 2.5 give Volume until GEDVI > 800 give catecholamines until MAP > 70
30 IV Volume on ICU Colloids Kolloide im Verlauf OP bis 48h postoperativ Algorithm (ml) Controls OP 8 hrs 16 hrs 24 hrs 32 hrs Goepfert MS et al. (submitted) 48 hrs
31 Total norepinephrine on ICU 16 Norepinephrine Arterenol (mg) OP bis 48h postoperativ (mg) Controls Algorithm OP 1 8 hrs 2 163hrs 244hrs 325hrs 486hrs Goepfert MS et al. (submitted)
32 Total epinephrine on ICU Epinephrine Suprarenin intraoperativ bis 48h postoperativ 3 2,5 2 Controls (mg) 1,5 1 0,5 0 Algorithm OP 8 hrs 16 hrs 24 hrs 32 hrs 48 hrs Goepfert MS et al. (submitted)
33 Rationale hemodynamic managment? - avoid dehydration - maintain preloading blood volume? determine it! - prevent inadequate tissue perfusion? measure SV /CO! - prevent fluid overload Consider escalating update monitoring strategies and adequate early goal directed algorithms including the complete periopertive process oriented at functional hemodynamic monitoring (e.g. SV, SVV, PPV, GEDVI, EVLW)
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