Παθοφυσιολογια αποτυχίας αποδέσμευσης. Καρδιαγγειακό

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1 Παθοφυσιολογια αποτυχίας αποδέσμευσης Καρδιαγγειακό Θεόδωρος Βασιλακόπουλος Καθηγητής Πνευμονολογίας-Εντατικής Θεραπείας Εθνικό & Καποδιστριακό Πανεπιστήμιο Αθηνών Νοσοκομείο «ο Ευαγγελισμός» Adjunct Professor, McGill University, Montreal, Canada Γενικός Γραμματέας Ελληνικής Πνευμονολογικής Εταιρείας

2 A 66 year-old patient with COPD was admitted to the ICU for pneumonia and respiratory failure Physical examination Fever (38,9 o C) Tachypnea (34 breaths/minute) Cyanosis Tachycardia (132 beats/minute) Accessory respiratory muscle use Abdominal muscle contraction during expiration

3 A 66 year-old patient with COPD was admitted to the ICU for pneumonia and respiratory failure Room air ph = 7,14 pco2 = 60 mmhg po 2 = 44 mmhg [HCO3-] = 22 meq/l Venturi Mask 31% ph = 7,05 pco2 = 78 mmhg po 2 = 51 mmhg [HCO3-] = 23 meq/l The patient became comatose and was intubated before NIV could be instituted

4 Mechanical Ventilation Volume Control Tidal Volume 520 ml Respiratory Rate = 16 breaths/min TI/TT = 0,25 PEEP = 5 cmh2o FiO2 = 50%

5 Therapy iv antibiotics Moxifloxacin Piperacilline/tazobactam bronchodilators Berovent qid Corticosteroids iv fluids

6 ICU course: Day 5 Mechanical Ventilation ph = 7,37 pco2 = 48 mmhg po 2 = 94 mmhg [HCO3-] = 26 meq/l [Glucose] = 133 mg/dl [Urea] = 78 mg/dl [Creatinine] = 2,1 mg/dl WBC = 8450 (58% PMNs) CRP = 3,4 mg/dl [Na + ] = 142 meq/l [Cl-] = 101 meq/l [K + ] = 4,2 meq/l Temperature = 36,9 o C

7 ICU course Radiologic improvement Patient was awakened Spontaneous breathing Trial T-piece FiO2 = 40%

8 SBT 1 (Day 5) Mechanical Ventilation ph = 7,37 pco2 = 48 mmhg po 2 = 94 mmhg [HCO3-] = 26 meq/l RR = 18 breaths/min HR = 82 b/min BP = 112 mmhg T-piece ph = 7,26 pco2 = 61 mmhg po 2 = 54 mmhg [HCO3-] = 27 meq/l RR = 38 breaths/min HR = 122 b/min BP = 128 mmhg

9 SBT 2 (Day 6) Mechanical Ventilation ph = 7,39 pco2 = 46 mmhg po 2 = 88 mmhg [HCO3-] = 25 meq/l RR = 16 breaths/min HR = 78 b/min BP = 114 mmhg T-piece ph = 7,28 pco2 = 57 mmhg po 2 = 52 mmhg [HCO3-] = 26 meq/l RR = 37 breaths/min HR = 129 b/min BP = 125 mmhg

10 SBT 3 (Day 7) Mechanical Ventilation ph = 7,38 pco2 = 45 mmhg po 2 = 84 mmhg [HCO3-] = 25 meq/l RR = 14 breaths/min HR = 79 b/min BP = 116 mmhg T-piece ph = 7,25 pco2 = 56 mmhg po 2 = 51 mmhg [HCO3-] = 26 meq/l RR = 37 breaths/min HR = 126 b/min BP = 138 mmhg

11 On Mechanical ventilation End expiratory occlusion: P=6 cmh2o (PEEPi) Maximum inspiratory pressure = 64 cmh2o

12 Pulmonary Artery Catheter Inserted: Hemodynamics on mechanical ventilation Right Atrial Pressure = 3 mmhg Pulmonary Artery Pressure= 24 mmhg Pulmonary artery occlusion pressure = 14 mmhg Cardiac index = 3,2 liters/min/m 2

13 Pulmonary Artery Catheter Inserted: Hemodynamics during T-piece trial Right Atrial Pressure = 15 mmhg Pulmonary Artery Pressure= 64 mmhg Pulmonary artery occlusion pressure = 44 mmhg Cardiac index = 4,3 liters/min/m 2

14 How did this happen?

15 Πνευμονικό οίδημα στο weaning Venous 3.2 L/min/m 2 Return 4.3 L/min/m2 Lemaire F et al Anesthesiology 1988; 69:171-9

16 Venous Return = = Upstream Pressure Downstream Pressure Resistance Mean Systemic Pressure Right Atrial Pressure

17 Dwonstream pressure (right atrial pressure) increased during the T-piece trial 3mmHg Downstream Pressure (RAP) 15mmHg

18 Venous Return = = Upstream Pressure Downstream Pressure Resistance Mean Systemic Pressure Right Atrial Pressure Abdomen

19 Venous return during spontaneous breathing trials Venous Return Pab : abdominal pressure, RAP: right atrial pressure Pivc : inferior vena cava pressure at the diaphragmatic inlet Pulmonary Edema

20 During Spontaneous breathing increased venous return decreased diastolic filling of the left ventricle THORAX

21 During mechanical ventilation positive intrathoracic pressure reduction in afterload THORAX

22 During Spontaneous breathing negative intrathoracic pressure increase in afterload THORAX

23 What was the solution? Diuresis What was the result?

24 SBT 4 (Day 10) Mechanical Ventilation ph = 7,38 pco2 = 44 mmhg po 2 = 89 mmhg [HCO3-] = 25 meq/l RR = 15 breaths/min HR = 81 b/min BP = 117 mmhg T-piece ph = 7,35 pco2 = 49 mmhg po 2 = 75 mmhg [HCO3-] = 26 meq/l RR = 25 breaths/min HR = 92 b/min BP = 122 mmhg

25 : Hemodynamics during T-piece trial after diuresis (day 10) Right Atrial Pressure = 6 mmhg Pulmonary Artery Pressure= 26 mmhg Pulmonary artery occlusion pressure = 16 mmhg Cardiac index = 3,9 liters/min/m 2

26 What was the mechanism?

27 West zones of the lung

28 Before diuresis: zone III conditions Pv,extraabdominal > Pivc > Pab Pv,extraabd Pab : abdominal pressure, RAP: right atrial pressure Pivc : inferior vena cava pressure at the diaphragmatic inlet Venous Return Pulmonary Edema

29 After Diuresis: zone II conditions Pv,extraabdominal > Pab > Pivc Pv,extraabd No increase in venous return Pab : abdominal pressure, RAP: right atrial pressure Pivc : inferior vena cava pressure at the diaphragmatic inlet No Pulmonary Edema

30 Diuresis for weaning failure in COPD patients with cardiac dysfunction 8/15 patients were successfully weaned Lemaire F et al Anesthesiology 1988; 69:171-9

31 Cardiovascular Dysfunction Jubran A et al, AJRCCM 1998; 158:1763-9

32 Is SvO 2 decrease specific to weaning failure?

33 Successful weaning Iso-VO 2 isopleths SvO2 De Backer D et al, Intensive Care Med 2000; 26:1201-6

34 SvO 2 decrease is not specific to weaning failure and can be observed even in patient who wean successfully

35 Weaning Success Iso-VO 2 isopleths Cardiac Index (l/min/m 2 ) Intensive Care Med 2005;31:

36 Weaning failure: 2 patterns VO 2 ml/min/m 2 Intensive Care Med 2005;31:

37 Weaning Failure: no increase in VO 2 Iso-VO 2 isopleths Cardiac Index (l/min/m 2 ) Intensive Care Med 2005;31:

38 Weaning Failure: increase in VO 2 Iso-VO 2 isopleths Cardiac Index (l/min/m 2 ) Zakynthinos et al, Intensive Care Med 2005;31:

39 Cardiac dysfunction Normal cardiac function Yalavatti et al, Chest 2000;118:782-7

40 Cardiac Ischemia during weaning Weaning Preload Afterload Contractility Heart rate VO2 MDO2<MVO2 Ischemia

41 Cardiac Ischemia during weaning Chatila et al Chest 1996;109:

42 Cardiac Ischemia during weaning % /83 Srivastava Chatila Abalos Crit Care Med 1999; 27: /93 5/62 Chest 1996; 109: Am J Crit Care 1992; 1:32-36 Ischemia

43 Cardiac Ischemia during weaning: consider angioplasty

44 Cardiac Ischemia during weaning: consider coronary artery bypass grafting

45 Search for unusual causes Systolic anterior motion of the mitral valve EE Septal hypertrophy Late peaking high velocity curve Doppler Hypertrophic obstructive cardiomyopathy Adamopoulos C et al Intensive Care Med 2005;31:734-7

46 Hypertrophic obstructive cardiomyopathy Prevalence 0,2 % Any age (25% may present at >70 years) Discontinue diuretics, inotropes, vasodilators Negative inotropic agents (β-blockers)

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49 Crit Care 2016;20:369

50 Crit Care 2016;20:369

51 Weaning outcome and LV diastolic dysfunction Konomi et al, Anaesth Intensive Care 2016,44:4

52 Weaning outcome and LV diastolic dysfunction Papanikolaou et al Intensive Care Med 2011, 37:

53 Weaning outcome prediction & LV diastolic dysfunction Papanikolaou et al Intensive Care Med 2011, 37:

54 Can we predict who is going to develop cardiovascular dysfunction during weaning?

55 Beginning of SBT End of SBT (2 hours) % change in BNP during the SBT Chien JY et al Crit Care Med 2008;36:

56 BNP and cardiac dysfunction Chien JY et al Crit Care Med 2008;36:

57 BNP, LV diastolic dysfunction & weaning Konomi et al, Anaesth Intensive Care 2016,44:4

58 BNP levels before weaning trials Mekontso-Dessap et al Intensive Care Med 2006;32:

59 BNP as predictor of weaning failure Mekontso-Dessap et al Intensive Care Med 2006;32:

60 BNP before and after WT, pg/ml Mekontso-Dessap et al Intensive Care Med 2006;32:

61 BNP & weaning Konomi et al, Anaesth Intensive Care 2016,44:4

62 ΒΝP & NT-proBNP change during SBTs Zapata L et al, Intensive Care Med 2011,37:

63 NT-proBNP in difficult to wean COPD patients who fail a SBT Grasso S et a,l Crit Care Med 2007;35:96-105

64 BNP in successful weaning 450 # normal LVD RVD # 0 MV 1 h T-piece Ait-Oufella et a,l Intensive Care Med 2007;33:1183-6

65 When BNP > 200pg/ml Fluid intake restricted < 500ml/24 hours baseline <1000ml/24 hours parenteral Furosemide mg every 3 hours

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69 Time (hours) to successful extubation

70 Fluid balance, ml Fluid balance and weaning outcome Success Failure Last 24 hours Cumulative Upadya A et al, Intensive Care Med 2005;31:1643-7

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73 Passive Leg Raising & Cardiac Index

74 Crit Care 2016;20:369

75 How should we diagnose weaning induced pulmonary edema?

76 Anguel et al Intensive Care Med 2008;34:1231-8

77 % change in plasma protein concentration Anguel et al Intensive Care Med 2008;34:1231-8

78 Καρδιακή δυσλειτουργία στο weaning Πολυπαραγοντική Υποκείμενη νόσος Ισοζύγιο υγρών Δείκτης που να την προβλέπει ;;; Πρέπει να την υποπτευόμαστε όταν αποτυγχάνει το weaning