Transpulmonary thermodilution in septic shock & ARDS
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1 Transpulmonary thermodilution in septic shock & ARDS F Michard, MD, PhD Lea Michard Photography
2 Disclosure Intensivist Pulsion, UPMED & Edwards Patents
3 Transpulmonary thermodilution CVC, A line (femoral)
4 Central venous catheter jugular subclavian Thermodilution arterial catheter femoral
5 EVLW RA RV PBV LA LV
6 Transpulmonary thermodilution CVC, A line (femoral) CO: thermodilution curve
7 Central venous catheter jugular subclavian Ti Vi Tb Thermodilution arterial catheter femoral
8 Stewart-Hamilton CO = k x Vi x (Tb - Ti) / AUC
9 EVLW
10 2-3 bolus are recommended
11 Transpulmonary thermodilution CVC, A line (femoral) CO: thermodilution curve GEDV: thermodilution curve
12 Michard & Perel. Yearbook of Intensive Care & Emergency Medicine 2003 RV end-diastolic volume (RVEDV) (pulmonary artery thermodilution) LV end-diastolic area (LVEDA) (echocardiography) Global end-diastolic volume (GEDV) (transpulmonary thermodilution)
13 GEDV Normal values ml/m 2
14 GEDV Normal values ml/m 2 Behaves as an indicator of cardiac preload
15 2005
16 GEDV Normal values ml/m 2 Behaves as an indicator of cardiac preload Although CO and GEDV are derived from the same thermodilution curve there is no mathematical coupling between both parameters
17 Chest 2003
18 GEDV Normal values ml/m 2 Behaves as an indicator of cardiac preload Although CO and GEDV are derived from the same thermodilution curve there is no mathematical coupling between both parameters Measuring GEDV to guide fluid therapy is useful to improve patient outcome
19 Anesthesiology 2013
20
21 Transpulmonary thermodilution CVC, A line (femoral) CO: thermodilution curve GEDV: thermodilution curve SVR: MAP/CO
22 Transpulmonary thermodilution CVC, A line (femoral) CO: thermodilution curve GEDV: thermodilution curve SVR: MAP/CO GEF: SV/GEDV
23 Michard & Perel. Yearbook of Intensive Care & Emergency Medicine 2003 RVEF = SV RVEDV SV LVEDV = LVEF RV ejection fraction (RVEF) (pulmonary artery thermodilution) LV ejection fraction (LVEF) (echocardiography) SV GEDV / 4 = GEF Global Ejection Fraction (GEF) (transpulmonary thermodilution)
24 Low GEF = Echo
25 Combes et al. Intensive Care Med 2004
26 Septic shock NO-induced vasodilation Cytokine-induced myocardial depression Hypovolemia (fever, fluid leak, tissue edema)
27 Septic shock NO-induced vasodilation (SVR) Cytokine-induced myocardial depression (GEF) Hypovolemia (GEDV)
28 Femoral arterial catheter Better estimate of central pressure Dorman et al. Crit Care Med 1998
29
30 Femoral arterial catheter Better estimate of central pressure Dorman et al. Crit Care Med 1998 Low rate of complications Belda et al. Br J Anaesth 2010: 512 PiCCO catheters infectious: 0.78%, thrombosis: 0.22% Comparable to radial Scheer et al. Crit Care 2002: meta-analysis radial vs 3899 femoral Frezza et al. Am Surg 1998: 4932 patients
31 Transpulmonary thermodilution CVC, A line (femoral) CO: thermodilution curve GEDV: thermodilution curve SVR: MAP/CO GEF: SV/GEDV EVLW: thermodilution curve
32 Animal validation against gravimetry Katzenelson et al. Crit Care Med 2004 (Dog) Mondejar et al. J Crit Care 2003 (Pig) Kirov et al. Crit Care 2005 (Sheep)
33 Animal validation against gravimetry Katzenelson et al. Crit Care Med 2004 (Dog) Mondejar et al. J Crit Care 2003 (Pig) Kirov et al. Crit Care 2005 (Sheep) Human validation against thermo-dye Sakka et al. Intensive Care Med 2000 Michard et al. Crit Care Med 2005
34 Diagnostic EVLW
35 EVLW Diagnostic Pulmonary edema?
36
37 In real life like in medicine things are frequently different from what they seem!
38 Courtesy from E Segal, Israel EVLW = 8 ml/kg
39 Eisenberg et al. Am Rev Respir Dis 1987
40 Crit Care Med 2013
41
42 EVLW Diagnostic Pulmonary edema? Hydrostatic vs permeability edema?
43 Transpulmonary thermodilution CVC, A line (femoral) CO: thermodilution curve GEDV: thermodilution curve SVR: MAP/CO GEF: SV/GEDV EVLW: thermodilution curve PVPI: EVLW/PBV
44 Pulmonary Vascular Permeability Index = PVPI Permeability pulmonary edema Hydrostatic pulmonary edema EVLW PBV PVPI = EVLW/PBV >>>> PVPI = EVLW/PBV
45 Bendjelid, Giraud, Siegenthaler, Michard. Crit Care 2010
46
47 EVLW Diagnostic Prognostic
48 Nuckton et al. N Engl J Med 2002 Dead space = best predictor of mortality in ARDS
49 Nuckton et al. N Engl J Med 2002 Dead space = best predictor of mortality in ARDS
50 Sakka et al. Chest 2002
51
52 p = predicted
53 EVLW Diagnostic Prognostic Therapeutic
54 ELWI > 10 ml/kg IBW
55
56
57 Mitchell et al. Am Rev Respir Dis 1992 Goal directed fluid depletion therapy based on EVLW measurements
58 A new and simple definition for ALI/ARDS Michard F, Fernandez-Mondejar E, Kirov M, Malbrain M, Tagami T Crit Care Med 2012
59 Transpulmonary thermodilution CVC, A line (femoral) CO: thermodilution curve GEDV: thermodilution curve SVR: MAP/CO GEF: SV/GEDV EVLW: thermodilution curve PVPI: EVLW/PBV RL shunt detection
60
61 19% Crit Care Med 2010
62 Detection of right-to-left intracardiac shunt using transpulmonary indicator dilution EVLW RA RV PBV LA LV
63 camel curve Great Wall, China, China,
64 NO off (PEEP 12 cmh 2 0) PEEP 12 cmh 2 0 (NO off) NO inhalation PEEP removal NO on (PEEP 12 cmh 2 0) PEEP 0 cmh 2 0 (NO off) Michard et al. Crit Care Med 2004
65 The camel curve: the icing on the transpulmonary thermodilution cake Michard & Phillips. Crit Care Med 2011
66 Transpulmonary thermodilution CO: thermodilution curve GEDV: thermodilution curve SVR: MAP/CO GEF: SV/GEDV EVLW: thermodilution curve PVPI: EVLW/PBV RL shunt detection and monitoring
67 One more thing
68 One more thing Who does the measurements?
69 One more thing Who does the measurements? A.A well trained intensivist B.A cardiovascular anaesthetist C.A skilled echocardiographist D.The nurse or the residents
70 One more thing Who does the measurements? A.A well trained intensivist B.A cardiovascular anaesthetist C.A skilled echocardiographist D.The nurse or the residents
71 Transpulmonary thermodilution devices PiCCO from Pulsion VolumeView from Edwards
72
73 PiCCO catheter in the RFA VolumeView catheter in the LFA
74
75
76
77 A&A 2013
78 A&A 2013
79 Conclusion
80 Septic shock & ARDS NO-induced vasodilation (SVR) Cytokine-induced myocardial depression (GEF) Hypovolemia (GEDV) Pulmonary edema (EVLW) Pulmonary fluid leak (PVPI) RL shunt (camel curve)
81 Septic shock & ARDS Low SVR: vasopressors Low GEF: inotropes Low GEDV: fluid High EVLW: caution with fluids, diuretics High PVPI: caution with fluids RL shunt: NO inhalation, decrease PEEP
82 Thank you! Lea Michard Photography
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