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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