Jarisch A. Kreislauffragen, Dünser et al. Critical Care 2013, 17:326 Sunday, March 30, 14

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1 It was fatal for the development of our understanding of circulation that blood flow is relatively difficult while blood pressure so easy to measure: This is the reason why the sphygmomanometer has gained such a fascinating influence, although most organs do not need blood pressure but flow. Jarisch A. Kreislauffragen, 1928 Dünser et al. Critical Care 2013, 17:326

2 Resuscitated? Use of US, CVP, ScvO2, Non-Inv COMs to restore flow Matthew S. Muller, MD, MS Emergency Medicine Baylor University Medical Center at Dallas

3 Riedemann NC et al. Nature Medicine 2003;9:

4 Pressure Flow

5 DO 2 = (SV, HR) x (Hgb, SaO2, PaO2) Survivors (%) Oxygen Delivery (ml/min/m 2 ) Bland, Shoemaker, et al. Crit Care Med 1985 ;13:85-92

6 Flat : NOT Fluid Responsive SV Ascending : Fluid Responsive

7 A. Initial Resuscitation 1. Protocolized, quantitative resuscitation of patients with sepsis-induced tissue hypoperfusion (defined in this document as hypotension persisting after initial fluid challenge or blood lactate concentration 4 mmol/l). Goals during the first 6 hrs of resuscitation: a) Central venous pressure 8 12 mm Hg b) Mean arterial pressure (MAP) 65 mm Hg c) Urine output 0.5 ml/kg/hr d) Central venous (superior vena cava) or mixed venous oxygen saturation 70% or 65%, respectively (grade 1C). 2. In patients with elevated lactate levels targeting resuscitation to normalize lactate (grade 2C).

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10 NQF Endorses Additional Infectious Disease Measures FOR IMMEDIATE RELEASE MAR 06, 2013 CONTACT: Erin Weireter NQF Endorses Additional Infectious Disease Measures Washington, DC - the National Quality Forum (NQF) Board of Directors has endorsed two additional infectious disease measures addressing severe sepsis and sepsis shock, and testing for chronic hepatitis C. These measures were originally evaluated as part of NQF s infectious disease measure endorsement project, which had 14 measures endorsed in January. NQF is a voluntary consensus standards-setting organization. Any party may request reconsideration of the endorsed quality measures listed below by submitting an appeal no later than April 4 (to submit an appeal, go to the NQF Measure Database). For an appeal to be considered, the notification must include information clearly demonstrating that the appellant has interests directly and materially affected by the NQF-endorsed recommendations and that the NQF decision has had (or will have) an adverse effect on those interests. Measures List 0500: Severe sepsis and septic shock: Management bundle (Henry Ford Hospital) 0393: Hepatitis C: Testing for chronic hepatitis C Confirmation of hepatitis C viremia (AMA-PCPI) NQF operates under a three-part mission to improve the quality of American healthcare by: building consensus on national priorities and goals for performance improvement and working in partnership to achieve them; endorsing national consensus standards for measuring and publicly reporting on performance; and promoting the attainment of national goals through education and outreach programs.

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14 Flat : NOT Fluid Responsive SV Ascending : Fluid Responsive

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16 it may well be that earlier recognition accounts for much of the signal in mortality reduction

17 1. Find them 2. Give them abx Go for Bronze! 2 Liter Bolus Are you lazy? If lazy and a bad person, give another 1-2 liters Assess MAP, continue resusc emcrit.org

18 IVC ultrasound

19 Advantages Repeatability Available, inexpensive Kinda sexy U/S fellowship grads need stipends, shift buy-down

20 1. Find them Go for Silver! 2. Give them abx 2 Liter Bolus Assess with IVC/Echo, give another 1-2 liters Still showing signs of needing more fluid? Y Start norepi 1 mcg/min N Are you lazy? If lazy and a bad person, give another 1-2 liters Assess MAP, continue resusc emcrit.org

21 Crit Care. 2012; 16(5): R188 In spontaneously breathing patients with ACF, high civc values (>40%) are usually associated with fluid responsiveness, while low values (< 40%) do not exclude fluid responsiveness.

22 Applying dynamic parameters to predict hemodynamic response to volume expansion in spontaneously breathing patients with septic shock. Shock Feb;39(2): Michael J Lanspa, Colin K Grissom, Eliotte L Hirshberg, Jason P Jones, Samuel M Brown Optimal thresholds: vena cava collapsibility index, 15% or greater (positive predictive value, 62%; negative predictive value, 100%; P = 0.03) read here: <15%,? fluid tolerance

23 Patient size, position Measurement site Manner of breathing IVCCI does not reliably predict fluid responsiveness in spontaneously breathing Expertise patients with acute circulatory failure IVCCI <15% seems to rule-out fluid responsiveness Axis, technique IVCCI >40% usually associated with fluid responsiveness (PPV 70%) Shock + collapsing = give fluids Serial exam useful + distended = don t maybe

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25 Date of download: 3/22/2014 Copyright American College of Chest Physicians. All rights reserved. Does Central Venous Pressure Predict Fluid Responsiveness? * : A Systematic Review of the Literature and the Tale of Seven Mares Chest. 2008;134(1): doi: /chest Shippy, CR, Appel, PL, Shoemaker, WC Reliability of clinical monitoring to assess blood volume in critically ill patients. Crit Care Med1984;12, Fifteen hundred simultaneous measurements of blood volume and CVP in a heterogenous cohort of 188 ICU patients demonstrating no association between these two variables (r = 0.27). The correlation between ΔCVP and change in blood volume was 0.1 (r 2 = 0.01). This study demonstrates that patients with a low CVP may have volume overload and likewise patients with a high CVP may be volume depleted. Reproduced with permission from Shippy et al. 11

26 Crit Care Med 2012 Vol. 40, No ventilated, septic shock patients, SSC vs TEE TEE led to withholding volume expansion in 30% of patients, all had CVP <12 mm Hg agreement was weak between TEE and SSC for the decision to fluid load (κ: 0.37 [0.16;0.59])

27 As the Infectious Disease Project Committee at NQF reviewing Sepsis #0500 has considered many times now, CVP may not be the most robust measure of volume status, but no other measure has ever been shown to be better, especially as part of a sepsis resuscitation protocol. We are left with the knowledge that when CVP is used as part of a larger protocol, mortality does decline in the peer reviewed literature. Thus, the committee has twice voted in favor of the inclusion of CVP and ScvO2. -NQF response to GNYHA

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29 A. Initial Resuscitation feedback on DO2 / VO2 relationship interpretation dependent on phase 1. Protocolized, quantitative resuscitation of patients with sepsis-induced tissue hypoperfusion (defined in this document as hypotension persisting after initial fluid challenge of or sepsis blood lactate concentration 4 mmol/l). Goals during the first 6 hrs of resuscitation: a) Central venous pressure 8 12 mm Hg b) Mean arterial pressure (MAP) 65 mm Hg c) Urine output 0.5 ml/kg/hr Chest December; 140(6): d) Central venous (superior vena cava) or mixed venous oxygen saturation 70% or 65%, respectively (grade 1C). 2. In patients with elevated lactate levels targeting resuscitation to normalize lactate (grade 2C).

30 A. Initial Resuscitation 1. Protocolized, quantitative resuscitation of patients with sepsis-induced tissue hypoperfusion (defined in this document as hypotension persisting after initial fluid challenge or blood lactate concentration 4 mmol/l). Goals during the first 6 hrs of resuscitation: a) Central venous pressure 8 12 mm Hg b) Mean arterial pressure (MAP) 65 mm Hg c) Urine output 0.5 ml/kg/hr Chest December; 140(6): d) Central venous (superior vena cava) or mixed venous oxygen saturation 70% or 65%, respectively (grade 1C). 2. In patients with elevated lactate levels targeting resuscitation to normalize lactate (grade 2C).

31 <70%

32 (Non-Invasive) Cardiac Output Monitor

33 Pulse Contour Analysis Direct correlation between the arterial pressure waveform and cardiac output

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36 An electric current of known frequency is applied across the thorax between the outer pair of sensors A signal is recorded between the inner pairs of sensors Change in phase of the frequency is recorded and the signal translated to flow (similar to Doppler concept)

37 Increase in SVI of >10% after 2-3 minutes is indicative of fluid responsiveness REGARDLESS of Preload/CVP In cases where PLR is not possible a fluid bolus of 250ml should yield the same results

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39 1. Find them 2. Give them abx Go for Gold! 2 Liter Bolus Assess with IVC/Echo, give another 1-2 liters Still showing signs of needing more fluid? Y Start norepi 1 mcg/min N Are you lazy? If lazy and a bad person, give another 1-2 liters Assess MAP, continue resusc Attach CO monitor, PLR/bolus, assess vol responsiveness emcrit.org

40 Resuscitated? Give them as much as they need, not a drop more US, CVP may help with fluid tolerance ScvO2 is an alarm PLR + Non-invasive COM... Holy Grail?

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42 Hotchkiss and Karl.The Pathophysiology and Treatment of Sepsis. NEJM 2003;348:138