Norepinephrine in septic shock
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1 Norepinephrine in septic shock Prof. Zsolt Molnár Department of Anaesthesia and Intensive Therapy University of Szeged, Hungary
2 A few months ago should we give it earlier? (Courtesy of Prof. Kula)
3 Case year old female IDDM, hypertension Vomiting, diarrhea for 3 days Admission with UTI via A&E to a medical ward Tx: AB ICU referral: general deterioration, hypotension (70/ mmhg) Molnár 99
4 ICU assessment at 13:45 pco2: 28.4 ph: HCO3: 10.5 Laktát: 6.9 Molnár 99
5 ICU admission at 14:00 Oxigén ml RL + Norepinephrine (10 µ/min) ph HCO3 Laktát Molnár 99
6 After CVC insertion at 14:30 Oxigen ml RL + Norepinephrine (10 µ/min) CV-blood gas ph HCO3 Laktát NA and my practice: ScvO2!! In severe hypotension start immediately and then taper it down Molnár 99
7 Pathophysiology
8 Why patients get into trouble? Fluid SaO Blood 2 Oxygen ScvO 2 ~100% ~70% For adequte assessment DO 2 = (SV P) (Hb 1.39 SaO PaO 2 ) ~ 1000ml/min Evaluation of physiology (VO 2 /DO 2 ) is VO 2 = CO (CaO 2 - CvO 2 ) ~ 300 ml/min Analgesia, anaesthesia, IPPV needed VO 2 /DO 2 ~30%
9 VO 2 /DO 2 and ScvO 2 Ctitical point DO 2 ScvO 2 VO 2 (ml/min) Shock DO 2 (ml/min)
10 Blood pressure and cardiac output Linton RA, et al. J Cardiothorac Vasc Anesth 2002; 16: 4-7. For adequte perfusion both MAP and CO is needed
11
12
13 59%
14 Pioneers Otto Frank ( ): Physiologist (Leipzich) Zur Dynamik des Herzmuskels, Z Biol 32 (1895) 370 Ernest Starling ( ): University College London Starling forces, hormones, etc. Molnár 99
15 Hemodynamics Otto Frank, Ernest Starling 1914: Law of the heart Within physiological limits, the force of contraction is directly proportional to the initial length of the muscle fiber No problem Stroke volume (ml)?? Preload Molnár 99 Starling EH. The Linacre Lecture on the Law of the Heart. London; 1918 Starling EH. J R Army Med Corps. 1920; 34:
16 Cardiac filling pressures are not appropriate to predict hemodynamic response to volume challenge Pre-infusion values Osman D, et al. Crit Care Med 2007; 35: 64-8 CVP: Sens: 62% (95% CI, 49 73%) Spec: 54% (95% CI, 43 65%) PAOP: Sens: 77% (95% CI, 65 87%) Spec: 51% (95% CI, 40 62%)
17 One size does not fit all! normal heart Stroke volume Static parameters preload (CVP, responsiveness PAOP, GEDV) cannot predict fluid responsiveness failing heart preload unresponsiveness Courtesy of Prof. Jean-Loius Teboul.CVP=8 mmhg.cvp=3 mmhg Ventricular preload
18 A thought on SVR Ohm s law: R = U I U MAP CVP I Georg Ohm
19 A thought on SVR Ohm s law: SVR = U I = MAP CVP CO K U MAP Warning! It is not measured! CVP I Georg Ohm
20 Multimodal hemodynamic monitoring Tánczos K, Németh M, Molnár Z. Ann. Up. in Int. Care and Em. Med. 2014, pp:355 CI SVI GEDVI GEF Hb SpO 2 Lactate ScvO 2 MAP Diuresis, etc.
21 Fluid responsiveness
22 Heart-lung interactions Antonio Maria Valsalva ( ) Physician, phylosopher, artist Anatomy of the ear Valsalva maneuvre:
23 IPPV = series of Valsalva-maneuvers PPV = PPmax - PPmin (PPmax +PPmin) /2 Molnár 99 PPmax PPmin
24 Stroke volume preload responsiveness preload unresponsiveness A B Ventricular preload IPPV: (Courtesy of Jean-Louis Teboul)
25 Molnár 99 Devices
26
27 ProAQT-outcome study Salzwedel C, et al. Crit Care 2013; 17: R191
28 Number of complications Salzwedel C, et al. Crit Care 2013; 17: R * 60 Control group Study group Number of complications * 0 Total Infection Abdominal Cardiovascular Respiratory Renal Others
29 Number of patients with complications Salzwedel C, et al. Crit Care 2013; 17: R * Control group Study group 30 Number of patients 20 * 10 0 Total Infection Abdominal Cardiovascular Respiratory Renal Others
30 Number of patients with complications Salzwedel C, et al. Crit Care 2013; 17: R Number of patients with complications * Control group Study group 0 Not every patient would benefit from Bowel surgery No bowel surgery this (i.e.: a certain) approach
31
32 although could not show significant reduction in the primary outcome of the complication rate at 30 days in the cardiac output guided group, but there was a measurable treatment effect, and at 180 days there was a non-significant reduction in mortality. (Quote from the ESICM interview with Rupert Pearse)
33 What are we actually using?
34 59% 43%
35 Molnár 99
36 We don t use adequate parameters in adequate numbers to guide therapy
37 Does the multimodal concept work?
38 Multimodal monitoring during free-flap surgery: Crystalloid vs. Colloid (PRCT) - 29 patients (15 crystalloid vs. 14 colloid) - Multimodal monitoring: PPV, SV (CI), MAP - ScvO 2, dco 2, lactate, ph, HCO 3 - Microcirculation: Laser Doppler Restrictive FR Restrictive FR Length of surgery (mean): 8.5 hours Maintenance fluid: 1 ml/kg/h Boluses: - Crystalloid group: 1600 ml (min=500, max=5000 ml) - Coloid group: 560 ml (min=450, max=1500 ml) No difference in outcome variables
39 Multimodal monitoring on the ICU GEDI: ml / / m2 EVLWI: 75 ml/kg SVI: SVI: ml /m2 /m2 CI: 4,1 3,1 l/min/m2 CI: 4,81 l/min/m2 SVV: 10% 9% P: 77/min 45/min P: 83/min ICP:17 ICP:14 Hgmm CPP: Hgmm SpO2:99% etco2: Hgmm Dobutamine PbO 2 : 2 : Hgmm Temp: 33,5 ºC ScvO 2 : 82% dco 2 : 5 Lactate: 0,7 mmol/l UO: ml/h
40 Instead of protocolized management:
41 Thinking has no alternative! Diagnosis can wait, but cells can t! Auguste Rodin: The Thinker, 1880
42 Free for junior doctors (<29)! Budapest, 9-11 November 2016
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