Radboud University Nijmegen Medical Centre Why measure cardiac output in critically ill children?

Transcription

1 Radboud University Nijmegen Medical Centre Why measure cardiac output in critically ill children? J. Lemson Anesthesiologist/(pediatric)intensivist

2 Case; Girl 2 years, 12 kg, severe meningococcal septic shock PO kpa (100% O 2 ) ph 7.03 BE -20 mmol/l Lactate 5.8 mmol/l HR 180 bpm MAP 60 mmhg Refill

3 Case; Girl 2 years, 12 kg, severe meningococcal septic shock PO kpa (100% O 2 ) ph 7.03 BE -20 mmol/l Lactate 5.8 mmol/l HR 180 bpm MAP 60 mmhg Refill CI 6.5 l/min/m 2

4 Hemodynamic monitoring in Brussels 2007 (adults)

5 Hemodynamic monitoring Geneva 2007

6 The Pulmonary Artery Catheter (PAC). our trial was never sufficiently powered to compare management with a PAC against no cardiac output monitoring => Not all PAC trials concern cardiac output measurement itself! Lancet 2005; 366:

7 PAC in children The use of the PAC is not advised in (small) children Courtesy of dr. Jeroen Verwiel

8 CO measurement; less invasive techniques Fick O 2 CO 2 (NICO2) Doppler pre sternal/jugulum (UScom) oesophageal (CardioQP / Hemosonic) Dilution technique Transpulmonary lithiumdilution (LidCO) Transpulmonary thermodilution (PiCCO) Transpulmonary ICG dilution (DDG analyser) Arterial Pulse contour analysis PiCCO LidCO (PulseCO) Modelflow PRAM FlowTrac Echocardiography Bioimpedance

9 Basic haemodynamics Controlled variable (baroreflex) Preload Afterload Contractility

10 Basic haemodynamics SV Normal contractility Decreased contractility preload Decreased myocardial contractility => decreased margin of preload

11 Septic cardiomyopathy Effects of normal and meningococcal serum on rat myocyte contraction amplitude. Crit Care Med 2002; 30:

12 Inflammation Neonates and infants undergoing congenital cardiac surgery using cardiopulmonary bypass. Pediatr Crit Care Med 2003; 4:

13 Inflammation Patients undergoing CPB with neonate or infants group. Eur J of Cardio-thoracic Surg 1997; 12:

14 Inflammation Sepsis Inflammation Surgery / Trauma Myocardial dysfunction Increased capillary permeability Vasodilation Autonomic dysregulation (Younger children more susceptible?) Cardiovascular Research 2007;73:26 36 Crit Care Med 2007; 35:

15 Clinical estimation of cardiac output Arch Dis Child 1997;77:

16 Heart rate and cardiac output cardiac output (%) R 2 = 0, HR (%) N = 11; Newborn animal model Fluid resuscitation (10 ml/kg) from hypovolemic shock J. Lemson et al; accepted Ped Crit Care Med 2007

17 Heart rate and cardiac output cardiac index (l/min/m 2 ) R 2 = 0, HR (bpm) N = 13; critically ill children (2 months - 8 years) J. Lemson et al. Europediatrics 2006

18 MAP and cardiac output delta MAP (%) delta MAP (%) delta CO (%) delta CO (%) N = 13; critically ill children (2 months - 8 years) J. Lemson et al. Europediatrics 2006

19 Stroke volume and cardiac output Before After p-value HR (bpm) 140 ( ) 139 ( ) NS MAP (mmhg) 33 (22 40) 37 (31 60) < CI (ml/min/kg) 295 ( ) 323 ( ) < 0.01 FS (%) 33 (23 40) 32 (23 44) NS n = 15; age hours Effect of 20 ml/kg fluid loading Int Care Med 1997;23:

20 Stroke volume and cardiac output delta SV (%) delta SV (%) delta CO (%) delta CO (%) N = 11; Newborn animal model Fluid resuscitation (10 ml/kg) from hypovolemic shock J. Lemson et al; accepted Ped Crit Care Med 2007

21 Give enough fluids. 34 patients (median age 13.5 months) with septic shock. Rapid fluid resuscitation in excess of 40 ml/kg in the first hour following emergency department presentation was associated with improved survival.. JAMA 1991;266: Early goal directed therapy ( Rivers study ) N Engl J Med 2001;345:

22 But not to much! adult patients with acute lung injury Variables Odds Ratio (95% Confidence Interval) Cancer 4.4 ( ) High tidal volume 2.3 ( ) Mean SOFA score 1.4 ( ) Mean fluid balance 1.5 ( ) Sepsis Occurrence in Acutely Ill Patients (SOAP) network in 24 European countries during a 14-day period from May 1, 2002, to May 15, Chest 2005;128;

23 Higher fluid balance => higher mortality 116 children with MODS requiring renal replacement therapy Variable Survivors Non-survivors p value Patient age (years) 8.49 ± ± 7.19 NS PRISM 2 at PICU admit 14.3 ± ± 9.7 NS Fluid overload (%) 14.2 ± ± 32.9 <0.03 Kidney International, 2005;67:

24 Fluid resuscitation increase preload cardiac output fluid responsive

25 Fluid resuscitation increase preload cardiac output = risk of fluid overloading Neth J Med 2000;57:82-93 Acta Anaesthesiol Scand 2004;8:69-73

26 Fluid resuscitation increase preload cardiac output Fluid responsiveness adults Arterial pressure variation Global end diastolic volume (GEDV) Passive leg raising etc fluid responsive

27 Fluid resuscitation increase preload cardiac output? Fluid responsiveness children????????? fluid responsive

28 Radboud University Nijmegen Medical Centre Conclusion 1. Clinical parameters, heart rate and blood pressure do not reflect changes in cardiac output 2. Cardiac output measurement is the cornerstone in haemodynamic management of children 3. Advanced hemodynamic monitoring could be beneficial

29 What s it all about? CardioQP BoMed NICO2 COLD Calorimeter (Fick) PiCCO USCom PiCCOplus CCO (PAC)

30 What s it all about? No monitoring device, no matter how simple or sophisticated, will improve patient-centered outcomes unless coupled with a treatment that, itself, improves outcome Pinsky & Vincent Crit Care Med 2005;33:

31 Statement The author has no financial or other relationship that might lead to a conflict of interest

32 Radboud University Nijmegen Medical Centre