Haemodynamic Support. (getting the blood to go round and round) philippelefevre.com
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1 Haemodynamic Support (getting the blood to go round and round) philippelefevre.com
2 Haemodynamic Support Whats wrong with your patient? What can we do about it? Volume expansion Inotropes, Chronotropes & Vasopressors
3 Whats wrong with your patient?
4 Types of Shock Obstructive PE Tamponade Hyperinflation Cardiogenic Arrhythmia Valve dysfunction Myocardial dysfunction Hypovolaemic Haemorrhage Interstitial fluid loss Redistributive Sepsis Anaphylaxis Toxic vasodilation Neurogenic vasodilation
5 Types of Shock Preload Perfusion Obstructive Cardiogenic Hypovolaemic Redistributive
6 Mixed Venous Saturation < 65% > 80% Pain / Anxiety Shivering O2 Consumtion Sedation Hypothermia Cytotoxic dysoxia L R shunts Microcirculatory shunts Anaemia Hypoxia Low Cardiac Output O2 Delivery Cardiac Output
7 What can we do about it?
8 Interventions Obstructive PE Cardiac tamponade Hyperinflation Pleural decompression Pericardial decompression Pulmonary decompression Cardiogenic Arrhythmia Valve dysfunction Myocardial dysfunction Pacing / defibrillation Chronotropes Valvuloplasty Inotropes Hypovolaemic Haemorrhage Interstitial fluid loss Volume Redistributive Sepsis Anaphylactic Toxic vasodilation Neurogenic Vasopressors
9 Interventions Obstructive PE Cardiac tamponade Hyperinflation Pleural decompression Pericardial decompression Pulmonary decompression Cardiogenic Arrhythmia Valve dysfunction Myocardial dysfunction Pacing / defibrillation Chronotropes Valvuloplasty Inotropes Hypovolaemic Haemorrhage Interstitial fluid loss Volume Redistributive Sepsis Anaphylactic Toxic vasodilation Neurogenic Vasopressors
10 Volume Expansion
11 Preload Force of contraction Pre-systolic sarcomere length
12 Preload CO LVEDV
13 Intravenous Fluids IV fluids don t stay in the vascular compartment CO IV volume doesn t necessarily result in preload Difficult to determine where a patient is on the curve Tissue oedema LVEDV
14 Intravenous Fluids Whole Body 70 Kg Water 42 L ECF 17 L IVF 3 L 1 L crystalloid 170 ml of plasma expansion
15 Predicting Fluid Responsiveness Prediction is very difficult, especially about the future. Niels Bohr
16 Predicting Fluid Responsiveness Pressure CVP RAP Ppao Static Volume GEDV RVEDA RVEDV LVEDA LVEDV Dynamic SPV ΔDown PPV SVV IVC diameter variation! End-expiratory occlusion test! Pasive leg raise Fluid bolus
17
18 Predicting Fluid Responsiveness Static Dynamic Pressure Volume CVP RAP Ppao GEDV RVEDA RVEDV LVEDA LVEDV SPV ΔDown PPV SVV IVC diameter variation! End-expiratory occlusion test! Pasive leg raise Fluid bolus 0.96 Marik et al. Annals of Intensive Care 2011
19 Inotropes, Chronotropes & Vasopressors
20 Sympathomimetics β1 Gs Adenylyl Cyclase Na + ATP camp AMP PDE3 Milrinone PKa Ca ++ Troponin C Ca ++ levosimendan Ca ++ 2K + Na + Na + Digoxin 3Na + Ca ++
21 α β1 β2 D V1 PDE3 Troponin C Noradrenaline Adrenaline Dopamine Dobutamine Isoprenaline Vasopressin ++ Milrinone ++ Levosimendan ++ Ca ++ ++
22 Dopamine HO CH2 CH2 NH2 Adrenaline HO CH CH2 NH OH CH3 HO HO Noradrenaline HO CH CH2 NH2 Isoprenaline HO CH CH2 NH OH OH CH HO HO CH3 CH3 Metaraminol HO CH CH OH NH2 CH3 Dobutamine HO CH CH2 NH CH (CH2)2 OH CH3 HO HO
23 Chronotrope Inotrope Isoprenaline Dobutamine Milrinone Levosimendan Ca ++ Adrenaline Dopamine Vasopressor Vasopressin Noradrenaline Metaraminol
24 Noradrenaline Arteriolar tone & SVR Myocardial perfusion Preload
25 Adrenaline H + Glucose Adrenaline Glycolysis Lactate Pyruvate Acetyl CoA Oxaloacetate Citrate Malate TCA cycle -Ketogluterate Fumerate Succinate NAD + ADP H + NADH etc ATP O2 H2O
26 Noradrenaline vs Adrenaline in Shock n = 280 RCT No difference in 28 and 90 day mortality Myburgh et al. Intensive Care Medicine 2008
27 Dopamine HO CH2 CH2 NH2 HO Dopamine β Hydroxylase HO CH CH2 NH2 Noradrenaline OH HO PNMT (only within the adrenal medulla) HO CH CH2 NH Adrenaline OH CH3 HO
28 Dopamine vs Noradrenaline in Shock SOAP I SOAP II n = 3147 observational study n = 1679 multicenter RCT Dopamine associated with higher in-hospital mortality (49.9% vs. 41.7%, p =.01) Sakr et al. (SOAP) NEJM 2010 de Backer et al. (SOAPII) NEJM 2010
29 Dopamine vs Noradrenaline in Shock de Backer et al. (SOAPII) NEJM 2010
30 Dopamine vs Noradrenaline in Shock de Backer et al. (SOAPII) NEJM 2010
31 Dopamine vs Noradrenaline in Shock de Backer et al. (SOAPII) NEJM 2010
32 Levosimendan vs Dobutamine in Heart Failure n = 1320 multicenter multinational double blind RCT Mebazza et al. (SURVIVE) NEJM 2010
33 Levosimendan vs Dobutamine in Heart Failure Mebazza et al. (SURVIVE) NEJM 2010
34 Levosimendan vs Dobutamine in Heart Failure Mebazza et al. (SURVIVE) NEJM 2010
35 Vasopressin in Septic Shock Health volunteer Cardiogenic shock Haemorrhagic shock Septic shock 4 pg/ml 20 pg/ml pg/ml 3 12 pg/ml
36 Vasopressin vs Noradrenaline in Septic Shock n = 779 multicenter RCT Low fixed dose vasopressin (0.03 units/min) Increased plasma concentration from 3 pg/ml to 70 pg/ml Russell et al. (VASST) NEJM 2008
37 Vasopressin vs Noradrenaline in Septic Shock Russell et al. (VASST) NEJM 2008
38 Vasopressin vs Noradrenaline in Septic Shock Russell et al. (VASST) NEJM 2008
39 Vasopressin vs Noradrenaline in Septic Shock Russell et al. (VASST) NEJM 2008
40 Steroids in Septic Shock 80 s studies on high dose methylprednisolone 90 s small studies on low dose hydrocortisone Annane 2002 CORTICUS 2008 ADRENAL study ongoing.
41 Noradrenaline / Adrenaline Concentrations Single 2 mg 40 mcg/ml Single 4 mg 80 mcg/ml Double 8 mg 160 mcg/ml Oct 16 mg 320 mcg/ml
42 Noradrenaline / Adrenaline Concentrations Single 2 mg 40 mcg/ml Single 4 mg 80 mcg/ml Double 8 mg 160 mcg/ml Oct 16 mg 320 mcg/ml 5 mls/hr 0.1 mcg/kg/min in a 70 Kg patient
43 Haemodynamic Support Start by determining your patient s problem Give fluids with great care Vasopressors also give you preload Dopamine = trouble No inotrope has an evidence based throne Remember Ca ++
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