How can the PiCCO improve protocolized care?

Transcription

1 How can the PiCCO improve protocolized care? Azriel Perel Professor and Chairman Department of Anesthesiology and Intensive Care Sheba Medical Center, Tel Aviv University, Israel ESICM, Vienna 2009

2 Disclosure The speaker cooperates with the following companies BMeye Drager-Siemens Pulsion

3 A number of large, randomized, prospective trials have demonstrated that protocol-based strategies can not only reduce variation and cost of ICU medicine but also improve morbidity and mortality of critically ill patients requiring ICU support. Pathways to standardize numerous facets of patient care are becoming the most sought-after means of improving patient outcomes and reducing overall ICU expenditures.

4 Medicine has become complex. Details have become overwhelming for clinicians to process at the bedside Surely, we recognize the need to give up some measure of autonomy yield some decision-making power The data certainly suggest that when we surrender this autonomy and standardize care, patients do better. M. Levy, SCCM th SCCM Conference Perspectives

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6 Computerized or paper-based protocols are detailed and, when used for complex clinical ICU problems, can generate patient-specific, evidence-based therapy instructions that can be carried out by different clinicians with almost no inter-clinician variability. Individualization of patient therapy can be preserved by these protocols when they are driven by individual patient data.

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8 The ICU will likely become a target for pay-forperformance plans, considering the high cost of care, development of ICU quality-of-care measures, and interest from healthcare regulators and funders. Crit Care Med 2009; 37:

9 THE LIMITATIONS OF PROTCOLIZED CARE JL Vincent, Int l J Int Care Spring 2006 Physicians should be careful not to get swept up in this protocol rush since there are many situations in which protocolized care is not helpful and could even be harmful.

10 Complex clinical ICU problems are best described by the Complexity Theory which is used for describing weather, traffic patterns, etc. The principles of the complexity theory include: 1. Critical nature of number of connections and how In the they complex interact. unstable critically ill patient It is nearly impossible to include all aspects of care in one fixed 2. Importance of explicit initial starting protocol! conditions to eventual outcome. 3. Effects of unexpected events. 4. Non-linear dynamics: Small things may have an enormous impact downstream!

11 We recommend the protocolized resuscitation of a patient with sepsis-induced shock, defined as tissue hypoperfusion (hypotension persisting after initial fluid challenge or blood lactate concentration equal to or greater than 4 mmol/l). This protocol should be initiated as soon as hypoperfusion is recognized and should not be delayed pending ICU admission.

12 During the first 6 hrs of resuscitation, the goals of initial resuscitation of sepsis-induced hypoperfusion should include all of the following as one part of a treatment protocol:

13 During the first 6 hrs of resuscitation, the goals of initial resuscitation of sepsis-induced hypoperfusion should include all of the following as one part of a treatment protocol:

14 This systematic review demonstrated a very poor relationship between CVP and blood volume as well as the inability of CVP / dcvp to predict the hemodynamic response to a fluid challenge. CVP should not be used to make clinical decisions regarding fluid management.

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16 Global end-diastolic diastolic volume as an indicator of cardiac preload in patients with septic shock. Michard F, et al. Chest 2003, 124: * Pre- infusion GEDV index (ml/m 2 ) responders non responders

17 Crit Care Med 2008; 36: 2348 Volume depletion was found in more than half the patients with necrotizing pancreatitis. ITBV and its changes, but not the CVP, significantly correlated to CI and its changes. ITBV appears to be more appropriate for volume management in necrotizing pancreatitis than CVP.

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19 Intravascular volume depletion in a 24-hour porcine model of intra-abdominal abdominal hypertension Schachtrupp A et al, J Trauma. 55: , 740, 2003

20 Responder Non-responder SPV PPV SVV

21 Filling pressures should not be used as part of protocolized care!

22 Rivers, NEJM 2001

23 The SvO 2 reflects both oxygen delivery (CO, CaO 2 ) and oxygen consumption and can be used to measure their (im)balance

24 The SvO 2 may serve as a surrogate of CO when oxygen extraction is normal or high

25 Low ScvO 2 perioperatively is related to increased risk of postoperative complications

26 ITBV and continuous ScvO 2 monitoring allowed early recognition of hypovolemia and myocardial depression increased increased administration of colloids and decreased hospital length of stay after OPCAB, as compared with conventional monitoring.

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28 Mixed venous oxygen saturation in critically ill septic shock patients. Krafft P, et al. Chest 1993; 103:900 Fluid resuscitation in severe sepsis and septic shock: An evidencebased review. Vincent JL, Gerlach H. CCM 2004; 32[Suppl.]:S451 Clinical manifestations of disordered microcirculatory perfusion in severe sepsis Trrzeciak S, Rivers E. Crit Care 2005; 9[Suppl] The SvO 2 of septic shock patients is mainly normal or even supra-normal due to reduced oxygen extraction. Therefore, a normal or high SvO 2 does not necessarily indicate adequate tissue oxygenation.

29 The major problems with the interpretation of ScvO 2 A low SvO2 tells you that something is wrong, but not what is wrong and what should be done about it (fluids? inotropes?). However, When the O 2 ER is reduced, as is frequently the case in septic patients, a normal or high ScvO 2 does not guarantee that perfusion is adequate and that resuscitation is complete.

30 Crit Care Med 2005; 33: Clearly, SvO 2 is the gold standard for defining global adequacy of cardiovascular performance.

31 Crit Care Med 2005; 33:

32 Crit Care Med 2005; 33:

33 44 septic patients from 12 European ICU s. ScvO 2 > 70% in 29 (66%) and < 70% in 15 (34%). ScvO2(%) Lactate

34 , et al In ICU-resuscitated patients, targeting only ScvO 2 may not be sufficient to guide therapy. When the 70% ScvO 2 goal-value is reached, the presence of a P(cv-a)CO 2 larger than 6 mmhg might be a useful tool to identify patients who still remain inadequately resuscitated.

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36 Because of the complexity of assessment of clinical variables in septic patients, direct measurement of CO by invasive hemodynamic monitoring is advisable, but other end points of global perfusion (e.g., SVO 2 ) should be followed as well.

37 I have a suspicion, however, that even the medical device manufacturers realize that CO is not an important variable in the critical care arena. quantification of the change in arterial pulse pressure alone is the best way to predict volume responsiveness. Therefore, it is less clear The why main we want reason to to know measure the CO CO in the first place. is to identify patients that have low (or high) CO values that are not evident clinically, and to assess response to therapeutic interventions.

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40 Initially the CI was high (5.3 L/min/m 2 ) and the GEDVi low (555 ml/m 2 ). CI progressively decreased Cardiac and output GEDVi in and was normalized by itself by is fluid not administration enough! aimed at normovolemia.

41 Practice parameters for hemodynamic support of sepsis in adults patients update. Hollenberg et al. Crit Care Med 2004; 32:

42 Pulmonary In most patients edema may with occur septic as shock, a complication CO will of fluid be resuscitation optimized and filling necessitates pressures between monitoring of arterial oxygenation. mmhg [26]. Crit Care Med 2004; 32:1928

43 C. Philips (with permission)

44 A fluid management protocol emphasizing supplemental colloid administration was used to attain the following targets: CI L/min/m 2 GEDVi ml/m 2 EVLW < 10 ml/kg

45 Decision tree for hemodynamic / volumetric monitoring** CI (l/min/m 2 ) <3.0 >3.0 R E S U L T S GEDI (ml/m 2 ) or ITBI (ml/m 2 ) ELWI (ml/kg) <700 <850 >700 >850 <700 <850 >700 >850 <10 >10 <10 >10 <10 >10 <10 >10 V+ V+! Cat Cat V+ V+! Cat V- V- T H E R A P Y T A R G E T GEDI (ml/m 2 ) > > > or ITBI (ml/m 2 ) > > > Optimise tosvv (%) <10 <10 <10 <10 <10 <10 <10 <10 CFI (1/min) or GEF (%) >4.5 >25 >5.5 >30 >4.5 >25 >5.5 >30 OK! ELWI (ml/kg)* (slowly responding) V+= volume loading (! = cautiously) V-= volume contraction Cat = catecholamine / cardiovascular agents + SVV only applicable in ventilated patients without cardiac ythmia arrh **without guarantee *not available in USA 45

46 Decision tree for hemodynamic / volumetric monitoring** R E S U L T S CI (l/min/m 2 ) <3.0 >3.0 GEDI (ml/m 2 ) or ITBI (ml/m 2 ) ELWI (ml/kg) <700 <850 >700 >850 CO (L) <700 <850 GEDV (L) EVLW (L) >700 >850 <10 >10 <10 >10 <10 >10 <10 >10 Fluids V+ V+! Cat Cat V+ V+! Cat V- V- T H E R A P Y T A R G E T GEDI (ml/m 2 ) > > > or ITBI (ml/m 2 ) > > > Optimise tosvv (%) <10 <10 <10 <10 <10 <10 <10 <10 CFI (1/min) or GEF (%) >4.5 >25 >5.5 >30 >4.5 >25 >5.5 >30 OK! ELWI (ml/kg)* (slowly responding) V+= volume loading (! = cautiously) V-= volume contraction Cat = catecholamine / cardiovascular agents + SVV only applicable in ventilated patients without cardiac ythmia arrh **without guarantee *not available in USA 46

47 R E S U L T S CI (l/m 2 ) T H E ITBVI R A P (ml/m 2 ) SVV % Y T A R G E T EVLW (ml/kg) Decision tree for hemodynamic / volumetric monitoring** CI (l/min/m 2 ) <3.0 >3.0 GEDI (ml/m 2 ) or ITBI (ml/m 2 ) ELWI (ml/kg) 1.9 ELWI (ml/kg)* (slowly responding) V+= volume loading (! = cautiously) V-= volume contraction Cat = catecholamine / cardiovascular agents + SVV only applicable in ventilated patients without cardiac ythmia arrh **without guarantee <700 <850 >700 >850 GEDI (ml/m 2 ) > > > or ITBI (ml/m 2 ) > > > Optimise tosvv (%) <10 <10 <10 <10 <10 <10 <10 < CFI (1/min) or GEF (%) <700 <850 >700 >850 <10 >10 <10 >10 <10 >10 <10 >10 V+ V+! Cat Cat V+ V+! V- Cat V- Fluids cautiously + >4.5 >25 >5.5 >30 >4.5 >25 >5.5 >30 CO (L) GEDV (L) EVLW (H) CAT OK! Classic therapeutic (heart vs. lungs) conflict *not available in USA 47

48 R E S U L T S CI (l/m 2 ) Decision tree for hemodynamic / volumetric monitoring** CI (l/min/m 2 ) <3.0 >3.0 GEDI (ml/m 2 ) or ITBI (ml/m 2 ) ELWI (ml/kg) 3.75 <700 <850 CO (H) GEDV (H) >700 >850 EVLW (H) <700 <850 >700 >850 <10 >10 <10 >10 <10 >10 <10 >10 Diuresis V+ V+! Cat Cat V+ V+! Cat V- V- ITBVI (ml/m 2 ) T GEDI (ml/m 2 ) > > > H 1. E or ITBI 1444 (ml/m 2 ) > > > R T + 2. Optimise tosvv (%) <10 <10 <10 <10 A <10 <10 <10 <10 A P R Y G!!! E CFI (1/min) >4.5 >5.5 >4.5 >5.5 T or GEF (%) >25 >30 >25 >30 OK! SVV % ELWI (ml/kg)* (slowly responding) EVLW (ml/kg) V+= volume loading (! = cautiously) V-= volume contraction Cat = catecholamine / cardiovascular agents + SVV only applicable in ventilated patients without cardiac ythmia arrh **without guarantee 15 *not available in USA 48

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50 GEDV (L) EVLW (L) fluids

51 CI (L) GEDV (H) (L) EVLW (H) CAT This may not always be true!

52 Guiding therapy by an algorithm based on GEDVI leads to a shortened and reduced need for vaso-pressors, catecholamines, mechanical ventilation, and ICU therapy in patients undergoing cardiac surgery. Total amount of norepinephrine

53 Guiding therapy by an algorithm based on GEDVI leads to a shortened and reduced need for vaso-pressors, catecholamines, mechanical ventilation, and ICU therapy in patients undergoing cardiac surgery. Total amount of epinephrine

54 When EVLW is high C. Philips et al

55 When EVLW is high EVLW (H) BP (L) CI (L) GEDV (L) Fluids, Dobutamine, Vasopressors C. Philips et al

56 When EVLW is high EVLW (H) BP (L) CI (H) GEDV (H) Vasopressors Diurese C. Philips et al

57 This protocol allows aggressive diuresis of excess preload even during periods of shock something not done in the FACTT trial and rarely done clinically. This is accomplished by better identifying preload state using superior metrics of preload and cardiovascular status GEDI, CI, and EVLW. C. Philips (with permission)

58 Conclusions: 1. Replacing complex decision making in the ICU by explicit fixed protocols presents an immense challenge. 2. Some protocols have been recommended prematurely and may pose risk to the patient. 3. Attempts to protocolize care in critically ill patients have to leave room for clinical judgment especially during therapeutic conflicts. 4. The PiCCO monitor, which provides CCO, volumetric preload, fluid responsiveness, cardiac function, and EVLW, is best suited for providing treatment protocols for critically ill patients.

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