Het belang van de CVD herontdekt. J.G. van der Hoeven
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1 Het belang van de CVD herontdekt J.G. van der Hoeven
2 Om te beginnen CO 5.8 L CO 10.4 L Inspanning 120 ml ml 0 CVD is normaal 0 en blijft ook 0
3 Veneuze terugstroom MSFP Vloeistof bolus Venous resistance VR = MSFP - CVD Veneuze weerstand 0 mm Hg 1,8 1,6 1,4 1,2 1 0,8 0,6 0,4 0,2 0 Before After MSFP Cecconi M. Intensive Care Med 2013;39:
4 Slower loss of fluid from vasculature Normal Maar ook omdat.. Rapid vascular refilling with fluid removal Normal oncotic pressure VCS VCS Arterial XNormal intersitium Interstitial oedema Venous Fluid therapy Ultrafiltration CVD CVD = 0 RV CVD = 10 RV Rapid loss of fluid from vasculature Low oncotic pressure Increased capillary permeability Plasma protein leak Hypoalbuminaemia Systemic inflammation Slow vascular refilling with fluid removal MFI CVD 2 20 VCI VCI Microvascular flow index 1,5 1 0, CVD 0 CVD 12 CVD > 12 0 Vellinga NAR. BMC Anesthesiology 2013;13:17
5 RV preload veel kleiner effect op RV output Stroke work (g.m) Mean atrial pressure (cm H2O)
6 Conclusie (1) Hoge CVD heeft veel ongunstige neveneffecten CVD betekent ofwel een hypertrofische RV met diastolische dysfunctie of wel rechter ventrikel dilatatie
7 Centraal veneuze druk Enkelvoudige statische meting is niet voorspellend voor volumestatus of vloeistof responsiviteit Veranderingen in CVD gecombineerd met cardiac output zijn wel een goede parameter voor volumebeleid Analyse van de centraal veneuze druk curve geeft belangrijke informatie (vloeistof responsiviteit, inspiratie poging, thoraxwand compliantie, T3 insufficiëntie, RV compliantie, tamponade)
8 CVD bepaald door CO en volumestatus Cardiac Function Return Function L Q R Rv MSFP Q Q Q MSFP Pra Pra
9 Drie oorzaken waardoor de CVD stijgt A Q B Q C Q Pra Pra Pra Cardiac function Stressed volume Venous resistance
10 Meting van CVD sternum; this point is called the sternal angle and is identified on clinical examination by a slight protuberance due to the angle formed by the articulation of the manubrium and sternum. On average, the midpoint of the right atrium is 5 cm vertically below the sternal angle. This is true whether a person lies flat or sits up at a 60! angle, because the right atrium is a relatively round structure and is just below the sternum.13 The center of the right atrium thus remains directly below the sternal angle when the torso is rotated upward. Bedside measurement of CVP gives a value in centimeters of water. This can be converted to millimeters of mercury by dividing the value in centimeters of water by This is based on the density of mercury, which is 13.6 times that of water, and conversion from centimeters to millimeters. When assessing jugular venous distention, the measurement should be made at the base of the pulsations seen in the neck rather than at the top of the pulsations, for this value is closest to the value obtained from the pressure waves on monitors. CVP can also be determined with a simple fluid column inserted into a central vessel and similarly by the column of fluid filling a central line, but one must guard against allowing air to be sucked in through the system. These values are closer to the mean value on electronic monitors. Ultrasonography can also be used to measure CVP noninvasively14,15 by assessing the level of collapse in the jugular veins, which is like looking at the top of the column. Three things must be considered when taking pressure measurements with fluid-filled catheters: zeroing, calibrating, and leveling. All pressures are measured relative to a reference value. The standard reference value or zero is atmospheric pressure, because this is this represents the location at which blood comes back to the heart and is the level from which blood is pumped out again (Fig 3). As indicated earlier for assessment of jugular venous distention on physical examination, the sternal angle is a good reference point because it is 5 cm vertically above the mid-right atrium, and this reference level can also be used to level transducers. This is done by placing a carpenter s leveling device on the sternal angle and setting the transducer 5 cm below it. However, most centers use the midaxillary line at the fourth interspace for the reference level, because a measuring device is not required, and this approach is more adaptable in the operating room (Fig 3). The proper level to use on the transducer is the level at which the stopcock can be opened to air, for this is the condition that was used to zero the system and accounts for the Optimaal A
11 Meting van CVD Eind-expiratoir tenzij patiënt actief expireert
12 S wave of QRS
13 Klinisch gebruik van CVD Klinisch redeneren Lage RR Lage CO CVD 0 Onwaarschijnlijk Tamponade PE RV falen tenzij: GI bloeding Ruime diurese Sepsis Lage RR Lage CO CVD Onwaarschijnlijk Hypovolemie tenzij: Hoge Ppl RV falen
14 Klinisch gebruik CVD Het is onwaarschijnlijk dat een patiënt met CVP > 10 mmhg een vloeistof responder zal zijn ( 15%) Patiënten die wel reageren hebben lang bestaande pulmonale HT met RV hypertrofie, hoge pleura drukken, hart tamponade of een restrictieve hartziekte
15 Klinisch gebruik CVD CVD CO Implicatie Voorbeeld Toegenomen hartfunctie Afgenomen hartfunctie Toegenomen veneuze return Afgenomen veneuze return Toename in beide functies Afname in beide functies HF, contractiliteit, afterload NB: pleuradruk Centraal volume of veneuze weerstand
16 Even logisch nadenken Echografie VCI Expiratie Inspiratie Expiratie Inspiratie Expiratie Responder Inspiratie Non- Responder
17
18 Conclusies Verhoogde CVD heeft belangrijke negatieve gevolgen voor veneuze terugstroom en microcirculatie CVD als geïsoleerde parameter niet bruikbaar bij de beoordeling / behandeling van de hemodynamiek CVD in combinatie met hartminuutvolume geeft een goede indruk van volumestatus Analyse van de CVD curve geeft belangrijke klinische informatie
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