Hemodynamic monitoring beyond cardiac output
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1 Hemodynamic monitoring beyond cardiac output Prof Xavier MONNET Medical Intensive Care Unit Bicêtre Hospital Assistance publique Hôpitaux de Paris FRANCE
2 Conflicts of interest Lilly GlaxoSmithKline Pulsion Medical Systems
3 Beyond cardiac output L/min/m 2 cardiac output cardiac preload pump function need for fluid? need for an inotrope?
4 Beyond cardiac output cardiac output fluid administration? inotrope? fluidbenefit responsiveness of fluid??
5 Prediction of fluid responsiveness Concept Stroke volume b' a' When we administer fluid, we expect an increase in SV b' a' All patients do not «respond» to fluid administration A B A B Ventricular preload VE VE
6 Prediction of fluid responsiveness Concept Stroke volume b' a' b' deleterious effects lung edema gas exchange alteration in case of ARDS a' How to predict fluid responsiveness? A B A B Ventricular preload
7 Prediction of fluid responsiveness CVP
8 Prediction of fluid responsiveness CVP CVP does not enable predicting fluid responsiveness?
9 Prediction of fluid responsiveness CVP Stroke volume normal ventricular function b' a' b a impaired ventricular function CVP Ventricular preload Test the Frank-Starling curve! without administering fluid
10 Prediction of fluid responsiveness respiratory variation of stroke volume? Which surrogate of stroke volume A B
11 Respiratory variation Which estimation of stroke volume? arterial pulse pressure
12 Respiratory variation arterial pressure = SV arterial compliance
13 Respiratory variation arterial pressure mmhg PPmax PPmin PPV = 32 % PPV = PPmax - PPmin (PPmax + PPmin) / 2
14 Respiratory variation arterial pressure Meta-analysis 29 studies 685 patients High level of evidence
15 Respiratory variation arterial pulse pressure pulse contour analysis
16 Respiratory variation pulse contour analysis The area under the systolic part of the arterial curve is proportional to SV = k. SV 20 0
17 Respiratory variation pulse contour analysis PiCCO and Vigileo enable a beatby-beat estimation of SV PiCCO and Vigileo assess the respiratory variation of SV
18 Respiratory variation pulse contour analysis 15 patients during brain surgery Graded volume loading PiCCO system
19 Respiratory variation Which estimation of stroke volume? arterial pulse pressure pulse contour-derived SV
20 Respiratory variation Which estimation of stroke volume? arterial pulse pressure pulse contour-derived SV easy and well demonstrated sub-aortic blood flow descending aortic blood flow less invasive but less easy plethysmography signal lower level of evidence
21 Respiratory variation of stroke volume limitations The respiratory variation of hemodynamic signals cannot be used in case of cardiac arrhythmias
22 Respiratory variation of stroke volume limitations mmhg 110 PPmax PPmin
23 Respiratory variation of stroke volume limitations The respiratory variation of hemodynamic signals cannot be used in case of cardiac arrhythmias low Vt
24 Respiratory variation of stroke volume limitations Prediction of fluid responsiveness in septic patients with a low tidal volume Monnet X, Bleibtreu A, Ferré A, Dres M, Richard C, Teboul JL 39 septic shock patients 19 ARDS and 20 non ARDS patients ESICM 2009 Poster # sensitivity PPV sensitivity Vt >7mL/kg 20 Vt 7mL/kg specificity specificity
25 Respiratory variation of stroke volume limitations The respiratory variation of hemodynamic signals cannot be used in case of cardiac arrhythmias low Vt spontaneous breathing
26 Respiratory variation of stroke volume limitations PPmin PPmax PPmax PPmin
27 Respiratory variation of stroke volume limitations The respiratory variation of hemodynamic signals cannot be used in case of cardiac arrhythmias low Vt frequent in the ICU spontaneous breathing
28 cardiac output fluid administration? inotrope? benefit of fluid? arrhythmias, low Vt, SB? no PPV/SVV yes?
29 Passive leg raising hemodynamic effects 45 Endogenous fluid challenge
30 Passive leg raising prediction of fluid responsiveness? ABF PLR Volume expansion 76 ICU patients with acute circulatory failure esophageal Doppler monitoring
31 Passive leg raising which monitoring tool? EDM 10 % increase in ABF 10 % increase in ABF echo 12 % increase in aovti 12 % increase in aovti PiCCO
32 Passive leg raising which monitoring tool? PLR-induced changes in pulse contour-derived CO patients with cardiac arrhythmias or SB Cut-off 10% Se = 95% Sp = 97% -10 nonresponders responders
33 Passive leg raising which monitoring tool? EDM 10 % increase in ABF 10 % increase in ABF echo 12 % increase in aovti 12 % increase in aovti PiCCO 10 % increase in PCCI
34 Tele-expiratory occlusion A B tele-expiratory occlusion
35 Tele-expiratory occlusion test 34 patients with SB or cardiac arrhythmias
36 Tele-expiratory occlusion test Effects of end-expiratory pause on cardiac index 50 Effects of end-expiratory pause on pulse pressure increase 5% Se = 91% Sp = 100 % 10 0 increase 5% Se = 87 % Sp = 100 %
37 cardiac output fluid administration? inotrope? benefit of fluid? risk of fluid? arrhythmias, low Vt, SB? no yes PPV/SVV PLR test TEO test PLR test TEO test
38 Respiratory variation of stroke volume limitations Prediction of fluid responsiveness in septic patients with a low tidal volume Monnet X, Bleibtreu A, Ferré A, Dres M, Richard C, Teboul JL ESICM 2009 Poster # PLR test 80 sensitivity TEO test PPV sensitivity Vt >7mL/kg 20 Vt 7mL/kg specificity specificity
39 cardiac output fluid administration? inotrope? benefit of fluid? risk of fluid? arrhythmias, low Vt, SB? no yes PPV/SVV PLR test TEO test PLR test TEO test
40 When to stop fluid administration? Limit fluid administration in ARDS! Limit lung edema!
41 When to stop fluid administration? Lung water is a prognostic factor in ARDS Lung water How to measure lung water??
42 When to stop fluid administration? cold bolus thermistor Estimation of lung water
43 When to stop fluid administration? Cumulative fluid balance (input - output; L) 7 5 * * * * PAOP group EVLW group -3-5 * p < vs time ARDS patients randomized to EVLW-guided management vs. PAOP-guided management Time (hours) Mitchell JP et al., Am Rev Respir Dis 1992
44 When to stop fluid administration? may guide fluid therapy in ARDS patients * * Management of fluid therapy with : 5 0 Ventilation days ICU days PAOP Group EVLW Group 101 ARDS patients randomized to EVLW-guided management vs. PAOP-guided management Mitchell JP et al., Am Rev Respir Dis 1992
45 Beyond cardiac output cardiac output fluid administration? inotrope? benefit of fluid? risk of fluid? systolic failure? arrhythmias, low Vt, SB? EVLW no yes PPV/SVV PLR test TEO test PLR test TEO test
46 When to stop fluid administration? high lung permeability
47 When to stop fluid administration? VERY high lung permeability
48 When to stop fluid administration? cold bolus thermistor Estimation of lung water
49 When to stop fluid administration? cold bolus pulmonary vascular permeability index PVPI = lung water pulmonary blood volume
50 When to stop fluid administration? PVPI 15 dogs Oleic acid iv. or left balloon inflation Transpulmonary thermodilution Control Inflammatory PE Cardiogenic PE in the clinical setting?
51 When to stop fluid administration? ALI/ARDS PVPI * Hydrostatic pulmonary edema Cut-off : 3 Se = 85 % Sp = 100 % 48 patients with pulmonary edema inflammatory vs. hydrostatic discriminated by experts PVPI by the PiCCO device
52 When to stop fluid administration? 100 PVPI sensitivity BNP specificity PVPI allows estimating n = 31 the lung permeability p < 0.05
53 Beyond cardiac output cardiac output fluid administration? inotrope? benefit of fluid? risk of fluid? systolic failure? arrhythmias, low Vt, SB? EVLW no PPV/SVV PLR test TEO test yes PLR test TEO test PVPI
54 Cardiac contractility echocardiography Echocardiography is the gold standard LVEF but you must be an expert now available 24/24 in all units does not allow continuous monitoring an alternative?
55 When to stop fluid administration? cold bolus stroke cardiacvolume index cardiac function index LVEF CFI = global LV end-diastolic volume
56 Cardiac contractility "Cardiac Function Index" 4 prediction of FAC > 40 % CFI
57 Cardiac contractility "Cardiac Function Index" Cardiac function index provided by transpulmonary thermodilution behaves as an indicator of left ventricular systolic function Jabot J, Monnet X, Lamia B, Chemla D, Richard C, Teboul J-L Critical Care Medicine in press min -1 Sensitivity continuous monitoring of LVEF alerts the clinician that LV systolic function is impaired CFI for detecting LVEF 35% specificity
58 Cardiac contractility "Cardiac Function Index" Cardiac function index provided by transpulmonary thermodilution behaves as an indicator of left ventricular systolic function Jabot J, Monnet X, Lamia B, Chemla D, Richard C, Teboul J-L Critical Care Medicine in press 120 % change in LVEF follow up of inotrope effect Changes induced by - volume expansion - dobutamine % change in CFI
59 Beyond cardiac output cardiac output fluid administration? inotrope? benefit of fluid? risk of fluid? systolic failure? arrhythmias, low Vt, SB? EVLW echo no yes PVPI CFI PPV/SVV PLR test PLR test TEO test TEO test
60 cardiac output fluid administration? inotrope? follow up cardiac output
61 cardiac output fluid administration? inotrope? follow up cardiac output S(c)vO 2
62 SvO 2 / ScvO 2 How to interpret? SvO 2 cardiac output does not fit the tissues requirements normal SvO 2 cardiac output fits the tissues requirements or O 2 extraction is reduced During cardiogenic failure, SvO 2 is a reliable marker of tissue oxygenation During sepsis, a high SvO 2 could mean that cardiac output is adequate that O 2 extraction is low
63 SvO 2 / ScvO patients at early phase of sepsis standard vs "early goal-directed" therapy Very high level of SvO 2 major hypovolemic component
64 SvO 2 / ScvO 2 ScvO 2 is not frequently low in the ICU
65 Beyond cardiac output cardiac output fluid administration? inotrope? benefit of fluid? risk of fluid? systolic failure? arrhythmias, low Vt, SB? EVLW echo no yes PVPI CFI PPV/SVV PLR test PLR test TEO test TEO test
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