Actualités de la prise en charge hémodynamique initiale Daniel De Backer
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1 Actualités de la prise en charge hémodynamique initiale Daniel De Backer Head Dept Intensive Care, CHIREC hospitals, Belgium Professor of Intensive Care, Université Libre de Bruxelles Past- President European Society of Intensive Care Medicine
2
3 JAMA 2017
4 ICM septic pts Voluntary submission of data
5 NEJM 2017 NY state pts 149 hosp Mandatory reporting
6 NY state pts 149 hosp NEJM 2017
7 HEMODYNAMIC RESUSCITATION
8 Rhodes et al ICM 2017 CCM 2017
9 Not too much but also not limited. Liu V et al Annals ATS pts with sepsis
10 NEJM 2017 Caution: the delay in fluid administration may be related to lower initial severity NY state pts 149 hosp
11 NEJM 2017 OR hospital mortality for each hour delay NY state pts 149 hosp
12 Rhodes et al ICM 2017 CCM 2017 The good Ø Emphasis on Fluid resuscitation Ø Amount in agreement with observational data The bad Ø No strong data Ø One size fits all? The ugly Ø Why delaying therapy?
13 Rhodes et al ICM 2017 CCM 2017
14 2012 Recommenda4on for Ini4al Resuscita4on. We recommend the protocolized, quan4ta4ve resuscita4on of pa4ents with sepsis- induced 4ssue hypoperfusion. During the first 6 hours of resuscita4on, the goals of ini4al resuscita4on should include all of the following as a part of a treatment protocol: a) CVP 8 12 mm Hg b) MAP 65 mm Hg c) Urine output 0.5 ml/kg/hr d) Scvo2 70%.
15 ICM 2015
16 NEJM 2017
17 Rhodes et al ICM 2017 CCM 2017
18
19 Most patient already reached target ScvO2 values in the recent trials Rivers et al PROCESS ARISE PROMISE ScvO2 % Rivers et al NEJM 2001 Angus D et al NEJM 2014 Peake S et al NEJM 2014 Mouncey P et al NEJM 2015 Inclusion: refractory hypotension and/or lactate 4 (despite fluids)
20 Peake S et al Most patients reached ScvO2 goal at inclusion NEJM 2014 and the proposed protocol was not able to significantly increase this proportion over time!
21 Major differences in mortality in control arm Rivers et al PROCESS ARISE PROMISE Mortality % (ctrl) ScvO2 % Rivers et al NEJM 2001 Angus D et al NEJM 2014 Peake S et al NEJM 2014 Mouncey P et al NEJM 2015 Inclusion: refractory hypotension and/or lactate 4 (despite fluids)
22 Prognostic value of lacate and impact of time from diagnosis Casserly B et al CCM 43:567;20150 Rivers ProMISe ARISE ProCESS pts / 218 sites / SSC database
23 Inclusion rates? Angus D et al NEJM 2014 Ø 0.9 Patients/ centre / month (included) 3.9 Patients/ centre / month (screened) (ED with at least admissions/ year) Ø 0.5 Patients/ centre / month (included) 1.6 Patients/ centre / month (screened) Peake S et al NEJM 2014 Ø 0.5 Patients/ centre / month (included) 1.6 Patients/ centre / month (screened) Rowan et al NEJM 2015
24 20 % of these «septic shock» patients were not admitted to the ICU!? Angus D et al ICM Inclusion: refractory hypotension and/or lactate 4 (despite fluids)
25 Ø The concept remains valid Ø Patient identification is crucial Ø The classical EGDT may be applied when better hemodynamic strategies cannot be used
26 Rhodes et al ICM 2017 CCM 2017 The good Ø Integrates other variables of tissue hypoperfusion to indicate fluids Ø No rigid follow up of EGDT bundles The bad Ø No strong data Ø Too evasive The ugly Ø No clear recommendation
27 What do you recommend to your junior doctors, ED colleagues, nurses,? Rhodes et al ICM 2017 CCM 2017
28 Variables to use to indicate further fluid administration? Ø Heart rate / blood pressure Ø Skin mottling Ø CVP Ø Lactate Ø Veno-arterial PCO2 gradients Ø Urine output Ø Echo Ø Other available hemodynamic measurements Most of these variables indicate poor tissue perfusion not that the patient will respond to fluids!
29 Rhodes et al ICM 2017 CCM 2017
30
31 Rhodes et al ICM 2017 CCM 2017
32 Dynamic variables to predict the response to fluids? => Evaluation of preload responsiveness during transient change in preload induced by respiration or external maneuver
33 Dynamic variables to predict the response to fluids? Heart-lung interactions Respiratory variations in stroke volume Respiratory variations in vena cava size Expiratory pause External maneuvers Passive leg raising test
34 SEPSIS Michard et al AJRCCM 162:134;2000 N= 40 Cut-off value: 13% DDB
35 Rhodes et al ICM 2017 CCM 2017
36
37 CVP: Never an optimal prediction but still some reasonable guidance if nothing better can be used. Eskesen et al ICM pts
38 CVP: Never an optimal prediction but still some reasonable guidance if nothing better can be used. Biais-M et al Crit Care pts
39 CVP: Never an optimal prediction but still some reasonable guidance if nothing better can be used. Biais-M et al Crit Care pts
40 Rhodes et al ICM 2017 CCM 2017
41 Rhodes et al ICM 2017 CCM 2017
42 High vs Low MAP? VS mmhg Asfar P et al NEJM 2014 Ø But lower incidence of AKI with high MAP in previously hypertensive patients Ø Higher rate of arrhythmias and AMI in high MAP 798 pts septic shock
43 Rhodes et al ICM 2017 CCM 2017
44 9190 pts with sepsis Liu V et al Annals ATS 2013
45 Janssens T et al AJRCCM 2010 Lactate guided therapy
46 Lactate guided therapy (-20%/2h for 8h) Janssens T et al AJRCCM 2010 N=348
47
48 Crit Care day mortality: 28 vs 18% p=0.033 N=360
49 Rhodes et al ICM 2017 CCM 2017
50 Bakker De Backer -Hernandez ICM 2016
51 FLUID THERAPY
52 Rhodes et al ICM 2017 CCM 2017
53 Rhodes et al ICM 2017 CCM 2017
54 Xu JY et al Crit Care 2014
55 Rhodes et al ICM 2017 CCM 2017
56 VASOPRESSOR SUPPORT
57 When to introduce vasopressors? Rhodes et al ICM 2017 CCM 2017
58 When to introduce vasopressors? Early introduction of vasopressors may decrease later need for fluids DDB USI
59 Early introduction of norepi decreased fluids requirements Sennoun N et al CCM 35:1736; ml Fluids Late NE Early NE 5 0 Category 1 Rats / LPS
60 Duration of hypotension before initiation of vasopressor agents is associated with poor outcome Bai X et al Crit Care pts with septic shock
61 Rhodes et al ICM 2017 CCM 2017
62 Norepinephrine vs Dopamine in shock (SOAP investigators) De Backer et al NEJM 362: 779; 2010
63 Dopamine vs norepinephrine in septic shock A meta-analysis De Backer et al CCM 40:725:2012 Norepi better
64 Vail E et al JAMA 2017 Shifting from norepi to phenylephrine + dopamine was associated with increased mortality
65 Rhodes et al ICM 2017 CCM 2017
66 VASST Russell et al NEJM 358:877; septic shock pts
67 VASST Russell et al NEJM 358:877;2008 Mortality (%) according to severity at baseline day 90 day NOREPI VP p< day 90 day p<0.05 More severe n= 400 (NE > 15 mcg/min) (15 mcg/min ~ mcg/kg.min for 80-70kg pts) Less severe n= 378 (NE < 15 mcg/min)
68 Gordon et al JAMA 2016 A double-blind randomised controlled trial of vasopressin (up to 0.06 u/min) vs noradrenaline within 6h of onset of septic shock. Norepi dose at randomization: 0.16 [ ] mcg/kg.min
69 NEJM 2017
70
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