Continuous monitoring of cardiac output: why and how

Transcription

1 33rd International Symposium of Intensive Care and Emergency Medicine, Brussels UNIVERSITÄTSKLINIKUM Schleswig-Holstein Continuous monitoring of cardiac output: why and how Berthold Bein, MD, MA, PhD, DEAA Professor of Anaesthesiology and Intensive Care Department of Anaesthesiology and Intensive Care Medicine University Hospital Schleswig-Holstein Campus Kiel

2 CONFLICT OF INTEREST Pulsion Medical Systems (Advisory Board) Edwards Life Sciences Deltex

3 AGENDA Examples from daily clinical routine What s it all about Algorithms Effects Summary

4 Question Probability to die after a laparoscopic cholecystectomy within 4 weeks? 1 : : : :

5 An example year old female patient; cardiopulmonary healty >4ME Pancreatic cancer; Procedure: Whipple! High risk patient: ASA II High risk surgery: yes Monitoring:?

6 The clinical case...whipple - OP

7 Intraop. Echocardiography

8 The clinical case...wertheim - OP 58-year old pat.; hypertension; β-blocker Monitoring: CVP and A-line

9 Wertheim - OP Emergency intraop.-toe TOE - induced change in therapy: β-blocker + volume

10 Had we been well prepared? and Did we target the right aims?

11 The clinical case...wertheim - OP High risk patient? 58 years; Hypertension; NO β-blocker; ASA II High risk surgery? Gynaecological cancer YES Procedure: Wertheim-Op.! Monitoring? Basic-monitoring plus experience plus RR invasive, CVP

12 Did we underestimate something? Patient: ASA II Procedure: major abdominal surgery Monitoring: CVP, A-line, experience Complication: Hypovolemia / Hemorrhage It is well known by those interested in this subject that the Young and healthy patients are able to maintain HR and BP up to a blood volume and cardiac output are usually diminished in traumatic shock blood before volume the loss arterial of 25%. blood pressure declines significantly Blalock A, (1943) Surgery 14: We relied on the wrong monitoring!

13 Predictors of increased risk Intraoperative Hemodynamic Predictors of Mortality, Stroke, and Myocardial Infarction After Coronary Artery Bypass Surgery Reich DL et al., Anesth Analg. 1999; 89: cardiosurgical patients Predictors: pulmonary Hypertension, Brady- /Tachykardia, Hypotension Intraoperative Tachycardia and Hypertension Are Independently Associated with Adverse Outcome in Noncardiac Surgery of Long Duration Reich DL et al., Anesth Analg. 2002; 95: patients with major procedures Predictors: OP-time, Tachykardia, Hypertension Anesthetic Management and One-Year Mortality After Noncardiac Surgery Monk TG et al., Anesth Analg. 2005; 100: patients with major procedures Predictors: Co-Morbidity, BIS < 45, Hypotension

14 HOW DO WE TARGET IN ANAESTHESIA AND INTENSIVE CARE Clinical experience

15 ACTUAL SITUATION IN ANAESTHESIA Routine monitoring ECG NIBDP SaO 2 CO 2 Advanced Monitoring CVP A-line

16 WHAT S S IT ALL ABOUT Supply DO 2 = HZV x Hb x 1,34 x SaO 2

17 CORRELATION OF BP AND CO Blood pressure (mm Hg) Linton et al.: J Cardiothorac Vasc Anesth 2002 (16):4 Cardiac index (l/min/m 2 )

18 Help the residents Physician staffing on a randomly chosen day... Anaesthetist A Anaesthetist B AnaesthetistC AnaesthetistD Anaesthetist E Anaesthetist E Anaesthetist F 1,5 years experience 3/4 year experience 1,0 year experience 1,5 years experience 1,0 year experience 2,5 years experience 3/4 year experience

19 WHICH PATIENTS BENEFIT Gurgel et al. Anesth Analg 2011

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21 Haemodynamic GDT in high risk patients is associated with reduced mortality!

22 WHICH EFFECTS TO EXPECT? Dalfino et al Crit Care 2011

23 WHICH EFFECTS TO EXPECT? Corcoran et al Anesth Analg 2012

24 WHICH TARGET VALUES? (SVV, PPV, S V O 2, Laktat) Hamilton et al. Anesth Analg 2011

25 WHICH VARIABLES TO MONITOR??? A haemodynamic GDT should target oxygen supply or at least CO!

26 WHICH ALGORITHM??? Simple Algorithm Complex Algorithm Reduced complications (p<0.05) Wakeling et al BJA 2005 Berlauk et al. Ann Surg 1991 Reduced complications (p<0.05)

27 Multi-Center, prospective, randomized Outcome Study comparing continuous cardiac index trending (ProAQT) via a radial arterial line versus standard care in general surgical patients n=160 patients, multicenter (Germany, Hungary, Spain, Russia) Major abdominal surgery (colorectal, urological, gynecological procedures) Duration of surgery > 2 hours and/or blood loss > 20% of total blood volume expected Primary end point: LOS hospital Secondary end points: incidence of complications and organ dysfunction

28 A simple algorithm

29 RESULTS

30 SUMMARY

31 Answer Probability to die after a laparoscopic cholecystectomy within 4 weeks? 1 : : : :

32 How we do it now Cardiac index 2,5 <2,5 SVV >10% Fluid bolus* l/min/m2 SVV <10% No therapy SVV >10% Fluid bolus* l/min/m2 SVV <10% Inotropes Re-evaluation every 15 min. MAP 65mmHg * 250 ml of colloids

33 Number needed to treat EDA for reduction of mortality NNT 477 Aspirin for prevention of MI NNT 44 to 182 Simvastatin for prevention of NNT cardiovascular complications GDT for prevention of complications NNT 7.7

34 GOAL DIRECTED DOES NOT MEAN HANDS-OFF

35 Many thanks for your attention!