EVOLUCIÓN DE LA MONITORIZACIÓN CARDIOVASCULAR EN LA UCI
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1 EVOLUCIÓN DE LA MONITORIZACIÓN CARDIOVASCULAR EN LA UCI Antonio Artigas Critical Care Center Sabadell Hospital CIBER Enfermedades Respiratorias Autonomos University of Barcelona Spain
2 MERCURY SPHYGMOMANOMETER (Circa 1905)
3 FORSSMANN S PLACEMENT OF A CATHETER INTO HIS RIGHT ATRIUM (Nobel Prize 1956)
4 SHOCK UNIT. Los Angeles County General Hospital (1967)
5 What Do I Want to Know Cardiovascular Performance Adequacy of Tissue Perfusion
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8 What to use......pressures!?!?? Art. BP is the most accessible surrogate of organ blood flow Central V. pressures estimate preload of Rt. and Lt. circulation P art P vein Resistance Intravascular pressures are easily acquired and exceedingly accurate!
9 The Determinants of the CVP: 1. Venous Return- a Pressure Gradient The venous reservoir- mean systemic pressure (MSP): 6-12 mmhg The heart: RA pressure (CVP): 0-6 mmhg Venous Return = (MSP - CVP) / R veins
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18 The Determinants Cardiac Output: 2. The Contractile State Ejection of blood from the RV depends on preload (venous return) and contractile state Q The relationship between venous return and contractile state determines the CVP Pra
19 Assumption: Pressures Reflect Volumes CVP RVEDV, PAOP LVEDV It Rarely Works Like That
20 PA-line vs. no PA- line: 1,000 pts. with ALI, ARDS, randomized to: CVP, monitoring phys. exam, UO & BP PA- line: all the above, and PAP, PAOP, CO No difference in outcome No difference in complications PAC is not for routine management of ALI
21 A single value of pressure (CVP, PAOP) does not adequately assess cardiocirculatory status Add a measure of flow (cardiac output or surrogates) Perturbate the system Dynamic Evaluation: Fluid Responsiveness Q Pra
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26 Other Hemodynamic Monitors Transthoracic thermodilution: CCO, SV, SVV, volumetric cardiopulmonary indices Arterial pressure- based CO: CCO, SV, SVV, SVR Partial CO 2 rebreathing Ultrasonic Esophageal Doppler Finger pulse plethysmography Thoracic bioimpedance ECHO Kaplan & Mayo, Chest 09
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28 Minimally-Invasive Estimates of Cardiac Output Alternative to PAC thermodilution CO Use the arterial pulse pressure to estimate flow Based on the principal that the primary determinant of changes in pulse pressure are changes in stroke volume PiCCO, BMEYE: Wessling algorithm LiDCO: power transfer FloTrac: modified version of power transfer Electrical resistance of the thorax BioZ and NICOM
29 Pulse Contour Analysis: Bottom Line Reports mean cardiac output, PPV and SVV well PiCCOplus, LiDCOplus, FloTrac (?SVV) Can be used in protocolized care to improve outcome LiDCOplus, FloTrac Can be used to assess dynamic step changes in flow (passive leg raising) LiDCOplus, LiDCOrapid, PiCCOplus, FloTrac Does not require external calibration FloTrac, LiDCOrapid Not clear if abilities and clinical benefit reported with one device can be extrapolated to the others
30 Non-invasive Methods to Measure Cardiac Output Finger pulse plethysmography Finepres CO 2 rebreathing NICO Thoracic Electrical Induction BioZ (bioempedence) NICOM (bioreactance)
31 NICOM BioReactance SV = DV DX EKG DV DX Global Blood volume X(t) dx/dt max VET dx/dt
32 NICOM vs. Transonic Flowprobe CO in L/min Transonic pulmonary artery doppler NICOM Time Keren et al. Am J Physiol 293:H583-9, 2007
33 Comparisons of Various Methods of Estimating Cardiac Output PAC vs. LiDCO PAC vs. PiCCO PAC CO - LIDCO CO SD 0.78 Mean SD Bias = ± 0.56 L/min LIDCO CO y=0.96 x r 2 = 0.89 p< PAC CO PAC CO PICCO CO SD 3.9 Mean SD Bias = ± 0.61 L/min PICCO CO y=0.92 x r 2 = 0.87 p< PAC CO PAC vs. Vigileo PAC vs. NICOM PAC CO - VIGILEO CO SD 2.1 Mean SD VIGILEO CO y=0.58 x r 2 = 0.46 p< PAC CO - NICOM CO SD 3.0 Mean SD NICOM CO y=0.48 x r 2 = 0.50 p< Bias = ± 1.25 L/min PAC CO Bias = 0.24 ± 1.39 L/min PAC CO Lamia et al. Am J Respir Crit Care Med 177: A631, 2008
34 Minimally invasive estimates of Cardiac Output Bottom Line All FDA-approved to assess cardiac output PiCCO, LiDCO and FloTrac are report CO accurately but may not trend similarly Bioreactance probably as accurate Consider the type of monitoring relative to the clinical setting OR and ICU with arterial catheter: LiDCO, FloTrac OR and ICU with femoral arterial catheter: PiCCO ED and acute triage elsewhere: NICOM
35 SUPRA-STERNAL DOPPLER
36 Percentage of error ~ 100% 94 ICU patients, 250 measurements USCOM1A vs. PA catheter
37 102 fluid challenges in 89 patients USCOM for performing a PLR test Since corss-sectional aortic area is expected to be fixed. Short-term changes in VTI should reflect short-term changes in SV Crit Care 2009;13:R11
38 SDF early Proportion of perfused vessels Functional capillary density
39 Conclusions Whichever the monitor, a dynamic assessment of the circulation (fluid challenge, respiratory- induced BP variations) is vastly superior than relying upon isolated values ECHO is coming NIRS may be coming
40 Thank you
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