Hemodynamics and Mechanical Ventilation
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1 Hemodynamics and Mechanical Ventilation Paolo Pelosi Department of Surgical Sciences and Integrated Diagnostics (DISC) IRCCS San Martino IST University of Genoa, Genoa, Italy
2 Conflicts of Interest I declare NO conflicts of interest
3 Determinants of Cardiac Output
4 What should we know for tx decisions? Preload Flow Flow adequacy Fluids Inotrops Pressors dilators Treatment!
5 Preload & Stroke Volume PRELOAD = RVEDV/LVEDV (Frank-Starling)
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10 RAP/CVP IS A FUNCTION OF FOUR INDIPENDENT PARAMETERS Blood volume and flow in the central veins Right ventricular compliance and contractility during diastolic filling Central veins tonus Ventricular interactions Intrathoracic pressure
11 .RAP/CVP IS A FUNCTION OF MANY OTHER FACTORS Patient s posture Venus obstruction Valvular alterations (stenosis/tricuspidal insufficiency) and ventricular compliance Cardiac rythm and respiratory rate
12 Venous Return VENOUS RETURN CURVE PmS - RAP VR = r THORAX P1 P2 ITP V HEART C AO 2 1 RV Rap LV Right Atrial Pressure Pms
13 PAWP LAP ZONE_WEST_ 1 PA>Pa>Pv_ 2 Pa>PA>Pv_ 3 Pa>Pv>PA_ PAWP - shape(eccentric) of the balloon - no zone III West - venous pulmonary occlusion LAP LVEDP - stenosis or insufficiency of the mitral valve - tachicardia and premature occlusion of mitral valve - atrial contraction during hypovolemia LVEDP LVEDV Compliance variations due to: - Stiffness of LV - Pressure around pericardium (effusion, ITP) - Ventricular interdependence
14 Intensive Care Med 2007; 33(1): 6-8 CVP PAOP Use transmural filling pressures! ITP CVP TM = CVP - IAP/2 PAOP TM = PAOP - IAP/2 IAP
15 CO determinants Preload = RVEDV/LVEDV Frequency CO Contractility Afterload
16 Intra Thoracic Blood Volume: preload? ITBV ITBV = TBV 3 ECHO Esophageal Doppler LiDCO Picco Vigileo
17 By the Nepean Institute of Critical Care Education and Research
18
19 Vieillard-Baron et al AJRCCM 168:1270;2003 CO can be preserved even when EF is markedly altered CO can be altered even when EF is normal (hypovolemia)
20 Invasive PAC PICCO LIDCO* Vigileo CO ECHO OED NICO FICK Nonivasive
21 Me asu re m e n t o f card iac o u tp SV = VTI x LVOTare a LVOT= left ventricular outflow tract VTI= velocity time integral
22 Measurement of cardiac output PARASTERNAL LONG AXI Apical 5 chambers
23 Ch o lle y B e t al He m o d y n am ic m o n ito rin g u sin g e ch o card io grap h y in th e critically ill Ed s: De Backe r e t al Measurement of cardiac output
24 Hu n tsm an e t al. Circu latio n Ech o vs Th e rm o d ilu tio n CO m e asu re m e n ts
25 Th e rm o d ilu tio n vs e ch o (stro ke vo lu m e ) Le wis JA e t al. Circu latio n
26 Le wis JA e t al. Circu latio n In ter-o bserver variability N = 3 9
27 CO with echocardiography Th e p ro s: Re liable Ad d itio n al m easu rem en ts (p re ssu re / vo lu m e s) Fu ll card iac e valu atio n Me asu re m e n t o f SVV Th e co n s: Skills re qu ire d Tim e co n su m in g In te rm itte n t
28 PiCCO2 EV-1000/VolumeView TM LiDCOplus TM Geisen M, et al. Curr Opin Crit Care 2012, 18:
29 Vigileo TM LiDCOrapid TM Geisen M, et al. Curr Opin Crit Care 2012, 18:
30 NICOM ECOM Nexfin NICO Geisen M, et al. Curr Opin Crit Care 2012, 18:
31 Intermittent Continuous Invasive Limitations Additional information PAC + + (5-12 min) PiCCO + + (3 sec) +++ Well described complication s +(+) Specific arterial catheter LiDCO Lithium injection Flotrac + (20 sec) PAP, PCWP, SVO2 GEDV, EVLW, SVV SVV (+) SVV
32 SPONTANEOUS VENTILATION Inspiration Expiration - 8 mmhg -2 mmhg
33 INTRATHORACIC PRESSURE
34
35 Effects of Different Ventilatory Modes on Cardiopulmonary Performance SPONT. Ass Part. AssTot Mofied from Synder 1984
36 Effects of the increase in ITP : RV pre-load Pappl Pcp Palv Changes in ITP will not alter the (RV afterload) pressure gradient V R Pra Pms RH ITP Increase in LH Pericardial Pressure Pcp Decrease in VR are due to increase in Pra because of increased in pericardial pressure abdominal pressure gut Pms= driving pressure to the RA
37 effects of changes in ITP: LV afterload Pappl Pcp Palv mechanical breath RH ITP LH spontaneous breath Pcp abdominal pressure gut
38 effects of changes in ITP: LV afterload Pappl Pcp Palv mechanical breath RH ITP LH spontaneous breath Pcp abdominal pressure gut
39
40 CPAP IN CARDIOGENIC PULMONARY EDEMA Rasen et al: Chest 1985; 87:
41
42 EFFECTS OF LUNG VOLUME CHANGES LOW LUNG VOLUME HIGH LUNG VOLUME
43 Effects of the increase in lung volume: RV afterload and preload Pappl V R Pra Pms Pcp RH ITP Palv LH Pcp Incresase in PAP afterload is due to increase in PA resistance Decrease in VR are due to increase in Pra because of increased PA resistance abdominal pressure gut
44 EFFECTS OF POSITIVE INTRATHORACIC PRESSURE ON VENOUS RETURN Pulmonary compliance HIGH (Emphisema) LOW (ARDS) Chest wall compliance HIGH LOW TAKE HOME MESSAGE
45 Chest ultrasound in Acute Respiratory Distress Syndrome Corradi F., Brusasco C., Pelosi P. Curr Opin Crit Care 2014, 20: Pelosi P., Corradi F. Anesthesiology 117(4): , 2012
46 Known Variations to Indexes at the Bedside Why use these Dynamic Indexes? Biais, Anesthesiology 2012
47 MECHANICAL VENTILATION C H E S T RA RV PA LUNGS LA LV INSPIRATION Venous Return AO
48 MECHANICAL VENTILATION C H E S T RA RV PA LUNGS LA LV EXPIRATION Venous Return AO
49 Overall Picture - Inspiration Broccard, J Clin Monit Comput 2012
50 Overall Picture - Expiration Broccard, J Clin Monit Comput 2012
51 Assessing Fluid Responsiveness by the Systolic Pressure Variation in Mechanically Ventilated Patients Perel A. Anesthesiology 1998
52 Looking back in 80 s Predict who could be responsive to volume restoration Szold, Intensive Care Med 1989
53 P sys MAX P sys MIN SV MAX SV = K A SV MAX PP MAX PP MIN
54 STROKE VOLUME VARIATION SVV = SV max SV min SV mean
55 Which Parameter can better recognize it? SVV > 10% SVV < 10% PPV > 15% PPV < 15% - Michard, Chest 2002
56 Which Parameter can better recognize it? Michard, Chest 2002
57 LOW R I S K MEDIUM HIGH Pulse oximeter / capnometry Plethysmography variability Arterial catheter / PPV Transesophageal Doppler Pulse contour CO Indicator dilution CO ScvO2 PAC
58 Limitations of functional hemodynamic parameters - Spontaneous breathing - Tidal volume should be 8 ml/kg - Nonstandardized airway pressure/respiratory rate - Open-chest conditions may affect the FHP - Pediatric patients - Nonsinus rithm - Right heart failure
59 Pressure PPV/SVV Dynamic Arterial Elastance PPV/SVV=1.5 Eadyn PPV=27% PPV=18.6% PPV/SVV=1.03 Eadyn Volume Giraud, Crit Care 2011
60 Cuttoff Values?
61 PPV/SVV Dynamic Arterial Elastance 0,89 Monge-Garcia, Crit Care 2011
62 present Arterial catheter Central venous catheter Fluid Responsiveness (FHP CVP) absent Hypovolemia likely ECHO Fluid challange Small chambers RV dilatation Poor contractile state Valvulopathy (cardiogenic) Tamponade
63 Physiological background Sat v O 2 = Sat a O 2 - VO 2 (ml/min) Q (L/min) * 1 Hb (gr/l) * 1.39 Sat v O 2 = Lung - metabolism hemodynamic * 1 carrier
64 Venous blood Venous PO 2 Reflects the tissue oxygenation PvCO 2 Reflects the arterial PaCO 2 the tissue acidosis Sat v O 2 Base excess v Reflects Sat a O 2, VO 2 /Q, Hb Assessment of metabolic status (always different from the arterial)
65 Venous-arterial sampling The shunt computation a-vo 2 difference It allows (Sat a Sat v )/Sat a PCO 2 PCO 2 / a-vo 2 content LACTATE!
66 Venous-Arterial blood gases allow to: Define the oxygenation status (PaO 2 -Shunt (not replaceable)) Define the ventilatory status Infere on the hemodynamic status ( a-vo 2, Sat v O 2, (Sat a O 2 Sat v O 2 )/Sat a O 2 (not replaceable)) Define the energy failure BE, ph, PCO 2 / a-vo 2
67 SVO2 = SaO2 VO2/Q * 1/(1.36*Hb) Fick equation SVO2 = LUNG - METABOLISM/HEMODYNAMIC * 1/ANEMIA CO HIGH Diagnostic process LOW SVO2 SVO2 HIGH LOW HIGH LOW Hyperd. States vasoact agents Hypervolemia Hypoxiemia (SaO2 ) Anemia (SaO2 = V02 =) Exercise (SaO2 = V02 ) Low anesthesia level Deep anaesthesia (V02 ) Hypothermia V02 ) Sepsi ( V02 ) Heart failure ( PAOP) Hypovolemia ( PAOP) Obstruction ( PAP) Stress (SaO2 = V02 )
68 Conclusions Preload, flow and flow adequacy Non invasive and Invasive methods (Echo and other Methods) Ventilatory assist affects hemodynamics Flow adequacy: consider ScvO 2 and Lactate
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