PCV and PAOP Old habits die hard!

PCV and PAOP Old habits die hard! F Javier Belda MD, PhD Head of Department Associate Professor Anaesthesia and Critical Care Hospital Clínico Universitario Valencia (SPAIN)

An old example TOBACO SMOKING HABIT High cost: smoker and health system Direct and indirect true damage Restrictive laws Menace in advertisements Smokers: Spain EU 1996: 40% 2002: 40% 2006: 32% 2006: 33%

Smoking in another countries

Measuring CVP-PAOP: PAOP: Facts In 95% of Cardiac operations at La Coruña (Galicia) in 1996 PAC was routinely inserted for monitoring (personal report) 90% of German intensivists in 1998, indicated that they use CVP for the management of fluid status Boldt J, Lenz M, Kumle B, et al. Volume replacement strategies on intensive care units: results from a postal survey. Intensive Care Med 1998; 24:147-151.

Rivers E et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001, 345:1368.

The Importance of Early Goal-Directed Therapy for Sepsis Induced Hypoperfusion Mortality (%) NNT to prevent 1 event (death) = 6-8 60 Standard therapy EGDT 50 40 30 20 10 0 In-hospital mortality (all patients) 28-day mortality 60-day mortality Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345:1368-1377

Crit Care Med 2004; 32:858 A. Initial Resuscitation 1....During the first 6 hrs of resuscitation, the goals of initial resuscitation of sepsis-induced hypoperfusion should include all of the following as one part of a treatment protocol: Central venous pressure: 8 12 mm Hg Mean arterial pressure 65 mm Hg Urine output 0.5 ml kg1 hr1 Central venous (superior vena cava) or mixed venous oxygen saturation 70%

Practice parameters for hemodynamic support of sepsis in adult patients: 2004 update Steven M. Hollenberg, MD; et al Crit Care Med 2004; 32:1928 Recommendation 3 Level D.... Fluid infusion should be titrated to a level of filling pressure associated with the greatest increase in cardiac output and stroke volume. For most patients, this will be a pulmonary artery occlusion pressure in the range of 12 15 mm Hg. If only central venous pressure is available, levels of 8 12 mm Hg should be targeted. Level D: Supported by at least ONE investigation level III nonrandomized, contemporaneous controls. Packman MJ, Rackow EC: Optimum left heart filling pressure during fluid resuscitation of patients with hypovolemic and septic shock. Crit Care Med 1983; 11:165 169 Rivers E, Nguyen B, Havstad S, et al: Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345:1368 1377

Lancet 2005; 365: 63-78 Conclusion: CVP measurement save lives (sepsis)?

When and how to make the measurement Transmural pressure: Piv-Ppl CVP measurements should be made at end-expiration when the pleural pressure is closest to atmospheric pressure. 30 CVP 2 ZEEP

When and how to make the measurement Transmural pressure: Piv-Ppl CVP measurements should be made at end-expiration when the pleural pressure is closest to atmospheric pressure. 30 CVP 2 ZEEP PEEP 10 cmh2o

Summary: measurements of CVP-PAOP PAOP Inaccurate: - Leveling - Point of measurement - PTM difficult to asses - Effect of the expiratory pattern Difficult interpretation of values: - Assessment of volume status - Assessment of the preload of the heart

Factors conditioning preload

measuring the CVP: assessment of volume status assessment of the preload of the heart

Relationship stroke volume-preload Effect of increasing Preload depends on - where the heart is operating - cardiac function (LV contractility) SV Preload

Sensitivity and specificity for the prognosis of the effect of volume loading in CVP: ROC curves Sensitivity ---CVP SVV Specificity Berkenstadt et al, Anesth Analg 92: 984-989, 2001 A value of ROC of 0.5 means that the predictive performance of the indicator is no better than chance.

18 patients Pre and post cardiac surgery Response to 2 volume loading steps (250 ml Haemaccel over 5 7 min) Haemodynamic measurements 3 min after each step.

Preload: Fluid responsiveness Lichtwarck-Aschoff et al, Intensive Care Med 18: 142-147, 1992

PiCCO plus setup Central venous catheter Injectate temperature sensor housing 13.03 16.28 TB37.0 AP AP 140 117 92 (CVP) 5 SVRI 2762 PC CI 3.24 HR 78 AUX adapter cable Interface cable PCCI SVI 42 SVV 5% dpmx 1140 (GEDI) 625 Injectate temperature sensor cable DPT Monitor cable Arterial thermodilution catheter disposable pressure transducer Connection cable to bedside monitor

Dye-dilution curve: (Indocyanin( green) ) Intra Thoracic Blood Volume Intrathoracic Blood Volume ITBV = CO * MTt MTt ICG MTt MTt: Mean transit time half of the indicator passed the point of detection ITTV = CO * MTt MTt cold Intrathoracic Thermal Volume MTt Thermo-dilution curve: (8ºC) Intra Thoracic Thermal Volume

n = 209 pts r = 0.97 Bias = 7.6 ml/m 2 SD = 57 ml/m 2 ITBVI measurement by the single (cold) transpulmonary thermodilution correlates very well with the double indicator technique

Anesthesia Analg 2002;95:835

Preload: Fluid responsiveness Lichtwarck-Aschoff et al, Intensive Care Med 18: 142-147, 1992

Preload (volume) ITBV: Fluid responsiveness Lichtwarck-Aschoff et al, Intensive Care Med 18: 142-147, 1992

- Measurements of volume - Sensitivity to fluid replacement Guide for haemodynamic therapy

13 papers 5057 pt

Evidence Based Medicine Invasive Takes time Complications Preload?

Max Plank Nobel Prize 1918 "A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it" or more succinctly "Science advances funeral by funeral".