Evolution of Shock Monitoring and ICU Scoring NTUH Anesthesiology/SICU Yu-Chang Yeh
Shock 組織灌流不足 (Hypoperfusion) 氧氣供應不足 / 無法利用 休克重要觀念 血壓 115/40 (65) mmhg, 有沒有休克? Usual BP 185/95 CAD ICP = 30 mmhg IAP = 30 mmhg RR 33/min HR 140/min BT 39.5 Agitation Analgesia Precedex Dopamine Norepinephrine Epinephrine Vasopressin
Diagnosis of Shock Symptoms & signs Mental change ( 意識變化 ) Hyperventilation Tachycardia hypotension Urine output < 0.5 ml/kg/h ABG (lactate > 4 mmol/l, base excess< -5, ph ) SvO 2 < 65% and ScvO 2 < 70% Intensive Care Med 2007;33:575 590 Differential diagnosis Current Opinion in Critical Care 2007, 13:318 323
Hemodynamic monitoring Ensure adequacy of perfusion Titrate therapy to specific endpoints of resuscitation Predict prognosis Parameters of hemodynamic monitoring Measured variables Heart rate/rhythm SBP/DBP CVP PAP/PAOP Cardiac output LVEF/RVEF SpO 2 / ScvO 2 /SVO 2 Calculated variables MAP MPAP Cardiac index SV / SVI SVR / PVR RVEDV (100-160 ml)
Heart functions Rate/Rhythm ECG Blood pressure NIBP/Arterial blood pressure Preload CVP/PAOP/Echo/CCO(Flo-Trac)/PiCCO Contractility TTE/TEE Valvular function TTE/TEE Cardiac output PAC/CCO/PiCCO Afterload PAC/CCO/PiCCO Myocardial ischemia and failure - Cardiac enzyme (CK, CK-MB, Troponin-I) and probnp CVP 觀念 CVP 絕對值是參考指標 (8-12[12-15]) PEEP 10 cmh 2 O 對 CVP 的影響? CVP 及治療反應可提供更多訊息, EX: CVP 4,MAP 45 mmhg x 0.3 輸 500 ml NS CVP 6,MAP 55 mmhg 繼續輸液 輸 500 ml NS CVP 12,MAP 48 mmhg 小心輸液, 注意心臟功能是否良好, 考慮給強心藥物 EX: CVP 8,MAP 110 mmhg, 體重增加 9 kg,hd HD 脫水 500 ml CVP 8,MAP 105 繼續脫水 HD 脫水 500 ml CVP 2,MAP 50 停止脫水, 補水
Systolic pressure variation ( 使用呼吸器時 ) If down > 10 mm Hg Or down + up >15 mm Hg hypovolemia response to fluid challenge Flo-Trac Continuous cardiac output Stroke volume index Calculated SVR Stroke volume variation - fluid responsiveness ScvO 2 (Combined with PreSep CVP)
Stroke volume variation Prediction of fluid responsiveness Eur J Anaesthesiol. 2004;21(2):132-8 Crit Care. 2008;12(3):R82 May be influenced by Spontaneous ventilation Arrhythmias Tidal volume > 8 ml/kg (controlled mode) Crit Care Med. 2008;36(10):2858-62 Pressure support ventilation Acta Anaesthesiol Scand. 2006;50(9):1068-73 CCO (FloTrac sensor, Edwards) Simplified Physiologic Protocol Developed by W.T. McGee, MD, MHA, Tufts University Medical School
Normal Range Others Transthoracic echo (TTE) Transesophageal echo (TEE) NICO - partial CO 2 re-breathing cardiac output Echo SVC/IVC collapsibility Preload Distribution volume of glucose Preload Pulse pressure variations Fluid responsiveness Whole-body electrical bioimpedance Cardiac output
Goal-directed treatment Goal directed treatment for Septic Shock ScvO2 CVP + Artery line (CCO) CVP > 8-12 (12-15) mm Hg MAP > 65 mm Hg Urine output > 0.5 ml/kg/h ScvO 2 > 70% Hct > 30% Cardiac output Systemic oxygen consumption. NEJM 2001;345:1368-77 Crit Care Med 2008; 36:296 327
Is everything ok when ScvO2 > 70%? ICU Scoring Severity Prognosis Work loading Quality control / assurance Research Others
Scoring system APACHE (Acute Physiologic and Chronic Health Evaluation) TISS (Therapeutic Intervention Scoring System) SOFA (Sequential Organ Failure Assessment) SAPS (Simplified Acute Physiologic Score) MPM (Mortality Prediction Model) ISS (Injury Severity Score) Organ specific scoring APACHE I-IV 1981 APACHE I 1985 - APACHE II Acute physiology score Age adjustment Chronic health evaluation 1991 APACHE III (1999-I, 2002-J) 2006 APACHE IV Curr Opin Crit Care 2008;14:491 497
APACHE IV Acute physiology score/age adjustment Chronic health evaluation Diagnosis Prior treatment location Logistical regression equation Predict mortality and ICU length of stay Provide daily updates of prognosis http://www.mecriticalcare.net/icu_scores/apacheiv.php Critical care medicine 2006;34(5):1297-310 Organ specific scoring Neurology GCS, WFNS, Fisher scale (SAH) Cardiovascular surgery EuroScore Lung Lung injury score Liver Child s classification, MELD Kidney - RIFLE Pancreas Ranson score DIC score
結論 Shock monitoring 目的 確保組織灌流足夠 使用適當的監視器 快速診斷 / 快速處理 / 調整治療達到目標 避免器官衰竭 / 改善預後減少死亡率 善用 Scoring system 判斷嚴重度及預後 決定治療方向 提升照護品質 研究新的治療 Thanks for your attention Have a nice weekend!