State of the Art Hemodynamic Monitoring III CO, preload, lung water and ScvO2 The winning combination! Dr. F Javier Belda Dept. Anesthesiology and Critical Care Hospital Clinico Universitario Valencia (Spain) Pulsion MAB ISICEM Brussels, March 26 th 2009
Hemodynamic failure-hypodynamic early phase Circulatory insufficiency: Hipovolemia Miocardial depression Vasoregulatory alteration Hypoperfusion Tisular ischemia Macrocirculation O2 Supply O2 Demand Flow maldistribution Tissue hypoxia Microcirculation
Ideal hemodynamic monitoring Monitoring tool: Diagnostic Therapeutic guide Results Low perfusion: Increase in oxygen delivery = oxygen demands DaO2 = CO x CaO2 = CO x [(Hb x 1,39 x SataO2)
Consensus Conference Baja California, Mexico 2008
Ideal hemodynamic monitoring Monitoring tool: Diagnostic Therapeutic guide Results Low perfusion: Increase in oxygen delivery = oxygen demands DaO2 = CO x CaO2 = CO x [(Hb x 1,39 x SataO2) Cardiac output Preload Afterload Contractility Hemoglobin Effect on Tissue hypoxia Lactate SvO2
However, what many people do is... Diagnosis by the effects Clinical signs: Hypotension (SBP<90, MAP<65 or BPdrop >40 mmhg) or Hypoperfusion: altered mental status, delayed capilary refill, decreased urine output and cooled skin or extremities Confirmation: BGA-Metabolic Acidosis Central venous line + arterial line Give fluids 1500-3000 ml Apply EGDT protocol
2001 EGDT Algorithm Increase Preload: Fluids 20-40 ml/kg Protocol: 1. Fluid infusion to CVP 8-128 2. Vasoactive drugs to MAP>65 <90
Problems with the significance of CVP No correlation between CVP or PCWP and Stroke Volume Kumar et al, Crit Care Med 2004;32: 691-699 Lichtwarck-Aschoff et al, Intensive Care Med 18: 142-147, 1992 Magder, Sheldon MD Central venous pressure: A useful but not so simple measurement. Critical Care Medicine 2006;34:2224-2227. Central venous pressure monitoring Current Opinion in Critical Care 2006;12: 219 227 Conclusions: the pathophysiological significance of the CVP should be considered only with a corresponding measurement of cardiac output.
PiCCO hemodynamic monitoring Central venous catheter Injectate cold sensor housing PULSIOCATH Arterial thermodilution catheter (femoral, axillar, brachial) Measurements: Cardiac Index Preload: GEDV
Crit Care Med 2009 [Epub ahead of print] 15 swine 60 Kg
Crit Care Med 2009 [Epub ahead of print] 15 swine 60 Kg Release NP Baseline NP 25 +1000 ml HES NP 25 p
Crit Care Med 2009 [Epub ahead of print] 15 swine 60 Kg Release NP Baseline NP 25 +1000 ml HES NP 25 p
Crit Care Med 2009 [Epub ahead of print] 15 swine 60 Kg Release NP Baseline NP 25 +1000 ml HES NP 25 p Responsiveness GEDV <963 ml sensitivity 87% specificity 83%.
Crit Care Med 2008; 36: 296-327 A. Initial Resuscitation Hemodynamic support: Early Goal-Directed Therapy
2001 EGDT Algorithm Protocol: 1. Fluid infusion to CVP 8-128 Fluids 1000 crystalloids + 500 colloids 2. Vasoactive drugs to MAP>65 <90 Early phase of supply dependency ScvO2 is a surrogate to detect global tissue hypoxia SvO2<70% increased extraction / limited O2O supply
EGDT: Results Restored SvO2>70% Fluid resucitation: 35,9% patients Blood transfusion: 50,4% patients Inotropic therapy: 13,7% patients Critical Care 2008; 12: 223 Critical Care 2008; 12: 130 Early goal-directed therapy and outcome in septic shock. Michael Bauer et al. International J Intens Care 2007
The final key factor: EVLW Central venous catheter Injectate cold sensor housing PULSIOCATH Arterial thermodilution catheter (femoral, axillar, brachial) Measurements: Cardiac Index Preload: GEDV SVO2 EVLW
Hemodynamic response to fluid loading Patients Definition of Responders N Challenge Responders Preisman S (2005) Cardiac surgery > 15% SV 18 250 ml colloids 32/70 VLS (46%) Hofer CK (2005) Cardiac surgery > 25% SVI 35 10 ml/kg (IBW) 6% HES 21 (60% ) Swensen CH (2006) Abdominal surgery Increase in CO 10 25 ml/kg of Ringer 4 (40%) Pulmonary edema may occur as a Tavernier Pulmonary B (1998) Sepsis w. circulatory edema > 15% SVI may 15 occur 500-1000 ml HES as a failure 21/35 VLS (60%) complication of fluid resuscitation. Michard complication F (2000) Sepsis w. circulatory > 15% CI 40 500 ml HES failure 16 of fluid resuscitation. (40%) Michard F (2003) Septic shock > 15% SVI 27 500 ml HES 32/66 VLS (48%) Practice parameters for hemodynamic support of sepsis in adult patients in sepsis Feissel M (2005) Septic shock Monnet X (2005) Critically ill w. circulatory failure > 15% CI 20 8 ml/kg HES 13/22 VLS (59%) Task Force of the ACCCM and the SCCM, CCM 2004 > 15% increase in ABF (Doppler) 38 500 ml NS 20 (53%) Vallee F (2005) Critically ill w. circulatory failure Heenan S (2006) Critically ill w. circulatory failure > 10% increase in SVI 51 4 ml/kg colloid X 2 > 15% in CO 21 1 L Ringer or 500 ml HES 20 (39%) 9 (43%) Lafanechère A Critically ill w. > 15% increase in ABF 22 PLR and 500 ml NS (2006) circulatory failure 10 (45%) 300 / 631 = 47.5% (Doppler) respondersr Osman D (2007) Sepsis > 15% in CO 96 500 ml HES 65/150 VLS (43%)
Comparison of Two Fluid-Management Strategies in Acute Lung Injury The National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network* NEJM 2006; 354 (15 June): 2564-2575 1000 patients with 24 h. ALI/ARDS 503 Conservative strategy 497 Liberal strategy Based on BP, CVP/PAOP, diuresis Cumulative fluid balance (7 days): Conservative: -136±491 ml Liberal: +6992±502 ml
Crit Care Med 2008;36:69-73 19 patients sepsis-induced induced ARDS MV: ARDSnet protocol Measurements (3 days) LIS, SOFA, P/F, VD/VT EVLW (Predicted body weight) Non survivors Ο Survivors EVLWp>16 ml/kg 100% Specificity 86% Sensitivity Sakka SG et al. Chest 2002;122:2080 Kirov MY et al. Anesteziol Reanimatol 2003;4:41 Martin GS et al. Crit Care 2005;9:R74
Ideal hemodynamic monitoring Monitoring tool: Diagnostic Therapeutic guide Results Low perfusion: Increase in oxygen delivery = oxygen demands DaO2 = CO x CaO2 = CO x [(Hb x 1,39 x SataO2) Cardiac output: TPTD/PC Preload: GEDV Afterload: RVS Contractility: GEF Hemoglobin Effect on Tissue hypoxia - Lactate clearance -SvO2 (continuous) Effect on lung edema - EVLW
Intensive Care Med 2006 40 CABG surgical patients vs historical control group Routine clinical practice: CVP, MAP and clinical evaluation Goal-directed therapy
MV duration: 12.6±3.6 vs15.4±4.3 h Time for ICU discharge: 25±13 vs 33±17 h
Proposed EGDT Systolyc BP<90 mmhg Lactate>4 mmol/l SvO2<70% Normalize Preload (GEDV) while avoiding lung edema EVLW Normalize Perfusion Pressure Normalize CI Increase TrO2 Monitor SvO2
Proposed EGDT Systolyc BP<90 mmhg Lactate>4 mmol/l SvO2<70% Normalize Preload (GEDV) while avoiding lung edema EVLW Normalize Perfusion Pressure Normalize CI Increase TrO2 The winning combination! Monitor SvO2
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