Cardiac output, preload, lung water and ScvO2

FJ Belda. Brussels ISICEM 2009

Dr. F Javier BeldaDept. Anesthesiology and Critical Care

Hospital Clinico UniversitarioValencia (Spain)

Pulsion MAB

ISICEM Brussels, March 26th 2009

CO, preload, lung water and ScvO2

The winning combination!

State of the Art Hemodynamic Monitoring III

State of the Art State of the Art Hemodynamic Monitoring IIIHemodynamic Monitoring III


Hemodynamic failureHemodynamic failure--hypodynamic early phasehypodynamic early phase

Circulatory insufficiency:Circulatory insufficiency:HipovolemiaHipovolemia

Miocardial depressionMiocardial depressionVasoregulatory alterationVasoregulatory alteration

OO22SupplySupply

OO22DemandDemand

Flow maldistributionFlow maldistributionTissue hypoxiaTissue hypoxia

Tisular ischemiaTisular ischemia

MacrocirculationMacrocirculation

MicrocirculationMicrocirculation

HypoperfusionHypoperfusion


Monitoring tool:Monitoring tool:DiagnosticDiagnosticTherapeutic guideTherapeutic guideResultsResults

Ideal hemodynamic monitoringIdeal hemodynamic monitoring

Low perfusion: Low perfusion: Increase in oxygen delivery Increase in oxygen delivery

= oxygen demands= oxygen demands

DaODaO22 = CO x CaO= CO x CaO22 = CO x [(Hb x 1,39 x Sat= CO x [(Hb x 1,39 x SataaOO22) )


Consensus ConferenceConsensus ConferenceBaja California, Mexico 2008Baja California, Mexico 2008


Monitoring tool:Monitoring tool:DiagnosticDiagnosticTherapeutic guideTherapeutic guide


Cardiac output– Preload– Afterload– Contractility

Hemoglobin



DaODaO22 = CO x CaO= CO x CaO22 = = COCO x [(x [(HbHb x 1,39 x Satx 1,39 x SataaOO22) )

Effect on Tissue hypoxia– Lactate– SvO2

ResultsResults


However, what many people do is... However, what many people do is... Diagnosis by the effectsDiagnosis by the effects

Clinical signs: Clinical signs: Hypotension (SBP<90, MAP<65 or BPdrop >40 mmHg) orHypotension (SBP<90, MAP<65 or BPdrop >40 mmHg) orHypoperfusion: altered mental status, delayed capilary refill, Hypoperfusion: altered mental status, delayed capilary refill,

decreased urine output and cooled skin or extremitiesdecreased urine output and cooled skin or extremitiesConfirmation: BGAConfirmation: BGA--Metabolic AcidosisMetabolic Acidosis

Apply EGDT protocolApply EGDT protocol

Central venous line + arterial lineCentral venous line + arterial lineGive fluids 1500Give fluids 1500--3000 ml3000 ml


2001 EGDT Algorithm2001 EGDT Algorithm

Protocol:Protocol:1.1. Fluid infusionFluid infusion

to CVP 8to CVP 8--1212

2. Vasoactive drugs2. Vasoactive drugsto MAP>65 <90to MAP>65 <90

Increase Preload:Increase Preload:Fluids 20Fluids 20--40 40 ml/kgml/kg


Problems with the significance of CVPProblems with the significance of CVP

Conclusions: … the pathophysiological significance of the CVP should be considered only with a corresponding measurement of cardiac output.

Central venous pressure: A useful but not so simple measurement.Critical Care Medicine 2006;34:2224-2227.

Central venous pressure monitoringCurrent Opinion in Critical Care 2006;12: 219–227

No correlation between CVP or PCWP and Stroke VolumeKumar et al, Crit Care Med 2004;32: 691-699 Lichtwarck-Aschoff et al, Intensive Care Med 18: 142-147, 1992

Magder, Sheldon MD


PiCCO hemodynamic monitoringPiCCO hemodynamic monitoring

Central venous catheter

PULSIOCATHArterial thermodilution catheter (femoral, axillar, brachial)

Injectate coldsensor housing

Measurements:Measurements:Cardiac IndexCardiac Index

Preload: GEDVPreload: GEDV


Crit Care Med 2009 [Epub ahead of print]

15 swine 60 Kg15 swine 60 Kg



15 swine 60 Kg 15 swine 60 Kg Release NPRelease NPBaseline NP Baseline NP 25 +1000 ml HES NP 25 p 25 +1000 ml HES NP 25 p



15 swine 60 Kg 15 swine 60 Kg Release NPRelease NPBaseline NP Baseline NP 25 +1000 ml HES NP 25 p 25 +1000 ml HES NP 25 p

Responsiveness Responsiveness GEDV <963 mlGEDV <963 mlsensitivity 87% sensitivity 87% specificity 83%.specificity 83%.


A. Initial ResuscitationHemodynamic support: Early Goal-Directed Therapy

…

Crit Care Med 2008; 36: 296-327


2001 EGDT Algorithm2001 EGDT Algorithm

Protocol:Protocol:1.1. Fluid infusionFluid infusion

to CVP 8to CVP 8--1212

2. Vasoactive drugs2. Vasoactive drugsto MAP>65 <90to MAP>65 <90

Fluids 1000 crystalloidsFluids 1000 crystalloids+ 500 colloids+ 500 colloids

Early phase of Early phase of supply dependencysupply dependencyScvOScvO22 is a surrogate is a surrogate

to detectto detectglobal tissue hypoxiaglobal tissue hypoxia

SvOSvO22<70% <70% ⇒⇒ increased extraction / limited Oincreased extraction / limited O22 supplysupply


EGDT: ResultsEGDT: ResultsRestored SvORestored SvO22>70%>70%

Fluid resucitation: 35,9% patientsFluid resucitation: 35,9% patients

Blood transfusion: 50,4% patientsBlood transfusion: 50,4% patients

Inotropic therapy: 13,7% patientsInotropic 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: EVLWThe final key factor: EVLW

Central venous catheter

PULSIOCATHArterial thermodilution catheter (femoral, axillar, brachial)

Injectate coldsensor housing

Measurements:Measurements:Cardiac Index Cardiac Index Preload: GEDVPreload: GEDV

SSVVOO22EVLWEVLW


PatientsPatients Definition of Definition of RespondersResponders

NN ChallengeChallenge RespondersResponders

Preisman S (2005)Preisman S (2005) Cardiac surgeryCardiac surgery > 15% SV> 15% SV 18 18 250 mL colloids250 mL colloids 32/70 VLS 32/70 VLS (46%)(46%)

Hofer CK (2005)Hofer CK (2005) Cardiac surgeryCardiac surgery > 25% SVI> 25% SVI 3535 10 mL/kg (IBW) 6% 10 mL/kg (IBW) 6% HESHES

21 21 (60% )(60% )

Swensen CH (2006)Swensen CH (2006) Abdominal surgeryAbdominal surgery Increase in COIncrease in CO 1010 25 mL/kg of Ringer25 mL/kg of Ringer 4 4 (40%)(40%)

Tavernier B (1998)Tavernier B (1998) Sepsis w. circulatory Sepsis w. circulatory failurefailure

> 15% SVI> 15% SVI 15 15 500500--1000 mL HES1000 mL HES 21/35 VLS 21/35 VLS (60%)(60%)

Michard F (2000)Michard F (2000) Sepsis w. circulatory Sepsis w. circulatory failurefailure

> 15% CI> 15% CI 4040 500 mL HES500 mL HES 16 16 (40%)(40%)

Michard F (2003)Michard F (2003) Septic shockSeptic shock > 15% SVI> 15% SVI 27 27 500 mL HES500 mL HES 32/66 VLS 32/66 VLS (48%)(48%)

Feissel M (2005)Feissel M (2005) Septic shockSeptic shock > 15% CI> 15% CI 20 20 8 ml/kg HES8 ml/kg HES 13/22 VLS 13/22 VLS (59%)(59%)

Monnet X (2005)Monnet X (2005) Critically ill w. Critically ill w. circulatory failurecirculatory failure

> 15% increase in ABF > 15% increase in ABF (Doppler)(Doppler)

3838 500 ml NS500 ml NS 20 20 (53%)(53%)

Vallee F (2005)Vallee F (2005) Critically ill w. Critically ill w. circulatory failurecirculatory failure

> 10% increase in SVI> 10% increase in SVI 5151 4 ml/kg colloid4 ml/kg colloidX 2X 2

20 20 (39%)(39%)

Heenan S (2006)Heenan S (2006) Critically ill w. Critically ill w. circulatory failurecirculatory failure

> 15% in CO> 15% in CO 2121 1 L Ringer or 500 1 L Ringer or 500 mL HESmL HES

9 9 (43%)(43%)

LafanechLafanechèère Are A(2006)(2006)

Critically ill w. Critically ill w. circulatory failurecirculatory failure

> 15% increase in ABF > 15% increase in ABF (Doppler)(Doppler)

2222 PLR and 500 ml NSPLR and 500 ml NS 10 10 (45%)(45%)

Osman D (2007)Osman D (2007) SepsisSepsis > 15% in CO> 15% in CO 9696 500 mL HES500 mL HES 65/150 VLS 65/150 VLS (43%)(43%)

Hemodynamic response to fluid loadingHemodynamic response to fluid loading

300 / 631 = 47.5% r300 / 631 = 47.5% responders

Pulmonary edema may occur as a Pulmonary edema may occur as a complication of fluid resuscitation.complication of fluid resuscitation.

Practice parameters for hemodynamic support of sepsis in adult patients in sepsis

Task Force of the ACCCM and the SCCM, CCM 2004


Comparison of Two Fluid-Management Strategies in Acute Lung InjuryThe 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/ARDS1000 patients with 24 h. ALI/ARDS503 Conservative strategy503 Conservative strategy497 Liberal strategy497 Liberal strategy

Based on BP, CVP/PAOP, diuresisBased on BP, CVP/PAOP, diuresis

Cumulative fluid balance (7 days):Cumulative fluid balance (7 days):Conservative: Conservative: --136136±±491 ml 491 ml Liberal: +6992Liberal: +6992±±502 ml 502 ml


Crit Care Med 2008;36:69-73

19 patients19 patientssepsissepsis--induced ARDSinduced ARDSMV: ARDSnet protocolMV: ARDSnet protocol

Measurements (3 days)Measurements (3 days)LIS, SOFA, P/F, VD/VTLIS, SOFA, P/F, VD/VTEVLW (Predicted body weight)EVLW (Predicted body weight)

Non survivorsNon survivorsΟΟ SurvivorsSurvivors

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

EVLWp>16 ml/KgEVLWp>16 ml/Kg100% Specificity100% Specificity86% Sensitivity86% Sensitivity


Monitoring tool:Monitoring tool:DiagnosticDiagnosticTherapeutic guideTherapeutic guideResultsResults


Cardiac output: TPTD/PCPreload: GEDVAfterload: RVSContractility: GEF

Hemoglobin

Cardiac output: Cardiac output: TPTD/PCTPTD/PCPreload: Preload: GEDVGEDVAfterload: Afterload: RVSRVSContractility: Contractility: GEFGEF

Hemoglobin Hemoglobin



DaODaO22 = CO x CaO= CO x CaO22 = = COCO x [(x [(HbHb x 1,39 x Satx 1,39 x SataaOO22) )

Effect on Tissue hypoxia- Lactate clearance- SvO2 (continuous)

Effect on lung edema- EVLW

Effect on Tissue hypoxiaEffect on Tissue hypoxia-- Lactate clearanceLactate clearance-- SvOSvO2 2 (continuous)(continuous)

Effect on lung edemaEffect on lung edema-- EVLWEVLW


40 CABG surgical patients vs historical control group40 CABG surgical patients vs historical control groupIntensive Care Med 2006Intensive Care Med 2006

Routine clinical practice:CVP, MAP and

clinical evaluationevaluation

GoalGoal--directeddirectedtherapytherapy


MV duration:12.6±3.6 vs15.4±4.3 h

Time for ICU discharge:25±13 vs 33±17 h


Normalize Preload (GEDV) while avoiding lung edema

EVLW

Normalize Perfusion Pressure

Normalize CI

Increase TrO2

Monitor SvO2

Proposed EGDTProposed EGDT Systolyc BP<90 mmHgLactate>4 mmol/l

SvO2<70%


Normalize Preload (GEDV)while avoiding lung edema

EVLW

Normalize Perfusion Pressure

Normalize CIIncrease TrO2

Monitor SvO2

Proposed EGDTProposed EGDT

The winning combination!

Systolyc BP<90 mmHgLactate>4 mmol/l

SvO2<70%


Another winning combination: Another winning combination: HOME, FAMILY, DOG, WINE, MUSICHOME, FAMILY, DOG, WINE, MUSIC

Thank you very much for your attentionThank you very much for your attention

Cardiac output, preload, lung water and ScvO2

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