Prof. Jean-Louis TEBOUL Medical ICU Bicetre hospital University Paris-South France
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Transcript of Prof. Jean-Louis TEBOUL Medical ICU Bicetre hospital University Paris-South France
Prof. Jean-Louis TEBOULProf. Jean-Louis TEBOUL
Medical ICUBicetre hospital
University Paris-SouthFrance
Ideal MAP for resuscitationIdeal MAP for resuscitation
A moving targetA moving target
1- 1- WhyWhy do we use vasopressors in septic shock? do we use vasopressors in septic shock?
3- 3- WhenWhen to start? to start?
4- 4- WhichWhich therapeutic therapeutic targettarget??
2- 2- WhichWhich first-line first-line agentagent??
Questions
1- 1- WhyWhy do we use vasopressors in septic shock? do we use vasopressors in septic shock?
Questions
2- Which first-line agent?
3- When to start?
4- Which therapeutic target?
Septic shock is characterized by a decreased vascular toneSeptic shock is characterized by a decreased vascular tone(inducible NO synthase activation, etc)(inducible NO synthase activation, etc)
HypotensionHypotension
Hypoperfusion worseningHypoperfusion worsening
Why do we use vasopressors in septic shock?Why do we use vasopressors in septic shock?
mean arterial pressure
organ blood flow
Autoregulation of organ blood flowAutoregulation of organ blood flow
2- Profound 2- Profound hypotensionhypotension worsens worsens organ hypoperfusionorgan hypoperfusion
1- Septic shock is characterized by a decreased vascular tone(inducible NO synthase activation, etc)
…… …… and represents an and represents an independent risk of deathindependent risk of death
Why do we use vasopressors in septic shock?Why do we use vasopressors in septic shock?
65 mmHg65 mmHg
48 hrs48 hrs
2- Profound hypotension worsens organ hypoperfusion
1- Septic shock is characterized by a decreased vascular tone(inducible NO synthase activation, etc)
…… and represents an independent risk of death
3- 3- Correction of hypotensionCorrection of hypotension with a vasopressor allows with a vasopressor allows improvingimproving organ perfusionorgan perfusion
Why do we use vasopressors in septic shock?Why do we use vasopressors in septic shock?
Creatinine clearanceCreatinine clearance
**
0-2 hrs 4-6 hrs0-2 hrs 4-6 hrs
60
30
5454 mmHg
7272 mmHg
while while cardiac outputcardiac output did did not changenot change
Urine flowUrine flow (ml/h)
**
**
baseline 4 hrs 8 hrsbaseline 4 hrs 8 hrs
5454 mmHg
7373 mmHg
7272 mmHg
Blood lactateBlood lactate (meq/l)(meq/l)
****
baseline 4 hrs 8 hrsbaseline 4 hrs 8 hrs
5454 mmHg
7373 mmHg
7272 mmHg
Probable “arterial pressure” effect
mean arterial pressure
renal blood flow
Autoregulation of Autoregulation of renalrenal blood flow blood flow
54 72
2- Profound hypotension worsens organ hypoperfusion
1- Septic shock is characterized by a decreased vascular tone(inducible NO synthase activation, etc)
…… and represents an independent risk of death
3- 3- Correction of hypotensionCorrection of hypotension with a vasopressor allows with a vasopressor allows improvingimproving organ perfusionorgan perfusion
Why do we use vasopressors in septic shock?Why do we use vasopressors in septic shock?
and and microcirculationmicrocirculation
95
90
85
80
75
70
65
60
55
StO2
before NEbefore NE with NEwith NE
%
p < 0.05StOStO22: 75 : 75 ±± 9% 9%
82 82 ±± 4 * 4 *
healthyvolunteers
NIRS technologyNIRS technology
StO2 (%)
Time
End point : 0.85 x baseline StO2
Start point : 1.05 x minimal StO2
Start point :
0.98 x baseline StO2
Deflation of the pneumatic cuff
Inflation of the pneumatic cuff
Occlusion time
AUC
40
50
60
70
80
90
Desaturationslope
Vascular Occlusion Test
Index of recruitment
of microvessels
RecoveryRecoveryslopeslope
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
StO2 recovery slope
before NEbefore NE with NEwith NE
(%/s)
p < 0.05p < 0.05
Restoration of a “goodgood” MAP MAP
with early early introduction of NE NE
resulted in recruitmentrecruitment
of microvessels microvessels and better tissue oxygenation better tissue oxygenation
1- Why do we use vasopressors in septic shock?
Questions
2- Which first-line agent?
3- When to start?
4- Which therapeutic target?
1- Why do we use vasopressors in septic shock?
Questions
2- Which first-line agent?
3- When to start?
4- Which therapeutic target?
20
40
60
80
100
120
140
vasodilatationvasodilatation
low DAPlow DAP
Consider vasopressorsConsider vasopressors
reflects reflects the vascular tonethe vascular tone
SAP
DAPDAP
MAP
20
40
60
80
100
120
140
When When to startto start vasopressors? vasopressors?
• when MAP MAP is < 65 mmHg < 65 mmHg despite “adequate” fluid resuscitation
• or when MAP MAP is < 65 mmHg < 65 mmHg and DAP DAP is low low even if the patient has not been yet fully fluid resuscitated
1- Why do we use vasopressors in septic shock?
Questions
2- Which first-line agent?
3- When to start?
4- Which therapeutic target?
mean arterial pressure
organ blood flow
Autoregulation of organ blood flowAutoregulation of organ blood flow
?? 65 mmHg?
MAP:MAP: 6565 mmHgmmHg
MAP:MAP: 8585 mmHgmmHg
MAP:MAP: 7575 mmHgmmHg
tonometry PCO2 gap
red cell velocity
capillaryflow
urineoutput
150150
100100
5050
13
%%
Mean Arterial Pressure (mmHg)
organ blood flow
Autoregulation of organ blood flowAutoregulation of organ blood flow
65 75 85
Crit Care Med 2000; 28:2729-2732
Crit Care Med 2005; 33:780 –786
increasing MAP above 65 mmHg
results in little benefit
65 mmHg65 mmHg
48 hrs48 hrs
Crit Care Med 2000; 28:2729-2732
Crit Care Med 2005; 33:780 –786
MAP target value: 6565 mmHg
Probably higher target value if:
• History of chronic hypertension
MAP:MAP: 6565 mmHgmmHg
MAP:MAP: 8585 mmHgmmHg
MAP:MAP: 7575 mmHgmmHg
tonometry PCO2 gap
red cell velocity
capillaryflow
urineoutput
150150
100100
5050
13
%%
10 patientsnone with history
of severe hypertension
Mean arterial pressureMean arterial pressure
OrganOrganBloodBloodflowflow
mmHgmmHg
no prior hypertensionno prior hypertension
with prior hypertensionwith prior hypertension
6565
pts with no chronic hypertensionpts with no chronic hypertension
pts with chronic hypertensionpts with chronic hypertension
Probably higher target value if:
• History of chronic hypertension
• High CVP
Probably higher target value if:
• History of chronic hypertension
• High CVP
• Increased abdominal pressure
Is it dangerous to target a MAP value
up to “normal values” (around 85 mmHg)
in septic shock?
65 75 85 65
Reco
very
slo
pe
Reco
very
slo
pe
%/m
in%
/min
MAP MAP mmHgmmHg
****
13 pts 13 pts with septic shockwith septic shock
6 pts 6 pts with septic shockwith septic shock
Perfused Vessel Density
Microvascular Flow Index
No worsening but improvement of microcirculation
for MAP target up to 85 mmHg with NE
20 pts 20 pts with septic shockwith septic shock
Highly variable response among patients
Perfused capillary density improved in pts with an altered
sublingual perfusion at baseline, and decreased in patients
with preserved basal microvascular perfusion.
20 pts 20 pts with septic shockwith septic shock
1- Why do we use vasopressors in septic shock?
3- When to start?
4- Which therapeutic target?
2- Which first-line agent?
ConclusionConclusion
at least 65 mmHg
probably higher value if:
• History of chronic hypertension• High CVP• Increased abdominal pressure
Thank you Thank you
65-85 mmHgseems to be a safe range