สอน fellow chest เรื่อง hemodynamic

1. Critical care
tutorial for
chest fellow

2. Contents
Basic hemodynamic monitoring for
chest physician
Fluid responsiveness
Resuscitation target/endpoint

3. Hemodynamic
BP = CO x SVR
BP = SV x HR x SVR
BP = (EDV-ESV) x HR x SVR
BP = preload x cardiac function x afterload

4. preload monitoring and
fluid responsiveness
d non-re sponsive
ive flui
ns
CO
po
Frank- Starling Curve
res
id
flu
preload

5. Frank-Starling
mechanism
n
c fu nctio
al c ardia
Norm
CO
a c function
Impa ired cardi
preload

6. preload
measurement
2 types of preload assessment
1. static preload monitoring
pressure: CVP, PAOP
Volumetric: ITBV, GEDV
Ultrasound: LVdD, IVCd

7. preload
measurement
2. dynamic preload monitoring
parameter variation: SVV, PPV, SPV
echocardiographic variation: Ao flow
velocity, IVC distensibility index.

8. CVP
(central venous pressure)

9. Central Venous
Pressure
B
RAP/RVEDP/LVEDP
A
RAV/RVEDV/LVEDV

10. Central Venous
Pressure
B
RAP/RVEDP/LVEDP
A
RAV/RVEDV/LVEDV

11. CVP as volume
measurement
Marik. Chest 2008.

12. CVP to predict fluid
responsiveness
Michard. Chest 2002.

13. Neither CVP or Ppao reflect
Ventricular Volumes or tract preload-
responsiveness
Kumar et al. Crit Care Med 32:691-9, 2004

14. CVP
Not a good parameter
to predict fluid
responsiveness
in both CVP and
dCVP

15. Predicting Fluid
Responsiveness
in ICU Patients by CVP
Responders / Non-responders % Responders
Calvin (Surgery 81)
20 / 8 71%
Schneider (Am Heart J 88) 13 / 5 72%
Reuse (Chest 90) 26 / 15 63%
Magder (J Crit Care 92) 17 / 16 52%
Diebel (Arch Surgery 92) 13 / 9 59%
Diebel (J Trauma 94) 26 / 39 40%
Wagner (Chest 98) 20 / 16 56%
Tavernier (Anesthesio 98) 21 / 14 60%
Magder (J Crit Care 99) 13 / 16 45%
Tousignant (A Analg 00) 16 / 24 40%
Michard (AJRCCM 00) 16 / 24 40%
Feissel (Chest 01) 10 / 9 53%
Mean 211 / 195 52%
Michard & Teboul. Chest 121:2000-8, 2002

16. PAOP pressure)
(pulmonary artery occlusive
measure LVEDP, not LVEDV or LV preload
limitation similar to CVP measurement

17. Predictors for fluid
responsiveness
15 % change in
CO
Michard. AJRCCM 2000.

18. LVED area
measure under echocardiogram
LV dimension during diastole
LVEDA correlate well to ITBV and GEDV
LVEDd < 25 mm or LVDA < 55 cm2 indicate
hypovolemia
not a good predictor for fluid responsiveness

19. IVC diameter
collapse IVC indicate volume depletion
Dilate IVC indicate hypervolemia
IVC distensibility/collapsibility index give an
appropriate clue for fluid deficit.
IVC distensibility idex = IVCd (ก่อน) - IVCd
(หลัง) / ก่อน รวมกับหลัง x 0.5...
> 13 percent represent preload deficit.

20. static volumetric
ITBV
GEDV index

21. ITBV and GEDV
Measured via PiCCO thermodilution (trans
pulmonary)
ITBV = volume in 4 chambers of heart
GEDV = good estimation of intravascular
volume and preload
Limitation to predict fluid responsiveness.

22. dynamic indices of
intravascular
volume

23. Correlation to F-S
curve

24. fluid responsiveness
- PPV give a best correlation to fluid responsiveness
- Static preload monitoring demonstrated the poor
correlation to fluid responsiveness

25. passive leg rising
test
consider as “autotransfusion”
recent study demonstrated the strong
correlation of PLR to predict fluid
responsiveness with ROC of 0.95
Continuous measure SV or CO on a real time
basis eg. echocardiogram, CCO-pulse
contour analysis
CO increase > 10% during PLR indicate fluid
responsiveness.

26. PLR

27. The endpoint of
shock resuscitation

28. PAOP MAP

29. Which parameter should
be used for the endpoint
of shock resuscitation?
PAOP MAP

30. Systolic
Blood SvO2
pressure Urine
output
consciousness Capillary
refilled
ScvO2 Lactate level
CVP CO PAOP MAP

31. Current aims for shock
management
Good tissue
oxygenation
Good BP Good CO

32. Upstream and
downstream theory
preload
Upstream
• CVP, POAP
• BP
• CO contractility
• SVR
afterload
downstream
Tissue perfusion and
oxygenation

33. Upstream
and
Downstream
theory

34. Tissue perfusion:
Oxygen delivery
Oxygen content
heart
= O2 in Hb + O2 in plasma
tissue
Oxygen delivery (DaO2) =
Cardiac output (CO) x oxygen content

35. Blood pressure
• Represent organ perfusion pressure
• MAP
–More reliable indication of tissue perfusion than
SBP and DBP
–Reflect autoregulation limit of organ blood flow
– CPP = MAP –ICP (normal 60-90 mmHg)
–APP = MAP – IAP (normal 50-70 mmHg)
–RPP normal 70-90 mmHg
Goodrich. AACN 2006.

36. Blood pressure
• Optimal MAP is unknown
• MAP > 65 mmHg is now recommended as
EGDT study
• Targeted BP does not necessarily equate to
tissue perfusion, but have to achieve for the
first step.
• Elderly may require higher MAP due to
vasculopathy
• Previous hypertensive group may require
MAP higher than normotensive one.

37. General
management of
• Reverse hypotension
• Adequate oxygen delivery/ organ
perfusion

38. Downstream monitoring
Global downstream Regional downstream
monitoring monitoring
• Serum lactate
• Mixed/ central venous
saturation and gases
• Base excess

39. Venous
blood
gases

40. Venous blood gases
• ScvO2
• SvO2
• PvCO2
• pH

41. Venous oxygen
saturation
CvO2 = 13.4 CaO2 = 13.4
x Hb x SvO2 x Hb x SaO2

42. Venous saturation
O2
consumption
O2 delivery

43. Oxygen delivery and
consumption

44. Venous
oxygen
saturation

45. Mixed venous blood
sampling
MvO2
(SvO2)

46. SvO2
SvO2 Consequence
level
> 75% •Normal extraction
•Oxygen supply > oxygen demand
51%-75% •Compensatory extraction
•Increase oxygen demand
31%-50% •Decrease oxygen supply
•Exhaustion of extraction
•Begin lactic acidosis
25%-30% •Oxygen supply < oxygen demand
•Severe lactic acidosis
< 25% •Cellular death
Targeted SvO2 > 70%

47. SvO2 as a treatment
endpoint
• Goal directed therapy to keep SvO2 > 70%
over 5 days did not lower the mortality in
septic shock.
Gattinoni. NEJM 1995.
• MAP > 65 mmHg and SvO2 > 70% in the
first 48 hours after resuscitation shown less
septic mortality. (retrospective study)
Varpula.ICM 2005.

48. Central venous
oxygen saturation
ScvO2

49. SvO2 vs ScvO2

50. SvO2 vs ScvO2

51. ScvO2 as a target
Van Beest. Crit Care 2008.

52. The first ScvO2 and
mortality
Mortality rate
Pope. Ann Emerg Med 2010.

53. Targeted ScvO2
• ScvO2 > 70 % reflected adequate tissue
perfusion (normoxia)
• Do not keep ScvO2 too high.
• Immediate ScvO2 level will be used for the
endpoint if it is on lower side.
• May require addition parameter to assess
perfusion state.

54. PvCO2
PvCO2
CO2 Cardiac CO2
production output elimination
The higher PvCO2,
the lower CO

55. PvCO2 and PaCO2
difference
• Inverse non linear significant relation
between oxygen delivery, P(v-a)CO2 and
pH(v-a)
Brandi. Minerva Anestesio 1995.
• Increase P(v-a)CO2 mainly related to
decrease in cardiac output and increased
in ischemic hypoxia not in hypoxic hypoxia
Vallet. J Appl Physiol 2000.

56. PvCO2 and PaCO2
difference and mortality
• dPCO2 is
significantly higher in
non survival group
• The cut of value of
dPCO2 is 6 mmHg
Bakker. Chest 1992.

57. PcvCO2 vs. PvCO2
Agreement = 0.978
Cuschieri. ICM 2005.

58. PcvCO2 vs. PvCO2
R2 = 0.892, p <0.0001
Cuschieri. ICM 2005.

59. PcvCO2 as a target for
resuscitation
P(cv-a)CO2
may serve as a
global tissue
perfusion
index when
ScvO2 goal
reached
Vallee. ICM 2008.

60. PcvCO2 as a target for
resuscitation Vallee. ICM 2008.
• High dPCO2
associated with lower
CI and higher lactate
level
R=0.58, p<0.0001

61. PvCO2 or PcvCO2
• Interchangeable
• Level of PvCO2 and PcvCO2 invert
correlation to cardiac index
• dPCO2 or P(cv-a)CO2 may be a better
parameter to indicate global tissue
perfusion than ScvO2
• Clinical study should be done to confirm
the hypothesis.

62. Metabolism of lactate
glucose
2 Pyruvate 2 Lactate 47 kcal
Kreb’s cycle
oxidation gluconeogenesis
673 kcal 652 kcal glucose

63. Lactate
• generated through anaerobic metabolism
• advocated as index of tissue hypoperfusion
• Endotoxin induced lactate production without
hypoperfusion
• level represents a balance between generation
and elimination
• Hyperlactatemia: lactate level > 2 mmol/L
• Lactic acidosis: lactate level > 4 mmol/L

64. Lactate
• high lactate levels (> 4mmol/L) in critically ill
patients associated with increased mortality
(Bakker et al. Chest 1991)
• lactate clearance better predictor of mortality
– lac-time: time in which blood lactate > 2 mmol/l
– survivors had decreased lac-time
– lac-time also directed correlated with number of organ
failures
(Bakker et al. (Am J Surg 1996)

65. Blood Lactate
serial lactate levels may improve the prognostic value and
help guide therapy
Nguyen et al. Crit Care Med 2004

66. Lactate clearance
as a target
Jones. JAMA 2010

67. Lactate clearance
as a target
Jones. JAMA 2010
Lactate <10%
clearance
>10%

68. Lactate clearance
as a target
p = NS
23% 10.0
17% 7.5
•p = NS
12% 5.0
6% 2.5
0% 0
mortality (%) LOS (D)
lactate guided
Jones. JAMA 2010
ScvO2 guided

69. Lactate clearance
as a target
Jansen. AJRCCM 2010.

70. Lactate clearance
as a target
Jansen. AJRCCM 2010.

71. Lactate clearance
as a target
44%
•p = 0.067
33%
22%
11%
0%
hospital mortality (%) lactate guided
non-lactate guided
Lactate guided group Hazard ratio P-value
In hospital mortality 0.61 (0.43-0.87) 0.006
ICU mortality 0.66 (0.45-0.98) 0.037
Jansen. AJRCCM 2010.

72. Lactate as a target
• Hyperlactatemia associated with mortality
• Rapid lactate clearance improved ICU
outcome
• Lactate guided resuscitation is feasible.
• Aggressive fluid resuscitation, inotropes
and vasodilator will reduce blood lactate.

73. Goal of shock
resuscitation
Reverse of hypotension (macro)
Clinically well perfused
Adequate tissue perfusion and oxygenation
(micro)
There has been no the best parameter to date.
 combine parameter is suggested
Use common parameters such as ScvO2 or lactate is
reasonable
The supporting data of sophisticated device is now
scanty.