When the heart is unable to meet the needs of the body, then the heart has failed. Whether the cause is due to myocardial infarction, valvular disease or arrhythmia. Heart failure is inadequate maintenance of blood pressure and or blood flow. Potential Energy (PE) is blood pressure and Kinetic Energy (KE) is blood flow. SMII is a measure of the heartโs energy or power.
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Case Study - Pediatric - Septic Shock - Fluid Responsiveness and SMII
1. The Measure of Lifewww.uscom.com.au
Fluid Responsiveness
and SMII
Pediatric Septic Shock
2. The Measure of Lifewww.uscom.com.au
Smith Madigan Inotropy Index
(SMII)
โข When the heart is unable to meet the demands of
the body then the heart has failed
โข Whether the cause is myocardial infarction,
valvular disease or arrhythmia
โข Heart failure is inadequate blood pressure and or
blood flow - CI < 2.4 l/min/m2
โข Potential Energy (PE) is blood pressure and
Kinetic Energy (KE) is blood flow.
โข PE + KE = SMI ; SMI / BSA = SMII
โข SMII is a measure of the heartโs energy or power
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Causes of a Low Stroke Volume
โข Low SV, and consequently low CI, may be due to:
โข Hypovolemia - inadequate preload in response to a
volume challenge
โข Hypovolemia and hypocontractility - low preload and
myocardial depression which may not respond to fluid
alone
โข The non-responders are on a lower, flatter Frank-Starling curve
โข Inotropes are needed to increase SV in the face of cardiac
failure, when there is enough preload
โข Hypocontractility โ Myocardial depression with
normovolemia
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Fluid Responders
โข Stroke volume (SV ml) and SMII (W/m2) after 40ml/kg
volume resuscitation show clinical or hemodynamic
improvement
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Fluid Non Responders
โข Stroke volume (SV ml) and SMII (W/m2) after 40ml/kg
volume resuscitation showing clear evidence of heart
failure
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Case 1
โข After 30 ml/kg of fluid, no increase in SV
โข SMII was 0.94W/m2, CI 2.35 l/min
โข Dobutamine was started at 10mcg/kg/min
โข At 40 ml/kg, SMII was 1.34
โข At 60 ml/kg, SMII was 1.66
and CI 4.4 l/min/m2
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Case 2
โข No increase in SV after 20 or 30 ml/kg
โข After 20 ml/kg, SMII was 0.88 W/m2, CI 2.15 l/min and
dobutamine was started at 15mcg/kg/min
โข At 40 ml/kg, SMII was 1.36
โข At 60 ml/kg, SMII was 1.73
and CI 4.7 l/min/m2
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Which Inotrope?
โข Both of the non-responders had very high SVRI
values of 3,300 d.s.cm-5 and 3,450 d.s.cm-5
โข A vaso-dilating inotrope, dobutamine, was
chosen
โข A vasoconstricting inotrope would be more
appropriate for a low SVR/high CI
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Which Inotrope?
โข A rational choice of inotrope can be made on the
basis of the CI, SMII and SVRI
โข We should ask three questions:
1). Is the CI high, low or normal?
2). Is the SVRI high, low or normal.
3). Is the SMII normal or low?
โข Is there a need to increase inotropy?
โข Is vasodilation or vasoconstriction necessary?
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Conclusion
USCOM
โข Measures the energy of the heart
โข Identifies patients who need an inotrope to
optimise SVI and CI
โข Identifies which inotrope to use
โข Measurement of SVI, SMII and SVRI
guides appropriate, effective and rapid
management