FJ Belda. Brussels ISICEM 2009 Dr. F Javier Belda Dept. Anesthesiology and Critical Care Hospital Clinico Universitario Valencia (Spain) Pulsion MAB ISICEM Brussels, March 26 th 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 III Hemodynamic Monitoring III
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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
FJ Belda. Brussels ISICEM 2009
Hemodynamic failureHemodynamic failure--hypodynamic early phasehypodynamic early phase
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
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
Measurements:Measurements:Cardiac Index Cardiac Index Preload: GEDVPreload: GEDV
SSVVOO22EVLWEVLW
FJ Belda. Brussels ISICEM 2009
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
FJ Belda. Brussels ISICEM 2009
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
Low perfusion: Low perfusion: Increase in oxygen delivery Increase in oxygen delivery
= oxygen demands= oxygen demands
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
FJ Belda. Brussels ISICEM 2009
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
FJ Belda. Brussels ISICEM 2009
MV duration:12.6±3.6 vs15.4±4.3 h
Time for ICU discharge:25±13 vs 33±17 h
FJ Belda. Brussels ISICEM 2009
Normalize Preload (GEDV) while avoiding lung edema