Monitoring of Heart-Kidney Interactions What Should we Monitor?

Monitoring of Heart-Kidney Interactions

What Should we Monitor?David Nelson, MD, PhDDirector, Cardiac Intensive Care The Heart InstituteCincinnati Childrens Hospital

Is this the response to Low Cardiac Output Syndrome in your ICU?

Survival is a necessary, but insufficient definition of outcome

Increasing CICU Length of Stay in Associated with Lower Verbal and Full Scale IQ 8 Years After Surgery

N=166

Quartile

P < 0.02

Boston Circulatory Arrest Study

Quartile

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107102

103.5101.4

10095.4

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Verbal IQ

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Full Scale IQVerbal IQ

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2nd101.4103.5

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4th92.890.2

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When adjusting for predictors of longer CICU length of stay, as well as for prior variables that were predictive of worse 8 year developmental outcome:

Longer CICU length of stay was associated with:Lower Full Scale IQ (P=0.02)Lower Verbal IQ (P=0.02)Lower Performance IQ (P=0.08)Lower Math Achievement (P=0.08)

Deleting top 5% of CICU LOS, each day in the CICU:

Led to a reduction of 1.4 points in full scale IQ

Led to a reduction of 1.6 points in math achievement

Newburger, Wernovsky et al, J Pediatr 2003;143:67-73

Neurologic Injury after Neonatal Congenital Heart Surgery2% overt neurological injury following pediatric heart surgery10% subclinical stroke in neonates undergoing surgery60% visuospatial/motor abnormalities, attention deficit, developmental delay by school age following neonatal surgeryHLHS survivors median IQ 6657% cerebral palsy

Physiologic Monitoring How effective is our current monitoring technology?What is the incidence of unanticipated cardiac arrest in your ICU?How quickly is LCOS detected in your ICU, and what is the sensitivity and specificity?When LCOS is detected in a patient, do the interventions minimize the duration of LCOS? Does monitoring cause complications (thrombosis, BSIs, etc)

What Should We Be Monitoring?Assessment of Low Output StatesWhat is the best marker of inadequate O2 Delivery?

What Should We Be Monitoring?Assessment of Low Output StatesWhat is the best marker of inadequate O2 Delivery?

What Should We Be Monitoring?Assessment of Low Output StatesWhat is the best marker of inadequate O2 Delivery?

Lactate is too late

What Should We Be Monitoring?Assessment of Low Output StatesWhat is the best marker of inadequate O2 Delivery?

Lactate is too late

The cardiac output needed depends upon the O2 DemandCardiac Output?

What is the best marker of inadequate Oxygen Delivery in shock states?

What is the best marker of inadequate Oxygen Delivery in shock states?Hypoxic hypoxia AnemiaHypovolemiaCarbon Monoxide Dysoxia

What is the best marker of inadequate Oxygen Delivery in shock states?Hypoxic hypoxia AnemiaHypovolemiaSepsis Regardless of the cause, SVO2 is the best marker of inadequate systemic and regional O2 delivery and anaerobic metabolism

We dont need no new monitors!We tend to have different standards for new technology than for the old technology.What data is there to support monitoring of blood pressure or heart rate?

Diagnosis of low output statesClinical Signs of Low OutputPallorTachycardiaTachpnoeaAltered mentationGI distressOlguria/AnuriaAcidosisLactateFalling Venous or regional O2 saturation ???If present then tissue hypoxia is already occuring}

Tibby SM et al. Arch Dis Child 1999;80(2):163-6 norm value for cap refill time of < or = 2 sec has little predictive value Bailey JM et al. Crit Care Med 1990;18(12):1353-6 no signif relationship between cap refill or extremity (toe or finger) core temp gradients and cardiac index (CI) Butt W et al. Anaesth Intensive Care 1991;19(1):84-7 peripheral temp (toe temp), and core-peripheral temp difference did not provide any guide to either CO or SVR.Raju NV et al. Clin Pediatr (Phila) 1999;38(3):139-44 no accepted standard for measuring decreased perfusion in the newborn

Capillary Refill and Toe Temperature Fail to predict Low Cardiac Output

Pediatric Critical Care Med, 2008Conclusions: We report the first case of a newly modified central venous catheter for children and demonstrate its utility in a patient with impaired oxygen delivery when traditional markers remain stable. This catheter enabled the rapid diagnosis of cardiac compromise due to pericardial effusion, leading to early treatment.

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Heart Rate

CVP MAP

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TimeSvO2CVPTime (hrs)LactateSvO2pHLactateCVPMAPHRSvO2CVPCo-OX

185913.49857.453.49956155859=72

2831023.7837.453.710551558310

3821134.2827.474.21154150821167

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Monitoring of Continuous Venous Oximetry is likely the Gold Standard for Cardiac Output AssessmentHypoxic hypoxia AnemiaHypovolemiaSepsisSVO2 is the best marker of inadequate systemic and regional O2 delivery and anaerobic metabolism

No Data on Continuous Oximetry and Acute Kidney Injury in Children

Use of Cerebral rSO2 as non-invasivesurrogate for mixed-venous saturation ????Tortoriello et al, Pediatric Anesthesia, 2005.

Owens, Ped Cardiology 2011

Owens, Ped Cardiology 2011LactateToo Late

Owens, Ped Cardiology 2011Renal rSO2Falls 4 hoursBefore Cardiac Arrest

Physiologic Monitoring How effective is our current monitoring technology?What is the incidence of unanticipated cardiac arrest in your ICU?How quickly is LCOS detected in your ICU, and what is the sensitivity and specificity?When LCOS is detected in a patient, do the interventions minimize the duration of LCOS? Does monitoring cause complications (thrombosis, BSIs, etc)

*Make sure to add the point that we went ahead and made the desmin mouse. Seems rather specialized but the story will show how what we learn may be broadly generalized to heart failure*Dx of LOS is primarily a clinical Dx. UOP, tachycardia, acidosis key findingsSince infection is unlikely in the first 24-48 hrs after surgery, LCOS is more likely to be the cause of hyperthermia early after surgeryIn Peds, brady and hypotension are a late sign that often predicts imminent cardiac arrest