06/03/56 1 Severe sepsis & MODS: Assessment and management DR. PONGDHEP THEERAWIT M.D. PULMONARY AND CRITICAL CARE RAMATHIBODI HOSPITAL Understanding shock state Inadequate tissue perfusion Low perfusion pressure Low CO Low oxygen Inadequate tissue perfusion in hypovolemic and septic shock Hypovolemic Septic Perfusion pressure Low Low Cardiac output Low High Oxygen Low Low Stroke volume in shock Oxygen transport CaO2 DO2 = CO x CaO2 VO2 = CO x (SaO2-SvO2) SvO2 Normal microcirculation DO2 = 100 VO2 = 30 SvO2 = 70
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060356
1
Severe sepsis
amp MODS Assessment and managementDR PONGDHEP THEERAWIT MD
PULMONARY AND CRITICAL CARE
RAMATHIBODI HOSPITAL
Understanding shock state
Inadequate
tissue perfusion
Low perfusion pressure
Low CO
Low oxygen
Inadequate tissue perfusion in hypovolemic and septic shock
Hypovolemic Septic
Perfusion pressure Low Low
Cardiac output Low High
Oxygen Low Low
Stroke volume in shock
Oxygen transport
CaO2
DO2 =CO x CaO2VO2 = CO x (SaO2-SvO2)SvO2
Normal microcirculation
DO2 = 100
VO2 = 30
SvO2 = 70
060356
2
Microcirculation in sepsis
DO2 = 100
VO2 = 10
SvO2 = 90
Understanding shock state
Inadequate
tissue perfusion
Low perfusion
Pressure by
low vascular resistance
High CO
Microcirculation dysfunction
Mortality outcome of decrease vascular density in septic shock
De Backer D etal AJRCCM 2002 Sakr etal Crit Care Med 2004
Mean arterial pressure and perfused capillaries density by OPS
For all vessels and for large vessels there was NOsignificant relationship between the proportion of perfused vessels
and MAP CI pH SvO2 Hb conc
De Backer et al AJRCCM 2002
Cardiac index MAP and Microcirculation dysfunction
Appropriate antibiotic ASAP within 1 hr (SSC 2012)
Hemodynamic assessment
Assess cardiac output
Assess fluid responsiveness
Assess pulmonary leakage
Assess tissue perfusion
Cardiac output monitoring
Intermittent
PA catheter
ICU-US
Continuous
Thermodilution
Pulse contour analysis
060356
5
PA catheter
bull Proximal ndash cold injectate ScvO2
bull Distal ndash Draw SvO2
bull Thermistor ndash Temperature
bull Balloon inflation and deflation
Wave form
Waveform In place PA catheter
Joining Zeroing
060356
6
Others parameter calculated from PAC parameters
SVR = ( MAP - CVP CO ) x 80
PVR = ( PAP - PAOP CO ) x 80
CO = VO2 ( CaO2 - CvO2 )
DO2 = CO x Ca O2 x 10
VO2 = ( Ca O2 - Cv O2 ) x CO x10
Ca O2 = ( 139 x Hb x SaO2 ) + ( 0003 x PaO2 ) - Arterial
O2 content
Cv O2 = ( 139 x Hb x SvO2 ) + ( 0003 x PvO2 ) - Venous
O2 content
O2 extraxtion = VO2 DO2
QsQt = ( PA-a O2 ) ( PA-a O2 ) ( Ca-v O2 )
Cardiac output measurement
Fickrsquos formular
CO = VO2
CaO2-CvO2
Poor feasibility
Indicator dilution method
Indocyanine green
More accurate and reproducible
Require blood sampling
Recirculation of dye can disturb measurement
Thermodilution
More efficient
Thermo dilution method
Inject 5-10 cc of cold water
Tem
pera
ture
change (
)
Time
Stewart ndashHamilton equation
CO = ( TB ndash TI )xK
0 TB(t) dt
Hemodynamic
parameters in 4 shocks
CVP PAP PCWP CO SVR
Hypovolemic Low Low Low Low High
Cardiogenic High High High Low High
Obstructive High Very high Normal Low High
Septic Not high Not high Not high High Low
Ultrasound CO by ultrasound
A mount of blood flow going through a fixed orifice =
CSA x Flow-Velocity
SV = CSA x LVOTTVI
CSA = LVOTd2 x 078540
SV = LVOTd2 x 078540 x LVOTTVI
060356
7
LVOT diameter
LVOT VTI
good correlation between the thermodilutiontechnique and
Simpsons two-chamber method (r = 091)
Simpsons four-chamber method (r = 077)
the LVOT Doppler method (r = 094)
the LVOT Doppler method demonstrated acceptable agreement with a mean of 02
litresminute standard deviation of 082 litresminute and 95 limits of agreement of -15 to +19 litresminute
CCO-thermodilution methods Model for CCOtd
Agreement between CCO and BCO
in cardio-thoracic surgeryIntensive Care Med 199925166
Compare CCO and BCO in 20 medical ptsJ Crit Care 199813184
Conditions Number
MV 15
Vasopressor 15
Malignancy 12
Aplastic anemia
5
SLE 1
Cushing 1
CGD 1
060356
8
Good correlation between
CCO and BCO in sepsisIntensive Care Med 2002281276
Good correlation between CCO and BCO in sepsisIntensive Care Med 2002281276
Poor correlation of
CCO during hypothermia
Conclusions
Despite an excellent correlation accuracy and
precision between CCO and ICO before CPB and more than 45 minutes after hypothermic CPB a lack
of correlation in the early phase after CPB has been
found Further investigation is needed to elucidate the underlying cause of these findings and to clarify
whether ICO or CCO or both fail to represent the
real cardiac output up to 45 minutes after weaning from hypothermic CPB
19959405
Response time after sudden reduction of COAnesthesiology 199889(6)1592
Response time after sudden reduction of COCrit Care Med 1995 23 860 Advantages over IBCO
Provide continuous trend
Reduce contamination
Less time consuming
Unnecessary fluid
060356
9
Limitations
Immediate CO measurement may not be done due to average time for reduce thermal noise
Transpulmoanry thermodilution method (TPTD)
Compare TPTD and IBTDAnesthesia amp Analgesia 2010
The respiratory variation affect IBTD rather than TPTD
IBTD
TPTD
Advantages over IBTD
Less invasive
Decrease complications result from PA catheter
GEDV and EVLW can be measuredAm J Physiol Lung Cell Mol Physiol 291 L1118ndashL1131 2006
060356
10
Limitations
Canrsquot assess PA pressure and its trend
Canrsquot assess SvO2
Pulse contour analysis
Non-calibrated
Calibrated
Basic Principles
Traditional CO = HR SV
FloTrac system CO = PR x (AP )
Where = M (HR AP C(P) BSA MAP 3ap 4ap)
Validation ICOCCOAPCOCrit Care 200711R105
Validation ICOCCOAPCOCrit Care 200711R105
FloTrac amp PACCrit Care 201014R212
060356
11
FloTrac amp PACCrit Care 201014R212
FloTrac in sepsisIntensive Care 201137233
FloTrac in sepsisIntensive Care 201137233
FloTrac Vigileo G3
Advantages
Real time
Less invasive
Non-calibrated
Informative
CO CI
PPV
SvO2
SVR
Disadvantages
Algorithm-gtnot real
Accuracy
Can not assess RV
derived parameters
Require new version software
PiCCO system Need calibration
060356
12
PAC and PiCCO (AP)Crit Care 201014R212
PiCCO
Advantages
Continuos monitoring
More accurate
Informative
COCI
SVV
SVR
GEDV
EVLW
AP
Disadvantages
Require calibration q 8 hrs
Femoral site risky to
CRBSI
Early goal directed therapy
What is the CVP
CVP = Central Venous Pressure
Frank Starling amp venous return line
Stroke volume
CVP0
Frank-Starling curve
Stroke volume or EDV
JVP or CVP or PCWP
ΔSV or Δ EDV
a
b
Responders
Non-responders
060356
13
b
CVP tells us who responders
Stroke volume or EDV
CVP or PCWP
ΔSV or Δ EDV
a
Good
Bad
CVP vs Fluid responders
Crit Care Med 20073564-8
39 cases25 cases
Does Central Venous Pressure Predict
Fluid ResponsivenessA Systematic Review of the Literature
CHEST 2008 134172ndash178
Fluid resuscitation in septic shock a positive fluid balance and elevated central venous pressure are associated with increased mortalityBoyd JH Forbes J Nakada TA Walley KR Russell JA
OBJECTIVE
To determine whether central venous pressure and fluid balance after resuscitation for septic shock are associated
with mortality
PATIENTS
The Vasopressin in Septic Shock Trial (VASST) study enrolled 778 patients who had septic shock and who were
receiving a minimum of 5 μg of norepinephrine per minute
MEASUREMENTS AND MAIN RESULTS
Based on net fluid balance we determined whether ones fluid balance quartile was correlated with 28-day
mortality We also analyzed whether fluid balance was predictive of central venous pressure and furthermore
whether a guideline-recommended central venous pressure of 8-12 mm Hg yielded a mortality advantage At
enrollment which occurred on average 12 hrs after presentation the average fluid balance was +42 L By day 4 the
cumulative average fluid balance was +11 L After correcting for age and Acute Physiology and Chronic Health
Evaluation II score a more positive fluid balance at both at 12 hrs and day 4 correlated significantly with increased
mortality Central venous pressure was correlated with fluid balance at 12 hrs whereas on days 1-4 there was no
significant correlation At 12 hrs patients with central venous pressure lt8 mm Hg had the lowest mortality rate
followed by those with central venous pressure 8-12 mm Hg The highest mortality rate was observed in those with
central venous pressure gt12 mm Hg Contrary to the overall effect patients whose central venous pressure was lt8
mm Hg had improved survival with a more positive fluid balance
CONCLUSIONS
A more positive fluid balance both early in resuscitation and cumulatively over 4 days is associated with an increased
risk of mortality in septic shock Central venous pressure may be used to gauge fluid balance le 12 hrs into septic
shock but becomes an unreliable marker of fluid balance thereafter Optimal survival in the VASST study occurred
with a positive fluid balance of approximately 3 L at 12 hrs
Functional hemodynamic for predicting fluidresponsiveness
Spontaneous respiration
CVP variation gt 1 mmHg
PLR cCO gt 15 ( can be used in arrhythmia)
On mechanical ventilation
PPV gt 13
IVCd variation gt 12 ( can be used in arrhythmia)
IVC distensibility index gt 18 ( can be used in arrhythmia)
Appropriate antibiotic ASAP within 1 hr (SSC 2012)
Hemodynamic assessment
Assess cardiac output
Assess fluid responsiveness
Assess pulmonary leakage
Assess tissue perfusion
Cardiac output monitoring
Intermittent
PA catheter
ICU-US
Continuous
Thermodilution
Pulse contour analysis
060356
5
PA catheter
bull Proximal ndash cold injectate ScvO2
bull Distal ndash Draw SvO2
bull Thermistor ndash Temperature
bull Balloon inflation and deflation
Wave form
Waveform In place PA catheter
Joining Zeroing
060356
6
Others parameter calculated from PAC parameters
SVR = ( MAP - CVP CO ) x 80
PVR = ( PAP - PAOP CO ) x 80
CO = VO2 ( CaO2 - CvO2 )
DO2 = CO x Ca O2 x 10
VO2 = ( Ca O2 - Cv O2 ) x CO x10
Ca O2 = ( 139 x Hb x SaO2 ) + ( 0003 x PaO2 ) - Arterial
O2 content
Cv O2 = ( 139 x Hb x SvO2 ) + ( 0003 x PvO2 ) - Venous
O2 content
O2 extraxtion = VO2 DO2
QsQt = ( PA-a O2 ) ( PA-a O2 ) ( Ca-v O2 )
Cardiac output measurement
Fickrsquos formular
CO = VO2
CaO2-CvO2
Poor feasibility
Indicator dilution method
Indocyanine green
More accurate and reproducible
Require blood sampling
Recirculation of dye can disturb measurement
Thermodilution
More efficient
Thermo dilution method
Inject 5-10 cc of cold water
Tem
pera
ture
change (
)
Time
Stewart ndashHamilton equation
CO = ( TB ndash TI )xK
0 TB(t) dt
Hemodynamic
parameters in 4 shocks
CVP PAP PCWP CO SVR
Hypovolemic Low Low Low Low High
Cardiogenic High High High Low High
Obstructive High Very high Normal Low High
Septic Not high Not high Not high High Low
Ultrasound CO by ultrasound
A mount of blood flow going through a fixed orifice =
CSA x Flow-Velocity
SV = CSA x LVOTTVI
CSA = LVOTd2 x 078540
SV = LVOTd2 x 078540 x LVOTTVI
060356
7
LVOT diameter
LVOT VTI
good correlation between the thermodilutiontechnique and
Simpsons two-chamber method (r = 091)
Simpsons four-chamber method (r = 077)
the LVOT Doppler method (r = 094)
the LVOT Doppler method demonstrated acceptable agreement with a mean of 02
litresminute standard deviation of 082 litresminute and 95 limits of agreement of -15 to +19 litresminute
CCO-thermodilution methods Model for CCOtd
Agreement between CCO and BCO
in cardio-thoracic surgeryIntensive Care Med 199925166
Compare CCO and BCO in 20 medical ptsJ Crit Care 199813184
Conditions Number
MV 15
Vasopressor 15
Malignancy 12
Aplastic anemia
5
SLE 1
Cushing 1
CGD 1
060356
8
Good correlation between
CCO and BCO in sepsisIntensive Care Med 2002281276
Good correlation between CCO and BCO in sepsisIntensive Care Med 2002281276
Poor correlation of
CCO during hypothermia
Conclusions
Despite an excellent correlation accuracy and
precision between CCO and ICO before CPB and more than 45 minutes after hypothermic CPB a lack
of correlation in the early phase after CPB has been
found Further investigation is needed to elucidate the underlying cause of these findings and to clarify
whether ICO or CCO or both fail to represent the
real cardiac output up to 45 minutes after weaning from hypothermic CPB
19959405
Response time after sudden reduction of COAnesthesiology 199889(6)1592
Response time after sudden reduction of COCrit Care Med 1995 23 860 Advantages over IBCO
Provide continuous trend
Reduce contamination
Less time consuming
Unnecessary fluid
060356
9
Limitations
Immediate CO measurement may not be done due to average time for reduce thermal noise
Transpulmoanry thermodilution method (TPTD)
Compare TPTD and IBTDAnesthesia amp Analgesia 2010
The respiratory variation affect IBTD rather than TPTD
IBTD
TPTD
Advantages over IBTD
Less invasive
Decrease complications result from PA catheter
GEDV and EVLW can be measuredAm J Physiol Lung Cell Mol Physiol 291 L1118ndashL1131 2006
060356
10
Limitations
Canrsquot assess PA pressure and its trend
Canrsquot assess SvO2
Pulse contour analysis
Non-calibrated
Calibrated
Basic Principles
Traditional CO = HR SV
FloTrac system CO = PR x (AP )
Where = M (HR AP C(P) BSA MAP 3ap 4ap)
Validation ICOCCOAPCOCrit Care 200711R105
Validation ICOCCOAPCOCrit Care 200711R105
FloTrac amp PACCrit Care 201014R212
060356
11
FloTrac amp PACCrit Care 201014R212
FloTrac in sepsisIntensive Care 201137233
FloTrac in sepsisIntensive Care 201137233
FloTrac Vigileo G3
Advantages
Real time
Less invasive
Non-calibrated
Informative
CO CI
PPV
SvO2
SVR
Disadvantages
Algorithm-gtnot real
Accuracy
Can not assess RV
derived parameters
Require new version software
PiCCO system Need calibration
060356
12
PAC and PiCCO (AP)Crit Care 201014R212
PiCCO
Advantages
Continuos monitoring
More accurate
Informative
COCI
SVV
SVR
GEDV
EVLW
AP
Disadvantages
Require calibration q 8 hrs
Femoral site risky to
CRBSI
Early goal directed therapy
What is the CVP
CVP = Central Venous Pressure
Frank Starling amp venous return line
Stroke volume
CVP0
Frank-Starling curve
Stroke volume or EDV
JVP or CVP or PCWP
ΔSV or Δ EDV
a
b
Responders
Non-responders
060356
13
b
CVP tells us who responders
Stroke volume or EDV
CVP or PCWP
ΔSV or Δ EDV
a
Good
Bad
CVP vs Fluid responders
Crit Care Med 20073564-8
39 cases25 cases
Does Central Venous Pressure Predict
Fluid ResponsivenessA Systematic Review of the Literature
CHEST 2008 134172ndash178
Fluid resuscitation in septic shock a positive fluid balance and elevated central venous pressure are associated with increased mortalityBoyd JH Forbes J Nakada TA Walley KR Russell JA
OBJECTIVE
To determine whether central venous pressure and fluid balance after resuscitation for septic shock are associated
with mortality
PATIENTS
The Vasopressin in Septic Shock Trial (VASST) study enrolled 778 patients who had septic shock and who were
receiving a minimum of 5 μg of norepinephrine per minute
MEASUREMENTS AND MAIN RESULTS
Based on net fluid balance we determined whether ones fluid balance quartile was correlated with 28-day
mortality We also analyzed whether fluid balance was predictive of central venous pressure and furthermore
whether a guideline-recommended central venous pressure of 8-12 mm Hg yielded a mortality advantage At
enrollment which occurred on average 12 hrs after presentation the average fluid balance was +42 L By day 4 the
cumulative average fluid balance was +11 L After correcting for age and Acute Physiology and Chronic Health
Evaluation II score a more positive fluid balance at both at 12 hrs and day 4 correlated significantly with increased
mortality Central venous pressure was correlated with fluid balance at 12 hrs whereas on days 1-4 there was no
significant correlation At 12 hrs patients with central venous pressure lt8 mm Hg had the lowest mortality rate
followed by those with central venous pressure 8-12 mm Hg The highest mortality rate was observed in those with
central venous pressure gt12 mm Hg Contrary to the overall effect patients whose central venous pressure was lt8
mm Hg had improved survival with a more positive fluid balance
CONCLUSIONS
A more positive fluid balance both early in resuscitation and cumulatively over 4 days is associated with an increased
risk of mortality in septic shock Central venous pressure may be used to gauge fluid balance le 12 hrs into septic
shock but becomes an unreliable marker of fluid balance thereafter Optimal survival in the VASST study occurred
with a positive fluid balance of approximately 3 L at 12 hrs
Functional hemodynamic for predicting fluidresponsiveness
Spontaneous respiration
CVP variation gt 1 mmHg
PLR cCO gt 15 ( can be used in arrhythmia)
On mechanical ventilation
PPV gt 13
IVCd variation gt 12 ( can be used in arrhythmia)
IVC distensibility index gt 18 ( can be used in arrhythmia)
Appropriate antibiotic ASAP within 1 hr (SSC 2012)
Hemodynamic assessment
Assess cardiac output
Assess fluid responsiveness
Assess pulmonary leakage
Assess tissue perfusion
Cardiac output monitoring
Intermittent
PA catheter
ICU-US
Continuous
Thermodilution
Pulse contour analysis
060356
5
PA catheter
bull Proximal ndash cold injectate ScvO2
bull Distal ndash Draw SvO2
bull Thermistor ndash Temperature
bull Balloon inflation and deflation
Wave form
Waveform In place PA catheter
Joining Zeroing
060356
6
Others parameter calculated from PAC parameters
SVR = ( MAP - CVP CO ) x 80
PVR = ( PAP - PAOP CO ) x 80
CO = VO2 ( CaO2 - CvO2 )
DO2 = CO x Ca O2 x 10
VO2 = ( Ca O2 - Cv O2 ) x CO x10
Ca O2 = ( 139 x Hb x SaO2 ) + ( 0003 x PaO2 ) - Arterial
O2 content
Cv O2 = ( 139 x Hb x SvO2 ) + ( 0003 x PvO2 ) - Venous
O2 content
O2 extraxtion = VO2 DO2
QsQt = ( PA-a O2 ) ( PA-a O2 ) ( Ca-v O2 )
Cardiac output measurement
Fickrsquos formular
CO = VO2
CaO2-CvO2
Poor feasibility
Indicator dilution method
Indocyanine green
More accurate and reproducible
Require blood sampling
Recirculation of dye can disturb measurement
Thermodilution
More efficient
Thermo dilution method
Inject 5-10 cc of cold water
Tem
pera
ture
change (
)
Time
Stewart ndashHamilton equation
CO = ( TB ndash TI )xK
0 TB(t) dt
Hemodynamic
parameters in 4 shocks
CVP PAP PCWP CO SVR
Hypovolemic Low Low Low Low High
Cardiogenic High High High Low High
Obstructive High Very high Normal Low High
Septic Not high Not high Not high High Low
Ultrasound CO by ultrasound
A mount of blood flow going through a fixed orifice =
CSA x Flow-Velocity
SV = CSA x LVOTTVI
CSA = LVOTd2 x 078540
SV = LVOTd2 x 078540 x LVOTTVI
060356
7
LVOT diameter
LVOT VTI
good correlation between the thermodilutiontechnique and
Simpsons two-chamber method (r = 091)
Simpsons four-chamber method (r = 077)
the LVOT Doppler method (r = 094)
the LVOT Doppler method demonstrated acceptable agreement with a mean of 02
litresminute standard deviation of 082 litresminute and 95 limits of agreement of -15 to +19 litresminute
CCO-thermodilution methods Model for CCOtd
Agreement between CCO and BCO
in cardio-thoracic surgeryIntensive Care Med 199925166
Compare CCO and BCO in 20 medical ptsJ Crit Care 199813184
Conditions Number
MV 15
Vasopressor 15
Malignancy 12
Aplastic anemia
5
SLE 1
Cushing 1
CGD 1
060356
8
Good correlation between
CCO and BCO in sepsisIntensive Care Med 2002281276
Good correlation between CCO and BCO in sepsisIntensive Care Med 2002281276
Poor correlation of
CCO during hypothermia
Conclusions
Despite an excellent correlation accuracy and
precision between CCO and ICO before CPB and more than 45 minutes after hypothermic CPB a lack
of correlation in the early phase after CPB has been
found Further investigation is needed to elucidate the underlying cause of these findings and to clarify
whether ICO or CCO or both fail to represent the
real cardiac output up to 45 minutes after weaning from hypothermic CPB
19959405
Response time after sudden reduction of COAnesthesiology 199889(6)1592
Response time after sudden reduction of COCrit Care Med 1995 23 860 Advantages over IBCO
Provide continuous trend
Reduce contamination
Less time consuming
Unnecessary fluid
060356
9
Limitations
Immediate CO measurement may not be done due to average time for reduce thermal noise
Transpulmoanry thermodilution method (TPTD)
Compare TPTD and IBTDAnesthesia amp Analgesia 2010
The respiratory variation affect IBTD rather than TPTD
IBTD
TPTD
Advantages over IBTD
Less invasive
Decrease complications result from PA catheter
GEDV and EVLW can be measuredAm J Physiol Lung Cell Mol Physiol 291 L1118ndashL1131 2006
060356
10
Limitations
Canrsquot assess PA pressure and its trend
Canrsquot assess SvO2
Pulse contour analysis
Non-calibrated
Calibrated
Basic Principles
Traditional CO = HR SV
FloTrac system CO = PR x (AP )
Where = M (HR AP C(P) BSA MAP 3ap 4ap)
Validation ICOCCOAPCOCrit Care 200711R105
Validation ICOCCOAPCOCrit Care 200711R105
FloTrac amp PACCrit Care 201014R212
060356
11
FloTrac amp PACCrit Care 201014R212
FloTrac in sepsisIntensive Care 201137233
FloTrac in sepsisIntensive Care 201137233
FloTrac Vigileo G3
Advantages
Real time
Less invasive
Non-calibrated
Informative
CO CI
PPV
SvO2
SVR
Disadvantages
Algorithm-gtnot real
Accuracy
Can not assess RV
derived parameters
Require new version software
PiCCO system Need calibration
060356
12
PAC and PiCCO (AP)Crit Care 201014R212
PiCCO
Advantages
Continuos monitoring
More accurate
Informative
COCI
SVV
SVR
GEDV
EVLW
AP
Disadvantages
Require calibration q 8 hrs
Femoral site risky to
CRBSI
Early goal directed therapy
What is the CVP
CVP = Central Venous Pressure
Frank Starling amp venous return line
Stroke volume
CVP0
Frank-Starling curve
Stroke volume or EDV
JVP or CVP or PCWP
ΔSV or Δ EDV
a
b
Responders
Non-responders
060356
13
b
CVP tells us who responders
Stroke volume or EDV
CVP or PCWP
ΔSV or Δ EDV
a
Good
Bad
CVP vs Fluid responders
Crit Care Med 20073564-8
39 cases25 cases
Does Central Venous Pressure Predict
Fluid ResponsivenessA Systematic Review of the Literature
CHEST 2008 134172ndash178
Fluid resuscitation in septic shock a positive fluid balance and elevated central venous pressure are associated with increased mortalityBoyd JH Forbes J Nakada TA Walley KR Russell JA
OBJECTIVE
To determine whether central venous pressure and fluid balance after resuscitation for septic shock are associated
with mortality
PATIENTS
The Vasopressin in Septic Shock Trial (VASST) study enrolled 778 patients who had septic shock and who were
receiving a minimum of 5 μg of norepinephrine per minute
MEASUREMENTS AND MAIN RESULTS
Based on net fluid balance we determined whether ones fluid balance quartile was correlated with 28-day
mortality We also analyzed whether fluid balance was predictive of central venous pressure and furthermore
whether a guideline-recommended central venous pressure of 8-12 mm Hg yielded a mortality advantage At
enrollment which occurred on average 12 hrs after presentation the average fluid balance was +42 L By day 4 the
cumulative average fluid balance was +11 L After correcting for age and Acute Physiology and Chronic Health
Evaluation II score a more positive fluid balance at both at 12 hrs and day 4 correlated significantly with increased
mortality Central venous pressure was correlated with fluid balance at 12 hrs whereas on days 1-4 there was no
significant correlation At 12 hrs patients with central venous pressure lt8 mm Hg had the lowest mortality rate
followed by those with central venous pressure 8-12 mm Hg The highest mortality rate was observed in those with
central venous pressure gt12 mm Hg Contrary to the overall effect patients whose central venous pressure was lt8
mm Hg had improved survival with a more positive fluid balance
CONCLUSIONS
A more positive fluid balance both early in resuscitation and cumulatively over 4 days is associated with an increased
risk of mortality in septic shock Central venous pressure may be used to gauge fluid balance le 12 hrs into septic
shock but becomes an unreliable marker of fluid balance thereafter Optimal survival in the VASST study occurred
with a positive fluid balance of approximately 3 L at 12 hrs
Functional hemodynamic for predicting fluidresponsiveness
Spontaneous respiration
CVP variation gt 1 mmHg
PLR cCO gt 15 ( can be used in arrhythmia)
On mechanical ventilation
PPV gt 13
IVCd variation gt 12 ( can be used in arrhythmia)
IVC distensibility index gt 18 ( can be used in arrhythmia)
Appropriate antibiotic ASAP within 1 hr (SSC 2012)
Hemodynamic assessment
Assess cardiac output
Assess fluid responsiveness
Assess pulmonary leakage
Assess tissue perfusion
Cardiac output monitoring
Intermittent
PA catheter
ICU-US
Continuous
Thermodilution
Pulse contour analysis
060356
5
PA catheter
bull Proximal ndash cold injectate ScvO2
bull Distal ndash Draw SvO2
bull Thermistor ndash Temperature
bull Balloon inflation and deflation
Wave form
Waveform In place PA catheter
Joining Zeroing
060356
6
Others parameter calculated from PAC parameters
SVR = ( MAP - CVP CO ) x 80
PVR = ( PAP - PAOP CO ) x 80
CO = VO2 ( CaO2 - CvO2 )
DO2 = CO x Ca O2 x 10
VO2 = ( Ca O2 - Cv O2 ) x CO x10
Ca O2 = ( 139 x Hb x SaO2 ) + ( 0003 x PaO2 ) - Arterial
O2 content
Cv O2 = ( 139 x Hb x SvO2 ) + ( 0003 x PvO2 ) - Venous
O2 content
O2 extraxtion = VO2 DO2
QsQt = ( PA-a O2 ) ( PA-a O2 ) ( Ca-v O2 )
Cardiac output measurement
Fickrsquos formular
CO = VO2
CaO2-CvO2
Poor feasibility
Indicator dilution method
Indocyanine green
More accurate and reproducible
Require blood sampling
Recirculation of dye can disturb measurement
Thermodilution
More efficient
Thermo dilution method
Inject 5-10 cc of cold water
Tem
pera
ture
change (
)
Time
Stewart ndashHamilton equation
CO = ( TB ndash TI )xK
0 TB(t) dt
Hemodynamic
parameters in 4 shocks
CVP PAP PCWP CO SVR
Hypovolemic Low Low Low Low High
Cardiogenic High High High Low High
Obstructive High Very high Normal Low High
Septic Not high Not high Not high High Low
Ultrasound CO by ultrasound
A mount of blood flow going through a fixed orifice =
CSA x Flow-Velocity
SV = CSA x LVOTTVI
CSA = LVOTd2 x 078540
SV = LVOTd2 x 078540 x LVOTTVI
060356
7
LVOT diameter
LVOT VTI
good correlation between the thermodilutiontechnique and
Simpsons two-chamber method (r = 091)
Simpsons four-chamber method (r = 077)
the LVOT Doppler method (r = 094)
the LVOT Doppler method demonstrated acceptable agreement with a mean of 02
litresminute standard deviation of 082 litresminute and 95 limits of agreement of -15 to +19 litresminute
CCO-thermodilution methods Model for CCOtd
Agreement between CCO and BCO
in cardio-thoracic surgeryIntensive Care Med 199925166
Compare CCO and BCO in 20 medical ptsJ Crit Care 199813184
Conditions Number
MV 15
Vasopressor 15
Malignancy 12
Aplastic anemia
5
SLE 1
Cushing 1
CGD 1
060356
8
Good correlation between
CCO and BCO in sepsisIntensive Care Med 2002281276
Good correlation between CCO and BCO in sepsisIntensive Care Med 2002281276
Poor correlation of
CCO during hypothermia
Conclusions
Despite an excellent correlation accuracy and
precision between CCO and ICO before CPB and more than 45 minutes after hypothermic CPB a lack
of correlation in the early phase after CPB has been
found Further investigation is needed to elucidate the underlying cause of these findings and to clarify
whether ICO or CCO or both fail to represent the
real cardiac output up to 45 minutes after weaning from hypothermic CPB
19959405
Response time after sudden reduction of COAnesthesiology 199889(6)1592
Response time after sudden reduction of COCrit Care Med 1995 23 860 Advantages over IBCO
Provide continuous trend
Reduce contamination
Less time consuming
Unnecessary fluid
060356
9
Limitations
Immediate CO measurement may not be done due to average time for reduce thermal noise
Transpulmoanry thermodilution method (TPTD)
Compare TPTD and IBTDAnesthesia amp Analgesia 2010
The respiratory variation affect IBTD rather than TPTD
IBTD
TPTD
Advantages over IBTD
Less invasive
Decrease complications result from PA catheter
GEDV and EVLW can be measuredAm J Physiol Lung Cell Mol Physiol 291 L1118ndashL1131 2006
060356
10
Limitations
Canrsquot assess PA pressure and its trend
Canrsquot assess SvO2
Pulse contour analysis
Non-calibrated
Calibrated
Basic Principles
Traditional CO = HR SV
FloTrac system CO = PR x (AP )
Where = M (HR AP C(P) BSA MAP 3ap 4ap)
Validation ICOCCOAPCOCrit Care 200711R105
Validation ICOCCOAPCOCrit Care 200711R105
FloTrac amp PACCrit Care 201014R212
060356
11
FloTrac amp PACCrit Care 201014R212
FloTrac in sepsisIntensive Care 201137233
FloTrac in sepsisIntensive Care 201137233
FloTrac Vigileo G3
Advantages
Real time
Less invasive
Non-calibrated
Informative
CO CI
PPV
SvO2
SVR
Disadvantages
Algorithm-gtnot real
Accuracy
Can not assess RV
derived parameters
Require new version software
PiCCO system Need calibration
060356
12
PAC and PiCCO (AP)Crit Care 201014R212
PiCCO
Advantages
Continuos monitoring
More accurate
Informative
COCI
SVV
SVR
GEDV
EVLW
AP
Disadvantages
Require calibration q 8 hrs
Femoral site risky to
CRBSI
Early goal directed therapy
What is the CVP
CVP = Central Venous Pressure
Frank Starling amp venous return line
Stroke volume
CVP0
Frank-Starling curve
Stroke volume or EDV
JVP or CVP or PCWP
ΔSV or Δ EDV
a
b
Responders
Non-responders
060356
13
b
CVP tells us who responders
Stroke volume or EDV
CVP or PCWP
ΔSV or Δ EDV
a
Good
Bad
CVP vs Fluid responders
Crit Care Med 20073564-8
39 cases25 cases
Does Central Venous Pressure Predict
Fluid ResponsivenessA Systematic Review of the Literature
CHEST 2008 134172ndash178
Fluid resuscitation in septic shock a positive fluid balance and elevated central venous pressure are associated with increased mortalityBoyd JH Forbes J Nakada TA Walley KR Russell JA
OBJECTIVE
To determine whether central venous pressure and fluid balance after resuscitation for septic shock are associated
with mortality
PATIENTS
The Vasopressin in Septic Shock Trial (VASST) study enrolled 778 patients who had septic shock and who were
receiving a minimum of 5 μg of norepinephrine per minute
MEASUREMENTS AND MAIN RESULTS
Based on net fluid balance we determined whether ones fluid balance quartile was correlated with 28-day
mortality We also analyzed whether fluid balance was predictive of central venous pressure and furthermore
whether a guideline-recommended central venous pressure of 8-12 mm Hg yielded a mortality advantage At
enrollment which occurred on average 12 hrs after presentation the average fluid balance was +42 L By day 4 the
cumulative average fluid balance was +11 L After correcting for age and Acute Physiology and Chronic Health
Evaluation II score a more positive fluid balance at both at 12 hrs and day 4 correlated significantly with increased
mortality Central venous pressure was correlated with fluid balance at 12 hrs whereas on days 1-4 there was no
significant correlation At 12 hrs patients with central venous pressure lt8 mm Hg had the lowest mortality rate
followed by those with central venous pressure 8-12 mm Hg The highest mortality rate was observed in those with
central venous pressure gt12 mm Hg Contrary to the overall effect patients whose central venous pressure was lt8
mm Hg had improved survival with a more positive fluid balance
CONCLUSIONS
A more positive fluid balance both early in resuscitation and cumulatively over 4 days is associated with an increased
risk of mortality in septic shock Central venous pressure may be used to gauge fluid balance le 12 hrs into septic
shock but becomes an unreliable marker of fluid balance thereafter Optimal survival in the VASST study occurred
with a positive fluid balance of approximately 3 L at 12 hrs
Functional hemodynamic for predicting fluidresponsiveness
Spontaneous respiration
CVP variation gt 1 mmHg
PLR cCO gt 15 ( can be used in arrhythmia)
On mechanical ventilation
PPV gt 13
IVCd variation gt 12 ( can be used in arrhythmia)
IVC distensibility index gt 18 ( can be used in arrhythmia)
Red blood cell transfusion during septic shock in the ICUA Perner etal Acta Anaesthesiol Scand 2012 56 718ndash723
The CRIT Study Anemia and blood transfusion in the critically illmdashCurrent clinical practice in the United States
(Observational study 284 ICU 4892 patients)
Crit Care Med 2004 3239 ndash52
060356
22
Microvascular response to red blood cell
transfusion in patients with severe sepsisYasser Sakr MD PhDetal Crit Care Med 2007 351639ndash1644
Clinical practice guideline Red blood cell transfusion in
adult trauma and critical careLena M Napolitano MD Stanley Kurek DO Fred A Luchette MD Howard L Corwin MD
Philip S Barie MD Samuel A Tisherman MD Paul C Hebert MD MHSc Gary L Anderson DO
Michael R Bard MD William Bromberg MD William C Chiu MD Mark D Cipolle MD PhD
Keith D Clancy MD Lawrence Diebel MD William S Hoff MD K Michael Hughes DO
Imtiaz Munshi MD Donna Nayduch RN MSN ACNP Rovinder Sandhu MD Jay A Yelon MD
for the American College of Critical Care Medicine of the Society of Critical Care Medicine and the Eastern
Association for the Surgery of Trauma Practice Management Workgroup (Crit Care Med 2009)
we recommend that red blood cell transfusion occur
only when hemoglobin concentration decreases to
lt70 gdL to target a hemoglobin concentration of 70 ndash90 gdL in adults
The
EGDT
started at a dose of 25 microg per kilogram of body weight per
minute a dose that was increased by 25 microg per kilogram
per minute every 30 minutes until the central venous
oxygen saturation was 70 percent or higher or until a
maximal dose of 20 microg per kilogram per minute was given
Median max dose of dobutamine to reach CI gt 45 DO2 gt 600 VO2 gt 170
Control group 023 mcgkgmin (005-10)
Treatment group 12 mcgkgmin (002-166)
P = 0029
060356
23
CI ge 45 CI = 25-35
in the presence of (a)myocardial dysfunction as suggested by elevated
cardiac filling pressures and low cardiac output or
(b)ongoing signs of hypoperfusion
060356
5
PA catheter
bull Proximal ndash cold injectate ScvO2
bull Distal ndash Draw SvO2
bull Thermistor ndash Temperature
bull Balloon inflation and deflation
Wave form
Waveform In place PA catheter
Joining Zeroing
060356
6
Others parameter calculated from PAC parameters
SVR = ( MAP - CVP CO ) x 80
PVR = ( PAP - PAOP CO ) x 80
CO = VO2 ( CaO2 - CvO2 )
DO2 = CO x Ca O2 x 10
VO2 = ( Ca O2 - Cv O2 ) x CO x10
Ca O2 = ( 139 x Hb x SaO2 ) + ( 0003 x PaO2 ) - Arterial
O2 content
Cv O2 = ( 139 x Hb x SvO2 ) + ( 0003 x PvO2 ) - Venous
O2 content
O2 extraxtion = VO2 DO2
QsQt = ( PA-a O2 ) ( PA-a O2 ) ( Ca-v O2 )
Cardiac output measurement
Fickrsquos formular
CO = VO2
CaO2-CvO2
Poor feasibility
Indicator dilution method
Indocyanine green
More accurate and reproducible
Require blood sampling
Recirculation of dye can disturb measurement
Thermodilution
More efficient
Thermo dilution method
Inject 5-10 cc of cold water
Tem
pera
ture
change (
)
Time
Stewart ndashHamilton equation
CO = ( TB ndash TI )xK
0 TB(t) dt
Hemodynamic
parameters in 4 shocks
CVP PAP PCWP CO SVR
Hypovolemic Low Low Low Low High
Cardiogenic High High High Low High
Obstructive High Very high Normal Low High
Septic Not high Not high Not high High Low
Ultrasound CO by ultrasound
A mount of blood flow going through a fixed orifice =
CSA x Flow-Velocity
SV = CSA x LVOTTVI
CSA = LVOTd2 x 078540
SV = LVOTd2 x 078540 x LVOTTVI
060356
7
LVOT diameter
LVOT VTI
good correlation between the thermodilutiontechnique and
Simpsons two-chamber method (r = 091)
Simpsons four-chamber method (r = 077)
the LVOT Doppler method (r = 094)
the LVOT Doppler method demonstrated acceptable agreement with a mean of 02
litresminute standard deviation of 082 litresminute and 95 limits of agreement of -15 to +19 litresminute
CCO-thermodilution methods Model for CCOtd
Agreement between CCO and BCO
in cardio-thoracic surgeryIntensive Care Med 199925166
Compare CCO and BCO in 20 medical ptsJ Crit Care 199813184
Conditions Number
MV 15
Vasopressor 15
Malignancy 12
Aplastic anemia
5
SLE 1
Cushing 1
CGD 1
060356
8
Good correlation between
CCO and BCO in sepsisIntensive Care Med 2002281276
Good correlation between CCO and BCO in sepsisIntensive Care Med 2002281276
Poor correlation of
CCO during hypothermia
Conclusions
Despite an excellent correlation accuracy and
precision between CCO and ICO before CPB and more than 45 minutes after hypothermic CPB a lack
of correlation in the early phase after CPB has been
found Further investigation is needed to elucidate the underlying cause of these findings and to clarify
whether ICO or CCO or both fail to represent the
real cardiac output up to 45 minutes after weaning from hypothermic CPB
19959405
Response time after sudden reduction of COAnesthesiology 199889(6)1592
Response time after sudden reduction of COCrit Care Med 1995 23 860 Advantages over IBCO
Provide continuous trend
Reduce contamination
Less time consuming
Unnecessary fluid
060356
9
Limitations
Immediate CO measurement may not be done due to average time for reduce thermal noise
Transpulmoanry thermodilution method (TPTD)
Compare TPTD and IBTDAnesthesia amp Analgesia 2010
The respiratory variation affect IBTD rather than TPTD
IBTD
TPTD
Advantages over IBTD
Less invasive
Decrease complications result from PA catheter
GEDV and EVLW can be measuredAm J Physiol Lung Cell Mol Physiol 291 L1118ndashL1131 2006
060356
10
Limitations
Canrsquot assess PA pressure and its trend
Canrsquot assess SvO2
Pulse contour analysis
Non-calibrated
Calibrated
Basic Principles
Traditional CO = HR SV
FloTrac system CO = PR x (AP )
Where = M (HR AP C(P) BSA MAP 3ap 4ap)
Validation ICOCCOAPCOCrit Care 200711R105
Validation ICOCCOAPCOCrit Care 200711R105
FloTrac amp PACCrit Care 201014R212
060356
11
FloTrac amp PACCrit Care 201014R212
FloTrac in sepsisIntensive Care 201137233
FloTrac in sepsisIntensive Care 201137233
FloTrac Vigileo G3
Advantages
Real time
Less invasive
Non-calibrated
Informative
CO CI
PPV
SvO2
SVR
Disadvantages
Algorithm-gtnot real
Accuracy
Can not assess RV
derived parameters
Require new version software
PiCCO system Need calibration
060356
12
PAC and PiCCO (AP)Crit Care 201014R212
PiCCO
Advantages
Continuos monitoring
More accurate
Informative
COCI
SVV
SVR
GEDV
EVLW
AP
Disadvantages
Require calibration q 8 hrs
Femoral site risky to
CRBSI
Early goal directed therapy
What is the CVP
CVP = Central Venous Pressure
Frank Starling amp venous return line
Stroke volume
CVP0
Frank-Starling curve
Stroke volume or EDV
JVP or CVP or PCWP
ΔSV or Δ EDV
a
b
Responders
Non-responders
060356
13
b
CVP tells us who responders
Stroke volume or EDV
CVP or PCWP
ΔSV or Δ EDV
a
Good
Bad
CVP vs Fluid responders
Crit Care Med 20073564-8
39 cases25 cases
Does Central Venous Pressure Predict
Fluid ResponsivenessA Systematic Review of the Literature
CHEST 2008 134172ndash178
Fluid resuscitation in septic shock a positive fluid balance and elevated central venous pressure are associated with increased mortalityBoyd JH Forbes J Nakada TA Walley KR Russell JA
OBJECTIVE
To determine whether central venous pressure and fluid balance after resuscitation for septic shock are associated
with mortality
PATIENTS
The Vasopressin in Septic Shock Trial (VASST) study enrolled 778 patients who had septic shock and who were
receiving a minimum of 5 μg of norepinephrine per minute
MEASUREMENTS AND MAIN RESULTS
Based on net fluid balance we determined whether ones fluid balance quartile was correlated with 28-day
mortality We also analyzed whether fluid balance was predictive of central venous pressure and furthermore
whether a guideline-recommended central venous pressure of 8-12 mm Hg yielded a mortality advantage At
enrollment which occurred on average 12 hrs after presentation the average fluid balance was +42 L By day 4 the
cumulative average fluid balance was +11 L After correcting for age and Acute Physiology and Chronic Health
Evaluation II score a more positive fluid balance at both at 12 hrs and day 4 correlated significantly with increased
mortality Central venous pressure was correlated with fluid balance at 12 hrs whereas on days 1-4 there was no
significant correlation At 12 hrs patients with central venous pressure lt8 mm Hg had the lowest mortality rate
followed by those with central venous pressure 8-12 mm Hg The highest mortality rate was observed in those with
central venous pressure gt12 mm Hg Contrary to the overall effect patients whose central venous pressure was lt8
mm Hg had improved survival with a more positive fluid balance
CONCLUSIONS
A more positive fluid balance both early in resuscitation and cumulatively over 4 days is associated with an increased
risk of mortality in septic shock Central venous pressure may be used to gauge fluid balance le 12 hrs into septic
shock but becomes an unreliable marker of fluid balance thereafter Optimal survival in the VASST study occurred
with a positive fluid balance of approximately 3 L at 12 hrs
Functional hemodynamic for predicting fluidresponsiveness
Spontaneous respiration
CVP variation gt 1 mmHg
PLR cCO gt 15 ( can be used in arrhythmia)
On mechanical ventilation
PPV gt 13
IVCd variation gt 12 ( can be used in arrhythmia)
IVC distensibility index gt 18 ( can be used in arrhythmia)
Red blood cell transfusion during septic shock in the ICUA Perner etal Acta Anaesthesiol Scand 2012 56 718ndash723
The CRIT Study Anemia and blood transfusion in the critically illmdashCurrent clinical practice in the United States
(Observational study 284 ICU 4892 patients)
Crit Care Med 2004 3239 ndash52
060356
22
Microvascular response to red blood cell
transfusion in patients with severe sepsisYasser Sakr MD PhDetal Crit Care Med 2007 351639ndash1644
Clinical practice guideline Red blood cell transfusion in
adult trauma and critical careLena M Napolitano MD Stanley Kurek DO Fred A Luchette MD Howard L Corwin MD
Philip S Barie MD Samuel A Tisherman MD Paul C Hebert MD MHSc Gary L Anderson DO
Michael R Bard MD William Bromberg MD William C Chiu MD Mark D Cipolle MD PhD
Keith D Clancy MD Lawrence Diebel MD William S Hoff MD K Michael Hughes DO
Imtiaz Munshi MD Donna Nayduch RN MSN ACNP Rovinder Sandhu MD Jay A Yelon MD
for the American College of Critical Care Medicine of the Society of Critical Care Medicine and the Eastern
Association for the Surgery of Trauma Practice Management Workgroup (Crit Care Med 2009)
we recommend that red blood cell transfusion occur
only when hemoglobin concentration decreases to
lt70 gdL to target a hemoglobin concentration of 70 ndash90 gdL in adults
The
EGDT
started at a dose of 25 microg per kilogram of body weight per
minute a dose that was increased by 25 microg per kilogram
per minute every 30 minutes until the central venous
oxygen saturation was 70 percent or higher or until a
maximal dose of 20 microg per kilogram per minute was given
Median max dose of dobutamine to reach CI gt 45 DO2 gt 600 VO2 gt 170
Control group 023 mcgkgmin (005-10)
Treatment group 12 mcgkgmin (002-166)
P = 0029
060356
23
CI ge 45 CI = 25-35
in the presence of (a)myocardial dysfunction as suggested by elevated
cardiac filling pressures and low cardiac output or
(b)ongoing signs of hypoperfusion
060356
6
Others parameter calculated from PAC parameters
SVR = ( MAP - CVP CO ) x 80
PVR = ( PAP - PAOP CO ) x 80
CO = VO2 ( CaO2 - CvO2 )
DO2 = CO x Ca O2 x 10
VO2 = ( Ca O2 - Cv O2 ) x CO x10
Ca O2 = ( 139 x Hb x SaO2 ) + ( 0003 x PaO2 ) - Arterial
O2 content
Cv O2 = ( 139 x Hb x SvO2 ) + ( 0003 x PvO2 ) - Venous
O2 content
O2 extraxtion = VO2 DO2
QsQt = ( PA-a O2 ) ( PA-a O2 ) ( Ca-v O2 )
Cardiac output measurement
Fickrsquos formular
CO = VO2
CaO2-CvO2
Poor feasibility
Indicator dilution method
Indocyanine green
More accurate and reproducible
Require blood sampling
Recirculation of dye can disturb measurement
Thermodilution
More efficient
Thermo dilution method
Inject 5-10 cc of cold water
Tem
pera
ture
change (
)
Time
Stewart ndashHamilton equation
CO = ( TB ndash TI )xK
0 TB(t) dt
Hemodynamic
parameters in 4 shocks
CVP PAP PCWP CO SVR
Hypovolemic Low Low Low Low High
Cardiogenic High High High Low High
Obstructive High Very high Normal Low High
Septic Not high Not high Not high High Low
Ultrasound CO by ultrasound
A mount of blood flow going through a fixed orifice =
CSA x Flow-Velocity
SV = CSA x LVOTTVI
CSA = LVOTd2 x 078540
SV = LVOTd2 x 078540 x LVOTTVI
060356
7
LVOT diameter
LVOT VTI
good correlation between the thermodilutiontechnique and
Simpsons two-chamber method (r = 091)
Simpsons four-chamber method (r = 077)
the LVOT Doppler method (r = 094)
the LVOT Doppler method demonstrated acceptable agreement with a mean of 02
litresminute standard deviation of 082 litresminute and 95 limits of agreement of -15 to +19 litresminute
CCO-thermodilution methods Model for CCOtd
Agreement between CCO and BCO
in cardio-thoracic surgeryIntensive Care Med 199925166
Compare CCO and BCO in 20 medical ptsJ Crit Care 199813184
Conditions Number
MV 15
Vasopressor 15
Malignancy 12
Aplastic anemia
5
SLE 1
Cushing 1
CGD 1
060356
8
Good correlation between
CCO and BCO in sepsisIntensive Care Med 2002281276
Good correlation between CCO and BCO in sepsisIntensive Care Med 2002281276
Poor correlation of
CCO during hypothermia
Conclusions
Despite an excellent correlation accuracy and
precision between CCO and ICO before CPB and more than 45 minutes after hypothermic CPB a lack
of correlation in the early phase after CPB has been
found Further investigation is needed to elucidate the underlying cause of these findings and to clarify
whether ICO or CCO or both fail to represent the
real cardiac output up to 45 minutes after weaning from hypothermic CPB
19959405
Response time after sudden reduction of COAnesthesiology 199889(6)1592
Response time after sudden reduction of COCrit Care Med 1995 23 860 Advantages over IBCO
Provide continuous trend
Reduce contamination
Less time consuming
Unnecessary fluid
060356
9
Limitations
Immediate CO measurement may not be done due to average time for reduce thermal noise
Transpulmoanry thermodilution method (TPTD)
Compare TPTD and IBTDAnesthesia amp Analgesia 2010
The respiratory variation affect IBTD rather than TPTD
IBTD
TPTD
Advantages over IBTD
Less invasive
Decrease complications result from PA catheter
GEDV and EVLW can be measuredAm J Physiol Lung Cell Mol Physiol 291 L1118ndashL1131 2006
060356
10
Limitations
Canrsquot assess PA pressure and its trend
Canrsquot assess SvO2
Pulse contour analysis
Non-calibrated
Calibrated
Basic Principles
Traditional CO = HR SV
FloTrac system CO = PR x (AP )
Where = M (HR AP C(P) BSA MAP 3ap 4ap)
Validation ICOCCOAPCOCrit Care 200711R105
Validation ICOCCOAPCOCrit Care 200711R105
FloTrac amp PACCrit Care 201014R212
060356
11
FloTrac amp PACCrit Care 201014R212
FloTrac in sepsisIntensive Care 201137233
FloTrac in sepsisIntensive Care 201137233
FloTrac Vigileo G3
Advantages
Real time
Less invasive
Non-calibrated
Informative
CO CI
PPV
SvO2
SVR
Disadvantages
Algorithm-gtnot real
Accuracy
Can not assess RV
derived parameters
Require new version software
PiCCO system Need calibration
060356
12
PAC and PiCCO (AP)Crit Care 201014R212
PiCCO
Advantages
Continuos monitoring
More accurate
Informative
COCI
SVV
SVR
GEDV
EVLW
AP
Disadvantages
Require calibration q 8 hrs
Femoral site risky to
CRBSI
Early goal directed therapy
What is the CVP
CVP = Central Venous Pressure
Frank Starling amp venous return line
Stroke volume
CVP0
Frank-Starling curve
Stroke volume or EDV
JVP or CVP or PCWP
ΔSV or Δ EDV
a
b
Responders
Non-responders
060356
13
b
CVP tells us who responders
Stroke volume or EDV
CVP or PCWP
ΔSV or Δ EDV
a
Good
Bad
CVP vs Fluid responders
Crit Care Med 20073564-8
39 cases25 cases
Does Central Venous Pressure Predict
Fluid ResponsivenessA Systematic Review of the Literature
CHEST 2008 134172ndash178
Fluid resuscitation in septic shock a positive fluid balance and elevated central venous pressure are associated with increased mortalityBoyd JH Forbes J Nakada TA Walley KR Russell JA
OBJECTIVE
To determine whether central venous pressure and fluid balance after resuscitation for septic shock are associated
with mortality
PATIENTS
The Vasopressin in Septic Shock Trial (VASST) study enrolled 778 patients who had septic shock and who were
receiving a minimum of 5 μg of norepinephrine per minute
MEASUREMENTS AND MAIN RESULTS
Based on net fluid balance we determined whether ones fluid balance quartile was correlated with 28-day
mortality We also analyzed whether fluid balance was predictive of central venous pressure and furthermore
whether a guideline-recommended central venous pressure of 8-12 mm Hg yielded a mortality advantage At
enrollment which occurred on average 12 hrs after presentation the average fluid balance was +42 L By day 4 the
cumulative average fluid balance was +11 L After correcting for age and Acute Physiology and Chronic Health
Evaluation II score a more positive fluid balance at both at 12 hrs and day 4 correlated significantly with increased
mortality Central venous pressure was correlated with fluid balance at 12 hrs whereas on days 1-4 there was no
significant correlation At 12 hrs patients with central venous pressure lt8 mm Hg had the lowest mortality rate
followed by those with central venous pressure 8-12 mm Hg The highest mortality rate was observed in those with
central venous pressure gt12 mm Hg Contrary to the overall effect patients whose central venous pressure was lt8
mm Hg had improved survival with a more positive fluid balance
CONCLUSIONS
A more positive fluid balance both early in resuscitation and cumulatively over 4 days is associated with an increased
risk of mortality in septic shock Central venous pressure may be used to gauge fluid balance le 12 hrs into septic
shock but becomes an unreliable marker of fluid balance thereafter Optimal survival in the VASST study occurred
with a positive fluid balance of approximately 3 L at 12 hrs
Functional hemodynamic for predicting fluidresponsiveness
Spontaneous respiration
CVP variation gt 1 mmHg
PLR cCO gt 15 ( can be used in arrhythmia)
On mechanical ventilation
PPV gt 13
IVCd variation gt 12 ( can be used in arrhythmia)
IVC distensibility index gt 18 ( can be used in arrhythmia)
Red blood cell transfusion during septic shock in the ICUA Perner etal Acta Anaesthesiol Scand 2012 56 718ndash723
The CRIT Study Anemia and blood transfusion in the critically illmdashCurrent clinical practice in the United States
(Observational study 284 ICU 4892 patients)
Crit Care Med 2004 3239 ndash52
060356
22
Microvascular response to red blood cell
transfusion in patients with severe sepsisYasser Sakr MD PhDetal Crit Care Med 2007 351639ndash1644
Clinical practice guideline Red blood cell transfusion in
adult trauma and critical careLena M Napolitano MD Stanley Kurek DO Fred A Luchette MD Howard L Corwin MD
Philip S Barie MD Samuel A Tisherman MD Paul C Hebert MD MHSc Gary L Anderson DO
Michael R Bard MD William Bromberg MD William C Chiu MD Mark D Cipolle MD PhD
Keith D Clancy MD Lawrence Diebel MD William S Hoff MD K Michael Hughes DO
Imtiaz Munshi MD Donna Nayduch RN MSN ACNP Rovinder Sandhu MD Jay A Yelon MD
for the American College of Critical Care Medicine of the Society of Critical Care Medicine and the Eastern
Association for the Surgery of Trauma Practice Management Workgroup (Crit Care Med 2009)
we recommend that red blood cell transfusion occur
only when hemoglobin concentration decreases to
lt70 gdL to target a hemoglobin concentration of 70 ndash90 gdL in adults
The
EGDT
started at a dose of 25 microg per kilogram of body weight per
minute a dose that was increased by 25 microg per kilogram
per minute every 30 minutes until the central venous
oxygen saturation was 70 percent or higher or until a
maximal dose of 20 microg per kilogram per minute was given
Median max dose of dobutamine to reach CI gt 45 DO2 gt 600 VO2 gt 170
Control group 023 mcgkgmin (005-10)
Treatment group 12 mcgkgmin (002-166)
P = 0029
060356
23
CI ge 45 CI = 25-35
in the presence of (a)myocardial dysfunction as suggested by elevated
cardiac filling pressures and low cardiac output or
(b)ongoing signs of hypoperfusion
060356
7
LVOT diameter
LVOT VTI
good correlation between the thermodilutiontechnique and
Simpsons two-chamber method (r = 091)
Simpsons four-chamber method (r = 077)
the LVOT Doppler method (r = 094)
the LVOT Doppler method demonstrated acceptable agreement with a mean of 02
litresminute standard deviation of 082 litresminute and 95 limits of agreement of -15 to +19 litresminute
CCO-thermodilution methods Model for CCOtd
Agreement between CCO and BCO
in cardio-thoracic surgeryIntensive Care Med 199925166
Compare CCO and BCO in 20 medical ptsJ Crit Care 199813184
Conditions Number
MV 15
Vasopressor 15
Malignancy 12
Aplastic anemia
5
SLE 1
Cushing 1
CGD 1
060356
8
Good correlation between
CCO and BCO in sepsisIntensive Care Med 2002281276
Good correlation between CCO and BCO in sepsisIntensive Care Med 2002281276
Poor correlation of
CCO during hypothermia
Conclusions
Despite an excellent correlation accuracy and
precision between CCO and ICO before CPB and more than 45 minutes after hypothermic CPB a lack
of correlation in the early phase after CPB has been
found Further investigation is needed to elucidate the underlying cause of these findings and to clarify
whether ICO or CCO or both fail to represent the
real cardiac output up to 45 minutes after weaning from hypothermic CPB
19959405
Response time after sudden reduction of COAnesthesiology 199889(6)1592
Response time after sudden reduction of COCrit Care Med 1995 23 860 Advantages over IBCO
Provide continuous trend
Reduce contamination
Less time consuming
Unnecessary fluid
060356
9
Limitations
Immediate CO measurement may not be done due to average time for reduce thermal noise
Transpulmoanry thermodilution method (TPTD)
Compare TPTD and IBTDAnesthesia amp Analgesia 2010
The respiratory variation affect IBTD rather than TPTD
IBTD
TPTD
Advantages over IBTD
Less invasive
Decrease complications result from PA catheter
GEDV and EVLW can be measuredAm J Physiol Lung Cell Mol Physiol 291 L1118ndashL1131 2006
060356
10
Limitations
Canrsquot assess PA pressure and its trend
Canrsquot assess SvO2
Pulse contour analysis
Non-calibrated
Calibrated
Basic Principles
Traditional CO = HR SV
FloTrac system CO = PR x (AP )
Where = M (HR AP C(P) BSA MAP 3ap 4ap)
Validation ICOCCOAPCOCrit Care 200711R105
Validation ICOCCOAPCOCrit Care 200711R105
FloTrac amp PACCrit Care 201014R212
060356
11
FloTrac amp PACCrit Care 201014R212
FloTrac in sepsisIntensive Care 201137233
FloTrac in sepsisIntensive Care 201137233
FloTrac Vigileo G3
Advantages
Real time
Less invasive
Non-calibrated
Informative
CO CI
PPV
SvO2
SVR
Disadvantages
Algorithm-gtnot real
Accuracy
Can not assess RV
derived parameters
Require new version software
PiCCO system Need calibration
060356
12
PAC and PiCCO (AP)Crit Care 201014R212
PiCCO
Advantages
Continuos monitoring
More accurate
Informative
COCI
SVV
SVR
GEDV
EVLW
AP
Disadvantages
Require calibration q 8 hrs
Femoral site risky to
CRBSI
Early goal directed therapy
What is the CVP
CVP = Central Venous Pressure
Frank Starling amp venous return line
Stroke volume
CVP0
Frank-Starling curve
Stroke volume or EDV
JVP or CVP or PCWP
ΔSV or Δ EDV
a
b
Responders
Non-responders
060356
13
b
CVP tells us who responders
Stroke volume or EDV
CVP or PCWP
ΔSV or Δ EDV
a
Good
Bad
CVP vs Fluid responders
Crit Care Med 20073564-8
39 cases25 cases
Does Central Venous Pressure Predict
Fluid ResponsivenessA Systematic Review of the Literature
CHEST 2008 134172ndash178
Fluid resuscitation in septic shock a positive fluid balance and elevated central venous pressure are associated with increased mortalityBoyd JH Forbes J Nakada TA Walley KR Russell JA
OBJECTIVE
To determine whether central venous pressure and fluid balance after resuscitation for septic shock are associated
with mortality
PATIENTS
The Vasopressin in Septic Shock Trial (VASST) study enrolled 778 patients who had septic shock and who were
receiving a minimum of 5 μg of norepinephrine per minute
MEASUREMENTS AND MAIN RESULTS
Based on net fluid balance we determined whether ones fluid balance quartile was correlated with 28-day
mortality We also analyzed whether fluid balance was predictive of central venous pressure and furthermore
whether a guideline-recommended central venous pressure of 8-12 mm Hg yielded a mortality advantage At
enrollment which occurred on average 12 hrs after presentation the average fluid balance was +42 L By day 4 the
cumulative average fluid balance was +11 L After correcting for age and Acute Physiology and Chronic Health
Evaluation II score a more positive fluid balance at both at 12 hrs and day 4 correlated significantly with increased
mortality Central venous pressure was correlated with fluid balance at 12 hrs whereas on days 1-4 there was no
significant correlation At 12 hrs patients with central venous pressure lt8 mm Hg had the lowest mortality rate
followed by those with central venous pressure 8-12 mm Hg The highest mortality rate was observed in those with
central venous pressure gt12 mm Hg Contrary to the overall effect patients whose central venous pressure was lt8
mm Hg had improved survival with a more positive fluid balance
CONCLUSIONS
A more positive fluid balance both early in resuscitation and cumulatively over 4 days is associated with an increased
risk of mortality in septic shock Central venous pressure may be used to gauge fluid balance le 12 hrs into septic
shock but becomes an unreliable marker of fluid balance thereafter Optimal survival in the VASST study occurred
with a positive fluid balance of approximately 3 L at 12 hrs
Functional hemodynamic for predicting fluidresponsiveness
Spontaneous respiration
CVP variation gt 1 mmHg
PLR cCO gt 15 ( can be used in arrhythmia)
On mechanical ventilation
PPV gt 13
IVCd variation gt 12 ( can be used in arrhythmia)
IVC distensibility index gt 18 ( can be used in arrhythmia)
Red blood cell transfusion during septic shock in the ICUA Perner etal Acta Anaesthesiol Scand 2012 56 718ndash723
The CRIT Study Anemia and blood transfusion in the critically illmdashCurrent clinical practice in the United States
(Observational study 284 ICU 4892 patients)
Crit Care Med 2004 3239 ndash52
060356
22
Microvascular response to red blood cell
transfusion in patients with severe sepsisYasser Sakr MD PhDetal Crit Care Med 2007 351639ndash1644
Clinical practice guideline Red blood cell transfusion in
adult trauma and critical careLena M Napolitano MD Stanley Kurek DO Fred A Luchette MD Howard L Corwin MD
Philip S Barie MD Samuel A Tisherman MD Paul C Hebert MD MHSc Gary L Anderson DO
Michael R Bard MD William Bromberg MD William C Chiu MD Mark D Cipolle MD PhD
Keith D Clancy MD Lawrence Diebel MD William S Hoff MD K Michael Hughes DO
Imtiaz Munshi MD Donna Nayduch RN MSN ACNP Rovinder Sandhu MD Jay A Yelon MD
for the American College of Critical Care Medicine of the Society of Critical Care Medicine and the Eastern
Association for the Surgery of Trauma Practice Management Workgroup (Crit Care Med 2009)
we recommend that red blood cell transfusion occur
only when hemoglobin concentration decreases to
lt70 gdL to target a hemoglobin concentration of 70 ndash90 gdL in adults
The
EGDT
started at a dose of 25 microg per kilogram of body weight per
minute a dose that was increased by 25 microg per kilogram
per minute every 30 minutes until the central venous
oxygen saturation was 70 percent or higher or until a
maximal dose of 20 microg per kilogram per minute was given
Median max dose of dobutamine to reach CI gt 45 DO2 gt 600 VO2 gt 170
Control group 023 mcgkgmin (005-10)
Treatment group 12 mcgkgmin (002-166)
P = 0029
060356
23
CI ge 45 CI = 25-35
in the presence of (a)myocardial dysfunction as suggested by elevated
cardiac filling pressures and low cardiac output or
(b)ongoing signs of hypoperfusion
060356
8
Good correlation between
CCO and BCO in sepsisIntensive Care Med 2002281276
Good correlation between CCO and BCO in sepsisIntensive Care Med 2002281276
Poor correlation of
CCO during hypothermia
Conclusions
Despite an excellent correlation accuracy and
precision between CCO and ICO before CPB and more than 45 minutes after hypothermic CPB a lack
of correlation in the early phase after CPB has been
found Further investigation is needed to elucidate the underlying cause of these findings and to clarify
whether ICO or CCO or both fail to represent the
real cardiac output up to 45 minutes after weaning from hypothermic CPB
19959405
Response time after sudden reduction of COAnesthesiology 199889(6)1592
Response time after sudden reduction of COCrit Care Med 1995 23 860 Advantages over IBCO
Provide continuous trend
Reduce contamination
Less time consuming
Unnecessary fluid
060356
9
Limitations
Immediate CO measurement may not be done due to average time for reduce thermal noise
Transpulmoanry thermodilution method (TPTD)
Compare TPTD and IBTDAnesthesia amp Analgesia 2010
The respiratory variation affect IBTD rather than TPTD
IBTD
TPTD
Advantages over IBTD
Less invasive
Decrease complications result from PA catheter
GEDV and EVLW can be measuredAm J Physiol Lung Cell Mol Physiol 291 L1118ndashL1131 2006
060356
10
Limitations
Canrsquot assess PA pressure and its trend
Canrsquot assess SvO2
Pulse contour analysis
Non-calibrated
Calibrated
Basic Principles
Traditional CO = HR SV
FloTrac system CO = PR x (AP )
Where = M (HR AP C(P) BSA MAP 3ap 4ap)
Validation ICOCCOAPCOCrit Care 200711R105
Validation ICOCCOAPCOCrit Care 200711R105
FloTrac amp PACCrit Care 201014R212
060356
11
FloTrac amp PACCrit Care 201014R212
FloTrac in sepsisIntensive Care 201137233
FloTrac in sepsisIntensive Care 201137233
FloTrac Vigileo G3
Advantages
Real time
Less invasive
Non-calibrated
Informative
CO CI
PPV
SvO2
SVR
Disadvantages
Algorithm-gtnot real
Accuracy
Can not assess RV
derived parameters
Require new version software
PiCCO system Need calibration
060356
12
PAC and PiCCO (AP)Crit Care 201014R212
PiCCO
Advantages
Continuos monitoring
More accurate
Informative
COCI
SVV
SVR
GEDV
EVLW
AP
Disadvantages
Require calibration q 8 hrs
Femoral site risky to
CRBSI
Early goal directed therapy
What is the CVP
CVP = Central Venous Pressure
Frank Starling amp venous return line
Stroke volume
CVP0
Frank-Starling curve
Stroke volume or EDV
JVP or CVP or PCWP
ΔSV or Δ EDV
a
b
Responders
Non-responders
060356
13
b
CVP tells us who responders
Stroke volume or EDV
CVP or PCWP
ΔSV or Δ EDV
a
Good
Bad
CVP vs Fluid responders
Crit Care Med 20073564-8
39 cases25 cases
Does Central Venous Pressure Predict
Fluid ResponsivenessA Systematic Review of the Literature
CHEST 2008 134172ndash178
Fluid resuscitation in septic shock a positive fluid balance and elevated central venous pressure are associated with increased mortalityBoyd JH Forbes J Nakada TA Walley KR Russell JA
OBJECTIVE
To determine whether central venous pressure and fluid balance after resuscitation for septic shock are associated
with mortality
PATIENTS
The Vasopressin in Septic Shock Trial (VASST) study enrolled 778 patients who had septic shock and who were
receiving a minimum of 5 μg of norepinephrine per minute
MEASUREMENTS AND MAIN RESULTS
Based on net fluid balance we determined whether ones fluid balance quartile was correlated with 28-day
mortality We also analyzed whether fluid balance was predictive of central venous pressure and furthermore
whether a guideline-recommended central venous pressure of 8-12 mm Hg yielded a mortality advantage At
enrollment which occurred on average 12 hrs after presentation the average fluid balance was +42 L By day 4 the
cumulative average fluid balance was +11 L After correcting for age and Acute Physiology and Chronic Health
Evaluation II score a more positive fluid balance at both at 12 hrs and day 4 correlated significantly with increased
mortality Central venous pressure was correlated with fluid balance at 12 hrs whereas on days 1-4 there was no
significant correlation At 12 hrs patients with central venous pressure lt8 mm Hg had the lowest mortality rate
followed by those with central venous pressure 8-12 mm Hg The highest mortality rate was observed in those with
central venous pressure gt12 mm Hg Contrary to the overall effect patients whose central venous pressure was lt8
mm Hg had improved survival with a more positive fluid balance
CONCLUSIONS
A more positive fluid balance both early in resuscitation and cumulatively over 4 days is associated with an increased
risk of mortality in septic shock Central venous pressure may be used to gauge fluid balance le 12 hrs into septic
shock but becomes an unreliable marker of fluid balance thereafter Optimal survival in the VASST study occurred
with a positive fluid balance of approximately 3 L at 12 hrs
Functional hemodynamic for predicting fluidresponsiveness
Spontaneous respiration
CVP variation gt 1 mmHg
PLR cCO gt 15 ( can be used in arrhythmia)
On mechanical ventilation
PPV gt 13
IVCd variation gt 12 ( can be used in arrhythmia)
IVC distensibility index gt 18 ( can be used in arrhythmia)
Red blood cell transfusion during septic shock in the ICUA Perner etal Acta Anaesthesiol Scand 2012 56 718ndash723
The CRIT Study Anemia and blood transfusion in the critically illmdashCurrent clinical practice in the United States
(Observational study 284 ICU 4892 patients)
Crit Care Med 2004 3239 ndash52
060356
22
Microvascular response to red blood cell
transfusion in patients with severe sepsisYasser Sakr MD PhDetal Crit Care Med 2007 351639ndash1644
Clinical practice guideline Red blood cell transfusion in
adult trauma and critical careLena M Napolitano MD Stanley Kurek DO Fred A Luchette MD Howard L Corwin MD
Philip S Barie MD Samuel A Tisherman MD Paul C Hebert MD MHSc Gary L Anderson DO
Michael R Bard MD William Bromberg MD William C Chiu MD Mark D Cipolle MD PhD
Keith D Clancy MD Lawrence Diebel MD William S Hoff MD K Michael Hughes DO
Imtiaz Munshi MD Donna Nayduch RN MSN ACNP Rovinder Sandhu MD Jay A Yelon MD
for the American College of Critical Care Medicine of the Society of Critical Care Medicine and the Eastern
Association for the Surgery of Trauma Practice Management Workgroup (Crit Care Med 2009)
we recommend that red blood cell transfusion occur
only when hemoglobin concentration decreases to
lt70 gdL to target a hemoglobin concentration of 70 ndash90 gdL in adults
The
EGDT
started at a dose of 25 microg per kilogram of body weight per
minute a dose that was increased by 25 microg per kilogram
per minute every 30 minutes until the central venous
oxygen saturation was 70 percent or higher or until a
maximal dose of 20 microg per kilogram per minute was given
Median max dose of dobutamine to reach CI gt 45 DO2 gt 600 VO2 gt 170
Control group 023 mcgkgmin (005-10)
Treatment group 12 mcgkgmin (002-166)
P = 0029
060356
23
CI ge 45 CI = 25-35
in the presence of (a)myocardial dysfunction as suggested by elevated
cardiac filling pressures and low cardiac output or
(b)ongoing signs of hypoperfusion
060356
9
Limitations
Immediate CO measurement may not be done due to average time for reduce thermal noise
Transpulmoanry thermodilution method (TPTD)
Compare TPTD and IBTDAnesthesia amp Analgesia 2010
The respiratory variation affect IBTD rather than TPTD
IBTD
TPTD
Advantages over IBTD
Less invasive
Decrease complications result from PA catheter
GEDV and EVLW can be measuredAm J Physiol Lung Cell Mol Physiol 291 L1118ndashL1131 2006
060356
10
Limitations
Canrsquot assess PA pressure and its trend
Canrsquot assess SvO2
Pulse contour analysis
Non-calibrated
Calibrated
Basic Principles
Traditional CO = HR SV
FloTrac system CO = PR x (AP )
Where = M (HR AP C(P) BSA MAP 3ap 4ap)
Validation ICOCCOAPCOCrit Care 200711R105
Validation ICOCCOAPCOCrit Care 200711R105
FloTrac amp PACCrit Care 201014R212
060356
11
FloTrac amp PACCrit Care 201014R212
FloTrac in sepsisIntensive Care 201137233
FloTrac in sepsisIntensive Care 201137233
FloTrac Vigileo G3
Advantages
Real time
Less invasive
Non-calibrated
Informative
CO CI
PPV
SvO2
SVR
Disadvantages
Algorithm-gtnot real
Accuracy
Can not assess RV
derived parameters
Require new version software
PiCCO system Need calibration
060356
12
PAC and PiCCO (AP)Crit Care 201014R212
PiCCO
Advantages
Continuos monitoring
More accurate
Informative
COCI
SVV
SVR
GEDV
EVLW
AP
Disadvantages
Require calibration q 8 hrs
Femoral site risky to
CRBSI
Early goal directed therapy
What is the CVP
CVP = Central Venous Pressure
Frank Starling amp venous return line
Stroke volume
CVP0
Frank-Starling curve
Stroke volume or EDV
JVP or CVP or PCWP
ΔSV or Δ EDV
a
b
Responders
Non-responders
060356
13
b
CVP tells us who responders
Stroke volume or EDV
CVP or PCWP
ΔSV or Δ EDV
a
Good
Bad
CVP vs Fluid responders
Crit Care Med 20073564-8
39 cases25 cases
Does Central Venous Pressure Predict
Fluid ResponsivenessA Systematic Review of the Literature
CHEST 2008 134172ndash178
Fluid resuscitation in septic shock a positive fluid balance and elevated central venous pressure are associated with increased mortalityBoyd JH Forbes J Nakada TA Walley KR Russell JA
OBJECTIVE
To determine whether central venous pressure and fluid balance after resuscitation for septic shock are associated
with mortality
PATIENTS
The Vasopressin in Septic Shock Trial (VASST) study enrolled 778 patients who had septic shock and who were
receiving a minimum of 5 μg of norepinephrine per minute
MEASUREMENTS AND MAIN RESULTS
Based on net fluid balance we determined whether ones fluid balance quartile was correlated with 28-day
mortality We also analyzed whether fluid balance was predictive of central venous pressure and furthermore
whether a guideline-recommended central venous pressure of 8-12 mm Hg yielded a mortality advantage At
enrollment which occurred on average 12 hrs after presentation the average fluid balance was +42 L By day 4 the
cumulative average fluid balance was +11 L After correcting for age and Acute Physiology and Chronic Health
Evaluation II score a more positive fluid balance at both at 12 hrs and day 4 correlated significantly with increased
mortality Central venous pressure was correlated with fluid balance at 12 hrs whereas on days 1-4 there was no
significant correlation At 12 hrs patients with central venous pressure lt8 mm Hg had the lowest mortality rate
followed by those with central venous pressure 8-12 mm Hg The highest mortality rate was observed in those with
central venous pressure gt12 mm Hg Contrary to the overall effect patients whose central venous pressure was lt8
mm Hg had improved survival with a more positive fluid balance
CONCLUSIONS
A more positive fluid balance both early in resuscitation and cumulatively over 4 days is associated with an increased
risk of mortality in septic shock Central venous pressure may be used to gauge fluid balance le 12 hrs into septic
shock but becomes an unreliable marker of fluid balance thereafter Optimal survival in the VASST study occurred
with a positive fluid balance of approximately 3 L at 12 hrs
Functional hemodynamic for predicting fluidresponsiveness
Spontaneous respiration
CVP variation gt 1 mmHg
PLR cCO gt 15 ( can be used in arrhythmia)
On mechanical ventilation
PPV gt 13
IVCd variation gt 12 ( can be used in arrhythmia)
IVC distensibility index gt 18 ( can be used in arrhythmia)
Red blood cell transfusion during septic shock in the ICUA Perner etal Acta Anaesthesiol Scand 2012 56 718ndash723
The CRIT Study Anemia and blood transfusion in the critically illmdashCurrent clinical practice in the United States
(Observational study 284 ICU 4892 patients)
Crit Care Med 2004 3239 ndash52
060356
22
Microvascular response to red blood cell
transfusion in patients with severe sepsisYasser Sakr MD PhDetal Crit Care Med 2007 351639ndash1644
Clinical practice guideline Red blood cell transfusion in
adult trauma and critical careLena M Napolitano MD Stanley Kurek DO Fred A Luchette MD Howard L Corwin MD
Philip S Barie MD Samuel A Tisherman MD Paul C Hebert MD MHSc Gary L Anderson DO
Michael R Bard MD William Bromberg MD William C Chiu MD Mark D Cipolle MD PhD
Keith D Clancy MD Lawrence Diebel MD William S Hoff MD K Michael Hughes DO
Imtiaz Munshi MD Donna Nayduch RN MSN ACNP Rovinder Sandhu MD Jay A Yelon MD
for the American College of Critical Care Medicine of the Society of Critical Care Medicine and the Eastern
Association for the Surgery of Trauma Practice Management Workgroup (Crit Care Med 2009)
we recommend that red blood cell transfusion occur
only when hemoglobin concentration decreases to
lt70 gdL to target a hemoglobin concentration of 70 ndash90 gdL in adults
The
EGDT
started at a dose of 25 microg per kilogram of body weight per
minute a dose that was increased by 25 microg per kilogram
per minute every 30 minutes until the central venous
oxygen saturation was 70 percent or higher or until a
maximal dose of 20 microg per kilogram per minute was given
Median max dose of dobutamine to reach CI gt 45 DO2 gt 600 VO2 gt 170
Control group 023 mcgkgmin (005-10)
Treatment group 12 mcgkgmin (002-166)
P = 0029
060356
23
CI ge 45 CI = 25-35
in the presence of (a)myocardial dysfunction as suggested by elevated
cardiac filling pressures and low cardiac output or
(b)ongoing signs of hypoperfusion
060356
10
Limitations
Canrsquot assess PA pressure and its trend
Canrsquot assess SvO2
Pulse contour analysis
Non-calibrated
Calibrated
Basic Principles
Traditional CO = HR SV
FloTrac system CO = PR x (AP )
Where = M (HR AP C(P) BSA MAP 3ap 4ap)
Validation ICOCCOAPCOCrit Care 200711R105
Validation ICOCCOAPCOCrit Care 200711R105
FloTrac amp PACCrit Care 201014R212
060356
11
FloTrac amp PACCrit Care 201014R212
FloTrac in sepsisIntensive Care 201137233
FloTrac in sepsisIntensive Care 201137233
FloTrac Vigileo G3
Advantages
Real time
Less invasive
Non-calibrated
Informative
CO CI
PPV
SvO2
SVR
Disadvantages
Algorithm-gtnot real
Accuracy
Can not assess RV
derived parameters
Require new version software
PiCCO system Need calibration
060356
12
PAC and PiCCO (AP)Crit Care 201014R212
PiCCO
Advantages
Continuos monitoring
More accurate
Informative
COCI
SVV
SVR
GEDV
EVLW
AP
Disadvantages
Require calibration q 8 hrs
Femoral site risky to
CRBSI
Early goal directed therapy
What is the CVP
CVP = Central Venous Pressure
Frank Starling amp venous return line
Stroke volume
CVP0
Frank-Starling curve
Stroke volume or EDV
JVP or CVP or PCWP
ΔSV or Δ EDV
a
b
Responders
Non-responders
060356
13
b
CVP tells us who responders
Stroke volume or EDV
CVP or PCWP
ΔSV or Δ EDV
a
Good
Bad
CVP vs Fluid responders
Crit Care Med 20073564-8
39 cases25 cases
Does Central Venous Pressure Predict
Fluid ResponsivenessA Systematic Review of the Literature
CHEST 2008 134172ndash178
Fluid resuscitation in septic shock a positive fluid balance and elevated central venous pressure are associated with increased mortalityBoyd JH Forbes J Nakada TA Walley KR Russell JA
OBJECTIVE
To determine whether central venous pressure and fluid balance after resuscitation for septic shock are associated
with mortality
PATIENTS
The Vasopressin in Septic Shock Trial (VASST) study enrolled 778 patients who had septic shock and who were
receiving a minimum of 5 μg of norepinephrine per minute
MEASUREMENTS AND MAIN RESULTS
Based on net fluid balance we determined whether ones fluid balance quartile was correlated with 28-day
mortality We also analyzed whether fluid balance was predictive of central venous pressure and furthermore
whether a guideline-recommended central venous pressure of 8-12 mm Hg yielded a mortality advantage At
enrollment which occurred on average 12 hrs after presentation the average fluid balance was +42 L By day 4 the
cumulative average fluid balance was +11 L After correcting for age and Acute Physiology and Chronic Health
Evaluation II score a more positive fluid balance at both at 12 hrs and day 4 correlated significantly with increased
mortality Central venous pressure was correlated with fluid balance at 12 hrs whereas on days 1-4 there was no
significant correlation At 12 hrs patients with central venous pressure lt8 mm Hg had the lowest mortality rate
followed by those with central venous pressure 8-12 mm Hg The highest mortality rate was observed in those with
central venous pressure gt12 mm Hg Contrary to the overall effect patients whose central venous pressure was lt8
mm Hg had improved survival with a more positive fluid balance
CONCLUSIONS
A more positive fluid balance both early in resuscitation and cumulatively over 4 days is associated with an increased
risk of mortality in septic shock Central venous pressure may be used to gauge fluid balance le 12 hrs into septic
shock but becomes an unreliable marker of fluid balance thereafter Optimal survival in the VASST study occurred
with a positive fluid balance of approximately 3 L at 12 hrs
Functional hemodynamic for predicting fluidresponsiveness
Spontaneous respiration
CVP variation gt 1 mmHg
PLR cCO gt 15 ( can be used in arrhythmia)
On mechanical ventilation
PPV gt 13
IVCd variation gt 12 ( can be used in arrhythmia)
IVC distensibility index gt 18 ( can be used in arrhythmia)
Red blood cell transfusion during septic shock in the ICUA Perner etal Acta Anaesthesiol Scand 2012 56 718ndash723
The CRIT Study Anemia and blood transfusion in the critically illmdashCurrent clinical practice in the United States
(Observational study 284 ICU 4892 patients)
Crit Care Med 2004 3239 ndash52
060356
22
Microvascular response to red blood cell
transfusion in patients with severe sepsisYasser Sakr MD PhDetal Crit Care Med 2007 351639ndash1644
Clinical practice guideline Red blood cell transfusion in
adult trauma and critical careLena M Napolitano MD Stanley Kurek DO Fred A Luchette MD Howard L Corwin MD
Philip S Barie MD Samuel A Tisherman MD Paul C Hebert MD MHSc Gary L Anderson DO
Michael R Bard MD William Bromberg MD William C Chiu MD Mark D Cipolle MD PhD
Keith D Clancy MD Lawrence Diebel MD William S Hoff MD K Michael Hughes DO
Imtiaz Munshi MD Donna Nayduch RN MSN ACNP Rovinder Sandhu MD Jay A Yelon MD
for the American College of Critical Care Medicine of the Society of Critical Care Medicine and the Eastern
Association for the Surgery of Trauma Practice Management Workgroup (Crit Care Med 2009)
we recommend that red blood cell transfusion occur
only when hemoglobin concentration decreases to
lt70 gdL to target a hemoglobin concentration of 70 ndash90 gdL in adults
The
EGDT
started at a dose of 25 microg per kilogram of body weight per
minute a dose that was increased by 25 microg per kilogram
per minute every 30 minutes until the central venous
oxygen saturation was 70 percent or higher or until a
maximal dose of 20 microg per kilogram per minute was given
Median max dose of dobutamine to reach CI gt 45 DO2 gt 600 VO2 gt 170
Control group 023 mcgkgmin (005-10)
Treatment group 12 mcgkgmin (002-166)
P = 0029
060356
23
CI ge 45 CI = 25-35
in the presence of (a)myocardial dysfunction as suggested by elevated
cardiac filling pressures and low cardiac output or
(b)ongoing signs of hypoperfusion
060356
11
FloTrac amp PACCrit Care 201014R212
FloTrac in sepsisIntensive Care 201137233
FloTrac in sepsisIntensive Care 201137233
FloTrac Vigileo G3
Advantages
Real time
Less invasive
Non-calibrated
Informative
CO CI
PPV
SvO2
SVR
Disadvantages
Algorithm-gtnot real
Accuracy
Can not assess RV
derived parameters
Require new version software
PiCCO system Need calibration
060356
12
PAC and PiCCO (AP)Crit Care 201014R212
PiCCO
Advantages
Continuos monitoring
More accurate
Informative
COCI
SVV
SVR
GEDV
EVLW
AP
Disadvantages
Require calibration q 8 hrs
Femoral site risky to
CRBSI
Early goal directed therapy
What is the CVP
CVP = Central Venous Pressure
Frank Starling amp venous return line
Stroke volume
CVP0
Frank-Starling curve
Stroke volume or EDV
JVP or CVP or PCWP
ΔSV or Δ EDV
a
b
Responders
Non-responders
060356
13
b
CVP tells us who responders
Stroke volume or EDV
CVP or PCWP
ΔSV or Δ EDV
a
Good
Bad
CVP vs Fluid responders
Crit Care Med 20073564-8
39 cases25 cases
Does Central Venous Pressure Predict
Fluid ResponsivenessA Systematic Review of the Literature
CHEST 2008 134172ndash178
Fluid resuscitation in septic shock a positive fluid balance and elevated central venous pressure are associated with increased mortalityBoyd JH Forbes J Nakada TA Walley KR Russell JA
OBJECTIVE
To determine whether central venous pressure and fluid balance after resuscitation for septic shock are associated
with mortality
PATIENTS
The Vasopressin in Septic Shock Trial (VASST) study enrolled 778 patients who had septic shock and who were
receiving a minimum of 5 μg of norepinephrine per minute
MEASUREMENTS AND MAIN RESULTS
Based on net fluid balance we determined whether ones fluid balance quartile was correlated with 28-day
mortality We also analyzed whether fluid balance was predictive of central venous pressure and furthermore
whether a guideline-recommended central venous pressure of 8-12 mm Hg yielded a mortality advantage At
enrollment which occurred on average 12 hrs after presentation the average fluid balance was +42 L By day 4 the
cumulative average fluid balance was +11 L After correcting for age and Acute Physiology and Chronic Health
Evaluation II score a more positive fluid balance at both at 12 hrs and day 4 correlated significantly with increased
mortality Central venous pressure was correlated with fluid balance at 12 hrs whereas on days 1-4 there was no
significant correlation At 12 hrs patients with central venous pressure lt8 mm Hg had the lowest mortality rate
followed by those with central venous pressure 8-12 mm Hg The highest mortality rate was observed in those with
central venous pressure gt12 mm Hg Contrary to the overall effect patients whose central venous pressure was lt8
mm Hg had improved survival with a more positive fluid balance
CONCLUSIONS
A more positive fluid balance both early in resuscitation and cumulatively over 4 days is associated with an increased
risk of mortality in septic shock Central venous pressure may be used to gauge fluid balance le 12 hrs into septic
shock but becomes an unreliable marker of fluid balance thereafter Optimal survival in the VASST study occurred
with a positive fluid balance of approximately 3 L at 12 hrs
Functional hemodynamic for predicting fluidresponsiveness
Spontaneous respiration
CVP variation gt 1 mmHg
PLR cCO gt 15 ( can be used in arrhythmia)
On mechanical ventilation
PPV gt 13
IVCd variation gt 12 ( can be used in arrhythmia)
IVC distensibility index gt 18 ( can be used in arrhythmia)
Red blood cell transfusion during septic shock in the ICUA Perner etal Acta Anaesthesiol Scand 2012 56 718ndash723
The CRIT Study Anemia and blood transfusion in the critically illmdashCurrent clinical practice in the United States
(Observational study 284 ICU 4892 patients)
Crit Care Med 2004 3239 ndash52
060356
22
Microvascular response to red blood cell
transfusion in patients with severe sepsisYasser Sakr MD PhDetal Crit Care Med 2007 351639ndash1644
Clinical practice guideline Red blood cell transfusion in
adult trauma and critical careLena M Napolitano MD Stanley Kurek DO Fred A Luchette MD Howard L Corwin MD
Philip S Barie MD Samuel A Tisherman MD Paul C Hebert MD MHSc Gary L Anderson DO
Michael R Bard MD William Bromberg MD William C Chiu MD Mark D Cipolle MD PhD
Keith D Clancy MD Lawrence Diebel MD William S Hoff MD K Michael Hughes DO
Imtiaz Munshi MD Donna Nayduch RN MSN ACNP Rovinder Sandhu MD Jay A Yelon MD
for the American College of Critical Care Medicine of the Society of Critical Care Medicine and the Eastern
Association for the Surgery of Trauma Practice Management Workgroup (Crit Care Med 2009)
we recommend that red blood cell transfusion occur
only when hemoglobin concentration decreases to
lt70 gdL to target a hemoglobin concentration of 70 ndash90 gdL in adults
The
EGDT
started at a dose of 25 microg per kilogram of body weight per
minute a dose that was increased by 25 microg per kilogram
per minute every 30 minutes until the central venous
oxygen saturation was 70 percent or higher or until a
maximal dose of 20 microg per kilogram per minute was given
Median max dose of dobutamine to reach CI gt 45 DO2 gt 600 VO2 gt 170
Control group 023 mcgkgmin (005-10)
Treatment group 12 mcgkgmin (002-166)
P = 0029
060356
23
CI ge 45 CI = 25-35
in the presence of (a)myocardial dysfunction as suggested by elevated
cardiac filling pressures and low cardiac output or
(b)ongoing signs of hypoperfusion
060356
12
PAC and PiCCO (AP)Crit Care 201014R212
PiCCO
Advantages
Continuos monitoring
More accurate
Informative
COCI
SVV
SVR
GEDV
EVLW
AP
Disadvantages
Require calibration q 8 hrs
Femoral site risky to
CRBSI
Early goal directed therapy
What is the CVP
CVP = Central Venous Pressure
Frank Starling amp venous return line
Stroke volume
CVP0
Frank-Starling curve
Stroke volume or EDV
JVP or CVP or PCWP
ΔSV or Δ EDV
a
b
Responders
Non-responders
060356
13
b
CVP tells us who responders
Stroke volume or EDV
CVP or PCWP
ΔSV or Δ EDV
a
Good
Bad
CVP vs Fluid responders
Crit Care Med 20073564-8
39 cases25 cases
Does Central Venous Pressure Predict
Fluid ResponsivenessA Systematic Review of the Literature
CHEST 2008 134172ndash178
Fluid resuscitation in septic shock a positive fluid balance and elevated central venous pressure are associated with increased mortalityBoyd JH Forbes J Nakada TA Walley KR Russell JA
OBJECTIVE
To determine whether central venous pressure and fluid balance after resuscitation for septic shock are associated
with mortality
PATIENTS
The Vasopressin in Septic Shock Trial (VASST) study enrolled 778 patients who had septic shock and who were
receiving a minimum of 5 μg of norepinephrine per minute
MEASUREMENTS AND MAIN RESULTS
Based on net fluid balance we determined whether ones fluid balance quartile was correlated with 28-day
mortality We also analyzed whether fluid balance was predictive of central venous pressure and furthermore
whether a guideline-recommended central venous pressure of 8-12 mm Hg yielded a mortality advantage At
enrollment which occurred on average 12 hrs after presentation the average fluid balance was +42 L By day 4 the
cumulative average fluid balance was +11 L After correcting for age and Acute Physiology and Chronic Health
Evaluation II score a more positive fluid balance at both at 12 hrs and day 4 correlated significantly with increased
mortality Central venous pressure was correlated with fluid balance at 12 hrs whereas on days 1-4 there was no
significant correlation At 12 hrs patients with central venous pressure lt8 mm Hg had the lowest mortality rate
followed by those with central venous pressure 8-12 mm Hg The highest mortality rate was observed in those with
central venous pressure gt12 mm Hg Contrary to the overall effect patients whose central venous pressure was lt8
mm Hg had improved survival with a more positive fluid balance
CONCLUSIONS
A more positive fluid balance both early in resuscitation and cumulatively over 4 days is associated with an increased
risk of mortality in septic shock Central venous pressure may be used to gauge fluid balance le 12 hrs into septic
shock but becomes an unreliable marker of fluid balance thereafter Optimal survival in the VASST study occurred
with a positive fluid balance of approximately 3 L at 12 hrs
Functional hemodynamic for predicting fluidresponsiveness
Spontaneous respiration
CVP variation gt 1 mmHg
PLR cCO gt 15 ( can be used in arrhythmia)
On mechanical ventilation
PPV gt 13
IVCd variation gt 12 ( can be used in arrhythmia)
IVC distensibility index gt 18 ( can be used in arrhythmia)
Red blood cell transfusion during septic shock in the ICUA Perner etal Acta Anaesthesiol Scand 2012 56 718ndash723
The CRIT Study Anemia and blood transfusion in the critically illmdashCurrent clinical practice in the United States
(Observational study 284 ICU 4892 patients)
Crit Care Med 2004 3239 ndash52
060356
22
Microvascular response to red blood cell
transfusion in patients with severe sepsisYasser Sakr MD PhDetal Crit Care Med 2007 351639ndash1644
Clinical practice guideline Red blood cell transfusion in
adult trauma and critical careLena M Napolitano MD Stanley Kurek DO Fred A Luchette MD Howard L Corwin MD
Philip S Barie MD Samuel A Tisherman MD Paul C Hebert MD MHSc Gary L Anderson DO
Michael R Bard MD William Bromberg MD William C Chiu MD Mark D Cipolle MD PhD
Keith D Clancy MD Lawrence Diebel MD William S Hoff MD K Michael Hughes DO
Imtiaz Munshi MD Donna Nayduch RN MSN ACNP Rovinder Sandhu MD Jay A Yelon MD
for the American College of Critical Care Medicine of the Society of Critical Care Medicine and the Eastern
Association for the Surgery of Trauma Practice Management Workgroup (Crit Care Med 2009)
we recommend that red blood cell transfusion occur
only when hemoglobin concentration decreases to
lt70 gdL to target a hemoglobin concentration of 70 ndash90 gdL in adults
The
EGDT
started at a dose of 25 microg per kilogram of body weight per
minute a dose that was increased by 25 microg per kilogram
per minute every 30 minutes until the central venous
oxygen saturation was 70 percent or higher or until a
maximal dose of 20 microg per kilogram per minute was given
Median max dose of dobutamine to reach CI gt 45 DO2 gt 600 VO2 gt 170
Control group 023 mcgkgmin (005-10)
Treatment group 12 mcgkgmin (002-166)
P = 0029
060356
23
CI ge 45 CI = 25-35
in the presence of (a)myocardial dysfunction as suggested by elevated
cardiac filling pressures and low cardiac output or
(b)ongoing signs of hypoperfusion
060356
13
b
CVP tells us who responders
Stroke volume or EDV
CVP or PCWP
ΔSV or Δ EDV
a
Good
Bad
CVP vs Fluid responders
Crit Care Med 20073564-8
39 cases25 cases
Does Central Venous Pressure Predict
Fluid ResponsivenessA Systematic Review of the Literature
CHEST 2008 134172ndash178
Fluid resuscitation in septic shock a positive fluid balance and elevated central venous pressure are associated with increased mortalityBoyd JH Forbes J Nakada TA Walley KR Russell JA
OBJECTIVE
To determine whether central venous pressure and fluid balance after resuscitation for septic shock are associated
with mortality
PATIENTS
The Vasopressin in Septic Shock Trial (VASST) study enrolled 778 patients who had septic shock and who were
receiving a minimum of 5 μg of norepinephrine per minute
MEASUREMENTS AND MAIN RESULTS
Based on net fluid balance we determined whether ones fluid balance quartile was correlated with 28-day
mortality We also analyzed whether fluid balance was predictive of central venous pressure and furthermore
whether a guideline-recommended central venous pressure of 8-12 mm Hg yielded a mortality advantage At
enrollment which occurred on average 12 hrs after presentation the average fluid balance was +42 L By day 4 the
cumulative average fluid balance was +11 L After correcting for age and Acute Physiology and Chronic Health
Evaluation II score a more positive fluid balance at both at 12 hrs and day 4 correlated significantly with increased
mortality Central venous pressure was correlated with fluid balance at 12 hrs whereas on days 1-4 there was no
significant correlation At 12 hrs patients with central venous pressure lt8 mm Hg had the lowest mortality rate
followed by those with central venous pressure 8-12 mm Hg The highest mortality rate was observed in those with
central venous pressure gt12 mm Hg Contrary to the overall effect patients whose central venous pressure was lt8
mm Hg had improved survival with a more positive fluid balance
CONCLUSIONS
A more positive fluid balance both early in resuscitation and cumulatively over 4 days is associated with an increased
risk of mortality in septic shock Central venous pressure may be used to gauge fluid balance le 12 hrs into septic
shock but becomes an unreliable marker of fluid balance thereafter Optimal survival in the VASST study occurred
with a positive fluid balance of approximately 3 L at 12 hrs
Functional hemodynamic for predicting fluidresponsiveness
Spontaneous respiration
CVP variation gt 1 mmHg
PLR cCO gt 15 ( can be used in arrhythmia)
On mechanical ventilation
PPV gt 13
IVCd variation gt 12 ( can be used in arrhythmia)
IVC distensibility index gt 18 ( can be used in arrhythmia)