ICN Victoria presents Dr Vin Pellegrino talking on advances in circulatory care including latest updates on ECMO

1. Advancing Circulatory
Care (2012 - )
Vincent Pellegrino
Victorian Intensive Care Network
August
2012

2. Choice

3. Before I start......

4. 1992: First ICU
Rotation
• 1800-0800 (14 beds) RMO only cover
• Closed loop control of circulation
• Open loop control of feeding
• Open loop control of tonicity

6. 1992: First ICU
Rotation
J Crit Care (1994) 9: 124-133

7. 1992: First ICU
Rotation
J Crit Care (1994) 9: 124-133
10 Patients
APII 30
CRRT-HF
601 hour
417 (L) lost
409 (L) administered
3 survived (hosp discharge)

8. 1992: First ICU
Rotation
J Crit Care (1994) 9: 124-133
Reduced
haemodynamic
variability compared to
standard care

9. PAC - Clinical Trials
• Shoemaker 1988

10. PAC - Clinical Trials
• Intensive Care 1988-
2006
• ARDS
• General ICU
• High Risk Surgery
• 12 Prospective RCT

11. PAC - Clinical Trials
• Evaluated different targets
• CO / Oxygen Delivery (explicit) or Physician
determined
• +/- MAP, Urine output, skin changes
• Used different guidance (rules)
• CVP and PAOP (explicit) or Physician determined
• Applied different therapy
• Fluids (crystalloids/colloids or RBC)
• Drugs (inotropes or pressors)

12. PAC - Clinical Trials
• Intensive Care 1988-
2006
• ARDS
• General ICU
• High Risk Surgery
• 12 Prospective RCT

13. PAC - Clinical Trials
• Various approaches to haemodynamic
care in numerous patient populations
using either....
• explicit targeting of cardiac output /
oxygen delivery
• guiding care based on perceived
needs
does not improve outcome in a number of
high risk patient groups

14. Where does that
leave us ?

15. Drug Trials
Text
Annane D. Lancet 2007

16. Drug Trials
Myburgh J. ICM 2008

17. Drug Trials
Text
De Becker D. NEJM 2010

18. Fluids - Obsevational
• ARDS Clinical Trial Network, NEJM 2006
Outcome Conservative Strategy Liberal Strategy P Value
Death at 60 days (%) 25.5 28.4 0.30
Ventilator-free days
from day 1 to day 28 
14.6 ± 0.5 12.1 ± 0.5 <0.001
ICU-free days 
Days 1 to 7
Days 1 to 28
0.9 ± 0.1
13.4 ± 0.4
0.6 ± 0.1
11.2 ± 0.4
<0.001
<0.001
Organ-failure-free days 
Days 1 to 7
Cardiovascular failure
CNS failure
Renal failure
Hepatic failure
Coagulation abnormalities
Days 1 to 28
Cardiovascular failure
CNS failure
Renal failure
Hepatic failure
Coagulation abnormalities
3.9 ± 0.1
3.4 ± 0.2
5.5 ± 0.1
5.7 ± 0.1
5.6 ± 0.1
19.0 ± 0.5
18.8 ± 0.5
21.5 ± 0.5
22.0 ± 0.4
22.0 ± 0.4
4.2 ± 0.1
2.9 ± 0.2
5.6 ± 0.1
5.5 ± 0.1
5.4 ± 0.1
19.1 ± 0.4
17.2 ± 0.5
21.2 ± 0.5
21.2 ± 0.5
21.5 ± 0.4
0.04
0.02
0.45
0.12
0.23
0.85
0.03
0.59
0.18
0.37
Dialysis to day 60
Patients (%) 10 14 0.06
Days 11.0 ± 1.7 10.9 ± 1.4 0.96
Liberal
fluids
associated
with
increased
ICU and
ventilator
time and
no
reduction
in renal
failure

19. Fluids -
Observational
After correcting for
age and APACHE
II, positive fluid
balance correlated
with increased
mortality
Boyd J.H.et al Crit Care Med 2011

20. Fluids -
Recommendations
CCM Feb 2011

21. Currently
Low Blood
Pressure
Low Cardiac
Output
Organ Failure Vasopressors
Inotropes
Fluids

22. Currently
Low Blood
Pressure
Low Cardiac
Output
Organ Failure Vasopressors
Inotropes
Fluids

23. The Future ??
• Each decade we reject a new
haemodynamic variable, on which, to
base interventions
• 1980: PAWP
• 1990: VO2-DO2 relationship
• 2000: LVEDV GEDVI
• 2010: Forget about monitoring - just
ECHO everything (over and over)

24. Where does that
leave us ?

25. Where does that
leave us ?• Prescriptive Approaches
• RELIEF (Restrictive versus Liberal
Fluid Therapy in Major Abdominal
Surgery)
• Clinical Trials.gov Id: NCT
01424150
• Random allocation of drugs
• Targeting Fluid Balance

26. A Physiological
Approach• Instead of targeting MAP or CO/O2D
indices
• using DEPENDENT circulatory
variables (e.g. CVP, EDV, PPV) to
guide therapy
• Target BOTH simultaneously using
• INDEPENDENT circulatory variables
- Volume state
- Cardiac function

27. Mean Systemic Filling
Pressure

28. Mean Systemic Filling
Pressure
Anaesthesia
2009(64):1218-1228

29. Mean Systemic Filling
Pressure
• Allows independent assessment of
volume state
and
• Allows independent assessment of
cardiac function

30. Modelling the
circulation

31. Stay with me.......

32. MSFP(modeled)
CO
Press av MSFP

33. Venous compliance
lower than assumed
CO
Press av MSFP

34. Venous compliance
higher than
assummed
CO
Press av

35. Independent variables of
the circulation
• MSFP = Volume state
= 0.96(CVP) + 0.04(MAP) + c(CO)
• HP (Heart Performance) = Inotropy
state
=(MSFP - RAP) / MSFP
• SVR = Arteriolar tone state
These are the numerical descriptors (indicators) of the circulation

36. Choosing the Target
• Cardiac output
• Mean arterial pressure
• (Cardiac Power = CO x MAP)
• Captures both kinetic and potential
energy of the circulation
• Allows assessment of volume
responsiveness

37. Cardiogenic Shock
• Cardiac Power

38. Cardiogenic Shock
• Cardiac Power

39. Navigator Guidance
Heart efficiency axis Mean systemic
filling pressure axis
Data from
Monitors
Targets set
by clinician
Main menu
area
Data link
Status area
Target zone
Systemic
resistance axis
Patient’s
current position
Arrow shows next therapeutic
direction
Other data

40. Intended Control:
Following the arrow
• Vertical Axis Control
• If Cardiac Power Low: increase MSFP or
Inotropy (depending on HP)
• If Cardiac Power High: decrease MSFP or
Inotropy* (depending on HP)
• Horizantal Axis Control
• If Cardiac Power is not well “geared” (SVR
too high or too low): dilators and
constrictors

41. Cardiac Power
Relevance

42. Navigator Screens:
NAV-1
Intervention
(Treatment compliance not required)
Control

43. What we learned
• Even if you know the independent
determinants of circulatory variables
(like CO)......
• Even if you use them to direct therapy
to a meaningful target (like cardiac
power).....
• You don’t necessarily know when you
should change the target and when you
should change the treatments

44. Structured approach to circulatory
care using Navigator
Determine Targets
Define (allowable)
interventions
Targets attained and
maintained (ASD < 1.5)
within intervention limits
Targets not maintained within
intervention limits (ASD >1.5)
New InterventionNew Target
+1. Medical
assessment
2. Nursing
assessment
or
3. Continual
maintenance
No change

45. Circulatory Targeting
Sheet
Volume resuscitation Colloids = 0 Colloids = < 1000 mls Colloids = < 2000ms
Vasopressor requirements Noradren = 0 Noradren = 1 - 10 Noradren = >10
AVP = 0 AVP = 1/hr AVP 2/hr
Vasodilator requirements GTN = 0 GTN =20 or more GTN ___ - ___
SNP 10 - 50 SNP 50 - 150 SNP ___ - ___
Inotrope requirements Adren: = 0 Adren: < 5 Adren: 5- ___
Milrinone = 0 Milrinone = 5 Milrinone = 5 - 20
MAP
Card Index
ScvO2 > 70
Heart Rate
HP inotrope trigger
HP medical review trigger

46. Improving Circulatory
Care .....
• Further investigations into
physiologically based treatments
• Cannot accept that understanding the
circulation can’t lead to improved care

47. Outcomes of cardiogenic shock (CS)
complicating acute coronary
syndromes/myocardial infarction

48. Outcomes of cardiogenic shock (CS)
complicating acute coronary
syndromes/myocardial infarction

49. Outcomes

50. •High early mortality (despite early intervention)
•Difficult to support medically
•Reasonable quality of life post
•Not invariably associated with irrecoverable myocardial damage
Cardiogenic Shock
Outcomes

51. Krischan D. Sjauw
European Heart Journal
(2009) 30, 459–468
IABP

52. Unverzagt S
Cochrane Library
2011
IABP

53. •Ongoing Trials
•IABP Shock II;
•RECOVER II Trial
•Planned Recruitment
•984
IABP

54. Elmir Omerovic
Vascular Health and Risk
Management
2010:6 657–663
Inotropes

56. • Extra Corporeal Membrane
Oxygenation is a form of
extracorporeal life support where
an external artificial circuit
carries venous blood from the
patient to a gas exchange device
(oxygenator) where blood
becomes enriched with oxygen
and has carbon dioxide
removed. This blood then re-
enters the patient circulation
• Veno-arterial ECMO
– Percutaneous
cardiopulmonary support
(bypass)
ECMO

57. return
access

58. Day 2-3Lymphocytic
myocarditis
What’s possible

59. What’s possible……
Day
10
Day 5

65. Christian A. Bermudez
Ann Thorac Surg 2011;92:2125–31

66. Diagnostic
Group
Number
(168)
Age
(43)
ECMO Days
(7.3)
SW SB NW Alive
Discharge
CM/FM
40 42 7.8 21 14 5 27(+3) (75%)
Heart Tx (0-
7) 46 51 6.6 43 1 2* 33 (72%)
AMI
25 52.4 9.1 12 8 5 14 (56%)
Heart Tx
(late) 10 44 11.9 4 3 3 3 (30%)
Septic Shock
7 38 4.9 3 0 4 2 (29%)
ECMO for Cardiac Failure 2003-
2012

67. •25 patients (2003-
2012)
•Average Age: 52.4
•Average Days on
Support: 9.14
•56% Survival to
hospital discharge
•5 NW
•8 SB
•12 SW
Alfred CS-AMI

68. •Veno-arterial ECMO
•Centrifugal VAD
•Tandem Heart
LVAD
•RVAD, LVAD,
BiVAD
•Impella Recover
•B2B (Bridge to
Bridge)
•Long term VAD
Current Mechanical Treatment
Options for Severe Acute Heart
Failure

70. Ischaemic C/M
60 month mortality
50%
Non-Ischaemic C/M
60 month mortality
35%

71. • Cardiogenic shock remains a
challenging syndrome to treat but the
early application of safe ECMO seems
possible to provide major patient
benefits
• Simple
• Transferable
Conclusion