ITBV and GEDVMeasured via PiCCO thermodilution (transpulmonary)ITBV = volume in 4 chambers of heartGEDV = good estimation of intravascularvolume and preloadLimitation to predict ﬂuid responsiveness.
fluid responsiveness- PPV give a best correlation to ﬂuid responsiveness- Static preload monitoring demonstrated the poorcorrelation to ﬂuid responsiveness
passive leg rising testconsider as “autotransfusion”recent study demonstrated the strongcorrelation of PLR to predict ﬂuidresponsiveness with ROC of 0.95Continuous measure SV or CO on a real timebasis eg. echocardiogram, CCO-pulsecontour analysisCO increase > 10% during PLR indicate ﬂuidresponsiveness.
Tissue perfusion: Oxygen delivery Oxygen contentheart = O2 in Hb + O2 in plasma tissue Oxygen delivery (DaO2) = Cardiac output (CO) x oxygen content
Blood pressure• Represent organ perfusion pressure• MAP –More reliable indication of tissue perfusion than SBP and DBP –Reﬂect autoregulation limit of organ blood ﬂow – CPP = MAP –ICP (normal 60-90 mmHg) –APP = MAP – IAP (normal 50-70 mmHg) –RPP normal 70-90 mmHg Goodrich. AACN 2006.
Blood pressure• Optimal MAP is unknown• MAP > 65 mmHg is now recommended as EGDT study• Targeted BP does not necessarily equate to tissue perfusion, but have to achieve for the ﬁrst step.• Elderly may require higher MAP due to vasculopathy• Previous hypertensive group may require MAP higher than normotensive one.
General management of• Reverse hypotension• Adequate oxygen delivery/ organ perfusion
Downstream monitoring Global downstream Regional downstream monitoring monitoring• Serum lactate• Mixed/ central venous saturation and gases• Base excess
SvO2 as a treatment endpoint• Goal directed therapy to keep SvO2 > 70% over 5 days did not lower the mortality in septic shock. Gattinoni. NEJM 1995.• MAP > 65 mmHg and SvO2 > 70% in the ﬁrst 48 hours after resuscitation shown less septic mortality. (retrospective study) Varpula.ICM 2005.
The first ScvO2 and mortalityMortality rate Pope. Ann Emerg Med 2010.
Targeted ScvO2• ScvO2 > 70 % reﬂected adequate tissue perfusion (normoxia)• Do not keep ScvO2 too high.• Immediate ScvO2 level will be used for the endpoint if it is on lower side.• May require addition parameter to assess perfusion state.
PvCO2 PvCO2 CO2 Cardiac CO2 production output elimination The higher PvCO2, the lower CO
PvCO2 and PaCO2 difference• Inverse non linear signiﬁcant relation between oxygen delivery, P(v-a)CO2 and pH(v-a) Brandi. Minerva Anestesio 1995.• Increase P(v-a)CO2 mainly related to decrease in cardiac output and increased in ischemic hypoxia not in hypoxic hypoxia Vallet. J Appl Physiol 2000.
PvCO2 and PaCO2difference and mortality • dPCO2 is signiﬁcantly higher in non survival group • The cut of value of dPCO2 is 6 mmHg Bakker. Chest 1992.
PcvCO2 vs. PvCO2 Agreement = 0.978 Cuschieri. ICM 2005.
PcvCO2 vs. PvCO2 R2 = 0.892, p <0.0001 Cuschieri. ICM 2005.
PcvCO2 as a target for resuscitation P(cv-a)CO2 may serve as a global tissue perfusion index when ScvO2 goal reached Vallee. ICM 2008.
PcvCO2 as a target for resuscitation Vallee. ICM 2008. • High dPCO2 associated with lower CI and higher lactate level R=0.58, p<0.0001
PvCO2 or PcvCO2• Interchangeable• Level of PvCO2 and PcvCO2 invert correlation to cardiac index• dPCO2 or P(cv-a)CO2 may be a better parameter to indicate global tissue perfusion than ScvO2• Clinical study should be done to conﬁrm the hypothesis.
Lactate• generated through anaerobic metabolism• advocated as index of tissue hypoperfusion• Endotoxin induced lactate production without hypoperfusion• level represents a balance between generation and elimination• Hyperlactatemia: lactate level > 2 mmol/L• Lactic acidosis: lactate level > 4 mmol/L
Lactate• high lactate levels (> 4mmol/L) in critically ill patients associated with increased mortality (Bakker et al. Chest 1991)• lactate clearance better predictor of mortality – lac-time: time in which blood lactate > 2 mmol/l – survivors had decreased lac-time – lac-time also directed correlated with number of organ failures (Bakker et al. (Am J Surg 1996)
Blood Lactateserial lactate levels may improve the prognostic value and help guide therapy Nguyen et al. Crit Care Med 2004
Lactate clearance as a target Jones. JAMA 2010
Lactate clearance as a target Jones. JAMA 2010 Lactate <10% clearance >10%
Lactate clearance as a target p = NS23% 10.017% 7.5 •p = NS12% 5.06% 2.50% 0 mortality (%) LOS (D) lactate guided Jones. JAMA 2010 ScvO2 guided
Lactate clearance as a target Jansen. AJRCCM 2010.
Lactate clearance as a target Jansen. AJRCCM 2010.
Lactate clearance as a target44% •p = 0.06733%22%11% 0% hospital mortality (%) lactate guided non-lactate guidedLactate guided group Hazard ratio P-valueIn hospital mortality 0.61 (0.43-0.87) 0.006ICU mortality 0.66 (0.45-0.98) 0.037 Jansen. AJRCCM 2010.
Lactate as a target• Hyperlactatemia associated with mortality• Rapid lactate clearance improved ICU outcome• Lactate guided resuscitation is feasible.• Aggressive ﬂuid resuscitation, inotropes and vasodilator will reduce blood lactate.
Goal of shock resuscitationReverse of hypotension (macro)Clinically well perfusedAdequate tissue perfusion and oxygenation (micro) There has been no the best parameter to date. combine parameter is suggested Use common parameters such as ScvO2 or lactate is reasonable The supporting data of sophisticated device is now scanty.