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Hemodynamic Puzzle

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How to evaluate the different moralities available in the assessment of fluid status for the critically ill patient!

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Hemodynamic Puzzle

  1. 1. The Hemodynamic Puzzle O2ER NIRS SVV Lactate
  2. 2. EnergyMetabolism (OxygenConsumption) (Ml/min/m2) Delayed Repayment of O2 Debt Full Recovery Possible Excessive O2 Deficit Produces Lethal Cell Injury with Non-recovery Recovery Possible Time Oxygen Deficit Oxygen Deficit Oxygen Deficit Oxygen Debt: To Pay or Not to Pay? The principle task of acute care is to avoid or correct oxygen debt by optimization of the oxygen supply and consumption.
  3. 3. Providing the right amount of fluid is vital in a critically ill patient, as both too little and too much can result in poor outcomes Under Resuscitation Over Resuscitation It is just as important to recognize that DO2 and tissue perfusion has normalized, therefore any further measures to increase DO2 may do harm by unnecessary over resuscitation
  4. 4. HR and BP as Resuscitation Endpoint NIRS SVV SvO2 Heart Rate Urine Output Mental Status OPSI GEDV SV
  5. 5. DO2 ml*m-2*min-1 100 300 500 700 900 1100 n= 1232 30 60 90 120 150 180 MAPmmHg Correlation Between Arterial Pressure And Oxygen Delivery
  6. 6. DO2 ml*m-2*min-1 100 300 500 700 900 1100 n= 1236 30 60 90 120 150 180 HRb/min Correlation Between Heart Rate And Oxygen Delivery
  7. 7. CVP as a Resuscitation Endpoint NIRS SVV SvO2 Heart Rate Urine Output Mental Status OPSI GEDV SV
  8. 8. Passive leg raising (PLR) Volume of blood transferred (usually 200-300 mL) to the heart during PLR is sufficient to increase the left cardiac preload and thus challenge the Frank-Starling curve. Maximal effect occurs at 30-90 seconds and assess for a 10% increase in stroke volume (cardiac output monitor) or using a surrogate such as pulse pressure (using an arterial line)
  9. 9. Diagnostic Accuracy of Passive Leg Raising for Prediction of Fluid Responsiveness in Adults: Systematic Review and Meta-analysis of Clinical Studies. β€’ Meta-analysis 9 studies β€’ PLR changes in CO predicts fluid responsiveness β€’ Regardless of ventilation mode and cardiac rhythm β€’ Difference in CO of 18% distinguished responder from NR Cavallaro, F. et al. Intensive Care Med. 2010 Sep;36(9):1475-83 The pooled sensitivity and specificity of PLR-cCO were 89.4% (84.1-93.4%) and 91.4% (85.9-95.2%) respectively AUC= 0.96
  10. 10. CVP as a Resuscitation Endpoint NIRS SVV SvO2 Heart Rate Urine Output Mental Status OPSI GEDV SV CVP
  11. 11. β€’ European survey: More the 90%of intensivist or anesthesiologists used the CVP to guide fluid management. β€’ Canadian survey: 90% of intensivists used the CVP to monitor fluid resuscitation in patients with septic shock.
  12. 12. Crit Care Med 2013; 41:1774–1781)
  13. 13. Paul E. Marik, MD, FCCP; Michael Baram, MD, FCCP; BobbakVahid, MD Chest. 2008;134(1):172-178.
  14. 14. Osman D1, Ridel C, Ray P, Monnet X, Anguel N, Richard C,Teboul JL. Crit Care Med. 2007 Jan;35(1):64-8. The study demonstrates that cardiac filling pressures are poor predictors of fluid responsiveness in septic patients. Therefore, their use as targets for volume resuscitation must be discouraged, at least after the early phase of sepsis has concluded
  15. 15. There are no data to support the widespread practice of using central venous pressure to guide fluid therapy.This approach to fluid resuscitation should be abandoned. Marik PE, Cavallazzi R . Crit Care Med. 2013 Jul;41(7):1774-81..
  16. 16. IVC Diameter and Collapsibility as End Point NIRS SVV SvO2 Heart Rate Urine Output Mental Status OPSI GEDV CVP
  17. 17. Simultaneous measurements of the central venous pressure (CVP) and IVC diameter at the end of expiration in 108 mechanically ventilated patients
  18. 18. Collapsibility Index = 𝑰𝑽π‘ͺ π’Žπ’‚π’™ βˆ’π‘°π‘½π‘ͺπ’Žπ’Šπ’ 𝑰𝑽π‘ͺ π’Žπ’‚π’™ >12% = responders (PPV 93% and NPV92%).
  19. 19. Collapsibility Index = 𝑰𝑽π‘ͺ π’Žπ’‚π’™ βˆ’π‘°π‘½π‘ͺπ’Žπ’Šπ’ 𝑰𝑽π‘ͺ π’Žπ’‚π’™ <12% = non-responders (PPV 93% and NPV92%).
  20. 20. Zhongheng Zhang, Xiao Xu, ShengYe, Lei Xu. Ultrasound in Medicine and Biology.Volume 40, Issue 5, Pages 845–853, May 2014 Total of 8 studies/235 Pts Ξ”IVC measured is of great value in predicting fluid responsiveness, particularly in patients on controlled mechanical ventilation
  21. 21. CO/SV as a Resuscitation Endpoint NIRS SVV SvO2 Heart Rate Urine Output Mental Status OPSI SV/CO CVP GEDV
  22. 22. Effects of Cardiac Output and Stroke Volume Guided Hemorrhage and Fluid Resuscitation CI-group SVI-group Tbsl T0 tend Tbsl T0 Tend SVI (ml/m2) 33.6 Β± 6.2 14.6 Β± 10.1 23.4 Β± 7.9 26.8 Β± 4.7 13.4 Β± 2.3 26.6 Β± 4.1 CI (l/min/m2) 2.88 Β± 0.42 1.79 Β± 0.53 2.73 Β± 0.35 2.6 Β± 0.4 1.8 Β± 0.3 2.9 Β± 0.5 MAP (mmHg) 127 Β± 13.07 75 Β± 25 85 Β± 22 112 Β± 23 74 Β± 18 91 Β± 19 Heart rate (beats/min) 87 Β± 16 140 Β± 40 124 Β± 37 95 Β± 12 131 Β± 27 107 Β± 16 Central venous oxygen saturation (%) 81 Β± 8 58 Β± 18 64 Β± 15 78 Β± 7 61 Β± 5 73 Β± 9 Venous to arterial carbon dioxide gap (mm Hg) 3.3 Β± 3.1 8.9 Β± 3.3 7.8 Β± 4.8 5.3 Β± 2 9.6 Β± 2.3 5.1 Β± 2.6 GEDV (ml/m2) 317 Β± 36 198 Β± 57 249 Β± 46 309 Β± 57 231 Β± 61 287 Β± 49 Stroke volume variation (%) 10.8 Β± 5.5 17.3 Β± 5.1 16.4 Β± 8.2 13.6 Β± 4.3 22.6 Β± 5.6 12.2 Β± 4.3 Nemeth, M. et al. Acta Anaesthesiol Scand (2014). doi:10.1111/aas.12312 21 animal subjects were bled until CI (n=9) or SVI (n=12) decreased by 50% then resuscitated during 60 minutes with LR till target is achieved
  23. 23. SVV & PPV as End Point SvO2 Heart Rate Urine Output Mental Status OPSI SV GEDV SVVCVP
  24. 24. Hemodynamics During Positive Pressure Ventilation: SVV and PPV
  25. 25. Preload Stroke Volume 0 0 Higher PVI = More likely to respond to fluid administration 24 % 10 % Lower PVI = Less likely to respond to fluid administration PVI to Help Clinicians Optimize Preload / Cardiac Output Frank-Starling Relationship
  26. 26. Determine success of fluid by the response in stroke volume/index and SvO2 30 Stroke Volume End-Diastolic Volume D < 10% D > 10% D 0% Fluid Responders Fluid Non-Responders
  27. 27. Dynamic parameters should be used preferentially to static parameters to predict fluid responsiveness in ICU patients
  28. 28. Dynamic Changes in Arterial Waveform DerivedVariables and Fluid Responsiveness in MechanicallyVentilated Patients: A Systematic Review of Literature Marik, PE et al. (2009). Citi Care Med. 37: 2642-2647 Sens. 0.89 Spec. 0.88 AUC= 0.94
  29. 29. Lactic Acid as Endpoint Resuscitation Heart Rate Urine Output Mental Status OPSI SV Lactate CVP GEDV SVV
  30. 30. Oxygen consumption VO2 mls/min Oxygen delivery DO2 mls/min 300mls/min Lactate Critical DO2 Oxygen Debt DO2 independent in normal patients DO2 dependent in septic patients
  31. 31. Prolonged lactate clearance is associated with increased mortality in the surgical intensive care unit J. McNelis et al. The American Journal of Surgery 182 (2001) 481–485
  32. 32. Early lactate-guided therapy in intensive care unit patients: a multicenter, open-label, randomized controlled trial. Jansen TC,van Bommel J, Schoonderbeek FJ,Sleeswijk Visser SJ, vander Klooster JM, Lima AP, et al. Am J Respir Crit Care Med (2010) 182:752– 61.doi:10.1164/rccm.200912-1918OC
  33. 33. Effects of Cardiac Output and Stroke Volume Guided Hemorrhage and Fluid Resuscitation CI-group SVI-group Tbsl T0 tend Tbsl T0 Tend Oxygen delivery (ml/min/m2) 335 Β± 63 158 Β± 62 284 Β± 52 419 Β± 62 272 Β± 56 341 Β± 62 VO2 (ml/min/m2) 44 Β± 25 62 Β± 38 76 Β± 34 77 Β± 26 96 Β± 19 82 Β± 27 Oxygen extraction (VO2/DO2) 0.13 Β± 0.08 0.38 Β± 0.19 0.32 Β± 0.14 0.20 Β± 0.07 0.36 Β± 0.05 0.24 Β± 0.09 Central venous oxygen saturation (%) 81 Β± 8 58 Β± 18 64 Β± 15 78 Β± 7 61 Β± 5 73 Β± 9 Venous to arterial carbon dioxide gap (mm Hg) 3.3 Β± 3.1 8.9 Β± 3.3 7.8 Β± 4.8 5.3 Β± 2 9.6 Β± 2.3 5.1 Β± 2.6 Lactate (mmol/L) 3.6 Β± 1.1 5.0 Β± 1.6 4.6 Β± 2.0 1.62 Β± 0.43 3.86 Β± 1.49 3.54 Β± 1.9 Hemoglobin (g/L) 9.0 Β± 0.7 8.0 Β± 2.7 6.9 Β± 1.3 12.05 Β± 1.37 11.22 Β± 1.39 8.45 Β± 1.1 Nemeth, M. et al. Acta Anaesthesiol Scand (2014). doi:10.1111/aas.12312
  34. 34. Oxygen Extraction-based Resuscitation SVVHeart Rate Urine Output Mental Status SV GEDV SVV O2ER SvO2 ScvO2 CVP
  35. 35. DO2= CO x [CaO2] CaO2= [Hb X 1.34 x SaO2] + 0.003 x PaO2 VO2= CO x [CaO2-CvO2] O2ER = 𝟏𝟎𝟎 𝐗 VO2 DO2 Oxygen Extraction-based Resuscitation ScVO2
  36. 36. Effects of Cardiac Output and Stroke Volume Guided Hemorrhage and Fluid Resuscitation CI-group SVI-group Tbsl T0 tend Tbsl T0 Tend Oxygen delivery (ml/min/m2) 335 Β± 63 158 Β± 62 284 Β± 52 419 Β± 62 272 Β± 56 341 Β± 62 VO2 (ml/min/m2) 44 Β± 25 62 Β± 38 76 Β± 34 77 Β± 26 96 Β± 19 82 Β± 27 Oxygen extraction (VO2/DO2) 0.13 Β± 0.08 0.38 Β± 0.19 0.32 Β± 0.14 0.20 Β± 0.07 0.36 Β± 0.05 0.24 Β± 0.09 Central venous oxygen saturation (%) 81 Β± 8 58 Β± 18 64 Β± 15 78 Β± 7 61 Β± 5 73 Β± 9 Venous to arterial carbon dioxide gap (mm Hg) 3.3 Β± 3.1 8.9 Β± 3.3 7.8 Β± 4.8 5.3 Β± 2 9.6 Β± 2.3 5.1 Β± 2.6 Lactate (mmol/L) 3.6 Β± 1.1 5.0 Β± 1.6 4.6 Β± 2.0 1.62 Β± 0.43 3.86 Β± 1.49 3.54 Β± 1.9 Hemoglobin (g/L) 9.0 Β± 0.7 8.0 Β± 2.7 6.9 Β± 1.3 12.05 Β± 1.37 11.22 Β± 1.39 8.45 Β± 1.1 Nemeth, M. et al. Acta Anaesthesiol Scand (2014). doi:10.1111/aas.12312
  37. 37. Mixed Venous Saturation in Critically Ill Patient Oxygen Supply: DO2 Oxygen Demand: VO2 SvO2/ScvO2 Low ↓DO2 ↑VO2 Anemia Bleeding Hypovolemia Hypoxia Heart faliure Pain Agitation Shivering Seizure Fever High ↑DO2 ↓VO2 Hg Oxygen Fluids Inotropics Sedation Analgesia Hypothermia Sepsis
  38. 38. SvO2 % DO2/VO2 25 705540 85 100 1.0 2.8 4.6 6.4 8.2 10.0 r= 0.906 y= -9.58 + 0.19*x n= 1149
  39. 39. Lee J et al. (1972) Anaesthesiology 36: 472 %SsvO2 % SvO2 100 80 60 40 20 0 20 40 60 80 100 r= 0.73 r= 0.88 Shock Normal
  40. 40. Reinhart K et al, Chest, 1989; 95:1216-1221 SvO2 closely correlates with ScvO2 Time (min) %Sat 80 60 40 20 0 300 60 90 120 150 180 210 240 Normoxia Bleeding VolumeTherapy (HAES) Bleeding Hypoxia Normoxia Hyperoxia Mixed venous Central venous
  41. 41. Pope, J et al. Ann Emerg Med. 55:40-46 ScvO2 of > 90%,ScvO2 of < 70%,
  42. 42. Oxygen Parameters as Endpoint SVVHeart Rate Urine Output Mental Status SV GEDV SVV O2ER SvO2 ScvO2 P(cv-a)CO2 CVP
  43. 43. P(cv-a)CO2 Normal is 2-5 mmHg. Is not a marker of tissue hypoxia but it is a marker of the adequacy of cardiac output βˆ†PCO2= K X 𝑽π‘ͺ𝑢 𝟐 π‘ͺπ’‚π’“π’…π’Šπ’‚π’„ 𝑢𝒖𝒕𝒑𝒖𝒕
  44. 44. Persistently high venous-to-arterial carbon dioxide differences during early resuscitation are associated with poor outcomes in septic shock Ospina-TascΓ³n GA et al., Crit Care. 2013; 17(6) The persistence of high Pv-aCO2 during the early resuscitation of septic shock was associated with more severe multi-organ dysfunction and worse outcomes at day-28 H-H, mixed venous-to-arterial carbon dioxide difference (Pv- aCO2) high at Time 0 (T0) and 6 hours later (T6); L-H, Pv- aCO2 normal at T0 and high at T6; H-L, Pv-aCO2 high at T0 and normal at T6; and L-L, Pv-aCO2 normal at T0 and T6
  45. 45. Central Venous-to-Arterial Gap Is a Useful Parameter in Monitoring Hypovolemia-Caused Altered Oxygen Balance: Animal Study ScvO2 < 73% and CO2 gap >6 mmHg can be complementary tools in detecting hypovolemia-caused imbalance of oxygen extraction. Kocsi S et al, Crit Care Res Pract. 2013; 583-598.
  46. 46. The Hemodynamic Puzzle SVVHeart Rate Urine Output Mental Status SV GEDV SVV O2ER SvO2 ScvO2 P(cv-a)CO2 NIRSOPSI CVP
  47. 47. Near-infrared spectroscopy (NIRS)
  48. 48. NIRS StO2 (at 20 mm, skeletal muscle) is an index of profusion that tracks DO2 during active resuscitation Crit Care. 2009; 13(Suppl 5): S10.
  49. 49. Orthogonal Polarization Spectral Imaging (OPS): Sublingual capillaroscopy. Orthogonal polarization spectral (OPS) imaging is an optical imaging technique that uses a handheld microscope and green polarized light to visualize the red blood cells in the microcirculation of organ surfaces
  50. 50. Orthogonal Polarization Spectral Imaging (OPS): Sublingual capillaroscopy. Red blood cells are visualised as black-grey points flowing along the vessels. Up-right and up-left: normal findings; bottom- left: septic shock; bottom-right: after cardiac arrest under therapeutic hypothermia
  51. 51. The Hemodynamic Puzzle O2ER NIRS SVV SvO2 ScvO2 Heart Rate Urine Output Mental Status OPSI GEDV P(cv-a)CO2 Lactate SV CVP

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