1. introduction and role of abdominal pressure in ecmo #beach2019 (malbrain)

3rd BEACH Course Introduction 11-10-2019 ⎮ 1
3rd BEACH Course
BElgian Annual eCmo
Hands-on course
Auditorium Kiekens
Course Director: Prof. Dr. Manu Malbrain
WORKSHOP
UZ Brussels – Belgium: Oct 11 – 2019

Welcome and Introduction
Manu Malbrain
manu.malbrain@uzbrussel.be
@manu_malbrain @Fluid_Academy

Manu Malbrain
• Internist – Intensivist
• Professor Faculty of Medicine,Vrije Universiteit Brussel (VUB)
• ICU Director, University Hospital Brussels (UZB)
• Past President, treasurerWSACS (wsacs.org)
• Co-Founder International Fluid Academy (fluidacademy.org)
• Educational Grant: ESICM Chris Stoutenbeek Award
• Member Medical Advisory Board
→ Getinge
→ Spiegelberg, Convatec, Serenno, Holtech Medical
• Consults for Cytosorbents, Baxter
• European Patent Holder: GEF/GEDVI - CiMON (PMS)
• Research Project: Draeger, Edwards, Bard,
• Fees - Honoraria: GSK, MSD, Fresenius-Kabi

1st BEACH COURSE .

www.fluidacademy.org

25 delegates – 10 Faculty

Hands-on Sessions

25 delegates – 14 Faculty

Hands-on Sessions

Simulation

Hands-on Sessions

Percutaneous assist devices in
cardiogenic shock
Werdan K et al. Eur Heart J 2014 & Thiele H et al. Eur Heart J 2007

Cardiogenic shock:The problem
Werdan et al. Eur Heart J. 2014.
Over the last 45 years not much improvement in survival rates

Alternatives for Cardiogenic Shock
• Opties voor support
Atkinson et al. JACC cardiovasc. Intervent. 2016.
ECMO needs bigger canulas
and has unfavourable
hemodynamic effects on the
heart…

NO !

Cardiogenic shock
European guidelines

cardiogenic shock

What is the Impella device?

Cardiogenic shock:Why Impella?
O‘ Neill. TCT 2018.

Basir et al. Cathet Cardiovasc Intervent. 2018.

Basir et al. Catheter Cardiovasc Intervent. 2019.

cardiogenic shock

Evolving epidemiology in VA ECMO
Karagiannidis C et al. Intensive Care Med 2016

Unloading concept
Donker et al. ASAIO J. 2018.
Normal
CS -> ECMO
ECMO alone
From the ECMO camp

Unloading in ECMO: evidence?
Papallardo et al. Eur J heart fail. 2017.
Patel et al. ASAIO. 2019.

VV ECMO
Karagiannidis et al. Int Care Med 2016

ARDS
Xü
Is this ARDS???
Chest X-ray does not
correlate with edema

Chest X-ray evolution
P/F 98
IPAP 30
PEEP 6
EVLWI 16
PVPI 2.1
P/F 308
IPAP 34
PEEP 19
EVLWI 12
PVPI 1.7
D5 D6
HFPV
PEEP
19
Lasix 10mg/hr
continuously
Xü
Treatment (PEEP, FB)
affects definition

VENTILATED
RECRUITABLE
COLLAPSED
Angio-CT ThoraxBy definition – ARDS =
the sponge model
Secondary ARDS = iatrogenic

One more thing….

•
1
When
to start
fluids
When
to stop
fluids
When
to start fluid
removal
2 3
When
to stop
removal
4

Minutes Hours Days Weeks
GDT
Rescue
LCFM
Optimize
LGFR
Stabilize
Evacuate
MAP
PPV
PLR
GEDVI
Nl lactate Nl PPV Nl MAPNo FR
Low PPV
EVLWI
POCUS
ICG-PDR
ScvO2
Nl GEDVI
P/F ratio
?

Respiratory
Pulmonary edema á
Pleural effusion á
Altered pulmonary and
chest wall elastance (cfr IAP á)
paO2 â paCO2 á PaO2/FiO2 â
Extra vascular lung water ä
Lung volumes â (cfr IAP á)
Prolonged ventilation á
Difficult weaning á
Work of breathingá
Cerebral edema, impaired
cognition, delirium
ICPá CPPâ IOPá
ICH, ICS, OCS
Ascites formation á Gut edema á
Malabsorption á Ileus á
Bowel contractility â
IAP á and APP (=MAP-IAP) â
Success enteral feeding â
Intestinal permeability á
Bacterial translocation á
Splanchnic microcirculatory flow â
ICG-PDR â, pHi â
Tissue edema á
Poor wound healingá
Wound infectioná
Pressure ulcers á
Abdominal compliance â
Myocardial edema á
Conduction disturbance
Impaired contractility
Diastolic dysfunction
CVP á and PAOP á
Venous return â
SV â and CO â
Myocardial depression
Pericardial effusion á
GEF â GEDVI á CARS á
Hepatic congestion á
Impaired synthetic function
Cholestatis á
Cytochrome P 450 activity â
Hepatic CS
Fluid
Overload
Hepatic
Gastrointestinal/visceral
Central NS
Cardiovascular
Renal
Abdominal Wall
Renal interstitial edema
Renal venous pressure á
Renal blood flow â
Interstitial pressure á
Salt + water retentioná
Uremia á GFR â RVR á
Renal CS
Prowle J. Nat Rev 2010
Malbrain M. AIT 2014
GIPS

Event
Systemic inflammatory
reponse
Increased capillary
permeability Organ dysfunction
Shock reversal
Negative fluid balance
spontaneously
Unresolved shock
Positive fluid balance
Need for DEresuscitation
Genetic
disposition?
1st HIT
2nd HIT
3rd HITGIPS

Time
VolumeStatus PERSISTENT POSITIVE
CUMULATIVE FB
ORGAN FAILURE
+ = GIPS
P/F – EVLWI – PVPI – IAP

Time
CUMULATIVE FB
ORGAN FAILURE
+ = GIPS

CUMULATIVE FB on Day 3 =
independent predictor 90-day mortality
Intensive Care Med (2014) 40:1256–1266

Time
CUMULATIVE FB
ORGAN FAILURE
+ = GIPS

Fluid IN Fluid OUT

BIA principles
• How does BIA calculate volume (TBW)?
Cylinder

BIA assumptions
ŒBody = cylinder
Body = 5 cylinders
(Height + weight)
ŽBody composition =
homogenous
No individual variation
y No impact of
environment (°C, stress)2 3
4 5
1

ŒImpedance
Height
ŽWeight
Gender + yAge
5
Factors

• Male 44 years
• Polytrauma
• Cum FB +5L on day 5
• P/F ratio 98
• EVLWI 16
4.9

P/F 98
IPAP 30
PEEP 6
EVLWI 16
PVPI 2.1
D5

P/F 98
IPAP 30
PEEP 6
EVLWI 16
PVPI 2.1
P/F 308
IPAP 34
PEEP 19
EVLWI 12
PVPI 1.7
D5 D6
HFPV
PEEP
19
Lasix 10mg/hr
continuously

Fluid Overload and Outcome
31%
49% 51% 54%
38%
57%
62%
65%
0%
10%
20%
30%
40%
50%
60%
70%
no FO FO 5% FO 7.5% FO 10%
ICU HOS

Kaplan-Meier Survival curves
0
10
20
30
40
50
60
70
80
90
100
0,0 10,0 20,0 30,0 40,0 50,0 60,0 70,0 80,0 90,0
CumulativeSurvival(%)
Days
Survival rate of ICU patients with or without fluid
overload
Fluid Overload no Fluid Overload

Woman, 54 years old
AML – AlloSTx – CMV/PJP

Fluid Balance
-10000
-5000
0
5000
10000
15000
20000
25000
30000
31/08/191/09/192/09/193/09/194/09/195/09/196/09/197/09/198/09/199/09/1910/09/1911/09/1912/09/1913/09/1914/09/1915/09/1916/09/1917/09/1918/09/1919/09/1920/09/1921/09/1922/09/1923/09/1924/09/1925/09/1926/09/1927/09/1928/09/1929/09/1930/09/191/10/192/10/19
FB cum FB

Fluid Balance

IVF: Intravascular Fluids

EVF: Extravascular Fluids

Hematocrit Evolution

Fluid Nomogram

ECMO patients are prone to FO
GIPS
Heart
Failure AKI
IVF ECC

One more thing….
last

Gut edema á
Ascites formation á
Malabsorption á
Bowel contractility â
Bacterial translocation áIleus á
IAP á and APP (=MAP-IAP) â
Success enteral feeding â
IAH and ACS á
Intestinal permeability á
Gastro-Intestinal system (FO)
Hepatosplanchnic flow â ICG-PDR â, pHi â
Malbrain M. Marik P. et al. Anaes Intensive Ther 2014; 46(5): 361-380

Ann Thorac Surg 2010;90:e40–1
Annals Academy of Medicine. December 2011, Vol. 40 No. 12

• Critical Care Medicine: January 2019 -Volume 47 - Issue 1 - p 107
• doi: 10.1097/01.ccm.0000551005.59364.a2
• Research SnapshotTheater: Cardiovascular Pediatrics II

ECMO patients are prone to IAH
GIPS
FO AKI
ascites

Follow us on SoMe #BEACH2019

@FOAMecmo - @avkwong

DownloadWhova App

Follow your group…

• (Contra-)indications + ECMO principles
• Different ECMO modes (VV,VA,VAV)
• Vascular access
• Medical management (AB, nutrition, sedation)
• Importance of imaging
• Lung protective ventilation
• Weaning from ECMO
• Alarm setting
• Monitoring during ECMO
Welcome to 3rd BEACH
+ Hands-On Sessions

1. introduction and role of abdominal pressure in ecmo #beach2019 (malbrain)

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