Septic shock hemodynamics vikas kohli

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Hemodynamics and Cardiac Issues in Septic Shock

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  • Changes in CO and SV!
  • The CO and the SVR will modulate to maintain blood pressure even if CO is very low. Because of this phenomenon, the BP is not a good measure of cardiac output
  • VOLUME
  • LASIX; INOTROPY INCR
  • AWAKE
  • ECHO : LOOK AT FX; CONISDER LASIX; CONSIDER HIGHER MIL DOB
  • CHECK IV VOLUME STATUS AND INCREASE MILRINONE
  • Figure 1 and E1 Example of respiratory variation in arterial pressure in patient who is post aorto-coronary bypass surgery. There were no spontaneous efforts and the patient is on a volume control mode with tidal volume = 700 ml and a rate of 12 b/min. The pulmonary artery (PAP) and Central Venous Pressure (CVP) are also shown and show a rise in pressure during inspiration. The dUp and dDown components of spontaneous variations in arterial pressure are shown. The bars at the bottom mark inspiration. The arrow at the point marked “apnea” represents the end-expiration value for determining dUp and dDown.
  • Septic shock hemodynamics vikas kohli

    1. 1. Hemodynamics of Septic Shock Dr. Vikas Kohli MD FAAP FACC American Board CertifiedFetal Neonatal & Pediatric Cardiologist Indraprastha Apollo Hospital & Delhi Child Heart Center DELHI CHILD HEART CENTER
    2. 2. Definition of Shock• Shock is defined as a condition where the tissues in the body dont receive enough oxygen and nutrients to allow the cells to function.• This ultimately leads to cellular death, progressing to organ failure, and finally, if untreated, whole body failure and death. DELHI CHILD HEART CENTER
    3. 3. What Defines the Cardiac Output• Cardiac Output is a function of – HEART RATE – STROKE VOLUME• Affected by oxygen carrying capacity• Variables Affecting are: – PRELOAD – MYOCARDIAL FUNCTION – AFTERLOAD DELHI CHILD HEART CENTER
    4. 4. Basic Concepts • Cardiac Output - amount of blood pumped out of the ventricles each minute • Stroke Volume - amount of blood ejected by the ventricle with each contraction • CO = HR x SV Decreased SV usually produces compensatory tachycardia.. So. . .changes in HR can signal changes in CO 4 DELHI CHILD HEART CENTER
    5. 5. Basic Concepts• Systemic Vascular Resistance – Measurement of the resistance (afterload) of blood flow through systemic vasculature – *Increased SVR = vasoconstriction – *Decreased SVR = vasodilation• Blood Pressure – BP = CO x SVR** SVR can increase to maintain BP despite inadequate CO 5 DELHI CHILD HEART CENTER
    6. 6. Basic Concepts• BP = CO x SVR• CO and SVR are inversely related CO and SVR will change before BP changes * Changes in BP are a late sign of hemodynamic alterations 6 DELHI CHILD HEART CENTER
    7. 7. Stroke Volume Components Stroke Volume  Preload: the volume of blood in the ventricles at end diastole and the stretch placed on the muscle fibers  Afterload: the resistance the ventricles must overcome to eject it’s volume of blood  Contractility: the force with which the heart muscle contracts 7 DELHI CHILD HEART CENTER
    8. 8. Cardiovascularcharacteristics of sepsis• Systemic vasodilation and hypotension• Tachycardia• Increased cardiac output (hyperdynamic), although contractility maybe depressed; hypodynamic in late shock• Ventricular dilation; decreased ejection fraction• Loss of sympathetic responsiveness DELHI CHILD HEART CENTER
    9. 9. Clinical Correlation of SVR• Clinical assessment of SVR – Would BP be a good reflection of decreasing myocardial function ?-NO – That would be a late indicator – When dec in CO starts: body first compensates by vasoconstriction – The peripheries are cold – You touch the feet of a pt and they are cold indicates increased SVR DELHI CHILD HEART CENTER
    10. 10. Drop in Urine Output• When Splanchnic circulation gets vasoconstricted renal being part of this- urine output drops• Early detection of Inc SVR is important• Clinical correlate – Cold Extremities• Warm well perfused extremities on the other hand indicate a vasodilated state DELHI CHILD HEART CENTER
    11. 11. • Is the Cardiac Output low ? – Cardiac output is the end point of • Preload, • Myocardial factors & • Afterload• Decreased Pulse volume with cold extremities is an indication of Low Cardiac output DELHI CHILD HEART CENTER
    12. 12. How do you clinicallydetermine preload is less• Press on the liver gently without waking the patient up• If heart rate decreases and BP increases by few points (on arterial trace) preload is less DELHI CHILD HEART CENTER
    13. 13. DELHI CHILD HEART CENTER
    14. 14. Clinical Scenarios-3 mo old• DOA 0: • Dopa 5 – Hr 180 • Dobuta 5 – Bp 60/40 • Mil .3 – CVP 8 – Urine OP 1.5 cc/Kg/hr – Extr: warm – Pulses fair DELHI CHILD HEART CENTER
    15. 15. SCENARIO 1• DOA 0: • Dopa 5 – Hr 190 Inc • Dobuta 5 – Bp 55/35 dec • Mil .3 – CVP 7 Dec – Urine 1.2cc/Kg/hr dec – Extr: not warm • WHAT WOULD – Pulses fair dec YOU DO ? DELHI CHILD HEART CENTER
    16. 16. SCENARIO 2• DOA 0: • Dopa 5 – Hr 190 • Dobuta 5 – Bp 54/32 dec • Mil .3 – CVP 10 inc – Urine OP 1 cc/Kg/hr • WHAT IS THE – Extr: cold INTERPRETATION – Pulses fair • WHAT ACTION DELHI CHILD HEART CENTER
    17. 17. SCENARIO 3• DOA 1: • Dopa 5 – Hr 190 inc • Dobuta 5 – Bp 95/65 • Mil .3 – CVP 10 – Urine OP 1.5 cc/Kg/hr – Extr: NOT • WHAT IS YOUR OPTIMALLY INTERPRETATION WARM – Pulses fair • WHAT ACTION DELHI CHILD HEART CENTER
    18. 18. SCENARIO 4• DOA 2: • Dopa 5 – Hr 190 INC • Dobuta 5 – Bp 52/36 DEC • Mil .3 – CVP 6 DEC – Urine OP 0.8 cc/Kg/hr • WHAT IS THE – Extr: WARM INTERPRETATION – Pulses WEAK • WHAT ACTION DELHI CHILD HEART CENTER
    19. 19. SCENARIO 5• DOA 2: • Dopa 5 – Hr 160 • Dobuta 5 – Bp 72/44 • Mil .3 – CVP 6 – Urine OP <1 cc/Kg/hr • INTERPRETATION – Extr: not optimally warm • ACTION – Pulses fair DELHI CHILD HEART CENTER
    20. 20. Cardiovascularcharacteristics of sepsis (II)• Hypovolemia due to vascular leakage; central venous pressure may be decreased or increased depending upon fluid resuscitation• Compromised nutrient blood flow (microcirculation) to organs; decreased organ oxygen extraction DELHI CHILD HEART CENTER
    21. 21. Perfusion of Organs • Brain/Heart are preferentially perfused vs. Kidneys/Liver • Kidneys/Liver are preferentially perfused over Skeletal muscle • Arteriolar constriction via sympathetic activation is mostly responsible for this shunting DELHI CHILD HEART CENTER
    22. 22. Maldistribution Cell ischemia CO2 O2 Rich perfusion DELHI CHILD HEART CENTER
    23. 23. Dellinger, Crit Care Med 2003 , 31(3): 946-55 DELHI CHILD HEART CENTER
    24. 24. Dellinger, Crit Care Med 2003 , 31(3): 946-55 DELHI CHILD HEART CENTER
    25. 25. Dellinger, Crit Care Med 2003DELHI CHILD HEART , 31(3): 946-55 CENTER
    26. 26. The nature of septic shock • Shock CO SVR MAP PCWP CVP Early ↑↑↑ ↓↓↓ ↔ or ↓↑ ↓ ↓ Late ↓↓ ↓↓ ↓↓ ↑ ↑ or ↔ • Abnormalities of microcirculation – Skeletal muscle: long arteriole contracted, short dilated – Intestine: redistribute from mucosa to muscle and serosa – Mesenteric: ↓ in liver, pancrease, stomach, colon – Kidney: hypoperfusion, vasoconstriction – Coronary: vasodilation • Abnormalities of Oxygen delivery and uptake DELHI CHILD HEART CENTER
    27. 27. TOE – CORE TEMP DIFFERENCERelationship between core/peripheral temperature gradient and central hemodynamics in children after open heart surgery Crit Care Med. 1989 Jul;17(7):638-40• core/peripheral temperature gradient correlated directly with SVRI & inversely with CI• not strong enough to be of value in predicting central hemodynamic status in children after heart surgery DELHI CHILD HEART CENTER
    28. 28. ECHOCARDIOGRAPHIC MONITORINGDELHI CHILD HEART CENTER
    29. 29. DELHI CHILD HEART CENTER
    30. 30. DELHI CHILD HEART CENTER
    31. 31. DELHI CHILD HEART CENTER
    32. 32. DELHI CHILD HEART CENTER
    33. 33. DELHI CHILD HEART CENTER
    34. 34. Mixed Venous Oxygen Saturation 34 DELHI CHILD HEART CENTER
    35. 35. Mixed Venous OxygenationMonitoring(SvO2) • Measures the amount of O2 in the blood (on the Hgb molecule) returned to the heart – Helps to demonstrate the balance between O2 supply & demand in the body (tissue oxygenation) • Helps to interpret hemodynamic dysfunction when used with other measurements • Normal: 70% (60-80) 35 DELHI CHILD HEART CENTER
    36. 36. Mixed Venous Oxygen Saturation End result of O2 delivery and consumption Measured in the SVC  An average estimate of venous saturation for the whole body.  **Does not reflect separate tissue perfusion or oxygenation 36 DELHI CHILD HEART CENTER
    37. 37. Mixed Venous Oxygen Saturation  Continuous measurement  “Early” warning signal to detect oxygen transport imbalances  Evaluates the effect of the therapeutic interventions  Identify potential patient care consequences (turning, suctioning) 37 DELHI CHILD HEART CENTER
    38. 38. Mixed Venous Oxygen Saturation There are four factors that affect SVO 2: 1. Hemoglobin 2. Cardiac output 3. Arterial oxygen saturation (SaO2) 4. Oxygen consumption (VO2) 38 DELHI CHILD HEART CENTER
    39. 39. SvO2 ApplicationIn a case of increased SVR with decreased CO. Nitroprusside wasstarted. The increase in SvO2 and increase in CO reflects theappropriateness of therapy. 39 DELHI CHILD HEART CENTER
    40. 40. Ways To Increase O2 Delivery Increase CO  increase HR, optimize preload, decrease afterload, add positive inotropes Increase Hgb, increase SaO2 Improve pulmonary function  pulmonary toilet, prevent atelectasis  ventilation strategies 40 DELHI CHILD HEART CENTER
    41. 41. Ways To Decrease O2 Demand Decrease muscle activity  sedatives, (paralytics)  prevent/control seizures  prevent/control shivering  space care activities Decrease temperature  prevent/control fever 41 DELHI CHILD HEART CENTER
    42. 42. Oxygen-hemoglobin DissociationCurve Tissue 02 Delivery DELHI CHILD HEART CENTER
    43. 43. How can Oxygen Delivery/Consumption be measured? • Mixed Venous Oxygen Saturation • Lactic Acid • pH > 7.2, Anion Gap closed DELHI CHILD HEART CENTER
    44. 44. Mixed Venous OxygenSaturation • Affected by both delivery and by consumption – An abnormally low value (<70) reflects either inadequate delivery or too high consumption by the body’s organs (or both) – An abnormally high value (>82-85) should raise concern for inadequate consumption by the body’s organs in the face of adequate delivery or shunting of blood from the arterial to the venous side DELHI CHILD HEART CENTER
    45. 45. Lactic Acid • Lactic Acid is produced when cells have decreased access to oxygen or decreased ability to utilize delivered oxygen, converting to anaerobic metabolism • Note: Lactic Acid levels should be available within ½ hour of blood draws (call the lab and also report to your ICU attending if there are significant delays) DELHI CHILD HEART CENTER
    46. 46. Lactic Acid Interpretation • All values > 2 are abnormal • A lactate of >3.5 on admission conveys a 57% mortality rate • A rise in serum lactate, as well as a failure to return to normal by 48 hours, is associated with a 74% mortality • Note: Lactate in trauma is NOT indicative of mortality (5.4% mortality with Lactate elevation), but is helpful in assessing adequacy of resuscitation DELHI CHILD HEART CENTER
    47. 47. TRACE WITH MARKED RESPVARIATION DELHI CHILD HEART CENTER
    48. 48. MAP = DBP + pulse pressure/3 DELHI CHILD HEART CENTER
    49. 49. • Mean Arterial Pressure (MAP) – Best indicator of tissue perfusion – Average driving pressure of blood during cardiac cycle – Time weighted – diastole is longer DELHI CHILD HEART CENTER
    50. 50. Pulse pressure – Reflects difference in volume ejected from LV into arterial vessels and volume that exits simultaneously – Function of SV and SVR – Wide PP – increase in SV and decrease in SVR – Narrow PP – Decreased SV and increased SVR DELHI CHILD HEART CENTER
    51. 51. DELHI CHILD HEART CENTER
    52. 52. CVP: Variables Affecting• Reflects Pressure while preload is affected by RVEDVolume• Therefore: RV Compliace is very important• Usually: Rv filling=LV filling• But, we usually deal with the unusual DELHI CHILD HEART CENTER
    53. 53. CVP Vs Peripheral Pressure• Peripheral venous pressure is an alternative to central venous pressure in pediatric surgery patients – Major surgery : 50 pts – PVP showed good agreement with CVP – During Controlled and Spont Ventilation• Acta Anaesthesiol Scand. 2004 Oct;48(9):1101-4 DELHI CHILD HEART CENTER
    54. 54. Low IVC Catheters• Low inferior vena caval catheters for hemodynamic and pulmonary function monitoring in pediatric critical care patients• 30 pts• LIVC and CVP pressures correlated• PCO2 correlated; Not PO2• Mean Airway and Intraabdominal Press did not affect these relationshipsPediatr Crit Care Med. 2004 Jan;5(1):14-8 DELHI CHILD HEART CENTER
    55. 55. Arterial Trace: Variables affectingOutput• overestimate of systolic pressure due to systolic overshoot• eliminated by increasing the damping of the system by using smaller gauge tubing• This reduces the resonant frequency of the system – frequency of > 30 Hz for heart rates up to 180/min – > 20 Hz for rates up to 120/min while retaining sufficient sensitivity DELHI CHILD HEART CENTER
    56. 56. Arterial Trace: Variables affectingOutput• In mechanically ventilated pts: IPPV during inspiration increases LV output & systolic arterial pressure early in inspiration• followed a few heart-beats later by a fall• This is exaggerated with reduced preload DELHI CHILD HEART CENTER
    57. 57. Arterial Trace: Variablesaffecting Output D DOWN normal: 5-6 mmHgA better predictor of responsiveness to fluid loadingDue to a a transient fall in venous returnDirectly affected by tidal volumeExaggerated in presence of air trapping or fall in chest wallcompliance DELHI CHILD HEART CENTER
    58. 58. Arterial Trace: Variablesaffecting Output D UP normal: 2-4 mmHgOccurs in early inspirationDue to augmentation of stroke volume due to increase in L sidedpreload.In patient with impaired LV contractility may also reflect afterloadreducing effect of positive intrathoracic pressure DELHI CHILD HEART CENTER
    59. 59. Pulse Oximetry• Indicative of Stroke volm also !• May be able to indicate Pulsus paradoxsus• Too many variables affecting it• PEDIATRICS Vol. 109 No. 4 April 2002, pp. 673-677 DELHI CHILD HEART CENTER
    60. 60. PiCCO • Thermodilution • Via Central Venous Line • Assess: – Preload – Afterload – Cardiac Output• Transplant Proc. 2005 Sep;37(7):3168-70 • Has pediatric size• Anesth Analg. 2003 Nov;97(5):1283-8 catherters DELHI CHILD HEART CENTER
    61. 61. THERMODILUTION CO• Beat to Beat Pulse Contour Cardiac Output (PCCO)• Global Enddiastolic Volume (GEDV)• Intrathoracic Blood Volume (ITBV)• Continuous volm responsiveness (SVV, PPV)• Global Ejection Fraction (GEF)• Cardiac Function Index (CFI)• Extravascular Lung Water (EVLW)• Pulm Vascular Permeability Index (PVPI) DELHI CHILD HEART CENTER
    62. 62. Continous Cardiac Output MonitoringDELHI CHILD HEART CENTER
    63. 63. FLOWTRAC SENSOR DELHI CHILD HEART CENTER
    64. 64. • Flowtrac sensor: for continous C.O. monitoring• PreSep:Continous Systemic Venous O2 measurement (ScVO2) DELHI CHILD HEART CENTER
    65. 65. • Continuous Cardiac Output, Cardiac• Index, Stroke Volume, Stroke Volume Index, Systemic Vascular Resistance*, Systemic• Vascular Resistance Index*, and Stroke Volume Variation DELHI CHILD HEART CENTER
    66. 66. Cardiac output Monitoring• Gold Standards: Fick method: CO=O2 consumption/avDO2• Alternatives: – indicator dilution methods • Dye dilution: Indocyanine green • Thermodilution: Swan Ganz, PiCCO – Echocardography – Doppler techniques – Bioimpedance DELHI CHILD HEART CENTER
    67. 67. PiCCO DELHI CHILD HEART CENTER
    68. 68. Hemosonics DELHI CHILD HEART CENTER
    69. 69. Hemosonics DELHI CHILD HEART CENTER
    70. 70. ASSESMENT OF FLUID REQUIREMENTDELHI CHILD HEART CENTER
    71. 71. IS FLUID REQUIRED ?• Systolic pressure Variation• Pulse Pressure Variation• Stroke Volume Variation DELHI CHILD HEART CENTER
    72. 72. Systolic Pressure Variation• ∆SPV=Max-Min Systolic pressure in a single Mech breath Berkenstadt et al British Journal of Anaesthesia 2005 94(6):721-726 DELHI CHILD HEART CENTER
    73. 73. Magder et al AmJRCCMed Vol 169. pp. 151-155, (2004) DELHI CHILD HEART CENTER
    74. 74. Eg of Systolic Pulse Variation BaselinemmHg (“apnea”)150- dUP dDown SPV 75-PAPCVP 0- E1 Insp Insp DELHI CHILD HEART Insp CENTER
    75. 75. DELHI CHILD HEART CENTER
    76. 76. Pulse pressure variability• PPV=max-min arterial pressure /(max+min/2)• Am J Respir Crit Care Med 2000; 162: 134–8 DELHI CHILD HEART CENTER
    77. 77. Stroke Volume VariationDELHI CHILD HEART CENTER
    78. 78. Stroke Volume Variation• SVV=Max-Min SV/Mean Stroke Volm• Calculated automatically by the PiCCO System DELHI CHILD HEART CENTER
    79. 79. Normal Variation of SV DELHI CHILD HEART CENTER
    80. 80. SVV and Ventilation DELHI CHILD HEART CENTER
    81. 81. Calculation of SVV Anesth Analg 2001; 92: 984–9 Intensive Care Med 2002; 28: 192–8 Crit Care Med 2003; 3: 1399–1404 DELHI CHILD HEART CENTER
    82. 82. Sensitivity & Specificity of SVV NS PTS SEPSIS• Sensitivity 94 96• Specificity 79 95 DELHI CHILD HEART CENTER
    83. 83. DELHI CHILD HEART CENTER
    84. 84. DELHI CHILD HEART CENTER
    85. 85. Contractility/ Inotropy Stroke Heart Volume Rate Preload Cardiac Afterload Output Adequacy of Oxygenation of Blood (Hemoglobin) Perfusion of Organs Oxygen Health of Dissociation Tissues toUtilize Available Ability of Organs to Curve—Ability to Release Oxygen Oxygen UtilizeCHILD HEART DELHI Oxygen at Tissues CENTER
    86. 86. Goals of Perfusion: • “Goal-Directed Therapy”: • maintain – MAP – Urine Output – CVP 8-10 – (Lactic Acid <2) – (SvO2 70-84) – (pH>7.2) DELHI CHILD HEART CENTER
    87. 87. Longterm outcome DELHI CHILD HEART CENTER
    88. 88. THANK YOU TALK WILL BE AVAILABLE ON WWW.SLIDESHARE.COMDELHI CHILD HEART CENTER
    89. 89. Reading the RA CVP) Waveform 90 DELHI CHILD HEART CENTER

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