Hemodynamic parameters for resuscitation in septic shock

ABLAUF DES HÄMODYNAMISCHEN MANAGEMENTS BEI SEPSIS
PROCESS OF HEMODYNAMIC MANAGEMENT IN SEPSIS
Hämodynamische Parameter bei der Stabilisierung des
septischen Schocks
Hemodynamic parameters for resuscitation in septic shock
Weimar, 5. – 08. September 2007
Michael Quintel
Universit Universitätsklinikum
tsklinikum
Georg Georg-August August Universit Universität t GGöttingen
Göttingen ttingen

Advanced hemodynamic monitoring:
clinical picture:
hemodynamic instability
oligo-anuria
lactate acidosis
high airway pressures
when and how?
volume status:
BP-tracing,
chest X ray,
fluid balance
hemoglobin
centralisation
ventilation:
mean airway pressure,
tidal volume,
respiratory frequency
therapeutic options:
volume therapy or
negative fluid balance
transfusion (Hb < 7,5 g/dl ? )
catecholamines
optimization of ventilation

Start with a Subjective Assessment of Skin Temperature to Identify
Hypoperfusion in Intensive Care Unit Patients
Kaplan LJ, et al. J Trauma 2001; 50: 620-7
Cold extremities = Hypoperfusion: 39% pos. pred.
Cold extr. + low HCO 3 = Hypoperfusion: 98% pos. pred.

VO 2
• stress
• pain
• hyperthermia
• shivering
• work of
breathing
-
SvO2 oder ScvO 2
DO 2
• PaO2
• Hgb
• cardiac
output
70%
DO 2
• PaO2
• Hgb
• cardiac
output
+
VO 2
• hypothermia
• anesthesia
• decrease
work of
breathing

Non-invasively: clinical signs
HR - MAP
capillary refill
urine output
core - peripheral temperature difference
• moderate bleeding
• sensitivity: 22% (95% CI: 6-48%)
McGee et al. JAMA 1999; 281:1022

clinical picture:
high airway pressures
hemodynamic instability
oligo-anuria
lactate acidosis
Advanced monitoring:
when and how?
advanced monitoring
volume status:
BP-tracing, ITBVI,
EVLWI a.s.o.
(PCWP, CVP, chest xray,
fluid balance
hemoglobin
centralisation,
SVR, HZV, PDR, UO
ventilation:
mean airway
pressure, tidal
volume, respiratory
frequency
SvO 2 , ScvO 2
DO 2 , VO 2
PaP, PVR
therapeutic options:
volume therapy or
negative fluid balance
transfusion (Hb < 7,5 g/dl ?)
catecholamines
optimization of ventilation
prostacycline inhalation, NO

6 8 12 14 16 18 20 22 24 26 28 30 ml/kg BW
volume load
EVLWI for "guidance" of volume therapy
catecholamines
volume restriction
negative fluid balance

Fluids improves outcome
"Early Goal-Directed Therapy" (EGDT)
Rivers E et al. N Engl J Med 2001; 345: 1368
6 hours of resuscitation in the ER:
– control group (n=133):
• O 2
• CVP: 8-12 mmHg
• MAP >65 mmHg
– EGDT group (n=130):
• same
• ScvO 2 > 70%
• more fluids, RBC
• more dobutamine
mortality: 46 vs. 30% (p=0.009)

elative reduction of mortality: 34,4%
Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M for
the early goal-directed therapy collaborative group.
Early goal-directed therapy in the treatment of severe sepsis and septic shock.
N Engl J Med 2001; 345:1368-1377

Fluids may be harmful: the SOAP study
Vincent JL, et al. Crit Care Med 2006; 34: 344–353

Rivers EP.
Fluid-management strategies in acute lung
injury--liberal, conservative, or both?
N Engl J Med 2006; 354:2598-600

Rivers EP.
Fluid-management strategies in acute lung
injury--liberal, conservative, or both?
N Engl J Med 2006; 354:2598-600

DO 2= (SV • P) • (Hb • 1.39 • SaO 2+0.003 • PaO 2) ~ 1000ml/min
VO 2 = CO • (CaO 2 - CvO 2 ) ~ 250 ml/min (ScvO 2 ~70-75%)
in the critically ill:
Basic physiology
in shock = VO 2 > DO 2
CO CaO 2
DO 2
VO 2

Hypovolaemia and DO 2
DO 2 = CO • CaO 2
CO = SV • P
First thing to do in hypovolemia:
oxygen
fluids

VO 2
Oxygen Delivery
volume status,
contractility,
π • ΔP • r 4
8 • η • l
DO 2
CO • CaO2 VO 2
temperatue analgesia, sedation
Hb • 1.39 • O 2-Sat.
+
0.003 • paO 2

Mauermann WJ, Nemergut EC.
The Anesthesiologist’s Role in the Prevention of Surgical Site Infections
Anesthesiology 2006; 105:413–21

Proportion Surviving
Connors AF et al.: JAMA 1996
SUPPORT: The effectiveness of right heart
catheterization in the initial care of critically
ill patients
1,0
0,9
0,8
0,7
0,6
p=0.02
0 5 10 15 20 25 30
Follow-up Time [d]
No RHC
RHC

SUPPORT: The effectiveness of right heart catheterization in
the initial care of critically ill patients
with PAC without PAK
• 30 d mortality 37,5% 32,8%
• 180 d mortality 54,0% 48,8%
• ICU stay 14,8 d 13,0 d
• costs [$] 49.300 35.700
• highest catheter-associated „risik" in postoperative less seroius ill patients
Connors AF et al.: JAMA 1996

Pulmonary Artery Catheter in shock and ARDS
Richard C. et al (2003) JAMA 26:2713-2720

Malbrain ML.
Is it wise not to think about intraabdominal hypertension in the ICU?
Curr Opin Crit Care 2004; 10:132-45

Kubitz JC, Kemming GI, Schultheiss G, Starke J, Podtschaske A, Goetz AE, Reuter DA.
The influence of PEEP and tidal volume on central blood volume.
Eur J Anaesthesiol 2006; 23:954-61

Kubitz JC, Kemming GI, Schultheiss G, Starke J, Podtschaske A, Goetz AE, Reuter DA.
The influence of PEEP and tidal volume on central blood volume.

Crit Care Med 2005; 33:1119–1122
a) the risks are mainly due to insertion of a central catheter, not a pulmonary artery catheter
b) continuous monitoring of left ventricular filling pressures, pulmonary vascular pressures, and
mixed venous oxygen saturation is a unique feature
c) additional costs are minimal relative to the cost of intensive care
d) measurement errors require ongoing programmatic educational efforts
e) pulmonary artery catheter-derived data need to be used within the context of a defined
treatment protocol
f) no monitoring device, no matter how simple or sophisticated, will improve patient-centered
outcomes unless coupled with a treatment that, itself, improves outcome.

National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network;
Wheeler AP, Bernard GR, Thompson BT, Schoenfeld D, Wiedemann HP, deBoisblanc B, Connors AF Jr, Hite RD, Harabin AL.
Pulmonary-artery versus central venous catheter to guide treatment of acute lung injury.
N Engl J Med 2006; 354(21):2213-24

National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network;
Wheeler AP, Bernard GR, Thompson BT, Schoenfeld D, Wiedemann HP, deBoisblanc B, Connors AF Jr, Hite RD, Harabin AL.
Pulmonary-artery versus central venous catheter to guide treatment of acute lung injury.
N Engl J Med 2006; 354(21):2213-24

National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network;
Wheeler AP, Bernard GR, Thompson BT, Schoenfeld D, Wiedemann HP, deBoisblanc B, Connors AF Jr, Hite RD, Harabin AL.
Pulmonary-artery versus central venous catheter to guide treatment of acute lung injury.
N Engl J Med 2006; 354(21):2213-24

Static measures in critical illness
Lichtwarck -Aschoff et al,
Intensive Care Med 1992;
18:142-7

Static measures in critical illness
r=0.1
ITBV
r=0.66
r=0.06
Sakka SG et al.,
J Crit Care 1999;
14:78-83

AUC=0.870
Volume responsiveness
Predictors of increase in SV by >5% after volume loading
AUC=0.493
AUC=0.593
AUC=0.729
Berkenstedt H et al., Anesth Analg 2001; 92:984-9

CI and preload parameters
Preload ≠ Fluid responsiveness
Reuter DA et al., Intensive Care
Med 2002; 28: 386-8

"overhydrated patient"

patient after "aggressive" CVVH (-17 l)

MAP
End point of fluid therapy
The…
PCWP
GEDV
ITBV
CVP
…normalization of
EVLW

How to get a clue ?
or
The story of invasiveness
Really non invasive
partial CO 2 rebreathing (NiCO), impedance cardiography
Non-invasive/invasive without need for vascular access
TTE, TEE, ultrasound mesurements
Invasive but hooking up to an established vascular access
Pulse contur, pulse pressure anylysis (Lidco, Vigileo)
Invasive own vascular access required
PiCCO, PAK

Reuter DA, Goetz AE.
Messung des Herzzeitvolumens
Anaesthesist 2005; 54:1135–1153

Critchley LAH, Peng ZY, Fok BS, James AE.
The effect of peripheral resistance on impedance
cardiography measurements in the anesthetized dog
Anesth Analg 2005; 100:1708 –12

The lack of agreement between this noninvasive method and cardiac output was
proportional to the intrapulmonary right-to-left shunt, indicating that this noninvasive
technique is not appropriate for monitoring of cardiac output in patients with increased
venous admixture.
de Abreu MG, Quintel M, Ragaller M, Albrecht DM.
Partial carbon dioxide rebreathing: a reliable technique for noninvasive measurement of nonshunted
pulmonary capillary blood flow.
Crit Care Med 1997; 25:675-83

Transthoracic or esophageal echo
low filling (empty ventricels)
RV-dilation and empty left ventricle
reduced motility
reduced EF
LV-Dilatation and so on

Bendjelid K, Romand JA.
Fluid responsiveness in mechanically ventilated patients: a rev iew of indices used in intensive care
Intensive Care Med 2003, 29:352–360

Pulse Pressure and stroke volume
SBP
DBP
PP ~
SV

SV
x
HR
CO
Calculation of stroke volume
stroke volume ist proportional to pulse pressure
patient related estimation of vascular bed influence
2 main factors influencing the arterial pulse pressure
compliance of large vessels (age, gender, height, body mass)
peripheral resistance
heart rate detection from the pressure tracing (upslope)

CVP
bolus -
injection
Transpulmonary indicator dilution
technique
−ΔT in °C
0.3
0.2
0.1
0.0
mtt
0 10 20 30 40 50
arterial thermistor catheter
CO/CI
GEDV (ITBV)
EVLW
dst
[s]

Isakow W, Schuster DP.
Extravascular lung water measurements and hemodynamic monitoring in the critically ill:
bedside alternatives to the pulmonary artery catheter.
Am J Physiol Lung Cell Mol Physiol 2006; 291:L1118-31

RA
Pressures to estimate LV preload
and influences
PA
PAP
CVP PAOP
LVEDP
RV
CVP PAP PAOP LAP LVEDP LVEDV
Trikuspidalis vitium
RV diastolic disturbane
pulmonalvascular resistance
HR
alveolar pressure
pulmonal vasculary disease
Mitralis vitium
HR
PV
LAP
LA
LV
LV diastolic disturbance
Ao

Extravascular lung water (EVLW)
EVLW corresponds to the water content of the whole lungs and is
calculated by subtraction of ITBV from ITTV
=
ITTV
ITBV
EVLW
RAEDV RVEDV PTV LAEDV LVEDV
RAEDV RVEDV PBV LAEDV LVEDV
EVLW
EVLW

Minimal invasive CO measurement
z. B. APCO, LiDCO, partial CO 2 rebreathing
identification of patient at/with risk
early "resuscitation" succesful
ScvO 2
"instable" – more information needed
continuous sophisticated monitoring required
minimal "invasive" PiCCO technique
Limon for splanchnic perfusion
TEE
sucessful
extended and individualized presentation of parameters
early identification

Bajorat J, Hofmockel R, Vagts DA, Janda M,
Pohl B, Beck C, Noeldge-Schomburg G.
Comparison of invasive and less-invasive techniques of cardiac
output measurement under different haemodynamic
conditions in a pig model
Europ J Anaesthesiol 2006; 23: 23–30

Sakka SG, Klein M, Reinhart K, Meier-Hellmann A.
Prognostic value of extravascular lung water in critically ill
patients.
Chest 2002; 122:2080-6

Sakka SG, Klein M, Reinhart K, Meier-Hellmann A.
Prognostic value of extravascular lung water in critically ill
patients.
Chest 2002; 122:2080-6

Sakka SG.
Assessing liver function
Curr Opin Crit Care 2007; 13:207–214

Poeze M, Solberg BC, Greve JW, Ramsay G.
Monitoring global volume-related hemodynamic or regional variables after initial resuscitation:
What is a better predictor of outcome in critically ill septic patients?
Crit Care Med 2005; 33:2494-500

PCWP, PAOP does not allow to distinguish
between hydrostatic and permeability edema !
Ware LB, Matthay MA.
Clinical practice.
Acute pulmonary edema.
N Engl J Med 2005; 353:2788-96

Monnet X, Anguel N, Osman D, Hamzaoui O, Richard C, Teboul JL.
Assessing pulmonary permeability by transpulmonary thermodilution allows differentiation of
hydrostatic pulmonary edema from ALI/ARDS.
Intensive Care Med 2007 Jan 13; [Epub ahead of print]

Rivers EP, Kruse JA, Jacobsen G, Shah K, Loomba M, Otero R, Childs EW.
The influence of early hemodynamic optimization on biomarker patterns of severe sepsis and septic shock.
Crit Care Med 2007; 35:2016-2024

Rivers EP, Kruse JA, Jacobsen G, Shah K, Loomba M, Otero R, Childs EW.
The influence of early hemodynamic optimization on biomarker patterns
of severe sepsis and septic shock.
Crit Care Med 2007; 35:2016-2024

clinical signs of hypoperfusion
CNS, temperature, capillary refill , UO
biochemical signals:
pH, ScvO 2 , lactate
hemodynamic values
CO, ITBV, SVV, MAP, HR
However treat the patient not values!
Actually your own brain is still the best available monitor !