download as .pdf - PULSION Medical Systems SE

More documents

Recommendations

Info

What are the relevant hemodynamic targets during septic shock and or during ARDS? (interactive session) Case Study A 62 year old woman is admitted to ICU in a coma related to drug induced self poisoning. This is complicated by aspiration pneumonia and moderate renal failure. She has a previous history of COPD (Chronic Obstructive Pulmonary Disease), and severe hypertension. A culture of her tracheal secretions reveals evidence of Staph aureus, so she was commenced on amoxicillin–clavulanic acid combination. She was intubated and ventilated. Her blood pressure then dropped from 90/63/50 to 65/43/32 mmHg, with a blood lactate of 3.5 mm/L, and PaO / FiO ratio 2 2 of 280. She was given a rapid infusion of one liter of normal saline, and a norepinephrine (NE) infusion was started at 0.3 µg/Kg/min. Post Infusion hemodynamics ABP 74/55/45 mmHg Urine flow Low PaO 2 /FiO 2 ratio 210 Lactate 4 mmol/L Echocardiography showed a left ventricular ejection fraction (LVEF) of 60%, no left ventricular dilatation and moderate right ventricular dilatation. An arterial catheter and central venous catheter were inserted - ScvO 2 70%, CVP 10 mmHg and PPV 20%. Professor Jean Louis Teboul Medical ICU, Bicetre Hospital, University Paris South, France Prof Teboul is a Professor of Therapeutics and Critical Care Medicine, at the University Paris- South in France. He works clinically at the medical intensive care unit of the Bicetre University Hospital near Paris. His main research interests are in heart-lung interactions, cardiovascular performance, regional blood flow assessment, tissue oygenation, invasive and noninvasive hemodynamic monitoring, and assessment of volume status. Prof Teboul has published around 130 original papers and 100 book chapters, almost all of them in the field of hemodynamics. He has given 230 invited lectures in international congresses and 150 invited lectures in French congresses. Question 1: How much can we rely on the CVP value in this patient (10mmHg)? 80 70 60 50 40 30 20 10 0 It suggests a normal right ventricular preload It suggests a high right ventricular preload Right ventricular preload can still be low It suggests fluid unresponsiveness *Results (in%) of the votes of an interactive session (audience 300) during ISICEM, 2012 Central venous pressure is commonly cited as one of the goals for resuscitation. The Surviving Sepsis Guidelines(1) give a range of 8-12mmHg for initial resuscitation (first 6 hours) quoting the Rivers study as its main source (2). This study however, used the same range in both treatment arms and so therefore did not test this parameter for its sensitivity as a resuscitation goal. The CVP is not a simple measurement. It is affected by many confounding factors including PEEP, the fact that it must be measured at the end of expiration, and even whether the transducer has been placed at the anatomical zero level. In fact the CVP has been repeatedly shown in the literature to not assess right ventricular preload appropriately, and it is not able to predict fluid responsiveness (3, 4). The CVP should not be used to make clinical decisions regarding fluid management.
Question 2: Which level of MAP is it best to target? 80 60 40 20 0 *Results (in%) of the votes of an interactive session (audience 300) during ISICEM, 2012 The Surviving Sepsis Guidelines cite a MAP of greater ≥ 65mmHg. The source of this was again the Rivers study where again this was used in both treatment arms. In fact there is evidence that the target MAP is more complicated than this. For example, a history of hypertension affects the point at which an increase in MAP will lead to an increase in organ blood flow because of auto-regulatory factors (5). There is also evidence in septic patients that incre- ” asing arterial blood pressure does not improve microcirculatory blood flow (6). All septic patients are not identical, and it is unrealistic to expect that the optimal arterial pressure will be identical in all patients – One size does not fit all! Therefore, MAP must be targeted after individualised assessment. Question 3: What do you think about the ScvO2 value in this patient (72%)? 80 60 40 20 0 55 mmHg 65 mmHg 75 mmHg It sugests a normal tisuue oxagention status The CVP should not be used to make clinical decisions regarding fluid management. It suggests an error since it is impossible to have both shock and an ScvO 2 of > 70% It suggests some impairment in oxygen extraction *Results (in %) of the votes of an interactive session (audience 300) during ISICEM, 2012 In the Rivers study the ScvO 2 was initially low (49%), suggesting a normal oxygen extraction capacity. However, actually this situation is uncommon in cases of severe sepsis where ScvO 2 is usually normal or even high (7-10). PULSION Abstract Book - ISICEM Brussels 2012 page 21 Question 4: What is your attitude in terms of hemodynamic therapy? 80 70 60 50 40 30 20 10 0 Infuse IV fluids again Add dopamine Increase norepinephrine Add doputamine Add steroids Nothing more *Results (in%) of the votes of an interactive session (audience 300) during ISICEM, 2012 The pulse pressure variation (PPV) is 20%. As this patient is not breathing spontaneously, has no arrhythmi- as, normal tidal volume (9mL/kg), and normal lung compliance, the PPV can be used as an ” indicator of fluid responsiveness so she was given one liter of saline and her hemodynamic and renal function improved. The NE infusion was stopped on day 2, however on day 3 she developed ARDS (Acute Respiratory Distress Syndrome), her P/F ratio decreased from 280 (day 1) to 120 (day 3). Protective lung ventilation was started with a tidal volume of 6mL/kg and PEEP 12 cmH O. On days 2 to 4 2 there was no other organ dysfunction.
Page 1: ISICEM 2012 in Brussels, Belgium PU
Page 4 and 5: The International Symposium on Inte
Page 6 and 7: A closer look at goal directed algo
Page 8 and 9: An algorithmic approach to the very
Page 10 and 11: Hemodynamic monitoring - accuracy v
Page 12 and 13: CVP, Blood Pressure and Urine Outpu
Page 14 and 15: CVP, Blood Pressure and Urine Outpu
Page 16 and 17: How to monitor fluid therapy - A cl
Page 18 and 19: How to monitor fluid therapy - A cl
Page 22 and 23: What are the relevant hemodynamic t
Page 24 and 25: Why should I bother about the ebb a
Page 26 and 27: Why should I bother about the ebb a
Page 28: PULSION Medical Systems SE • Hans

download as .pdf - PULSION Medical Systems SE

Create successful ePaper yourself

Delete template?

Save as template?