functional hemodynamic monitoring and management a practical
TRANSCRIPT
![Page 1: Functional Hemodynamic Monitoring and Management A practical](https://reader034.vdocuments.site/reader034/viewer/2022051522/587f57f91a28abca2d8c6a16/html5/thumbnails/1.jpg)
Functional Hemodynamic Monitoring and Management
A practical Approach
Daniel A. Reuter
Center of Anesthesiology and Intensive Care Medicine
Hamburg-Eppendorf University Hospital
Hamburg, Germany
Euronaesthesia 2006, Madrid, June 4
![Page 2: Functional Hemodynamic Monitoring and Management A practical](https://reader034.vdocuments.site/reader034/viewer/2022051522/587f57f91a28abca2d8c6a16/html5/thumbnails/2.jpg)
Early Optimization of Hemodynamics improves outcome
Kern JW and Shoemaker WC
Crit Care Med 30: 1686 – 1692, 2002
Metaanalysis of hemodynamic optimizaton
in high risk patientsRivers et al., N Engl J Med 345: 1368 – 1377, 2001
Early goal-directed therapy in the treatment
of severe sepsis and septic shock
![Page 3: Functional Hemodynamic Monitoring and Management A practical](https://reader034.vdocuments.site/reader034/viewer/2022051522/587f57f91a28abca2d8c6a16/html5/thumbnails/3.jpg)
• Measurement of Preload
• Assessing Fluid Responsiveness
• Measurement of SV/CO
1. Optimizing Stroke volume /Cardiac Output:
2. Optimizing Preload:
Goals of hemodynamic Management
3. Avoiding Fluid Overload• Assessing Pulmonary Edema
![Page 4: Functional Hemodynamic Monitoring and Management A practical](https://reader034.vdocuments.site/reader034/viewer/2022051522/587f57f91a28abca2d8c6a16/html5/thumbnails/4.jpg)
Preload Optimizitation as primary Step to optimize SV/CO
CO ?
? MacrocirculatoryDysfunctions
? MicrozirculatoryDysfunctions
? Organ Failure
low (too) high
CO ??
? (MacrozirculatoryDysfunctions)
? Formation of Edema
? MicrozirculatoryDysfunctions
? Organ Failure
Preload
![Page 5: Functional Hemodynamic Monitoring and Management A practical](https://reader034.vdocuments.site/reader034/viewer/2022051522/587f57f91a28abca2d8c6a16/html5/thumbnails/5.jpg)
Strokevolume
Preload
Ventricular Function Curve
![Page 6: Functional Hemodynamic Monitoring and Management A practical](https://reader034.vdocuments.site/reader034/viewer/2022051522/587f57f91a28abca2d8c6a16/html5/thumbnails/6.jpg)
Stepwise Fluid Loading to optimize SV
![Page 7: Functional Hemodynamic Monitoring and Management A practical](https://reader034.vdocuments.site/reader034/viewer/2022051522/587f57f91a28abca2d8c6a16/html5/thumbnails/7.jpg)
Stepwise Fluid Loading to optimize SV
![Page 8: Functional Hemodynamic Monitoring and Management A practical](https://reader034.vdocuments.site/reader034/viewer/2022051522/587f57f91a28abca2d8c6a16/html5/thumbnails/8.jpg)
CVP
PAOP
Kumar et al; Crit Care Med ; 2005
CVP and PAOP do not allowquantitative Assessment of Preload
![Page 9: Functional Hemodynamic Monitoring and Management A practical](https://reader034.vdocuments.site/reader034/viewer/2022051522/587f57f91a28abca2d8c6a16/html5/thumbnails/9.jpg)
Strokevolume
Preload
Ventricular function curve
Volume
![Page 10: Functional Hemodynamic Monitoring and Management A practical](https://reader034.vdocuments.site/reader034/viewer/2022051522/587f57f91a28abca2d8c6a16/html5/thumbnails/10.jpg)
Transesophageal Echocardiography
Volumetric preload monitoring
LVEDA
![Page 11: Functional Hemodynamic Monitoring and Management A practical](https://reader034.vdocuments.site/reader034/viewer/2022051522/587f57f91a28abca2d8c6a16/html5/thumbnails/11.jpg)
arterial Catheter (PiCCO)
Injection of Indicator(cv-line)
Volumetric Preoad Monitoring
ITBV: intrathoracic Blood Volume
RAEDV PBV LAEDV LVEDVRVEDV
EVLW
GEDV: global end-diastolic Volume
![Page 12: Functional Hemodynamic Monitoring and Management A practical](https://reader034.vdocuments.site/reader034/viewer/2022051522/587f57f91a28abca2d8c6a16/html5/thumbnails/12.jpg)
Michard F et al; Chest 125: 1900-1908; 2003
Volumetric Preload Monitoring
![Page 13: Functional Hemodynamic Monitoring and Management A practical](https://reader034.vdocuments.site/reader034/viewer/2022051522/587f57f91a28abca2d8c6a16/html5/thumbnails/13.jpg)
How to define “best“ Preload?
strokevolume
preload volume
volume dependency
volume independency
![Page 14: Functional Hemodynamic Monitoring and Management A practical](https://reader034.vdocuments.site/reader034/viewer/2022051522/587f57f91a28abca2d8c6a16/html5/thumbnails/14.jpg)
Reuter DA et al. Intensive Care Med 2002; 28: 392-398
∆CI [%]
0 10 20 30 40 50
CV
P base
line [
mm
Hg]
0
2
4
6
8
10
12
r² = -0.08p > 0.05
r² = 0.08p > 0.05
Fluid Responsiveness: CVP
![Page 15: Functional Hemodynamic Monitoring and Management A practical](https://reader034.vdocuments.site/reader034/viewer/2022051522/587f57f91a28abca2d8c6a16/html5/thumbnails/15.jpg)
⇒ Pintrathoracic ↑⇒ venous
Return to RV/LV ↓⇒ LV Preload ↓
⇒ LVSV ↓
Heart-Lung-Interactions during MV
![Page 16: Functional Hemodynamic Monitoring and Management A practical](https://reader034.vdocuments.site/reader034/viewer/2022051522/587f57f91a28abca2d8c6a16/html5/thumbnails/16.jpg)
Stroke Volume Variation (SVV)
SVV = (SVmax - SVmin) / SVmean
80 ml50 ml
Stroke Volume Variation by arterial Pulse Contour Analysis
![Page 17: Functional Hemodynamic Monitoring and Management A practical](https://reader034.vdocuments.site/reader034/viewer/2022051522/587f57f91a28abca2d8c6a16/html5/thumbnails/17.jpg)
SVV- Mechanism -
SV
Preload (Volume)
SVV
SVV
![Page 18: Functional Hemodynamic Monitoring and Management A practical](https://reader034.vdocuments.site/reader034/viewer/2022051522/587f57f91a28abca2d8c6a16/html5/thumbnails/18.jpg)
r² = 0.55p < 0.05
∆CI [%]
0 10 20 30 40 50
SV
Vb
asel
ine [
%]
0
5
10
15
20
25
30
35
Prediction of fluid responsiveness: SVV
Reuter DA et al. Intensive Care Med 2002; 28: 392-398
r² = 0.55p < 0.05
CVP
Berkenstadt H, et al:Anesth Analg 92: 984-989, 2001
SVV
![Page 19: Functional Hemodynamic Monitoring and Management A practical](https://reader034.vdocuments.site/reader034/viewer/2022051522/587f57f91a28abca2d8c6a16/html5/thumbnails/19.jpg)
Organ Function
optimized SV
optimized preload prevent pulm. edema
Early hemodynamic Goals
![Page 20: Functional Hemodynamic Monitoring and Management A practical](https://reader034.vdocuments.site/reader034/viewer/2022051522/587f57f91a28abca2d8c6a16/html5/thumbnails/20.jpg)
Avoiding Fluid Overlad
![Page 21: Functional Hemodynamic Monitoring and Management A practical](https://reader034.vdocuments.site/reader034/viewer/2022051522/587f57f91a28abca2d8c6a16/html5/thumbnails/21.jpg)
Eisenberg PR et al., CritCare Med 5: 549-553,1984
Chest X-Ray vs. EVLW
![Page 22: Functional Hemodynamic Monitoring and Management A practical](https://reader034.vdocuments.site/reader034/viewer/2022051522/587f57f91a28abca2d8c6a16/html5/thumbnails/22.jpg)
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
Prob
abili
ty o
f req
uiri
ng m
ech.
ven
t.
0.0
0.2
0.4
0.6
0.8
1.0
Prob
abili
ty o
f stil
l bei
ng in
ICU
0 10 20 30 40days on mechanical ventliation
0 10 20 30 40days in ICU
EVLW (n=40)WP (n=42)
EVLW (n=52)WP (n=49)
Mitchell JP, et al., Am Rev Respir Dis, 1992
EVLW in ARDS : The Mitchell-Study
![Page 23: Functional Hemodynamic Monitoring and Management A practical](https://reader034.vdocuments.site/reader034/viewer/2022051522/587f57f91a28abca2d8c6a16/html5/thumbnails/23.jpg)
arterial Catheter (PiCCO)
Injection of Indicator
(cv-line)
EVLW: extravascular Lung Water
RAEDV PBV LAEDV LVEDVRVEDV
EVLW
Transcardiopulmonary Thermodilution:Extravascular Lung Water (EVLW)
![Page 24: Functional Hemodynamic Monitoring and Management A practical](https://reader034.vdocuments.site/reader034/viewer/2022051522/587f57f91a28abca2d8c6a16/html5/thumbnails/24.jpg)
Experimental Validation EVLW by Thermodilution
Kirov MY et al; J Crit Care 2004
![Page 25: Functional Hemodynamic Monitoring and Management A practical](https://reader034.vdocuments.site/reader034/viewer/2022051522/587f57f91a28abca2d8c6a16/html5/thumbnails/25.jpg)
![Page 26: Functional Hemodynamic Monitoring and Management A practical](https://reader034.vdocuments.site/reader034/viewer/2022051522/587f57f91a28abca2d8c6a16/html5/thumbnails/26.jpg)
![Page 27: Functional Hemodynamic Monitoring and Management A practical](https://reader034.vdocuments.site/reader034/viewer/2022051522/587f57f91a28abca2d8c6a16/html5/thumbnails/27.jpg)
‚Preload-directed Therapy‘
CO, GEDV, ITBV, EVLW
The Practical Approach
![Page 28: Functional Hemodynamic Monitoring and Management A practical](https://reader034.vdocuments.site/reader034/viewer/2022051522/587f57f91a28abca2d8c6a16/html5/thumbnails/28.jpg)
• 80 cardiac surgery patients (CABG)
• Study group: n = 40
• Controls: n = 40 (matched pairs)
• Study period: start of surgery –48 h post op
‚Preload-directed Therapy‘
![Page 29: Functional Hemodynamic Monitoring and Management A practical](https://reader034.vdocuments.site/reader034/viewer/2022051522/587f57f91a28abca2d8c6a16/html5/thumbnails/29.jpg)
Treatment Algorithm CO / GEDV / EVLW
GEDVI > 640 ?GEDVI > 640 ? MAP > 70 ?MAP > 70 ?
give Volume until
GEDVI >640
yesCI > 2.5 ?CI > 2.5 ?
give catecholamines until CI > 2.5
no
yes
yesEVLWI >10 ?
GEDVI > 800 ?EVLWI >10 ?
no
give Volume until
GEDVI > 800
no
no
no
give catecholamines until MAP > 70
EVLWI >10 ?
GEDVI > 800 ?
give Volume until
GEDVI > 800
no
no
no
GOOD!!yes
yes
yes
![Page 30: Functional Hemodynamic Monitoring and Management A practical](https://reader034.vdocuments.site/reader034/viewer/2022051522/587f57f91a28abca2d8c6a16/html5/thumbnails/30.jpg)
Kolloide im Verlauf OP bis 48h postoperativ
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
1 2 3 4 5 6
(ml)
IV Volume on ICU
OP 8 hrs 16 hrs 24 hrs 32 hrs
Colloids
Controls
Algorithm
48 hrs
Goepfert MS et al. (submitted)
![Page 31: Functional Hemodynamic Monitoring and Management A practical](https://reader034.vdocuments.site/reader034/viewer/2022051522/587f57f91a28abca2d8c6a16/html5/thumbnails/31.jpg)
Arterenol (mg) OP bis 48h postoperativ
0
2
4
6
8
10
12
14
16
1 2 3 4 5 6
(mg)
Norepinephrine
OP 8 hrs 16 hrs 24 hrs 32 hrs 48 hrs
Algorithm
Controls
Goepfert MS et al. (submitted)
Total norepinephrine on ICU
![Page 32: Functional Hemodynamic Monitoring and Management A practical](https://reader034.vdocuments.site/reader034/viewer/2022051522/587f57f91a28abca2d8c6a16/html5/thumbnails/32.jpg)
Suprarenin intraoperativ bis 48h postoperativ
0
0,5
1
1,5
2
2,5
3
1 2 3 4 5 6
(mg)
OP 8 hrs 16 hrs 24 hrs 32 hrs 48 hrs
Algorithm
Controls
Epinephrine
Goepfert MS et al. (submitted)
Total epinephrine on ICU
![Page 33: Functional Hemodynamic Monitoring and Management A practical](https://reader034.vdocuments.site/reader034/viewer/2022051522/587f57f91a28abca2d8c6a16/html5/thumbnails/33.jpg)
Rationale hemodynamic managment ?
- avoid dehydration- maintain preloading blood volume ? determine it !- prevent inadequate tissue perfusion ? measure SV /CO !- prevent fluid overload
Consider escalating update monitoring strategiesand adequate early goal directed algorithmsincluding the complete periopertive processoriented at functional hemodynamic monitoring(e.g. SV, SVV, PPV, GEDVI, EVLW)