Case 1; hypovolemic shock - PULSION · GEDV CHEST 2003; 124:1900 –1908 36 ICU patients with...
Transcript of Case 1; hypovolemic shock - PULSION · GEDV CHEST 2003; 124:1900 –1908 36 ICU patients with...
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Case 1; hypovolemic shock
• Fluid responsiveness St
roke
vo
lum
e
Preload
”fluid responsive”
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Fluid responsiveness
• GEDV (PiCCO)
• Arterial pressure variations
• Passive leg raising test
• CVP / PCWP
• Echo (global ventricular volume / ICV collapsibility)
• Fluid challenge with CO monitoring
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GEDV
CHEST 2003; 124:1900 –1908 36 ICU patients with “septic shock” (GEDVI normal 650 – 800 ml/m2)
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Arterial pressure variations
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Pulmonary vascular resistance va
scu
lar
resi
stan
ce
Lung volume FRC RV TLC
alveolar extra-alveolar
total
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Arterial pressure variations
• SPV
• PPV
• SVV
• dDown
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Arterial pressure variations
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• Only controlled mechanical ventilation
• Vt > ca. 8ml/kg
• HR/RR > 3,6
• No arrhythmia’s
• Sufficient RV / LV function
• Closed abdomen
• (closed chest)
Arterial pressure variations
BMC anesthesiology 2014;14:90
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Br J Anaesth. 2014 Apr;112(4):681-5
Arterial pressure variations
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Passive leg raising
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Passive leg raising (PLR)
Critical Care 2009; 13: R111
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Intensive Care Med. 2013 Jan;39(1):93-100
PLR and capnography
ETCO2 > 5% with PLR CI > 15%
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Passive leg raising
• Also in awake patients
• Few limitations
• Not with blood pressure!
• Needs fast CO methode (or echo-doppler)
• Some practical disadvantages
• Sympathic activation?
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Echo (cava inferior)
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Stro
ke v
olu
me
Preload
CVP, CO and fluid therapy
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Curr Opin Crit Care 2015, 21:369–375
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Optimal fluid challenge
• Small volume
• Fast (max 10 min)
• Measure cardiac output and CVP/PCWP before and after
• If CO (SV) increase > 10-15% => responder
• precision CO measurement
• small changes might be very beneficial
• No increase in CO + increase in CVP/PCWP (2 mmHg) => non
responder
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Am J Respir Crit Care Med Vol 190, Iss 3, pp 252–257, Aug 1, 2014
Supine
• Axis 1: through fourth intercostal space
• Axis 2: midway between posterior surface and base
of xiphoid process
Supine or 60 degrees up
• 5 cm below sternal angle
Reference point CVP
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Central venous trace
a c
x v
y
atrial contraction
bulging T valve with ventricular contraction
atrial relaxation and downward movement of contracting RV
Filling right atrium
atrial emptying, T valve opening
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Central venous trace
a c
x v
y
1 2
3
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Central venous trace
a c
x v
y
1 2
3
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Central venous trace
a c
x v
y
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