HEMODYNAMIC MONITORING Understanding the physiology

CHOOSING YOUR TARGETS WHILE RESUSCITATING SEPSISAntoine Vieillard-Baron, Boulogne, France

Crit Care 2008IS IT REALLY SERIOUS TO BELIEVE THAT EVERYONE COULD BE RESUSCITATED USING THE SAME TARGETS?THIS IS THE MAIN ISSUE OF THE EVIDENCE-BASED MEDICINE

CVP 8-12 mmHgSVRMSPRAP

From Guyton Physiol Rev 1955 In physiology, the principle is to maintain the CVP as low as possibleto promote systemic venous return. And this is the role of the RV

CCM 2007

MAP > 65 mmHg

Laminary flow in a patient under VA ECMO8

MAP is a determinant for organ perfusionWindkessel effect: Transformation of the pulsatile flow into a continuous one (Stephen Hales 1677-1761)MAP = CO x SVR + RAPVolume, inotropesVasopressorsVolume10

No change in CO

BaselineVasodilation388 patients in each group(65-70 versus 80-85)

Sv(c)O2 > 65% (70)

Crit Care Med 2012

Pattern 1Pattern 2

LACTATE CLEARANCE

Jama 2010Study of non-inferiorityGoal: 10% lactate clearance

NO DIFFERENCE IN LACTATE CLEARANCE BETWEEN BOTH GROUPS??AJRCCM 2010

IS THERE SOMETHING NEW?

Usual-care: 439 patientsEGDT: 446 patients

90d-Mortality ~31-33% May 2014

Usual-care: 804 patientsEGDT: 796 patients90d-Mortality ~18% October 2014H0-6Rivers (EGDT)Arise (usual care)ProCESS (usual care)Rivers (control)Fluids (mL)49811713(+2591)23003499Vasopressors (%)27584430Red-cell transfusion (%)6477.518.5Dobutamine (%)13.72.60.90.8CVP (mmHg)13.811.9NA11.8MAP (mmHg)9575768160-d mortality (%)4418.818.957

ProCESS: CVP not permitted in the usual care groupArise: CVP permitted according to physicians decision (62% of patients)

0.7%/site/3 months27

CONCLUSIONTOO MUCH MONEY TO DEMONSTRATENOTHING, EXCEPT THAT YOU HAVE TO RESUSCITATEPATIENTS AND THAT TIME IS CRUCIALLITTERATURE IS VERY CONFUSINGAND THE MAIN GOAL SEEMS TO PUBLISHIN BIG JOURNALSIN AN IDEAL WORLD, RESUSCITATION HAS TO BE ADAPTED TO EACH PATIENT BASED ON A GOOD KNOWLEDGE OF PHYSIOLOGY