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

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

• 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

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

Strokevolume

Preload

Ventricular Function Curve

Stepwise Fluid Loading to optimize SV

Stepwise Fluid Loading to optimize SV

CVP

PAOP

Kumar et al; Crit Care Med ; 2005

CVP and PAOP do not allowquantitative Assessment of Preload

Strokevolume

Preload

Ventricular function curve

Volume

Transesophageal Echocardiography

Volumetric preload monitoring

LVEDA

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

Michard F et al; Chest 125: 1900-1908; 2003

Volumetric Preload Monitoring

How to define “best“ Preload?

strokevolume

preload volume

volume dependency

volume independency

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

⇒ Pintrathoracic ↑⇒ venous

Return to RV/LV ↓⇒ LV Preload ↓

⇒ LVSV ↓

Heart-Lung-Interactions during MV

Stroke Volume Variation (SVV)

SVV = (SVmax - SVmin) / SVmean

80 ml50 ml

Stroke Volume Variation by arterial Pulse Contour Analysis

SVV- Mechanism -

SV

Preload (Volume)

SVV

SVV

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

Organ Function

optimized SV

optimized preload prevent pulm. edema

Early hemodynamic Goals

Avoiding Fluid Overlad

Eisenberg PR et al., CritCare Med 5: 549-553,1984

Chest X-Ray vs. EVLW

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

arterial Catheter (PiCCO)

Injection of Indicator

(cv-line)

EVLW: extravascular Lung Water

RAEDV PBV LAEDV LVEDVRVEDV

EVLW

Transcardiopulmonary Thermodilution:Extravascular Lung Water (EVLW)

Experimental Validation EVLW by Thermodilution

Kirov MY et al; J Crit Care 2004

‚Preload-directed Therapy‘

CO, GEDV, ITBV, EVLW

The Practical Approach

• 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‘

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

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)

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

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

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)