Sepsis and Cardiac Output Measurement

S GowerConsultant Anaesthetist

Aim Glimpse of history of

sepsis management Overview of

pathophysiology Comment on cardiac

output measurement Update on sepsis

treatment, particularly early management.

History Swan Ganz

catheter, 1970 Bp=COxSVR Shoemaker, 1979 DO2 =(SaO2xHb)xCO Supranormal values

PA Catheter

Cardiac Output Measurement

Swan song for the Swan Ganz? Soni 1996

Connors, JAMA 1996

Retrospective study of 5735 patients

Increased mortality with swan.

PiCCO Lithium Dilution Thoracic electrical

bioimpedance Oesophageal

doppler CCCombo

Edwards lifesciences

Clinical Assessment of C.O.Palazzo

BJA 2001

BP maintained at expense of CO

Poor cerebral perfusion, agitation and confusion

Metabolic acidosis and increased resp rate

Diminished renal and splanchnic flow

Decreased urine output and ileus

Clinical assessment all you have on the ward

Recognise decreased CO before it’s too late

Infection SIRS Sepsis Severe Sepsis Death

The Sepsis Disease Continuum

Severe SepsisSepsis associated with acute organ dysfunction

•Renal•Respiratory•Hepatic•Haematological•CNS•Unexplained metabolicacidosis

•Cardiovascular

Severe SepsisSepsis associated with acute organ dysfunction

•Renal•Respiratory•Hepatic•Haematological•CNS•Unexplained metabolicacidosis

•Cardiovascular

Septic ShockSevere sepsis with cardiovascular dysfunction (refractory hypotension unresponsive to fluid support)

Septic ShockSevere sepsis with cardiovascular dysfunction (refractory hypotension unresponsive to fluid support)

Bone et al. Chest. 1992;101:1644.

SepsisSIRS with a presumed or confirmed infectious process

SepsisSIRS with a presumed or confirmed infectious process

SIRSA clinical response arising from a nonspecific insult, including 2 of the following:

•Temperature >38oC or <36oC•HR >90 beats/min•Respiratory rate >20/min•WBC count >12,000/mm3 or <4,000/mm3 or >10% immature neutrophils

SIRS can also be caused byTrauma BurnsPancreatitis Other insults

SIRSA clinical response arising from a nonspecific insult, including 2 of the following:

•Temperature >38oC or <36oC•HR >90 beats/min•Respiratory rate >20/min•WBC count >12,000/mm3 or <4,000/mm3 or >10% immature neutrophils

SIRS can also be caused byTrauma BurnsPancreatitis Other insults

Pathophysiology of sepsis Margination of

leukocytes Induction of nitric

oxide synthetase Impaired

anticoagulation Microvascular

thrombosis DIC

Activated Protein C

The role of endogenous activated protein C in patients with severe sepsis95

7.6

Endothelium

Neutrophil

Monocyte

IL-6IL-1TNF-

IL-6

Inactivation

Inactivation

Inactivation

Pre

ven

tio

n o

f ac

tiva

tio

n

Inflammatory responseto infection

Thrombotic responseto infection

Fibrinolytic responseto infection

TAFI

PAI-1

SuppressedfibrinolysisActivated

protein CInh

ibit

ion

Inh

ibit

ion

Factor VIIIaTissue factor

COAGULATION CASCADE

Factor Va

THROMBIN

Fibrin

Fibrin clotTissue factor

Organisms

Activatedprotein C

Activatedprotein C Activated

protein C

Reproduced with permission from Bernard et al.95 Copyright © 2003 Massachusetts Medical Society. All rights reserved.

Timing of the intervention is vital

Summary of management Aggressive goal

orientated treatment of sepsis

Fluids and dobutamine

Restore effective blood volume and CO

Sepsis and two organ failure give Activated protein C

Summary of sepsis and Cardiac Output

Very Exciting! Early recognition

of hypovolaemia of sepsis

Rapid restitution of effective CO

Appropriate usage of Xigris

Experience teaches that to place reliance upon a single sign is precarious. Compare this sign and that, and confident recognition of the patients state grows. Sir Thomas Lewis 1942