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Using Arterial Pressure-Based Cardiac Output to Guide Therapy

Chris Saraceno, DNAP, CRNADistrict 3 & 4 Meeting

February 4th, 2017

FloTrac-EV1000™

78 y.o. Male Severe sepsis 2° LLL pneumonia h/o TB 30 yrs ago MAP 58/ HR 135/ RR 42/ Temp 39.1/

UOP~5

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Intubated, arterial line with Vigileo, CVP 7.30/41/78 (70%)/28/-10/ Lactate 4.2 SVV 18%

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Levophed @ 0.5/mg/kg/min Fluid challenges until SVV < 10% UOP increased, lactate decreased, weaned

from ventilator

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Why Arterial-Pressure Based CO? Tissue hypoperfusion inadequate oxygen

delivery to tissues MSOF

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Oxygen Delivery

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What’s wrong with current monitoring? SWAN and CVP

• Have NOT proven to improve outcomes• Carry their own risks

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PAC-Man trial• No difference in patient mortality with SWAN

or no SWAN Osman

• Retrospective study: 96 pts with SWANs• Fluid challenges• Fluid responders/ nonresponders

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Pulsus Paradoxus

PPV Decreased venous return Seen a few beats later

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Mechanism of Pulsus Paradoxus

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Fluid Responsiveness Starling’s curve

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Arterial Based C.O. Monitoring Current Monitors

• FloTrac/ Vigileo/EV1000, Edwards Lifesciences

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Arterial Based C.O. Monitoring• LiDCO

– London group– Lithium

• PiCCO– Manual calibration– Thermodilution via central venous line

• Sets parameters• Requires femoral arterial line

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Stroke Volume Variation (SVV)

Minimally invasive• WORKING arterial line• Zero arterial line anesthesia monitor & EV1000

Enter HT, WT, age and gender• Baseline vascular resistance database

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SVV Displays hemodynamic parameters

continuously (20 sec)• 100 pressure points over 10 seconds (2000 data

points)• Calculates std of arterial waveform X

compliance No manual calibration

• Calibrates q 1 minute15

SVV calculation

% SVV = SVmax-SVmin /SVmean

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SVV Evolving technology

- Vigileo• 3 generations

EV 1000• 4th generation

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Limitations Intubated, sedated, paralyzed

• Required • Spontaneously breathing- naturally varies

Severe arrythmias Have to have a pulse rate

• IABP• Ventricular assist devices

Vasodilation therapy- consider in “big picture”18

Case Study # 1 78 y.o. male

• HTN• Atherosclerosis• EVAR- AAA

GA with Aline/Flotrac• 134/78• 64 bpm• C.O. 4.5• SVV 7%

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Case Study # 1 1 hour into case

• 110/60• 76 bpm• C.O. 3.1 L/min• SVV 35%

Dye study- no leak 3u PRBCs, 500 mL 5% albumin, 500 mL crystalloid “covert” blood loss ~ 750mL

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Volume Responsiveness

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Case Study #2 32 yo male

• Type 2 DM• Idiopathic dilated CMO

– EF 20%

• Meds – Torsemide– Ramipril– Carveilol– Digoxin– Insulin

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BiV pacemaker• GA• CVP• A line• 500 LR• 300 EBL• 1200 UOP

Case Study #2 5 hour case Dopamine 5-8 mcg/kg/min for BP

• ABG:7.19 74 62 28.3100% O2

ICU - intubated

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Case Study # 2 Post BiV:

• 84/50 with MAP of 61 mmHg• 130 bpm• CVP 18-20 mmHg

Questions• Fluid: worsen pulmonary edema• Increase Dopamine: worsen tachycardia• NTG, NTP or Dobutamine: wosen HOTN

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Case Study # 2 FloTrac connected to existing Aline Patient ventilated and sedated CO 4.7 L/min SVV 20-22% Fluid challenge: CO 5 L/min, MAP inc to

66 mmHg Fluid until SVV < 15%

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Case Study # 2 Vitals normalized Extubated within 24 hours EF 25%

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Case Study #3 18 y.o. male MVA No PMH MVA with prolonged

extraction SBP 70 HR 160 Abdomen firm Pelvic fracture

FloTrac in ER• SVI: 14 mL/m2

• SVV: 40-45% OR

• Splenectomy• SMV repair• 12 units PRBCs• 14 L NaCl

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Case Study #3 ICU-

• 23 L of NaCl• 16 u PRBCs

• SVI 66 ml/m2

• Furosemide

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Extremes in Cases DIEP Flap

• Young, healthy– Fluid – Flap integrity

Open AAA repair• Comorbidities

– HTN– CKD

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What else can EV1000 monitor tell us?

Another piece of the puzzle

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Case Study #4 54 yo male for liver

resection Hepatocellular

carcinoma A-line 150/85 HR 66 GA CVP = 8 mmHg

2 hours into surgery:• BP 95/44• HR 126• CVP= 7 mmHg

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Case Study #4 Flo Trac connected to existing arterial line:

• SVV 20%• SV 25 mL• CO 1.9• Fluid given: SVV to 10%, but SV low = 35 mL• Epi gtt started

– Titrated to 1mcg/kg/min– Vitals improved

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Case Study # 4 Left intubated at the end of the case Troponin I and CK levels elevated MI

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Caution:• Surgeon?

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Thank you

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