Download - Vin Presentation
Advancing Circulatory Care
(2012 - )Vincent Pellegrino
Victorian Intensive Care NetworkAugust2012
Choice
Before I start......
1992: First ICU Rotation
•1800-0800 (14 beds) RMO only cover
•Closed loop control of circulation
•Open loop control of feeding
•Open loop control of tonicity
1992: First ICU Rotation
J Crit Care (1994) 9: 124-133
1992: First ICU Rotation
J Crit Care (1994) 9: 124-133
10 Patients APII 30
CRRT-HF601 hour
417 (L) lost409 (L) administered
3 survived (hosp discharge)
1992: First ICU Rotation
J Crit Care (1994) 9: 124-133
Reduced haemodynamic
variability compared to standard care
PAC - Clinical Trials
• Shoemaker 1988
PAC - Clinical Trials
• Intensive Care 1988-2006
• ARDS
•General ICU
•High Risk Surgery
• 12 Prospective RCT
PAC - Clinical Trials• Evaluated different targets
• CO / Oxygen Delivery (explicit) or Physician determined
• +/- MAP, Urine output, skin changes
• Used different guidance (rules)
• CVP and PAOP (explicit) or Physician determined
• Applied different therapy
• Fluids (crystalloids/colloids or RBC)
• Drugs (inotropes or pressors)
PAC - Clinical Trials
• Intensive Care 1988-2006
• ARDS
•General ICU
•High Risk Surgery
• 12 Prospective RCT
PAC - Clinical Trials•Various approaches to
haemodynamic care in numerous patient populations using either....
•explicit targeting of cardiac output / oxygen delivery
•guiding care based on perceived needs
does not improve outcome in a number of high risk patient groups
Where does that leave us ?
Drug Trials
Text
Annane D. Lancet 2007
Drug Trials
Myburgh J. ICM 2008
Drug Trials
Text
De Becker D. NEJM 2010
Fluids - Obsevational
•ARDS Clinical Trial Network, NEJM 2006
Outcome Conservative Strategy Liberal Strategy P Value
Death at 60 days (%) 25.5 28.4 0.30
Ventilator-free days from day 1 to day 28
14.6 ± 0.5 12.1 ± 0.5 <0.001
ICU-free days Days 1 to 7 Days 1 to 28
0.9 ± 0.113.4 ± 0.4
0.6 ± 0.111.2 ± 0.4
<0.001<0.001
Organ-failure-free days Days 1 to 7 Cardiovascular failure CNS failure Renal failure Hepatic failure Coagulation abnormalities Days 1 to 28 Cardiovascular failure CNS failure Renal failure Hepatic failure Coagulation abnormalities
3.9 ± 0.13.4 ± 0.25.5 ± 0.15.7 ± 0.15.6 ± 0.1
19.0 ± 0.518.8 ± 0.521.5 ± 0.522.0 ± 0.422.0 ± 0.4
4.2 ± 0.12.9 ± 0.25.6 ± 0.15.5 ± 0.15.4 ± 0.1
19.1 ± 0.417.2 ± 0.521.2 ± 0.521.2 ± 0.521.5 ± 0.4
0.040.020.450.120.23
0.850.030.590.180.37
Dialysis to day 60 Patients (%) 10 14 0.06
Days 11.0 ± 1.7 10.9 ± 1.4 0.96
Liberal fluids
associated with
increased ICU and
ventilator time and
no reduction in renal failure
Fluids - Observational
After correcting for age and APACHE II, positive fluid balance correlated with increased mortality
Boyd J.H.et al Crit Care Med 2011
Fluids - Recommendations
CCM Feb 2011
Currently
Low Blood Low Blood PressurePressure
Low Blood Low Blood PressurePressure
Low Cardiac Low Cardiac OutputOutput
Low Cardiac Low Cardiac OutputOutput
Organ FailureOrgan FailureOrgan FailureOrgan Failure VasopressorsVasopressorsVasopressorsVasopressors
InotropesInotropesInotropesInotropes
FluidsFluidsFluidsFluids
Currently
Low Blood Low Blood PressurePressure
Low Blood Low Blood PressurePressure
Low Cardiac Low Cardiac OutputOutput
Low Cardiac Low Cardiac OutputOutput
Organ FailureOrgan FailureOrgan FailureOrgan Failure VasopressorsVasopressorsVasopressorsVasopressors
InotropesInotropesInotropesInotropes
FluidsFluidsFluidsFluids
The Future ??•Each decade we reject a new
haemodynamic variable, on which, to base interventions
•1980: PAWP
•1990: VO2-DO2 relationship
•2000: LVEDV GEDVI
•2010: Forget about monitoring - just ECHO everything (over and over)
Where does that leave us ?
Where does that leave us ?
•Prescriptive Approaches
•RELIEF (Restrictive versus Liberal Fluid Therapy in Major Abdominal Surgery)
•Clinical Trials.gov Id: NCT 01424150
•Random allocation of drugs
•Targeting Fluid Balance
A Physiological Approach
•Instead of targeting MAP or CO/O2D indices
•using DEPENDENT circulatory variables (e.g. CVP, EDV, PPV) to guide therapy
•Target BOTH simultaneously using
•INDEPENDENT circulatory variables
- Volume state
- Cardiac function
- Systemic vascular resistance
Mean Systemic Filling Pressure
Mean Systemic Filling Pressure
Anaesthesia2009(64):1218-1228
Mean Systemic Filling Pressure
•Allows independent assessment of volume state
and
•Allows independent assessment of cardiac function
Modelling the circulation
Stay with me.......
MSFP(modeled)
CO
Press av MSFP
Venous compliance lower than assumed
CO
Press av MSFP
Venous compliance higher than assummed
CO
Press av
Independent variables of the circulation
•MSFP = Volume state= 0.96(CVP) + 0.04(MAP) + c(CO)
•HP (Heart Performance) = Inotropy state
=(MSFP - RAP) / MSFP
•SVR = Arteriolar tone stateThese are the numerical descriptors (indicators) of the circulation
Choosing the Target
•Cardiac output
•Mean arterial pressure
•(Cardiac Power = CO x MAP)
•Captures both kinetic and potential energy of the circulation
•Allows assessment of volume responsiveness
Cardiogenic Shock
•Cardiac Power
Cardiogenic Shock
•Cardiac Power
Navigator GuidanceHeart efficiency axis Mean systemic
filling pressure axisData from Monitors
Targets set by clinician
Main menuarea
Data linkStatus area
Target zone
Systemicresistance axis
Patient’s current position
Arrow shows next therapeutic direction
Other data
Intended Control: Following the arrow• Vertical Axis Control
• If Cardiac Power Low: increase MSFP or Inotropy (depending on HP)
• If Cardiac Power High: decrease MSFP or Inotropy* (depending on HP)
•Horizantal Axis Control
• If Cardiac Power is not well “geared” (SVR too high or too low): dilators and constrictors
Cardiac Power Relevance
Navigator Screens: NAV-1
Intervention(Treatment compliance not required)
Control
What we learned•Even if you know the independent
determinants of circulatory variables (like CO)......
•Even if you use them to direct therapy to a meaningful target (like cardiac power).....
•You don’t necessarily know when you should change the target and when you should change the treatments
Structured approach to circulatory care using
Navigator
Determine TargetsDefine (allowable)
interventions
Targets attained andmaintained (ASD < 1.5)within intervention limits
Targets not maintained within intervention limits (ASD >1.5)
New InterventionNew Target
+1. Medicalassessment
2. Nursingassessment
or3. Continual maintenance No change
Circulatory Targeting Sheet
Volume resuscitation Colloids = 0Colloids = < 1000
mlsColloids = < 2000ms
Vasopressor requirements Noradren = 0 Noradren = 1 - 10 Noradren = >10
AVP = 0 AVP = 1/hr AVP 2/hr
Vasodilator requirements GTN = 0 GTN =20 or more GTN ___ - ___
SNP 10 - 50 SNP 50 - 150 SNP ___ - ___
Inotrope requirements Adren: = 0 Adren: < 5 Adren: 5- ___
Milrinone = 0 Milrinone = 5 Milrinone = 5 - 20
MAP
Card Index
ScvO2 > 70
Heart Rate
HP inotrope trigger
HP medical review trigger
Improving Circulatory Care .....
•Further investigations into physiologically based treatments
•Cannot accept that understanding the circulation can’t lead to improved care
Outcomes of cardiogenic shock (CS) complicating acute coronary
syndromes/myocardial infarction
Outcomes of cardiogenic shock (CS) complicating acute coronary
syndromes/myocardial infarction
Outcomes
•High early mortality (despite early intervention)
•Difficult to support medically•Reasonable quality of life post•Not invariably associated with irrecoverable myocardial damage
Cardiogenic Shock Outcomes
Krischan D. Sjauw European Heart Journal
(2009) 30, 459–468
Krischan D. Sjauw European Heart Journal
(2009) 30, 459–468
IABP
Unverzagt S Cochrane
Library 2011
Unverzagt S Cochrane
Library 2011
IABP
•Ongoing Trials•IABP Shock II;•RECOVER II Trial
•Planned Recruitment•984
IABP
Elmir Omerovic Vascular Health and Risk
Management 2010:6 657–663
Elmir Omerovic Vascular Health and Risk
Management 2010:6 657–663
Inotropes
• Extra Corporeal Membrane Oxygenation is a form of extracorporeal life support where an external artificial circuit carries venous blood from the patient to a gas exchange device (oxygenator) where blood becomes enriched with oxygen and has carbon dioxide removed. This blood then re-enters the patient circulation
• Veno-arterial ECMO– Percutaneous
cardiopulmonary support (bypass)
ECMO
return
access
Day 2-3Lymphocytic myocarditis
What’s possible
What’s possible……
Day 10
Day 5
Christian A. Bermudez Ann Thorac Surg 2011;92:2125–31
Diagnostic Group
Number(168)
Age(43)
ECMO Days (7.3)
SW SB NW Alive Discharge
CM/FM40 42 7.8 21 14 5
27(+3) (75%)
Heart Tx (0-7) 46 51 6.6 43 1 2* 33 (72%)
AMI25 52.4 9.1 12 8 5 14 (56%)
Heart Tx (late) 10 44 11.9 4 3 3 3 (30%)
Septic Shock 7 38 4.9 3 0 4 2 (29%)
ECMO for Cardiac Failure 2003-2012
•25 patients (2003-2012)•Average Age: 52.4•Average Days on Support: 9.14•56% Survival to hospital discharge•5 NW•8 SB•12 SW
Alfred CS-AMI
•Veno-arterial ECMO•Centrifugal VAD•Tandem Heart LVAD
•RVAD, LVAD, BiVAD
•Impella Recover•B2B (Bridge to Bridge)•Long term VAD
Current Mechanical Treatment Options for
Severe Acute Heart Failure
Ischaemic C/M60 month
mortality 50%
Non-Ischaemic C/M
60 month mortality 35%
•Cardiogenic shock remains a challenging syndrome to treat but the early application of safe ECMO seems possible to provide major patient benefits
•Simple
•Transferable
Conclusion