hemodynamic monitoring beyond cardiac output - · pdf filecardiac function index provided by...

Prof Xavier MONNET

Medical Intensive Care UnitBicêtre Hospital

Assistance publique – Hôpitaux de ParisFRANCE

Hemodynamic monitoring

beyond cardiac output

Conflicts of interest

Lilly

GlaxoSmithKline

Pulsion Medical Systems

Beyond cardiac output

3.2L/min/m2

3.23.13.33.23.23.23.03.02.82.62.62.52.42.22.02.01.61.51.6

need for fluid ?

cardiac output

cardiac preload pump function

need for an inotrope ?

2.13.2

cardiac output

fluid administration ? inotrope ?


benefit of fluid ?fluid responsiveness ?

Ventricular preload

Strokevolume

A B

a'

b'

a'b'

A B

Prediction of fluid responsiveness Concept

VE VE

When we administer fluid, we expect an increase in SV

All patients do not « respond » to fluidadministration

Ventricular preload

Strokevolume

A B

a'

b'

a'b'

A B

deleterious effects lung edemagas exchange alterationin case of ARDS

How to predict fluid responsiveness ?

Prediction of fluid responsiveness Concept

Prediction of fluid responsiveness CVP

CVP does not enable predictingfluid responsiveness

?


Ventricular preload

Strokevolume

CVP

impaired ventricular function

a'

b'

ab

normal ventricular function


Test the Frank-Starling curve ! … without administering fluid

A B

Which surrogate of stroke volume ?

Prediction of fluid responsiveness respiratory variation of stroke volume

Respiratory variation

arterial pulse pressure

Which estimation of stroke volume ?

►

►

►

►

►

►

20

40

60

80

100

120

0

SV

arterial compliance=

Respiratory variation arterial pressure

50

70

90

110

mmHgPPmax

PPmin

PPV = 32 %

PPV =PPmax - PPmin

(PPmax + PPmin) / 2


High level of evidence

Meta-analysis29 studies685 patients


arterial pulse pressure►

pulse contour analysis►

Respiratory variation

20

40

60

80

100

120

0

= k . SV

The area under the systolic part of the arterial curve is proportional to SV

Respiratory variation pulse contour analysis

PiCCO and Vigileo enable a beat-by-beat estimation of SV

PiCCO and Vigileo assess the respiratory variation of SV


15 patients during brain surgeryGraded volume loadingPiCCO system



pulse contour-derived SV►

Respiratory variation Which estimation of stroke volume ?


pulse contour-derived SV►

sub-aortic blood flow►

descending aortic blood flow►

plethysmography signal►

Respiratory variation Which estimation of stroke volume ?

easy andwell demonstrated

less invasivebut less easy

lower level of evidence

The respiratory variation of hemodynamic signals cannot be used in case of

cardiac arrhythmias

limitationsRespiratory variation of stroke volume

50

70

90

110

mmHg PPmax

PPmin



cardiac arrhythmias

low Vt


Monnet X, Bleibtreu A, Ferré A, Dres M, Richard C, Teboul JL

Prediction of fluid responsiveness in septic patients with a low tidal volume


ESICM 2009 Poster # 0599

100 - specificity

sens

itivi

ty

0 20 40 60 80 100

100

80

60

40

20

0

PPV

Vt >7mL/kg

100 - specificity

sens

itivi

ty

0 20 40 60 80 100

100

80

60

40

20

0

Vt 7mL/kg

39 septic shock patients

19 ARDS and 20 non ARDS patients


cardiac arrhythmias

low Vt


spontaneous breathing

PPmin

PPmax PPmaxPPmin


frequent in the ICU

spontaneous breathing


cardiac arrhythmias

low Vt


cardiac output


benefit of fluid ?

PPV/SVV

arrhythmias, low Vt, SB?

yesno

?

Passive leg raising hemodynamic effects

Endogenous fluid challenge

45°

ABFPLR

Volume expansion

Passive leg raising prediction of fluid responsiveness ?

76 ICU patients with acute circulatory failure

esophageal Doppler monitoring

echo

EDM 10 %increase in ABF

10 %increase in ABF

12 %increase in aoVTI


which monitoring tool ?

PiCCO

Passive leg raising

-100

102030405060708090

100

nonresponders responders

34 patients with cardiac arrhythmias or SB

PLR-induced changes inpulse contour-derived CO

Cut-off 10%

Se = 95%Sp = 97%

which monitoring tool ?Passive leg raising

echo

EDM 10 %increase in ABF

10 %increase in ABF



PiCCO 10 %increase in PCCI

which monitoring tool ?Passive leg raising

A B

Tele-expiratory occlusion

tele-expiratory occlusion

Tele-expiratory occlusionTele-expiratory occlusion test

34 patients with SB or cardiac arrhythmias

-10

0

10

20

30

40

50

Effects of end-expiratory pause

on cardiac index

-10

0

10

20

30

40

50

Effects of end-expiratory pause

on pulse pressure

increase 5%Se = 87 %Sp = 100 %

increase 5%Se = 91%Sp = 100 %

Tele-expiratory occlusion test

cardiac output


benefit of fluid ?

PPV/SVV


yesno

PLR test PLR test

TEO testTEO test

risk of fluid?

Monnet X, Bleibtreu A, Ferré A, Dres M, Richard C, Teboul JL

Prediction of fluid responsiveness in septic patients with a low tidal volume

100 - specificity

sens

itivi

ty

0 20 40 60 80 100

100

80

60

40

20

0

PLR test

TEO test

PPV


ESICM 2009 Poster # 0599

Vt >7mL/kg

100 - specificity

sens

itivi

ty

0 20 40 60 80 100

100

80

60

40

20

0

Vt 7mL/kg

cardiac output


benefit of fluid ?

PPV/SVV


yesno

PLR test PLR test

TEO testTEO test

risk of fluid?

Limit fluid administration in ARDS !

When to stop fluid administration?

Limit lung edema !


Lung water is a prognostic factor in ARDS

How to measurelung water ? ?

Lung water


cold bolus

thermistor

Estimation of lung water

PAOP group

EVLW group

Time (hours)

Cumulative fluid balance (input - output; L)7

3

1

5

-1

-3

-50 12 24 36 48 60 72

***

*

* p < 0.0001 vs time 0

Mitchell JP et al., Am Rev Respir Dis 1992


101 ARDS patientsrandomized to EVLW-guided management vs.PAOP-guided management

0

5

10

15

20

25

Ventilation days ICU days

PAOP Group

EVLW Group

* *

Mitchell JP et al., Am Rev Respir Dis 1992

may guide fluid therapy in ARDS patients

Management of fluid therapy with :


101 ARDS patientsrandomized to EVLW-guided management vs.PAOP-guided management

cardiac output

systolic failure ?



risk of fluid?

EVLW

benefit of fluid ?

PPV/SVV


yesno

PLR test PLR test

TEO testTEO test


high lung permeability


VERY high lung permeability


cold bolus

thermistor

Estimation of lung water


lung water

cold bolus pulmonary blood volume

pulmonary vascularpermeability index =PVPI

PVPI

… in the clinical setting ?

15 dogsOleic acid iv. or left balloon inflationTranspulmonary thermodilution

Cardiogenic PEInflammatory PEControl


0123456789

10PVPI

ALI/ARDS Hydrostaticpulmonary edema

*

Cut-off : 3

Se = 85 %

Sp = 100 %

48 patients with pulmonary edemainflammatory vs. hydrostatic discriminated by expertsPVPI by the PiCCO device


0

20

40

60

80

100

0 20 40 60 80 100100 - specificity

sens

itivi

ty

PVPI

BNP

n = 31p < 0.05

PVPI allows estimating

the lung permeability


cardiac output

systolic failure ?



risk of fluid?

EVLW

benefit of fluid ?

PPV/SVV


yesno

PLR test PLR test

TEO testTEO test

PVPI

Cardiac contractility

Echocardiography is the gold standard

but you must be an expert

now available 24/24 in all units

does not allow continuous monitoring

an alternative

echocardiography

?

LVEF


cardiac index

cold bolus global end-diastolic volumecardiac function index =CFI

stroke volume

LVLVEF

4

CFI

prediction of FAC > 40 %

"Cardiac Function Index"Cardiac contractility

0

20

40

60

80

100

0 20 40 60 80 100100 - specificity

Sen

sitiv

ity

3.2 min-1

CFI for detectingLVEF 35%

alerts the clinician that LV systolic function is impaired

continuous monitoring of LVEF

Cardiac contractility "Cardiac Function Index"

Cardiac function index provided by transpulmonary thermodilution behaves as an indicator of left ventricular systolic functionJabot J, Monnet X, Lamia B, Chemla D, Richard C, Teboul J-LCritical Care Medicine in press

-40

-20

20

40

60

80

100

120

-40 -20 20 40 60 80 100 120

% c

hang

e in

LV

EF

% change in CFI

Changes induced by- volume expansion- dobutamine

follow up of inotrope effect

Cardiac contractility "Cardiac Function Index"

Cardiac function index provided by transpulmonary thermodilution behaves as an indicator of left ventricular systolic functionJabot J, Monnet X, Lamia B, Chemla D, Richard C, Teboul J-LCritical Care Medicine in press

cardiac output

systolic failure ?



risk of fluid?

EVLW echo

benefit of fluid ?

PPV/SVV


yesno

PLR test PLR test

TEO testTEO test

CFIPVPI

cardiac output


follow up

cardiac output

cardiac output


follow up

cardiac output

S(c)vO2

SvO2 / ScvO2

During cardiogenic failure, SvO2 is a reliable marker of tissue oxygenation

How to interpret ?

SvO2 cardiac output does not fit the tissues requirements

cardiac output fits the tissues requirements

O2 extraction is reduced

normal SvO2

or

During sepsis, a high SvO2 could mean

that cardiac output is adequate

that O2 extraction is low

SvO2 / ScvO2

major hypovolemic component

Very high level of SvO2

263 patients at early phase of sepsisstandard vs "early goal-directed" therapy

SvO2 / ScvO2

ScvO2 is not frequently low in the ICU

cardiac output

systolic failure ?


risk of fluid?

EVLW echo

benefit of fluid ?

PPV/SVV


yesno

PLR test PLR test

TEO testTEO test

CFIPVPI


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