Alain Cariou Intensive Care Unit – Cochin University Hospital Paris Descartes University – INSERM U970 (France)

Liens d’intérêt

�  Lilly France (consultant)

�  Edwards Lifesciences (consultant)

1.  Pressions

2.  Débit Cardiaque

3.  PvCO2, PvO2 & SvO2

A trial of goal-oriented hemodynamic therapy in critically ill patients Gattinoni et al. N Engl J Med 1995 ;333:1025-32

A trial of goal-oriented hemodynamic therapy in critically ill patients Gattinoni et al. N Engl J Med 1995 ;333:1025-32

Shah et al. JAMA 2005

Hemodynamic goals in randomized clinical trials in patients with sepsis: a systematic review of the literature Sevransky JE et al. Critical Care 2007

Hemodynamic goals in randomized clinical trials in patients with sepsis: a systematic review of the literature Sevransky JE et al. Critical Care 2007

Conclusion: the wide range of treatment targets suggest a lack of agreement on blood pressure and filling pressure goals for management of patients with sepsis. There was also

inconsistency between trials in which measures were targeted. Further research is necessary to determine whether this lack of consistency in hemodynamic goals may contribute to

heterogeneity in treatment effects for clinical trials of novel sepsis therapies.

The three 'windows' on shock

Hemodynamic monitoring: arterial pressure signal

SAP

Pulse pressure

DAP

MAP

1913

1733

2012

30-day mortality for categories of fluid resuscitation volume

30-day mortality according to timing of antibacterial administration

Association of arterial blood pressure and vasopressor load with septic shock mortality: a post hoc analysis of a multicenter trial Dunser MW et al. Crit Care 2009

Interpretation of blood pressure signal: physiological bases, clinical relevance, and objectives during shock states Augusto JF et al. Intensive Care Med 2011

Targeted blood pressure ? Summary of relevant prospective studies

Essai SEPSISPAM Pierre ASFAR, Angers

Essai SEPSISPAM Pierre ASFAR, Angers

Publication des résultats complets en attente…

SRLF 2013: pas de différence significative

Monitoring de la macrocirculation ? Nécessaire…. mais probablement pas suffisant !

SvO2 = reflet global de l’oxygénation tissulaire

Considérant comme négligeable la quantité d'oxygène dissout dans le sang, l'équation de Fick peut être exprimée ainsi :

VO2 = (CaO2 - CvO2) . Q

VO2 # (SaO2 - SvO2) . (Hb . 1,36 . Q) Fick…

Une variation de SvO2 provient nécessairement de la variation d’un ou de plusieurs de ces déterminants …

SvO2 = SaO2 - VO2

CO x Hb x 1.36

Central Venous Oximetry Catheter

Monitorage de la ScvO2

Pulmonary Artery Oximetry Catheter

46.5% 49.2%

56.9%

30.5% 33.3%

44.3%

Early goal-directed therapy in the treatment of severe sepsis and septic shock Rivers et al. N Engl J Med 2001

Early goal-directed therapy in the treatment of severe sepsis and septic shock Rivers et al. N Engl J Med 2001

AC – novembre 2009

Crit Care Med 2005

Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock, 2012 Dellinger RP et al. Intensive Care Med 2013

ICU physicians stated volume resuscitation end-points

A survey of Canadian intensivists’ resuscitation practices in early septic shock Mc Intyre et al. Crit Care 2007

The incidence of low venous oxygen saturation on admission to the ICU: a multi-center observational study in The Netherlands Van Beest P et al. Crit Care 2008

The three 'windows' on shock. Max H. Weil

Serum Lactate as a Predictor of Mortality in Emergency Department Patients With Infection

Shapiro et al. AEM 2005

Nguyen et al. CCM 2004

Lactate Clearance vs Central Venous Oxygen Saturation as Goals of Early Sepsis Therapy: A Randomized Clinical Trial Jones AE et al. JAMA 2010

Lactate Clearance vs Central Venous Oxygen Saturation as Goals of Early Sepsis Therapy: A Randomized Clinical Trial Jones AE et al. JAMA 2010

Administered treatments: no difference Outcome: no difference

The triangular basis of circulatory shock

Assessment of the microcirculation

� Global perfusion end-points ¡ Oxygen delivery ¡ Base deficit ¡  Lactate

� Regional perfusion end-points ¡ Gastric tonometry ¡  Sublingual capnography ¡ Near-infrared spectrometry (NIRS) ¡ OPS imaging

� Mitochondrial function

De Backer et al. Intensive Care Med 2010

Techniques used to evaluate the microcirculation at the bedside

Near infrared spectroscopy (NIRS) of the thenar eminence in anesthesia and intensive care Lipcsey et al. Ann Intensive Care 2012

Restoring arterial pressure with norepinephrine improves muscle tissue oxygenation assessed by near-infrared spectroscopy in severely hypotensive septic patients Georger JF et al. Intensive Care Med 2010

What are the consequences of the heterogeneity of microvascular perfusion? De Backer D et al. Intensive care Med 2010

Orthogonal polarization spectral video-microscope image of sublingual mucosa

Healthy individual

Sepsis

De Backer et al. AJRCCM 2002

Proportion (%) of perfused

vessels

Early Increases in Microcirculatory Perfusion During Protocol-Directed Resuscitation are Associated with Reduced Multi-Organ Failure at 24 hours in Patients with Sepsis Trzeciak V et al. Intensive Care Med 2008

Mottling score predicts survival in septic shock Ait-Oufella H et al. Intensive Care Med 2011

Mottling score predicts survival in septic shock Ait-Oufella H et al. Intensive Care Med 2011

Knee area tissue oxygen saturation is predictive of 14-day mortality in septic shock Ait-Oufella H et al. Intensive Care Med 2012

Invasiveness

Informative

ECG NIP

CVP – ScvO2

Arterial pressure

Swan Ganz

Cost

PICCO Vigileo