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Caroline Hällsjö Sander MD Department of Anaesthesia, Surgical Services and Intensive Care Medicine, Karolinska University Hospital Solna The answer is blowing in the wind; cardiac output and lung volume monitoring in intubated patients

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  • Caroline Hällsjö Sander MDDepartment of Anaesthesia, Surgical Services and Intensive Care Medicine, Karolinska University Hospital Solna

    The answer is blowing in the wind; cardiac output and lung volume monitoringin intubated patients

  • This work has been supported by;

    The regional agreement on medical training and research (ALF) between Stockholm County Council and the Karolinska Institutet

    The HMT project (Health, Medicine and Technology) a collaboration project between the Stockholm County Council and the Royal Institute of Technology

    Maquet Critical Care AB

    2KARISMA Karolinska Anaesthesia Research Group for Major Surgery

  • 3

    (Anesth Analg 2011;112:1392–402)

    Anesth Analg. 2011 Jun;112(6):1384-91

    KARISMA Karolinska Anaesthesia Research Group for Major Surgery

  • Perioperative monitoring during high-risk surgery?

    4KARISMA Karolinska Anaesthesia Research Group for Major Surgery

  • 5

    A modified Fick's principleNon-invasive

    KARISMA - Karolinska Anaesthesia Research Group for Major Surgery

    Invasive

    Gedeon A, et al; Pulmonary blood flow (cardiac output) and the effective lung volume determined from a short breath hold using the differential Fick method. J Clin Monit 2002; 17: 313-321Peyton P, Pulmonary carbon dioxide elimination for cardiac output monitoring in peri-operative and critical care patients; history and current status. J of Healthcare engineering 2013; 4:2 :203-222

    Partial rebreathing

    A capnodynamic method

  • The capnodynamic equation

    6

    ELV Effective lung volume [L]

    EPBF Effective pulmonary blood flow [L/min]n current breath n-1 previous breathFACO2 mean alveolar carbon dioxide fractionCvCO2 mixed venous carbon dioxide content [Lgas/Lblood]CcCO2n end-pulmonary capillary carbon dioxide content [Lgas/Lblood]VTCO2n volume [L] of carbon dioxide eliminated by the current breath∆t n current breath cycle time [min]

    ( ) ( )12 2 2 2 2n n n n nA A v cELV F CO F CO EPBF t C CO C CO VTCO−⋅ − = ⋅∆ ⋅ − −

    KARISMA - Karolinska Anaesthesia Research Group for Major Surgery

  • Ventilatory pattern

    Inspiratory holds Expiratory holds

    7KARISMA - Karolinska Anaesthesia Research Group for Major Surgery

  • 8

    List of errata

    KARISMA - Karolinska Anaesthesia Research Group for Major Surgery

  • Reference method for cardiac output (COTS)

    9

    An ultrasonic flow probe placed around truncus pulmonalis

    KARISMA - Karolinska Anaesthesia Research Group for Major Surgery

  • Hemodynamic challenges in a porcine model (N=6-10)

    10KARISMA - Karolinska Anaesthesia Research Group for Major Surgery

    Hällsjö Sander C, Hallbäck M, Wallin M, Emtell P, Oldner A, Björne HNovel continuous capnodynamic method for cardiac output assessment during mechanical ventilation.Br J Anaesth. 2014 May;112(5):824-31. doi: 10.1093/bja/aet486.

  • Hemodynamic and ventilatory challenges before and after lung lavage in a porcine model (N=9)

    11

    Hällsjö Sander C Hallbäck M, Suarez Sipmann F, Wallin M, Oldner A, Björne HA novel continuous capnodynamic method for cardiac output assessment in a porcine model of lung lavage. ActaAnaesthesiologica Scandinavica 2015 Sep; 59(8):1022-31

    KARISMA - Karolinska Anaesthesia Research Group for Major Surgery

  • 12KARISMA - Karolinska Anaesthesia Research Group for Major Surgery

    The capnodynamic method COEPBF with a modified ventilatory pattern compared to the reference method for cardiac output COTS in a porcine model (N=8).

  • 13

    141 paired cardiac output values obtained from the reference method for CO (COTS)and the capnodynamic method (COEPBF) (L/min)

    KARISMA - Karolinska Anaesthesia Research Group for Major Surgery

  • Conclusion

    The capnodynamic method (COEPBF) with a ventilatory pattern based on expiratory holds did not display the paradoxical trending shown in our previous animal studies with a ventilatory pattern based on inspiratory holds.

    Trending ability was preserved during all hemodynamic and respiratory interventions.

    14KARISMA - Karolinska Anaesthesia Research Group for Major Surgery

  • The capnodynamic equation

    15

    ELV Effective lung volume [L]

    EPBF Effective pulmonary blood flow [L/min]n current breath n-1 previous breathFACO2 mean alveolar carbon dioxide fractionCvCO2 mixed venous carbon dioxide content [Lgas/Lblood]CcCO2n end-pulmonary capillary carbon dioxide content [Lgas/Lblood]VTCO2n volume [L] of carbon dioxide eliminated by the current breath∆t n current breath cycle time [min]

    ( ) ( )12 2 2 2 2n n n n nA A v cELV F CO F CO EPBF t C CO C CO VTCO−⋅ − = ⋅∆ ⋅ − −

    KARISMA - Karolinska Anaesthesia Research Group for Major Surgery

  • ELV effective lung volume

    The stability of ELV during significant hemodynamic alterations.

    The correlation of ELV and a reference method for FRC (FRCPEEP) at different PEEP levels.

    16KARISMA - Karolinska Anaesthesia Research Group for Major Surgery

  • The sulfur hexa fluoride method reference for FRC (FRCPEEP)

    17KARISMA - Karolinska Anaesthesia Research Group for Major Surgery

  • Hemodynamic alterations in a porcine model (N=9)

    18

    ELV

    COTS

    KARISMA - Karolinska Anaesthesia Research Group for Major Surgery

  • ELV compared the FRCPEEP during PEEP alterations (N=9)

    19KARISMA - Karolinska Anaesthesia Research Group for Major Surgery

  • Conclusions

    ELV remained stable during hemodynamic alterations and was closely related to FRCPEEP.

    20KARISMA - Karolinska Anaesthesia Research Group for Major Surgery

  • Clinical and future perspectives

    Evaluation of the modified ventilatory pattern after lung lavage

    Correction for shunt flow

    Human study; 30 patients high risk surgery COEPBF

    Could ELV and EPBF be used in combination for optimisation of CO and and PEEP?

    21KARISMA - Karolinska Anaesthesia Research Group for Major Surgery

  • Thank you for your attention!

    22

    [email protected]

    KARISMA - Karolinska Anaesthesia Research Group for Major Surgery

  • Materials and MethodsA 10 Fr Reliant catheter was placed below the diaphragm and inflatedHemodynamic measurements were obtained-Before inflation of the balloon-27 minutes after inflation -1,3 and 5 minutes after deflation

    Reference method for cardiac output; The ultrasonic flow probe placed around truncus pulmonalis COTSThe capnodynamic method COEPBFThe pulmonary artery catheter COPACPigs (N=8)

    KARISMA - Karolinska Anaesthesia Research Group for Major Surgery 23

  • 24KARISMA - Karolinska Anaesthesia Research Group for Major Surgery

  • Conclusion

    The ischemic model resulted in significant changes in lactate levels and severe hemodynamic changes.

    COEPBF showed good agreement at BL but markedly overestimated CO at minute one and three after deflation. Five minutes after deflation COEPBFhad re-established agreement with the reference method.

    25KARISMA - Karolinska Anaesthesia Research Group for Major Surgery

    Caroline Hällsjö Sander MDThis work has been supported by;Slide Number 3Perioperative monitoring during high-risk surgery?Slide Number 5The capnodynamic equationVentilatory patternSlide Number 8Reference method for cardiac output (COTS)Hemodynamic challenges in a porcine model (N=6-10)Hemodynamic and ventilatory challenges before and after lung lavage in a porcine model (N=9)Slide Number 12Slide Number 13ConclusionThe capnodynamic equationELV effective lung volumeThe sulfur hexa fluoride method reference for FRC (FRCPEEP)Hemodynamic alterations in a porcine model (N=9)ELV compared the FRCPEEP during PEEP alterations (N=9)ConclusionsClinical and future perspectives�Thank you for your attention!�Materials and MethodsSlide Number 24Conclusion


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