Download - Download PDF of Hemodynamic Monitoring
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Hemodynamic MonitoringTo Guide Volume Resuscitation
Nick Johnson, MDActing Assistant Professor
Division of Emergency MedicineAttending Physician, Medical & Neuro-Intensive Care Units
Harborview Medical Center
No Conflicts of Interest
Objectives
1. To highlight a key challenge: excess volume can hurt patients, but so can tissue hypoperfusion.
2. To discuss the challenges of evaluating hemodynamic monitoring tools when there is no gold standard.
3. To review several endpoints for volume resuscitation and discuss their utility.
4. To discuss three interesting hemodynamic monitoring tools, which can be used in a variety of clinical settings.
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The Problem
Boyd CCM 2011 Sadaka J Int Care Med 2014
FACCT NEJM 2006
Elofson J Crit Care 2015 Shim J Crit Care 2014 Payan Crit Care 2008
Goldilocks Principle
The Gold Standard Conundrum
SUPPORT JAMA 1996Sandham et al. NEJM 2003Richard et al. JAMA 2003
PAC-Man Lancet 2005FACCT NEJM 2006
Cochrane Review 2013
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Preload
CardiacOutput
Yes
Responsiveness
Preload
CardiacOutput
Yes
No
Responsiveness
Endpoints
Tolerance
Responsiveness
Organ Perfusion
Patient-Centered Outcomes
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Upstream:IVC ultrasound
Downstream:End-tidal CO2
Mid-Stream:Pulse pressure variation
Point-of-Care Ultrasound (POCUS)
Spontaneously breathing
Gestalt
Mechanicallyventilated
“The IVC looks full or empty”
IVC Diameter or Percent Collapse
Estimate CVP
IVC collapse index or ∆IVC
VolumeResponsive
Spontaneously Breathing
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Spontaneously Breathing
Rudski et al. J Am Soc Echo. 2010.
IVC Size(cm)
Respiratory Change CVP (cmH20)
<1.5 Total collapse 0-5
1.5-2.5 >50% collapse 6-10
1.5-2.5 <50% collapse 11-15
>2.5 <50% collapse 16-20
>2.5 No change >20
Mechanically Ventilated
Barbier ICM 2004, Feissel ICM 2004
dIVC = Max-Min ≥ 18%Min
∆DIVC = Max-Min ≥ 12%Mean
All patients had tidal volume > 8 ml/kg
Pulse Pressure Variation
>12-15% ~ Fluid responsive
Musts:Mechanically ventilatedControlled modeNot triggeringTidal volume > 8ml/kgSinus rhythm
Michard AJRCC 2010, Michard Chest 2002, Lanspa Shock 2013
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Pulse Pressure VariationFlotrac/Vigileo
LiDCO Rapid with CNAP module
PiCCO
Pleth Variability
Feissel et al. Int Care Med 2007. Feissel et al. J Crit Care 2013. Natalini et al. Anesth Analg 2006. Cannesson et al. Anesthesiology 2007.
Pleth Variability
Feissel et al. Int Care Med 2007. Feissel et al. J Crit Care 2013. Natalini et al. Anesth Analg 2006. Cannesson et al. Anesthesiology 2007.
Respiratory variation > 12-15%
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End-Tidal CO2
Monnet ICM 2013
End-Tidal CO2
Monnet ICM 2013
Cardiac Index
Arterial pulse pressure
EtCO2
100-Specificity
Sen
sitiv
ity
End-Tidal CO2
Monnet ICM 2013
Cardiac Index
Arterial pulse pressure
EtCO2
100-Specificity
Sen
sitiv
ity Passive leg raise →
↑ EtCO2 ≥ 5% ~
↑ Cardiac index ≥15%
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Summary
1. Give the right amount of fluid, but not a drop more.
2. There is no gold standard hemodynamic monitor.
3. Endpoints: tolerance, responsiveness, perfusion, mortality?
4. A variety of monitoring tools exist, each with limitations. Use multiple tools along with your clinical judgement.
Thank you!
Nick Johnson, [email protected]
@NickJohnsonMD
Additional References• Flotrac
– Review of 45 published studies:• Marik PE. J Cardiothorac Vasc Anesth 2013;27(1):121–34.
– 1st & 2nd generation devices• Slagt C, et al. Eur J Anaesthesiol 2015;32(1):5–12.• Compton FD, et al. Br J Anaesth 2008;100(4):451–6.• Hadian M, et al. Crit Care 2010;14(6):R212.• De Backer D, et al. Intensive Care Med 2011;37(2):233–40.• Monnet X, et al. Critical Care 2010;14(3):R109.
– 3rd generation devices• Machare-Delgado E, et al. J Intensive Care Med 2011;26(2):116–24.• Monnet X, et al. Br J Anaesth 2012;108(4):615–22.• Monnet X, Lahner D. Care Med 2011;37(2):183–5.
– OR setting• Benes J, et al. Crit Care 2010;14(3):R118.
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Additional References
• CNAP– Jeleazcov C, et al British Journal of Anaesthesia
2010;105(3):264-272.– Ilies C, et al. British Journal of Anaesthesia 2012;108
(2): 202–10– Jagadeesh A, et al. Ann. Card. Anaesth
2012;15(3):180-4..– Siebig S, et al. International Journal of Medical
Sciences 2009;6(1): 37-42– Ilies, H. et al. British Journal of Anaesthesia
2012;109(3): 413–19– Monnet X, et al . British Journal of Anaesthesia
2012Sep;109(3):330-8
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