how hight should map be ? c martin md,fccm,fccp icu and trauma center nord university marseilles...
TRANSCRIPT
How Hight Should MAP
Be ?C Martin MD,FCCM,FCCP
ICU and Trauma Center
Nord University Marseilles France
20 40 60 80 100
Organ Artery Pressure (mmHg)
Organ Blood Flow (% baseline)
150
100
50
0
Subautoregulatory slope
Autoregulatorythreshold
Autoregulationin Health and Disease
•Below their autoregulatory thresholds, organ flows are linearly dependent on perfusion pressure.
What about settings
where organ
autoregulation is
lost ?
20 40 60 80 100
Organ Artery Pressure (mmH g)
Organ Blood Flow (% baseline)
150
100
50
0
Autoregulationin Disease
Control3 weeks
1 week
Any increase in organ
perfusion is likely to
augment
organ blood flow
20 40 60 80 100
Ogan Artery Pressure (mmH g)
Organ Blood Flow (% baseline)
150
100
50
0
Autoregulationin Disease
Control3 weeks
1 week
Norepinephrine and Regional Blood
Giantomasso ICM 2004
MAP(mmHg)
Placebo NE Placebo NE
COL/min
Flow during Hyperdynamic Sepsis
69+8
87+7 (p < 0.05)
7.2+12
8 + 0.8 (p<0.05 )
Merino ewes IV bolus of E. coli (3x109)Norepinephrine 0.4 g/kg/min or placebo
Norepinephrine and Regional Blood
Giantomasso ICM 2004
UF(ml/h)
Placebo NE Placebo NE
CrCLmlL/min
Flow during Hyperdynamic Sepsis
52+23
117+101 p < 0.05)
41+30
83 + 54 (p<0.05 )
What is the relevance of these experimental
studies to clinical practice???
Norepinephrine and Renal Blood Flow
Urine Flow ml/hMAPressure
Desjars CCM 1983, 1987Meadows CCM 1988
Hesselvik CCM 1989Martin CCM 1990Martin Chest 1994……….
Time Time
Norepinephrine in Septic and Non-Septic Patients
Septic shock
Head trauma
Creatinine
Creatinine
before 24hr before 24hr
24hr 24hrbefore before
300+137
180+110 p < 0.050.7 + 0.3
1.7+0.9 p < 0.05
100+27 107+17 2.8+0.7 2.7+ 0.6
Cr CL
Cr CL
Albanese et al Chest 2004,126,534-539
MAP : 65-75-85 mmHg ???
20 40 60 80 100
Organ Artery Pressure (mmH g)
Organl Blood Flow (% baseline)
150
100
50
0
Autoregulationin Disease
Control3 weeks1 week
20 40 60 80 100
Organ Artery Pressure (mmH g)
Organ Blood Flow (% baseline)
150
100
50
0
Autoregulationin Disease
Control3 weeks1 week
20 40 60 80 100
Organ Artery Pressure (mmH g)
Organ Blood Flow (% baseline)
150
100
50
0
Autoregulationin Disease
Control3 weeks1 week
4,2
4,4
4,6
4,8
5
5,2
5,4
5,6
MAP 65 MAP 75 MAP 85
CI
* *
560
580
600
620
640
660
680
700
720
MAP 65 MAP 75 MAP 85
DO2
0
20
40
60
80
100
120
140
160
MAP 65 MA 75 MAP 85
VO2
*
Increasing MAP ?10 septic shock patientstreated by NE
•LeDoux et al Crit Care Med2000 , 28 , 2729
CI
VO2
DO2
0
10
20
30
40
50
60
MAP 65 MAP 75 MAP 85
Urine flow
0
0,05
0,1
0,15
0,2
0,25
0,3
0,35
0,4
0,45
MAP 65 MAP 75 MAP 85
Red cell velocity
0
2
4
6
8
10
12
14
16
18
MAP 65 MAP 75 MAP 85
Pa-PiCo2
•Increasing MAP ?•10 septic shock patients treated by NE
•LeDoux et al Crit Care Med2000 , 28 , 2729
UF
65 85
A Bourgoin et al CCM 2005,33,780-786
Increasing MAP ?Lactate
DO2
VO2
65 85
Increasing MAP ?UF
Creatinine
Cr ClA Bourgoin et al CCM 2005,33,780-786
8565
MAP : 65 mmHg
Unresolved issues :
Formerly hypertensive patients ?Elderly patients ?
Atherosclerotic patients ?Others ????
Coronary Artery flow
Cardiogenic ShockManagement of Hypotension
SBP> 90
mmHg
ESC Guidelines. Eur Heart J 2005, 26,384-416
CI > 2 l.min-
1.m-2
Prehospital Hypotension
and Outcome in Trauma
0
10
20
30
40
50
60
70
120 + 120-90 90-60 60-0
Blunt
Penetrating
Arbabi et al J Trauma 2004 , 56 1029
• Register of Ann Arbor Seattle USA
• 19 409 patients• 2373
hypotension
SAP
Mortality
Prehospital Hypotension = Predictive Factor of Mortality in Trauma
Uncontrolled Hemorrhage :Is Normal Blood Pressure the
Target ?Roberts et al Lancet 2001
Normal blood pressure is not the target !
Bleeding or
Re-bleeding
Hemodilution
Coagulation disorders
Agressive Volume Loading
AnemiaHypothermia Hypoxemia
SAPIncrease Mechanic effect
on vascular clot
Is Normalisation of blood Pressure Dangerous ?????
• Fluid resuscitation interferes with the physiological response to hemorrhage
• Elevated blood pressure favors bleeding by a mechanical effect
• Hemodilution aggavates bleeding
Bickell et al NEJM 1994
The effect of vigorous fluid resuscitation in uncontrolled hemorrhagic shock after massive splenic injury
Solomonov E , Krausz M CRIT CARE MED 2000;28:749-754
Uncontrolled Hemorrhage in Rats
After FR ( LVNS ) : Fall of BP , increase in blood losses and mortality
SurvivalMAP
No fluids
LVNS
No fluids
LVNS
Should We Raise Blood Pressure in Case of Uncontrolled Hemorrhage ?????
• Meta-analysis of clinical randomized studies– 3 studies on survival
– 2 studies on coagulation
• Maximal heterogeneity
Kwan I, Bunn F, Roberts I; WHO Pre-Hospital Trauma Care Steering Committee
Cochrane group 2003.
Timing and volume of fluid administration for patients with bleeding
1. « We found no evidence from randomised controlled trials for or against early or larger volume of
intravenous fluid administration in uncontrolled haemorrhage. There is continuing uncertainty about the best fluid administration strategy in bleeding trauma patients. Further randomised
controlled trials are needed to establish the most effective fluid resuscitation strategy »
Kwan I, Bunn F, Roberts I; WHO Pre-Hospital Trauma Care Steering Committee
Cochrane group 2003.
Should We Raise Blood Pressure in Case of Uncontrolled Hemorrhage ?????
• Meta-analysis of clinical randomized studies– 3 studies on survival
– 2 studies on coagulation
• Maximal heterogeneity
==> No conclusion !!!!!
==> Experimental data
Kwan I, Bunn F, Roberts I; WHO Pre-Hospital Trauma Care Steering Committee
Cochrane group 2003.
Uncontrolled hemorrhage and fluid resuscitation with HSS+HEA or LR in Rats
Burris et Col J Trauma 1999
Permissive
hypotension
rather than the
type of fluid
reduces re
bleeding
REBLEEDING
0%
50%
100%
1 2 3
Mortality (%) and level of MAP
Stern et al Ann Emerg Med 1993
40 mmHg 60 mmHg 80 mmHg
Fluid ResuscitationPermissive Hypotension and Hemorrhagic Shock
Fluid ResuscitationPermissive Hypotension and Hemorrhagic Shock
Fluid ResuscitationPermissive Hypotension and Hemorrhagic Shock
Fluid ResuscitationPermissive Hypotension and Hemorrhagic Shock
Burris et al J Trauma 1999; 46 : 216-23
Aortotomy (rat)
01020304050607080
Survival (%)
1 2 3 4
NONE
MAP 80 mmHg MAP
40 mmHgMAP
100 mmHg
Improved Outcome with Hypotensive Resuscitation ? Uncontrolled Hemorrhagic shock in a Swine Model
Improved Outcome with Hypotensive Resuscitation ? Uncontrolled Hemorrhagic shock in a Swine Model
Kowalenko T , et Al J. Trauma , 33 , 349 , 1992
24 immature swines - Aortotomy - Saline Infusion
%Survival
Time ( min )
•• ••• •• •• • • •
••MAP = 40 mmHg
MAP = 80 mmHg
NO RESUSCITATION
100
Normotensive or hypotensive
resuscitation ?A meta analysis
• 9 randomized studies
• Improvement
• Pooled Risk ratio : 0.37 (0.27 - 0.52)
Permissive hypotension improve survival !
Mapstone J, Roberts I, Evans PH , J TRAUMA 2003, 55 , 571
Favour hypotensive Favour normotensive
Immediate Versus Delayed FluidResuscitation for Hypotensive Patients
with Penetrating Torso Injuries
Immediate Versus Delayed FluidResuscitation for Hypotensive Patients
with Penetrating Torso Injuries
. 598 patients with torso or cervical injury
. SAP ≤ 90 mmHg at the scene
. No fluid survival 70 %
. Fluid at the scene survival 62 % *
Bickell WH, Wall MJ, N. Engl. J. Med. 1994 , 331, 1105 - 9
p < 0.04(level I)
Hemorrhagic shock (rat)
Capone et al J Am Coll Surg 1995; 180 : 49-5A = « prehospital » period (1 hour) B = « hospital period (72 h)
Group 1 : 0 VL
Group 2 : A = No VL ; B = VL for MAP = 80 mmHg
Group 3 : A = VL for MAP = 40 mmHg ; B MAP = 80 mmHg
Group 4 : A = VL for MAP = 80 mmHg ; B = MAP=80 mmHg
0
10
20
30
40
50
60
3-DSurvival
(%)
1 2 3 4
Must We Perform Vascular Loading in Multiple Trauma Patients ?
Hypotensive Resuscitation during Active Hemorrhage: Impact on In-Hospital Mortality
• Clinical study at Trauma Centrer arrival
• SBP ≤ 90 mmHg and uncontrolled hemorrhage
• Randomisation:
• SBP 100 (n = 55) SBP 70 (n = 55)
• Survival 92.7 % in each group
Dutton R, Mackenzie CF , et Al J trauma 2002 , 52, 1141
Penetrating Trauma and
Hemorrhagic Shock
A military Point of View
American Armed Forces Medical ServicesCombat Fluids Conference July 2001
• Fluid for
– Radial pulse
• SBP 80 mmHg
– If impossible, carotide pulse
• SBP # 60 mmHg
• Or keep the patients conscious !!!!
Permissive Hypotension for Uncontrollde Hemorrhage
• Strong clinical arguments
• Less clinical evidences
• Indirect arguments– SBP : 70-90 mmhg
SBP < 90 mmHg
MORTALITY x 3(level III)
Hypotension and Prognosis in Head Trauma Patients
The role of secondary brain injury in determining outcome from severe head injuryChesnut et al J Trauma 1993, 34 : 216-22
Prospective study in 717 severe brain trauma patients
Fluid resuscitation of patients with multiple injuries
and severe closed head injury
Experience with an aggressive fluid resuscitation strategy
• 34 patients ISS> 16
•CGS < 8
•PPC > 80 mmHg,
York et al J Trauma 2000; 48 : 376-80
74 % of patients with no cerebral sequellae
6 % mortality
Hemorrhagic ShockGoals for Blood Pressure
• SBP : 70-90 mmHg if no head trauma(modulate according to age and underlying disease)
. MAP : 40 mmHg until bleeding is controlled and then 80 mmHg
• SBP : 120 mmHg in case of head and / or medullar trauma
How High Should M(S)AP Be ?
Septic shock MAP : 65 mmHg1 controlled study (30 patients)1 open study (10 patients)
Cardiogenic shock SAP : > 90-100mmHg expert opinion
Hemorrhagic shockSBP : 70-90 mmHgMAP : 40 mmHgin case of TBI : SBP 120 mmHg expert opinion
THE END
Vasoconstrictors
Arterial bed
Increased venous returnwith less volume loading
Increased preload Increased blood
pressure
Edema ?
Venous bed
Vasoconstrictor Effets in Hemorrhagic Shock Vasoconstrictor Effets in Hemorrhagic Shock
From De La Coussaye
Prehospital volume loading and vasoconstrictors for Prehospital volume loading and vasoconstrictors for severe traumasevere trauma
Prehospital volume loading and vasoconstrictors for Prehospital volume loading and vasoconstrictors for severe traumasevere trauma
SBP < 90mmHgSBP < 90mmHg
Volume loadingVolume loading
Crystalloids Crystalloids
Colloids < 20 Colloids < 20 ml/kgml/kg
Transport and direct Transport and direct admission to trauma admission to trauma
centercenter
++
First priorityFirst priority
surgical hemostasissurgical hemostasis
--
StopStop volume loadingvolume loading VasoconstrictorVasoconstrictor StopStop volume loadingvolume loading
--++
SBP unstable SBP unstable
or target non or target non reachedreached
From Carli P, 2005
Blunt trauma
+ TBI GCS < 8
Target: SBP = 120, Ht = 30%
Penetrating injury
Target: SBP = 70 90
HypovolemiaHemorrhage Vasoplegia Myocardial
Depression
SurgeryVascular loading ?Transfusion ?
Vasopressors ? Inotropic support ?
Hemorrhagic Shock
Meta- analysis of Fluid Challenge onSurvival in Rat Tail resection
Favour fluids Favour NO fluids
2.88 (1.72 -1.80)
0.25 (0.15 - 0.42)
0.86 (0.63 -1.18)
Section ≤ 50%
Section ≥ 50%
Roberts I et Al, BMJ 2002 324, 474
Animal models and Uncontrollded Hemorrhage Literature Analysis
Large Heterogeneity: Stratification by Model and Severity
Mapstone J, Roberts I, Evans PH , J TRAUMA 2003, 55 , 571
ModelAdjusted
Risk Ratio p
Aortotomy0.48
(0.33 - 0.71)< 0.001
Organ Injury0.76
(0.49 - 1.18)0.229
Tail resection
> 50 %0.69
(0.38 - 1.25)0.221
Tail resection
< 50 %1.86
(1.13 - 3.07)0.015
Other vascular
Injury1.70
(1.01 - 2.85)0.046
44 experimental studies
Massive Hemorrhage:
Fluid resuscitation improves the mortality rate
Massive Hemorrhage:
Fluid resuscitation improves the mortality rate
Moderate Hemorrhage :
Fluid resuscitation worsens the mortality rate
Moderate Hemorrhage :
Fluid resuscitation worsens the mortality rate
FAUT IL CORRIGER LA PRESSION ARTERIELLE A LA PHASE AIGUE DU CHOC HEMORRAGIQUE ??
Occult hypoperfusion is associated with increased morbidity in patients undergoing early femur fixation
Crowl et al J Trauma 2000, 48 : 260-7
• 57 Adultes avec fracture(s) fémorale(s) nécessitant ostéosynthèse
Groupe 1 : 20 patients avec lactate < 2,5
Groupe 2 : 37 patients avec lactate > 2,5 (hypoperfusion occulte)
Score de gravité identique
• Complications post opératoires :
Groupe 1 : 20 %
Groupe 2 : 50 %
Norepinephrine and Renal Flow(Endotoxemic Dogs)
Bellomo et al AJRCCM, 1999, 159, 1186-1192
PA (mmHg)
CORVR
(dynes)
Qr/ml/min
cont NE endoEndo+ NE
cont NE endoEndo+ NE
*
cont NE endoEndo+ NE
*
cont NEendoEndo+ NE
**
* *
*
Cardiogenic Shock :Management of Hypotension
Use Norepinephrine to raiseSBP > 80 mmHg
Change to dopamine (5-15 mcg/kg/min)
ACC/AHA Guidelines 2004
Dobutamine may be given when SBP > 90 mmHg
Norepinephrine and Regional Blood
Giantomasso ICM 2004
UF(ml/h)
Placebo NE Placebo NE
Cr CLml/min
Flow in the Normal MammalianCirculation
91+17
491+360
61+18
90+12 (p<0.05 )
(p<0.05 )
Norepinephrine and Regional Blood
Merino ewesPlacebo or NE : 0.4 g/kg/min
Giantomasso ICM 2004
MAP(mmHg)
Placebo NEPlacebo NE
COL/min
Flow in the Normal Mammalian Circulation
84
104 (p< 0.05) 3.76
4.78 (p<0.05)