Cardiac Output As Cardiac Output As End Point for End Point for Resusitation In Resusitation In Sepsis (Pro) Sepsis (Pro)

Zuswayudha Samsu Zuswayudha SamsuUPF Anestesi Perfusi dan PerawatanUPF Anestesi Perfusi dan Perawatan Intensif IntensifPusat antun! "asiona# $arapan %itaPusat antun! "asiona# $arapan %ita a&arta a&artaEmai# ' p(s)centrin*net*id Emai# ' p(s)centrin*net*id Inter+re#ation ,etween Systemic Inter+re#ation ,etween Systemic In-ammatory Response Syndrome (SIRS). In-ammatory Response Syndrome (SIRS). Sepsis. and InfectionSepsis. and InfectionInfectionInfectionSIRSSIRSPancreatitis PancreatitisBurns BurnsTraumaTraumaOther OtherBacteremiaBacteremiaFungemia FungemiaSepsisSepsisOther Other TERM TERM CRITERIA CRITERIASIRS Presense of 2 to 4 of the following signs* of systemic inflammation : yperthermia !"#$o % or &'&()o F* or hypothermia !+#,o % or $4o F*Tachycar-ia !"$' or &'' .eats per minute*Tachypnea !"2' .reaths per minute*/le0ate- !or -epresse-* white .loo- cell count !"&)1''' cells234 or +2''' cells234*Sepsis SIRS criteria plus 5nown or suspecte- presence of serious infection1 inclu-ing .acteremia or -istant site of infection(Se0ere sepsisSepsis plus e0i-ence of en-6organ -ysfunction* as follows :&( ypotension !systolic .loo- pressure +$' mm g or "4' mm g fall from .aseline in patients with chronic hypertension7 or mean arterial pressure+,' mm g*2( Oliguria !urine output +#' m42h*#( ypo8emia consistent with acute lung un9ury !PaO22FlO2+#''*4( %hange in mental status !-ecrease of 2 points on :lasgow %oma Scale*)( ;nion gap meta.olic aci-osis,( ( 4ow systemic 0ascular resistance !+>'' -ynes(sec(cm6)*Septic shoc5 Se0ere sepsis criteria inclu-ing hypotensionPaul N. Lanken : Septic shock and other low after load states the intensive care unit manual. Ed.Paul N. Lanken : Septic shock and other low after load states the intensive care unit manual. Ed. P.N. Lanken 2001 W Saunders. !o. P.N. Lanken 2001 W Saunders. !o. 2001 SCCM/ESICM.ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med 31:1250!"2003. Mortality Mortality7-17%Sepsis400,000 Incidence Incidence#al$" %.A. Crit Care Clin 2000&33':52Mortalit( Increases in Septic S)oc$ PatientsMortalit( Increases in Septic S)oc$ Patients20-5%Se!ere Sepsis00,000Septic S"oc#5-$% I%&ECTI'% I%&ECTI'%symptomsSpecific careSupporti0ecareSE(SIS SE(SISSE)ERE SE(SIS SE)ERE SE(SIS SE(TIC S*'C+ SE(TIC S*'C+M',S M',S -( '.y/enation-('.y/enation'li/0ria&e!er &e!erTac"ycardia Tac"ycardiaTac"ypnea Tac"ypneaE1piric E1piricanti2iotic t"erapy anti2iotic t"erapySo0rce control So0rce control* *&l0ids3'.y/en t"erapy3 )asopressors3Mec"anical&l0ids3'.y/en t"erapy3 )asopressors3Mec"anical 3E4,T 3(ress0re s0pport 3 Inotropes !entilation 3E4,T 3(ress0re s0pport 3 Inotropes !entilation!entilation 3 Moderate 3lo5 T) !entilation 3 Moderate 3lo5 T)3%I) corticosteroids 3Recr0it1ent 3%I) corticosteroids 3Recr0it1ent3 )asopressin1ano!re0s 3 )asopressin1ano!re0s 3(rone 3(rone position position 3C))* etc 3C))* etcs R2R4RR1:rd Sta!e + Resuscitated Sepsis:rd Sta!e + Resuscitated SepsisF#uid Responsi5e + Increased Cardiac Output F#uid Responsi5e + Increased Cardiac Output55%15%8%5%Coronary (er70sionMA($5 11*/S!'2?s.ppl @A:S20S2!4oal-directed T"erapy 2oa#s of Resuscitation2oa#s of Resuscitation9* 9* $eart rate F 96= ,eatsAminute (F 9==$eart rate F 96= ,eatsAminute (F 9== e5en ,etter) e5en ,etter)6* 6* Respiratory rate F := ,reathsAminute Respiratory rate F := ,reathsAminute:* :* Arteria# O Arteria# O6 6 saturation G ;:H saturation G ;:HE* E* ?ean Arteria# Pressure?ean Arteria# Pressure G G CI mm$!CI mm$! I* I* Centra# 5enous pressure G D mm$! Centra# 5enous pressure G D mm$!C* C* Centra# 5enous O Centra# 5enous O6 6 saturationsaturation G G J=H J=HJ* J* Arteria# #actate F 6*= mmo#AKArteria# #actate F 6*= mmo#AK Patient in Patient in Emer!ency Emer!ency 0epartment0epartment4reatment options'4reatment options'9* 9* Epinephrine Epinephrine6* 6* 0opamine 0opamine:* :* "orepinephrine "orepinephrineE* E* 1asopressin 1asopressinI* I* Pheny#ephrine Pheny#ephrineC* C* 0o,utamine 0o,utamineJ* J* ?i#rinone ?i#rinoneD* D* F#uids F#uids A 0e#icate /a#ancin! ActLA 0e#icate /a#ancin! ActL%enalMesentericPerf.sionCere9ralCoronar(Perf.sion A 0e#icate /a#ancin! ActLA 0e#icate /a#ancin! ActL%enalMesentericPerf.sionCere9ralCoronar(Perf.sionB a+onistP)en(lep)rine0ocal Tiss.e D(so7ia A 0e#icate /a#ancin! ActLA 0e#icate /a#ancin! ActL%enalMesentericPerf.sionCere9ralCoronar(Perf.sion=asodilatorC3" adenosine5enerali6ed Tiss.e D(so7ia A 0e#icate /a#ancin! ActLA 0e#icate /a#ancin! ActL%enalMesentericPerf.sionCere9ralCoronar(Perf.sionCorepinep)rineDopa/ineDo9.ta/ineDo9.ta/ineDopa/ineCorepinep)rineD.dicio.s .se of fl.ids" norepinep)rine" do9.ta/ine and dopa/ine Early 4oal-,irected T"erapyRivers E. NEJM 2001 Patient in 4ransferred to the ICUPatient in 4ransferred to the ICU8reatment options:8reatment options:

7er, diGcult to 7er, diGcult to tellHtellHDo (o. 2ant to treat 9lood press.reEor tiss.e perf.sionE 0.>0.& 0.&0.2 0.20.0 0.00.1 0.10.0 0.0 0.9 0.9 1.0 1.0 1.9 1.9 2.0 2.0 2.9 2.9 >.0 >.0 >.9 >.9 &.0 &.0 &.9 &.9 9.0 9.0P7=*==E P7=*==EP$3

0

5L58L 3: 13SP580L %E081P$3

0

5L58L 3: 13SP580L %E081B0!E8E !0$%50! :05LE$ECB0!E8E !0$%50! :05LE$EC CI a#so predicts hospita# CI a#so predicts hospita# deathdeathBIirklin et al 0@! 1*J1C BIirklin et al 0@! 1*J1C!0$%50! 5N%EK !0$%50! 5N%EK1.0 1.00.* 0.*0.J 0.J0.( 0.(0.? 0.?0.9 0.90.> 0.>0.& 0.&0.2 0.20.0 0.00.1 0.10.0 0.0 0.9 0.9 1.0 1.0 1.9 1.9 2.0 2.0 2.9 2.9 >.0 >.0 >.9 >.9 &.0 &.0 &.9 &.9 9.0 9.0P$3

0

5L58L 3: 0!E8E !0$%50! %E081P$3

0

5L58L 3: 0!E8E !0$%50! %E081 CI a#so predicts hospita# CI a#so predicts hospita# deathdeathBIirklin et al 0@! 1*J1C BIirklin et al 0@! 1*J1C.i2ed 7enous P3 .i2ed 7enous P32 20.J 0.J0.( 0.(0.? 0.?0.9 0.90.> 0.>0.& 0.&0.2 0.20.0 0.00.1 0.10.0 0.0 10.0 10.0 >0.0 >0.0 &0.0 &0.0 90.0 90.0 ?0.0 ?0.0Pro/a/ilit, of acute cardiac deathPro/a/ilit, of acute cardiac death20.0 20.0Iirklin= /arrat o,es : Post operative care in cardiac sur#er,. > Iirklin= /arrat o,es : Post operative care in cardiac sur#er,. >nd nd ed. 200>= !hurchilled. 200>= !hurchill Livin#stone Livin#stone /n-6points OfResuscitation/n-6points OfResuscitation:lo.al en- points :lo.al en- points !0ital signs1 lactate1 .ase -eficit1 S0O!0ital signs1 lactate1 .ase -eficit1 S0O2 2*1*1e0en though imperfecte0en though imperfectare the most usefulare the most usefulTissue specific resuscitation is Tissue specific resuscitation is promising .ut as yet clinically unpro0enpromising .ut as yet clinically unpro0en $ow A,out Coronary $ow A,out Coronary Perfusion@Perfusion@Ot.er t."n #l"cing " c"t.eter in t.e coron"ry Ot.er t."n #l"cing " c"t.eter in t.e coron"ry sinus1 t.ere is no #r"ctic"l /et.o& wit. w.ic. to sinus1 t.ere is no #r"ctic"l /et.o& wit. w.ic. to "ssess coron"ry #er'usion in t.e %C2"ssess coron"ry #er'usion in t.e %C2).ere is no reli"le w"y to &eter/ine t.e /e"n ).ere is no reli"le w"y to &eter/ine t.e /e"n "rteri"l #ressure re3uire& to #revent /yoc"r&i"l "rteri"l #ressure re3uire& to #revent /yoc"r&i"l &ysoxi"&ysoxi" (0lse, -lood (ress0re(0lse, -lood (ress0re>rine o0tp0tCapillary re7illCapillary re7illEnd+points of End+points of resuscitationresuscitation4he archaic4he archaic Endpoints of res.scitationEndpoints of res.scitationT)e sop)isticated for t)e 21 st Cent.r(T)e sop)isticated for t)e 21 st Cent.r(Tiss0e speci7ic 1onitorin/Tiss0e speci7ic 1onitorin/O8imetryB %apnometryO8imetryB %apnometryInterstitial p measuresInterstitial p measuresImaging of the microcirculationImaging of the microcirculation A#!orithm for $emodynamic A#!orithm for $emodynamic ?ana!ement?ana!ementMEA% ARTERIA; (RESS>RE MEA% ARTERIA; (RESS>RE)entric0lar)entric0lar &0nction &0nction?$0 11*/ ?$0 11*/ $0-100 11*/ $0-100 11*/ @100 11*/ @100 11*/,yna1ic ;)E& @,yna1ic ;)E& @ $5% or Cl@5 or S!o $5% or Cl@5 or S!o2 2 @ 80% @ 80%*yperdyna1ic "ypotensi!e *yperdyna1ic "ypotensi!estate A !asopressors state A !asopressors*yperdyna1ic*yperdyna1ic nor1otensi!e nor1otensi!estate A o2ser!e state A o2ser!e*yperdyna1ic "ypertensi!e *yperdyna1ic "ypertensi!eState A (ain controlB State A (ain controlBC-drener/ic 2loc#adeB C-drener/ic 2loc#adeB*ypertension A )asodilators *ypertension A )asodilatorsAdeD0ate ;)E& 25- AdeD0ate ;)E& 25-$5% or Cl 2:2-5 or$5% or Cl 2:2-5 or S!o S!o2 2 55-80% 55-80%*ypotension A I11ediate E*ypotension A I11ediate E /i!e !ol01e and/i!e !ol01e and !asopressorsF t"en, i7 ( lo5,!asopressorsF t"en, i7 ( lo5, titrate !ol01e, or i7 'titrate !ol01e, or i7 ' "i/"titrate inotropes "i/"titrate inotropes%or1al F%or1al F o2ser!e o2ser!e(oor ;)E& ?25% or(oor ;)E& ?25% or Ci ?2:2 or S!o Ci ?2:2 or S!o2 2 ?55% ?55%(erip"eral "ypoper70sion A i7 ((erip"eral "ypoper70sion A i7 ( lo5, /i!e !ol01e i7 ( "i/", /i!elo5, /i!e !ol01e i7 ( "i/", /i!e inotropes inotropes*ypo!ole1ia F i7*ypo!ole1ia F i7 ( lo5, /i!e( lo5, /i!e !ol01e i1pared!ol01e i1pared contractilityB I7contractilityB I7 ( nor1al or( nor1al or "i/", /i!e"i/", /i!e !asodilators !asodilators*ypo!ole1iaB *ypo!ole1iaBI7 ( lo5, /i!e !ol01e I7 ( lo5, /i!e !ol01eI1pared contractilityB I1pared contractilityBI7 ( nor1al or "i/", /i!eI7 ( nor1al or "i/", /i!e !asodilators !asodilators;e( : 0= , left 8entric.lar& E1 , eFection fraction& CI , Cardiac Inde7& S8o2, /i7ed 8eno.s o7(+en sat.ration& P , p.l/onar( arter( occl.sion;e( : 0= , left 8entric.lar& E1 , eFection fraction& CI , Cardiac Inde7& S8o2, /i7ed 8eno.s o7(+en sat.ration& P , p.l/onar( arter( occl.sion press.re. press.re.#elo.cif. S" Pa(en D : >> C).rcill#elo.cif. S" Pa(en D : >> C).rcill 0i8in+stone 0i8in+stone !entral 7enous S !entral 7enous Sc c3 32 2 M S M Sv v3 322 /, >N to 9N /, >N to 9NC)a2la et al. C)est 200&'12?:1J*1GS!'2 H Sc!'2I 6 240 50 $0 70 80 0 >0 &0 &0 ?0 ?0 (0 (0 J0 J0 *0 *0O O"lucose mmo54L"lucose mmo54L90 90 0iNerences in OKactateP 0iNerences in OKactateP (0ista# Q Pro8ima#) Ports(0ista# Q Pro8ima#) Portsn , 35So far" a little disappointin+!oronar, Perfusion Pressure Bmm1#C !oronar, Perfusion Pressure Bmm1#C0.& 0.&0.2 0.20.> 0.>0.1 0.1)0.1 )0.10.0 0.0>0 >0 &0 &0 ?0 ?0 (0 (0 J0 J0 *0 *0O Olactate mmo54Llactate mmo54L90 90 :uture aspects:uture aspects ,'2crit)'2;actate,eli!ery Independent )'2,eli!ery ,ependent )'2S)'6'ER,'2)'2;actateS)'2B