ALTERATIONS HEMODYNAMIQUES AU COURS DU SDRA · COURS DU SDRA Antoine Vieillard-Baron, Boulogne,...

ALTERATIONS

HEMODYNAMIQUES AU

COURS DU SDRA

Antoine Vieillard-Baron, Boulogne, France

Jama 2010

AJRCCM 2000

98 ARDS ventilés > 48H

72 (73%) avec amines vasoactives

Shock may lead to misinterpretation

of blood gas analysis

• Decrease in pulmonary shunt:

Underestimation of lung injury

Kumar

NEJM 1970

PEEP 13

F. Lemaire, F. Jardin et al. J Thorac Cardiovasc Surg 1978 ; 75 : 839-46

Shock may lead to misinterpretation

of blood gas analysis

• Decrease in pulmonary shunt:

Underestimation of lung injury

• Low PvO2 effect: Overestimation of lung

injury

Shock may lead to misinterpretation

of blood gas analysis

• Decrease in pulmonary shunt:

Underestimation of lung injury

• Low PvO2 effect: Overestimation of lung

injury

• Patent foramen ovale: Overestimation of

lung injury

Crit Care Med 2010

Prevalence 19,2%

Intensive Care Med 2003

• 401 ARDS

– 53% had associated circulatory failure

• 26% in a context of severe sepsis or septic

shock

Am J Respir Crit Care Med 2003

Intensive Care Med 2003

• 401 ARDS

– 53% had associated circulatory failure

• 26% in a context of severe sepsis or septic

shock

• 27% due to “another” mechanism

Am J Physiol Lung Cell Mol Physiol 2012

55.3%

49.3%

N Engl J Med 1977

Crit Care Med 2014

J Appl Physiol 1999

45/200 = 22.5%

49/226 = 22%

19/75 = 25%

Crit Care Med 2001

La défaillance VD a un impact sur

l’hémodynamique

PP = 27%

La défaillance VD a un impact sur le

pronostic

Boissier ICM 2013

Am J Respir Crit Care Med 2010

349/475 = 73%

Multicentric cohort of

752 ARDS with ECHO

EN PRATIQUE

Intensive Care Med 2016

PRISE EN CHARGE DE

L’INSUFFISANCE

CIRCULATOIRE

VENTILATION PROTECTRICE

POUR LA CIRCULATION

PULMONAIRE ET LE VD

Table S3 % of patients with

vasopressors 1 day after randomization

HFO group: 78%

Control group: 58%

20% difference for RV failure?

Crit Care Med 2012

8 pigs

Repeated BAL

ECCO2R (Cardiohelp)

Intensive Care Med 2009

Baseline

T1

PaCO2 52 mmHg 71 mmHg

pH 7.30 7.17

DrivingP 17cmH2O 12cmH2O

RV/LV 0.64 0.85

D1, 10 p.m

PaCO2: 88 mmHg

BD 14 mmol/l

D2, 7 a.m

PaCO2: 55 mmHg

BD 2.3 mmol/l

Duggan M, AJRCCM 2003

Before PP After 18 hours PP

Chest 2007

1996-2006

42 patients

P/F < 100 mmHg

ACP 50%

CATECHOLAMINES

SAP 80 mmHg NE 1µg/kg/min

SAP 110 mmHg

www.echo-rea.uvsq.fr

MERCI