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10/28/15
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Advanced Hemodynamic Monitors: Do We Need Them?
T. J. Gan, M.D., M.H.S., F.R.C.A. Professor and Chairman
Department of Anesthesiology Stony Brook University Medical Center
Outline • Physiology of circulation and fluid dynamics • Measuring fluid responsiveness • Goal directed fluid therapy • Hemodynamic monitoring and patient
outcomes • Intergrating fluid management protocol in an
ERAS strategy
Com
plic
atio
ns
The Challenge
Bellamy MC. Br J Anaesth. 2006;97:755-757.
Volume Load
OPTIMAL
Edema Organ dysfunction Adverse outcome
Hypoperfusion Organ dysfunction Adverse outcome
Overloaded Hypovolemic
BOWEL WALL EDEMA BOWEL
ISCHEMIA
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Monitoring Fluid Responsiveness
Pressure vs. Flow Variables?
Fluid responsiveness is defined as
a significant increase ( > 10%) in SV (or CO) in response
to a fluid challenge
Neither CVP nor Ppao Predict Preload-Responsiveness
Kumar et al. Crit Care Med 32:691-9, 2004
Preload ≠ Preload Responsiveness
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Responders / Non-Responders % Responders Calvin (Surgery 81) 20 / 8 71 % Schneider (Am Heart J 88) 13 / 5 72 %
Reuse (Chest 90) 26 / 15 63 %
Magder (J Crit Care 92) 17 / 16 52 %
Diebel (Arch Surgery 92) 13 / 9 59 %
Diebel (J Trauma 94) 26 / 39 40 % Wagner (Chest 98) 20 / 16 56 %
Tavernier (Anesthesio 98) 21 / 14 60 % Magder (J Crit Care 99) 13 / 16 45 %
Tousignant (A Analg 00) 16 / 24 40 % Michard (AJRCCM 00) 16 / 24 40 %
Feissel (Chest 01) 10 / 9 53 %
Mean 211 / 195 52 %
Predicting Fluid Responsiveness in ICU Patients
Michard & Teboul. Chest 121:2000-8, 2002
Why Not Give Volume to All Hemodynamically Unstable Patients?
Chest 2008;134:172
• Very poor relationship between CVP and blood volume
• Inability of CVP / ΔCVP to predict the hemodynamic response to a fluid challenge
• CVP should not be used to make clinical decisions regarding fluid management
Muller et al. Anesthesiology 2011; 115:541–7
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What is the
ideal
monitor?
Minimally Invasive Cardiac Output • Indicator/Thermodilution
– Pulse contour (PiCCO) – Lithium indicator dilution (LiDCO) – NICO (CO2)
• Pulse pressure and stroke volume variation – Lithium indicator dilution (LiDCO) – Arterial pulse waveform (APCO) – Clear Sight
• Doppler – (EDM, UMSCOM, Hemosonic) – Transesophageal echo
• Thoracic electrical bioimpedence / bioreactance (NICOM) • Pulse oximetry plethysmography (respiratory variation) • End organ perfusion
– Gastric tonometer, Cytoscan
Thermodilution - CVP
Required for Calibration Thermodilution
Usually Femoral A-line
PiCCO Pulse Contour
http://www3.pulsion.de
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http://www.pulsion.com/index.php?id=38
Trans-Pulmonary Thermodilution
• Can use pre-existing arterial line or central line
• Continuous CO measurements
• Provides estimation of extravascular lung water
• Can be used with goal directed therapy
• Requires access to the central circulation
• Radial artery not suitable • Not truly a non invasive
technology • Limited use in the OR
Advantages Disadvantages
Calibration - Lithium Dilution
No CVP Required
Lithium Dilution Any A-line
LiDCO Lithium Dilution
http://lidco-ir.co.uk
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Lithium Dilution
• Ease of set up • Only require arterial line • Continuous CO
measurements • Can be used to measure
stroke volume and stroke volume variation
• Requires access to the circulation
• Repetitive blood draws • Calibration interfered in
the presence of neuromuscular blocking drugs
Advantages Disadvantages
Partial CO2 Rebreathing
NICO Partial CO2 Rebreathing
• Easy to set up • Does not require access to
the circulation • Provides for continuous
CO measurement
• Have not been proven for goal directed therapy
• Changes in dead space or V/Q matching may erroneously change CO measurement
• Not validated in non-ventilated patients
• Delayed responsiveness
Advantages Disadvantages
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Positive Pressure Breath
MECHANISM OF SVV
↓RV Preload ↑RV Afterload
↑LV Preload
Acute ↑SV
Delayed↓↓SV
Empty Pulmonary Venous System
↑ Intrathoracic Pressure
SVmax - SVmin SVV = SVmean
Stroke Volume Variation Calculation
Cardiac Output
FloTrac sensor (arterial catheter)
http://www.edwards.com
EV 1000
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FloTrac Validation Studies Authors Year Patients Comparator Manecke 2006 CABG & ICU PA (ICO and CCO) Cannesson 2007 CABG PA (ICO) Breukers 2007 CABG & ICU PA (ICO) Button 2007 CABG PA (ICO) & PiCCO Mayer 2007 CABG PA (ICO) Lorsomradee 2007 CABG PA (CCO) De Waal 2007 CABG & ICU PA (ICO) Sakka 2007 Sepsis PiCCO Mayer 2008 CABG PA (ICO)
LiDCO Rapid
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Monitoring Fluid Responsiveness - PVI
http://www.masimo.com/pvi/
Arterial Pulse Cardiac Output - Clinical Utilities
• Simple to use • Only require arterial line • Validated in clinical studies under many different
conditions • Continuous CO measurements • Can be used to measure stroke volume and stroke
volume variation • Validated in goal directed therapy
Arterial Pulse Cardiac Output - Limitations
• Requires access to the circulation • Requires high fidelity arterial tracing • Not well validated in arrhythmias • Not well validated in non-ventilated
patients
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Clear Sight
O Broch et al. Anaesthesia 2012, 67, 377–383
CO with Fluid Challenges
0
2
4
6
8
10
12:00 12:20 12:40 13:00
time
CO
SVV = 17
SVV = 8
SVV = 16
SVV = 12
SVV = 15
SVV = 8
200 mL colloid challenge
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VIGILEO vs. PAC-CCO
PEEP 0,
1,
2,
3,
4,
5,
1 21 41 61 81 101 121 Time in Min.
CO
in L
/min
.
CCO SWAN
Vigileo
Cardiac Output
FloTrac sensor (arterial catheter)
Esophageal Doppler Monitor
Doppler probe in mid esophagus
Ø SV Ø CO Ø FTc Ø PV Ø SD
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HemoSonic® Esophageal Doppler
USCOM® Suprasternal Doppler
• Doppler technology • Suprasternal Doppler
probe
www.uscom.com.au
Esophageal Doppler
• Simple to use • Does not require access to the
circulation • Reliable • Many clinical studies proving
utility • Can be used as a monitor of
volume responsiveness in goal directed therapy
• Mathematical assumptions about aortic size might be erroneous
• Only measures descending aortic blood flow
• Occasional difficulty in obtaining optimal probe position
• Learning curve • Uncomfortable in awake
patients
Advantages Disadvantages
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Gan et al., Anesthesiology 2002;97:820-6 Mythen 1995, Arch. Surg.,130(4), 423-429 Wakeling 2005, BJA, 95(5), 634-642
Measure CVP and
stroke volume
200ml of colloid i.v. over
10 minutes
Wait 5 minutes
CVP rise < 3mmHg and increase in stroke volume
YES
Measure CVP and
stroke volume every 15 minutes
NO
Fall in stroke volume
NO
YES
Thoracic Electrical Bioimpedance • Thorax is a cylinder that perfused
with a fluid (blood) of a specific resistivity
• Bioimpedance is the electrical resistance transmitted from electrodes placed on the upper and lower thorax
• Changes in electrical resistance during cardiac cycle
• Factors affect values: changes in Hb, excessive lung fluid, body habitus and vasodilation
BioZ®
CardioDynamics
Endotracheal CO Monitoring (ECOM) • Patented endotracheal tube design • Changes in electrical resistance
during cardiac cycle • Measure CO, SV, HR and BP • No calibration
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Thoracic Electrical Bioimpedance
• Completely non-invasive
• Easy setup
• Numerous mathematical assumptions
• Variability with different thoracic cavities
• Not useful for patients with dysrhythmias
• “Noise” from OR limits use • Requires hemodynamic
stability • Not proven for use in goal
directed therapy
Advantages Disadvantages
NICOM Bioreactance
Bioreactance
• When blood flows out of the heart, Phase Shifts are created in alternating radiofrequency electrical currents applied across the patients’ chest.
• Similar to a Frequency Modulation, or FM, as used in FM radio transmissions.
• Changes in frequency correlate well with instantaneous changes in blood volume and blood flow in the aorta.
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Gastric Tonometer
H+ + HCO3- = H2CO3 = CO2 + H2O
Cytoscan® Video Microscope
• Orthogonal Polarization Spectral (OPS) Imaging
• Scattered polarized light • Measure real time images of
the microcirculation • Operator dependent
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Goepfert et al, ICM 2007
Blood Lactate Levels
Gastric Tonometer
Hofer CK et al. Chest 2005;128:848-854
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Comparison of Cardiac Output
APCO vs. ICO Bias 0.19 Precision 1.28
CCO vs. ICO Bias 0.66 Precision 1.05
Does goal directed fluid administration improves
outcomes?
Which Goal?
• Stroke Volume • Stroke Volume Variation (SVV) • Cardiac Index • Oxygen Delivery (DO2) • Oxygen Consumption (VO2) • Venous Saturation (SVO2) • Gastric Mucosal pH (pHi) • FTc, Stroke Distance of Esophageal Doppler
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Owned, published, and © copyrighted, 2001, by the MASSACHUSETTS MEDICAL SOCIETY
Volume 345(19) 8 November 2001 pp 1368-1377 Early Goal-Directed Therapy in the Treatment of Severe Sepsis and
Septic Shock [Original Articles]
Rivers, Emanuel; Nguyen, Bryant; Havstad, Suzanne; Ressler, Julie; Muzzin, Alexandria; Knoblich, Bernhard; Peterson, Edward; Tomlanovich, Michael
For the Early Goal-Directed Therapy Collaborative Group* From the Departments of Emergency Medicine (E.R., B.N., J.R., A.M., B.K., M.T.), Surgery (E.R.), Internal Medicine (B.N.), and Biostatistics and Epidemiology (S.H., E.P.), Henry Ford Health Systems, Case Western Reserve University, Detroit. Address reprint requests to Dr. Rivers at the Department of Emergency Medicine, Henry Ford Hospital, 2799 West Grand Blvd., Detroit, MI 48202, or at [email protected]. *The members of the Early Goal-Directed Therapy Collaborative Group are listed in the Appendix.
Rivers et al. New Engl J Med 345:1368-77, 2001
Volume
Pressors
Inotropes
Treatment algorithm
Goal Directed Therapy in ER Patients
Protocol Control
SVO2 (%) 70.4 ± 10.7* 65.3 ± 11.4
Lactate (mmol/L) 3.0 ± 4.4* 3.9 ± 4.4
Base Deficit 2.0 ± 6.6* 5.1 ± 6.7
APACHE II 13.0 ± 6.3* 15.9 ± 6.4
Mortality (%) 30.5* 46.5 * p<0.01 Rivers et al. NEJM 2001;345:1368-77
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Perioperative Plasma Volume Expansion Reduces the Incidence of Gut mucosal Hypoperfusion During cardiac Surgery Mythen, MG and Webb AR. Arch Surg. 1995;130:423-9
• 60 ASA III patients • Protocol and Control groups • Fluid optimization with EDM in protocol group • Standard practice in control group • 200 ml 6% hetastarch to maintain maximum SV
Perioperative Plasma Volume Expansion Guided by EDM
Control Protocol P value
pHi <7.32 56% 7% <0.001
Complications 6 0 0.01
ICU Days 1.7 1 0.02
Hospital Days 10.1 6.4 0.01
Mythen et al. Arch Surg 1995;130:423-9
• 100 ASA II and III patients • Surgery with expected blood loss > 500 ml • Intraoperative goal directed fluid management vs. control • Background crystalloid infusion & colloid bolus • Fluid management algorithm with EDM • Primary outcome: LOS
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Gan et al . Anesthesiology 97:820-6, 2002
Volume
60
64
68
72
76
80
Baseline End of Surgery
Stroke Volume
SV (m
L)
Control Therapy
Control Therapy
Doppler Derived Variables
0.34
0.36
0.38
0.4
0.42
Baseline End of Surgery
Corrected Flow Time
FTc
(sec
onds
)
Control Therapy
Gan et al., Anesthesiology 2002;97:820-6
* p<0.05
* *
Baseline End of Surgery 70
72
74
76
78
80 Control Therapy
Heart Rate
HR
(Bea
ts p
er M
inut
e)
Control Therapy
75
80
85
90
95
Baseline End of Surgery
Mean Arterial Pressure
MA
P (m
mH
g)
Control Therapy
Gan et al., Anesthesiology 2002;97:820-6
Traditional Hemodynamic Variables
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Goal Directed Fluid Management
0
1
2
3
4
5
6
7
Tolerating Solids LOS
ControlTherapy
*
* p<0.05 *
Gan et al., Anesthesiology 2002;97:820-6
Days
Hamilton M et al. Anesth Analg 2011;112:1392–402
Summary • Hypovolemia is common and potentially avoidable. • Monitoring of SV and SVV and SVO2 may be more
sensitive in detecting hypovolemia than HR and pressure based monitoring.
• Goal directed fluid therapy appears to improve postoperative outcome.
• Integrating fluid management protocol in ERAS strategy reduces LOS and improve patient outcome
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