CVP Blood PrCVP, Blood PrUrine Output:Urine Output:

h?enough?

Eran Segal, MDDi tDirectorDepartment of Anesthesia,MedicineA t M di l C t I

ressure andressure and Are they everAre they ever

, Critical Care and Pain

l

Disclosure:Disclosure:

Member of the Pulsion MMember of the Pulsion MMABMAB

urine output anpenough?g

1.Yes they can be enough

2.No, they are never enoug

3. I have never needed any

nd CVP ever

in many patients

gh

ything else

Young traumYoung traum

25 year old injured by a c25 year old injured by a c

brought to the ER -Chestbrought to the ER Chest

ma patientma patient

carcar

t and head injuryt and head injury

In the ERIn the ER

Blood pressure is 86/50

CVP is 4 cmH2O

Urine output is 30 ml/houur

Q2: What isb bl diprobable dia

1.Septic shockp

2.Anaphylactic shock2.Anaphylactic shock

3 Hemorrhagic shock3.Hemorrhagic shock

4 Cardiogenic shock4.Cardiogenic shock

s the most i ?agnosis?

Blood pressure is 86/50

CVP is 4 cmH2O

Urine output is 30 ml/hourml/hour

Q3: What sd ?done?

1.Administer fluids

2.Urine electrolytes2.Urine electrolytes

3 PA catheter3.PA catheter

4 PiCCO4.PiCCO

hould be

Blood pressure is 86/50

CVP is 4 cmH2O

Urine output is 30 ml/hourml/hour

The CVP and Baccurate re

hhypo

BUT WE PROBABLYBUT WE PROBABLY

lood pressure werpeflectors of his

l iovolemia

Y DID NOT NEED THEMY DID NOT NEED THEM......

Things areThings are so simpleso simple...

not alwaysnot always ..

A 55 year old brought to theacute MI

Hypotensive

Hypoxemic

Low urine output

man is e ICU after

In the ICUIn the ICUMechanical ventilation

Patient with pulmonaryp y

Blood pressure 130/66Blood pressure 130/66

On NoradrenalineOn Noradrenaline

Urine output is 110 ml/hoUrine output is 110 ml/ho

On furosemide dripOn furosemide drip

y edemay

ourour

What does ?us?

1.Heʼs hypovolemic - need

2.Heʼs hypervolemic - need

3.Fluid is OK - does not ne

the CVP tell

ds fluids

ds more diuretics

eed anything

OSMAN ET AL, CCM 2007

KUMAR ET AL, CCM 2

Q4: What imh dhemodynam

1.He received 500ml of col

2.He received a bolus of no2.He received a bolus of no

3 We stopped the diuretic3.We stopped the diuretic

4 We changed the way we4.We changed the way we

mproved his i ?mics?

lloid (Haes)( )

oradrenalineoradrenaline

looked at the CVP looked at the CVP

BLOOD PRESSUBLOOD PRESSUMMHGHR: 80/MINCVP: 18 MMHG

CI 1.7 LPGEDI 550 MGEDI 550 M

URE 94/40URE: 94/40

PMML/M2ML/M2

Tricky inducTricky induc

A 64 year old woman is bymajor debulking of peritotumortumor

ctionction

brought to the OR for goneal spread of a colonic

and 40 mg Rocurgmidzolam and 10

After induction - blood prmmHg

CVP is 6 mmHg

A catheter is being insertknow urine outputknow urine output

ronium, after 2 mg, g00 mcg fentanyl

ressure decreases to 80/46

ted - itʼll be a while until we

What wouldWhat would

1.Sheʼs obviously hypovolefluidsfluids

2 Sheʼs obviously vasodila2.She s obviously vasodilaphenylephrin

3.Her cardiac output has dpinduction drugs - give ep

d you do?d you do?

emic - give a bolus of

ted Give a dose ofted - Give a dose of

ecreased because of the hedrin or noradrenaline

a PiCCO cathinsertedse ted

Cardiac index is 1.8LPM

GEDI is 505 ml/M2GEDI is 505 ml/M

EVLWI is 6ml/kgEVLWI is 6ml/kg

SVV is 18SVV is 18

heter is

NORMAL VALUES

CI - 3-5 LPM

GEDI - 680-800GEDI 680 800

EVLWI <7ML/KGEVLWI -<7ML/KG

SVV 10 %SVV - <10 %

What wouldt ?next move?

1.Give fluids for hypovolem

2.Start a noradrenaline infuoutputoutput

3 bolus with phenylephrine3.bolus with phenylephrineCardiac index i

GEDI is 505 mlGEDI is 505 ml

EVLWI is 6ml/kEVLWI is 6ml/k

d be your ??mia

usion for low cardiac

e for vasodilationNORMAL VAL

e for vasodilations 1.8LPM CI - 3-5 LP

l/M2 GEDI 680l/M2

kg

GEDI - 680-

EVLWI -<7MLkg EVLWI 7ML

SVV - <10

Is optimizing flup gperioperative peworthwhile?

uid therapy in the pyeriod

rioperative Fluid anagement rategies in Major rgery: A Stratifiedrgery: A Stratified

eta-Analysiseta Analysis

What aboutoutput?output?

t urine

in the periopep pperiod?period?

HypovoHypovo

low flowlow flow

low blood low blood pressurepressure

PostrPostr

pressurepressure

PostrPostr

erative

olemiaolemiaacute kidney acute kidney

injuryinjuryj yj y

SIADHSIADH

renalrenalrenalrenal

ICU after an esophagectomesop agecto

The patient is hypotensiv100/56 mmHg100/56 mmHg

CVP i 14 HCVP is 14 mmHg

he is mechanically ventila

Urine output while receiv

myy

ve - Blood pressure is

ated and hypoxemic

ving diuretics - 40ml/hr

A PiCCO cai t dinserted

CI - 1.5LPM

GEDI - 600 ml/m2GEDI 600 ml/m2

EVLW - 16 ml/kgEVLW 16 ml/kg

SVV 22%SVV - 22%

atheter is

NORMAL VALUESNORMAL VALUES

CI - 3-5

GEDI - 680-800

EVLWI - <7

SVV <10

We adminisWe adminisster fluidsster fluids

Q5: Blood pressure CQ5: Blood pressure, CAre they always enoug

1 I never need more data1. I never need more data

2 Itʼs extremely rare that th2. It s extremely rare that th

3 D fi it l t3.Definitely not - many commore advanced monitorin

CVP and urine output:CVP and urine output: gh?

hey are not enoughhey are not enough

l ti t implex patients require ngg

ConclusionsConclusions

Blood pressure ,CVP andpindicators of hemodynam

In some patients, the histpresentation is enough topresentation is enough to

I l it tiIn more complex situatiohemodynamic managemy gcardiac output, volumetriresponsivenessresponsiveness

ss

d urine output are rough p gmic status.

tory and clinical o make clinical decisionso make clinical decisions

d i i b tns, decisions about ent requires more data -qc preload and fluid

Thank yoThank yoatteatte

ou for yourou for your entionention