1

Volume Optimization in Severe Sepsis

Dr. Yasser Sakr Dept. of Anesthesiology and Intensive Care

Uniklinikum Jena, Germany

Antalya/ 2016

The ultimate goal of the cardiovascular system –  Supply

Energy substrates (O2/Nutrition) Hormones Mediatores (e.g. cytokines)

–  Elimination Metabolic products

i.e to ensure adequate tissue perfusion

Physiologic backgrounds

Supply

Demand

DO2 = Hb% x SaO2 x CI x 10

ü  SvO2 ü  ScO2 ü  Lactate VO2

Physiologic backgrounds

Microcirculation

Global

Regional

Physiologic backgrounds

Global hemodynamic parameters do not correlate with microvascular perfusion

Dellinger, Crit Care Med 2003 , 31(3): 946-55

Septic shock

2

-- DO2

++ VO2 Myocardial dysfunction

Vascular derangements Relative hypovolemia

Organ dysfunction

Severe sepsis

Pathophysiology

VO2 DO2

optimal = normal

Therapeutic target

?? Medikament

Benefit Risk

++ DO2 Primum non nocere ! Florence Nightingale Notes on hospitals / London 1859

Therapeutic targets

Pres

sures

Flow

Resistence

Target vs. Indices

SV

Target vs. indices

3

SV

Preload Afterload

Contractility Heart rate

Therapeutic targets

Fluids

Frank Starling Law

Preload assessment Static parameters –  CVP/PCWP (Neither reflect ventricular volumes or

track preload-responsiveness) –  LVEDV/LVEDP –  GEDV/ITBV

Kumar et al. Crit Care Med 32:691-9, 2004

Predicting Fluid Responsiveness in ICU Patients

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%

Michard & Teboul. Chest 121:2000-8, 2002

V

V

SV

SV

SV

Preload

Frank-Starling revisited

High contractility

Normal Contractility

target area volume responsive volume overloaded

Poor contractility

Preload assessment

Dynamic parameters –  SVV –  PPV –  PLR –  dRAP during inspiration –  dAP with valsalva –  dVC

4

SV

Target vs. indices

PPV/SVV/PLR GEDV/ITBV

EDV CVP/PAOP

Fluid challenge

Principle Method Advantages Disadvantages Fick Calorimetry Accurate Require MVO2, error when ETT leak, PTX,

FiO2>0.5

NICO Accurate, non-invasive

>20kg, hypercapnea

Dilution PA Accurate, semi-continuous

Affect by respiration, difficult for children, complications, R≠L CO

Trans-pulmonary

Easy for small p’t, continuous

Require dedicated A line, safe duration?

Dye Accurate Sequential measurement limited by dye clearance,

Lithium Accurate, use pre-existing CV/A line

Toxicity, blood sampling

Doppler Echo Structural and function Expertise, users variations

Trans-esophageal

Continuous, rapid insertion, less invasive

Probe fixation, individual errors, tracked accurately

Bio-impedance

Non-invasive Doubtful accuracy in critical illness

Monitoring, Toy or Tool?

PAWP/PACP RAP/RVP/PAP CO SvO2 RVEF

1) Fick method/principle

2) Indicator dilution technique

-dye dilution

CO measurement

Pulmonary artery catheter

Tranosophageal Doppler (TOD) Lithium indicator dilution (LiDCO) Minimally invasive/simple/reliable

CVC/AC Lithium Chlorid (150 mM) as Indicator 0.15 -0.30 mmol (adult) BW > 40kg, good renal function

Simple Reliable

CO = (Li Dose x 60)/ (Area x (1-PCV))

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PiCCO

Pulse contour analysis

Continuous pulse contour cardiac analysis (PCCO) Arterial blood pressure (AP) Heart rate (HR) Stroke volume (SV) Stroke volume variation (SVV) Systemic vascular resistance (SVR) Index of left ventricular contractility

Intermittent transpulmonary thermodilution

Transpulmonary cardiac output (CO) Intrathoracic blood volume (ITBV) Extravascular lung water (EVLW) Cardiac function index (CFI)

Microcirculation

Global

Regional

Physiologic backgrounds

§ Physical Exam – Hypoperfused state

•  Cool extremities •  Low urine output •  Increasing HR •  Confusion •  Nausea/Vomiting •  SOB

Labs –  Increasing BUN/CR

ratio –  Lactate –  Coagulation

abnormalities –  BNP –  Hyponatremia –  Acidosis

SSC-Guidelines

We recommend that initial fluid challenge in patients with sepsis-induced tissue hypoperfusion with suspicion of hypovolemnic be started with ≥ 1000 mL of crystalloids (to achieve a minimum of 30ml/kg of crystalloids in the first 4 to 6 hours). (Grade 1B).

1. Identify the problem

2. Choose monitoring 3. Measure indices

4. Assess the target

Therapeutic optimization Early Goal-Directed Therapy

Rivers et al. N Engl J Med 2001;345:1368-77

0

10

20

30

40

50

60

Hosp mortality

Hosp (sev sep)

Hosp (sep shock)

Hosp (sep)

28d mortality

60d mortality

Standard EGDT

6

PAC; the right patients, the appropriate indication, the right way ….

31    Pinsky  M  and  Vincent  JL.  Crit  Care  Med  2005;  33:1119–1122  

Cardiac output

High Low

SvO2 SvO2

High Low High Low SEPSIS EXCESSIVE BLOOD FLOW (hypervolemia, excessive vasoactive therapy)

ANEMIA HYPOXIA HIGH VO2 (Inadequate cardiac output?)

LOW VO2 (anesthesia, hypothermia, ...) (Adequate cardiac output?)

LOW OUTPUT SYNDROME (hypervolemia, heart failure pulmonary embolism ...)

Vincent Critical Care 2003, 7:276-278

PAC; the right patients, the appropriate indication, the right way ….

LiDCO Decision tree for hemodynamic / volumetric monitoring**

*not available in USA **without guarantee

*

+

+

CI (l/min/m 2 )

GEDI (ml/m 2 ) or ITBI ( ml/m 2 )

ELWI (ml/kg) (slowly responding)

>3.0 <3.0

>700 >850

<700 <850

>700 >850

<700 <850

ELWI (ml/kg)

GEDI (ml/m 2 ) or ITBI (ml/m 2 )

CFI (1/min) or GEF (%)

<10 >10 <10 <10 <10 >10 >10 >10

V+ V+! V+! V+ Cat Cat

OK!

V -

>700 >850

700 - 800 850 - 1000

>4.5 >25

>5.5 >30

>4.5 >25

700 - 800 850 - 1000

Cat

>5.5 >30

>700 >850

700 - 800 850 - 1000

700 - 800 850 - 1000

≤ 10 ≤ 10 ≤ 10 ≤ 10

V -

V + = volume loading (! = cautiously) V - = volume contraction Cat = catecholamine / cardiovascular agents SVV only applicable in ventilated patients without cardiac arrh ythmia

>700 >850

<10 Optimise to SVV (%) <10 <10 <10

R E S U L T S

T A R G E T

T H E R A P Y

1.

2. <10 <10 <10 <10

Take home message Physiologic knowledge is essential Consider global but do not forget microvascular perfusion Target SV preferably using dynamic assessment of volume responsiveness Use whichever monitor you want but understand the meaning what you are measuring Hemodynamic monitorng do not replace medical sense, choose the right patient, the time, and the right approach