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DIVISION OF CRITICAL CARE MEDICINE GWUMC
Pulmonary Artery Catheters
or perhaps not
DIVISION OF CRITICAL CARE MEDICINE GWUMC
Housestaff perception of PA catheters:
MAP=SBP+2DBP/3 CO=HRxSV/1000CI=CO/BSA SVR=80x(MAP-RAP)/COPVR=80x(MAP-PAWP)/CORVEF=SV/EDVCaO2=(.0138xHgbxSaO2)+.0031xPaO2VO2=(C(a-v)O2) x CO x 10
DIVISION OF CRITICAL CARE MEDICINE GWUMC
Some Equations...
• MAP = 1/3 SBP + 2/3DBP• CO = SV x HR• CI = CO/BSA• SVR = (MAP-CVP)/CO x 80• PVR = (MPAP - PAOP)/CO x 80• LVSWI = SVI x (MPAP-PAOP)/BSA x
0.0136
DIVISION OF CRITICAL CARE MEDICINE GWUMC
Normal Values
• Cardiac Output (CO) : 4 -8 L/min• Cardiac Index (CI) : 2.4 - 4.0 L/min/m2• MAP : 70-105 mm Hg• Systemic Vascular Resistance (SVR):
800 - 1200 dynes/sec/cm5• Pulmonary Vascular Resistance (PVR):
<250 dynes/sec/cm5 • Stroke Volume (SV): 60-100 ml/beat
DIVISION OF CRITICAL CARE MEDICINE GWUMC
1. Why is this patient hypotensive?
2. Why is this patient in shock?
3. Why is this patient in pulmonary edema?
4. How can I minimize fluid infusion while maintaining perfusion in my hypoxic patient?
4. Will this patient tolerate empiric resuscitation and diagnosis through therapeutic challenge?
DIVISION OF CRITICAL CARE MEDICINE GWUMC
“The patient’s dead, he just doesn’t know it yet”
Dennis Quinlan, MD 1995
DIVISION OF CRITICAL CARE MEDICINE GWUMC
DIVISION OF CRITICAL CARE MEDICINE GWUMC
DIVISION OF CRITICAL CARE MEDICINE GWUMC
Volume 345:1368-1377 November 8, 2001 Number 19
Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock
Emanuel Rivers, M.D., M.P.H., Bryant Nguyen, M.D., Suzanne Havstad, M.A., Julie Ressler, B.S., Alexandria Muzzin, B.S., Bernhard Knoblich, M.D., Edward Peterson, Ph.D., Michael Tomlanovich, M.D., for the Early Goal-Directed Therapy Collaborative Group
DIVISION OF CRITICAL CARE MEDICINE GWUMC
DIVISION OF CRITICAL CARE MEDICINE GWUMC
DIVISION OF CRITICAL CARE MEDICINE GWUMC
DIVISION OF CRITICAL CARE MEDICINE GWUMC
Central venous O2 saturation (SCVO2)
?Mixed venous O2 saturation (SMVO2)
SMVO2 is approximately 5% lower than SCVO2
-10.0
-5.0
0.0
5.0
10.0
15.0
20.0
40 50 60 70 80 90 100
(Sv cO2 + SvO2)/2 %
(Svc
O2
- S
vO
2) %
Zia et al Crit.Care Medicine 2003;30:A71
Bland-Altman Plot
DIVISION OF CRITICAL CARE MEDICINE GWUMC
DIVISION OF CRITICAL CARE MEDICINE GWUMC
BP = CO x SVR
DIVISION OF CRITICAL CARE MEDICINE GWUMC
BP = CO x SVR
HR SV
DIVISION OF CRITICAL CARE MEDICINE GWUMC
BP = CO x SVR
HR SV
LVEDV Contractility
DIVISION OF CRITICAL CARE MEDICINE GWUMC
DIVISION OF CRITICAL CARE MEDICINE GWUMC
DIVISION OF CRITICAL CARE MEDICINE GWUMC
DIVISION OF CRITICAL CARE MEDICINE GWUMC
DIVISION OF CRITICAL CARE MEDICINE GWUMC
DIVISION OF CRITICAL CARE MEDICINE GWUMC
DIVISION OF CRITICAL CARE MEDICINE GWUMC
The four (five) causes of hypotension
Hypovolemia Pump failure Hemorrhage Myocardial ischemia GI losses Cardiomyopathy Dehydration Valvular disease Insensible Arrhythmias Distribution Obstruction Sepsis Pulmonary Embolism Anaphylaxis Tension pneumothorax Neurogenic Cardiac tamponade Adrenal insufficiency Constrictive pericarditis
DIVISION OF CRITICAL CARE MEDICINE GWUMC
The four (five) causes of hypotension
Hypovolemia Pump failure Hemorrhage Myocardial ischemia GI losses Cardiomyopathy Dehydration Valvular disease Insensible Arrhythmias Distribution Obstruction Sepsis Pulmonary Embolism Anaphylaxis Tension pneumothorax Neurogenic Cardiac tamponade Adrenal insufficiency Constrictive pericarditis
DRUGS&
DOCTORS
DIVISION OF CRITICAL CARE MEDICINE GWUMC
DIVISION OF CRITICAL CARE MEDICINE GWUMC
DIVISION OF CRITICAL CARE MEDICINE GWUMC
DIVISION OF CRITICAL CARE MEDICINE GWUMC
DIVISION OF CRITICAL CARE MEDICINE GWUMC
DIVISION OF CRITICAL CARE MEDICINE GWUMC
HR/RHYTHM CVP/PCWP SVR CO DX RX
⇑ ⇓ ⇓ ⇑ ⇓ Hypovolemia Volume
⇓ or ? ⇑ ⇑ ⇓ Pump Pacer, antiarrhythmic
⇑ ⇑ ⇑ ⇑ ⇓ Pump Inotrope
nl, ⇑ ⇑ ⇑ ⇑⇑ ⇓ Pump Valve,
rate control
⇑ ⇓ ⇓ ⇓ ⇑ Distribution Pressors,
volume ⇑ ⇑ ⇓ ⇑ ⇓ Obstruction Chest tube TPA
DIVISION OF CRITICAL CARE MEDICINE GWUMC
The data obtained from pulmonaryartery catheters should aid, not replace, clinical judgement.Treat the patient, not the numbers.
Remember
DIVISION OF CRITICAL CARE MEDICINE GWUMC
And of course…