Periopera(eve hemodynamische op(malisa(e met cardiac output monitoring: verbetering van pa(entenzorg of verrijking van aandeelhouders?
Brecht De Tavernier Staf Anesthesie GZA St Augus6nus 22/11/2013
Brecht De Tavernier Staf Anesthesie GZA St Augus6nus 22/11/2013
Inhoud • Frank Starling en occulte hypoperfusie • Cardiac Output monitors • Evidence Based Benefit?
Frank‐Starling
NOBLE MI. The Frank‐Starling curve. Clin Sci Mol Med. 1978 Jan;54(1):1‐7.
Probleemstelling: occulte hypoperfusie en weefsel hypoxie • Perifere BD: slechte parameter – – – – –
Interesse: centrale BD (cardiale a]erload en centrale circula6e) Hypotensie: late parameter (klassiek ACS: 30 % volumeverlies) Effect medica6e Aspecifiek Onvoldoende als target voor adequate goal‐directed therapy
• HR: ma6ge parameters – 20% pa6enten: paradoxale bradycardie bij hypovolemie – Effect medica6e
• Cardiac Output (CO), Le] Atrial Pressure (LAP) en Right Atrial Pressure (RAP) zijn veel gevoeliger voor occulte hypoperfusie • Slechte klinische inschafng van shock (en e6ologie) MUKKAMALA R, XU D. Con6nuous and less invasive central hemodynamic monitoring by blood pressure waveform analysis. Am J Phsyiol Heart Circ Physiol 2010; 299: H584‐H599. NOWAK RM, SEN A, GARCIA AJ. The inability of emergency physicians to adequately clinically es6mate the underlying hemodynamic profiles of acutely ill pa6ents. Am J Emerg Med. 2011 Jul 28.
Slechte klinische inschafng van Shock?
NOWAK RM, SEN A, GARCIA AJ. The inability of emergency physicians to adequately clinically es6mate the underlying hemodynamic profiles of acutely ill pa6ents. Am J Emerg Med. 2011 Jul 28.
Slechte klinische inschafng van Shock?
NOWAK RM, SEN A, GARCIA AJ. The inability of emergency physicians to adequately clinically es6mate the underlying hemodynamic profiles of acutely ill pa6ents. Am J Emerg Med. 2011 Jul 28. Rivers E. et al. Early goal‐directed therapy in the treatment of severe sepsis and sep6c shock. N Engl J Med 2001; 345: 1368‐1377.
Slechte klinische inschafng van Shock?
NOWAK RM, SEN A, GARCIA AJ. The inability of emergency physicians to adequately clinically es6mate the underlying hemodynamic profiles of acutely ill pa6ents. Am J Emerg Med. 2011 Jul 28.
De hemodynamische black‐box
De queeste begint
De ideale CO monitor • • • • • •
Betrouwbaar Con6nu Niet invasief Operator‐independent Kosteneffec6ef Snelle respons (‘beat‐to‐beat varia6ons’)
DE WAAL EE, WAPPLER F, BUHRE WF. Cardiac output monitoring. Curr Opin anesthesiology 2009; 22: 71 – 73.
1970: Dr Ganz
1970: Swan Ganz: Thermodilu6e Pulmonary Artery Catheter Indicator (cold saline or dye) injection in proximal lumen
Indicator sensor and Peripheral or central Catheter
Thermodilution:
Dye dilution:
Thermodilution or dye dilution CO calculator device
Calculate Cardiac Output using applied Stewart‐Hamilton equation: Dye: indicator dose / area under the curve Thermodilution: constant x (temperature blood ‐ injectate) / area under the curve
MATHEWS L, SINGH RK. Swang Ganz catheter in haemodynamic monitoring. J Anaesth Clin Pharmacol 2006; 22: 335‐345.
Thermodilu6e
Swan – Ganz of Pulmonary Artery Catheter • Me6ngen: Pulmonary Blood Flow (PBF) = +‐ Cardiac Output, Right Ventricular Ejec6on Frac6on (RVEF), Right Ventricular End‐Diastolic Volume (RVEDV), PAPsys/dia/Mean en Pulmonary Cappillary Wedge Pressure (PCWP). • Neveneffecten: 0.03 – 1.0% levens‐ bedreigende compl. met 40 – 70 % mortaliteit Complications Infection Pneumothorax Arrhythmias on insertion Right ventricular wall rupture Knotting op the PAC
Lifethreatening potential effect Catheter sepsis Tension pneumothorax Ventricular Tachycardia/Fibrillation Cardiac tamponade Venous or valve lacerations while retracting Rupture of a pulmonary artery Hemothorax Pulmonary hypoperfusion Pulmonary Infarction Suturing of the PAC during Laceration of anastomosis and cardiac surgery hemothorax or cardiac tamponade
McDANIEL DD, STONE JG, FALTAS AN et al. Catheter‐induced pulmonary artery hemorrhage. Diagnosis and management in cardiac opera6ons. J Thorac Cardiovasc Surg 1981; 82: 1‐4. KEARNEY TS, SHABOT MM. Pulmonary artery rupture associated with the Swan‐Ganz catheter. Chest 1995; 108: 1349‐1352.
En de RCT’s?
RICHARD C, WARSZAWSKI J, ANGUEL N, et al. Early use of the pulmonary artery catheter and outcomes in pa6ents with shock and acute respiratory distress syndrome: a randomized controlled trial. JAMA 2003; 290: 2713‐2720
En de RCT’s?
Niet‐cardiale heelkunde
SANDHAM JD, HULL RD, BRANT RF, et al. A randomized, controlled trial of the use of pulmonary‐artery catheters in high‐risk surgical pa6ents. N Engl J Med 2003; 348: 5‐14.
En de RCT’s?
HARVEY S, HARRISON DA, SINGER M, et al. Assessment of the clinical effec6veness of pulmonary artery catheters in management of pa6ents in intensive care (PAC‐Man): a randomised controlled trial. Lancet 2005; 366: 472‐477.
En de RCT’s? • Geen verschil in morbiditeit en mortaliteit: Nulbalans tussen complica6es en opbrengst in een high risk surgery popula6e • Interpreta6es – Complica6es wegen door? – Geen invloed op beleid? – Foute therapie ons baserende op resultaten? Besluit: enige mogelijke rol PAC blij] bij hoog risico cardiale heelkunde (en valt te overwegen bij INZO pa6enten met rechter harsalen en/of pulmonale hypertensie) HARVEY S, HARRISON DA, SINGER M, et al. Assessment of the clinical effec6veness of pulmonary artery catheters in management of pa6ents in intensive care (PAC‐Man): a randomised controlled trial. Lancet 2005; 366: 472‐477. SANDHAM JD, HULL RD, BRANT RF, et al. A randomized, controlled trial of the use of pulmonary‐artery catheters in high‐risk surgical pa6ents. N Engl J Med 2003; 348: 5‐14. RICHARD C, WARSZAWSKI J, ANGUEL N, et al. Early use of the pulmonary artery catheter and outcomes in pa6ents with shock and acute respiratory distress syndrome: a randomized controlled trial. JAMA 2003; 290: 2713‐2720
Op de minimaal invasieve weg… • Transpulmonary thermodilu6on calibrated arterial pressure‐based Cardiac Output: PiCCO • Transpulmonary lithium indicator dilu6on calibrated arterial pressure‐based CO: LiDCO • CO, Stroke Volume Varia6on (SVV), Pulse Pressure Varia6on (PVV), Global End‐Diastolic Volume (GEDV), ExtraVascular Lung Water (EVLW), Pulmonary Vascular Permeability Index (PVPI), IntraThoracalBloodVolume (ITBV), SVRI
Pulse Contour Analyse Radial/femoral/brachial artery Pressure sensor
Algorithm (Windkissel model)
Model to estimate ascending aortic blood flow when the peripheral blood pressure curve is measured using conductance, compliance and resistance
Calibration: Thermodilution (PiCCO) or lithium dilution (LiDCO) Non‐calibrated: weight, length, age, gender (FloTrac/Vigileo)
Cardiac Output
GEERTS BF, AARTS LP, JANSEN JR et al. Methods in pharmacology: measurement of cardiac output Br J Clin Pharmacol 2010; 71 (3): 316‐330.
PiCCO
PiCCO
Trend
Shi] van barometrische naar volumetrische en dynamische (fluid responsiveness) parameters
CVD in GDT?
Shippy CR, Appel PL, Shoemaker WC. Reliability of clinical monitoring to assess blood volume in cri6cally ill pa6ents. Crit Care Med 1984; 12:107–112
Noncalibrated arterial pressure‐based CO: Flo Trac/Vigileo en Nexfin
Noncalibrated arterial pressure‐based CO • 100 me6ngen pulse contour per seconde gedurende 20 seconden: schafng Stroke Volume via formule: – Constanste K (biometrische gegevens zoals beschreven door Langewouters: lee]ijd, gewicht, geslacht en lengte) – Pulse contour analysis (s6jlheid, spitsheid): – Pulsa6lity (afwijking van curve gedurende de voorbije 20 seconden) LANGEWOUTERS GJ, WESSELING KH, GOEDHARD WJ. The pressure dependent dynamic elas6city of 35 thoracic and 16 abdominal human aortas in vitro described by a five component model. J Biomechanics 1985; 18: 613 – 620.
SVV
PPV
SVV & Frank‐Starling
Opmerkingen SVV/PPV • Gesedeerde en mechanisch geven6leerde pa6enten • TV > 6 ml/kg • Sinusaal • 140 kg > Lichaamsgewicht > 55 kg • (geen IABP) • Fluid Responsiveness: SVV> 10‐12 %
Accuraatheid noncalibrated arterial pressure‐based CO? • Kri6ek op de accuraatheid, vooral op de arteriële impedan6eme6ng • Lagere accuraatheid bij pathologie met een lage Systeem Vasculaire Resisten6e (SVR), zoals sep6sche shock, leverfalen of bij snelle veranderingen van de SVR (vb. Opstarten vasopressie), vooral in hoge CO range • Recente RCT’s tonen een sterk verbeterde accuraatheid met de derde en vierde genera6e so]ware, ook bij pa6enten met een sep6sche shock. DE BACKER D, MARX G, TAN A, et al. Arterial pressure‐based cardiac output monitoring: a mul6center valida6on of the third‐ genera6on so]ware in sep6c pa6ents. Intensive Care Med 2011; 37 (2): 233‐240.
Andere devices?
Andere gevalideerde minimaal of niet invasieve devices: NICO2
Andere gevalideerde minimaal of niet invasieve devices: Oesofagale Echografie
Maar de cruciale vraag blij] …
Periopera6eve hemodynamische op6malisa6e met CI en SVV/ PPV doelen: Verbetering van pa6entenzorg of verrijking van aandeelhouders?
FloTrac/Vigileo device in high risk abdominal surgery
BENES J, CHYTRA I, ALTMANN P. et al. Intraopera6ve fluid op6miza6on using stroke volume varia6on in high risk surgical pa6ents: results of a prospec6ve randomized study. Cri6cal Care 2010, 14: R118.
FloTrac/Vigileo device in high risk abdominal surgery
BENES J, CHYTRA I, ALTMANN P. et al. Intraopera6ve fluid op6miza6on using stroke volume varia6on in high risk surgical pa6ents: results of a prospec6ve randomized study. Cri6cal Care 2010, 14: R118.
FloTrac/Vigileo device in high risk abdominal surgery
BENES J, CHYTRA I, ALTMANN P. et al. Intraopera6ve fluid op6miza6on using stroke volume varia6on in high risk surgical pa6ents: results of a prospec6ve randomized study. Cri6cal Care 2010, 14: R118.
FloTrac/Vigileo device in high risk abdominal surgery
BENES J, CHYTRA I, ALTMANN P. et al. Intraopera6ve fluid op6miza6on using stroke volume varia6on in high risk surgical pa6ents: results of a prospec6ve randomized study. Cri6cal Care 2010, 14: R118.
FloTrac/Vigileo device in high risk abdominal surgery
BENES J, CHYTRA I, ALTMANN P. et al. Intraopera6ve fluid op6miza6on using stroke volume varia6on in high risk surgical pa6ents: results of a prospec6ve randomized study. Cri6cal Care 2010, 14: R118.
Meta‐analyse
Hamilton MA, Cecconi M, Rhodes A: A systema6c review and meta‐analysis on the use of preemp6ve hemodynamic interven6on to improve postopera6ve outcomes in moderate and high‐risk surgical pa6ents. Anesth Analg 2011, 112:1392‐1402
Meta‐analyse
Hamilton MA, Cecconi M, Rhodes A: A systema6c review and meta‐analysis on the use of preemp6ve hemodynamic interven6on to improve postopera6ve outcomes in moderate and high‐risk surgical pa6ents. Anesth Analg 2011, 112:1392‐1402
FTc = Flow Time van bloed gedurende systole, gecorrigeerd voor HR; volw: 330 – 360 ms; laag: hypovolemie
Meta‐analyse
Hamilton MA, Cecconi M, Rhodes A: A systema6c review and meta‐analysis on the use of preemp6ve hemodynamic interven6on to improve postopera6ve outcomes in moderate and high‐risk surgical pa6ents. Anesth Analg 2011, 112:1392‐1402
Meta‐analyse
Hamilton MA, Cecconi M, Rhodes A: A systema6c review and meta‐analysis on the use of preemp6ve hemodynamic interven6on to improve postopera6ve outcomes in moderate and high‐risk surgical pa6ents. Anesth Analg 2011, 112:1392‐1402
Meta‐analyse
Hamilton MA, Cecconi M, Rhodes A: A systema6c review and meta‐analysis on the use of preemp6ve hemodynamic interven6on to improve postopera6ve outcomes in moderate and high‐risk surgical pa6ents. Anesth Analg 2011, 112:1392‐1402
Problemen RCT in deze sefng • Blindering onmogelijk • Hawthorne‐effect erg uitgesproken
Survey
Cannesson M, Pestel G, Ricks C, Hoe] A, Perel A: Hemodynamic monitoring and management in pa6ents undergoing high risk surgery: a survey among North American and European anesthesiologists. Crit Care 2011; 15: R 197
USA: 1 500 000 PAC’s/jaar
Survey
Cannesson M, Pestel G, Ricks C, Hoe] A, Perel A: Hemodynamic monitoring and management in pa6ents undergoing high risk surgery: a survey among North American and European anesthesiologists. Crit Care 2011; 15: R 197
Besluit • We weten drukken terwijl we de flow willen kennen • Hemodynamische black‐box • PAC hee] geen plaats buiten sefng cardiale heelkunde • Keuze van de correcte hemodynamische doelstellingen (CVP: geen plaats in GDT, CI: flow parameters, GEDVI: vullingsvolume, SVV/PPV: fluidresponsiveness…) • Enkele RCT’s tonen duidelijke reduc6e postopera6eve infec6euze complica6es met minimaal invasieve hemodynamische monitoring voor majeure heelkunde bij ASA 3 – 4 pa6enten • Technologie is heden nog (te?) duur
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