advanced hemodynamic monitors. do we need...

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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


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


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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


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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


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


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


Mean Arterial Pressure

MA

P (m

mH

g)

Control Therapy


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 *


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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advanced hemodynamic monitors. do we need...

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