il monitoraggio emodinamico invasivo in anestesia · il monitoraggio emodinamico invasivo in...

IL MONITORAGGIO EMODINAMICO INVASIVO IN ANESTESIA

A.O.R.N. SAN SEBASTIANOCASERTA

Luigi Belloni

Corso in Anestesiologia:SCUOLA DI DOTTORATO

“SCIENZE BIOMEDICHE VETERINARIE,SANITA’ ANIMALE E SICUREZZA ALIMENTARE

“Federico II”

L. Belloni, NAPOLI 16/03/05

CARDIOANESTESIAE TERAPIA INTENSIVA

caserta

Who benefits from invasive hemodynamic monitoring?

M.R.Pinsky ANESTH ANALG 2003 ;96:1245-7

Hemodynamicallyunstable patients

Incorrect treatment or delay in appropriate treatment results in markedly increased

morbidity and mortality.

Evaluation of cardiopulmonary status

and the subsequentphysiologic response.

Whymonitoring

Appropiatetreatment


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HIGH RISK SURGERYMortality: 30%

Who benefits from invasive hemodynamic monitoring?

CARDIAC SURGERY

CABG IN HIGH RISK PATIENTS

CABG IN OFF PUMP SURGERY

HIGH RISK SURGERY



caserta

STRATIFICAZIONE PRE-OPERATORIA DEL RISCHIO

OPERATORIO

Categorie di rischio Categorie di rischio cardiovascolare cardiovascolare

(ACC/AHA)(ACC/AHA)

Stratificazione delrischio in rapportoal tipo di procedura

chirurgica

Stratificazione delStratificazione delrischio in rapportorischio in rapportoal tipo di procedura al tipo di procedura

chirurgicachirurgica

Condizioni cliniche preoperatoria


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Categorie di rischio cardiovascolare

Categorie di rischio Categorie di rischio cardiovascolarecardiovascolare

Fattori di rischio maggioriFattori di rischio maggioriAngina instabile.IMA (<30 gg)Insuff.cardiaca scompensataBAV avanzato, aritmie ventricolari

sintomatiche, aritmie sopraventricolari ipercinetiche

Approfondimento cardiologico


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Stratificazione delrischio in rapporto

al tipo di procedura chirurgica

Stratificazione delStratificazione delrischio in rapportorischio in rapporto

al tipo di procedura chirurgicaal tipo di procedura chirurgica

Rischio maggioreRischio maggiore Rischio minore

Rischio intermedio


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Rischio maggiore

Urgenze, specie nell’anzianoChir. Aortica e vascolare arteriosa perifericaProcedure chirurgiche prolungate e/o associate a importanti variazioni volemiche

Urgenze, specie nell’anzianoChir. Aortica e vascolare arteriosa perifericaProcedure chirurgiche prolungate e/o associate a importanti variazioni volemiche

ESISTONO DEI LIVELLI DI RACCOMANDAZIONE PER

L’IMPIANTO DI UN MONITORAGGIO EMODINAMICO?



caserta

L’American College of Cardiology in risposta alle numerose richieste di chiarimento in merito ha prodotto recentemente un documento validato da una ConsensusConference di esperti e pubblicato nel settembre 1998.

Limitatamente all’indicazione nella chirurgia non cardiaca l’uso del catetere di Swan-Ganz ha un ruolo

riconosciuto nella guida al trattamento di pazienti selezionati con insufficienza cardiaca scompensata che devono essere sottoposti a chirurgia non cardiaca con

rischio medio od alto, mentre le opinioni divergono notevolmente se l’insufficienza è compensata.

GRADO DI RACCOMANDAZIONE ?


caserta


Hemodynamic patterns of survivors and nonsurvivors during high risk elective surgical operations.Shoemaker WC, Wo CC, Thangathurai D, Velmahos G,Belzberg H, Asensio JA, Demetriades D.

World J Surg. 1999 Dec

Outcome was improved whenpotentially lethal circulatorypatterns were treated during the early (the first 8-12 hours)postoperative period but after the appearence of organfailure,reversal of non survivalpatterns ,did not improve the outcome.

But clinical evidence ……

Early postoperativemonitoring revealeddifferences in survivor and non survivors patterns and provided goals for improvingoutcomeIntraoperative evaluation of tissue perfusion in high-risk patients by invasive and noninvasive hemodynamicmonitoring Shoemaker WC, Thangathurai D, Wo CC, KuchtaK, Canas M, Sullivan MJ, Farlo J, Roffey P, Zellman V, Katz RL

Crit Care Med. 1999 Oct


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The three most prognostic variables were:

Cardiac index > 4.5 l/min/m2,

Oxygen delivery > 600 ml/ min/m2

Oxygen consumption > 170 ml/min/m2 -’dysoxia’ First noted by Shoemaker et al - 30 years ago

• Through evaluation of 30 physiological variables in thousands of patients.

• Only those variables related to blood volume and flow had a significant

prognostic value in terms of morbidity and mortality.

• Most commonly measured variables of: blood pressure, heart rate,

temperature, CVP and urine output were poorly prognostic of outcome.

Clinical Experience in high risk surgery patients

Which prognostic variables??


caserta


Clinical Experience

in high risk surgery patientsStudy n Timing Monitor Goals Intervention

Bender 1997 104 Pre PAC

PAC

PAC

PAC

ODM

PAC

PAC

ODM

PAC

PAC

PAC

PAC

CI Fluids + vasoactives

Berlauk 1991 89 Pre, Intra CI Fluids + vasoactives

Boyd 1993 107 Pre, Intra, Post DO2 Fluids + vasoactives

Lobo 2000 37 Pre DO2 Fluids + vasoactives

Mythen 1995 60 Intra SV Fluids

Polonen 2000 393 Post SvO2/Lactate Fluids + vasoactives

Shoemaker 1988 58 Pre CO/DO2/VO2 Fluids + vasoactives

Sinclair 1997 40 Intra SV Fluids + vasoactives

Ueno 1998 34 Post CI/DO2/VO2 Fluids

Valentine 1998 120 Pre CI Fluids + vasoactives

Wilson 1999 138 Pre DO2 Fluids + vasoactives

Ziegler 1997 72 Pre SvO2 Fluids + vasoactives


caserta


11 22 33 44 55 66

CCardiac ardiac IIndex (First 4 P.O. ndex (First 4 P.O. HrsHrs))

1.01.0

0.20.2

0.40.4

0.80.8

0.60.6Pr

obab

ility

Prob

abili

tyof

Car

diac

of

Car

diac

Dea

thD

eath

p = 0.0002p = 0.0002

11 22 33 44 55 66

CCardiac ardiac IIndex (First 4 P.O. I)ndex (First 4 P.O. I)

00

1.01.0

0.20.2

0.40.4

0.80.8

0.60.6

p = 0.0001p = 0.0001

JW Kirklin UAB, 1975JW Kirklin UAB, 1975--1979 1979


caserta


O2O2ERER%%

SvO2SvO2%%

RelationshipRelationship betweenbetween intra and intra and postoperativepostoperative

oxygenoxygen transporttransport and and prolongedprolongedintensive care after cardiac surgery: intensive care after cardiac surgery:

a a prospectiveprospective studystudy

Pölönen P. et al.A.A. Scandinavica 1997: 810-817


caserta


1971

Realizzato il primo microprocessore

Ottenuto il DNA ricombinante

“A new technique for measurement of

cardiac output by thermodilution in men”

HJC Swan - W Ganz

Am J. Cardiol 1971

Which parameters are detectable?


caserta


How will the PAC’s guide my therapy?

Low

SvO2

Low

Cardiac Output

High

SvO2

High LowHigh

SepsisExcessive Blood flow

(Hypervolemia, excessivevasoactive therapy)

AnemiaHypoxemiaHigh VO2

InadeguateCardiac output

Low VO2 (anesthesia,Hypotermia)

AdeguateCardiac output

Low outputsyndrome

(hypovolemia,heart failure,

pulmonary enbolism)


caserta


Cateterismo di Swan-Ganz: Rilevamento pressorio

PVC: 0-8 mmHgPr.Sist.:15-25 mmHgPr.Diast.: 0-8 mmHg

Pr.Sist.: 15-25mmHgPr.Diast.: 6-12 mmHg 4-12 mmHg


caserta


Implicazione clinica del valore di PAOP

(pressione wedge)PAOP< 8mmHg

Tra 8-12 mmHg

Tra 12-18 mmHg

18 mmHg

IPOVOLEMIA POTENZIALE

NORMALITA’

AREA GRIGIA (potenzialmente può significare un incremento di contrattilità se seguente a riempimento volemico).

SVILUPPO DI DISFUNZIONE ED INSUFFICIENZA VENTRICOLARE SX.


caserta


Filling pressure are staticparameters and are not a gold standards for ………

CautionCaution!!!!!!!!!!!!

PRELOAD ASSESSMENT!!!


caserta



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Changes in ventricularcompliance

Decreased compliance (Compliance curve to the left)

IschemiaRestrictive cardiomyopathiesIncreased intratoracic pressure (PPV and PEEP)Increased pericardial pressure (cardiac tamponade)Increased abdominal pressure

In a non compliant ventricle, a greater pressure isgenerated with very little increase in volume.


caserta


La PVC la PAOP sono buon indicatori di Stato

Volemico,Pre-load nel paziente in anestesia

CVP-PAOP

VOLEMIA

TONO VENOSO

PRESSIONE

ADDOMINALE

PRESSIONE INTRATORACICA

COMPLIANCE VENTRICOLARE……….NO !!!!


caserta


Dynamic CVP changes rather thanstatic or mean CVP values might be

most accurate.

The rise in Cardiac Output after volume challenge is muchbetter in critically ill patients who experience a greater than1 mm Hg change in CVP during a single breath than in those

with a less than 1 mmHg fluctuation.Magder S,J Crit Care,7:76-85,1992

Pressure DerivedData (PAC)

Volume DerivedData (Volumetric

Technology: PiCCO andLiDCO)

Vs

EchoCVP PAOP

PAD


caserta


Echocardiography provides a measurementof true cardiac preload : LVEDA and LVEDV

Echo is a tool forhemodynamic monitoring


caserta


Respiratory Changes of AorticBlood Flow Velocity

Respiratory Changes in Aortic Blood Velocity as an Indicator ofFluid Responsiveness in Ventilated Patients with Septic Shock

Preload index by ECHO TEE

Marc Feissel, Frederic Michard, et al.CHEST 2001; 119:867-873


caserta


Technologies - PiCCO & LiDCO-Volumetric Measurement

Pulse contour methods and continuous real time measurement

of Stroke Volume

SV= K x ASV= K x A


caserta


The patient is the more preload responsive the greater the

arterial pressure/stroke volume variation is.


caserta


Before fluid loading After fluid loading

RESPONDER

Percent change in stroke volume over a floating period of 7.5 secs

StrokeStroke Volume Volume VariationVariation


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pts

resp

onde

rs

T0 T1

HR 84.6±15 85±15

mAP 72±10.4 75±8

CVP 5.3±2.5 6.1±2.7

PAOP 12±3 13±2

CI 3.0±0.5 3.2±0.6

SVV 13.7±3.1 7.8±2.1*

SVI 34.4±7 39.6±6.9*p<0.05

Anesthesiology 2001; 95:A243

Della Rocca G, Pompei L, Costa MG, Coccia C, Pierconti F and Pietropaoli P.

STROKE VOLUME VARIATION DURING ANESTHESIA



caserta

The anesthesiologist’s job is toassess the patient, surgeon, and anesthetic thecnique with

minimal hemodynamic disturbance plus activeischemia monitoring, and

aggressive treatment of bothhemodynamic abnormalities and

myocardial ischemia.



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If is done poorly, the Anesthesiologistbecomes a major

risk factor. Kaplan JA, 1993


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L. Belloni, NAPOLI 16/03/05A.O.R.N. “San Sebastiano” Caserta

Cardioanestesia e Terapia Intensiva

Monitoraggio emodinamicostandard (ECG, PA,

saturimetria transcutanea, EtCO2)parametri ventilatori

Echo TEE

PAC/PAC modified

Volumetric monitoring

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