ultrasound and precision medicine in sepsis...high svr low svr high pap ... • ultrasound as a...
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Ultrasound and Precision Medicine in Sepsis Resuscitation
Pietro Bertini – Cardiothoracic and Vascular Anesthesia and Intensive Care
Azienda Ospedaliera Universitaria Pisana. Pisa, Italy
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No Disclosures
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Precision medicine
Tailored approach
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In the “PAC era”
«Septic shock patients consistently show a
hyperdynamic circulatory state with high CO
and low SVR»
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Despite the strong evidence characterizing
sepsis as a hyperdynamic state, studies that
examined myocardial performance still
showed LV dysfunction in resuscitated
septic patients.
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The numbers we love to treat
• BP
• Volume status
• Cardiac output
• Urine output
• ScVO2 / SVO2
• Lactate
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Hemodynamic categorizations
High CO
Low CO
High SVR
Low SVR
High PAP
Low PAP
High filling pressures
Low filling pressures
……..
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Ventriculo-arterial couplingOptimal efficiency: Ea/Ees 1
Failing heart: Ea/Ees >1
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Hemodynamics of Septic Shock
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Volume Expansion
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Reduction in Ees
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Volume and then vasoactive support inefficient
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Therapies aiming to restore VAC by increasing Ees (inotropes) and reducing Ea (beta blockers, vasodilators…)
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30 %
Same CO, different EF: which is the best?
60 %
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Haddad et al, circulation 2008;117:1717-1731
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Let’s move to a new pathophysiology paradigm
• LV function
• Diastole and filling
• Acute RV failure
• Relationship between
ventricular elastance
and arterial elastance
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Echocardiography
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Echocardiography
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Heart and sepsis
• Complex pathophysiology
• Full echodynamic evaluation
• Monitoring biomarkers (BNP, Tp)
• Echo-guided treatment in the light of heart-arterial
coupling (Ea/Ees)
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Tailored Approach
• Pathophysiological oriented
• Ultrasound as a point-of-care device to
plumb hemodynamic state while screening
for unexpected structural finding and
underlining condition
• One needs to also apply functional and
convenient techniques in unison
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SVR =𝑀𝐴𝑃−𝐶𝑉𝑃
𝐶𝑂
SVR =𝑀𝐴𝑃−𝐶𝑉𝑃
𝐻𝑅∙𝑆𝑉
SVR ≅𝐸𝑆𝑃
𝐻𝑅∙𝑆𝑉Ea=
𝐸𝑆𝑃
𝑆𝑉
SVR ≅𝐸𝑎
𝐻𝑅
Ea ≅ 𝑆𝑉𝑅 ∙ 𝐻𝑅
SVR ≅𝐸𝑎∙𝑆𝑉
𝐻𝑅∙𝑆𝑉
Ea=𝐸𝑆𝑃
𝑆𝑉
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