Prim. Univ. Prof. Dr. Walter Hasibeder

Abteilung für Anästhesie und Operative Intensivmedizin

VOLUMEN UND MIKROZIRKULATION

Am J Physiol 1964;206:213-216

No Reflow Phenomenon

0 – No mottling 1 – Coin sized mottling area on the knee 2 – To the superior area of the knee cap 3 – Mottling up to the middle thigh 4 – Mottling up to the fold of the groin 5 – Severe mottling that extends beyond the the groin

MOTTLING SCORE PREDICTS SURVIVAL IN SEPTIC SHOCK Ait-Oufella H et al.

Intensive Care Med 2011;37:801-807

Prospective observational study 60 ptt in septic shock SAPS II 59 (45-71) SOFA 11,5 (8,5-15,5) 14 day mortality rate 45%

MOTTLING SCORE PREDICTS SURVIVAL IN SEPTIC SHOCK Ait-Oufella H et al.

Intensive Care Med 2011;37:801-807

14-day survival predicted by Mottling Score

Mottling Score 3-4: 65% Mortalität nach 4 Tagen Mottling Score 5-6: 90% Mortalität nach 4 Tagen

30ptt in septic shock CRT, mottling score, peripherial temperature Pulsatility index liver, spleen, kidney, intestine at 24h, 48h and 72h after ICU admission Comparison of Survivors and non-Survivors

Changes in peripheral perfusion relate to visceral organ perfusion in early septic shock: A pilot study Brunauer A et al. J Crit Care 2016; 35:105-109

Am J Physiol 1964;206:213-216

No Reflow Phenomenon

?

VOLUMEN UND MIKROZIRKULATION

Zusammenhänge zwischen

Makrohämodynamik und Mikrozirkulation

Both passive leg raising and intravascular volume expansion improve sublingual microcirculatory perfusion in severe sepsis and septic shock patients

Pottecher J et al. Int Care Med 2010;36:1867-1874

Pulse pressure variation (ΔPP), cardiac output (CO) and sublingual microcirculation indices were assessed at five consecutive steps: (1) semi-recumbent position (Baseline 1) (2) during PLR maneuver (PLR) (3) after returning to semi-recumbent position (Baseline 2) (4) at the time when VE induced the same degree of preload responsiveness as PLR (5) at the end of VE (VE(END)).

25 mechanically ventilated patients in septic shock within the first 24h after admission

Functional capillary density = FCD, defined as the length of red cell-perfused capillaries per observation area (cm-1) (cut off for capillaries = vessels < 20µm) Proportion of perfused vessels = 100 x (total vessel number-(no flow+intermittent flow vessels))/total number of vessels) Mean flow index (MFI) = Averaged value of vessels with absent flow (0), intermittend flow (1), sluggish flow (2), normal flow (3) Heterogeniety Index (HI) = (Highest site flow velocity – lowest site flow velocity)/ mean flow velocity of all observed sites

Both passive leg raising and intravascular volume expansion improve sublingual microcirculatory perfusion in severe sepsis and septic shock patients

Pottecher J et al. Int Care Med 2010;36:1867-1874

Effects of fluids on microvascular perfusion in patients with severe sepsis

Ospina-Tascon G et al. Int Care Med 2010; 36:949-955

within 24h after 48h

Effects of fluids on microvascular perfusion in patients with severe sepsis

Ospina-Tascon G et al. Int Care Med 2010; 36:949-955

Survival rates decreased markedly with severity of alterations in the proportion of perfused small vessels (70% and 75% in the two upper proportion of perfused small vessel quartiles compared with 3% and 44% in the two lower quartiles. Multivariable analysis identified proportion of perfused small vessels and SOFA score as independent predictors of outcome.

Interaction between fluids and vasoactive agents on mortality in septic shock: A multicenter observational study

Waechter J et al. Crit Care Med 2014; 42:2158-2168

N=2849

Mortality was lowest when vasoactive agents were begun 1-6 hours after onset, with more than 1 l of fluids in the

Initial hour after shock onset, more than 2,4l from hour 1-6, and 1,6-3,5l from 6-24 hours

VOLUMEN UND MIKROZIRKULATION

Der Endotheliale „Surface Layer“ und die Mikrozirkulation

Endotheliale Glycocalyx 100-750nm Glycoproteine und Proteoglycane der Syndecan und Glypican Familie

Endothelialer „Oberflächenfilm“ ESL > 1µm

Albumin

Aufgaben des intakten ESL: - Regulation der hydraulischen Leitfähigkeit - Shearstress vermittelte NO-Freisetzung - Regulation des Organblutflusses - Regulation von Zelladhäsion und Passage - Antithrombotische Eigenschaften

Ischämie/Reperfusion Hypoxie/Reoxygenierung

Inflammation Hypervolämie

The endothelial glycocalix prefers albumin for evoking shear stress-induced, nitric oxide-mediated coronary dilatation

Jacob M, et al. J Vasc Res 2007;44:435-443

Changes in blood volume and hematocrit during acute preoperative volume loading with 5% albumin or 6% hetastarch solutions in patients before radical hysterectomy

Rehm M et al. Anesthesiology 2001; 95:849-856

von Bruegger D et al. Am J Physiol 2005;289:H1993-H1999

n = 20 gynecologic procedures VL: 20ml/kg colloid at 90cc/min ANH: 1:1 exchange colloids against blood Group 1: 5% Alb Group 2: 6% HES

Mean 1350ml colloid within 15 minutes

Hypervolemia increases release of atrial natriuretic peptide and shedding of the endothelial glycocalyx

Chappell D et al. Crit Care 2014;18:358

elective surgery with VL (n=9) or ANH (n=9)

Elevated Central Venous Pressure is associated with Impairment of Microcirculatory Blood Flow in Sepsis: A Hypothesis generating Post Hoc Analysis

Vellinga NAR, Ince C, Boerma EC. BMC Anesthesiology 2013;13:17-

140 measurements in 70 patients with mean APACHE II Score 21

Fluid Resuscitation in Septic Shock: A Positive Fluid Balance and Elevated Central Venous Pressure are Associated with Increased Mortality

Boyd JH et al. Crit Care Med 2011;39:259-265

Patients with septic shock (n=778; NE > 5µg/min) Net fluid balance and 28 day mortality ? Net cumulative fluid balance at 12h and 4 days and outcome ? ? Net cumulative fluid balance at 12h and 4 days and CVP dynamics and vasopressor needs ?

At enrollment in the study the average fluid balance was +4,2l

Fluid Resuscitation in Septic Shock: A Positive Fluid Balance and Elevated Central Venous Pressure are Associated with Increased Mortality

Boyd JH et al. Crit Care Med 2011;39:259-265

Volume Overload: Prevalence, Risk Factors, and Functional Outcome in Survivors of Septic Shock

Mitchell KH. Et al. Ann Am Thorac Soc 2015; 12:1837-1844

Volume Overload = Fluid balance expected to increase the subjects admission weight by 10%

Mortality 24%

86% with positive fluid balance at ICU discharge 35% were volume overloaded upon ICU discharge

Emergency Department

ICU during Shock phase

Only 42% of patients Received at least one dose of a diuretic during hospital stay

1

1,5

0,4

Volume Overload: Prevalence, Risk Factors, and Functional Outcome in Survivors of Septic Shock

Mitchell KH. Et al. Ann Am Thorac Soc 2015; 12:1837-1844

VOLUMEN UND MIKROZIRKULATION

„Die klinische Wirklichkeit“

Fluid challanges in intensive care: the FENICE study – a global inception cohort study Cecconi M, Hofer C, Teboul JL et al. Int Care Med 2015;41:1529-1537

Observationsstudie 2213 Patienten ? Wann und Warum Flüssigkeitsbolus (FC)? FC jede Flüssigkeit, die außerhalb der „normalen“ Flüssigkeitstherapie und Innerhalb von 2 Stunden appliziert wird Daten zur FC: FC Median = 500ml (500ml-1000ml) FC mediane Geschwindigkeit = 1000ml/h Hauptindikation: Hypotension

Fluid challanges in intensive care: the FENICE study – a global inception cohort study Cecconi M, Hofer C, Teboul JL et al. Int Care Med 2015;41:1529-1537

Fluid challanges in intensive care: the FENICE study – a global inception cohort study Cecconi M, Hofer C, Teboul JL et al. Int Care Med 2015;41:1529-1537

ZENTRALISATION TG 0-1; KFZ 0-1

Volumen

?TG 2; KFZ 2?

Ausschluss von Schmerzen, Angst, Hypothermie Ausschluss schwerer Gefäß- Erkrankungen

Primäre Herzkreislauftherapie

erfolgreich

Primäre Herzkreislauftherapie

nicht erfolgreich

MAP < 55- 60mmHg +

Vasopressoren

Herzfunktion normal/leicht eingeschränkt Volumen zentrales Kompartment ↓

Herzfunktion deutlich eingeschränkt Volumen zentrales Kompartment ↑

Inotropica + Volumen

Ja Nein

Preload

SVi

+ 10%

Persistierende Zentralisation

Volumen- und/oder Inotropika-therapie unter systemischer Blutflussmessung (PICCO)

Persistierende Zentralisation

TG 2; KFZ 2

Herzkreislauftherapie erfolgreich

Körpertemperaturkontrolle Herzfrequenzkontrolle

Nitro-Perfusor

Ausschluss IACS

ÜBERWACHUNG

Ja Nein