what is the future of haemodynamic monitoring? steven m. hollenberg, md professor of medicine robert...
TRANSCRIPT
![Page 1: What is the future of haemodynamic monitoring? Steven M. Hollenberg, MD Professor of Medicine Robert Wood Johnson Medical School/UMDNJ Director, Coronary](https://reader036.vdocument.in/reader036/viewer/2022062518/5697bf761a28abf838c80cbc/html5/thumbnails/1.jpg)
What is the future of haemodynamic monitoring?
Steven M. Hollenberg, MD
Professor of Medicine
Robert Wood Johnson Medical School/UMDNJ
Director, Coronary Care Unit
Cooper University Hospital, Camden NJ
![Page 2: What is the future of haemodynamic monitoring? Steven M. Hollenberg, MD Professor of Medicine Robert Wood Johnson Medical School/UMDNJ Director, Coronary](https://reader036.vdocument.in/reader036/viewer/2022062518/5697bf761a28abf838c80cbc/html5/thumbnails/2.jpg)
“Prediction is very difficult, especially about the future.”
Yogi Berra
Niels Bohr
![Page 3: What is the future of haemodynamic monitoring? Steven M. Hollenberg, MD Professor of Medicine Robert Wood Johnson Medical School/UMDNJ Director, Coronary](https://reader036.vdocument.in/reader036/viewer/2022062518/5697bf761a28abf838c80cbc/html5/thumbnails/3.jpg)
“The only way to predict the future is to invent it.”
Alan Kay
$100 laptop to be designed and given to schools around the world to educate childrenLaptop.org
![Page 4: What is the future of haemodynamic monitoring? Steven M. Hollenberg, MD Professor of Medicine Robert Wood Johnson Medical School/UMDNJ Director, Coronary](https://reader036.vdocument.in/reader036/viewer/2022062518/5697bf761a28abf838c80cbc/html5/thumbnails/4.jpg)
The future of hemodynamic monitoring
• New technologies
• New hemodynamic parameters
• New methods of analysis
• Methods of evaluation
![Page 5: What is the future of haemodynamic monitoring? Steven M. Hollenberg, MD Professor of Medicine Robert Wood Johnson Medical School/UMDNJ Director, Coronary](https://reader036.vdocument.in/reader036/viewer/2022062518/5697bf761a28abf838c80cbc/html5/thumbnails/5.jpg)
New technologies
• Implantable monitors
![Page 6: What is the future of haemodynamic monitoring? Steven M. Hollenberg, MD Professor of Medicine Robert Wood Johnson Medical School/UMDNJ Director, Coronary](https://reader036.vdocument.in/reader036/viewer/2022062518/5697bf761a28abf838c80cbc/html5/thumbnails/6.jpg)
New technologies
• Miniaturization– Imagers
• X-ray• MRI• Ultrasound
– Sensors, effectors, and transmitters• Surgical instruments• Analyzers• Optical sensors
![Page 7: What is the future of haemodynamic monitoring? Steven M. Hollenberg, MD Professor of Medicine Robert Wood Johnson Medical School/UMDNJ Director, Coronary](https://reader036.vdocument.in/reader036/viewer/2022062518/5697bf761a28abf838c80cbc/html5/thumbnails/7.jpg)
New technologies
• Noninvasive methods of evaluation– Echocardiography
• Myocardial contrast: visualization, perfusion• Tissue Doppler• Strain rate imaging• Hand-held devices
– Bioimpedance– Magnetic resonance imaging
![Page 8: What is the future of haemodynamic monitoring? Steven M. Hollenberg, MD Professor of Medicine Robert Wood Johnson Medical School/UMDNJ Director, Coronary](https://reader036.vdocument.in/reader036/viewer/2022062518/5697bf761a28abf838c80cbc/html5/thumbnails/8.jpg)
New hemodynamic parameters
• Microcirculatory flow and density
• Cardiac power
![Page 9: What is the future of haemodynamic monitoring? Steven M. Hollenberg, MD Professor of Medicine Robert Wood Johnson Medical School/UMDNJ Director, Coronary](https://reader036.vdocument.in/reader036/viewer/2022062518/5697bf761a28abf838c80cbc/html5/thumbnails/9.jpg)
![Page 10: What is the future of haemodynamic monitoring? Steven M. Hollenberg, MD Professor of Medicine Robert Wood Johnson Medical School/UMDNJ Director, Coronary](https://reader036.vdocument.in/reader036/viewer/2022062518/5697bf761a28abf838c80cbc/html5/thumbnails/10.jpg)
Cooper MARS Mission
To study the alterations of the sublingual microcirculatory network in humans with severe sepsis undergoing early goal-directed resuscitation
To determine if microcirculatory flow velocity and perfused vessel density correlate with conventional hemodynamic parameters in patients with severe sepsis
![Page 11: What is the future of haemodynamic monitoring? Steven M. Hollenberg, MD Professor of Medicine Robert Wood Johnson Medical School/UMDNJ Director, Coronary](https://reader036.vdocument.in/reader036/viewer/2022062518/5697bf761a28abf838c80cbc/html5/thumbnails/11.jpg)
Microcirculatory flow in Sepsis
![Page 12: What is the future of haemodynamic monitoring? Steven M. Hollenberg, MD Professor of Medicine Robert Wood Johnson Medical School/UMDNJ Director, Coronary](https://reader036.vdocument.in/reader036/viewer/2022062518/5697bf761a28abf838c80cbc/html5/thumbnails/12.jpg)
Cardiac Power
Cardiac Power Output [(Mean Arterial Pressure*Cardiac Output)/451]
Est
imat
ed I
n-ho
spita
l Pro
port
ion
Dea
d
0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
Cardiac Power Output [watt] = Mean Arterial Pressure x Cardiac Output / 451
Cardiac Power Output [watt] = Mean Arterial Pressure x Cardiac Output / 451
Fincke R, et al. J Am Coll Cardiol 2006; 44:340
![Page 13: What is the future of haemodynamic monitoring? Steven M. Hollenberg, MD Professor of Medicine Robert Wood Johnson Medical School/UMDNJ Director, Coronary](https://reader036.vdocument.in/reader036/viewer/2022062518/5697bf761a28abf838c80cbc/html5/thumbnails/13.jpg)
New methods of analysis
• Reductionist approach– Take things apart– Simple rules will yield simple results
• Output is proportional to input
– Engineering paradigms for hemodynamics• Heart as a pump• Electrical analogy with impedance as resistance
![Page 14: What is the future of haemodynamic monitoring? Steven M. Hollenberg, MD Professor of Medicine Robert Wood Johnson Medical School/UMDNJ Director, Coronary](https://reader036.vdocument.in/reader036/viewer/2022062518/5697bf761a28abf838c80cbc/html5/thumbnails/14.jpg)
Hemodynamic waveforms
• Time series measurements– Smooth, large-scale continuous signal– Discontinuous, small-scale, erratic disruptions
(noise)– Filter out the noise– Describe the average state toward which
homeostatic mechanisms are heading
![Page 15: What is the future of haemodynamic monitoring? Steven M. Hollenberg, MD Professor of Medicine Robert Wood Johnson Medical School/UMDNJ Director, Coronary](https://reader036.vdocument.in/reader036/viewer/2022062518/5697bf761a28abf838c80cbc/html5/thumbnails/15.jpg)
Biology is a complex system• Body is complex, open and dynamic• System: a group of independent but interconnected
elements that function together to comprise a unified whole.
• “Emergent” properties: properties of the system as a whole that cannot be predicted from individual components
• Fluctuations around the average are not just “noise,” but convey information
• Healthy variability: nonstationary, nonlinear, and multiscaled
• Disease is characterized not by loss of regularity but by loss of complexity
![Page 16: What is the future of haemodynamic monitoring? Steven M. Hollenberg, MD Professor of Medicine Robert Wood Johnson Medical School/UMDNJ Director, Coronary](https://reader036.vdocument.in/reader036/viewer/2022062518/5697bf761a28abf838c80cbc/html5/thumbnails/16.jpg)
Nonlinear analysis
• Can in theory be automated by computer• Changes in frequency spectrum
components of variability• Breakdowns of fractal scaling with disease• Challenges
– Some of the measures are nonintuitive– Volume of data to be captured is daunting– Artifacts are a real problem– Paucity of therapeutic interventions directed
at nonlinear measures
![Page 17: What is the future of haemodynamic monitoring? Steven M. Hollenberg, MD Professor of Medicine Robert Wood Johnson Medical School/UMDNJ Director, Coronary](https://reader036.vdocument.in/reader036/viewer/2022062518/5697bf761a28abf838c80cbc/html5/thumbnails/17.jpg)
Evaluation of new technologies
• Monitoring tools would not be expected to improve outcome unless tied to an effective therapeutic strategy prompted by data they provide
• Hemodynamic measures are not used in isolation but in clinical context– Thus, a single hemodynamic variable taken
alone is rarely a good predictor of the response to an intervention
• Implications for trial design
![Page 18: What is the future of haemodynamic monitoring? Steven M. Hollenberg, MD Professor of Medicine Robert Wood Johnson Medical School/UMDNJ Director, Coronary](https://reader036.vdocument.in/reader036/viewer/2022062518/5697bf761a28abf838c80cbc/html5/thumbnails/18.jpg)
New evaluation paradigms
• Polar ideas that no approach can be adopted without a pivotal RCT and that since no approach can be rigorously tested that theory is enough are equally constricting
• Consensus conferences– Uniform definitions– Uniform processes of evaluation– Managing differences of opinion
![Page 19: What is the future of haemodynamic monitoring? Steven M. Hollenberg, MD Professor of Medicine Robert Wood Johnson Medical School/UMDNJ Director, Coronary](https://reader036.vdocument.in/reader036/viewer/2022062518/5697bf761a28abf838c80cbc/html5/thumbnails/19.jpg)
Evaluating existing evidence and planning new trials
• Surrogate endpoints– Skepticism is appropriate, but there may be
no alternative• Tradeoff between power and feasibility
– How should surrogates be developed and validated?
• Translation of measures of proven efficacy in clinical trials into effective strategies when applied broadly
![Page 20: What is the future of haemodynamic monitoring? Steven M. Hollenberg, MD Professor of Medicine Robert Wood Johnson Medical School/UMDNJ Director, Coronary](https://reader036.vdocument.in/reader036/viewer/2022062518/5697bf761a28abf838c80cbc/html5/thumbnails/20.jpg)
The way forward
• We make our own future
• We need active engagement with the evaluation and implementation of new concepts and technologies– New hemodynamic parameters– New ways of measurement– New methods of analysis