Transcript La Terapia di Supporto secondo le Linee Guida e nella `Real Life` di

La Terapia di Supporto secondo le
Linee Guida e nella ‘Real Life’ di
una Terapia Intensiva
G. De Pascale
Istituto di Anestesia e Rianimazione, Pol. A. Gemelli, Roma, Italia
USA 49.1%
Europe 36.2%
JAMA.2016;315(8):801-810.doi:10.1001/jama.2016.0287
O2 Delivery (DO2)
DO2 = CaO2
x
DO2 = Hb x 1,34 x SaO2
CO x 10
x
CO x 10
1000=15x1,34x1 x 5x10
ml/min g/dl
100%
l/min
Minerva Anestesiologica 2014
O2 Consumption (VO2)
VO2 = CaO2 – CvO2
x CO x 10
VO2 = Hb x 1,34 x (SaO2 – SvO2) x CO x 10
250=15x1,34x(1–0,75)x5x10
ml/ming/dl 100% 75%l/min Minerva Anestesiologica 2014
Extraction ratio (ER)
SaO2 = 100%
SvO2 = 75%
SaO2 − S vO2
ER(%) =
x100 = 25%
SaO2
DO2 / VO2 ratio
VO2
SvO2
Anaerobic threshold
250
75%
é lactates
50%
ER=60%
500
1000
DO2
DO2/VO2 Optimization
éDO2 = Hb x 1,34 x SaO2 x CO x 10
Which Target???
Max 100%!!!!!
Cardiac Output (CO)
• Heart rate
• PreLoad
• Contractility
• AfterLoad
PreLoad – SV
(Fluid Responsiveness)
SV
ΔSV2
ΔSV1
ΔV1
ΔV2
EDV
PreLoad Indices
•  Static Indices:
–  Pressometric (CVP, PAOP)
–  Volumetric- eco(LVEDV, LVEDA, RVEDV, RVEDA)
–  Volumetric- PiCCO/LidCO (ITBV, GEDV)
•  Dynamic Indices:
–  Fluid challenge
–  Respiratory variations(PPV, SVV, SPV, ΔVpeak..)
–  Preload redistribution (passive leg raising)
Therateofdeathdidnotdiffersignificantlybetween
thegroupofptstreatedwithdopamineandthe
grouptreatedwithnorepinephrine
Dopamine,ascomparedwithnorepinephrine,more
arrhythmiasandwithanincreasedrateofdeathin
thesubgroupofptswithcardiogenicshock.
physicianscoulduseeitherepinephrine
alone,ornorepinephrinealoneorincombinaUon
withdobutamineinptswithlowcardiacindex
Lancet2007;370:676–84
Why so many differences ?
Anticoagulants
Endotoxin antagonists
High and low-dose steroids
Intravenous immunoglobulins
Nitric oxide synthase inhibitor
Inflammatory modulating agents
Host response in severe infections
Anti-inflam/cytokines
sTNFrp55
sTNFrp75
IL-1r antagonist
IL-10
Pro-inflam/cytokines
TNF-α
IL-1β
IL-6
IL-8
Cytokine Storm
One who argues "You're just treating the symptoms" is
tacitly assuming that symptoms are side effects of an infection. An
evolutionarily astute observer recognizes that symptoms might be just
side effects, but they might represent adaptations that benefit the host
or the parasite. For easy reference, I shall call the former a
by the host and the latter a
manipulation of the host
defense
High-volume Hemofiltration (HVHF)
High-cutoff Membranes (HCO)
Hemoadsorption (CytoSorb/PMX)
Coupled Plasma F/A (CPFA)
857 ICU patients
“Hit Fast, Hit Hard”
Paul Ehrlich, Lancet 1913