Transcript Sepsis and Cardiac Output Measurement

Sepsis and Cardiac Output
Measurement
S Gower
Consultant Anaesthetist
Aim
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Glimpse of history of
sepsis management
Overview of
pathophysiology
Comment on cardiac
output measurement
Update on sepsis
treatment, particularly
early management.
History
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Swan Ganz catheter,
1970
Bp=COxSVR
Shoemaker, 1979
DO2 =(SaO2xHb)xCO
Supranormal values
PA Catheter
Cardiac Output Measurement
Swan song for the Swan
Ganz? Soni 1996
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Connors, JAMA 1996
Retrospective study
of 5735 patients
Increased mortality
with swan.
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PiCCO
Lithium Dilution
Thoracic electrical
bioimpedance
Oesophageal
doppler
CCCombo Edwards
lifesciences
Clinical Assessment of C.O.
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BP maintained at
expense of CO
Poor cerebral
perfusion, agitation
and confusion
Metabolic acidosis
and increased resp
rate
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Palazzo BJA 2001
Diminished renal
and splanchnic flow
Decreased urine
output and ileus
Clinical assessment
all you have on the
ward
Recognise decreased CO before it’s too late
The Sepsis Disease Continuum
Sepsis
Sepsis
SIRSwith
withaapresumed
presumedor
or
SIRS
confirmed
infectious
process
confirmed infectious process
Infection
SIRS
Sepsis
SIRS
SIRS
SevereSepsis
Sepsis
Severe
oC or <36oC
•Temperature>38
>38oC
•Temperature
or <36oC
•HR
>90
beats/min
•HR >90 beats/min
•Respiratoryrate
rate>20/min
>20/min
•Respiratory
•WBCcount
count>12,000/mm
>12,000/mm33oror
•WBC
<4,000/mm33or
or>10%
>10%immature
immature
<4,000/mm
neutrophils
neutrophils
•Renal
•Renal
•Respiratory
•Respiratory
•Hepatic
•Hepatic
•Haematological
•Haematological
•CNS
•CNS
•Unexplainedmetabolic
metabolic
•Unexplained
acidosis
acidosis
•Cardiovascular
•Cardiovascular
clinicalresponse
responsearising
arisingfrom
fromaa
AAclinical
nonspecific
insult,
including
2ofof
nonspecific insult, including 2
the
following:
the following:
SIRScan
canalso
alsobe
becaused
causedby
by
SIRS
Trauma
Burns
Trauma
Burns
Pancreatitis Other
Otherinsults
insults
Pancreatitis
Bone et al. Chest. 1992;101:1644.
Severe Sepsis Death
Sepsisassociated
associatedwith
with
Sepsis
acute
organ
dysfunction
acute organ dysfunction
Septic Shock
Shock
Septic
Severe sepsis
sepsis with
with
Severe
cardiovascular
cardiovascular
dysfunction (refractory
(refractory
dysfunction
hypotension
hypotension
unresponsive to
to fluid
fluid
unresponsive
support)
support)
Pathophysiology of sepsis
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Margination of
leukocytes
Induction of nitric
oxide synthetase
Impaired
anticoagulation
Microvascular
thrombosis
DIC
Activated Protein C
Timing of the intervention is vital
Summary of management
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Aggressive goal
orientated treatment of
sepsis
Fluids and dobutamine
Restore effective blood
volume and CO
Sepsis and two organ
failure give Activated
protein C
Summary of sepsis and Cardiac Output
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Very Exciting!
Early recognition of
hypovolaemia of
sepsis
Rapid restitution of
effective CO
Appropriate usage
of Xigris
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Experience teaches
that to place
reliance upon a
single sign is
precarious. Compare
this sign and that,
and confident
recognition of the
patients state
grows. Sir Thomas Lewis 1942