Transcript Folie 1 - PULSION Medical Systems SE: Startseite

Haemodynamic Monitoring
Theory and Practice
Haemodynamic Monitoring
2
A.
Physiological Background
B.
Monitoring
C.
Optimizing the Cardiac Output
D.
Measuring Preload
E.
Introduction to PiCCO Technology
F.
Practical Approach
G.
Fields of Application
H.
Limitations
Monitoring
Monitoring the Vital Parameters
Respiration Rate
Temperature
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Monitoring
Monitoring the Vital Parameters
Respiration Rate
Temperature
ECG
• Heart Rate
• Rhythm
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Monitoring
Monitoring the Vital Parameters
Respiration Rate
Temperature
ECG
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Blood Pressure (NiBP)
• no correlation with CO
• no correlation with oxygen delivery
Monitoring
Monitoring the Vital Parameters
MAP mmHg
150
The Mean Arterial Pressure does not correlate with Oxygen Delivery!
120
90
60
n= 1232
30
6
100
300
500
MAP: Mean Arterial Pressure, DO2: Oxygen Delivery
700
DO2 ml*m-2*min-1
Reinhart K in: Lewis, Pfeiffer (eds): Practical Applications of Fiberoptics in Critical Care Monitoring, Springer Verlag Berlin - Heidelberg - NewYork 1990, pp 11-23
Monitoring
Monitoring the Vital Parameters
Respiration Rate
Temperature
ECG
Blood Pressure (NiBP)
• No correlation with CO
• No correlation with oxygen delivery
• No correlation with volume status
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Monitoring
Monitoring the Vital Parameters
80% of blood volume is found in the venous
blood vessels,
only 20% in the arterial blood vessels!
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Monitoring
Monitoring the Vital Parameters
Respiration Rate
Temperature
ECG
Blood Pressure (NiBP)
• No correlation with CO
• No correlation with oxygen delivery
• No correlation with volume status
• No evidence of what is the ‘right’ perfusion pressure
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Monitoring
Standard Monitoring
Respiration Rate
Temperature
ECG
NIBP
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Oxygen Saturation
• No information re the O2 transport capacity
• No information re the O2 utilisation in the tissues
Monitoring
Standard Monitoring
Respiration Rate
Temperature
ECG
NIBP
Oxygen Saturation
Urine Production
Blood Circulation
(clinical assessment)
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Monitoring
Advanced Monitoring
The standard parameters do not give
enough information in unstable patients.
What other parameters do I need?
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Monitoring
Advanced Monitoring
Invasive Blood Pressure (IBP)
• Continuous blood pressure recording
• Arterial blood extraction possible
• Limitations as with NiBP
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Monitoring
Advanced Monitoring
IBP
Arterial BGA
Information re:
• Pulmonary Gas exchange
• Acid Base Balance
No information re oxygen supply at the cellular level
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Monitoring
Advanced Monitoring
IBP
Lactate
Arterial BGA
Marker for global metabolic situation
Significant limitations due to:
• Liver metabolism
• Reperfusion effects
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Monitoring
Advanced Monitoring
IBP
Arterial BGA
CVP
• central venous blood gas analysis possible
• When low: hypovolaemia probable
Lactate
• When high: hypovolaemia not excluded
• Not a reliable parameter for volume status
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Monitoring
Advanced Monitoring
IBP
Arterial BGA
ScvO2
• Good correlation with SvO2 (oxygen consumption)
• Surrogate parameter for oxygen extraction
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Lactate
• Information on the oxygen consumption situation
CVP
• When compared to SvO2 less invasive
(no pulmonary artery catheter required)
Monitoring
Monitoring of the central venous oxygen saturation
The ScvO2 correlates well with the SvO2!
ScvO2 (%)
SvO2
90
90
85
80
80
70
75
60
70
50
r = 0.945
40
30
n = 29
r = 0.866
ScvO2 = 0.616 x SvO2 + 35.35
65
60
30
40
50
60
70
80
90
ScvO2
Reinhart K et al: Intensive Care Med 60, 1572-1578, 2004;
40
50
60
70
80
90
SvO2 (%)
Ladakis C et al: Respiration 68, 279-285, 2000
Monitoring
Monitoring of the central venous oxygen saturation
avDO2 ml/dl
A low ScvO2 is a marker for increased global
oxygen extraction!
7.0
6.0
7.0
4.0
3.0
r= -0.664
2.0
n= 1191
1.0
avDO2= 12.7 -0.12*ScvO2
0
30
40
50
60
70
80
90
100
ScvO2 %
avDO2: arterial-venous oxygen content difference, ScvO2: central venous oxygen saturation
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Reinhart K in: Lewis, Pfeiffer (eds): Practical Applications of Fiberoptics in Critical Care Monitoring, Springer Verlag Berlin - Heidelberg - NewYork 1990, pp 11-23
Monitoring
Monitoring of the central venous oxygen saturation
avDO2 ml/dl
7.0
CO
6.0
SaO2
Delivery DO2:
DO2 = CO x Hb x 1.34 x SaO2
Consumption VO2: VO2 = CO x Hb x 1.34 x (SaO2 - S(c)vO2)
7.0
Hb
Mixed / Central Venous Saturation S(c)vO2
4.0
3.0
2.0
1.0
r= -0.664
n= 1191
avDO2= 12,7 -0.12*ScvO2
0
30
40
50
60
70
80
avDO2: arterial-venous oxygen content difference, ScvO2: central venous oxygen saturation
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90
100
ScvO2 %
Reinhart K in: Lewis, Pfeiffer (eds): Practical Applications of Fiberoptics in Critical Care Monitoring, Springer Verlag Berlin - Heidelberg - NewYork 1990, pp 11-23
Monitoring
Monitoring of the central venous oxygen saturation
Early goal-directed therapy
O2- Therapy and Sedation
Intubation + Ventilation
Rivers E et al. New Engl J Med 2001;345:1368-77
Cardiovascular Stabilisation
CVP
< 8 mmHg
Volume therapy
Mortality
Central Venous Catheter
Invasive Blood Pressure Monitoring
8-12 mmHg
MAP
< 65 mmHg
Vasopressors
Hospital
65 mmHg
ScVO2
< 70%
Blood transfusion to
Haematocrit 30%
>70%
no
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Goal achieved?
ScVO2
 70%
yes
Therapy maintenance,
regular reviews
< 70%
Inotropes
60 days
Monitoring
Monitoring of the ScvO2 – Clinical Relevance
Significance of the ScvO2 for therapy guidance
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Monitoring
Monitoring of the ScvO2 – Clinical Relevance
Early monitoring of ScvO2 is crucial for fast and effective
hemodynamic management!
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Monitoring
Monitoring ScvO2 – therapeutic consequences in the example of sepsis
Pt unstable
ScvO2 < 70%
Volume bolus
(when absence of contraindications)
ScvO2 > 70% or < 80%
ScvO2 < 70%
Continuous ScvO2 monitoring – CeVOX
Advanced Monitoring - PiCCO
Re - evaluation
Volume / Catecholamine
Erythrocytes
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Monitoring
Monitoring ScvO2 – Limitations
Tissue hypoxia despite ”normal“ or high ScvO2?
SxO2 in %
?
Microcirculation disturbances
in SIRS / Sepsis
25 modified from:
Reinhart K in: Lewis, Pfeiffer (eds): Practical Applications of Fiberoptics in Critical Care Monitoring, Springer Verlag Berlin - Heidelberg - NewYork 1990, pp 11-23
Monitoring
Monitoring ScvO2 – therapeutic consequences in the example of sepsis
Tissue hypoxia despite „normal“ or high ScvO2?
ScvO2
Pt unstable ScvO2 < 70%
ScvO2 > 80%
Volume administration
(when absence of
contraindications)
ScvO2 > 70% but < 80%
Re- evaluation
ScvO2 < 70%
Advanced Monitoring
cont. ScvO2 monitoring
Volume / Catecholamine / Erythrocytes
?
Monitoring
Monitoring ScvO2 – therapeutic consequences in the example of sepsis
Tissue hypoxia despite ”normal“ or high ScvO2?
Pt unstable
ScvO2 > 80%
Volume bolus
(when absence of contraindications)
ScvO2 < 80% but > 70%
ScvO2 > 80%
Microcirculation?
Re-evaluation
Organ perfusion?
Further information needed
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Macro-haemodynamics (PiCCO)
Liver function (PDR – ICG)
Renal function
Neurological assessment
Monitoring
Summary and Key Points
• Standard monitoring does not give information re the volume status or the
adequacy of oxygen delivery and consumption.
• The CVP is not a valid parameter to measure volume status
• The measurement of central venous oxygen saturation gives important
information re global oxygenation balance and oxygen extraction
• Measuring the central venous oxygenation can reveal when more
advanced monitoring is indicated
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