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Hemodynamics in critical care - an overview
J.G. van der HoevenRadboud University Nijmegen Medical Centre
1
Treatment of shock
Cardiac outputHemoglobin
SaO2
Serious defects Serious defects
Macrocirculation Microcirculation Mitochondria
Preload - volume therapyContractility - inotropic agents
Afterload - vasodilatorsTransfusion
Oxygenation
No treatmentVasodilators?
No treatment
2
DO2 - VO2 relationship
0 100 200 300 400 500 600 700 800 900 1000
DO2 (ml/min/m2)
VO2
(ml/m
in/m
2 ) Increase in oxygen extraction
Increa
se in
lactat
e170
3
DO2 - VO2 relationship
0 100 200 300 400 500 600 700 800 900 1000
DO2 (ml/min/m2)
VO2
(ml/m
in/m
2 ) Increase in oxygen extraction
Increa
se in
lactat
e170
3
-0,4
-0,3
-0,2
-0,1
0
0,1
Mor
talit
y d
iffer
ence
bet
wee
n p
roto
col a
nd c
ontr
ol g
roup
Increasing oxygen transport
Supranormalafter OF
Mortality risk > 20%
Supranormalbefore OF
Mortality risk > 20%
SupranormalMortality risk < 15%
4
Early intervention
0
15
30
45
60
Hospital mortality 28 D mortality 60 D mortality
44,3
33,330,5
56,9
49,246,5
Mor
talit
y (%
)
Control Goal directed therapy
Rivers E, et al. N Engl J Med 2001;345:1368-1377
30
40
50
60
70
80
90
100
Baseline 6 hours 7 - 72 hours
Cen
tral
ven
ou o
xyge
n sa
tura
tion
(%)
5
ScvO2 and cardiac output in sepsis
Perner A. Acta Anaesthesiol Scand 2010;54:98-1026
ScvO2 and cardiac output in sepsis
Perner A. Acta Anaesthesiol Scand 2010;54:98-1026
ScvO2 and cardiac output in sepsis
Perner A. Acta Anaesthesiol Scand 2010;54:98-1026
ScvO2 and cardiac output in sepsis
Perner A. Acta Anaesthesiol Scand 2010;54:98-1026
7
What happens during shock?
7
What happens during shock?
7
65What happens during shock?
7
65What happens during shock?
7
65
62
62
What happens during shock?
7
Venous saturation in septic shock
50
60
70
80
90
100
Central venous Right atrium Right ventricle Pulmonary artery
70,270,971,5
78,6
Veno
us s
atur
atio
n (%
)
N = 37
Kopterides P. Shock 2009;31:561-5678
Lactate ↑
Lactate production ↑ Lactate clearance ↓
Tissue hypoxia
Local production (lung)Glucose metabolism ↑
Activity PDH ↓
Liver function ↓Decreased liver flow
Anaerobic Aerobic
Increased lactate at admission and persistent lactate elevation have a strong relation with mortality
9
Non-clearance is decrease in lactate < 10%
Initial lactate clearance and mortality
0
20
40
60
80
100
In-Hosptal mortality
%
Lactate clearance Lactate non-clearance
N = 166
N = 38N = 128
Lactate Non-
clearance
Lactate clearance
ScvO2 < 70% 3 20 23
ScvO2 ≥ 70% 11 114 125
14 134 148
P = 0.457
No relation between ScvO2 > 70 and lactate clearance
Arnold RC. Shock 2009;32:35-3910
Lactate driven therapy
0
10
20
30
40
50
33,9
43,5
Mor
talit
y (%
)
Control Lactate driven
N = 348P = 0.067
Admission lactate ≥ 3 mmol/lGoal: lactate ↓ ≥ 20% in 2 hrs
• After correction for risk factors mortality lower in lactate group (HR 0.61, p = 0.006)
• Duration MV ↓, duration ICU stay ↓, lower SOFA score
Jansen TC. Am J Respir Crit Care Med 2010, Epup 12 mei11
Lactate or ScvO2?
Variable Lactate clearance ScvO2 > 70% P-value
Hospital mortality (%) 17 23 ns
ICU stay (D) 5,9 5,6 0,75
Hospital stay (D) 11,4 12,1 0,60
Ventilator free days 9,3 9,9 0,67
MODS (%) 25 22 0,68
Treatment withdrawal (%) 9 15 0,15
N = 300
Noninferiority trialJones AE. JAMA 2010;303:739-746
12
Microcirculation in sepsis
0
25
50
75
100
% perfused vessels % perfused capillaries % absent blood flow % intermittent blood flow
Control Acetylcholine
De Backer D. Am J Respir Crit Care Med 2002;166:98-104
Normal Sepsis
13
Nitroglycerin and microcirculation in sepsis
Boerma EC. Crit Care Med 2010;38:93-100
N = 70
Patients with severe sepsis/septic shock treated with EGDT
14
Boerma EC. Crit Care Med 2010;38:93-10015
Fluid therapy and microcirculation
Proportion perfused small vessels
Baseline Fluids
Early septic shock
Late septic shock Ospina-Tascon G. Intensive Care Med 2010;36:949-955
Despite similar changes in CI
16
17
XXX XXX
Sepsis ONOO- ↑↑
Peroxynitrite
17
XXX XXX
Sepsis ONOO- ↑↑
Peroxynitrite
17
XXX XXX
Sepsis ONOO- ↑↑
Peroxynitrite
PARP + Caspase activation
ApoptosisNecrosis
17
Delayed fluorescence lifetime of endogenous PpIX
Mik EG. Nat Methods 2006;3:939-94518
19
Do we have a circulation problem?
19
Do we have a circulation problem?
Physical examinationUrine production
ScvO2 / BE / lactateNIRS / OPS / SDF
19
Do we have a circulation problem?
No actionNo
Physical examinationUrine production
ScvO2 / BE / lactateNIRS / OPS / SDF
19
Do we have a circulation problem?
No actionNo
Is this patient volume responsive?
YesPhysical examination
Urine productionScvO2 / BE / lactateNIRS / OPS / SDF
19
Do we have a circulation problem?
No actionNo
Is this patient volume responsive?
YesPhysical examination
Urine productionScvO2 / BE / lactateNIRS / OPS / SDF
Dynamic parameters
19
Do we have a circulation problem?
No actionNo
Diagnosticechocardiography
No Is this patient volume responsive?
YesPhysical examination
Urine productionScvO2 / BE / lactateNIRS / OPS / SDF
Dynamic parameters
19
Do we have a circulation problem?
No actionNo
Diagnosticechocardiography
No Is this patient volume responsive?
Yes
Volume therapy
Yes
Physical examinationUrine production
ScvO2 / BE / lactateNIRS / OPS / SDF
Dynamic parameters
19
Do we have a circulation problem?
Volume therapy successful?
No actionNo
Diagnosticechocardiography
No Is this patient volume responsive?
Yes
Volume therapy
Yes
Physical examinationUrine production
ScvO2 / BE / lactateNIRS / OPS / SDF
Dynamic parameters
19
Do we have a circulation problem?
Volume therapy successful?
No actionNo
Diagnosticechocardiography
No Is this patient volume responsive?
Yes
Volume therapy
Yes
No
Physical examinationUrine production
ScvO2 / BE / lactateNIRS / OPS / SDF
Dynamic parameters
19
Do we have a circulation problem?
Volume therapy successful?
No actionNo
Diagnosticechocardiography
No Is this patient volume responsive?
Yes
Volume therapy
Yes
YesNo
Physical examinationUrine production
ScvO2 / BE / lactateNIRS / OPS / SDF
Dynamic parameters
19
Do we have a circulation problem?
Volume therapy successful?
No actionNo
Diagnosticechocardiography
No Is this patient volume responsive?
Yes
Volume therapy
Yes
YesNo
Severe LV/RV dysfunction?
Physical examinationUrine production
ScvO2 / BE / lactateNIRS / OPS / SDF
Dynamic parameters
19
Do we have a circulation problem?
Volume therapy successful?
No actionNo
Diagnosticechocardiography
No Is this patient volume responsive?
Yes
Volume therapy
Yes
YesNo
Severe LV/RV dysfunction?
Yes
Specific analysisCO monitoring
Specific measuresInodilator therapy
Physical examinationUrine production
ScvO2 / BE / lactateNIRS / OPS / SDF
Dynamic parameters
19
Do we have a circulation problem?
Volume therapy successful?
No actionNo
Diagnosticechocardiography
No Is this patient volume responsive?
Yes
Volume therapy
Yes
YesNo
Severe LV/RV dysfunction?
Yes
Specific analysisCO monitoring
Specific measuresInodilator therapy
No
Persistent hypotension?
Physical examinationUrine production
ScvO2 / BE / lactateNIRS / OPS / SDF
Dynamic parameters
19
Do we have a circulation problem?
Volume therapy successful?
No actionNo
Diagnosticechocardiography
No Is this patient volume responsive?
Yes
Volume therapy
Yes
YesNo
Severe LV/RV dysfunction?
Yes
Specific analysisCO monitoring
Specific measuresInodilator therapy
No
Persistent hypotension?
Yes
AnalysisVasopressor
Physical examinationUrine production
ScvO2 / BE / lactateNIRS / OPS / SDF
Dynamic parameters
19
Do we have a circulation problem?
Volume therapy successful?
No actionNo
Diagnosticechocardiography
No Is this patient volume responsive?
Yes
Volume therapy
Yes
YesNo
Severe LV/RV dysfunction?
Yes
Specific analysisCO monitoring
Specific measuresInodilator therapy
No
Persistent hypotension?
Yes
AnalysisVasopressor
Physical examinationUrine production
ScvO2 / BE / lactateNIRS / OPS / SDF
Dynamic parameters
No
Reevaluate
19
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