vin presentation

Advancing Circulatory Care

(2012 - )Vincent Pellegrino

Victorian Intensive Care NetworkAugust2012

Choice

Before I start......

1992: First ICU Rotation

•1800-0800 (14 beds) RMO only cover

•Closed loop control of circulation

•Open loop control of feeding

•Open loop control of tonicity

1992: First ICU Rotation

J Crit Care (1994) 9: 124-133

1992: First ICU Rotation

J Crit Care (1994) 9: 124-133

10 Patients APII 30

CRRT-HF601 hour

417 (L) lost409 (L) administered

3 survived (hosp discharge)

1992: First ICU Rotation

J Crit Care (1994) 9: 124-133

Reduced haemodynamic

variability compared to standard care

PAC - Clinical Trials

• Shoemaker 1988

PAC - Clinical Trials

• Intensive Care 1988-2006

• ARDS

•General ICU

•High Risk Surgery

• 12 Prospective RCT

PAC - Clinical Trials• Evaluated different targets

• CO / Oxygen Delivery (explicit) or Physician determined

• +/- MAP, Urine output, skin changes

• Used different guidance (rules)

• CVP and PAOP (explicit) or Physician determined

• Applied different therapy

• Fluids (crystalloids/colloids or RBC)

• Drugs (inotropes or pressors)

PAC - Clinical Trials

• Intensive Care 1988-2006

• ARDS

•General ICU

•High Risk Surgery

• 12 Prospective RCT

PAC - Clinical Trials•Various approaches to

haemodynamic care in numerous patient populations using either....

•explicit targeting of cardiac output / oxygen delivery

•guiding care based on perceived needs

does not improve outcome in a number of high risk patient groups

Where does that leave us ?

Drug Trials

Text

Annane D. Lancet 2007

Drug Trials

Myburgh J. ICM 2008

Drug Trials

Text

De Becker D. NEJM 2010

Fluids - Obsevational

•ARDS Clinical Trial Network, NEJM 2006

Outcome Conservative Strategy Liberal Strategy P Value

Death at 60 days (%) 25.5 28.4 0.30

Ventilator-free days from day 1 to day 28

14.6 ± 0.5 12.1 ± 0.5 <0.001

ICU-free days Days 1 to 7 Days 1 to 28

0.9 ± 0.113.4 ± 0.4

0.6 ± 0.111.2 ± 0.4

<0.001<0.001

Organ-failure-free days Days 1 to 7 Cardiovascular failure CNS failure Renal failure Hepatic failure Coagulation abnormalities Days 1 to 28 Cardiovascular failure CNS failure Renal failure Hepatic failure Coagulation abnormalities

3.9 ± 0.13.4 ± 0.25.5 ± 0.15.7 ± 0.15.6 ± 0.1

19.0 ± 0.518.8 ± 0.521.5 ± 0.522.0 ± 0.422.0 ± 0.4

4.2 ± 0.12.9 ± 0.25.6 ± 0.15.5 ± 0.15.4 ± 0.1

19.1 ± 0.417.2 ± 0.521.2 ± 0.521.2 ± 0.521.5 ± 0.4

0.040.020.450.120.23

0.850.030.590.180.37

Dialysis to day 60 Patients (%) 10 14 0.06

Days 11.0 ± 1.7 10.9 ± 1.4 0.96

Liberal fluids

associated with

increased ICU and

ventilator time and

no reduction in renal failure

Fluids - Observational

After correcting for age and APACHE II, positive fluid balance correlated with increased mortality

Boyd J.H.et al Crit Care Med 2011

Fluids - Recommendations

CCM Feb 2011

Currently

Low Blood Low Blood PressurePressure

Low Blood Low Blood PressurePressure

Low Cardiac Low Cardiac OutputOutput

Low Cardiac Low Cardiac OutputOutput

Organ FailureOrgan FailureOrgan FailureOrgan Failure VasopressorsVasopressorsVasopressorsVasopressors

InotropesInotropesInotropesInotropes

FluidsFluidsFluidsFluids

Currently

Low Blood Low Blood PressurePressure

Low Blood Low Blood PressurePressure

Low Cardiac Low Cardiac OutputOutput

Low Cardiac Low Cardiac OutputOutput

Organ FailureOrgan FailureOrgan FailureOrgan Failure VasopressorsVasopressorsVasopressorsVasopressors

InotropesInotropesInotropesInotropes

FluidsFluidsFluidsFluids

The Future ??•Each decade we reject a new

haemodynamic variable, on which, to base interventions

•1980: PAWP

•1990: VO2-DO2 relationship

•2000: LVEDV GEDVI

•2010: Forget about monitoring - just ECHO everything (over and over)

Where does that leave us ?

Where does that leave us ?

•Prescriptive Approaches

•RELIEF (Restrictive versus Liberal Fluid Therapy in Major Abdominal Surgery)

•Clinical Trials.gov Id: NCT 01424150

•Random allocation of drugs

•Targeting Fluid Balance

A Physiological Approach

•Instead of targeting MAP or CO/O2D indices

•using DEPENDENT circulatory variables (e.g. CVP, EDV, PPV) to guide therapy

•Target BOTH simultaneously using

•INDEPENDENT circulatory variables

- Volume state

- Cardiac function

- Systemic vascular resistance

Mean Systemic Filling Pressure

Mean Systemic Filling Pressure

Anaesthesia2009(64):1218-1228

Mean Systemic Filling Pressure

•Allows independent assessment of volume state

and

•Allows independent assessment of cardiac function

Modelling the circulation

Stay with me.......

MSFP(modeled)

CO

Press av MSFP

Venous compliance lower than assumed

CO

Press av MSFP

Venous compliance higher than assummed

CO

Press av

Independent variables of the circulation

•MSFP = Volume state= 0.96(CVP) + 0.04(MAP) + c(CO)

•HP (Heart Performance) = Inotropy state

=(MSFP - RAP) / MSFP

•SVR = Arteriolar tone stateThese are the numerical descriptors (indicators) of the circulation

Choosing the Target

•Cardiac output

•Mean arterial pressure

•(Cardiac Power = CO x MAP)

•Captures both kinetic and potential energy of the circulation

•Allows assessment of volume responsiveness

Cardiogenic Shock

•Cardiac Power

Cardiogenic Shock

•Cardiac Power

Navigator GuidanceHeart efficiency axis Mean systemic

filling pressure axisData from Monitors

Targets set by clinician

Main menuarea

Data linkStatus area

Target zone

Systemicresistance axis

Patient’s current position

Arrow shows next therapeutic direction

Other data

Intended Control: Following the arrow• Vertical Axis Control

• If Cardiac Power Low: increase MSFP or Inotropy (depending on HP)

• If Cardiac Power High: decrease MSFP or Inotropy* (depending on HP)

•Horizantal Axis Control

• If Cardiac Power is not well “geared” (SVR too high or too low): dilators and constrictors

Cardiac Power Relevance

Navigator Screens: NAV-1

Intervention(Treatment compliance not required)

Control

What we learned•Even if you know the independent

determinants of circulatory variables (like CO)......

•Even if you use them to direct therapy to a meaningful target (like cardiac power).....

•You don’t necessarily know when you should change the target and when you should change the treatments

Structured approach to circulatory care using

Navigator

Determine TargetsDefine (allowable)

interventions

Targets attained andmaintained (ASD < 1.5)within intervention limits

Targets not maintained within intervention limits (ASD >1.5)

New InterventionNew Target

+1. Medicalassessment

2. Nursingassessment

or3. Continual maintenance No change

Circulatory Targeting Sheet

Volume resuscitation Colloids = 0Colloids = < 1000

mlsColloids = < 2000ms

Vasopressor requirements Noradren = 0 Noradren = 1 - 10 Noradren = >10

AVP = 0 AVP = 1/hr AVP 2/hr

Vasodilator requirements GTN = 0 GTN =20 or more GTN ___ - ___

SNP 10 - 50 SNP 50 - 150 SNP ___ - ___

Inotrope requirements Adren: = 0 Adren: < 5 Adren: 5- ___

Milrinone = 0 Milrinone = 5 Milrinone = 5 - 20

MAP

Card Index

ScvO2 > 70

Heart Rate

HP inotrope trigger

HP medical review trigger

Improving Circulatory Care .....

•Further investigations into physiologically based treatments

•Cannot accept that understanding the circulation can’t lead to improved care

Outcomes of cardiogenic shock (CS) complicating acute coronary

syndromes/myocardial infarction

Outcomes of cardiogenic shock (CS) complicating acute coronary

syndromes/myocardial infarction

Outcomes

•High early mortality (despite early intervention)

•Difficult to support medically•Reasonable quality of life post•Not invariably associated with irrecoverable myocardial damage

Cardiogenic Shock Outcomes

Krischan D. Sjauw European Heart Journal

(2009) 30, 459–468

Krischan D. Sjauw European Heart Journal

(2009) 30, 459–468

IABP

Unverzagt S Cochrane

Library 2011

Unverzagt S Cochrane

Library 2011

IABP

•Ongoing Trials•IABP Shock II;•RECOVER II Trial

•Planned Recruitment•984

IABP

Elmir Omerovic Vascular Health and Risk

Management 2010:6 657–663

Elmir Omerovic Vascular Health and Risk

Management 2010:6 657–663

Inotropes

• Extra Corporeal Membrane Oxygenation is a form of extracorporeal life support where an external artificial circuit carries venous blood from the patient to a gas exchange device (oxygenator) where blood becomes enriched with oxygen and has carbon dioxide removed. This blood then re-enters the patient circulation

• Veno-arterial ECMO– Percutaneous

cardiopulmonary support (bypass)

ECMO

return

access

Day 2-3Lymphocytic myocarditis

What’s possible

What’s possible……

Day 10

Day 5

Christian A. Bermudez Ann Thorac Surg 2011;92:2125–31

Diagnostic Group

Number(168)

Age(43)

ECMO Days (7.3)

SW SB NW Alive Discharge

CM/FM40 42 7.8 21 14 5

27(+3) (75%)

Heart Tx (0-7) 46 51 6.6 43 1 2* 33 (72%)

AMI25 52.4 9.1 12 8 5 14 (56%)

Heart Tx (late) 10 44 11.9 4 3 3 3 (30%)

Septic Shock 7 38 4.9 3 0 4 2 (29%)

ECMO for Cardiac Failure 2003-2012

•25 patients (2003-2012)•Average Age: 52.4•Average Days on Support: 9.14•56% Survival to hospital discharge•5 NW•8 SB•12 SW

Alfred CS-AMI

•Veno-arterial ECMO•Centrifugal VAD•Tandem Heart LVAD

•RVAD, LVAD, BiVAD

•Impella Recover•B2B (Bridge to Bridge)•Long term VAD

Current Mechanical Treatment Options for

Severe Acute Heart Failure

Ischaemic C/M60 month

mortality 50%

Non-Ischaemic C/M

60 month mortality 35%

•Cardiogenic shock remains a challenging syndrome to treat but the early application of safe ECMO seems possible to provide major patient benefits

•Simple

•Transferable

Conclusion