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Hemodynamic
Monitoring
Pressure or Volumes?
Antonio Pesenti
University of Milan
Italy
CCCF 2017
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CVP• Is it useful?
• YES:
– It is an important diagnostic element !
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Your best guess
• CVP CI HR SBP
• 0-2 2.0 160 70/ ??
• CVP CI HR SBP
• 10 2.0 160 70/ ??
•
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Your best guess
• CVP CI HR SBP
• 0-2 2.0 160 70/ ??
• CVP CI HR SBP
• 10 2.0 160 70/ ??
•
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Your best guess
• CVP CI HR SBP
• 0-2 2.0 160 70/ ??
• CVP CI HR SBP
• 15 2.0 160 70/ ??
•
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Hemodynamic monitoring Tools
• Cardiac function or cardiac output?
• Filling pressures?
• Single measure or trend?
• Accuracy, precision, stability?
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Tools
• Echo ( TEE vs TTE)
– CO +-
– Trend+-
– No real pressure
• (Thermo)dilution: reference
– Pressures, continuous
• Doppler output +-
• Pulse contour (calibration)
• Impedance +---
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Cecconi et al Intensive Care Med 2015
• 500 ml in 24 min
• Static Marker in 36%
• Dynamic Markers in 22%
• No safety parameter in 72%
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What is a Positive fluid
challenge ?• We give the prescribed amount of fluid
and the CO or the SV or the BP increased
more than a certain amount ( 10-15%).
• In my book:
– if no improvement and CVP increases more
than 3 mmHg, then stop
– If improvement and no change in CVP then
may repeat
– If no improvement and no change: think
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FLUID RESPONSIVENESS
• Is not a disease
• Normal subjects respond to fluid load by
an increase in CO ( transient)
• Preload Dependence is a normal condition
• Lack of fluid responsiveness is an
abnormal state ( not necessarily
pathological)
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Effect of 3 l saline infusion in 3hrsnormal subjects
Kumar Crit Care Med 2004
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Fluid responsiveness tests
• Q . Why a test for fluid responsiveness?
• A. To be able to administer fluid safely.
• Q. When is fluid administration safe?
• A. When it does not cause filling pressures
to rise over safety limits.
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Am Heart J 1984:107: 404
We assert that the essential function of the rightventricle is not to provide blood flow through thepulmonary but to maintain a low pressure in thehighly compliant systemic venous system.
By maintaining this low central venous pressure , theRV prevents the development of venous distensionand massive peripheral edema
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Function of the right ventricle
Keep systemic
venous pressure
low
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Function of the Left ventricle
Keep pulmonary
venous pressure
low
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Value of filling pressures
Filling pressures tell us how well the heart
works
A better working heart gives the same
output with a lower filling pressure
A worse heart function results in higher
filling pressures for the same output
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Filling Pressures
It is true that Frank Starling’s law of the
heart is based upon lenght rather than
pressures
Lenght and volumes are best to study the
heart
Pressures however is what tissues see
The body survives on pressures not
volumes
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CVP• CVP is a stopping rule
– Would you give a fluid load to this patient:
• MAP 55 mmHg
• CVP 18 mmHG
• CO 4.5 l/min
• Sat v 65%?
• What if this patient had 20 cm H20 PEEP?
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CVP• Would you give a fluid load to this patient:
– MAP 55 mmHg
– CVP 0 to 2,
– CO 4.5 l/min
– Sat 65%
• What if this patient is spontaneously breathing?
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CVP• CVP in itself is not a predictor of fluid
responsiveness
• CVP is always a predictor of the risk of
fluid loading and of the price your patient
is going to pay.
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CONCLUSION 1
Filling pressures are important global
parameters for adequacy of volemia and
heart function
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CONCLUSION 1
Filling pressures are important global
parameters for adequacy of volemia and
heart function
Identical filling pressures may be
associated with very different CO
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CONCLUSION 1
Filling pressures are important global
parameters for adequacy of volemia and
heart function
Identical filling pressures may be
associated with very different CO
Identical CO may be associated with
different filling pressures
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CONCLUSION 1
Filling pressures are important global
parameters for adequacy of volemia and
heart function
Identical filling pressures may be
associated with very different CO
Identical CO may be associated with
different filling pressures
Filling pressures AND fluid responsiveness
are notthe same thing
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CONCLUSION 2 PAOP is critical because it is the major
determinant of EVLW
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CONCLUSION 2 PAOP is critical because it is the major
determinant of EVLW
CVP is critical because it is the major
determinant of body organs edema and
dysfunction
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CONCLUSION 2 PAOP is critical because it is the major
determinant of EVLW
CVP is critical because it is the major
determinant of body organs edema and
dysfunction
If you want to do a fluid responsiveness
test, best are DRY Fluid challenges:
Mech Ventilation
Leg Raising
Anti shock trousers
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Monnet and Teboul Crit Care 2015