ultrasound and precision medicine in sepsis...high svr low svr high pap ... • ultrasound as a...
TRANSCRIPT
Ultrasound and Precision Medicine in Sepsis Resuscitation
Pietro Bertini – Cardiothoracic and Vascular Anesthesia and Intensive Care
Azienda Ospedaliera Universitaria Pisana. Pisa, Italy
No Disclosures
Precision medicine
Tailored approach
In the “PAC era”
«Septic shock patients consistently show a
hyperdynamic circulatory state with high CO
and low SVR»
Despite the strong evidence characterizing
sepsis as a hyperdynamic state, studies that
examined myocardial performance still
showed LV dysfunction in resuscitated
septic patients.
The numbers we love to treat
• BP
• Volume status
• Cardiac output
• Urine output
• ScVO2 / SVO2
• Lactate
Hemodynamic categorizations
High CO
Low CO
High SVR
Low SVR
High PAP
Low PAP
High filling pressures
Low filling pressures
……..
Ventriculo-arterial couplingOptimal efficiency: Ea/Ees 1
Failing heart: Ea/Ees >1
Hemodynamics of Septic Shock
Volume Expansion
Reduction in Ees
Volume and then vasoactive support inefficient
Therapies aiming to restore VAC by increasing Ees (inotropes) and reducing Ea (beta blockers, vasodilators…)
30 %
Same CO, different EF: which is the best?
60 %
Haddad et al, circulation 2008;117:1717-1731
Let’s move to a new pathophysiology paradigm
• LV function
• Diastole and filling
• Acute RV failure
• Relationship between
ventricular elastance
and arterial elastance
Echocardiography
Echocardiography
Heart and sepsis
• Complex pathophysiology
• Full echodynamic evaluation
• Monitoring biomarkers (BNP, Tp)
• Echo-guided treatment in the light of heart-arterial
coupling (Ea/Ees)
Tailored Approach
• Pathophysiological oriented
• Ultrasound as a point-of-care device to
plumb hemodynamic state while screening
for unexpected structural finding and
underlining condition
• One needs to also apply functional and
convenient techniques in unison
SVR =𝑀𝐴𝑃−𝐶𝑉𝑃
𝐶𝑂
SVR =𝑀𝐴𝑃−𝐶𝑉𝑃
𝐻𝑅∙𝑆𝑉
SVR ≅𝐸𝑆𝑃
𝐻𝑅∙𝑆𝑉Ea=
𝐸𝑆𝑃
𝑆𝑉
SVR ≅𝐸𝑎
𝐻𝑅
Ea ≅ 𝑆𝑉𝑅 ∙ 𝐻𝑅
SVR ≅𝐸𝑎∙𝑆𝑉
𝐻𝑅∙𝑆𝑉
Ea=𝐸𝑆𝑃
𝑆𝑉
