using arterial pressure based cardiac output to guide therapy - chris saraceno
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Using Arterial Pressure-Based Cardiac Output to Guide Therapy
Chris Saraceno, DNAP, CRNADistrict 3 & 4 Meeting
February 4th, 2017
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FloTrac-EV1000™
78 y.o. Male Severe sepsis 2° LLL pneumonia h/o TB 30 yrs ago MAP 58/ HR 135/ RR 42/ Temp 39.1/
UOP~5
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Intubated, arterial line with Vigileo, CVP 7.30/41/78 (70%)/28/-10/ Lactate 4.2 SVV 18%
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Levophed @ 0.5/mg/kg/min Fluid challenges until SVV < 10% UOP increased, lactate decreased, weaned
from ventilator
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Why Arterial-Pressure Based CO? Tissue hypoperfusion inadequate oxygen
delivery to tissues MSOF
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Oxygen Delivery
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What’s wrong with current monitoring? SWAN and CVP
• Have NOT proven to improve outcomes• Carry their own risks
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PAC-Man trial• No difference in patient mortality with SWAN
or no SWAN Osman
• Retrospective study: 96 pts with SWANs• Fluid challenges• Fluid responders/ nonresponders
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Pulsus Paradoxus
PPV Decreased venous return Seen a few beats later
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Mechanism of Pulsus Paradoxus
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Fluid Responsiveness Starling’s curve
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Arterial Based C.O. Monitoring Current Monitors
• FloTrac/ Vigileo/EV1000, Edwards Lifesciences
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Arterial Based C.O. Monitoring• LiDCO
– London group– Lithium
• PiCCO– Manual calibration– Thermodilution via central venous line
• Sets parameters• Requires femoral arterial line
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Stroke Volume Variation (SVV)
Minimally invasive• WORKING arterial line• Zero arterial line anesthesia monitor & EV1000
Enter HT, WT, age and gender• Baseline vascular resistance database
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SVV Displays hemodynamic parameters
continuously (20 sec)• 100 pressure points over 10 seconds (2000 data
points)• Calculates std of arterial waveform X
compliance No manual calibration
• Calibrates q 1 minute15
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SVV calculation
% SVV = SVmax-SVmin /SVmean
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SVV Evolving technology
- Vigileo• 3 generations
EV 1000• 4th generation
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Limitations Intubated, sedated, paralyzed
• Required • Spontaneously breathing- naturally varies
Severe arrythmias Have to have a pulse rate
• IABP• Ventricular assist devices
Vasodilation therapy- consider in “big picture”18
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Case Study # 1 78 y.o. male
• HTN• Atherosclerosis• EVAR- AAA
GA with Aline/Flotrac• 134/78• 64 bpm• C.O. 4.5• SVV 7%
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Case Study # 1 1 hour into case
• 110/60• 76 bpm• C.O. 3.1 L/min• SVV 35%
Dye study- no leak 3u PRBCs, 500 mL 5% albumin, 500 mL crystalloid “covert” blood loss ~ 750mL
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Volume Responsiveness
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Case Study #2 32 yo male
• Type 2 DM• Idiopathic dilated CMO
– EF 20%
• Meds – Torsemide– Ramipril– Carveilol– Digoxin– Insulin
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BiV pacemaker• GA• CVP• A line• 500 LR• 300 EBL• 1200 UOP
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Case Study #2 5 hour case Dopamine 5-8 mcg/kg/min for BP
• ABG:7.19 74 62 28.3100% O2
ICU - intubated
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Case Study # 2 Post BiV:
• 84/50 with MAP of 61 mmHg• 130 bpm• CVP 18-20 mmHg
Questions• Fluid: worsen pulmonary edema• Increase Dopamine: worsen tachycardia• NTG, NTP or Dobutamine: wosen HOTN
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Case Study # 2 FloTrac connected to existing Aline Patient ventilated and sedated CO 4.7 L/min SVV 20-22% Fluid challenge: CO 5 L/min, MAP inc to
66 mmHg Fluid until SVV < 15%
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Case Study # 2 Vitals normalized Extubated within 24 hours EF 25%
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Case Study #3 18 y.o. male MVA No PMH MVA with prolonged
extraction SBP 70 HR 160 Abdomen firm Pelvic fracture
FloTrac in ER• SVI: 14 mL/m2
• SVV: 40-45% OR
• Splenectomy• SMV repair• 12 units PRBCs• 14 L NaCl
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Case Study #3 ICU-
• 23 L of NaCl• 16 u PRBCs
• SVI 66 ml/m2
• Furosemide
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Extremes in Cases DIEP Flap
• Young, healthy– Fluid – Flap integrity
Open AAA repair• Comorbidities
– HTN– CKD
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What else can EV1000 monitor tell us?
Another piece of the puzzle
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Case Study #4 54 yo male for liver
resection Hepatocellular
carcinoma A-line 150/85 HR 66 GA CVP = 8 mmHg
2 hours into surgery:• BP 95/44• HR 126• CVP= 7 mmHg
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Case Study #4 Flo Trac connected to existing arterial line:
• SVV 20%• SV 25 mL• CO 1.9• Fluid given: SVV to 10%, but SV low = 35 mL• Epi gtt started
– Titrated to 1mcg/kg/min– Vitals improved
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Case Study # 4 Left intubated at the end of the case Troponin I and CK levels elevated MI
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Caution:• Surgeon?
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Thank you
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