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Vin Presentation

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Information about Vin Presentation
Health & Medicine

Published on February 17, 2014

Author: oliflower

Source: slideshare.net

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Advancing Circulatory Care (2012 ) Vincent Pellegrino Victorian Intensive Care Network August 2012

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 10 Patients APII 30 CRRT-HF 601 hour 417 (L) lost 409 (L) administered 3 survived (hosp discharge) J Crit Care (1994) 9: 124-133

1992: First ICU Rotation Reduced haemodynamic variability compared to standard care J Crit Care (1994) 9: 124-133

PAC - Clinical Trials • Shoemaker 1988

PAC - Clinical Trials • Intensive Care 19882006 • • • • 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 Liberal fluids associated with increased ICU and ventilator time and no reduction in renal failure • Outcome Death at 60 days (%) Ventilator-free days from day 1 to day 28  ICU-free days  Days 1 to 7 Days 1 to 28 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 Dialysis to day 60 Patients (%) Days Conservative Strategy Liberal Strategy P Value 25.5 28.4 0.30 14.6 ± 0.5 12.1 ± 0.5 <0.001 0.9 ± 0.1 13.4 ± 0.4 0.6 ± 0.1 11.2 ± 0.4 <0.001 <0.001 3.9 ± 0.1 3.4 ± 0.2 5.5 ± 0.1 5.7 ± 0.1 5.6 ± 0.1 4.2 ± 0.1 2.9 ± 0.2 5.6 ± 0.1 5.5 ± 0.1 5.4 ± 0.1 0.04 0.02 0.45 0.12 0.23 19.0 ± 0.5 18.8 ± 0.5 21.5 ± 0.5 22.0 ± 0.4 22.0 ± 0.4 19.1 ± 0.4 17.2 ± 0.5 21.2 ± 0.5 21.2 ± 0.5 21.5 ± 0.4 0.85 0.03 0.59 0.18 0.37 10 14 0.06 11.0 ± 1.7 10.9 ± 1.4 0.96 ARDS Clinical Trial Network, NEJM 2006

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 Pressure Low Blood Pressure Fluids Fluids Low Cardiac Output Low Cardiac Output Inotropes Inotropes Organ Failure Organ Failure Vasopressors Vasopressors

Currently Low Blood Pressure Low Blood Pressure Fluids Fluids Low Cardiac Output Low Cardiac Output Inotropes Inotropes Organ Failure Organ Failure Vasopressors Vasopressors

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 Anaesthesia 2009(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 v MSFP Press a

Venous compliance lower than assumed CO v MSFP Press a

Venous compliance higher than assummed CO v Press a

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 state These 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 Guidance Heart efficiency axis Mean systemic filling pressure axis Data from Monitors Target zone Targets set by clinician Other data Systemic resistance axis Main menu area Data link Status area Patient’s current position Arrow shows next therapeutic direction

• 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 1. Medical assessment 2. Nursing assessment 3. Continual maintenance Determine Targets Targets attained and maintained (ASD < 1.5) within intervention limits No change + Define (allowable) interventions Targets not maintained within intervention limits (ASD >1.5) New Target or New Intervention

Circulatory Targeting Sheet MAP HP inotrope trigger ScvO2 > 70 Card Index HP medical review trigger Heart Rate Volume resuscitation Colloids = 0 Colloids = < 1000 mls Colloids = < 2000ms Vasopressor requirements Noradren = 0 Noradren = 1 - 10 Noradren = >10 AVP = 0 AVP = 1/hr AVP 2/hr GTN = 0 GTN =20 or more GTN ___ - ___ SNP 10 - 50 SNP 50 - 150 SNP ___ - ___ Adren: = 0 Adren: < 5 Adren: 5- ___ Milrinone = 0 Milrinone = 5 Milrinone = 5 - 20 Vasodilator requirements Inotrope requirements

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

Cardiogenic Shock Outcomes •High early mortality (despite early intervention) •Difficult to support medically •Reasonable quality of life post •Not invariably associated with irrecoverable myocardial damage

IABP Krischan D. Sjauw Krischan D. Sjauw European Heart Journal (2009) European Heart Journal (2009) 30, 459–468 30, 459–468

IABP Unverzagt S Unverzagt S Cochrane Library Cochrane Library 2011 2011

IABP •Ongoing Trials •IABP Shock II; •RECOVER II Trial •Planned Recruitment •984

Inotropes Elmir Omerovic Elmir Omerovic Vascular Health and Risk Vascular Health and Risk Management Management 2010:6 657–663 2010:6 657–663

ECMO • 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)

access return

What’s possible Lymphocytic myocarditis Day 2-3

What’s possible…… Day 5 Day 10

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

ECMO for Cardiac Failure 20032012 Diagnostic Group CM/FM Heart Tx (0-7) AMI Heart Tx (late) Septic Shock Number Age (168) (43) ECMO Days SW SB (7.3) NW Alive Discharge 40 42 7.8 21 14 5 27(+3) (75%) 46 51 6.6 43 1 2* 33 (72%) 25 52.4 9.1 12 8 5 14 (56%) 10 44 11.9 4 3 3 3 (30%) 7 38 4.9 3 0 4 2 (29%)

Alfred CS-AMI •25 patients (20032012) •Average Age: 52.4 •Average Days on Support: 9.14 •56% Survival to hospital discharge • 5 NW • 8 SB • 12 SW

Current Mechanical Treatment Options for Severe Acute Heart Failure •Veno-arterial ECMO •Centrifugal VAD • Tandem Heart LVAD • RVAD, LVAD, BiVAD •Impella Recover •B2B (Bridge to Bridge) •Long term VAD

Ischaemic C/M 60 month mortality 50% Non-Ischaemic C/M 60 month mortality 35%

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

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