Cirkulationsmonitorering Optimerad praxis Anders Åneman Anestesi/IVA SU/Sahlgrenska sjukhuset Göteborg

Praxis 92 97 Oldner A et al. A practice survey on vasopressor and inotropic drug therapy in Scandinavian intensive care units. Acta Anaesthesiol Scand 2003;47:693-701

Praxis Antal svar, kolla mot antal patienter Oldner A et al. A practice survey on vasopressor and inotropic drug therapy in Scandinavian intensive care units. Acta Anaesthesiol Scand 2003;47:693-701

Praxis Oldner A et al. A practice survey on vasopressor and inotropic drug therapy in Scandinavian intensive care units. Acta Anaesthesiol Scand 2003;47:693-701

Praxis Oldner A et al. A practice survey on vasopressor and inotropic drug therapy in Scandinavian intensive care units. Acta Anaesthesiol Scand 2003;47:693-701

Optimering Optimering av DO2 hos kirurgiska och septiska patienter leder till förbättrad överlevnad/minskad morbiditet Optimeringsstudiernas effektivaste intervention är ökad volymstillförsel (inte val av farmaka) Expansion av intravaskulär volym är ändamålsenlig så länge SV ökar, därefter negativa effekter

Optimering Artärtrycket är mindre intressant än flöde/perfusion Flödet relaterar till volym Utmaningen består i att identifiera de patienter som “svarar på volym”

Praxis 87% av de rapporterade patienterna var “volymsladdade” inför fortsatt farmakologisk behandling Oldner A et al. A practice survey on vasopressor and inotropic drug therapy in Scandinavian intensive care units. Acta Anaesthesiol Scand 2003;47:693-701

Fysiologi variabel compliance i seriekopplade kärl variabel HK preload/compliance * variabel HK afterload * variabel VK preload/compliance * variabel VK afterload * * relaterar till övertrycksandning

Övertrycksventilation Michard F et al. Using heart-lung interactions to assess fluid responsiveness during mechanical ventilation. Crit Care 2000;4:282-289

Statiska variabler CVP PAP PAOP LVEDA

Statiska tryck Michard F et al. Predicting fluid responsiveness in ICU patients. A critical analysis of the evidence. Chest 2002;121:2000-2008

Statiska volymer Michard F et al. Predicting fluid responsiveness in ICU patients. A critical analysis of the evidence. Chest 2002;121:2000-2008

Statiska tryck * * * PAOP Michard F et al. Predicting fluid responsiveness in ICU patients. A critical analysis of the evidence. Chest 2002;121:2000-2008

Statisk area LVEDA Michard F et al. Predicting fluid responsiveness in ICU patients. A critical analysis of the evidence. Chest 2002;121:2000-2008

Dynamiska variabler Systolisk tryck variation (SPV) Puls tryck variation (PPV) HF tryck variation (RAPV) (Doppler)

SPV

PPV

PPV PPmax - PPmin PPmedel PPV =

Prediktion Övertrycksventilerade patienter Sinusrytm

Klinisk praxis optimerad Optimera intravaskulär volym utifrån dynamiska parametrar Utnyttja all information i artärtrycksregistreringen Pulstrycksvariation relaterar till SV PPV > 13% indikerar att SV kan ökas med volymstillförsel

Referenser Michard et al: Predicting fluid responsiveness in ICU patients. A critical analysis of the evidence. Chest 2003;121:2000-8 Michard et al: Using heart-lung interactions to assess fluid responsiveness during mechanical ventilation. Crit Care 2000;4:282-9 Michard et al: Clinical use of respiratory changes in arterial pulse pressure to monitor the hemodynamic effect of PEEP. AJCCRM 1999;159:935-9 Reuter et al: Usefulness of left ventricular stroke volume variation to assess fluid responsiveness in patients with reduced cardiac function. CCM 2003;31:1399-1404 Marx et al: Assessing fluid responsiveness by stroke volume variation in mechanically ventilated patients with severe sepsis. Eur J Anaesth 2004;21:132-8 Michard et al: Relation between respiratory changes in arterial pulse pressure and fluid responsiveness in septic patients with actue circulatory failure. AJCCRM 2000;162:134-8 Tavernier et al: Systolic pressure variation as a guide to fluid therapy in patients with sepsis-induced hypotension. Anesthesiology 1998;89:1313-21 Pinksy MR. Functional hemodynamic monitoring. ICM 2002;28:386-88 Pinksy MR. Probing the limits of arterial pulse contour analysis to predict preload responsiveness. Anesth Analg 2003;96:1245-7 Viellard-Baron et al: Hemodynamic instability in sepsis. Bedside assessment by Doppler Echocardiography. AJCCRM 2003;168:1270-6 Chaney et al: Minimally invasive hemodynamic monitoring for the intensivist: Current and emerging technology. CCM 2002;30:2338-45 Reuter et al: Influence of tidal volume on left ventricular stroke volume variation measured by pulse contour analysis in mechanically ventilated patients. ICM 2003;29:476-80 Magder S. Clinical usefulness of respiratory variations in arterial pressure. AJRRCM 2004;169:151-5