Cirkulationsmonitorering

En presentation över ämnet: "Cirkulationsmonitorering"— Presentationens avskrift:

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

2 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:

3 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:

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

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

6 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

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

8 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:

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

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

11 Statiska variabler CVP PAP PAOP LVEDA

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

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

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

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

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

17 SPV

18 PPV

19 PPV PPmax - PPmin PPmedel PPV =

20 Prediktion Övertrycksventilerade patienter Sinusrytm

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25 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

26 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: 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: 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: 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