3. (r)evolution in hemodynamic monitoring in critically ill #uzb40 icu (monnet)
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This symposium provides an overview of the (r)evolution in intensive care medicine. The programme is based on lectures of 20 minutes where each speaker presents in two 10 minute talks (in der Beschränkung zeigt sich erst der Meister) the good things that happened in the last 40 years in critical care vs our mistakes or what is missing with respect to that topic. At the end of the session the speakers participate in an interactive round table discussion with online voting to get the audience involved. Will be discussed: Theoretical concepts, basic physiology and pathophysiology, monitoring, and future directions.
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3. (r)evolution in hemodynamic monitoring in critically ill #uzb40 icu (monnet)
- 1. Prof. Xavier MONNET Medical Intensive Care Unit Paris-Sud University Hospitals xavier.monnet@aphp.fr Time to look back… Haemodynamics
- 2. Pulsion Medical Systems (Member of the medical advisory board) Cheetah Medical (Lecturer) Links of interest
- 4. Fluids The controversy between crystalloids and colloids
- 5. 7000 patients admitted to ICU Voluven (130/0.4) vs. 0.9% sodium chloride Fluids The controversy between crystalloids and colloids
- 6. 798 patients with severe sepsis Tetraspan vs Ringer’s acetate Fluids The controversy between crystalloids and colloids
- 7. Fluids The controversy between crystalloids and colloids
- 9. Fluids The concept of fluid responsiveness
- 10. Systematic review 13 studies 0 10 20 30 40 50 60 70 80 Rate of Response to fluids (%) Chest 2002; 121: 2000 - 8 Fluid responsiveness: 50% of cases! Fluids The concept of fluid responsiveness
- 11. Fluids The prediction of fluid responsiveness
- 12. ↗ Lung water ↗ Abdominal pressure ↘ Pressure perfusion gradient ↗ risk of RV failure Haemodilution Fluids The prediction of fluid responsiveness
- 13. 15 patients with septic shock Fluids The prediction of fluid responsiveness
- 14. 40 patients with septic shock PA catheter But… Fluids The prediction of fluid responsiveness PPV is reliable for predicting fluid responsiveness Cannot be used in case of: ! spontaneous breathing activity cardiac arrhythmias ARDS with low Vt / compliance
- 15. 83 patients with circulatory failure The Applicability of Fluid Responsiveness Indices in Circulatory failure (AFRIC study) SHI Rui, DE VITA Nello, GAVELLI Francesco, TEBOUL Jean-Louis, PAVOT Arthur, MONNET Xavier In preparation Interpretable (16%) Low Vt (27%) Several causes (51%) Spontaneous breathing (12%) Fluids The prediction of fluid responsiveness
- 16. Aortic Blood Flow PLR Volume expansion PLR predicts… … fluid responsiveness Fluids The prediction of fluid responsiveness
- 17. yes no Should I give fluid? ? Obvious fluid loss? First 60-90’of sepsis? ? Fluid ! Is CO too low ? ? ? + Fluid ! No fluid !- ΔIVC/SVC PPV, SVV… PLR test EEO/EIO tests Fluid challenge Mini-fluid challenge Recruitment manoeuvers Fluids The prediction of fluid responsiveness
- 18. Fluids The prediction of fluid responsiveness
- 20. Vasopressors Dopamine vs. noradrenaline
- 21. Deleterious effects Less efficacy than norepinephrine No beneficial renal effects Cardiac arrhythmias ↗ myocardial O2 consumption Vasopressors Dopamine vs. noradrenaline
- 22. 1 679 pts with shock Dopamine vs. norepinephrine No difference between norepinephrine and dopamine Vasopressors Dopamine vs. noradrenaline
- 23. 1 679 pts with shock Dopamine vs. norepinephrine Vasopressors Dopamine vs. noradrenaline
- 24. Landry et al. Circulation Patel et al. Anesthesiology 1997 2002 2002- 2008 Several studies 2008 VASST 2016 VANISH 2017 VANCS RCT 330 patients ? Vasopressors New solutions ?
- 25. 778 pts receiving NE low dose vasopressin (0.01-0.03 U/min) vs NE increase (8-15 µg/min) Relative defect in vasopressin during sepsis → Vasopressin reduces requirements in NE and improves renal function Disappointing results in a large RCT→ → Vasopressors New solutions ?
- 26. 886 septic shock patients Selepressin vs. placebo Vasopressors New solutions ?
- 28. Inotropes The old dobutamine
- 29. 14 patients with congestive heart failure 1st human study with dobutamine Inotropes The old dobutamine
- 30. Chest, 1989 dobutamine dopamine 8 patients with acute hypoxic respiratory failure Inotropes The old dobutamine
- 31. Deleterious effects Factor independently associated with mortality Imune and metabolic side effects Cardiac arrhythmias ↗ myocardial O2 consumption Inotropes The old dobutamine
- 32. AMPc AMP b Ca++ Sarcoplasmic reticulum TnC Ca++ P P P P AMP PDE inhibitors Phosphodiesterase E - Dobutamine AMPc Inotropes The old dobutamine
- 33. Inotropes The old dobutamine
- 34. Inotropes The old dobutamine
- 35. Disappointing results in AHF (without shock) 1 327 patients with severe congestive heart failure dobutamine vs. levosimendan Inotropes Levosimendan
- 36. 658 pts with refractory shock after AMI standard treatment + L-NAME or placebo No change in survival No change in shock duration Inotropes New solutions ?
- 38. 109 surgical ICU patients Maximalisation of CO with fluids and dobutamine Goals of resuscitation
- 39. 762 medical ICU patients Maximalisation of CO with fluids and dobutamine Goals of resuscitation
- 41. The old pulmonary artery catheterMonitoringHaemodynamic monitoring
- 42. Haemodynamic monitoring The old pulmonary artery catheter
- 43. Supposed drawbacks No benefit on survival Invasive Pitfalls in interpretation Haemodynamic monitoring The old pulmonary artery catheter
- 44. Proportionsurviving Follow-up time (days) JAMA 1996; 270:899-897 no PAC PAC p = 0.02 5735 heterogeneous patients with and without PAC prospective observation for 30 days Haemodynamic monitoring The old pulmonary artery catheter
- 45. 13 RCTs 5051 patients Haemodynamic monitoring The old pulmonary artery catheter
- 46. mainly because of the invasiveness of PAC Haemodynamic monitoring The old pulmonary artery catheter
- 47. Supposed drawbacks Not easy to set up No benefit on survival Invasive Pitfalls in interpretation Haemodynamic monitoring The old pulmonary artery catheter
- 48. PiCCO EV 1000 Pulsioflex Vigileo PA catheter LidCO Starling Clearsight CNAP LidCO rapid Oeso Doppler esCCO Not any more effect on prognosis Not less invasive… … easier to install Haemodynamic monitoring New alternatives
- 49. Haemodynamic monitoring New alternatives
- 50. 10 patients with acute respiratory failure The revolution of echocardiography
- 52. Sepsis-Act VANCS Sepsispam Arise Promise Process Licorne PROWESS-Shock ADDRESS ABDOMIX IVOIRE Failures and disappointments Did we do so bad ?
- 53. 44 RCTs 13,315 patients Failures and disappointments Did we do so bad ? Mortality ↘
- 54. 1997-2012 Cub-Réa French database Mortality ↘ Failures and disappointments Did we do so bad ?
- 55. Prof. Xavier MONNET Medical Intensive Care Unit Paris-Sud University Hospitals xavier.monnet@aphp.fr Time to look back… Haemodynamics