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08-Dec-04. WRAP IT UP Manu Malbrain, MD. Director Intensive Care Unit Ziekenhuis Netwerk Antwerpen Campus Stuivenberg B-2060 Antwerp BELGIUM. [email protected] Isn’t it time to pay attention?.

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Wrap it up manu malbrain md

08-Dec-04

WRAP IT UP

Manu Malbrain, MD

Director Intensive

Care Unit

Ziekenhuis Netwerk Antwerpen

Campus Stuivenberg

B-2060 Antwerp

BELGIUM

[email protected]


Isn t it time to pay attention

Isn’t it time to pay attention?

Ivatury RR. Sugerman HJ. Abdominal compartment syndrome: A century later, isn't it time to pay attention? Crit Care Med 2000; 28:2137-2138.

Sugrue M. Intra-abdominal pressure: time for clinical practice guidelines? Intensive Care Med 2002; 28(4):389-391.


It is time to pay attention

It is time to pay attention!

Malbrain MLNG. Intraabdominal hypertension in the critically ill: it is time to pay attention. Current Opinion Crit Care 2005; 11(2)

(Ed. Julia Wendon)


Why didn t you pay attention

Why didn’t you pay attention!

Malbrain MLNG. Intraabdominal hypertension in the critically ill: why didn’t you pay attention. Current Opinion Crit Care 2006; 12(2)

(Ed. Julia Wendon)


Evolution of baro and volo indicators

Evolution of baro- and volo-indicators


Iap assessment

IAP Assessment


Wrap it up manu malbrain md

ACS Publications

80

70

60

50

40

30

20

10

1990

1995

2000


Pathophysiology

CENTRAL NERVOUS SYSTEM

Intracranial pressure 

Cerebral perfusion pressure

Idiopathic intracranial hypertension (obesity)

Pathophysiology

CARDIOVASCULAR SYSTEM

Difficult preload assessment

Wedge pressure 

Central venous pressure 

Intra thoracic blood volume index =

Extra vascular lung water =

Right ventricular end-diastolic volume index =

Cardiac output 

Venous return 

Systemic vascular resistance 

Venous thrombosis 

Pulmonary embolism 

Heart rate  =

Mean arterial pressure  =

Pulmonary artery pressure 

RESPIRATORY SYSTEM

Intrathoracic pressure 

Pleural pressure 

Functional residual capacity 

All lung volumes 

(~restrictive disease)

Auto-PEEP  ?

Peak airway pressure 

Plateau pressures 

Dynamic compliance 

Static compliance 

Chest wall compliance 

Hypercarbia 

PaO2 

PaO2/FiO2 

Dead-space ventilation 

Intrapulmonary shunt 

Lower inflection point 

Upper inflection point 

Prolonged ventilation ?

Difficult weaning ?

RENAL SYSTEM

Renal blood flow 

Diuresis 

Tubular dysfunction 

Glomerular filtration rate 

Renal vascular resistance 

Renal vein compression 

Compression ureters 

Anti-diuretic hormone 

Adrenal blood flow =

GASTRO-INTESTINAL SYSTEM

Celiac blood flow 

Superior mesenteric artery blood flow 

Blood flow to intra-abdominal organs 

Mucosal blood flow 

Mesenteric vein compression 

Intramucosal pH 

Regional CO2 

CO2-gap 

Success enteral feeding  ?

Intestinal permeability 

Bacterial translocation  ?

Multiple organ failure  ?

Gastro-intestinal (re)bleeding 

HEPATIC SYSTEM

Hepatic arterial flow 

Portal venous blood flow 

Portocollateral flow 

Lactate clearance 

Glucose metabolism 

Mitochondrial function 

Cytochrome p450 function 

ABDOMINAL WALL

Compliance 

Rectus sheath blood flow 

Wound complications 

Incisional hernia 


Pathophysiology1

CENTRAL NERVOUS SYSTEM

Intracranial pressure 

Cerebral perfusion pressure

Idiopathic intracranial hypertension (obesity)

Pathophysiology

CARDIOVASCULAR SYSTEM

Difficult preload assessment

Wedge pressure 

Central venous pressure 

Intra thoracic blood volume index =

Extra vascular lung water =

Right ventricular end-diastolic volume index =

Cardiac output 

Venous return 

Systemic vascular resistance 

Venous thrombosis 

Pulmonary embolism 

Heart rate  =

Mean arterial pressure  =

Pulmonary artery pressure 

IAP-HYPE?

RESPIRATORY SYSTEM

Intrathoracic pressure 

Pleural pressure 

Functional residual capacity 

All lung volumes 

(~restrictive disease)

Auto-PEEP  ?

Peak airway pressure 

Plateau pressures 

Dynamic compliance 

Static compliance 

Chest wall compliance 

Hypercarbia 

PaO2 

PaO2/FiO2 

Dead-space ventilation 

Intrapulmonary shunt 

Lower inflection point 

Upper inflection point 

Prolonged ventilation ?

Difficult weaning ?

RENAL SYSTEM

Renal blood flow 

Diuresis 

Tubular dysfunction 

Glomerular filtration rate 

Renal vascular resistance 

Renal vein compression 

Compression ureters 

Anti-diuretic hormone 

Adrenal blood flow =

MASS-HYSTERIA?

FASHION?

GASTRO-INTESTINAL SYSTEM

Celiac blood flow 

Superior mesenteric artery blood flow 

Blood flow to intra-abdominal organs 

Mucosal blood flow 

Mesenteric vein compression 

Intramucosal pH 

Regional CO2 

CO2-gap 

Success enteral feeding  ?

Intestinal permeability 

Bacterial translocation  ?

Multiple organ failure  ?

Gastro-intestinal (re)bleeding 

HEPATIC SYSTEM

Hepatic arterial flow 

Portal venous blood flow 

Portocollateral flow 

Lactate clearance 

Glucose metabolism 

Mitochondrial function 

Cytochrome p450 function 

ABDOMINAL WALL

Compliance 

Rectus sheath blood flow 

Wound complications 

Incisional hernia 


Pathophysiology2

CENTRAL NERVOUS SYSTEM

Intracranial pressure 

Cerebral perfusion pressure

Idiopathic intracranial hypertension (obesity)

Pathophysiology

CARDIOVASCULAR SYSTEM

Difficult preload assessment

Wedge pressure 

Central venous pressure 

Intra thoracic blood volume index =

Extra vascular lung water =

Right ventricular end-diastolic volume index =

Cardiac output 

Venous return 

Systemic vascular resistance 

Venous thrombosis 

Pulmonary embolism 

Heart rate  =

Mean arterial pressure  =

Pulmonary artery pressure 

RESPIRATORY SYSTEM

Intrathoracic pressure 

Pleural pressure 

Functional residual capacity 

All lung volumes 

(~restrictive disease)

Auto-PEEP  ?

Peak airway pressure 

Plateau pressures 

Dynamic compliance 

Static compliance 

Chest wall compliance 

Hypercarbia 

PaO2 

PaO2/FiO2 

Dead-space ventilation 

Intrapulmonary shunt 

Lower inflection point 

Upper inflection point 

Prolonged ventilation ?

Difficult weaning ?

RENAL SYSTEM

Renal blood flow 

Diuresis 

Tubular dysfunction 

Glomerular filtration rate 

Renal vascular resistance 

Renal vein compression 

Compression ureters 

Anti-diuretic hormone 

Adrenal blood flow =

NO it is real!

GASTRO-INTESTINAL SYSTEM

Celiac blood flow 

Superior mesenteric artery blood flow 

Blood flow to intra-abdominal organs 

Mucosal blood flow 

Mesenteric vein compression 

Intramucosal pH 

Regional CO2 

CO2-gap 

Success enteral feeding  ?

Intestinal permeability 

Bacterial translocation  ?

Multiple organ failure  ?

Gastro-intestinal (re)bleeding 

HEPATIC SYSTEM

Hepatic arterial flow 

Portal venous blood flow 

Portocollateral flow 

Lactate clearance 

Glucose metabolism 

Mitochondrial function 

Cytochrome p450 function 

ABDOMINAL WALL

Compliance 

Rectus sheath blood flow 

Wound complications 

Incisional hernia 


Dilemma

Dilemma:

“dry lungs are happy lungs”

“keep them dry watch them die”

“the patient does not die of anasarca, he dies of MOF”

DON’T FLUID OVERLOAD !

Give Fluids cautious

Give the right fluids


Chicken

Chicken?

Egg?


Chicken1

Chicken

Global View - PIRO

  • Patient factors – Predisposing conditions

  • Infection – Inflammation – Immunedeficiency-Ischemia-Iatrogenic

  • Response to stimulus - Reperfusion

  • Organ Failure

  • Genetic ?


Wrap it up manu malbrain md

To answer these questions we need multicentre studies !


Certainties in life

Certainties in Life

  • World Congress every 2 years

  • Next Meeting will be in Belgium

  • Next venue will be in Brussels ?, Antwerp?, Ghent?, Bruges?

  • Number of participants will increase from 50 – 160 – 300?


The more you look the more you see

The more you look the more you see

The more you see, the more you learn

The more you learn, the more you know

The more you know, the more you see


Wrap it up manu malbrain md

Time is an issue

Time is tissue


Wrap it up manu malbrain md

LiDCO

NiCO2

CEDVi

Monitor

Ideal Situation ?

PiCCO

Tonometer

Evita 4

HemoSonic


Wrap it up manu malbrain md

Thanks

Shadow

people

Thank You

all

Thanks

Faculty

WSACS

You

Monastery

Germany

Meditation

Michael

WCACS

We’ll

Be

Back!!!


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