DOES MONITORING REGIONAL CIRCUALTION VARIABLES INFLUENCE OUTCOME ?
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DOES MONITORING REGIONAL CIRCUALTION VARIABLES INFLUENCE OUTCOME ?. Daniel De Backer Department of Intensive Care Erasme University Hospital Brussels, Belgium. PATHOGENESIS OF ORGAN FAILURE IN SEVERE SEPSIS. WHOLE BODY. REGIONAL. gastric tonometry ShO2 ICG. ORGAN FAILURE.

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Daniel de backer department of intensive care erasme university hospital brussels belgium

DOES MONITORING REGIONAL CIRCUALTION VARIABLES INFLUENCE OUTCOME ?

Daniel De Backer

Department of Intensive Care

Erasme University Hospital

Brussels, Belgium


Daniel de backer department of intensive care erasme university hospital brussels belgium

PATHOGENESIS OF ORGAN FAILURE IN SEVERE SEPSIS

WHOLE BODY

REGIONAL

  • gastric tonometry

  • ShO2

  • ICG

ORGAN FAILURE

MICROCIRCULATORY

MITOCHONDRIAL

  • OPS (sublingual)

  • PslCO2


Daniel de backer department of intensive care erasme university hospital brussels belgium

IS THERE A LINK BETWEEN REGIONAL AND SYSTEMIC CIRCULATIONS ?


Daniel de backer department of intensive care erasme university hospital brussels belgium

LeDoux et al

CCM 28:2729;2000


Daniel de backer department of intensive care erasme university hospital brussels belgium

LeDoux et al

CCM 28:2729;2000

=> Manipulation of global hemodynamics may fail to alter regional circulations


Daniel de backer department of intensive care erasme university hospital brussels belgium

+++

Severe sepsis

(50)

Percentage of vessels perfused

(small vessels)

%

100

De Backer et al AJRCCM 166:98-104;2002

80

60

40

20

0

Volunteers

(10)

+++ p <0.001 vs volunteers

DDB USI


Daniel de backer department of intensive care erasme university hospital brussels belgium

Influence of systemic factors on the microcirculation ?


Daniel de backer department of intensive care erasme university hospital brussels belgium

Nakajima et al

AJRCCM 164:1526:2001

Mice

intravital µscopy

Low ETX: 1.5 mg/kg, MAP 70 mmHg

High ETX: 10 mg/kg, MAP 40 mmHg

HEM: MAP 40 mmHg


Daniel de backer department of intensive care erasme university hospital brussels belgium

De Backer et al

AJRCCM 166:98;2002


Daniel de backer department of intensive care erasme university hospital brussels belgium

De Backer et al

CCM 34:403;2006

Change in capillary perfusion

%

DOBU 5 mcg/kg.min

L/min.M²

Change in cardiac index


Daniel de backer department of intensive care erasme university hospital brussels belgium

De Backer et al

CCM 34:403;2006

Change in capillary perfusion

%

DOBU 5 mcg/kg.min

mmHg

Change in arterial pressure


Daniel de backer department of intensive care erasme university hospital brussels belgium

IS THERE A LINK BETWEEN REGIONAL AND SYSTEMIC CIRCULATIONS ?

No: regional and microcirculatory alterations may occur, even after correction of global hemodynamic alterations.


Daniel de backer department of intensive care erasme university hospital brussels belgium

DOES MONITORING OF REGIONAL CIRCULATIONS OR MICROCIRCULATION PREDICT OUTCOME ?


Daniel de backer department of intensive care erasme university hospital brussels belgium

ICG-PDR

Sakka et al

Chest 122:1715:2002


Daniel de backer department of intensive care erasme university hospital brussels belgium

ICG-PDR

Sakka et al

Chest 122:1715:2002


Daniel de backer department of intensive care erasme university hospital brussels belgium

  • Gastric tonometry in septic patients

    • Increased mucosal PCO2 (or decreased pHi)

      • Maynard et al JAMA 270: 1203; 1993

      • Friedman et al CCM 23: 1185; 1995

      • Oud et al Chest 115: 1390; 1999

      • Levy et al CCM 31: 474; 2003

Association with outcome


Daniel de backer department of intensive care erasme university hospital brussels belgium

PCO2gap as a marker of mortality in ICU ventilated patients

Levy B et al

CCM 31:474;2003

N = 95 patients


Daniel de backer department of intensive care erasme university hospital brussels belgium

PCO2gap as a marker of mortality in ICU ventilated patients

Levy B et al

CCM 31:474;2003

N = 95 patients


Daniel de backer department of intensive care erasme university hospital brussels belgium

Variables associated with outcome

on admission and after hemodynamic stabilization

Poeze et al

CCM 33:2494;2005


Daniel de backer department of intensive care erasme university hospital brussels belgium

MICROVASCULAR PERFUSION IN SEVERE HEART FAILURE

Heart failure and cardiogenic shock

De Backer et al

AHJ 147:91;2004

Capillary perfusion

%

100

p < 0.05

80

60

40

20

0

Survivors

Non Survivors


Daniel de backer department of intensive care erasme university hospital brussels belgium

  • ROC curve area:

    • Baseline:

      • APACHE II0.74

      • Lactate0.68

    • Changes between day 1 and day 2:

      • heart rate0.57

      • mean arterial pressure0.53

      • CVP0.51

      • PAOP0.64

      • cardiac index0.51

      • SvO20.52

      • DO20.52

      • VO20.50

      • Lactate0.63

      • Microvascular perfusion0.77

      • SOFA score0.61

Sakr et al

CCM 32:1825;2004


Daniel de backer department of intensive care erasme university hospital brussels belgium

Sublingual capnometry in patients with

circulatory failure

Marik. Chest. 2001; 120:923

# 22 patients (76 data sets)

Admission

PslCO2-PaCO2 (mm Hg)

*


Daniel de backer department of intensive care erasme university hospital brussels belgium

Sublingual capnometry in patients with

circulatory failure

Rackow et al. Chest. 2001; 120:1633

# 50 patients

Admission

PslCO2-PaCO2 (mm Hg)

*


Daniel de backer department of intensive care erasme university hospital brussels belgium

Sublingual capnometry versus traditional markers

of tissue oxygenation in critically ill patients

Marik et al. Crit Care Med. 2003; 31: 818-822

N = 54 ICU unstable ICU patient (septic shock 39%)

Prediction of mortality

Best cut-off value for PslCO2-gap : 25 mm Hg


Daniel de backer department of intensive care erasme university hospital brussels belgium

DOES MONITORING OF REGIONAL CIRCULATIONS OR MICROCIRCULATION PREDICT OUTCOME ?

Yes: monitoring regional and microcirculatory alterations may help to identify patients at greater risk of death


Daniel de backer department of intensive care erasme university hospital brussels belgium

RESUSCITATION CENTERED ON REGIONAL CIRCULATIONS ?


Daniel de backer department of intensive care erasme university hospital brussels belgium

EFFICACY OF pHi GUIDED THERAPY

Gutierrez G et al

Lancet 339:195;1992

260 critically ill patients

Therapy guided on pHi (dobutamine-fluids), goal = 7.35

Data analyzed according to 2 subgroups (pHi < or >7.35)


Daniel de backer department of intensive care erasme university hospital brussels belgium

EFFICACY OF pHi GUIDED THERAPY

Gutierrez G et al

Lancet 339:195;1992

Survival rate

%

Days after admission in ICU


Daniel de backer department of intensive care erasme university hospital brussels belgium

EFFICACY OF pHi GUIDED THERAPY

Gutierrez G et al

Lancet 339:195;1992

Survival rate

%

Days after admission in ICU


Daniel de backer department of intensive care erasme university hospital brussels belgium

Mythen M et al.


Daniel de backer department of intensive care erasme university hospital brussels belgium

  • Problems with these interventional studies:

  • Underpowered studies

  • Investigate the technique as well as the interventions


Daniel de backer department of intensive care erasme university hospital brussels belgium

CONCLUSIONS

Monitoring the splanchnic circulation and the microcirculation can be useful to identify patients with under-resuscitated areas, despite correction of global hemodynamic variables.

Regional and microcirculatory alterations are associated with a poor outcome.

Whether resuscitation guided on regional monitoring can affect outcome remains to be determined.


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