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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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 OUTCOME ?

WHOLE BODY

REGIONAL

  • gastric tonometry

  • ShO2

  • ICG

ORGAN FAILURE

MICROCIRCULATORY

MITOCHONDRIAL

  • OPS (sublingual)

  • PslCO2



LeDoux et al OUTCOME ?

CCM 28:2729;2000


LeDoux et al OUTCOME ?

CCM 28:2729;2000

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


+++ OUTCOME ?

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



Nakajima et al OUTCOME ?

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


De Backer et al OUTCOME ?

AJRCCM 166:98;2002


De Backer et al OUTCOME ?

CCM 34:403;2006

Change in capillary perfusion

%

DOBU 5 mcg/kg.min

L/min.M²

Change in cardiac index


De Backer et al OUTCOME ?

CCM 34:403;2006

Change in capillary perfusion

%

DOBU 5 mcg/kg.min

mmHg

Change in arterial pressure


IS THERE A LINK BETWEEN REGIONAL AND SYSTEMIC CIRCULATIONS ? OUTCOME ?

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



ICG-PDR PREDICT OUTCOME ?

Sakka et al

Chest 122:1715:2002


ICG-PDR PREDICT OUTCOME ?

Sakka et al

Chest 122:1715:2002


  • Gastric tonometry in septic patients PREDICT OUTCOME ?

    • 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


PCO PREDICT OUTCOME ?2gap as a marker of mortality in ICU ventilated patients

Levy B et al

CCM 31:474;2003

N = 95 patients


PCO PREDICT OUTCOME ?2gap as a marker of mortality in ICU ventilated patients

Levy B et al

CCM 31:474;2003

N = 95 patients


Variables associated with outcome PREDICT OUTCOME ?

on admission and after hemodynamic stabilization

Poeze et al

CCM 33:2494;2005


MICROVASCULAR PERFUSION IN SEVERE HEART FAILURE PREDICT OUTCOME ?

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


  • ROC curve area: PREDICT OUTCOME ?

    • Baseline:

      • APACHE II 0.74

      • Lactate 0.68

    • Changes between day 1 and day 2:

      • heart rate 0.57

      • mean arterial pressure 0.53

      • CVP 0.51

      • PAOP 0.64

      • cardiac index 0.51

      • SvO2 0.52

      • DO2 0.52

      • VO2 0.50

      • Lactate 0.63

      • Microvascular perfusion 0.77

      • SOFA score 0.61

Sakr et al

CCM 32:1825;2004


Sublingual capnometry in patients with PREDICT OUTCOME ?

circulatory failure

Marik. Chest. 2001; 120:923

# 22 patients (76 data sets)

Admission

PslCO2-PaCO2 (mm Hg)

*


Sublingual capnometry in patients with PREDICT OUTCOME ?

circulatory failure

Rackow et al. Chest. 2001; 120:1633

# 50 patients

Admission

PslCO2-PaCO2 (mm Hg)

*


Sublingual capnometry versus traditional markers PREDICT OUTCOME ?

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


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



EFFICACY OF pHi GUIDED THERAPY PREDICT OUTCOME ?

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)


EFFICACY OF pHi GUIDED THERAPY PREDICT OUTCOME ?

Gutierrez G et al

Lancet 339:195;1992

Survival rate

%

Days after admission in ICU


EFFICACY OF pHi GUIDED THERAPY PREDICT OUTCOME ?

Gutierrez G et al

Lancet 339:195;1992

Survival rate

%

Days after admission in ICU


Mythen M et al. PREDICT OUTCOME ?



CONCLUSIONS PREDICT OUTCOME ?

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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