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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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Presentation Transcript
slide1

DOES MONITORING REGIONAL CIRCUALTION VARIABLES INFLUENCE OUTCOME ?

Daniel De Backer

Department of Intensive Care

Erasme University Hospital

Brussels, Belgium

slide2

PATHOGENESIS OF ORGAN FAILURE IN SEVERE SEPSIS

WHOLE BODY

REGIONAL

  • gastric tonometry
  • ShO2
  • ICG

ORGAN FAILURE

MICROCIRCULATORY

MITOCHONDRIAL

  • OPS (sublingual)
  • PslCO2
slide4

LeDoux et al

CCM 28:2729;2000

slide5

LeDoux et al

CCM 28:2729;2000

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

slide11

+++

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

slide13

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

slide14

De Backer et al

AJRCCM 166:98;2002

slide15

De Backer et al

CCM 34:403;2006

Change in capillary perfusion

%

DOBU 5 mcg/kg.min

L/min.M²

Change in cardiac index

slide16

De Backer et al

CCM 34:403;2006

Change in capillary perfusion

%

DOBU 5 mcg/kg.min

mmHg

Change in arterial pressure

slide17

IS THERE A LINK BETWEEN REGIONAL AND SYSTEMIC CIRCULATIONS ?

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

slide22

ICG-PDR

Sakka et al

Chest 122:1715:2002

slide23

ICG-PDR

Sakka et al

Chest 122:1715:2002

slide24

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

slide26

PCO2gap as a marker of mortality in ICU ventilated patients

Levy B et al

CCM 31:474;2003

N = 95 patients

slide27

PCO2gap as a marker of mortality in ICU ventilated patients

Levy B et al

CCM 31:474;2003

N = 95 patients

slide28

Variables associated with outcome

on admission and after hemodynamic stabilization

Poeze et al

CCM 33:2494;2005

slide34

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

slide37

ROC curve area:

    • 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

slide38

Sublingual capnometry in patients with

circulatory failure

Marik. Chest. 2001; 120:923

# 22 patients (76 data sets)

Admission

PslCO2-PaCO2 (mm Hg)

*

slide39

Sublingual capnometry in patients with

circulatory failure

Rackow et al. Chest. 2001; 120:1633

# 50 patients

Admission

PslCO2-PaCO2 (mm Hg)

*

slide40

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

slide41

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

slide43

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)

slide44

EFFICACY OF pHi GUIDED THERAPY

Gutierrez G et al

Lancet 339:195;1992

Survival rate

%

Days after admission in ICU

slide45

EFFICACY OF pHi GUIDED THERAPY

Gutierrez G et al

Lancet 339:195;1992

Survival rate

%

Days after admission in ICU

slide50

Problems with these interventional studies:

  • Underpowered studies
  • Investigate the technique as well as the interventions
slide52

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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