Category Archives: Circulation

Advanced echo: Right Ventricular function #LIVES2017

Prof Anthony McLean from the Nepeam in Sydney delivered this excellent masterclass using a case from his unit as an example.

Assessing RV function using echocardiography is not easy- the gold standard is MRI https://t.co/CcJ0nBrDTP

There are a number of tools available to us as echocardiographers to monitor RV function:

Wall motion

RV:LV ratio https://t.co/d3eskf2N5n

Spectral Doppler through the right ventricular outflow tract

Fractional area change https://t.co/EerYxVytB0

myocardial performance index (Tei index) https://t.co/IEGrCMdkdk

Tissue Doppler imaging

Tricuspid annular plane systolic excursion (TAPSE)

And indirectly using the tricuspid regurgitation jet and IVC size/collapsibility.

The American society of Echocardiography has excellent guidelines on full assessment of RV function https://t.co/1llzJSBszL which are reviewed and simplified by Cardioserv here https://t.co/Mz49Il1Oq0

ARDS has its own set of challenges and RV function needs to be assessed in conjunction with LV function https://t.co/JUkxw8HNN4

Prof McLean’s advice: measurements are all well and good but can be misleading in practice…

His summary:

RV assessment is complex. Both subjective and objective parameters are necessary to quantify its function. Be careful with patients on inotropes as they confound things.

Prof McLean’s daily “go-tos” are TAPSE, TR/PASP. If still unsure, he adds FAC and TDI (S’).

Upcoming methods in future: speckle tracking/strain https://t.co/hNRuU6NDTg with reference values here https://t.co/GKq9dyeBYx

Prof reckons if you have a machine in your unit that currently measures strain, you should start using it as it will become mainstream in a few years time…

 

 

EDIC 1 refresher course – Cardiogenic Shock #LIVES2017

 

The ESICM Vienna mega-conference that is #LIVES2017 kicked off Saturday morning with a number of workshops and courses – of course many people are here preparing for the EDIC exam today (Monday), and so there are prep courses running for that – Marco Maggiorini from Zurich, Switzerland gave the opening talk today on heart lung interactions followed by Cardiogenic shock from the emphatic Frenchman Jean-Louis Teboul from Kremlin-Bicetre; see this thread:

All of these sessions are a run through of basic physiology and science, its clinical significance and aim at preparing people for the exam.  They finish with MCQs that you can vote with your app for which is a really neat feature:

Stay tuned for more blogs and tweets from the #LIVES2017 SoMe team!

 

 

ESICM LIVES 2017 NEXT Day – ECMO #LIVES2017

ECMO Course

Session 1 – Antonio Pesenti, Refractory Hypoxaemia Therapuetic Strategies

Before deciding on support, first need to know what targets. One might be PaO2? If you climb up a mountain it’s low? Is this important – not according to Grocott in NEJM 2009 where low levels were compensated for by higher Hb.

Rx hypoxia broadly divided as follows

  1. Treat cause – antibiotics, thrombolysis, etc, etc
  2. Increase FiO2
  3. Reduced atelectasis – PEEP
  4. Increase pulmonary blood flow
  5. Reduce venous admixture – ECMO

Reabsorption atelectasis complicates high FiO2 administration.

PEEP prevents collapse = recruitment manoeuvres are needed to open collapsed lung. Indeed main difference between traditional IPPV & HFOV/APRV is high airway pressure – theory being more recruitment AND retention.

Don’t forget effects of heart + shunt upon O2 but iNO doesn’t work.

The benefits of proning extend beyond its effects on PaO2 – failure to improve this variable does not mean you should stop doing it.

Longer term, hypoxemia is a risk factor for long-term neuropsychological impairment but HYPEROXIA IS BAD.

 

Session 2 – Jan Bakker, Haemodynamic effects upon ECMO

Very variable! Limited prospective scores – ENCOURAGE might be useful for VA, or clearing fluid balance on day three but in essence little evidence.

When considering you need to ask:

  • What other support have you got?
  • What configuration are you using?

Peripheral VA-ECMO can significantly increase after load – first consider dilators, then increase forward flow whilst remember to treat acidodsis/anaemia. If that doesn’t work, add an IABP.

With VV-ECMO, RV afterload will fall with PVR effect because of beneficial effects upon CO2/PAO2.

 

Session 3 – Weaning from ECMO Giacomo Grasselli

No science to this – lack of definite criteria, indications from guidelines and local protocol and personal experience

Four scenarios

  1. wean ECMO, then vent
  2. Emergency discontinuation, e.g. bleed
  3. First wean vent, then ECMO
  4. Withdraw

Weaning from VV is weaning gas flow – you don/t need to reduce flow

Weaning GF increases muscle effort and needs vent support 

ELSO guidelines

You need haemodynamic stability as well as respiratory improvement. Measure oxygen delivery – the target is tissue oxygenation NOT PaO2.

How long do you keep the gas off? – Karolinska say 4 hours

Some authors propose leaving cannulae in place for put to 48 hours flushed with heparinised solution – practice VARIABLE

How to decannulate VV?

  • Stop/reduce heparin
  • Put purse string around insertion cannula
  • Clamp lines
  • Stop pump
  • Remove pipe allowing small amount of leakage to red air embolism
  • Manual compression 20 min for venous and 30 min for arterial.
  • Close monitoring distal perfusion for arterial and consider  vascular ultrasound in both as high incidence of clot or injury

 

Keynote – Michael QUINTEL, 50 years of ECMO

ECLS first developed by John Gibbon and Mali in 1936 in response to sudden death young patient with PE and first used in ORD for ASD repair May 1953

First trials negative – but badly done – so perhaps can be better interpreted as even if you do ECMO badly, you don’t kill everyone…

CESAR trial goo.gl/T6tdEL

First oxygenators bubble before developed hollow fibre oxygenator

The development of heparin-coated circuits allowing limiting APTT was one the major steps in reducing morbidity and mortality

Single centres such as Michigan have led the way – now more adult/paed, less neonates

Then H1N1 prompted exploration http://ja.ma/2xp301Q

H1N1 make worldwide excessive use of the technology but there is no new real data.

Reasonable data about risk/benefit ratio does not exist. Cerebral micro emboli are universal. 85% get DVT.

Is informed consent even possible?

 

Pro: Is ECMO always an Option? Steffen Weber-Carstens

UK evidence summarised by @CochraneUK in 2015

Similar International Consensus Position Paper by Coombes and colleagues on what defines an ECMO centre

Triage essentially as duration IPPV significant risk factor of deaths.

Con: Giacomo Bellani 

In one series, 87% of referrals had at least one relative contraindication

25% of patients in CESAR didn’t get it

EOLIA trial has not reported and is ongoing – we are in the infancy of what we know

16% rates of head bleed

20% nosocomial infection

Why use more resources when you can achieve the same thing with less? LungSafe shows we still don’t get optimium PEEP, NMBA, fluid balance and supportive care in ARDS.

 

ESICM Regional Conference Athens 2017: Management of Shock – Others

Right then – last session on other techniques/approaches to managing shock…..

Mechanical assist devices – Alain Combes

Classical indications for mechanical assistance:

IMG_7451

INTERMACS classification of indications for mechanical assist devices

IMG_3893

LVADs should be for stable patients – not for acute cardiogenic shock

IABP

What about IABP? SHOCK-2 trial Lancet 2013 —> no difference between control/balloon

Indication downgraded from I —> III: no indication for routine use in cardiogenic shock

Should it now be in the “Museum of Medicine” — along with the iron lung and swan ganz? 😉

IMG_7424

ESC/ – evidence now low

Tandem heart pVAFD

Not available in Europe – only US

IMG_0383

Difficult transeptal cannulation – fair number of issues with this device to be fair

Impella miniature intraaortic pump

Available in Europe

Up to 4L/min (Impella 5.0)

Issues

  1. Cost – 10-15K euros for few days use
  2. Concerns about haemolysis

Recent study – IABP v Impella —-> No difference in mortality

HeartMate PHP

IMG_6166

No data as of today for this pump

Major issues – only drain LV. Not of use in RV. New Impella for RV but cost ~20K euros

VA-ECMO

IMG_0381

Worth remembering that it’s low cost compared to Impella (but still 8-9K Euros per patient….)

Accepted indications:

A: ST-elevation with profound cardiogenic shock?

Paper —-> ST-elevation with profound cardiogenic shock

Close to 50% survival and 68% weaning in survivors

B: End stage DCM?

https://www.ncbi.nlm.nih.gov/pubmed/28471885

C: Fulminant myocarditis?

https://www.ncbi.nlm.nih.gov/pubmed/21336134

Most surviving without need for complex heart surgery/transplant

D: After cardiac surgery?

Old data but benefit —-> https://www.ncbi.nlm.nih.gov/pubmed/20106393

E: Post cardiac transplant?

https://www.ncbi.nlm.nih.gov/pubmed/21414795

What are the trends/emerging indications?

1. Septic shock with severe LV failure

Small study (n=14) but very unwell – SOFA score 18 with LVEF 16 and mean lactate 10

2. Pulmonary embolism

IMG_9353

3. Post-cardiac arrest

Post-resuscitation syndrome

Conflicting data on E-CPR —> benefit or no benefit

4. Combination – ECMO + Impella

Take home messages:

IMG_0687

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Cristalloids or colloids? Balanced or not? – Luciano Gattinoni

Why do we give fluids?

IMG_0212

Review from 2013 in NEJM on resuscitation fluids —> here

So which fluid and what is the price to pay in terms of “health”?

IMG_4212

Low pressure

IMG_9816

Mechanics of fluid – no difference. Volume that creates a pressure

Issue is what price we pay by giving different fluids

CHEST trial – small differences in Cr. No standard deviations. Be careful interpreting data

IMG_6218

CONCLUSIONS:

IMG_6925

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Individualising haemodynamic targets – Bernd Saugel

Precision medicine popular term – as is personalised medicine

e.g

http://www.nejm.org/doi/full/10.1056/NEJMp1500523#t=article

https://link.springer.com/article/10.1007/s00134-016-4471-8

https://www.ncbi.nlm.nih.gov/pubmed/26928384

 

Personalised medicine approach can be applied to haemodynamic management of ICU patients

https://www.ncbi.nlm.nih.gov/pubmed/28562384

 

Does personalising BP in the operating room improve outcomes?

https://www.ncbi.nlm.nih.gov/labs/articles/27792044/

Seems not to be important at first glance —-> MAP > 65 as food as one based on percentage reduction from baseline

But BP does not mean perfusion —-> autoregulation

https://annalsofintensivecare.springeropen.com/articles/10.1186/s13613-015-0085-5

IMG_4642

SSC recommends target of 65 BUT state ” when a better understanding of any pts condition obtained, BP target should be individualised”

Asfar et al NEJM 2014 – here

No difference in high v low target BP

BUT —-> Patients with chronic HT in the  low target group = increased RRT

 

What about SV/CO etc?

Pearse et al. Cardiac output guided management —> here

Maximisation of SV may not equate to optimisation

 

DO2 targeted?

Achievement of preoperative DO2 value associated with reduction in morbidity —> here

How to combine PERSONALISED treatment approached with PROTOCOLISED care?

 

What is the future?

Smaller sensors to record biosignals without heavy monitors/machines/cables

“Wearables”

 

Take home messages:

IMG_3457