EuroAsia 2017 Day 1: Haemodynamics

What is circulatory failure? (D De Backer)

Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine

Circulatory Shock

The significance of non-sustained hypotension in emergency department patients with sepsis.

Use of venous-to-arterial carbon dioxide tension difference to guide resuscitation therapy in septic shock

 

Volume status (M Cecconi)

Volume in the system divided into stressed volume (mean circulatory filling pressure, Pms) or unstressed volume.

Pms provides the gradient for filling to the right heart

Dynamic rather than static measures to determine fluid status and responsiveness

The goal is perfusion improvement

Give minimum dose possible for the maximum benefit

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References:

Fluid challenges in intensive care: the FENICE study

Effects of fluid administration on arterial load in septic shock patients.

Passive leg raising predicts fluid responsiveness in the critically ill.

Prognostic value of extravascular lung water in critically ill patients.

Can one size fit all? The fine line between fluid overload and hypovolemia.

 

Tissue perfusion: from clinical examination to bedside test (JLV)

Need to combine haemodynamic variables to come to a conclusion

If vasopressors are required, place an arterial line as soon as possible

3 windows to circulation – skin, altered mental status,  decreased urine output

4 phases of fluid therapy – salvage, optimisation, stabilisation, de-escalation (SOSD)

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References:

The value of blood lactate kinetics in critically ill patients: a systematic review.

Four phases of intravenous fluid therapy: a conceptual model

The Future of Critical Care Medicine: Integration and Personalization.

Measure, interpret, apply — the MIA rule in critical care monitoring

 

Cardiac function: putting the picture together (JL Teboul)

3 components of CVS failure – hypovolaemia, depressed vascular tone, myocardial dysfunction

Stepwise approach

  • Detect presence of shock
  • Measure lactate
  • Optimise microcirculation – adequate MAP (but also Diastolic pressure as it is reflective of tone), DO2 adequate to VO2 (ScvO2)
  • Dynamic variables over static variables – heart-lung interaction techniques e.g. pulse pressure variation or passive leg raise
  • PCO2 gap marker of ‘adequacy’ of systemic venous blood flow to clear CO2 produced at peripheral level

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References:

Early lactate-guided therapy in intensive care unit patients: a multicenter, open-label, randomized controlled trial.

Use of ‘tidal volume challenge’ to improve the reliability of pulse pressure variation

Less invasive hemodynamic monitoring in critically ill patients.

How Do I Integrate Hemodynamic Variables When Managing Septic Shock?

Critical role for echocardiography (D De Backer)

What differs usual echocardiography by intensivists and that of cardiologists?

  • Focused hemodynamic evaluation
  • Repeated exams to evaluate effect of therapies
  • Available by bedside 24/7 without delay

Evaluation of pt with shock

  • Tamponade
  • Hypovolaemic
  • Obstructive shock (RV)
  • Cardiogenic shock (LV)
  • Distributive shock (none of the above)

 

References:

Focused transthoracic echocardiography during critical care medicine training: curriculum implementation and evaluation of proficiency*.