Alain Cariou Intensive Care Unit – Cochin University Hospital Paris Descartes University – INSERM U970 (France)
Liens d’intérêt
� Lilly France (consultant)
� Edwards Lifesciences (consultant)
1. Pressions
2. Débit Cardiaque
3. PvCO2, PvO2 & SvO2
A trial of goal-oriented hemodynamic therapy in critically ill patients Gattinoni et al. N Engl J Med 1995 ;333:1025-32
A trial of goal-oriented hemodynamic therapy in critically ill patients Gattinoni et al. N Engl J Med 1995 ;333:1025-32
Shah et al. JAMA 2005
Hemodynamic goals in randomized clinical trials in patients with sepsis: a systematic review of the literature Sevransky JE et al. Critical Care 2007
Hemodynamic goals in randomized clinical trials in patients with sepsis: a systematic review of the literature Sevransky JE et al. Critical Care 2007
Conclusion: the wide range of treatment targets suggest a lack of agreement on blood pressure and filling pressure goals for management of patients with sepsis. There was also
inconsistency between trials in which measures were targeted. Further research is necessary to determine whether this lack of consistency in hemodynamic goals may contribute to
heterogeneity in treatment effects for clinical trials of novel sepsis therapies.
The three 'windows' on shock
Hemodynamic monitoring: arterial pressure signal
SAP
Pulse pressure
DAP
MAP
1913
1733
2012
30-day mortality for categories of fluid resuscitation volume
30-day mortality according to timing of antibacterial administration
Association of arterial blood pressure and vasopressor load with septic shock mortality: a post hoc analysis of a multicenter trial Dunser MW et al. Crit Care 2009
Interpretation of blood pressure signal: physiological bases, clinical relevance, and objectives during shock states Augusto JF et al. Intensive Care Med 2011
Targeted blood pressure ? Summary of relevant prospective studies
Essai SEPSISPAM Pierre ASFAR, Angers
Essai SEPSISPAM Pierre ASFAR, Angers
Publication des résultats complets en attente…
SRLF 2013: pas de différence significative
Monitoring de la macrocirculation ? Nécessaire…. mais probablement pas suffisant !
SvO2 = reflet global de l’oxygénation tissulaire
Considérant comme négligeable la quantité d'oxygène dissout dans le sang, l'équation de Fick peut être exprimée ainsi :
VO2 = (CaO2 - CvO2) . Q
VO2 # (SaO2 - SvO2) . (Hb . 1,36 . Q) Fick…
Une variation de SvO2 provient nécessairement de la variation d’un ou de plusieurs de ces déterminants …
SvO2 = SaO2 - VO2
CO x Hb x 1.36
Central Venous Oximetry Catheter
Monitorage de la ScvO2
Pulmonary Artery Oximetry Catheter
46.5% 49.2%
56.9%
30.5% 33.3%
44.3%
Early goal-directed therapy in the treatment of severe sepsis and septic shock Rivers et al. N Engl J Med 2001
Early goal-directed therapy in the treatment of severe sepsis and septic shock Rivers et al. N Engl J Med 2001
AC – novembre 2009
Crit Care Med 2005
Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock, 2012 Dellinger RP et al. Intensive Care Med 2013
ICU physicians stated volume resuscitation end-points
A survey of Canadian intensivists’ resuscitation practices in early septic shock Mc Intyre et al. Crit Care 2007
The incidence of low venous oxygen saturation on admission to the ICU: a multi-center observational study in The Netherlands Van Beest P et al. Crit Care 2008
The three 'windows' on shock. Max H. Weil
Serum Lactate as a Predictor of Mortality in Emergency Department Patients With Infection
Shapiro et al. AEM 2005
Nguyen et al. CCM 2004
Lactate Clearance vs Central Venous Oxygen Saturation as Goals of Early Sepsis Therapy: A Randomized Clinical Trial Jones AE et al. JAMA 2010
Lactate Clearance vs Central Venous Oxygen Saturation as Goals of Early Sepsis Therapy: A Randomized Clinical Trial Jones AE et al. JAMA 2010
Administered treatments: no difference Outcome: no difference
The triangular basis of circulatory shock
Assessment of the microcirculation
� Global perfusion end-points ¡ Oxygen delivery ¡ Base deficit ¡ Lactate
� Regional perfusion end-points ¡ Gastric tonometry ¡ Sublingual capnography ¡ Near-infrared spectrometry (NIRS) ¡ OPS imaging
� Mitochondrial function
De Backer et al. Intensive Care Med 2010
Techniques used to evaluate the microcirculation at the bedside
Near infrared spectroscopy (NIRS) of the thenar eminence in anesthesia and intensive care Lipcsey et al. Ann Intensive Care 2012
Restoring arterial pressure with norepinephrine improves muscle tissue oxygenation assessed by near-infrared spectroscopy in severely hypotensive septic patients Georger JF et al. Intensive Care Med 2010
What are the consequences of the heterogeneity of microvascular perfusion? De Backer D et al. Intensive care Med 2010
Orthogonal polarization spectral video-microscope image of sublingual mucosa
Healthy individual
Sepsis
De Backer et al. AJRCCM 2002
Proportion (%) of perfused
vessels
Early Increases in Microcirculatory Perfusion During Protocol-Directed Resuscitation are Associated with Reduced Multi-Organ Failure at 24 hours in Patients with Sepsis Trzeciak V et al. Intensive Care Med 2008
Mottling score predicts survival in septic shock Ait-Oufella H et al. Intensive Care Med 2011
Mottling score predicts survival in septic shock Ait-Oufella H et al. Intensive Care Med 2011
Knee area tissue oxygen saturation is predictive of 14-day mortality in septic shock Ait-Oufella H et al. Intensive Care Med 2012
Invasiveness
Informative
ECG NIP
CVP – ScvO2
Arterial pressure
Swan Ganz
Cost
PICCO Vigileo