Does monitoring cardiac output

influence outcome?

David Bennett St George’s HospitalLondon

Disclosures

•I act as a consultant for Deltex and Lidco

•Can cardiac output (CO) be accurately assessed clinically?•Why are there so many different technologies for measuring CO?

•Does monitoring CO, particularly with PAC increase morbidity and/or mortality?

•Does monitoring CO or surrogate have prognostic value?•Does targeting CO improve outcome?

•or •Because we believe the data to be clinically relevant?

Questions to be posed

How Accurate Is Clinical Assessment of Cardiac Output in the Early Postoperative Period Following Cardiac Surgery?

Robert A. Linton, MD, FRCA; Nick W. Linton, MEng; Fiona Kelly, MBBChirThe Rayne Institute, St Thomas' Hospital, London, United Kingdom

•Can cardiac output (CO) be accurately assessed clinically?

PhysiciansÕ Estimates of Cardiac Indexand Intravascular Volume.Ireguri MG Am J Crit Care 2003;12:336.

0

5

10

15

20

25

30

35

40

45

%

Overestimate

Correct Underestimate

0

10

20

30

40

50

60

%

Overestimate

Correct Underestimate

Cardiac Index Volume Status

Why are there so many different technologies for measuring CO?

Fick: Direct, Indirect

Dilution tehniques:

ICG,

Hot and cold, intermittent and semi-continuousScvO2 and SvO2

ECHO

Oesophageal, Supra-sternal Doppler

Impedance cardiography

Pulse contour analysis

C02 rebreathing

Conners AF,Jr, Speroff T, Dawson NV, Thomas C, et al: The effectiveness of right heart catheterizaion in the initial care of critically ill patients. JAMA 1996; 276: 899-97

Does monitoring CO, particularly with PAC increase morbidity and/or mortality?

The incidence of major morbidity in critically ill patients managed with pulmonary artery catheters:

A meta-analysisIvanov, Rada MD; Allen, Jill MSc; Calvin, James E. MD, FACC, FRCPC

28(3), March 2000, pp 615-619CCM

Impact of the Pulmonary Artery Catheter in Critically Ill PatientsMeta-analysis of Randomized Clinical TrialsMonica R. Shah, MD, MHS, MSJ; Vic Hasselblad, PhD; Lynne W. Stevenson, MD; Cynthia Binanay, RN, BSN; Christopher M. O’Connor, MD; George Sopko, MD, MPH; Robert M. Califf, MD JAMA. 2005;294:1664-1670.

Impact of the Pulmonary Artery Catheter in Critically Ill PatientsMeta-analysis of Randomized Clinical TrialsMonica R. Shah, MD, MHS, MSJ; Vic Hasselblad, PhD; Lynne W. Stevenson, MD; Cynthia Binanay, RN, BSN; Christopher M. O’Connor, MD; George Sopko, MD, MPH; Robert M. Califf, MD JAMA. 2005;294:1664-1670.

508 240 205 194 188 186 183

506 232 191 179 174 168 166

No PAC

PAC

No PAC

PAC

0.00

0.25

0.50

0.75

1.00

P(s

urv

iva

l)

0 15 30 45 60 75 90Time from randomisation (days)

Assessment of the clinical effectiveness of pulmonary artery catheters in management of patients in intensive care (PAC-Man): a randomised controlled trial.Harvey S, Harrison DA, Singer M, Ashcroft J, Jones CM, Elbourne D, Brampton W, Williams D, Young D, Rowan K; PAC-Man study collaboration.: Lancet. 2005 Aug 6-12;366(9484):472-7.

Does monitoring CO or a surrogate have prognostic value?

Effect of Oxygen Delivery on Mortalityand Morbidity in High Risk Surgery.

Shoemaker Chest. 1988: 94; 1176

0

10

20

30

40

50

60

70

%

<300 301-400 401-500 >501

% Mortality

0

10

20

30

40

50

60

% o

f P

atie

nts

<400 400-500 500-600 >600

DO2 l/min/m2

% Patients with Morbidity

Does monitoring CO or a surrogate have prognostic value?

Does monitoring CO or surrogate have prognostic value?

0

50

100

150

200

250

0 200 400 600 800 1000 1200 1400

Non Responders0

50

100

150

200

250

300

350

0 200 400 600 800 1000 1200 1400

Oxygen delivery L/min/m2

Oxygen c

onsu

mpti

on L

/min

/m2

Responders

Before dobutamine

After dobutamine

Rhodes A. CCM 1999; 11; 2361

cc

Outcome of Patients

Responders Non Responders

PredictedMortality %

39 58

Actualmortality %

14 90.9

Rhodes A. CCM 1999; 11; 2361

Impact of LOW Post-Operative Central Venous Oxygen Saturation on Morbidity & Mortality in Surgical

PatientsV PRIYA*, J V DIVATIA, RASHMI S, R SAREEN

ScvO

2 at 2

hou

rs :

95%

CI

Low (n = 51)Normal (n = 32)90

80

70

60

76.8 + 5.7

63.9 + 8.9

p = 0.00*

ScvO2 at 2 hrs

80

78

76

74

72

70

68

66

ScvO

2 at 1

2 ho

urs

: 95%

CI

76.2 + 4.1

68.7 + 6.1

Low (n = 51)Normal (n = 32)

ScvO2 at 12 hrsp = 0.00*

0.03*13 (26%)2 (9%)Anastomotic leak (no. of pts)

0.163 (6%)0 (0%)Hospital mortality (no. of pts)

0.002*17.8 + 10.513.5 + 5.0Hospital stay (days, Mean+SD)

0.163 (6%)0 (0%)ICU mortality (no. of patients)

0.009*5.6 + 6.71.7 + 2.5ICU stay (days, Mean+SD)

0.009*3.5 + 6.10.59 + 1.5Days on ventilator (Mean+SD)

p ValueLow (n=51)Normal (n=32)

OUTCOME

DO2 does not always correlate with CO

20 30 40 50 60 70 80 90 1000

100

200

300

400

500

600

700

800

900

1000

1100

1200

Central Venous Saturation

Oxygen Delivery Index

Relationship Between Central Venous OxygenSaturation and Oxygen Delivery.

DO2 I ml/min/m2

•Does targeting CO improve outcome?

Meta-analysis of hemodynamic optimization: relationship to methodological qualityMartijn Poeze, Jan Willem M Greve and Graham RamsayCritical Care 2005, 9:10.1186/cc3902)This article is online at: http://ccforum.com/content/9/6/R771 R771-R779 (DOI

Control

Treatment

% Mortality

10.4 4.7

Peri-operative

Wilson et al:- BMJ :1999 318 1099

Days

*

% Surviving

Meta-analysis of hemodynamic optimization: relationship to methodological qualityMartijn Poeze, Jan Willem M Greve and Graham RamsayCritical Care 2005, 9:10.1186/cc3902)This article is online at: http://ccforum.com/content/9/6/R771 R771-R779 (DOI

Control

Treatment

% Mortality

54 53

Sepsis

Hayes, M A. Timmins, A C. Yau, E H. Palazzo, M. Hinds, C J. Watson, D.Title Elevation of systemic oxygen delivery in the treatment of critically ill patientsSource New England Journal of Medicine. 330(24):1717-22, 1994 Jun 16.

% Mortality

ScvO2%ScvO2%

HoursHours

* * * * *

Early goal-directed therapy in the treatment of sepsis and septic shock: An outcome evaluation of early intervention

Rivers et al N Eng J Med 2001 345 19

Early goal-directed therapy in the treatment of sepsis and septic shock: An outcome evaluation of early intervention

Rivers et al N Eng J Med 2001 345 19

MortalityControl n (%)

Treatmentn (%)

p

In-hospital:All patients

59 (46.5)

38 (30.5) 0.009

Severe sepsis 19 (30) 9 (14.9) 0.06

Septic shock40

(56.8)29 (42.3) 0.04

Septic syndrome

44 (45.4)

35 (35.1) 0.01

Early goal-directed therapy in the treatment of sepsis and septic shock: An outcome evaluation of early intervention

Rivers et al N Eng J Med 2001 345 19

Early goal-directed therapy in the treatment of sepsis and septic shock: An outcome evaluation of early intervention

Rivers et al N Eng J Med 2001 345 19

* * * * * * *DO

2I

ml/min/

m2

Hours

Early goal -directed therapy after major surgery reduces complications and duration of hospital stay

Pearse et al Critical Care 2005 9 R687 -693

Number of infections

EGDT

Control

p

Number of complications / patient

0 (0-4)

mean 0.7

1 (0-5)

mean 1.5

0.002

*

***

*

*

Control

n=60

EGDTn=62

Difference

% Reducti

on

Median14(6-188)

11(0.4-110)

3 21

Mean 29.5 17.5 12.0 41

Total 1770 1085 685 39

Chittock DR. Dhingra VK. Ronco JJ. Russell JA. Forrest DM. Tweeddale M. Fenwick JC. Severity of illness and risk of death associated with pulmonary artery catheter use.[see comment]. Critical Care Medicine. 32(4):911-5, 2004 Apr.

Does goal directed therapy using the oesophageal Doppler reduce surgical mortality and morbidity?Hamilton M. A.1, Grocott M. P. W.1, Mythen M1, Bennett D2

Mean reduction in LOS of 4 days (25%)

Conclusions

•Cardiac output is a frequently measured variable

•There are several technologies allowing it’s measurement

•Despite earlier claims it is unlikely that measuring CO particularly with the PAC is harmful

•Low CO and it’s failure to respond to treatment has prognostic significance

•There is now reasonable evidence suggesting that targeting CO very early in the course of critical illness is of real benefit

•This is particularly so in patients undergoing major surgery where increasing DO2 to a target value has profound beneficial effects

•

META-ANAYSIS OF HEMDYNAMIC OPTIMIZATION IN HIGH RISK PATIENTSJack W. Kern1,2,3, Pharm D, William C Shoemaker2,3, MDCCM 2001

In all patients maintain SaO2 ≥94%, Hb≥ 8g.dl-1 , Temp.at 37oC. HR≤100 or <20% above baseline. MAP 60-100 mmHg

In all patients maintain SaO2 ≥94%, Hb≥ 8g.dl-1 , Temp.at 37oC. HR≤100 or <20% above baseline. MAP 60-100 mmHg

Patient identification. Written informed consent. Lines inserted. Surgery. RandomisationPatient identification. Written informed consent. Lines inserted. Surgery. Randomisation

Admit to ICU. Monitor cardiac output in all patients using Lidco. Data concealed from clinical staff

Admit to ICU. Monitor cardiac output in all patients using Lidco. Data concealed from clinical staff

CONTROL GROUPCONTROL GROUP

Fluid challenge with 250 ml bolus IV colloid until sustained 2mm Hg rise in CVP is

achieved for ≥20 min. Repeat if CVP falls

Fluid challenge with 250 ml bolus IV colloid until sustained 2mm Hg rise in CVP is

achieved for ≥20 min. Repeat if CVP falls

If CI <2.5l min-1m2 commence epinephrine, if > 2.5l min-1m2 continue current treatment

If CI <2.5l min-1m2 commence epinephrine, if > 2.5l min-1m2 continue current treatment

If urine output <0.5ml kg -1 hr-1 for 2 hours or consecutive hourly lactate rises to >2 mmol l -1 then CI revealed

to clinical staff

If urine output <0.5ml kg -1 hr-1 for 2 hours or consecutive hourly lactate rises to >2 mmol l -1 then CI revealed

to clinical staff

EGDT GROUPEGDT GROUP

Fluid challenge with 250 ml bolus IV colloid until sustained 10% rise in SV for ≥20 min.

Repeat if SV falls

Fluid challenge with 250 ml bolus IV colloid until sustained 10% rise in SV for ≥20 min.

Repeat if SV falls

If DO2 <600ml min -1 m2 start dopexamine at 0.25µg kg -1 min -1 and increase to maximum of

0.25µg kg -1 min -1 until DO2 reaches target value. Dose reduced if tachycardia or myocardial

ischemia develops

If DO2 <600ml min -1 m2 start dopexamine at 0.25µg kg -1 min -1 and increase to maximum of

0.25µg kg -1 min -1 until DO2 reaches target value. Dose reduced if tachycardia or myocardial

ischemia develops

After 8 hours study period ends all decisions taken by clinical staff. Patient followed for hospital morbidity and 60 day mortality

After 8 hours study period ends all decisions taken by clinical staff. Patient followed for hospital morbidity and 60 day mortality

Crit Care Med. 2005 May;33(5):1119-22.

Pinsky MR, Vincent JL.

META-ANAYSIS OF HEMDYNAMIC OPTIMIZATION IN HIGH RISK PATIENTSJack W. Kern1,2,3, Pharm D, William C Shoemaker2,3, MDCCM 2001

•Audit of >53,000 trauma patients in USA

•Older patients with severe injury and shock had a survival benefit when managed with PAC

•Odds ratio, 0.33; 95% confidence interval, (ratio 0.17-0.62)

•

1: Crit Care Med. 2006 Apr 4; [Epub ahead of print]Related Articles, Links

Pulmonary artery catheter use is associated with reduced mortality in severely injured patients: A National Trauma Data Bank analysis of 53,312 patients*

Friese RS, Shafi S, Gentilello LM.