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abstract book isicem 2012 in brussels belgium international symposium on intensive care and emergency medicine

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pulsion abstract book isicem brussels 2012 table of contents perioperative hemodynamic optimization when why and how panel members wolfgang huber germany eran segal israel a closer look at goal directed algorithms the good the bad and the ugly berthold bein germany an algorithmic approach to the very high risk surgical patient daniel reuter germany hemodynamic monitoring ­ accuracy vs continuity azriel perel israel basic vs advanced approach to hemodynamic monitoring panel members javier belda spain julia wendon united kingdom cvp blood pressure and urine output are they ever enough eran segal israel how to monitor fluid therapy ­ a clinical case xavier monnet france hemodynamic monitoring during septic shock and or ards panel members greg martin usa zsolt molnar hungary what are the relevant hemodynamic targets during septic shock and or during ards jean louis teboul france why should i bother about the ebb and flow phases of shock manu malbrain belgium

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the international symposium on intensive care and emergency medicine isicem organized annually by the departments of intensive care and emergency medicine of erasme university hospital université libre de bruxelle took place in brussels from march 20 ­ 23 2012 during the isicem pulsion medical systems se organized as platinum sponsor three satellite meetings regarding the different aspects of hemodynamic monitoring in this abstract book you will find the abstracts from all the presentations held during these meetings our special thanks go to our panel members and speakers for their outstanding presentations and contribution making all three satellite meetings a success the excellent feedback from more than 600 participants provides a clear and very positive message for the success of these meetings furthermore many thanks to harriet adamson senior clinical resource manager pulsion medical systems for her efforts in creating this abstract book patricio lacalle ceo dr volker humbert head of medical

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pulsion abstract book isicem brussels page 5 the abstract book is also available at www.pulsion.com for online view furthermore register now for our free literature service we will send you current publications on haemodynamic monitoring on a monthly basis with each selected publication you will find a short summary and the link to pubmed.

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professor berthold bein vice chair department of anaesthesiology and intensive care medicine university hospital schleswig-holstein campus kiel germany prof bein has been working as an anaesthesiologist since 1989 after completing his resident training in munich and hamburg he started working as a board certified anaesthesiologist and intensivist at the department of anaesthesiology and intensive care medicine university hospital schleswig-holstein campus kiel in 2000 currently he is the vice chair and head of the research department amongst several areas of interest his research has predominantly been dedicated to hemodynamic monitoring and hemodynamic optimization a closer look at goal directed algorithms the good the bad and the ugly background the purpose of goal directed therapy is to ensure that adequate oxygen and energy rich substrates reach the tissues despite showing such positive outcomes for the patient including reductions in hospital length of stay complications and mortality to date goal directed therapy algorithms have had only a limited impact on daily clinical practice the reasons for this are discussed in this abstract the evidence is strong enough to suggest that the inclusion of map cvp or poap into treatment algorithms as target goals should be avoided altogether despite their widespread and ongoing use there have also been algorithms that used supranormal oxygen delivery values do2 4,5 or even mixed or central venous oxygen saturation 6 as their treatment goals however in high risk patients it is of paramount important that supranormal values should be targeted before organ failure 7 which may not be feasible in everyday clinical practice the bad these days the most commonly used target for directed therapy is to define a specific cardiac output co with the main options for increasing co being volume loading and /or the use of catecholamines however since the establishment of goal directed therapy there have been various other parameters proposed for directing patient care the literature contains several examples of algorithms that have used inappropriate goals for targeting therapies in particular the use of cardiac filling pressures such as central venous pressure cvp and pulmonary artery occlusion pressure paop and the use of mean arterial pressure map these parameters have been repeatedly shown in multiple publications to poorly predict what the it has been shown hemodynamic response there is no correlation of the patient will be to a volume challenge which co and map calls into question their suitability for inclusion in to treatment algorithms in particular it has been shown that there is no correlation between co and map 1 changes in cvp have been shown to not correlate with changes in stroke volume following fluid loading 2 and the pulmonary artery occlusion pressure has been shown to be ineffective for predicting who is hypervolemic and who is hypovolemic and therefore likely to respond to volume 3 despite this because map and cvp remain standard monitoring parameters they often appear in one or other of the treatment arms that compare one treatment algorithm against another the ugly another issue with the development of a goal directed algorithm should be its ease of use and clinical relevance monitoring equipment that is difficult to set up expensive to use or carries inherent side effects should be avoided when comparing two different treatment arms both should be equal in terms of time it takes to set up any monitoring equipment and costs and risks associated with the different monitoring systems to ensure clinical equipoise8 for example the pulmonary artery catheter the most invasive form of hemodynamic monitoring currently available clinically has been that shown to be the most time consuming to set up between it also carries the most risks and side effects for the patients so for these reasons its use simply as a cardiac output monitor in a goal directed algorithm should be avoided other algorithms have been published that use less invasive monitoring to obtain their treatment goals 9 however some of these algorithms have been complex and difficult to follow not reflecting normal clinical routine or at least inhibiting their acceptance into routine management indeed there is no evidence that the more complicated the algorithm the better the outcome for the patient however it is strongly suspected that the more complex the algorithm the less likely it is to be accepted by non-research staff and into general clinical practice even if has

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pulsion abstract book isicem brussels 2012 page 7 been shown to be of benefit to the patient references fortunately there have been some algorithms published which 1 linton ra linton nw kelly f is clinical assessment of the circulation reliable in postoperative cardiac surgical patients are simple and easy to follow use well validated parameters for j cardiothorac vasc anesth 2002 161 4-7 their treatment goals and largely reflect clinical routine for ex2 michard f alaya s zarka v bahloul m richard c teboul jl ample using the stroke volume a component of the cardiac outglobal end-diastolic volume as an indicator of cardiac preload in patients with septic shock chest 2003 1245 1900-8 put as the treatment goal has affected the amount the treatment goals should 3 osman d ridel c ray p monnet x anguel n richard c teboul jl cardiac filling pressures are not appropriate to predict of fluids patients receive from a physiological standhemodynamic response to volume challenge crit care med 2007 and significantly shortened 351 64-69 point be flow based using hospital length of stay 4 shoemaker wc appel pl kram hb waxman k lee ts prothere have been a number parameters such as cardiac spective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients chest 1988 946 1176-86 of studies that have used output or stroke volume the esophageal doppler for 5 perz s uhlig t kohl m bredle dl reinhart k bauer m kortgen a low and supranormal central venous oxygen saturation and markers fluid replacement in abdominal surgery10 although in most of tissue hypoxia in cardiac surgery patients a prospective observational study cases the results favored treatment with the doppler certain intensive care med 2011 371 52-59 aspects of the use of this technology should be considered the 6 rivers e nguyen b havstad s ressler j muzzin a knoblich b peterson e tomlanovich m early goal-directed therapy in the treatment of severe sepsis probe may be difficult to place 8 and may need to be reposiand septic shock n engl j med 2001 34519 1368-77 tioned particularly following cardio-pumonary bypass surgery 7 kern jw and shoemaker wc meta-analysis of hemodynamic optimization in 11 there is also evidence to show that the more experienced high-risk patients crit care med 2001 308 1686-92 the user the better the correlation of the cardiac output measu8 stawicki sp hoff ws cipolla j de quevedo r use of non-invasive esopharements with a reference method 12 in summary measuregeal echo-doppler system in the icu a practical experience ment tools used in a goal directed treatment algorithm will most j trauma 2005 592 506-7 likely not become widely accepted if they are largely observer 9 mayer j boldt j mengistu a rohm kd suttner s goal-directed intradependent and if they need frequent readjustments operative therapy based on autocalibrated arterial pressure waveform analysis the good in summary in order for a goal directed treatment algorithm to be accepted into the clinical routine it should be simple and straightforward to use it should be seen to be of benefit both for patients and staff the treatment goals should from a physiological standpoint be flow based using parameters such as cardiac output or stroke volume 13 because of the ongoing trend towards less invasive monitoring the inclusion of such technology is also warranted here such technologies should be as accurate as is possible given their less invasive nature a large scale multicenter trial is on its way to test the effectiveness of the new autocalibrated proaqt device for hemodynamic optimization using a simple and straightforward algorithm reduces hospital stay in high-risk surgical patients a randomized controlled trial crit care 141 r18 10 abbas sm and hill ag systematic review of the literature for the use of oesophageal doppler monitor for fluid replacement in major abdominal surgery anaesthesia 2008 631 44-51 11 bein b worthmann f tonner ph paris a steinfath m hedderich j scholz j comparison of esophageal doppler pulse contour analysis and realtime pulmonary artery thermodilution for the continuous measurement of cardiac output j cardiothorac vasc anesth 2004 182 185-9 12 lefrant jy bruelle p aya ag saissi g dauzat m de la coussaye je eledjam jj training is required to improve the reliability of esophageal doppler to measure cardiac output in critically ill patients intensive care med 1998 244 347-52 13 hamilton ma cecconi m rhodes a a systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high-risk surgical patients anesth analg 2011 112 1392-1402

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professor daniel reuter department of anesthesiology and intensive care medicine university clinic hamburg-eppendorf germany prof reuter completed his medical education at the julius maximilians university in würzburg germany columbia university new york usa and finally at the ludwig-maximilians-university munich germany he has specialized in both anesthesiology and intensive care medicine in tübingen germany and in munich germany prof reuter is currently professor of anesthesiology and vice chair of the department of anesthesiology in the center of anesthesiology and intensive care medicine hamburg-eppendorf university medical center germany an algorithmic approach to the very high risk surgical patient why use an algorithmic approach according to its definition an algorithm is a set of rules that precisely defines a sequence of operations to perform a procedure or to solve a problem in the perioperative setting such an algorithmic approach can be useful firstly to analyze and secondly to reduce perioperative risks during and after very complex surgical procedures this comprises of a defining the procedure associated risks b defining the patient associated risks c outlining strategies to optimize the preoperative status d defining adequate hemodynamic monitoring and finally e defining an adequate hemodynamic management regimen by the determination of metabolic equivalents and the presence of clinical risk factors known coronary artery disease heart insufficiency insulin dependent diabetes mellitus cerebrovascular diseases and renal insufficiency this information can then be transferred into a treatment-matrix which defines which further diagnostic and therapeutic steps should be taken prior to surgery 3 furthermore this information can also serve as the basis for the definition of an appropriate hemodynamic monitoring strategy the complexity and invasiveness of monitoring increases based on the quantification of patient associated and surgery associated risks as described above the underlying ratio should always be to have the tools to optimize blood flow in order to ensure an adequate circulation leading to adequate end-organ perfusion resulting in less complications and improved outcome these tools are comprised of the assessment of should cardiac output preload and fluid responsiveness as well as the measurement of blood pressure when considering procedure associated risks the guidelines of the task force for preoperative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery from the european society of cardiology and the eurothe underlying ratio pean society of anaesthealways be to have the tools to siology esc/esa repremore and more technologies are becoming sents a very helpful tool optimize blood flow in order to 1 in these guidelines ensure an adequate circulation available to assess these parameters with less and less or indeed no invasiveness ­ however surgical procedures are leading to adequate end-organ in highly complex pathophysiological states such stratified to low 1 risk perfusion resulting in less com as in severe hemodynamic instability shock or of myocardial infarction or cardiac death within 30 plications and improved outcome systemic inflammation those low or non-invasive tools will potentially fail to provide the correct days of surgery intermemeasurements ­ so that in these circumstances escalation to diate 1-5 risk and high-risk procedures 5 risk however monitoring techniques such as transpulmonary and pulmonary each individual surgical and anesthesiological experience also artery thermodilution are justified needs to be taken in account with such stratifications the patient associated risk should also be stratified preoperatively into an algorithmic approach the esc/esa guidelines also propose a practical procedure based on the modified lee criteria 2 the individual risk is stratified according to the presence of active cardiovascular/pulmonary diseases unstable coronary syndrome acute heart insufficiency significant arrhythmias symptomatic valvular disease recent myocardial infarction the determination of the patients functional capacity quantified however and most importantly hemodynamic monitoring can only help to improve the outcome if it is embedded into a treatment strategy here the algorithmic approach which by its very definition clearly determines the goals of hemodynamic optimization is essential the basis of all these thus far proposed treatment algorithms is very similar step one is preload optimization which is followed by an improvement in central blood flow cardiac output optimization of perfusion pressure blood

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pulsion abstract book isicem brussels 2012 page 9 pressure then comes in the second tier the positive effects on outcome have been demonstrated in several recent clinical trials 4,5 however it is very however and most important to point out that particularly in the groups importantly hemoof high risk surgery patidynamic monitoring ents e.g cardiac surgery patients with underlying can only help to imcardiac diseases and sepprove the outcome if tic patients the proposed it is embedded into a optimal values for the parameters of preload treatment strategy global end-diastolic volume index obtained by transpulmonary thermodilution enddiastolic area index from the transesophageal echocardiography and others may vary from the proposed normal values 6 titration and definition of patient-individual optimimal values may be the choice here for optimizing hemodynamic management as recently demonstrated in a prospective trial in 100 cardiac surgical patients 7 references 1 poldermans d bax jj et al guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery the task force for preoperative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery of the european society of cardiology esc and endorsed by the european society of anaesthesiology esa eur j anaesthesiol 2010 272 92-137 2 lee th marcantonio er et al derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery circulation 1999 10010 1043-9 3 petzoldt m kahler j goetz ae friederich p [perioperative pharmacological myocardial protection systematic literature-based process optimization anaesthesist 2008 577 655-69 4 goepfert ms reuter da akyol d lamm p kilger e goetz ae goal-directed fluid management reduces vasopressor and catecholamine use in cardiac surgery patients intensive care med 2007 33 96-103 5 hamilton ma cecconi m rhodes a a systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high-risk surgical patients anesth analg 112 13921402 6 eichhorn v goepfert ms eulenburg c malbrain ml reuter da comparison of values in critically ill patients for global end-diastolic volume and extravascular lung water measured by transcardiopulmonary thermodilution a metaanalysis of the literature med intensiva 2012 epub 7 goepfert m richter p von sanersleben a et al does early perioperative goal directed therapy using functional and volumetric hemodynamic parameters improve therapy in cardiac surgery a prospective randomized controlled trial asa 2011 boc 12

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professor azriel perel visiting professor charité university hospital in berlin prof perel graduated from the hadassah-hebrew university medical school jerusalem in 1974 and then completed his residency in anesthesia and intensive care at the same institute from 1977 ­ 1979 he received the fulbright fellowship which he completed at the cardiovascular research institute uc san francisco he also completed a critical care fellowship in the university of florida gainesville from 1979-80 and was a visiting professor in critical care at uc san diego in 1985 prof perel was appointed the chairman dept anesthesiology and intensive care sheba medical center tel aviv in 1987 he has served as the treasurer and member of the executive board european society of anesthesiologists esa 1998-2002 in 2004 he was a visiting professor at hôpital pitie salpetrière paris in 2005 prof perel was appointed president of the israel society of anesthesiologists a position he held until 2011 currently 2012 prof perel is a visiting professor at the charité university hospital in berlin hemodynamic monitoring ­ accuracy vs continuity why is it important to measure cardiac output co cardiac output co is the main determinant of oxygen delivery and may be compromised or inadequate in many disease states therefore many of our therapeutic efforts are aimed at improving low or inadequate-flow states and yet physical examination and vital signs alone often fail to reflect significant derangements in co the two main reasons for monitoring co in clinical practice include the identification of patients who have low or high co values that are not evident clinically and the quantification of the response to diagnostic and therapeutic interventions the monitoring of co is therefore very useful for proper decision-making in critically ill and high-risk surgical patients the fact that this statement is not supported by evidence-based medicine tells us more about the shortcomings of ebm than those of the measurement of co by analogy we could not imagine ourselves driving a car without a speedometer and yet speedometers in cars and similar devices in airplanes have not been introduced following randomized controlled trials thus it is high time to consider the co as an additional vital sign in critically ill and high risk surgical patients dynamic parameters that we use in our practice are either inaccurate or are considerably influenced by many confounding factors e.g blood pressure during vasoconstriction heart rate in a beta blocked patient cvp or paop in the presence of high peep etc last but not least when evaluating the role of new co devices in clinical care the fundamental question is whether the new device can replace thermodilution co measurement as a guide to clinical decisions how should we deal with the inherent inaccuracies of our monitored parameters a maximize the information that can be provided by real-time continuous measurements the continuity of measurement of physiological parameters is a powerful tool the best and most common example is the vast amount of information that is offered by the continuous analog signal of the blood pressure waveform in comparison with its digital readout in the same way when it comes to assessing the response to therapeutic or diagnostic events with short time constants a continuous real-time co is more useful and informative than co measured by intermittent bolus thermodilution which has a precision of ±10-20 examples of such therapeuare co monitors accurate tic and diagnostic events include fluid loading passive leg raithe introduction of uncalibrated continuous co monitors into sing plr and the immediate response to inotropes to name a clinical practice has been associated with reports that raised few in the field of perioperative optimization it has long been requestions about their accuracy in comparison with co meacognized that the gold standard to monitor the response to a flusured by the pulmonary artery catheter pac which is still id challenge is the continuous measurement of co continuous considered by many to measurement in many other novel monitoring the monitoring of co is devices offer this extra dimension by allowing be the `gold standard the current convention therefore very useful for proper real-time assessment of response to therapy or is that any new method a change in patient status the close assessfor measuring co e.g decision making in critically ill and ment of continuous physiological analog signals pulse contour should high-risk surgical patients should receive the recognition that the classic achieve an agreement physical examination has had in medicine for with bolus thermodilution which meets the expected 30 limits decades such assessment should be termed physiological exhowever the relevance in clinical practice of these arbitrary amination and should become a part of formal medical training limits may need to be reassessed moreover all of the hemo

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pulsion abstract book isicem brussels page 11 b beware of protocolized care d due to the inherent inaccuracies and confounding factors of the parameters that we routinely monitor one should beware of protocols especially those which include pre-defined phy the `gray zone approach that has been recently applied to siological end-points that should be reached in all patients the ppv for prediction of fluid responsiveness fr is an exampbest examples for such a need for caution are the cvp and le of such a strategy since there is a range of ppv values scvo2 values that have been advocated by the surviving sep 9 13 for which fr cannot be reliably predicted in 25 of mechanically ventilated anesthetized patients and in sis guidelines the recontinuity of measurement a situation where fluid overload may be particularly ported improved survival deleterious higher-than-normal ppv values should following the adoption of a multi-parametric approach serve as an indication for fluid administration these guidelines cannot and more reliable decisionwe often target and attempt to normalize abnormal be viewed as justification physiological variables such a therapeutic approach of the recommended ini making strategies are some tial hemodynamic resusof the means that would allow may be hazardous because it may lead to ignoring the underlying problem and may induce harm this citation protocol which us to correctly use new tech is especially true during therapeutic conflicts a thephysiologically and clinically may be wrong nologies for the benefit of our rapeutic conflict is a situation where each of the possible therapeutic decisions carries some potential and even dangerous for patients harm therapeutic conflicts are commonly found in many septic patients in the same manner any perioperative optimization protocol that critical care and present the biggest challenge for protocolized advocates a ci 4.5 l/min/m2 for all high risk patients may be cardiovascular management a common example is the patient inappropriate one reason being the insufficient accuracy of any with high lung water and low preload in some cases the correct answer is to optimize preload first but in others and especially co monitor in those with extreme resistant hypoxemia the answer may be different such a conflict should be solved by a-priori assessc adopt a multi-parametric approach when making ment of the possible harm that each of the respective potential a potentially critical decision decisions may cause when found to be wrong the decision of due to the inherent limitations of the parameters that we mo which the price of a possible mistake is lower is most probably nitor one should not base a critical decision on one single pa the correct way to go rameter take for example the limitations of the co itself the in conclusion we have to recognize that all our measurements optimal co for an individual patient is difficult to assess a low are a lot less informative and accurate than we may want or co does not tell us what to do a `normal or even high co does think we have to face this challenge rather than become skepnot preclude the presence of inadequate regional tics passive or even the hottest places in hell are nihilistic continuity of and microcirculatory flow therefore a perioperative hemodynamic strategy that assumes that any reserved for those who in times measurement a multidecrease in co should be treated with fluids will be parametric approach of great crisis do nothing very often wrong adding a functional hemodynaand more reliable decidante sion-making strategies mic parameter like the ppv may be of great benefit in such clinical scenarios in the critically ill a multi-parametric are some of the means that would allow us to correctly use new approach that includes co volumetric preload and extra-vas technologies for the benefit of our patients cular lung water will lead to better decisions than relying on just one of these parameters adopt decision-making strategies that take into account the uncertainty of our measurements

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eran segal md eran segal md director department of anesthesia critical care and pain medicine assuta medical centers israel dr segal is the director of anesthesia intensive care and pain medicine of assuta medical centers in israel dr segal was trained in the sheba medical center and in gainesville florida he is the chairman of the israeli society of critical care medicine his main interests are advanced hemodynamic monitoring and mechanical ventilation cvp blood pressure and urine output are they ever enough interactive session background when caring for critically ill patients the question of hemodynamic monitoring is a cardinal one we have to assess and decide whether the tools at our disposal are adequate for the clinical scenario at hand clearly it makes sense that in the most severely compromised patients there is a need for information regarding cardiovascular and pulmonary function unfortunately the situations in which these measurements can be helpful and sometimes even mandatory and in which this information may improve outcome are not clearly established in this presentation i have attempted to look at the question of whether basic monitoring tools are ever enough question 2 what is the probable diagnosis 100 80 60 40 20 0 septic shock anaphylactic shock hemorrhagic shock cardiogenic shock results of the votes of an interactive session audience 300 during isicem 2012 question 1 are blood pressure urine output and central venous pressure ever enough 80 60 40 20 0 yes they can be enough in many patients no they are never enough i have never needed anything else as the audience thought the diagnosis here is quite clear and in fact as reflected by the history blood pressure urine output and cvp in this instance are enough question 3 what should be done 100 80 60 40 20 results of the votes of an interactive session audience 300 during isicem 2012 0 administer fluids urine electrolytes pa catheter picco case study 1 the first example of a trauma case illustrates this point a 25 year old male is injured by a car and brought into the emergency room er with chest and head injuries in the er the following parameters were measured blood pressure cvp urine output 86/50 4 cmh20 30 ml/hr results of the votes of an interactive session audience 300 during isicem 2012 in this instance the cvp and blood pressure were accurate reflectors of his hypovolemia but we probably didn t need them anyway given his clinical presentation again the data and the history are enough in this case to evaluate his status and formulate a plan however things are not always so simple.

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pulsion abstract book isicem brussels 2012 page 13 case study 2 a 55 year old man is brought to the intensive care unit after an acute myocardial infarction on examination he is hypotensive hypoxemic and has low urine output he is intubated and mechanically ventilated he has clinical signs of pulmonary edema is normotensive on noradrenaline 131/69 heart rate 80 beats per min and his urine output 110ml/hour once he is put on a frusemide lasix infusion his cvp is around 3 cmh20 what is the cvp telling the treating physicians is he hypo or hyper-volemic or is his fluid status ok this patient is far more complex and in his case the cvp is very difficult to interpret a low cvp does not really give reliable information about the patient s preload or cardiac function ten minutes later his cvp was 10cmh2o question 4 what improved his hemodynamics 100 80 60 40 20 0 he received 500 ml colloids haes he received a bolus of noradrenaline we stopped the diuretic we changed the way looked at the cvp lot of evidence in the literature regarding the variability in cvp measurements and the potential impact that this can have on fluid management 1,2,3,4 other issues which may impact on the cvp are demonstrated in this patient with severe tricuspid regurgitation and a high cvp despite being hypovolemic here is another example a 64 yr old woman is brought to the operating room for major debulking of a peritoneal spread of a colonic tumor she is induced with 120mg propofol and 40mg rocuronium after receiving 2mg midazolam and 100 mcg fentanyl after induction her blood pressure decreases to 80/46 mmhg her cvp is 6mmhg and a urinary catheter is inserted the question is what to do next does she need fluids to improve her hemodynamics should she receive a bolus of phenylephrine to improve her vasodilation or should she receive epinephrine or norepinephrine to increase her cardiac output that has decreased because of the drugs given for the induction all of these are very common questions which anesthesiologists face on a daily basis immediately after induction a picco catheter is inserted which gave the following parameters cardiac index ci global end diastolic volume index ­ gedi preload extravascular lung water index ­ evlwi ­ lung water stroke volume variation ­ svv volume responsiveness 1.8 l/min/m2 3-5 l/min/m2 680 ­ 800 ml/m2 505 ml m2 results of the votes of an interactive session audience 300 during isicem 2012 6 ml/kg 7 ml/kg in fact when the patient was checked it was discovered that the transducer was placed incorrectly on the patient s bed a level with the patients shoulder and therefore giving an incorrect reading when it was re-positioned correctly at the 5th intercostal space the cvp was actually 10 cmh20b indeed there is a 18 10 normal range a b given these parameters the patient was given fluids for hypovolemia low ci low gedi and high svv her co improved significantly is it worth optimizing fluid therapy during the perioperative period evidence from two meta-analysis has shown that goal directed hemodynamic therapy reduces major gastrointestinal complications 5 and improves overall outcome 6 we know that we should optimize hemodynamics in the perioperative period and we probably need more advanced monitoring tools to enable us to do so.

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cvp blood pressure and urine output are they ever enough continuation and finally what about the urine output there are multiple reasons why a patient may be oliguric during the perioperative period these include hypovolemia low flow low blood pressure acute kidney injury post renal syndrome and even syndrome of inappropriate antidiuretic hormone hypersecretion siadh so relying on urine output to indicate if the patient requires volume or not is crude and potentially very inaccurate case study 3 a male patient is admitted to icu following an esophagectomy he is hypotensive blood pressure 100/56mmhg cvp is 14 mmhg he is mechanically ventilated and hypoxemic and his urine output remains low 40 ml/hr despite receiving diuretics a picco catheter is inserted which gives the following parameters cardiac index ci global end diastolic volume index ­ gedi preload extravascular lung water index ­ evlwi ­ lung water stroke volume variation ­ svv volume responsiveness 1.5 l/min/m2 3-5 l/min/m2 680 ­ 800 ml/m2 600 ml m2 16 ml/kg 7 ml/kg 22 10 normal range despite the very high lung water evlw 16 the patients was given fluids as he had low preload gedi 600 and was volume responsive svv 22 over the next 12 hours the preload gedi and ci increased and evlw and svv decreased the ci increases as gedi becomes higher evlwi decreases despite the fluid loading so to summarize maybe the more important question is not whether cvp blood pressure and urine output are ever enough the question should really be are they always enough as can be seen in the answers to the final question ­ there is an almost unanimous agreement that this is not the case and many complex patients require more advanced monitoring.

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pulsion abstract book isicem brussels 2012 page 14 question 5 blood pressure cvp and urine output are they always enough 120 100 80 60 40 20 0 i never need more data its extremely rare that they are not enough many complex pateints require more advanced monitoring references 1 jain rk antonio bl bowton dl houle tt macgregor da variability in central venous pressure measurements and the potential impact on fluid management shock 2010 333 253-7 2 marik pe baram m vahid b does central venous pressure predict fluid responsiveness a systematic review of the literature and the tale of seven mares chest 2008 1341 172-8 3 osman d ridel c ray p monnet x anguel n richard c teboul jl cardiac filling pressures are not appropriate to predict hemodynamic response to volume challenge crit care med 2007 351 64-69 4 kumar a anel r et al pulmonary artery occlusion pressure and central venous pressure fail to predict ventricular filling volume cardiac performance or the response to volume infusion in normal subjects crit care med 2004 323 691-9 5 giglio mt marucci m testini m brienza n goal-directed haemodynamic therapy and gastrointestinal complications in major surgery a meta-analysis of randomized controlled trials br j anaesth 200 1035 637-46 6 corcoran t rhodes ej clarke s myles ps ho km perioperative fluid management strategies in major surgery a stratified meta-analysis anesth analg 2012 1143 640-51 results of the votes of an interactive session audience 300 during isicem 2012 key messages · blood pressure cvp and urine output are rough indicators of hemodynamic status in some patients the history and clinical presentation is enough to make clinical decisions in more complex sitations decisions about hemodynamic management requires more data ­ cardiac output volumetric preload and fluid responsiveness · ·

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