Echo, und was dann? Welches Monitoring für welchen Patienten?

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1 Echo, und was dann? Welches Monitoring für welchen Patienten? Heinrich V. Groesdonk Interdisziplinäre Operative Intensivstation (IOI) Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie Universitätsklinikum des Saarlandes

2 Conflict of interest (COI-5) Mitsubishi Chemical Europe/Global Edwards Lifescience Deutschland GE Healthcare Europe & Global Orion Pharma GmbH Amomed GmbH

3 Therapie der akut dekompensierten Herzinsuffizienz Neue Aspekte? Echo, und was dann? Welches Monitoring für welchen Patienten?

4 Dilemma Leitlinie

5 Einführung European Society of Cardiology Arterie ggf. Pulmonaliskatheter European Heart Journal (2016) 37,

cardiac abnormality resulting in a reduced cardiac output and/

6 Einführung Definition clinical syndrome characterized by typical symptoms caused by a structural and/or functional cardiac abnormality resulting in a reduced cardiac output and/ or elevated intracardiac pressures European Heart Journal (2016) 37,

7 Einführung Definition rapid onset or worsening of symptoms and/or signs of HF life-threatening medical condition AHF may present as a first occurrence (de novo) as a consequence of acute decompensation of chronic HF caused by primary cardiac dysfunction or precipitated by extrinsic factors European Heart Journal (2016) 37,

8 Einführung European Heart Journal (2016) 37,

9 Einführung European Heart Journal (2016) 37,

10 Einführung vereinfachte qualitative Einteilung normal erniedrigte Vorlast RV Versagen LV Versagen biventrikuläres Versagen

11 Einführung AINS Dec;49(11-12):

12 Einführung Welches Monitoring für welchen Patienten RV Versagen Monitor biventrikuläres Versagen erniedrigte Vorlast LV Versagen

13 Einführung 1. Fazit Echokardiographische Kenntnisse sind unabdingbar in der Behandlung der akut dekompensierten Herzinsuffizienz Das Monitoring sollte sich an der zugrundeliegenden Pathologie orientieren DAS EINE MONITORING existiert nicht

14 Allgemein

15 Allgemein Extensives Monitoring = gute Therapie?

16 Allgemein

17 erweitertes hämodynamisches Monitoring

18 erweitertes hämodynamisches Monitoring Monitor

19 invasive arterielle Druckmessung Standart care Arterial pressure is a key determinant of organ perfusion Mean arterial pressure is often used to target vasopressor or vasodilator therapy Pulse pressure estimation A narrow pulse pressure suggests a low stroke volume

20 invasive arterielle Druckmessung RR = SV * SVR

21 invasive arterielle Druckmessung RR = SV SVR *

22 invasive arterielle Druckmessung RR = SV * SVR

23 invasive arterielle Druckmessung

24 zentraler Venendruck (ZVD)

zentraler Venendruck (ZVD) Central venous access is often required for the care of critically ill patients Central venous pressure and oxygen saturation can provide important information on the

25 zentraler Venendruck (ZVD) Central venous access is often required for the care of critically ill patients Central venous pressure and oxygen saturation can provide important information on the hemodynamic state of the patient A high CVP reflects an impaired cardiac function (biventricular or right heart) Measurement of central venous oxygen saturation (ScvO2) provides information on the adequacy of oxygen transport, and hence cardiac output Curr Heart Fail Rep (2015) 12:

26 zentraler Venendruck (ZVD) In conclusion, there are no data to support the widespread practice of using CVP to guide fluid therapy. This approach to fluid resuscitation is without a scientific basis and should be abandoned. Crit Care Med Jul;41(7):

27 zentralvenöse Sauerstoffsättigung No agreement of mixed venous and central venous saturation in sepsis, independent of sepsis origin van Beest et al. Critical Care 2010, 14:R219

28 erweitertes hämodynamisches Monitoring Monitor addapted from M. Heringlake

transpulmonale Thermodilution Table 2 Hemodynami c eval uati on wi th transpul monary thermodilution in patients with clinical signs of acute heart failure Clinical condition CO GEDV CFI EVLW

29 transpulmonale Thermodilution Table 2 Hemodynami c eval uati on wi th transpul monary thermodilution in patients with clinical signs of acute heart failure Clinical condition CO GEDV CFI EVLW Hemodynamic pulmonary edema or or Hypovolemic shock or Cardiogenic shock (left or global) or Pulmonary embolism Primary pulmonary hypertension or Right ventricular infarction Tamponade CO cardiac output, GEDVglobal end diastolic volume, CFI cardiac function index,evlwextravascular lung water, increased, unchanged or normal, decreased mo trar ada nat per [40 sho imp dia lev req ana crea W ma Eva Wh ven resu P pre Curr Heart Fail Rep (2015) 12:

30 transpulmonale Thermodilution Critical Care 2009, 13:R133

transpulmonale Thermodilution Table 4 Comparing hemodynamic characteristics between patients with sepsis and acute heart failure PAC Prospective studies are now needed to demonstrate that the PiCCO

31 transpulmonale Thermodilution Table 4 Comparing hemodynamic characteristics between patients with sepsis and acute heart failure PAC Prospective studies are now needed to demonstrate that the PiCCO technology is superior to a standard of care based on the current recommendations for Sepsis n = 36 hemodynamic monitoring and management in shock Acute heart failure n = 48 P value CI, L/minute per m ( ) 2.6 ( ) < CP, W 1.14 ( ) 0.80 ( ) < LVSWI, g-m/m 2 38 (30 49) 23 (18 29) a < RAP, mm Hg 13 (9 15) 12 (8 14) 0.26 PAOP, mm Hg 16 (15 18) 20 (15 24) a MPAP, mm Hg 29 (26 32) 32 (26 37) 0.02 SmvO 2, percentage 68 (62 74) 57 (50 62) b < PiCCO CI, L/minute per m ( ) 2.7 ( ) < CFI, 1/minute 6.1 ( ) 2.8 ( ) < GEF, percentage 23 (17 30) 14 (10 16) < GEDVI, ml/m ( ) 995 ( ) 0.16 ELWI, ml/kg 18.0 ( ) 14.7 ( ) 0.09 PVPI 2.8 ( ) 2.4 ( ) 0.01 ELWI/GEDVI, ( ) 1.6 ( ) 0.01 Data represent the median (interquartile range) of the four consecutive measurements obtained during the observation period. Reduced numbers because of missing values are indicated with superscript a ( a ), where n = 40, and superscript b ( b ), where n = 44. CFI: cardiac function index; CI: cardiac index; CP: cardiac power; ELWI: extravascular lung water index; GEDVI: global end-diastolic volume index; GEF: global ejection fraction; LVSWI: left ventricular stroke work index; MPAP: mean pulmonary arterial pressure; PAC: pulmonary artery catheter; PAOP: pulmonary artery occlusion pressure; PiCCO: transpulmonary thermodilution technique; PVPI: pulmonary vascular permeability index; RAP: right atrial pressure; SmvO 2 : mixed venous oxygen saturation. patients [32-34]. In our study, we found a good correlation between CFI and both LVSWI and CP, independently of whether patients had sepsis or AHF. Of note, the median left ventricular ejection fractions were below 30% in heart failure patients and normal in septic patients. The PiCCO parameters CFI and GEF have previously been shown to be reliable markers of left ventricular function when compared with echocardiographic assessments [27] and left ventricular dp/dt max [44]. Interestingly, CFI and GEF identified a subpopulation of septic patients with a myocardial function as poor as in AHF patients. The CFI cutoff level for a depressed myocardial function in our septic population was between 4 and 5 per minute, which is in agreement with the results of a recent study indicating that a CFI of less than 4 per minute estimated a left ventricular fractional area of change of less than 40% with a sensitivity of Critical Care 2009, 13:R133

32 transpulmonale Thermodilution Wien Klin Wochenschau Published online 15 August 2016

33 transpulmonale Thermodilution Wien Klin Wochenschau DOI /s z

34 erweitertes hämodynamisches Monitoring Monitor addapted from M. Heringlake

35 Pulmonary artery catheter European Heart Journal (2016) 37,

36 Pulmonary artery catheter

37 Pulmonary artery catheter

38 Pulmonary artery catheter

Pulmonary artery catheter & RHF In patients with advanced heart failure, echocardiographic RAP prediction methods showed only modest precision

39 Pulmonary artery catheter & RHF In patients with advanced heart failure, echocardiographic RAP prediction methods showed only modest precision Furthermore, none of the tested methods resulted in clinically relevant improvements of RAP estimates Tsutsui et al. J Am Soc Echocardiogr 2014;27:1072-8

40 Pulmonary artery catheter & GDT Intensive Care Med 2007; 33:

41 Pulmonary artery catheter & GDT Anesth Analg Jun;112(6):

42 Zusammenfassung I Arterie ggf. Pulmonaliskatheter European Heart Journal (2016) 37,

43 Zusammenfassung II erniedrigte Vorlast RV Versagen LV Versagen biventrikuläres Versagen

44 Zusammenfassung III Echokardiographische Kenntnisse sind unabdingbar in der Behandlung der akut dekompensierten Herzinsuffizienz DAS EINE MONITORING existiert nicht Das Monitoring mittels PAK kann sinnvoll sein Zum Monitoring mittels transpulmonaler Thermodilution liegen kaum Daten vor, valide Daten scheinen aber bestimmbar zu sein

45 Zusammenfassung III

46 Vielen Dank für Ihre Aufmerksamkeit Priv.-Doz. Dr. med. Heinrich V. Groesdonk

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