How and when should we
monitor CO and SV in shock?
When would I want to measure
CO or SV in shock ?
Alexandre Mebazaa, MD, PhD
University Paris 7
Anesthesiology and Critical care medicine
Hôpital Lariboisière, Paris, France
SHOCK
MAP < 65mmHg
Oliguria (<0.5ml/Kg/hour)
Clinical signs of tissue hypoperfusion
Volemia
Vessel
tone
Heart
function
If shock is prolonged, mechanisms of shock are combined
Hochman JS Circulation 2003, 107: 2998-3002
Here is the summary
of my talk!
SHOCK
MAP < 65mmHg
Oliguria (<0.5ml/Kg/hour)
Clinical signs of tissue hypoperfusion
1) Clinical approach
First step
-HR/BP
-Peripheral perfusion
-Impact of volume loading
-Urine output
Second step
Third step
Fourth step
2) CVP/SvcO2
3) Echocardiography
should preceed any CO monitoring
Predominant
RVF or global F
PAC catheter
Predominant LVF
any CO monitoring
Hemodynamic management
of shock:
first step- clinical evaluation
SHOCK
MAP < 65mmHg
Oliguria (<0.5ml/Kg/hour)
Clinical signs of tissue hypoperfusion
Heart rate
Normal / high
Heart rate
< 40 bpm
Give fluid challenge of
250 ml over 5 min
Isoprenaline or
pacemaker as necessary
Yes,
repeat
if needed
Improvement?
No
CVP/SvcO2
Hemodynamic management
of shock: second step
Hemodynamic management
of shock:
second step- CVP/ScvO2
Insert
CVP/SvcO2
SvO2 >70%
CVP N or low
Sepsis
?
SvO2 <70%
Hypovolaemic/
Haemorrhagic/
cause?
Consider
global/right
ventricular failure
Repeat Fluid
challenge
250ml/ 5mins
Echocardiography that preceeds
cardiac output monitoring
Continue until
normal values
obtained
Repeat fluid
challenge
(250ml/5mins)
or transfusion
if necessary.
Continue until normal
values obtained
Haemodynami
c improvement
?
Yes
CVP low
CVP high
No response
N
o
Vasopressors
Haemodynami
c
improvement
Echocardiography that preceeds
CO monitoring
Hemodynamic management
of shock:
third step- echocardiography
The « pyramid » of echocardiography skills in ICU
Cholley,Vieillard-baron, Mebazaa, ICM 2006
Echocardiography
Predominent right
ventricular failure
Global heart
failure
Predominent left
ventricular failure
TAMPONADE ?
Massive mitral
regurgitation ?
Yes
No
No
Echocardiographic guided
pericardiocentesis or
surgical intervention
PA catheter
LV dysfunction
Pulmonary
hypertension?
Pulmonary
vasodilators
RV ischaemia?
Reduce RV afterload,
avoid excess volume, use
inotropes if CO low
Mebazaa et al. Intensive Care Med, 2004;30:185-96
Any CO
Monitoring,
ideally non
invasive
Optimise LV pre- and afterload,
Inotropes if required
Hemodynamic management
of shock:
fourth step- CO monitoring
Why/when would I want to
measure CO or SV in shock?

Failure hemodynamic management based on
clinical signs and CVP-ScvO2; this should
always direct to echocardiography

Echocardiography should, ideally, always
preceed CO monitoring

CO monitoring shoud be a PAC catheter in
case of RV dysfunction while any CO
monitoring, less invasive than PAC, should
be favored for LV dysfunction
SHOCK
MAP < 65mmHg
Oliguria (<0.5ml/Kg/hour)
Clinical signs of tissue hypoperfusion
1) Clinical approach
-HR/BP
-Peripheral perfusion
-Impact of volume loading
-Urine output
2) CVP/SvcO2
3) Echocardiography
should preceed any CO monitoring
Predominant
RVF or global F
PAC catheter
Predominant LVF
any CO monitoring