Monitoring of Heart-Kidney
Interactions
What Should we Monitor?
David Nelson, MD, PhD
Director, Cardiac Intensive Care
The Heart Institute
Cincinnati Children’s Hospital
Is this the response to Low Cardiac Output
Syndrome in your ICU?
Survival is a necessary, but
insufficient definition of outcome
Increasing CICU Length of Stay in Associated with
Lower Verbal and Full Scale IQ 8 Years After Surgery
Longer Length of Stay
110
N=166
P < 0.02
105
When adjusting for predictors of longer CICU length of
stay, as well as for prior variables that were predictive
of worse 8 year developmental outcome:
Longer CICU length of stay was associated with:
Lower Full Scale IQ (P=0.02)
Lower Verbal IQ (P=0.02)
Lower Performance IQ (P=0.08)
Lower Math Achievement (P=0.08)
100
95
90
Deleting top 5% of CICU LOS, each day in the CICU:
Led to a reduction of 1.4 points in full scale IQ
85
1st
Quartile
2nd
3rd
Verbal IQ
Full Scale IQ
4th
Led to a reduction of 1.6 points in math achievement
Quartile
Boston Circulatory Arrest Study
Newburger, Wernovsky et al, J Pediatr 2003;143:67-73
Neurologic Injury after Neonatal
Congenital Heart Surgery
 2%
overt neurological injury following
pediatric heart surgery
 10% subclinical stroke in neonates
undergoing surgery
 60% visuospatial/motor abnormalities,
attention deficit, developmental delay by
school age following neonatal surgery
 HLHS survivors’ median IQ 66
– 57% cerebral palsy
Physiologic Monitoring
How effective is our current monitoring technology?
 What
is the incidence of “unanticipated”
cardiac arrest in your ICU?
 How quickly is LCOS detected in your ICU,
and what is the sensitivity and specificity?
 When LCOS is detected in a patient, do the
interventions minimize the duration of LCOS?
 Does monitoring cause complications
(thrombosis, BSI’s, etc)
Syste
O2 Consu
150
What Should We Be Monitoring?
100
50
0
0
Assessment of Low Output States
500
1000
1500
Systemic
O2 Consumption
Lactate
14
300
12
250
10
200
8
150
6

100
4
50
2
00
00
500
500
1000
1000
1500
1500
Systemic O2 Delivery
14
Lactate
12
10
8
6
4
2
0
0
500
1000
Systemic O2 Delivery
1500
What is the best
marker of inadequate
O2 Delivery?
Syste
O2 Consu
150
What Should We Be Monitoring?
100
50
0
0
Assessment of Low Output States
500
1000
1500
Systemic
O2 Consumption
Lactate
14
300
12
250
10
200
8
150
6

100
4
50
2
00
00
500
500
1000
1000
1500
1500
Systemic O2 Delivery
14
Lactate
12
10
8
6
4
2
0
0
500
1000
Systemic O2 Delivery
1500
What is the best
marker of inadequate
O2 Delivery?
What Should We Be Monitoring?
Assessment of Low Output States
Systemic
O2 Consumption
300
250

What is the best
marker of inadequate
O2 Delivery?

Lactate is “too late”
200
150
100
50
0
0
500
0
500
1000
1500
14
Lactate
12
10
8
6
4
2
0
1000
Systemic O2 Delivery
1500
What Should We Be Monitoring?
Assessment of Low Output States
Systemic
O2 Consumption
300
250

What is the best
marker of inadequate
O2 Delivery?

Lactate is “too late”

The cardiac output
needed depends
upon the O2 Demand
200
150
Cardiac Output?
100
50
0
0
500
1000
1500
14
Lactate
12
10
8
6
4
2
0
0
500
1000
Systemic O2 Delivery
1500
Systemi
O2 Consump
200
What is the best marker of inadequate
Oxygen Delivery in shock states?
150
100
50
Mixed-venous
O2 Saturation (SVO2)
Systemic
Mixed-venous
2 Consumption
O2OSaturation
(SVO2)
0
0
500
1000
1500
0
500
1000
1000
1500
1500
90
300
80
250
70
60
200
50
150
40
30
100
20
50
10
0
Systemic O2 Delivery
90
80
70
60
50
40
30
20
10
0
0
500
1000
Systemic O2 Delivery
1500
Systemi
O2 Consump
200
What is the best marker of inadequate
Oxygen Delivery in shock states?
150
100
50
0
Systemic
Mixed-venous
2 Consumption
O2OSaturation
(SVO2)
0
90
300
80
250
70
60
200
50
150
40
30
100
20
50
10
0
1000
1500
Hypoxic hypoxia
Anemia
Hypovolemia
Carbon Monoxide Dysoxia
0
Mixed-venous
O2 Saturation (SVO2)
500
500
1000
1000
1500
1500
Systemic O2 Delivery
90
80
70
60
50
40
30
20
10
0
0
500
1000
Systemic O2 Delivery
1500
What is the best marker of inadequate Oxygen
Delivery in shock states?
Systemic
O2 Consumption
300
250
200
Hypoxic hypoxia
Anemia
Hypovolemia
Sepsis
150
100
50
Mixed-venous
O2 Saturation (SVO2)
0
0
500
1000
1500
0
500
1000
1500
90
80
70
60
50
40
30
20
10
0
Systemic O2 Delivery
Regardless of the
cause, SVO2 is the
best marker of
inadequate systemic
and regional
O2 delivery and
anaerobic metabolism
We don’t need no new monitors!
What data is there to support
monitoring of blood pressure or
heart rate?
We tend to have different standards
for new technology than for the old
technology.
Diagnosis of low output states
Clinical Signs of Low Output









Pallor
Tachycardia
If present then
Tachpnoea
Altered mentation
tissue hypoxia
GI distress
is already
Olguria/Anuria
occuring
Acidosis
Lactate
Falling Venous or regional O2 saturation ???
Capillary Refill and Toe Temperature
Fail to predict Low Cardiac Output




Tibby SM et al. Arch Dis Child 1999;80(2):163-6 “norm value
for cap refill time of < or = 2 sec has little predictive value “
Bailey JM et al. Crit Care Med 1990;18(12):1353-6 “no signif
relationship between cap refill or extremity (toe or finger)
core temp gradients and cardiac index (CI)”
Butt W et al. Anaesth Intensive Care 1991;19(1):84-7
“peripheral temp (toe temp), and core-peripheral temp
difference …did not provide any guide to either CO or SVR.”
Raju NV et al. Clin Pediatr (Phila) 1999;38(3):139-44 “no
accepted standard for measuring decreased perfusion in the
newborn “
160
150
140
130
120
110
100
90
80
100
90
80
70
60
50
40
30
20
10
0
HR
MAP
SvO2
CVP
CVP
Heart Rate
170
MAP
Pediatric Critical Care Med, 2008
Conclusions:
1
5
9
13 17 21 25 29 33 37
“We report the first case of Time
a newly
modified central venous catheter for
(hr)
children and demonstrate its utility in a patient with impaired oxygen
delivery when traditional markers remain stable. This catheter
enabled the rapid diagnosis of cardiac compromise due to
pericardial effusion, leading to early treatment.”
10
90
9
80
8
70
7
60
6
50
5
40
4
30
3
20
2
10
1
0
0
1
5
9
13 17 21 25 29 33 37 41
Time(Hrs)
Lactate
ScvO2
100
ScvO2
Lactate
Monitoring of Continuous Venous Oximetry is likely the
“Gold Standard” for Cardiac Output Assessment
Systemic
O2 Consumption
300
250

SVO2 is the best marker
of inadequate systemic
and regional
O2 delivery and
anaerobic metabolism

No Data on Continuous
Oximetry and Acute
Kidney Injury in Children
200
Hypoxic hypoxia
Anemia
Hypovolemia
Sepsis
150
100
50
0
Mixed-venous
O2 Saturation (SVO2)
0
500
1000
1500
90
80
70
60
50
40
30
20
10
0
0
500
1000
Systemic O2 Delivery
1500
Use of Cerebral rSO2 as non-invasive
surrogate for mixed-venous saturation ????
Tortoriello et al, Pediatric Anesthesia, 200
Owens, Ped Cardiology 2011
Lactate
Too Late
Owens, Ped Cardiology 2011
Renal rSO2
Falls 4 hours
Before
Cardiac Arrest
Owens, Ped Cardiology 2011
Physiologic Monitoring
How effective is our current monitoring technology?
 What
is the incidence of “unanticipated”
cardiac arrest in your ICU?
 How quickly is LCOS detected in your ICU,
and what is the sensitivity and specificity?
 When LCOS is detected in a patient, do the
interventions minimize the duration of LCOS?
 Does monitoring cause complications
(thrombosis, BSI’s, etc)