Does monitoring
cardiac output
influence outcome?
David Bennett
St George’s Hospital
London
Disclosures
•
I act as a consultant for Deltex and Lidco
Questions to be posed
• 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?
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, MBBChir
The Rayne Institute, St Thomas' Hospital, London, United Kingdom
• Can
cardiac output (CO) be accurately assessed
clinically?
PhysiciansÕEstimates of Cardiac Index
and Intravascular Volume.
Ireguri MG Am J Crit Care 2003;12:336.
45
40
35
30
25
%
20
15
10
5
0
60
50
40
% 30
20
10
0
Over Correct Under
estimate
estimate
Cardiac Index
Over Correct Under
estimate
estimate
Volume Status
Why are there so many different technologies for measuring CO?
Fick: Direct, Indirect
Dilution tehniques:
ICG,
Hot and cold, intermittent and semi-continuous
ScvO2 and SvO2
ECHO
Oesophageal, Supra-sternal Doppler
Impedance cardiography
Pulse contour analysis
C02 rebreathing
Does monitoring CO, particularly with PAC increase morbidity and/or
mortality?
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: 89997
The incidence of major morbidity in critically ill patients managed with pulmonary artery catheters:
A meta-analysis
Ivanov, Rada MD; Allen, Jill MSc; Calvin, James E. MD, FACC, FRCPC
CC 28(3), March 2000, pp 615-619
M
Impact of the Pulmonary Artery Catheter in Critically Ill Patients
Meta-analysis of Randomized Clinical Trials
Monica R. Shah, MD, MHS, MSJ; Vic Hasselblad, PhD; Lynne W. Stevenson, MD; Cynthia Binanay, RN, BSN; Christopher M. O’Connor, MD
MD, MPH; Robert M. Califf, MD
JAMA. 2005;294:1664-1670.
Impact of the Pulmonary Artery Catheter in Critically Ill Patients
Meta-analysis of Randomized Clinical Trials
Monica 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.
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.
P(survival)
1.00
0.75
0.50
No PAC
PAC
0.25
No PAC
PAC
508
506
240
232
0
15
205
191
194
179
188
174
186
168
183
166
30
45
60
Time from randomisation (days)
75
90
0.00
Does monitoring CO or a surrogate have prognostic value?
Effect of Oxygen Delivery on Mortality
Does monitoring CO or a surrogate have prognostic value?
and Morbidity in High Risk Surgery.
Shoemaker Chest. 1988: 94; 1176
70
60
50
40
%
% Mortality
30
20
10
0
301-400
401-500
60
>501
50
% of Patients
<300
40
30
% Patients with Morbidity
20
10
0
<400
400-500
500-600
>600
Does monitoring CO or surrogate have prognostic value?
Oxygen consumption L/min/m 2
Responders
350
300
250
200
150
Before dobutamine
After dobutamine
100
50
Non Responders
0
0
200
400
600
800
1000
1200
1400
Oxygen delivery L/min/m2
Rhodes A. CCM 1999; 11; 2361
250
200
150
100
50
0
0
200
400
600
800
1000
1200
Outcome of Patients
cc
Responders Non Responders
Predicted
Mortality %
39
58
Actual
mortality %
14
90.9
Rhodes A. CCM 1999; 11; 2361
Impact of LOW Post-Operative Central Venous Oxygen Saturation on Morbidity & Mortality in Surgical
Patients
V PRIYA*, J V DIVATIA, RASHMI S, R SAREEN
80
Normal (n = 32) Low (n = 51)
ScvO2 at 2 hrs
76.8 + 5.7
p = 0.00*
70
63.9 + 8.9
60
80
ScvO2 at 12 hrs
p = 0.00*
ScvO2 at 12 hours : 95% CI
ScvO2 at 2 hours : 95% CI
90
78
76
Normal (n = 32) Low (n = 51)
76.2 + 4.1
74
72
70
68
66
68.7 + 6.1
OUTCOME
Normal (n=32)
Low (n=51)
p Value
Days on ventilator (Mean+SD)
0.59 + 1.5
3.5 + 6.1
0.009*
Anastomotic leak (no. of pts)
2 (9%)
13 (26%)
0.03*
ICU stay (days, Mean+SD)
1.7 + 2.5
5.6 + 6.7
0.009*
Hospital stay (days, Mean+SD)
13.5 + 5.0
17.8 + 10.5
0.002*
ICU mortality (no. of patients)
0 (0%)
3 (6%)
0.16
Hospital mortality (no. of pts)
0 (0%)
3 (6%)
0.16
DO2 does not always correlate with CO
Relationship Between Central Venous Oxygen
Saturation and Oxygen Delivery.
x
e
d
n
I
1200
y
r
e
v
i
l
e
D
1100
n
e
g
y
x
O
600
1000
900
800
DO2 I ml/min/m7002
500
400
300
200
100
0
20
30
40
50
60
70
Central Venous Saturation
80
90
100
• Does targeting CO improve outcome?
Meta-analysis of hemodynamic optimization: relationship to methodological quality
Martijn Poeze, Jan Willem M Greve and Graham Ramsay
Critical Care 2005, 9:10.1186/cc3902)
This article is online at: http://ccforum.com/content/9/6/R771 R771-R779 (DOI
Peri-operative
Cont Treatm
ro
ent
l
%
Mortalit 10.4
y
4.7
Wilson et al:- BMJ :1999 318 1099
*
Days
Meta-analysis of hemodynamic optimization: relationship to methodological quality
Martijn Poeze, Jan Willem M Greve and Graham Ramsay
Critical Care 2005, 9:10.1186/cc3902)
This article is online at: http://ccforum.com/content/9/6/R771 R771-R779 (DOI
Sepsis
%
Mortalit
y
Cont Treatm
ro
ent
l
54
53
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 patients
Source New England Journal of Medicine. 330(24):1717-22, 1994 Jun 16.
% Mortality
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
*
*
*
ScvO2%
Hours
*
*
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
Control
n (%)
Treatment
n (%)
p
59 (46.5)
38 (30.5)
0.009
Severe sepsis
19 (30)
9 (14.9)
0.06
Septic shock
40 (56.8)
29 (42.3)
0.04
44 (45.4)
35 (35.1)
0.01
Mortality
In-hospital:
All patients
Septic syndrome
DO2I
ml/min/m
2
Early goal -directed therapy after major surgery reduces complications and duration of
hospital stay
Pearse et al
Critical Care 2005 9 R687 -693
*
*
*
Hours
*
*
*
*
Number of infections
*
*
*
Control
n=60
EGDT
n=62
14
11
Median
(6-188) (0.4-110)
%
Difference
Reduction
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
META-ANAYSIS OF HEMDYNAMIC OPTIMIZATION IN HIGH
RISK PATIENTS
Jack W. Kern1,2,3, Pharm D, William C Shoemaker2,3, MD
CCM 2001
Patient identification. Written informed consent. Lines inserted. Surgery. Randomisation
Admit to ICU. Monitor cardiac output in all patients using Lidco. Data
concealed from clinical staff
In all patients maintain SaO2 ≥94%, Hb≥ 8g.dl-1 , Temp.at 37oC.
HR≤100 or <20% above baseline. MAP 60-100 mmHg
CONTROL GROUP
EGDT 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 10% rise in SV for
≥20 min. Repeat if SV falls
kg -1
If urine output <0.5ml
hr-1 for 2
hours or consecutive hourly lactate
rises to >2 mmol l -1 then CI revealed
to clinical staff
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 CI <2.5l min-1m2 commence epinephrine, if > 2.5l min-1m2 continue current
treatment
After 8 hours study period ends all decisions taken by clinical staff. Patient
followed for hospital morbidity and 60 day mortality
Pinsky MR, Vincent JL.
Crit Care Med. 2005
May;33(5):1119-22.
META-ANAYSIS OF HEMDYNAMIC OPTIMIZATION IN HIGH
RISK PATIENTS
Jack W. Kern1,2,3, Pharm D, William C Shoemaker2,3, MD
CCM 2001
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.
•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)
•