Cardiovascular support

Tom Woodcock Southampton University Hospitals

http://www.scolopax.co.uk/

Systemic Inflammatory Response Syndrome

The clinical manifestation of hypermetabolism that may occur after a lifethreatening insult Defined (SCCM) as two or more of the following;
Pyrexia (>38C) or hypothermia (<36C) Tachycardia (>90bpm) Tachypnoea (>20 bpm or PaCO2 <4.3kPa) White cell count >12x10-9/L or <4x10-9/L or >10% band forms

Sepsis & MODS definitions (SCCM)

Sepsis Severe sepsis Systemic inflammatory response to infection. Criteria as for SIRS. Sepsis associated w ith organ dysfunction, perfusion abnormality, or hypotension. Sepsis w ith hypotension (unresponsive to adequate fluid resuscitation) and perfusion abnormality (e.g. lactic acidosis, oliguria, acute alteration in mental status). Systolic blood pressure <90mmHg or <40mmHg below baseline for the patient. Presence of altered organ function in an acutely ill patient such that homeostasis cannot be maintained w ithout intervention.

Septic shock

Hypotension Multiple organ dysfunction syndrome (MODS)

SIRS/MODS initiators

Trauma
accidental surgical multiple blood transfusions fat embolism syndrome

Sepsis
Primary infections Nosocomial infections

Shock (ischaemic & reperfusion injury)

hypovolaemic, cardiogenic, distributive.

Burns Non-septic inflammatory disease

pancreatitis amniotic fluid embolism diabetic ketoacidosis

Ventilator induced lung injury (VILI) Double hit theory

priming the immune system?

SIRS/MODS pathophysiology

direct tissue cell injury by angry white cell attack

systemic inflammatory response compensating anti-inflammatory response

indirect tissue cell injury by dysoxia

VO2/DO2 mitochondrial utilisation block

the gut as the motor of sepsis

translocation of organisms and toxins

SIRS/MODS risk factors

inadequate or delayed resuscitation persisting septic or inflammatory process chronic organ dysfunction or failure age alcohol abuse, hepatic dysfunction or cirrhosis

bowel infarction, surgical misadventures diabetes mellitus immune impairment;

malignancy, malnutrition, morphine, steroids, AIDS.

Improving the outcome from SIRS/Sepsis

Resuscitation

Posture;

Early, rapid

Anti-microbial therapy Fluid balance;

supine position is bad for you enteral is best. i.v. insulin to keep blood glucose in normal range.

Feeding;

ARDS is usually preceded by positive fluid balance (weight gain) and hypoproteinaemia supported ventilation preferred to controlled use normal tidal volumes during PPV.

Insulin resistance

Ventilator prescription;

Anti-inflammatory therapy

rhAPC (when available). Hydrocortisone?

Thromboprophylaxis

Pre-emptive therapy I
-trying to reduce morbidity and mortality in surgical patients

surgical patients achieving supranormal (150%) DO2 have lower risk of mortality. sympathomimetic therapy to achieve supranormal DO2 can reduce postoperative mortality for very high risk groups (>20% mortality in control group)

Pre-emptive therapy II
-trying to reduce morbidity and mortality in surgical patients volume challenge (gelofusin) against stroke volume (Doppler aortography) can reduce post-operative morbidity Sympatholytic therapy (beta blockade with atenolol or bisoprolol) can reduce cardiac morbidity and mortality after major surgery in patients with or at risk of ischaemic heart disease

Speculation; are other sympatholytics such as alpha-2 agonists or thoracic epidural analgesia as efficacious?

Shock and resuscitation.

Shock

is an acute syndrome of circulatory insufficiency leading to inadequate tissue perfusion and cellular dysfunction.
Hypotension (systolic <90) Perfusion abnormalities

Sequential

resuscitation procedes until shock reversal.

Get a diagnosis for specific treatments.

High venous pressure

Tension pneumothorax Pulmonary embolism Pericardial tamponade Acute coronary syndromes

Low venous pressure

Haemorrhage Severe extra cellular fluid depletion Vasoparesis

Ventricular dysfunction Mechanical (valvular dysfunction, VSD etc)

Anaphylaxis Fulminant hepatic failure Endocrine emergency Septicaemia Tissue hypoxia Other causes of MODS

Shock reversal goals; cardiac output vs oxygenation

core-peripheral temperature gradient indicator dilution techniques Doppler flow velocity

ascending aorta descending aorta

perfusion abnormalities gastric tonometry

intramucosal pH, regional-arterial PCO2 difference

mixed venous blood analysis

oxygen saturation, acid base status

Sequential resuscitation.

Oxygen therapy.

Initially high FIO2 intravascular volume therapy inotropes?

II Cardiac output/ oxygen delivery by

A B

Early window of opportunity?

III Perfusion pressure to autoregulatory range by pressors. IV Augment microvascular perfusion?

Fluids or inotropes to increase the cardiac output?

fluids Improved DO2 with preserved autoregulation Increased Qt with increased stroke volume Excess leads to oedema Receptor downregulation inotropes possible steal

increased heart rate cardiac ischaemia a problem.

Which fluids?
increased mortality for resuscitation with colloids increased mortality for resuscitation with albumin increased mortality for liberal red cell transfusion in intensive care

Crystalloids are mainstay of fluid therapy but avoid drowning

Special caution in acute lung injury and hepatic failure

Restrictive / selective approach to use of colloids/ albumin/ blood products.

E.g. hepatorenal syndrome. E.g. acute coronary syndromes.

Functional assessments of adequacy of ventricular preload

filling pressures are a poor index of ventricular preload so continue fluid resuscitation until the stroke volume no longer responds to changes in preload

stroke volume assessed by Doppler aortic flow, indicator dilution square wave arterial pressure response during strain phase of Valsalva manoeuvre Systolic pressure variation, pulse pressure variation.

Systolic pressure variation as an indicator of hypovolemia Rooke G. A. Current Opinion in Anaesthesiology 1995, 8:511-515.

Delta Down < 5 mmHg

significant hypovolemia is unlikely,

Delta Down is the difference in systolic pressure at endexpiration and the nadir during the respiratory cycle. during mechanical ventilation the nadir occurs in the early phase of expiration.

Delta Down > 10 mmHg

appears to be associated with a blood volume deficit of at least 0.5

Compare pulsus paradoxus in lung diseases.

Filling pressures
ventricular preload not always proportionate to CVP or PAOP pulmonary capillary pressure not reliably measured by PAOP SVC pressure important in ALI as it determines thoracic duct pressure. intrathoracic blood volume a useful concept?

PAOP and LV preload

end diastolic muscle fibre length end diastolic volume end diastolic transmural pressure
compliance pericardial/ pleural pressure

left atrial pressure

mitral valve dysfunction

pulmonary artery occlusion pressure

West zone tachycardia

Transmural vascular pressure

Transmural = vascular - pleural pressure Transpulmonary = alveolar - pleural

Perfusion pressure.
normal autoregulatory range is MAP 70-140mmHg. may be higher in chronic hypertensive patients. consider perfusion pressure if ICP (for brain) or intraabdominal pressure ( for kidney) elevated. judicious use of pressors in patients with hyperdynamic circulation can restore function of these vital organs.

Regulating vascular tone

sympathetic vasopressin Renin/ angiotensin

Mediators of Norepi, epi constriction

Pharm. antagonists
Alpha and beta antagonists

AVP

Angiotensin
(plasma renin activity)

ACEI

Commonly used adrenergics

Norepinephrine (0.02-0.2mcg/kg/min)

pressor

Epinephrine (0.02-0.2 mcg/kg/min)

inopressor may cause lactic acidosis Dopamine (5-20 mcg/kg/min) inopressor inhibits anterior pituitary hormones Dobutamine (2.5-25 mcg/kg/min) inotrope Dopexamine (0.5-2 mcg/kg/min) Inodilator

Flexible combinations, e.g Norepi + Dob

Phosphodiesterase inhibitors

... competitively inhibit cyclic nucleotidase phosphodiesterase FIII in cardiac and vascular smooth muscle.
bipyridine

amrinone, milrinone enoximone, piroximone

specific for cGMP sensitive enzyme

imidazole

benzimidazole

sulmazole, pimobendan

Adrenocortical insufficiency?

absolute; cortisol < 280nmol/L

Give hydrocortisone +/- fludrocortisone response to Synacthen; rise <250nmol/L Patients with relative adrenal insufficiency benefit from hydrocortisone/ fludrocortisone supplements for 7 days.

relative?

therapeutic implication

Resistance to alpha 1 agonists

alternative pressors

vasopressin infusion, terlipressin angiotensin II infusion steroids false NOS substrate eg N-methyl aspartate methylene blue diaspirin or polyoxyethylene cross-linked haemoglobin

iNOS / Guanylate cyclase overactivity

NO scavengers

Augment microvascular perfusion?

renal dose dopamine agonists

splanchnic vasodilation, GI mucosa protection

GTN, vasodilator prostanoids (epoprostenol, alprostadil)

general vasodilation

n-acetyl cysteine
corrects glutathione depletion free radical scavenger increases VO2 and DO2

pentoxifylline
red cell deformability, TNF levels reduced

Mechanical circulatory assist

Intra-aortic balloon counterpulsation stabilises mortally ill patients with acute coronary syndromes (MAST, external lower body counterpulsation)

Ventricular assist devices as a bridge to transplant and for post- cardiac surgical shock (ECMO for meningococcal shock)

Recommended drugs;

for high-risk surgery

see Eagle & Fleisher NEJM 2001;345:1677-82

Identify risk factors

Higher risk surgery Heart disease (ischaemic, ventricular failure etc) Diabetes mellitus Renal insufficiency Poor functional status

Beta-block
Atenolol or metoprolol; hr <60

Recommended drugs;

Shock complicating acute coronary syndromes

Lancet 2000 vol 356:749

estimated LVEDP high,

systolic BP >100

Diuretic + inodilator Inopressor

systolic BP<100

Estimated LVEDP low, high CVP

systolic BP<100 (right ventricular failure);

Volume loading + Inopressor

Recommended drugs;

Vasodilatory shock
see Landry & Oliver NEJM 2001;345:588-95

Volume loading Norepinephrine Consider hydrocortisone, vasopressin (or terlipressin).

Recommended drugs;

Anaphylaxis
Epinephrine Volume loading Hydrocortisone, antihistamines