Cardiac Output in

Clinical Practice
Differentiation the etiology of
hypoperfusion using cardiac output
monitoring

Sejarah syok
1960s
Sejak 1905 Sfignomanometer
Syok = Hipotensi
1970s
Swan & Ganz
Syok = Hipovolemik, cardiogenik, distributif
1980s
Teori supranormal value in High risk surgery (Shoemaker),
Syok = hipoperfusion/ Decrease DO2 (oxygen delivery)
2000s
SvO2 (saturasi mixed vein), ditemukan sebagai target end-point
resuscitation pada tissue
Syok = ketidakseimbangan antara oksigen delivery dan oksigen
konsumsi DO2/VO2
2009-presents
Anaerobic metabolisme Hyperlactatemia indikator dari tissue
hypoperfusion atau Imbalance between DO2 and VO2
Dont take the vitals, take the lactate

SO WHAT IS
SHOCK ?

SO..SHOCK IS NOT
HYPOTENSION BUT
HYPOPERFUSION
(REDUCED OXYGEN DELIVERY TO MEET
THE OXYGEN CONSUMPTION)

PHYSIOLOGY OF THE DO2/VO2 RELATIONSHIP

THE OXYGEN CASCADE

Uptake in the Lung

PaO2

CaO2
Carrying capacity
Delivery

SaO2

DO2

Flow rate

Organ distribution
Mikrosirkulasi
Diffusion

VO2

Cellular use

ATP = energy

In Shock

1. There is an Imbalance between the oxygen

demand of the tissue and the oxygen delivery
2. Reduced oxygen delivery is the key factor
(Hypoperfusion)

RESUSCITATION FROM
SHOCK IS

To restore the imbalance between

oxygen demand to the oxygen supply

HOW TO RESTORE THE

IMBALANCE DO2 and VO2

 Intubation Mech
Ventilation
Sedation & Muscle
relaxation
Betabloker

Microvascular pressure (fluid

load)(?)
Microcirculatory recruitmenr
(vasodilator and inhibitor of
vasoconstriction)(?)
Rheology(anticoagulant,antiaggregants)(?)

Reduce O22
Demand

Optimization
of oxygen
consumption

Microcirculation

Microvascular permeability
(attenuation of tissue oedema
(?)
Blood purification (e.g. CVVH,
inhibitors of cytokines and
mediators
(?) uptake
Oxygen

(mitochondrial
function)

Management of shock
1. Optimization
Oxygen saturation

Respiratory support
Additional oxygen and
physiotherapy

1. Contractility

Contractility (inotropes, betablockers)

Heart rate and rhythm
(pacing,chronotropes, antiarrytmics, anesthetics/sedatives
Valvular function (repair,
replacement)

Optimization
of oxygen
delivery
3. Cardiovascular
performance
(cardiac output)

2. Hemoglobin
concentration

RBC transfusion
Blood saving
tachnologies

2. Preload

3. Afterload

Fluid load (colloids or

crystaloid)
Fluid removal (diuretics,
ultrafiltration, restrictive
fluid therapy)

Vasopressor/vasodilators
Regional anaesthesia
Intra-aortic baloon pump

Assesment of DO2
Clinical evaluation of Consciousness and
Urine Output
Calculated using formula
Blood Lactate faster

Oxygen Delivery
DO2 = CI (L/min/m2) x CaO2 (L/min/m2)
DO2 =

(1.34 x Hb x SaO2) x 10

DO2 =

(1.34 x 14 x 0.98) x 10

DO2 = 551 ml/min

(10 dL/L adalah kator koreksi, sebab CI dalam L/min/m2 sedangkan CaO2
in ml/dl)

Normal Range (CO): 800 1000 ml/min

Normal Range (CI) : 520 - 720 ml/min/m2

Serum Lactate
1. Peningkatan kadar laktat darah mengindikasikan
terjadinya ketidak seimbangan antara oksigen delivery
dan oksigen konsumsi (shock) di tingkat selular,
menandakan sel melakukan metabolisme tanpa adanya
oksigen (metabolisme anaerob) yg menghasilkan laktat.
2. Penurunan kadar laktat darah selama resusitasi
menunjukkan keberhasilan resusitasi

Kadar laktat yg berbahaya (Shock)

Aduen, et al. JAMA 1994;272:16781685

Hubungan kadar serum Lactate dengan cardiac

Index

Pathophysiology and monitoring

of decrease DO2

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Kompensasi mikro dan makro

dinamik untuk mempertahankan
TEKANAN DARAH tetap normal
SYOK TERKOMPENSASI
DO2 = Hb, SaO2 or CO

Kompensasi
Kompensasi
Microcirculation ScvOMacrocirculation
2
tekanan darah
tekanan darah
masih normal, mulai
masih normal
delirium dan aritmia kompos mentis dan
masih sinus ritme

Pada fase ini hipoperfusi sudah terjadi,

deteksi awal (SvO2 <70%) dan Lactate
mulai naik. Koreksi DO2 O
dan
kurangi VO2
Extraction
2
segera diperlukan (fase syok kompensasi)
Lactate

saat yg tepat untuk

intervensi
18

DIAGNOSTIC AND CLASSIFICATION OF

SHOCK BASED ON OXYGEN DELIVERY
DO2 =

CaO2 =
Hypoxemia,
Hemorrhagic
Arterial Oxygen
Content
poisoning

SaO2

2. Distributive Shock/ hyperdynamic

Lactate

shock

x 1.34 x Hb

1. Quantitative Shock/ hypodynamic

1. Decreased CaO2
2. Decreased Flow or CO

=
x

HypovolemicVasodilatoryCardiogenic
shock
shock
shock

Cytophatic
hypoxia

VO2
Septic
Shock/MODS

=
Capillary
Flow
recruitmentredistribution

N-Lactate

THE RELATIONSHIP
BETWEEN ARTERIAL
PRESSURE AND FLOW
(CARDIAC OUTPUT)
Blood pressure is the driving pressure to
perfuse organs and it is directly related to
cardiac output
MAP = CO x SVR

Cardiogenic
Shock/Acute
Heart Failure

Distributive/
Septic Shock

Vasopress
Inotropes
or VASCULAR RESISTANCE
SYSTEMIC

CONTRACTILITY

Pump = Pipe = Vascular BP = CO x SVR

Heart
Cardiac Output

Release
tamponade,
etc
Obstructive
Shock

CONTRACTILITY

Volume =
Blood

Fluid
s

PRELOAD
SVR

Hypovolemi
c Shock

PRELOAD

THE RELATIONSHIP BETWEEN BLOOD PRESSURE AND FLOW

(CARDIAC OUTPUT)
Homeostasis between CO and Vascular resistance to maintain normal
Blood Pressure (Poiseuille's Law)
Normal
Blood Pressure

Normal
Cardiac Output

Normal
SVR

Normal
Blood Pressure

Cardiac Output

SVR

Preload:
Hypovolemia
Haemorrhage

Normal
Blood Pressure

Contractility:
Cardiac Failure

Cardiac Output

Compensatory
response

Compensatory
response

SVR

Septic Shock
Anaphylactic Shock
Spinal Shock

George

Uptake in the Lung

PaO2

Oxygenation

CaO2
Carrying capacity

SaO2

Haemoglobin

Delivery

DO2

Flow rate

Cardiac Output

OXYGEN DELIVERY (DO2)

Cardiac Output (CO)

Heart Rate
(HR)

(SaO2 or SpO2)

Stroke Volume
(SV)

Hemoglobin (Hgb)

Parameters routinely meassure

Need tools

Preload

Afterload

Contractility

General Resuscitation
Principles

mfda

Treatment Priorities of
Circulatory Shock
Source Control/etiology:
1. Correct arterial
Resuscitation
and
(myocardial
reperfusion,
hypotension
antimicrobial, surgery,
If volume
responsive

removal of toxin/flow
obstruction)

Stabilization
If
Give vasopressor to
IV Fluids
doesnt

Transfusion??

work

If DONE

achieve adequate MAP

65-70 mmHg

not
2. Optimize DO2 (Increase Blood 1.Volume
responsive
2.Adequate MAP
Flow)
Critical Care Management
Cardiac Output
Further IV
Maintaining
tissue perfusion
Monitoring
Fluids
Transfusion??

Dobutamine

STEPWISE TREATMENT OF
CIRCULATORY SHOCK
CRITICAL CARE GOES TO EMERGENCY
ORGAN PROTECTION AFTER RESUSCITATION AND
STABILIZATION

1. RESUSCITATION AND STABILIZATION

(Achieving the Pressure)
Treat hypotension

If volume responsive

IV Fluids
Transfusion??

Source Control - Damage Control:

(myocardial reperfusion, lifethreatening antimicrobial, emergency
surgery, removal of toxin/flow
obstruction, pleural puncture)

If failed to
improve MAP
Central venous line

Protect airway & reduced work

of breathing:
CPAP, Intubation, Mechanical
Ventilation

Give vasopressor to
achieve adequate MAP
65-70 mmHg

George

2. MAINTAINING OXYGEN DELIVERY

(Maintaining The Flow)
After Resuscitation &
Stabilization

Occult
Hypoperfusion ?
Lactate
>2

<2
Heart Rate
Normal

Tachycardia

Hb < 8

Cardiac Output
Monitoring

SpO2 < 95%

Transfusion
Bradycardia

Isoproterenol,
Pacemaker

PEEP

WOB
Sedation/NMB
A

Low Stroke Volume

Preload

Contractility

Afterload

Fluid

Dobutamine

Vasopressor

Re-check
lactate

If normal INTENSIVE CARE UNIT

Georg
e

TERIMAKASIH

mfda