il catetere arterioso polmonare: un presidio per pochi - Siti-Isic

Transcription

il catetere arterioso polmonare: un presidio per pochi - Siti-Isic
il catetere arterioso
polmonare: un presidio
per pochi pazienti o per
pochi medici?
luigi tritapepe
UOD Anestesia e Terapia Intensiva
In Cardiochirurgia
Sapienza Università di Roma
luigi.tritapepe@uniroma1.it
1970
Swan HJC, Ganz W et al. Catheterization of the heart
in man with use of a flow-directed baloon-tiped
catheter. N Engl J Med, 1970
disclosure: nothing to declare
It was possible to measure cardiac output and
stroke volume and pulmonary artery and pulmonary
wedge pressures with an accuracy and precision
adequate for clinical use.
The PAC was introduced initially to conduct a
safe and rapid right heart catheterization (RHC)
in patients with acute myocardial infarction.
1) The PAC is a diagnostic device only and has no therapeutic role.
2) Mortality/PAC: sicker pts received PAC monitoring.
3) Complication/PAC: poorly trained, unsupervised personnel, a long
period of continuous monitoring
Anesthesiology 2005; 103;890-3
CO/EF
SV 100 ml
EF 60%
SV 100 ml
EF 40%
SV 100 ml
EF 25%
Hemodynamic optimization
and
Swan-Ganz Catheters
Hemodynamic optimization
70
Cardiac Index > 4,5 L/min/m2
O2 delivery
> 600 ml/min /m2
O2 consumption > 170 ml/min/m2
60
50
40
30
20
10
0
Control
PAC control
patients
PAC hemodynamic
optimization
Perioperative oxygen debt
10
Survivors
without
complications
Surgery
Oxygen debt
L/m2
5
0
0
-5
-10
2
4
6
8
10
12
16
20
24
Survivors
with
complications
-15
-20
-25
-30
Non-survivors
York Study
Post-operative survival
100
Percentage survivors
95
90
85
epinephrine
Dopexamine
Control
80
75
70
65
60
0
20
40
60
80
Days after surgery
100
120
RED CAP SYNDROME
Shah MR, et al. JAMA, 2005
7 of 13 studies
have not target
8 of 13 studies
have not TS
PAC is not a drug
diagnostic tool
Hemodynamic Target: are
the end points right?
Are the guidelines observed?
monitoring tool
Are the population of patients
omogeneous?
What is the quality of the data?
goal-directed therapy
Practice guidelines for PAC – ASA 1993
PATIENT
PAC
PROCEDURE
PRACTICAL
SETTING
Anesthesiology 1993;78:380-394
CONTRAINDICATIONS
• Tricuspid or pulmonary valve mechanical
prosthesis
• Right heart mass (thrombus and/or tumor)
• Tricuspid or pulmonary valve endocarditis
Pulmonary Artery Catheter
COMPLICATIONS:
Insertion:
After insertion:
Arrhythmias (TV, FV) 0.3-63 %
Infection (0-22%)
Right bundle branch (0.1-4.3 %),
Septicemia
Total AVB (0-8.5 %)
Endocarditis (2.2 -100%)
Intracardiac and valve damage
Pulmonary infarction (0.1 -7 %)
Tromboembolic complication
Pulmonary artery perforation (0.06-0.2 %)
“Knotting” (loop)
Balloon rupture
JAMA 1996; 276(11)
200 pts
Intensive Care Med 2002;28:256-264
Harvey et al: PAC-Man 2005 Lancet
- Game Over?
1014 patients at 65
UK institutions:
NO DIFFERENCE
between PA cath
versus no PA cath
34
59-34=25
NEJM 2006;354:2331-24
1996
1995
2005
Critical Care Med 2008;36:3093-3096
If I do not see,
I do not think,
and I do not
damage
Additional Information
• PAP
• PAOP/CVP
• SVR/PVR
• DO2/VO2/SvO2
• CCO/cEDVI/REF
“Conditio sine qua non”
a) non vi sia perdita di indicatore
b) il mixing sia completo
c) il flusso sia costante
d) la temperatura di base sia costante
e) l'iniezione sia a bolo
f) il rapporto segnale/rumore sia adeguato.
Anaesthesia 2002;57:562-6
.....non vi sia perdita di indicatore
......il mixing sia completo
Insufficienza valvolare
Con insufficienze tricuspidale e polmonare vi è flusso anterogrado e
retrogrado con possibile sottostima della CO.
Nei pazienti in VAM è dimostrabile una IT (50% moderata/grave).
IT con PEEP è presente in 6 pazienti su 7.
La sottostima causata da IT e quindi dal recircolo, è bilanciata dalla
sovrastima causata dalla perdita dell'indicatore.
Anaesthesia 2002;57:562-6
......il flusso sia costante
Flusso non costante durante ventilazione
La ventilazione comporta variazioni in- ed espiratorie di flusso.
In inspirazione spontanea SV del VD aumenta, in espirazione si riduce.
L'inverso avviene durante MV.
Variazioni interindividuali dell'ampiezza della variazione di CO, ma
anche della fase del ciclo in cui tali variazioni avvengono.
Quindi si suole usare la media di 3-5 misurazioni effettuate random nel
ciclo respiratorio.
Anaesthesia 2002;57:562-6
3/5 TD random nell’arco del ciclo respiratorio
80 patients
8 injection5%of 10 NS
638 measurements
Acta Anaesth Scand 2004;48:1322-1327
......la temperatura di base sia costante
........il rapporto segnale/rumore sia adeguato
Fluttuazioni della temperatura di base
cicliche (respirazione)
slow temperature baseline drift
Temperatura dell'iniettato
normalmente non vi sono differenze fra T ambiente e T <5 oC.
Comunque, poiché il rapporto segnale/rumore è minore a T ambiente, la
riproducibilità è minore (maggiori variazioni).
Lo stesso vale per minori volumi.
Anaesthesia 2002;57:562-6
watch the waves, not the numbers!
watch the waves, not the numbers!
Wedge alta (20 mmHg).
PAP alta (ipertensione) con un
gradiente tra PAD e Wedge di 9
mmHg.
watch the waves, not the numbers!
Wedge elevata. Onde a e v
male interpretabili –
dovrebbero essere 28/35, 25
mmHg.
Ipertensione polmonare con
assenza di gradiente (wedge
media = PAD).
watch the waves, not the numbers!
Prima della trombolisi
Dopo la trombolisi
watch the waves, not the numbers!
watch the waves, not the numbers!
Eguaglianza P diast.
Tamponamento cardiaco
watch the waves, not the numbers!
watch the waves, not the numbers!
watch the waves, not the numbers!
watch the waves, not the numbers!
Limitations
• Respiratory variation
• Valvular problem
• Intracardiac shunts
• Dysrhythmias
• Invasiveness
how many hours?
no more than 72 hrs
PAC use is now reduced in the
world
-Performance
-Preload evaluation
TEE
ASEcho guidelines
No routinary use in CABG!
Postop evaluation
hemodynamic instability
echo
RV
re-evaluation
is heart the
problem?
yes
no
PAC
secondary to
PH
vasodilator,
iNO
LV
low CO
high CO
primary
Systolic
dysfunction
Measure
CO
Inotropes,
vasopressors
Diastolic
dysfunction
Warning for AF,
avoid inotropes,
diuretics, etc.
Hypovolemia
Fluid
challenge
until obtain hemodynamic goals
(PA>65 mmHg, UO > 1,5 mlKg/hr, SvO2 >70%, < lactates)
vasoplegia
vasopressors
winning combination
Cardiac filling
pressures are
poor measures
of preload and
volume
responsiveness
Squara et al. Chest 2002;121:2009-15
Dispersion of suggested treatments after PAC 1
Dispersion of suggested treatments before PAC 1
Filling
50%
Don’t know
40%
Filling
80%
Diuretics
Dont know
30%
10%
20%
Dobutamine +
0%
Vasodilators
Diuretics
40%
20%
PEEP
60%
PEEP
Dobutamine -
Vasodilators
Dobutamine +
0%
Dobutamine -
ESICM
SRLF
Vasopressors
Dobutamine =
Vasopressors
Dobutamine +
SCCM
Pressure
Volume
Flow
AP:Hypo/Hyper
PA: Hypo/Hyper
CVP:/PAOP
Dynamic
ITBVI/GEDVI
CEDVI
EDAI
CO TD
CO TPID
CCO/PCCO/PulseCO
/APCO
SVV/PPV/SPV
FTc
cRVEF
ECHO
ScVO2
ScVO2
DO2I/VO2I/SvO2
my own conclusion (1)
swan-ganz is still useful:
•for measuring CO and “SvO2”
•for optimizing mismatch DO2/VO2
•for diagnosis and tailored treatment of PH
•in every situation in which pulse contour CO
measure is not reliable
three key principles: correct measurement,
correct data interpretation, and correct application.
my own conclusion (2)
• because I think they are few doctors
able to make the best use of the PAC
data, it is better that few patients
receive Swan-Ganz catheter
follow the guidelines and the decision making algorithm, but……….
critically
ie: BLS, the goal is
chest compression
ventilation
and