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