Evolution of Shock Monitoring and ICU Scoring

NTUH Anesthesiology/SICUNTUH Anesthesiology/SICU

YuYu--Chang Chang YehYeh

ShockShock

組織灌流不足組織灌流不足 ((HypoperfusionHypoperfusion))

氧氣供應不足氧氣供應不足//無法利用無法利用

休克重要觀念

•血壓115/40 (65) mmHg，有沒有休克?

RR 33/min

HR 140/min

BT 39.5 ℃Agitation

Analgesia

Precedex

Dopamine

Norepinephrine

Epinephrine

Vasopressin

Usual BP 185/95

CADICP = 30 mmHg

IAP = 30 mmHg

Diagnosis of Shock• Symptoms & signs

– Mental change (意識變化)

– Hyperventilation

– Tachycardia→→→hypotension

• Urine output < 0.5 mL/kg/h

• ABG (lactate > 4 mmol/L, base excess< -5, pH↓)

• SvO2 < 65% and ScvO2 < 70%

Intensive Care Med 2007;33:575–590

Differential diagnosis

Current Opinion in Critical Care 2007, 13:318–323

Hemodynamic monitoring Hemodynamic monitoring

Ensure adequacy of perfusionEnsure adequacy of perfusion

Titrate therapy to specific Titrate therapy to specific

endpoints of resuscitation endpoints of resuscitation

Predict prognosisPredict prognosis

Parameters of hemodynamic monitoring

• Measured variables

– Heart rate/rhythm

– SBP/DBP

– CVP

– PAP/PAOP

– Cardiac output

– LVEF/RVEF

– SpO2 / ScvO2/SVO2

• Calculated variables

– MAP

– MPAP

– Cardiac index

– SV / SVI

– SVR / PVR

– RVEDV (100-160 ml)

Heart functions

• Rate/Rhythm – ECG

• Blood pressure – NIBP/Arterial blood pressure

• Preload – CVP/PAOP/Echo/CCO(Flo-Trac)/PiCCO

• Contractility – TTE/TEE

• Valvular function – TTE/TEE

• Cardiac output – PAC/CCO/PiCCO

• Afterload – PAC/CCO/PiCCO

• Myocardial ischemia and failure - Cardiac enzyme

(CK, CK-MB, Troponin-I) and proBNP

△CVP 觀念

•CVP絕對值是參考指標 (8-12[12-15])

–PEEP 10 cmH2O對CVP的影響?

•△CVP及治療反應可提供更多訊息，

–EX: CVP 4，MAP 45 mmHg

•輸500 ml NS→CVP 6，MAP 55 mmHg→繼續輸液

•輸500 ml NS→CVP 12，MAP 48 mmHg→小心輸液，注意心臟功能是否良好，考慮給強心藥物

–EX: CVP 8，MAP 110 mmHg，體重增加9 kg，HD

•HD脫水500 ml → CVP 8，MAP 105 → 繼續脫水

•HD脫水500 ml → CVP 2，MAP 50 → 停止脫水，補水

x 0.3

Systolic pressure variation (使用呼吸器時)

• If △ down > 10 mm Hg

• Or △ down + △ up >15 mm Hg

• → hypovolemia• → response to fluid challenge

Flo-Trac

• Continuous cardiac output

• Stroke volume index

• Calculated SVR

• Stroke volume variation - fluid responsiveness

• ScvO2 (Combined with PreSep CVP)

Stroke volume variation

• Prediction of fluid responsiveness

Eur J Anaesthesiol. 2004;21(2):132-8

Crit Care. 2008;12(3):R82

• May be influenced by

– Spontaneous ventilation

– Arrhythmias

– Tidal volume > 8 ml/kg (controlled mode)

Crit Care Med. 2008;36(10):2858-62

– Pressure support ventilation

Acta Anaesthesiol Scand. 2006;50(9):1068-73

CCO (FloTrac sensor, Edwards)

Simplified Physiologic Protocol

Developed by W.T. McGee, MD, MHA, Tufts University Medical School

Normal Range

Others

• Transthoracic echo (TTE)

• Transesophageal echo (TEE)

• NICO - partial CO2 re-breathing cardiac output

• Echo – SVC/IVC collapsibility – Preload

• Distribution volume of glucose – Preload

• Pulse pressure variations – Fluid responsiveness

• Whole-body electrical bioimpedance – Cardiac output

GoalGoal--directed treatmentdirected treatment

Goal directed treatment for Septic Shock

• ScvO2 CVP + Artery line (CCO)

– CVP > 8-12 (12-15) mm Hg

– MAP > 65 mm Hg

– Urine output > 0.5 ml/kg/h

– ScvO2 > 70%

• Hct > 30%

• Cardiac output

•↓Systemic oxygen consumption.

NEJM 2001;345:1368-77

Crit Care Med 2008; 36:296–327

Is everything ok when ScvO2 > 70% ?

ICU ScoringICU Scoring

Severity

Prognosis

Work loading

Quality control / assurance

ResearchOthers

Scoring system

• APACHE (Acute Physiologic and Chronic Health Evaluation)

• TISS (Therapeutic Intervention Scoring System)

• SOFA (Sequential Organ Failure Assessment)

• SAPS (Simplified Acute Physiologic Score)

• MPM (Mortality Prediction Model)

• ISS (Injury Severity Score)

• Organ specific scoring

APACHE I-IV

• 1981 – APACHE I

• 1985 - APACHE II

– Acute physiology score

– Age adjustment

– Chronic health evaluation

• 1991 – APACHE III (1999-I, 2002-J)

• 2006 – APACHE IV

Curr Opin Crit Care 2008;14:491–497

APACHE IV

– Acute physiology score/Age adjustment

– Chronic health evaluation

– Diagnosis

– Prior treatment location

– Logistical regression equation

• Predict mortality and ICU length of stay

– Provide daily updates of prognosis

http://www.mecriticalcare.net/icu_scores/apacheIV.php

Critical care medicine 2006;34(5):1297-310

Organ specific scoring

• Neurology – GCS, WFNS, Fisher scale (SAH)

• Cardiovascular surgery – EuroScore

• Lung – Lung injury score

• Liver – Child’s classification, MELD

• Kidney - RIFLE

• Pancreas – Ranson score

• DIC score

結論結論�� Shock monitoringShock monitoring

�� 目的目的––確保組織灌流足夠確保組織灌流足夠

�� 使用適當的監視器使用適當的監視器

�� 快速診斷快速診斷//快速處理快速處理//調整治療達到目標調整治療達到目標

�� 避免器官衰竭避免器官衰竭//改善預後減少死亡率改善預後減少死亡率

�� 善用善用Scoring systemScoring system

�� 判斷嚴重度及預後判斷嚴重度及預後

�� 決定治療方向決定治療方向

�� 提升照護品質提升照護品質

�� 研究新的治療研究新的治療

Thanks for your attention

Have a nice weekend!