Monitoring of Heart-Kidney Interactions What Should we Monitor?

1. Monitoring of Heart-Kidney InteractionsWhat Should we Monitor? David Nelson, MD, PhD Director, Cardiac Intensive Care The Heart Institute Cincinnati Children’s Hospital

2. Is this the response to Low Cardiac Output Syndrome in your ICU?

3. Survival is a necessary, but insufficient definition of outcome

4. Neurologic Injury after Neonatal Congenital Heart Surgery • 2% overt neurological injury following pediatric heart surgery • 10% subclinical stroke in neonates undergoing surgery • 60% visuospatial/motor abnormalities, attention deficit, developmental delay by school age following neonatal surgery • HLHS survivors’ median IQ 66 • 57% cerebral palsy

8. Physiologic MonitoringHow effective is our current monitoring technology? • What is the incidence of “unanticipated” cardiac arrest in your ICU? • How quickly is LCOS detected in your ICU, and what is the sensitivity and specificity? • When LCOS is detected in a patient, do the interventions minimize the duration of LCOS? • Does monitoring cause complications (thrombosis, BSI’s, etc)

9. What is the best marker of inadequate O2 Delivery? What Should We Be Monitoring?Assessment of Low Output States

10. What is the best marker of inadequate O2 Delivery? What Should We Be Monitoring?Assessment of Low Output States

11. What is the best marker of inadequate O2 Delivery? Lactate is “too late” What Should We Be Monitoring?Assessment of Low Output States

12. What is the best marker of inadequate O2 Delivery? Lactate is “too late” The cardiac output needed depends upon the O2 Demand What Should We Be Monitoring?Assessment of Low Output States Cardiac Output?

13. What is the best marker of inadequate Oxygen Delivery in shock states?

14. What is the best marker of inadequate Oxygen Delivery in shock states? Hypoxic hypoxiaAnemia Hypovolemia Carbon Monoxide Dysoxia

15. What is the best marker of inadequate Oxygen Delivery in shock states? Regardless of the cause, SVO2 is the best marker of inadequate systemic and regional O2 delivery and anaerobic metabolism Hypoxic hypoxiaAnemia Hypovolemia Sepsis

16. We don’t need no new monitors! What data is there to support monitoring of blood pressure or heart rate? We tend to have different standards for new technology than for the old technology.

17. Diagnosis of low output statesClinical Signs of Low Output } • Pallor • Tachycardia • Tachpnoea • Altered mentation • GI distress • Olguria/Anuria • Acidosis • Lactate • Falling Venous or regional O2 saturation ??? If present then tissue hypoxia is already occuring

19. Capillary Refill and Toe Temperature Fail to predict Low Cardiac Output • Tibby SM et al. Arch Dis Child 1999;80(2):163-6“norm value for cap refill time of < or = 2 sec has little predictive value “ • Bailey JM et al.Crit Care Med 1990;18(12):1353-6“no signif relationship between cap refill or extremity (toe or finger) core temp gradients and cardiac index (CI)” • Butt W et al.Anaesth Intensive Care 1991;19(1):84-7“peripheral temp (toe temp), and core-peripheral temp difference …did not provide any guide to either CO or SVR.” • Raju NV et al.Clin Pediatr (Phila) 1999;38(3):139-44“no accepted standard for measuring decreased perfusion in the newborn “

20. Pediatric Critical Care Med, 2008 Conclusions: “We report the first case of a newly modified central venous catheter for children and demonstrate its utility in a patient with impaired oxygen delivery when traditional markers remain stable. This catheter enabled the rapid diagnosis of cardiac compromise due to pericardial effusion, leading to early treatment.”

22. Monitoring of Continuous Venous Oximetryis likely the “Gold Standard” for Cardiac Output Assessment • SVO2 is the best marker of inadequate systemic and regional O2 delivery and anaerobic metabolism • No Data on Continuous Oximetry and Acute Kidney Injury in Children Hypoxic hypoxiaAnemia Hypovolemia Sepsis

23. Use of Cerebral rSO2 as non-invasivesurrogate for mixed-venous saturation ???? Tortoriello et al, Pediatric Anesthesia, 2005.

28. Owens, Ped Cardiology 2011

29. Lactate Too Late Owens, Ped Cardiology 2011

30. Renal rSO2 Falls 4 hours Before Cardiac Arrest Owens, Ped Cardiology 2011

31. Physiologic MonitoringHow effective is our current monitoring technology? • What is the incidence of “unanticipated” cardiac arrest in your ICU? • How quickly is LCOS detected in your ICU, and what is the sensitivity and specificity? • When LCOS is detected in a patient, do the interventions minimize the duration of LCOS? • Does monitoring cause complications (thrombosis, BSI’s, etc)