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Daniel De Backer Department of Intensive Care Erasme University Hospital Brussels, Belgium

DOES MONITORING REGIONAL CIRCUALTION VARIABLES INFLUENCE OUTCOME ?. Daniel De Backer Department of Intensive Care Erasme University Hospital Brussels, Belgium. PATHOGENESIS OF ORGAN FAILURE IN SEVERE SEPSIS. WHOLE BODY. REGIONAL. gastric tonometry ShO2 ICG. ORGAN FAILURE.

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Daniel De Backer Department of Intensive Care Erasme University Hospital Brussels, Belgium

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  1. DOES MONITORING REGIONAL CIRCUALTION VARIABLES INFLUENCE OUTCOME ? Daniel De Backer Department of Intensive Care Erasme University Hospital Brussels, Belgium

  2. PATHOGENESIS OF ORGAN FAILURE IN SEVERE SEPSIS WHOLE BODY REGIONAL • gastric tonometry • ShO2 • ICG ORGAN FAILURE MICROCIRCULATORY MITOCHONDRIAL • OPS (sublingual) • PslCO2

  3. IS THERE A LINK BETWEEN REGIONAL AND SYSTEMIC CIRCULATIONS ?

  4. LeDoux et al CCM 28:2729;2000

  5. LeDoux et al CCM 28:2729;2000 => Manipulation of global hemodynamics may fail to alter regional circulations

  6. +++ Severe sepsis (50) Percentage of vessels perfused (small vessels) % 100 De Backer et al AJRCCM 166:98-104;2002 80 60 40 20 0 Volunteers (10) +++ p <0.001 vs volunteers DDB USI

  7. Influence of systemic factors on the microcirculation ?

  8. Nakajima et al AJRCCM 164:1526:2001 Mice intravital µscopy Low ETX: 1.5 mg/kg, MAP 70 mmHg High ETX: 10 mg/kg, MAP 40 mmHg HEM: MAP 40 mmHg

  9. De Backer et al AJRCCM 166:98;2002

  10. De Backer et al CCM 34:403;2006 Change in capillary perfusion % DOBU 5 mcg/kg.min L/min.M² Change in cardiac index

  11. De Backer et al CCM 34:403;2006 Change in capillary perfusion % DOBU 5 mcg/kg.min mmHg Change in arterial pressure

  12. IS THERE A LINK BETWEEN REGIONAL AND SYSTEMIC CIRCULATIONS ? No: regional and microcirculatory alterations may occur, even after correction of global hemodynamic alterations.

  13. DOES MONITORING OF REGIONAL CIRCULATIONS OR MICROCIRCULATION PREDICT OUTCOME ?

  14. ICG-PDR Sakka et al Chest 122:1715:2002

  15. ICG-PDR Sakka et al Chest 122:1715:2002

  16. Gastric tonometry in septic patients • Increased mucosal PCO2 (or decreased pHi) • Maynard et al JAMA 270: 1203; 1993 • Friedman et al CCM 23: 1185; 1995 • Oud et al Chest 115: 1390; 1999 • Levy et al CCM 31: 474; 2003 Association with outcome

  17. PCO2gap as a marker of mortality in ICU ventilated patients Levy B et al CCM 31:474;2003 N = 95 patients

  18. PCO2gap as a marker of mortality in ICU ventilated patients Levy B et al CCM 31:474;2003 N = 95 patients

  19. Variables associated with outcome on admission and after hemodynamic stabilization Poeze et al CCM 33:2494;2005

  20. MICROVASCULAR PERFUSION IN SEVERE HEART FAILURE Heart failure and cardiogenic shock De Backer et al AHJ 147:91;2004 Capillary perfusion % 100 p < 0.05 80 60 40 20 0 Survivors Non Survivors

  21. ROC curve area: • Baseline: • APACHE II 0.74 • Lactate 0.68 • Changes between day 1 and day 2: • heart rate 0.57 • mean arterial pressure 0.53 • CVP 0.51 • PAOP 0.64 • cardiac index 0.51 • SvO2 0.52 • DO2 0.52 • VO2 0.50 • Lactate 0.63 • Microvascular perfusion 0.77 • SOFA score 0.61 Sakr et al CCM 32:1825;2004

  22. Sublingual capnometry in patients with circulatory failure Marik. Chest. 2001; 120:923 # 22 patients (76 data sets) Admission PslCO2-PaCO2 (mm Hg) *

  23. Sublingual capnometry in patients with circulatory failure Rackow et al. Chest. 2001; 120:1633 # 50 patients Admission PslCO2-PaCO2 (mm Hg) *

  24. Sublingual capnometry versus traditional markers of tissue oxygenation in critically ill patients Marik et al. Crit Care Med. 2003; 31: 818-822 N = 54 ICU unstable ICU patient (septic shock 39%) Prediction of mortality Best cut-off value for PslCO2-gap : 25 mm Hg

  25. DOES MONITORING OF REGIONAL CIRCULATIONS OR MICROCIRCULATION PREDICT OUTCOME ? Yes: monitoring regional and microcirculatory alterations may help to identify patients at greater risk of death

  26. RESUSCITATION CENTERED ON REGIONAL CIRCULATIONS ?

  27. EFFICACY OF pHi GUIDED THERAPY Gutierrez G et al Lancet 339:195;1992 260 critically ill patients Therapy guided on pHi (dobutamine-fluids), goal = 7.35 Data analyzed according to 2 subgroups (pHi < or >7.35)

  28. EFFICACY OF pHi GUIDED THERAPY Gutierrez G et al Lancet 339:195;1992 Survival rate % Days after admission in ICU

  29. EFFICACY OF pHi GUIDED THERAPY Gutierrez G et al Lancet 339:195;1992 Survival rate % Days after admission in ICU

  30. Mythen M et al.

  31. Problems with these interventional studies: • Underpowered studies • Investigate the technique as well as the interventions

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