Acute heart failure in the ICU

Fabio Guarracino

Dept. of Anaesthesia and Critical Care Medicine

Cardiothoracic Anaesthesia and ICU
Azienda Ospedaliero Universitaria, Pisa, Italy

No disclosure

Hemodynamic derangement

Low BP
Low cardiac output
Tachycardia
Filling pressures ?
Low urine output
Low ScVO2 / SVO2
Increased lactate
Increased BNP

Acute heart failure in ICU

Myocardial dysfunction

Ventricular function

Acute arrhythmias
Tamponade

Pericardial space

Volume mismatch
haemorrage
renal function

Volume assessment

Sepsis

RV dysfunction

Pulm. Artery & RH

STROKE VOLUME

STROKE VOLUME

Acute failure?

Same signs and symptoms

Hemodynamic monitoring
Pulse contour analysis
Thermodilution

Bioimpedance
Oesophageal Doppler

LIDCO
..

Hemodynamic derangement

Low BP
Low cardiac output

Tachycardia
Filling pressures ?
Low urine output
Low ScVO2 / SVO2
Increased lactate

Hemodynamic categorizations

Hypotensive

Low CO
Vasodilated
Vasoconstricted

Fluid responder
..

The numbers we love to treat

BP

Volume status
Cardiac output

Urine output
ScVO2 / SVO2
Lactate

Diagnosis: definition
The process of indentifying the nature and cause
of a disease through evaluation of patient history,
examination of symptoms and signs, and review
of laboratory and other investigation data.

Hemodynamic instability
Hypotension
Low CO
High SVR

Low SVR
Filling pressures ?

Low urine output

Low SvcO2/SVO2

Hemodynamic instability
Hypotension
Low CO
High SVR

Low SVR
Filling pressures ?

Low urine output

Low SvcO2/SVO2

Hemodynamic instability
Hypotension

Low CO
High SVR

Low SVR
Filling pressures ?
Low urine output
Low SvcO2/SVO2

Hemodynamic instability
Hypotension
Low CO
High SVR

Low SVR
Filling pressures ?

Low urine output

Low SvcO2/SVO2

Hemodynamic instability
Hypotension
Low CO
High SVR

Low SVR
Filling pressures ?

Low urine output

Low SvcO2/SVO2

Hemodynamic instability
Hypotension
Low CO
High SVR

Low SVR
Filling pressures ?

Low urine output

Low SvcO2/SVO2

Hemodynamic instability
Hypotension
Low CO
High SVR

Low SVR
Filling pressures ?

Low urine output

Low SvcO2/SVO2

Hemodynamic instability
Hypotension
Low CO
High SVR

Low SVR
Filling pressures ?

Low urine output

Low SvcO2/SVO2

Acute heart failure in ICU

Myocardial dysfunction

Ventricular function

Acute arrhythmias
Tamponade

Pericardial space

Volume mismatch
haemorrage
renal function

Volume assessment

Sepsis

RV dysfunction

RVF & Pulm. Circ.

HD monitoring: pittfalls
Method

System

Thermodilution

PA catheter
Catheter CCOmbo

Transpulmonary
indicator

PiCCO
LiDCO

Arterial-pressure
waveform derived
Dopplers principle

Bioimpedance (T, ET)

Bioreactance

Pittfalls
IT
PFO & shunt
ASD VSD
IT
Intracardiac shunt
AoV disease

Vigileo (Flotrac)
MostCare (PRAM)

AoV disease
AF
Arrhythmias

Esophageal Doppler

AoV disease

BioZ, ECOM, Lifegard

NICOM

AoV regurgitation
AF
IABP

AHF in ICU
Acute hemodynamic derangement
Diagnosis and pathophysiology to be elucidated
Echocardiography plays a major role
Treatment should target the etiology