Professional Documents
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USCOM Background Slides
USCOM Background Slides
Individualized haemodynamic
Management
www.uscom.com.au The Measure of Life
Circulation the big picture
Preload CO Afterload
Systemic
Fluid volume Vascular
Resistance
Vasodilators
Inotrope
Increase +ve or -ve contractility, SV + CO
Decrease afterload, increase CO
Volume expansion- packed red cells, Nitrpprusside and nitrates
Dobutamine and dopamine
crystalloid, colloid Vasopressors
Decrease Chronotrope Increase afterload, decrease CO
Rate control Epinephrine and norepinephrine
diuretic
AND
100 BP = CO x SVR
Blood Pressure
Compensated Decompensated
Shock Shock Cardiac Output
Time SV x HR
BP CO and BP DO2
Anybody NOT (Courtesy
www.uscom.com.au wantof Drto know her CI,The
Joe Brierley, GOSH, London.)
SVRI, DO2?!!
Measure of Life
a very poor relationship between CVP and blood
volume
inability of the CVP/CVP to predict haemodynamic
response to a fluid challenge
USCOM 1A
Quantitative
Safe
Sensitive
Accurate
Reproducible
Economical
x
Vti (stroke distance) CSA
(directly measured by USCOM)
www.uscom.com.au The Measure of Life
Flow Area
Flow area (OTD) determined by Algorithm
Linear relationship with Height
Neonates (<50cm/20ins) Weight
Height Area
Nidorf SM, Picard MH, Triulzi MO, Thomas JD, Newell J, King ME, Weyman AE. New perspectives in the
assessment of cardiac chamber dimensions during development and adulthood. J Am Coll Cardiol 1992;19:983-8
USCOM 1.6
probe 1.4
1.2
Velocity (m/s)
Tank
1
FlowProbe
0.8
Flow USCOM
0.6
probe
Pump 0.4
0.2
0
-1 -0.8 -0.6 -0.4 -0.2 0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6
4
3.5
3
2.5
FlowProbe
2
USCOM
1.5
1
0.5
0
Dog1 Dog2 Dog3 Dog6 Dog7 Dog8
Professor Lester Critchley
CUHK, Prince of Wales Hospital
Hong Kong
http://www.ntac.nhs.uk/
Thiel SW, Kollef MH, Isakow W. Non-invasive stroke volume measurement
and passive leg raising predict volume responsiveness in medical ICU
patients: an observational cohort study. Critical Care 2009;39:666-688.
29
www.uscom.com.au The Measure of Life
The new standard of care
Asc Ao
AV AV AV AV
Ascending
Aorta
Aortic
Valve
Asc Ao
AV AV AV AV
Ascending
Aorta
Aortic
Valve
Pulmonary
Valve
Pulmonary
Valve
method of measuring CO in
Fremantle (Dey I, Sprivulis P. Emergency Physicians can reliably assess Emergency Department patient cardiac output using the USCOM
continuous wave Doppler cardiac output monitor. Emerg Med Aus 2005;17,193-199) "With the aid of an appropriate training package,
clinical staff with no prior ultrasonographic experience can be trained to reliably obtain cardiac output estimations."
100
90
80
70
60
% 50 Success
40
30
20
10
0
0 5 10 15 20 25 30 35 40 45 50
Cases
SpO2
hb
0.4
0.3
0.2
0.1
0 FTc=Flow Time
BNP CVP FTc corrected for HR
USCOM
* Sturgess DJ, Pascoe RLS, Scalia G, Venkatesh B. A comparison of transcutaneous Doppler corrected flow time, b-type natriuretic peptide and central venous pressure as
predictors of fluid responsiveness in septic shock: a preliminary study. Anesth Int Care 2009;38(2):336-341
Subjects included
- AF
- On and off ventilation
- On vasoactive therapies
Follows Frank-Starling
Theory
Fluid responsiveness not predicted by any other parameter. Thiel Critical Care 2009;13:R111
www.uscom.com.au The Measure of Life
Rational Circulatory Management
Rational and Personalised optimisation to Frank-Starling Curve
+ve
Dilator
Stroke
Volume
(mls) Constrictor
-ve
Preload (mls)
the mortality of
Deaths/Year
200,000
40 to 50% 0
what are we
missing?...
1.0ml/kg
1.2ml/kg
1.1ml/kg II = 1.68
II = 1.74
II = 1.65
Courtesy of:
Associate Professor Brendan Smith
School of Biomedical Science, Charles Sturt University,
Bathurst,
Courtesy Newof:South Wales, Australia.
www.uscom.com.au
Specialist in Anaesthesia and Intensive Care,
Professor Brendan
Bathurst Base Hospital, E. Smith
New South Wales, Australia. The Measure of Life
FLUID NON RESPONSIVE
(Negative response)
II = 0.94
II = 0.86
0.8ml/kg
II = 0.79
0.66ml/kg
0.75ml/kg
Courtesy of:
Associate Professor Brendan Smith
School of Biomedical Science, Charles Sturt University,
Bathurst,
Courtesy Newof:South Wales, Australia.
www.uscom.com.au
Specialist in Anaesthesia and Intensive Care,
Professor Brendan
Bathurst Base Hospital, E. Smith
New South Wales, Australia. The Measure of Life
~90% of severe sepsis and septic
shock patients have significant
myocardial depression with low
Inotropy!
Determinants are:
SV*, Flow Time*, Velocity*, Pressure.
www.uscom.com.au *) Measured by USCOM The Measure of Life
Measurement of Inotropy
Normal adults (1,467) = 1.6 2.2 W/m2
Normal INO pediatric = 1.4 to 2.0 W/m2
High CO, CI
Low SVR
High DO2
Low PKR
SVI < 45
FLUID HEART
PROBLEM >1.4 W/m2 <1.1 W/m2 PROBLEM
INO
If INO is between 1.1 and 1.3, try a small test dose of fluid. If SVI increases, carefully
add more fluid to achieve adequate SVI. If SVI does not increase give inotrope
www.uscom.com.au The Measure of Life
USCOM-Limitations
Advanced haemodynamics
* Haemodynamic understanding is Learning curve
limited USCOM Success with Experience
* Requires education to apply 100
90
Success
Ultrasound limitations 80
70
* Air, Bone, patient position 60
%
50
Operator learning curve 40
30
* 30-50 patients 20
* The more you do the better you get 10
0
Patient conditions
0 5 10 15 20 25 30 35 40 45 50