Hemodynamic Monitoring for Next Pathway:

Basics of physiology, variables and how to interpret

them

Prof. dr. Iwan van der Horst

Head of the department of Intensive Care
Maastricht University Medical Center+
On behalf of the Cardiovascular Dynamics Section & NEXT
Conflict of interest
None
Basic physiology and variables
 Average ward 2022

MAP <60 MAP <60 MAP <60 MAP 0 MAP 65 MAP 70 MAP 65 MAP 70 MAP 72

T >40 HR >100 HR >100 ECG + HR >100 HR >100 HR >100 HR >100 HR >100

CRP >100 Lactate >4 Hb <4 pH <7 CRP 80 CRP 80 CRP 80 CRP 80 CRP 80

Renal transplant Diabetes Trauma Heart failure Coughing Coughing Coughing Coughing Coughing
Why? Could you please come to bed 2?

▪ ♀59 year
▪ St. aureus bacteremia
▪ ABP 85/48 mmHg
MAP <60 ▪ Urine output 45 ml/h
HR >100 ▪ Ventilated
Lactate >4 ▪ FiO2 40%
Diabetes ▪ Resp rate 14/min
▪ PEEP 5
What?

Fluids Vasopressor Inotrope Combination

How?

+ + +

Diagnosis:
septic shock
+ + Treatment:
fluids, AB,
vasopressor,
inotropic agent
Time
How? Learning goals

Kaufmann T, van der Horst IC, Scheeren TW. This is your toolkit in hemodynamic monitoring. Curr opinion in critical care 2020;26: 303-12
Physiology in a few slides
Why? Basic problem
• The incapacity to maintain adequate tissue perfusion causes
an increase in peripheral (microcirculatory) oxygen extraction,
together with the intervention of anaerobic pathways in order
to maintain cellular respiration
– Perfusion pressure - supply
– Global oxygen transport (DO2) - supply
– Oxygen consumption (VO2) - demand

https://www.cvphysiology.com
Gillespie M, Shackell E. Exploring the oxygen supply and demand framework as a learning tool in undergraduate nursing education.
Nurse Education in Practice 2017;27:107-113
Supply - Cardiac output

Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/, Jun 19, 2013
Stroke volume
Volume reservoir
 Preload ↑ Sympathetic stimulation or
increased filling Increased ventricular filling time

Greater expansion of the chamber

during filling at a given filling pressure

Sympathetic activation of venous smooth muscle

Head-down
Preload ↓
Hypovolemia or gravity

Ventricular hyperplasia
Mitral or tricuspid stenosis

Decreased filling time

Arrhythmias
Venous return curve
Venous return curve
Venous return and cardiac output

Med Intensiva 2017;41:483-6

Perfusion pressure
• Blood flow (F)
𝐹 = (𝑃𝑎 − 𝑃𝑣)/𝑅

• Arterial pressure = an estimation of tissue perfusion

– Current paradigm direct sense of organ
Autoregulation
• Local blood flow regulation
– Intrinsic ability of an organ to maintain a constant blood flow despite changes in
perfusion pressure
• F↓ → R↓ → F↑
• Mechanisms
1. Myogenic (arterial pressure)
2. Feedback (function)
3. Nonlinear interaction of 1. and 2. and varying over time
– Albeit different in different end-organs
• Good Coronary, renal, cerebral
• Moderate Skeletal, splanchnic
• Poor Cutaneous

Larsson JS, et al. Renal effects of norepinefphrine-induced variations in mean arterial pressure after liver transplantation: a randomized
cross-over trial. Acta Anaest Scan 2018;62:1229-36
Organ perfusion
Blood flow in a single vessel
1. vessel diameter (or radius)
2. vessel length
3. viscosity of the blood
Hematocrit,
temperature Fahraeus-Lindqvist effect
Demand - Oxygen consumption
• Oxygen extraction ~ oxygen consumption/F
• Oxygen extraction = 𝐶𝑎𝑂2 − 𝐶𝑣𝑂2

• F↓ → oxygen extraction ↑
Oxygen consumption and delivery
Association between DO2 and VO2

Should we monitor ScVO2 in critically ill patients?

△CO2

Gavelli et al. How can CO2-derived indices guide resuscitation in critically ill patients? J of Thorac Dis 2019
△CO2
Gillespie M, Shackell E. Exploring the oxygen supply and demand framework as a learning tool in undergraduate nursing education.
Nurse Education in Practice 2017;27:107-113
Hemodynamics without advanced monitoring
What’s NEXT?
1. Why do you obtain variables?
2. Which variables could help us in understanding
hemodynamics?
3. Which variables do you measure in each patient to guide
you?
Variables to obtain

Corradi F, Via G, Tavazzi G. What’s new in ultrasound-based assessment of organ perfusion in the critically ill: expanding the bedside
clinical monitoring window for hypoperfusion in shock. Intensive Care Med 2020;46:775-779
Variables to obtain

Teboul JL, Saugel B, Cecconi M, De Backer D, Hofer CK, Monnet X, et al. Less invasive hemodynamic monitoring in critically ill patients.
Intensive Care Med. 2016;42:1350–9.
FENICE study (2015)

Cecconi M, et al. Fluid challenges in intensive care: the FENICE study. Intensive Care Med 2015;41:1529-37
How to obtain variables?
• AVPU scale
– ‘Alert’, ‘responsive to Voice’, ‘responsive to Pain’ and
‘Unresponsive.’
– Part of the Modified Early Warning Score (MEWS)
– Part of the qSOFA (altered mentation)
• Physiologic examination (monitor)
– Heart rate, blood pressures, central venous pressure
• Urine output (ml/kg/h)
Consciousness and shock stages
Clinical gestalt

http://dx.doi.org/10.1098/rspb.2017.2430
 Temperature

Severity of illness
Altered mental status: diagnosis and prognosis

Kataja et al. Altered mental status predicts mortality in cardiogenic shock – results from the Card-Shock study. EHJ 2017
The determinants of cardiac output
• Variables
– Heart rate
– Blood pressure
• Trend
Heart rate: diagnosis

Sasse SA, et al. Relationship of changes in cardiac output to changes in heart rate in medical ICU patients. Intensive Care Med
1996;22:409-414
MAP and HR: diagnosis

61 high-risk trauma patients with accidental injury and 163 critically ill postoperative ICU patients

Wo CC et al. Unreliability of blood pressure and heart rate to evaluate cardiac output in emergency resuscitation and critical illness. Crit
Care Med 1993;21:218-23
Univariable outcome

SICS data
MAP: surrogate for perfusion pressure

Varpula et al. Hemodynamic variables related to outcome in septic shock. ICM 2005
MAP target: outcome

High versus low blood-pressure target in patients with septic shock. N Engl J Med 2014;370:17
Eyeballing preload variables

Rinehart J, et al. Visual estimation of pulse pressure variation is not reliable: a randomized simulation study. J Clin Monit Comput
2012;26:191-6
CVP does not predict volume status

Marik P, et al. Does Central venous pressure predicts fluid responsiveness, a systematic review. Chest 2008
CVP and fluid responsiveness: diagnosis

Marik P, et al. Does Central venous pressure predicts fluid responsiveness, a systematic review. Chest 2008
CVP and volume challenge: diagnosis

Osman D, et al. Cardiac filling pressures are not appropriate to predict hemodynamic response to volume challenge.
CVP: prognosis

Critical Care volume 24, Article number: 80 (2020)

Urinary output: prognosis

Heffernan et al. Association between urine output and mortality in critically ill patients. A machine learning approach. CCM 2021.
Urinary output: prognosis
How to perform clinical assessment appropriate?
+
• Temperature skin (Tskin): subjective
– Dorsal surface of hand on dorsum of foot, both extremities
should be cool
• Delta temperature (Tcentral-to-peripheral): objective
– Bladder/rectal and skin probe on big toe and dorsum of foot
• Capillary refill time (CRT)
– 15 seconds of firm pressure on sternum, knee and index finger
• Mottling
– Inspection and grading

Hariri G et al. Narrative review: clinical assessment of peripheral tissue perfusion in septic shock. Ann Intensive
Care 2019;9:37
Peripheral temperature: diagnosis

Joly, Weil. Temperature of the Great Toe as an Indication of the Severity of Shock. Circulation 1969
Peripheral temperature: diagnosis cardiac output
1st author, year N Population Site Non- Significant
significant
Kaplan, 2001 264* Severe injury and septic shock Foot ‘cool’ or ‘warm’ - 'Cool' : CI = 2.9 ± 1.2
'Warm': CI = 4.3 ± 1.2
Schey, 2009 10* Post cardiac surgery Foot ‘cool’, ‘cool- Tskin, objective: 'Cool' : CO = 3.71
warm’ or ’warm’ r=.11 'Cool-warm': CO = 4.83
Tskin, foot 'Warm' : CO = 5.12
Joly, 1969 100 Circulatory shock Tskin, toe - Tskin,toe: r=.71
ΔT: toe - ambient ΔTp-a: r=.73
Woods, 1987 26* Circulatory shock ΔT: central - toe ΔTc-p: no
correlation
Vincent, 1988 15* Cardiogenic and septic shock ΔT: toe - ambient No correlation ΔTp-a cardiogenic shock: r=.63
Bailey, 1990 40* Post cardiac surgery ΔT: central - toe Day of operation: Post-operative day 1: r=-.60
no correlation
Sommers, 1995 21* Post cardiac surgery Tskin, axillary, groin, No correlation on -
knee, ankle, toe any site
Boerma, 2008 35 Sepsis and septic shock ΔT: central - foot ΔTc-p: r=-.15 -
Bourcier, 2016 103* Sepsis and septic shock ΔT: toe - ambient No correlation -

* Repeated measurements in each patient. Abbreviations: CO, cardiac output; CI, cardiac index
Peripheral temperature: diagnosis

Hiemstra B et al. The diagnostic accuracy of clinical examination for estimating cardiac index in critically ill patients: the Simple Intensive
Care Studies-I. Intensive Care Med. 2019;1–11
Toe-ambient temperature in CS: diagnosis
Peripheral temperature: outcome

Bourcier S et al. Toe‐to‐room temperature gradient correlates with tissue perfusion and predicts outcome in selected critically ill
patients with severe infections. Ann Intensive Care 2016;6:63
SICS-I: independent but little additive value

Hiemstra B et al. Clinical Examination for the Prediction of Mortality in the Critically Ill: The Simple Intensive Care Studies-I. Crit Care
Med. 2019;47:1301-9
Capillary refill time: what is normal?

Schriger DL et al. Defining normal capillary refill: variation with age, sex, and temperature. Ann Emerg Med 1988;17:932-5
 Capillary refill time: what is (ab)normal?
1st author, year N Population Site Cut-off Findings
Beecher, 1947 1 “Severely wounded man” - “Normal”; “No shock”
“Definite slowing”; “Moderate shock”
“Very sluggish” “Severe shock”
Champion, 1980 1084 Critically ill trauma patients Nail bed, finger pad 2.0 s Embedded in Trauma score

Schriger, 1988 304 Healthy volunteers Middle finger 4.5 s

Bailey, 1990 40 Post cardiac surgery Thumb or great toe <1.5; 1.5-3.0; >3.0 s No relationship with CI
Anderson, 2008 1000 Healthy adults Index finger 3.5 s Upper limit 3.5 s (95% 3.4 – 3.7)

Lima, 2009 50 Critically ill Index finger 4.5 s -

Ait-Oufella, 2014 59 Septic shock Index finger, knee 2.4 s Index: 2.3 ± 1.8 vs 5.6 ± 3.5 s*
Knee: 2.9 ± 1.7 vs 7.6 ± 4.6 s*
Mrgan, 2014 3046 Medical admission unit Index finger 2.0 s OR 1.11 (0.58 – 2.13; p=0.75)**
4.5 s OR 4.24 (1.88 – 9.56; p<0.01)**

* Univariate; ** Multivariate
Capillary refill time: prognosis

Ait-Oufella H et al. Capillary refill time exploration during septic shock. Intensive Care Med 2014;40:958–64
SICS-I: no independent prognostic variable

Hiemstra B et al. Clinical Examination for the Prediction of Mortality in the Critically Ill: The Simple Intensive Care Studies-I. Crit Care
Med. 2019;47:1301-9
Skin mottling: what is (ab)normal?

0 to 5, depending on the extensiveness of the mottled area

Skin mottling: prognosis

Ait Oufella et al. Intensive Care Med 2011;37:801–7 - De Moura et al. Intensive Care Med 2016;42:479–80
SICS-I: prognostic factors

Hiemstra B et al. Clinical Examination for the Prediction of Mortality in the Critically Ill: The Simple Intensive Care Studies-I. Crit Care
Med. 2019;47:1301-9
Kaufmann T, van der Horst IC, Scheeren TW. This is your toolkit in hemodynamic monitoring. Curr opinion in critical care 2020;26: 303-12
Clinical assessment: prognosis
Largest study - retrospective

• Population: acute lung injury (n=405)

• Physical examination:
– CRT, mottling, cool extremities
• Measurement method: PAC, thermodilution CRT, mottling and
• Outcome: cardiac index <2.5 ml/min subjective skin
• Analysis: had LR+ of 7.52
– 92% correct estimations (all 3 signs present)
• Sens 12% (3–28%) Spec 98% (97–99%)
• PPV 40% (17–69%) NPV 93% (92–93%)
• LR+ 7.52 (2.23–25.3) LR– 0.89 (0.79–1.01)

Grissom CK et al. Association of physical examination with pulmonary artery catheter parameters in acute lung injury. Crit Care
Med 2009;37:2720-6
Physical examination and hemodynamic parameters

• Estimation of volume status in 71

patients
Diagnostic accuracy: 18 – 33 %
– 1 to 9
5 – 17% specificity 84 – 87%
Hypovolemia:
–sensitivity
1 means massive hypovolemic
Hypervolemia: volume
sensitivity 8 –status,
26% 9 means
specificity massive
74 – 76% fluid
overload
• Comparison PAC-derived measures
(GEDVI)

Saugel B et al. Physical examination, central venous pressure, and chest radiography for the prediction of transpulmonary
thermodilution-derived hemodynamic parameters in critically ill patients: a prospective trial. J Crit Care 2011;26:402-10
SICS-I: diagnosis of low cardiac output

Hiemstra B et al. The diagnostic accuracy of clinical examination for estimating cardiac index in critically ill patients: the Simple Intensive
Care Studies-I. Intensive Care Med. 2019;1–11
SICS-I: results

7 / 19 signs were independently associated with cardiac

index

Insufficient to estimate cardiac index in individual patients

Low sens, high spec

Hiemstra B, Koster G, Wiersema R, et al. The diagnostic accuracy of clinical examination for estimating cardiac
index in critically ill patients: the Simple Intensive Care Studies-I. Intensive Care Med. 2019;1–11
Laboratory values and hemodynamics
Laboratory measures
• SvO2
• ScvO2
• PCO2
• Lactate
ScvO2 as surrogate for SvO2

Reinhardt et al. Continous central venous and pulmonary artery oxygen saturation monitoring in the critically ill. ICM 2004
ScvO2: prognosis

Protti A, et al. Persistence of centrial venous oxygen desaturation during early sepsis is associated with higher mortality. A retrospective
analysis of the ALBIOS trial. Chest 2018;154:1291-1300
ScvO2: prognosis

Gattinoni et al. Understanding hyperlactatemia in human sepsis. AJRCCM

CO2 gap correlates with cardiac index

Cushieri et al. Central venous-arterial carbon dioxide difference as an indicator of cardiac index. ICM 2005
Causes of lactate acidosis
Identifying the cause – different approaches
• Supply
– A: absolute or relative tissue hypoxia
– B: no tissue hypoxia

• Factory
– Increased production
– Decreased removal
Lactate and prognosis
Laboratory variables: differential diagnosis

Scheeren TWL, et al. Understanding the carbon dioxide gaps. Curr Opinion Crit Care.
Interventions based on simple variables
Jansen TC et al. Am J Respir Crit Care Med. 2010
Lactate to guide teatment: outcome

Hernandez G et al. Effect of a resuscitation strategy targeting peripheral perfusion status vs serum lactate levels on 28‐day mortality
among patients with septic shock: the ANDROMEDA‐SHOCK randomized clinical trial. JAMA 2019;321:654–64
Target CRT to lower lactate: pathophysiology

Hernandez G et al. Effect of a resuscitation strategy targeting peripheral perfusion status vs serum lactate levels on 28‐day mortality
among patients with septic shock: the ANDROMEDA‐SHOCK randomized clinical trial. JAMA 2019;321:654–64
Conclusion
Many variables are available to get insight in underlying mechanisms and these
variables can be used for prognosis
Care has to be taken to translate individual variables into decisions
More data is needed on multiple basic variables in more homogenous patient
groups to value the variables even more
Case
• ♀ 54 years old
• Medical history
• Hypertension
• 2020 stroke left hemisphere
• 2021 claudicatio intermittens
• Admitted on the recovery ward after de-obstruction visceral aorta
and aorta-bifemoral bypass
• Post-operative chest pain and ST deviation on the scope
• BP 85/50, pulse 90 bpm
ECG
CAG
PCI
ECG post PCI
Chest X-ray
In the ICU …
• A: airway clear
• B: 5L O2 nasal canula, saturation 98%, BF 20 bpm
• C: norepinephrine 0.139 mcg/kg/min, BP 98/53 (68), pulse 94
SR, CRT 3 seconds, no mottling, Cor: no souffles
• D: EMV = 15, AVPU = A
• E: T 37.9
What’s NEXT?
Laboratory values
• Hb 5.8 mmol/L
• CRP 260 mg/L
• Creat 62 mmol/L
Laboratory parameters
• Lactate 3.1 mmol/L
• Art blood gas: 7.48/4.7/9.8/26/27/2.6/94%
• CV blood gas: 7.45/4.8/5.6/25/26/1.1/78%

• ScvO2 = 78%
• Venous-arterial CO2 gap = 0.1 kPa = 0.75 mmHg
Echocardiography
Echocardiography
In conclusion..
• Low BP with moderate vasopression, however MAP > 65
• No mottling, slight prolonged CRT (3 s), slight hyperlactatemia
• No CO2 gap, normal ScvO2
• Echocardiography showing normal LVEF, low to normal filling
pressures
Underlying cause
• Cardiogenic? → normal ScvO2, no CO2 gap, normal LVEF
• Obstructive? → no pericardial effusion/pneumothorax/PE,
VCI collapse +
• Hypovolemic? → possible, low to normal filling pressures,
blood loss during OR?
• Redistributive? → possible, possible inflammatory respons to
extensive vascular surgery
Laboratory variables: differential diagnosis

Scheeren TWL, et al. Understanding the carbon dioxide gaps. Curr Opinion Crit Care.
What’s NEXT?
Medication
• Norepinephrine 0.056 mcg/kg/minute
• Piperacillin/Tazobactam 18000 mg/day continous
• Nadroparin 2850 IE 1dd1
• Acetylsalicylic acid 80 mg 1dd1
• Ticagrelor 90 mg 2dd1
• Atorvastatin 40 mg 1dd1
• Furosemide 40 mg 2dd1
• Pregabalin 150 mg 2dd1
Systematic approach of shock
Ultrasonography*

ABCDE Normal chambers

Normal function Redistributive/septic

SvO2 Small chambers

normal/high Hypovolemic
Normal function
Lactate
MAP <60 mmHg CVP low
Large chamber(s)
Signs of hypoperfusion Cardiogenic
Reduced function
Altered mental state
Mottled, clammy
Tachycardia
Pericardial effusion
Elevated blood lactate
SvO2 low Large R chamber Obstructive
CVP high
Lactate Small L chamber
* Other additional investigations
Systematic approach of shock advanced

De Backer D. Detailing the cardiovascular profile in shock patients. Crit Care 2017;21:311
Educated guess or are we at the level of need
for more advanced monitoring?
 Educated guess of physicians
Author, year Patients Setting Variables of interest Physical examination Measurement method Estimation

Connors et al. 1983 [13] 62* ICU CI categorical: Clinical assessment, lab, X-Ray PAC, thermodilution 44% correct
<2.5; 2.5-3.5; >3.5
Eisenberg et al. 1984 97 ICU CO categorical: Not described PAC, thermodilution 51% correct
[14] <4.5; 4.5-7.5; >7.5
Connors et al. 1990 [17] 461 ICU CI dichotomous: Clinical assessment, lab, X-Ray, PAC, thermodilution 64% correct
<2.2; ≥2.2 ECG

9 studies in ICU patients, 1

Celoria et al. 1990 [16] 114 Surgical ICU CO categorical: Clinical assessment, lab, X-Ray PAC, thermodilution 51% correct

post surgery and 1 in the ED

Steingrub et al. 1991 [53] 152 Surgical and
<4; 4-8; >8
CO categorical: Clinical assessment, lab, X-Ray PAC, thermodilution 51% correct
medical ICU <4; 4-8; >8
Staudinger et al. 1998 149 ICU CI categorical: Clinical assessment, lab, X-Ray PAC, thermodilution 62% correct

Physicians correct
[54]
Linton et al. 2002 [56] 50 Post cardiac
<2.0; 2.0-4.0; >4.0
CI categorical: Not described LiDCOTM, indicator-dilution 54% correct

estimation of cardiac index

Iregui et al. 2003 [57] 105
surgery
ICU
<1.9; 1.9-3.5; >3.5
CI categorical: Clinical assessment, lab, X-Ray TEE, Doppler wave 44% correct

in 42-62%
Veale et al. 2005 [58] 68 ICU
<2.5; 2.5-4.5; >4.5
CI categorical: Not described BioZ CO monitorTM, Impedance 42% correct
<2.5; 2.5-4.2; >4.5 cardiography
Nowak et al. 2011 [60] 38 ED + respiratory CO categorical Clinical assessment NexfinTM, ABP waveform analysis 50% correct
distress <4.0; 4.0-8.0; >8.0
Duan et al. 2014 [61] 132 ICU CI categorical: Not described PiCCOTM, thermodilution 50% correct
<3; 3-5; >5

Kaufmann T et al. Bayesian Network Analysis of the Diagnostic Process and its Accuracy to Determine How Clinicians Estrimate Cardiac
Function in Critically iIl Patients: prospective observational study. JMIR Med Inf 201
SICS-I: educated guess

Students (n=602) Interns (n=201) Residents (n=25) All Groups (n=828)

Sensitivity (%) 49 (38 – 59) 47 (35 – 60) 67 (9 – 99) 48 (41 – 56)

Specificity (%) 65 (61 – 69) 76 (68 – 83) 64 (41 – 83) 67 (63 – 71)

PPV (%) 22 (18 – 26) 50 (40 – 60 ) 20 (9 – 40) 28 (24 – 32)

NPV (%) 86 (84 – 88) 74 (69 – 78) 93 (73 – 99) 83 (81 – 85)

LR + 1.39 (1.10 – 1.75) 1.96 (1.32 – 2.90) 1.83 (0.69 – 4.85) 1.47 (1.22 – 1.78)

LR - 0.79 (0.65 – 0.97) 0.70 (0.55 – 0.89) 0.52 (0.10 – 2.68) 0.77 (0.66 – 0.90)

Overall accuracy 62 (58 – 66) 66 (59 – 73) 64 (43 – 82) 63 (60 – 67)

Kaufmann T et al. Bayesian Network Analysis of the Diagnostic Process and its Accuracy to Determine How Clinicians Estrimate Cardiac
Function in Critically iIl Patients: prospective observational study. JMIR Med Inf 2019
SICS-I: educated guess

• Bayesian Network
Analysis showing
the conditional
dependency.

Kaufmann T et al. Bayesian Network Analysis of the Diagnostic Process and its Accuracy to Determine How Clinicians Estrimate Cardiac
Function in Critically iIl Patients: prospective observational study. JMIR Med Inf 2019
Trigger: yes → echocardiography
Whole body ultrasonography (WBU)
• Definition

• Case out of the Simple Intensive Care Studies

– Possibilities for WBU

• Literature on WBU in
– Emergency Care
– Critical Care

• Conclusions
Definition
• The ability to image virtually any portion of any patient
Female with sepsis, day 1
Day 1

▪ Respiratory rate 22/min

▪ SpO2 ventimask (40%) 93%

▪ Heart rate 113/min

▪ Blood pressure 109/62 (76) mmHg

▪ Noradrenaline 2.5 ml/h

▪ Cerebral EMV 4-6-5

▪ Urinary output 135 ml/h

▪ Skin perfusion
• Knee: 3 sec
• Sternum 3 sec
• Subjective: warm
• ∆T: 4,9 ºC
• Mottling: 2

▪ Hemoglobine 7.9 mmol/l

▪ Lactate 8.5 mmol/l

Sepsis – day 1 (cardiac, kidney)
Sepsis – day 1 (lungs, VCI not obtained)
B-lines Right Left
Superior 0 0
Inferior 0 0
Lateral 0 0
Female with sepsis, day 3
Day 1 Day 3
▪ Respiratory rate 22/min
▪ Respiratory rate22/min
▪ SpO2 ventimask (40%) 93%
▪ SpO2 optiflow 60% 90%
▪ Heart rate 113/min
▪ Heart rate 98/min
▪ Blood pressure 109/62 (76) mmHg
▪ Blood pressure 131/70 (94) mmHg
▪ Noradrenaline 2.5 ml/h
▪ Noradrenaline -

▪ Cerebral EMV 4-6-5

▪ Urinary output 135 ml/h ▪ Cerebral EMV 3-6-5

▪ Skin perfusion
▪ Urinary output 60 ml/h
• Knee: 3 sec
• Sternum 3 sec ▪ Skin perfusion
• Subjective: warm • Knee: 3 sec
• ∆T: 4,9 ºC
• Sternum 4 sec
• Mottling: 2
• Subjective: warm
• ∆T: 4,2 ºC
▪ Hemoglobine 7.9 mmol/l
• Mottling: 0
▪ Lactate 8.5 mmol/l

▪ Hemoglobine 6.9 mmol/l

▪ Lactate 1.8 mmol/l

Sepsis – day 3 (cardiac, kidney)
Sepsis – day 3 (lungs, vena cava inferior)
B-lines Right Left
Superior 5 5
Inferior 3 4
Lateral 5 3

VCI max VCI min % collaps

1.79 1.51 16%
Female with sepsis, day 5
Day 1 Day 3 Day 5
▪ Respiratory rate 22/min
▪ Respiratory rate22/min ▪ Respiratory rate21/min
▪ SpO2 ventimask (40%) 93%
▪ SpO2 optiflow 60% 90% ▪ SpO2 optiflow 60% 94%
▪ Heart rate 113/min
▪ Heart rate 98/min ▪ Heart rate 107/min
▪ Blood pressure 109/62 (76)
mmHg
▪ Blood pressure 131/70 (94) ▪ Blood pressure 128/69 (90)
▪ Noradrenaline 2.5 ml/h mmHg mmHg

▪ Noradrenaline - ▪ Noradrenaline -

▪ Cerebral EMV 4-6-5

▪ Urinary output 135 ml/h

▪ Cerebral EMV 3-6-5 ▪ Cerebral EMV 4-6-5
▪ Skin perfusion
▪ Urinary output 60 ml/h ▪ Urinary output 140 ml/h
• Knee: 3 sec
• Sternum 3 sec ▪ Skin perfusion ▪ Skin perfusion
• Subjective: warm
• Knee: 3 sec • Knee: 3 sec
• ∆T: 4,9 ºC
• Sternum 4 sec • Sternum 3 sec
• Mottling: 2
• Subjective: warm • Subjective: warm
• ∆T: 4,2 ºC • ∆T: 4,0 ºC
▪ Hemoglobine 7.9 mmol/l
• Mottling: 0 • Mottling: 0
▪ Lactate 8.5 mmol/l

▪ Hemoglobine 6.9 mmol/l ▪ Hemoglobine 7.5 mmol/l

▪ Lactate 1.8 mmol/l ▪ Lactate 2.0 mmol/l

Sepsis – day 5 (cardiac, kidney)
Sepsis – day 5 (lungs, vena cava inferior)
B-lines Right Left
Superior 0 5
Inferior 0 5
Lateral 0 5

VCI max VCI min % collaps

1.65 1.38 16%
Number of images with sufficient quality
Limitations of ultrasonography
• Acoustic window
– 9/15, ‘at least 1 view in 99%’
• Image quality
– 10/15, adequate 81-99%
• Independent judging
– 8/15, ‘in case of doubt’ or ‘cardiologist’
Conclusions
• WBU is feasible in critically ill patients

• WBU can give insight into multiple organs

• WBU even allows for obtaining variables to monitor or guide

treatment
Conclusion
Thank you