WHEN and HOW
PHITPHIBOON DEAWTRAKULCHAI,MD,INTENSIVIST
Critical care unit, Department of Internal medicine,
Faculty of medicine, KKU
When
• Indications
How
• Gold standard
• Qualitative Vs Quantitative methods
A: Patient who required NE >1.0 mkm but not achieved MAP.
B: Patient with unknow shock type.
C: VA ECMO patient.
D: Post cardiac surgery.
E: Pulmonary HT crisis.
↑VO2
VO2
↓DO2+
↑VO2
↓DO2
DO
2
DO2 = CO x CA
DO2 = CO x CA
DO2 = CO x [(1.34xHbxSpO2x10)+(0.003xPaO2)]
Stagnant Hypoxia Hypoxemic Hypoxia
Anemic Hypoxia
Fick equation
• (Qin)xCvO2 + VO2 = (Qout)xCaO2
• [CO xCvO2] + VO2 = [COxCaO2]
• VO2 = [COxCaO2]-[CO xCvO2]
• VO2 = COx[CaO2-CvO2]
• VO2 = COx[CaO2-CvO2]
• CO = VO2/[CaO2-CvO2]
• CO = VO2/[1.34xHbx10(SaO2-SvO2)]
Alex Yartsev - Jun 30, 2015Cardiovascular system
Marino, ICU book 4th edition
▪ CO ↓
▪ CO = HR x SV
▪ CO = HR x (LVEDV-LVESV)
▪ CO = HR x (LVEDV-LVESV) x (LVEDV/LVEDV)
▪ CO = HR x [(LVEDV-LVESV)/ LVEDV] x LVEDV
▪ CO = HR x EF x LVEDV
Cardiogenic shock Hypovolemic and Obstructive shock
CO = VO2/[1.34xHbx10x(SaO2-SvO2)]
CO = [MAP-CVP]/SVR
CO = [PAP-PCWP]/PVR
CO = SV x HR
CO = DO2/CA
Deranged cardiac function
in the context of shock Goal-directed resuscitation of
• Refractory septic shock complex multifactorial shock
(NE>0.25 mkm) states
• Suspected Stress • Balanced DO2 and VO2
cardiomyopathy
• Suspected Sepsis induced
cardiomyopathy
• Overt MI
CO monitoring
Qualitative Quantitative
Pv-aCO2 gap Calibrated Non-calibrated
Invasive Minimally invasive Minimally invasive noninvasive
Thermodilution Transpulmonary Pulse pressure
analysis Transthoracic
thermodilution impedance and
bioreactance
LidCo Esophageal analysis
doppler
LVOTVTI
CO measurement
PV-ACO2 GAP
▪ CO = k x VCO2/[(PvCO2-PaCO2)]
Ltaief, Z., Schneider, A.G. & Liaudet, L. Pathophysiology and clinical implications of the veno-arterial
PCO2 gap. Crit Care 25, 318 (2021). https://doi.org/10.1186/s13054-021-03671-w
CO measurement
CO Measurement
Cardiol Clin 31 (2013) 545–565
http://dx.doi.org/10.1016/j.ccl.2013.07.008
▪ Stewart-Hamilton equation
Cardiol Clin 31 (2013) 545–565
http://dx.doi.org/10.1016/j.ccl.2013.07.008
▪ Case:Thai female 56 yo underlying with PHT presented with unknown shock type
and ongoing high dose NE (1.0 mkm).
Final Dx:………………
▪ Case: Thai female 45 yo S/P DVR (MVR+AVR) with T1+2 PHT presented with UTI
and PHT crisis
PVR = ………………………………….
CO Measurement
Thermodilution
+Pulse contour
analysis
Clinical use→ ARDS+Shock W/O PHT,Rt.Heart failure
Lithium dilution
technique
+Pulse contour analysis
Annals of Cardiac Anaesthesia | Volume 22 | Issue 1 |
January-March 2019
CO Measurement
FloTrac sensor (Edwards
Lifesciences, USA)
LidCO rapid system (LidCO
Ltd., UK)
Nexfin monitor (BMEYE,
Netherlands)
esCCO (Nihon Kohden, Japan)
▪ Case: Thai Male 73 Y-O with HAP ARDS s/p VV ECMO, A.baumannii septicemia and
refractory septic shock during ECMO session.
▪ Case: Thai Male 73 Y-O with HAP ARDS s/p VV ECMO, A.baumannii septicemia and
refractory septic shock during ECMO session.
CardioQ
Deltex
CO = CSA x doppler VTI x HR
CO Measurement
BIOZ, USA
ECOM TM, USA
NICOM Reliant system,UK
SV = × L/Z02 × (dZ/dt)max VET
USCOM ,
Australia
CO = CSA x
doppler VTI x HR
CO = LVOT CSA x doppler VTI x HR
PAC Thermodilution
Esophageal Calibrated
doppler Invasive
Calibrated
Pulse contour Minimally
analysis Invasive
Non-calibrated
Minimally Invasive Transpulmonary
thermodilution
Non-calibrated LidCO plus
Noninvasive
LVOTVTI
Transthoracic impedance and bioreactance analysis
Transthoracic aortic arch
doppler
J Thorac Dis. 2019 Jul;11(Suppl 11):S1551-S1557
CO 6.6 CO 5.2
CI 3.1 CI 3.0
SVR 824 SVR 901
Lactate 109 mg/dL Lactate 124 mg/dL
What is your next management?
• A: decrease NE
• B: check thiamine level
• C: Echocardiogram
• D: ScVO2
• E: check CPK LDH
CO 5.0
CI 2.8
SVR 1146
Gas pH PaCO2 PaO2 HCO3 O2 sat
Venous 7.27 50 33 23.0 40.7%
What should you do?
• A: Echocardiogram
• B: increase FiO2
• C: add adrenaline iv drip
• D: P(v-a)CO2 gap
• E: Swan-Ganz PAOP
Gas pH PaCO2 PaO2 HCO3 O2 sat P(v-a)CO2Gap
Arterial 7.39 25 95 17.9 97% =………….
Venous 7.27 50 33 23.0 40.7%
What should you do?
• A: Echocardiogram
• B: increase FiO2
• C: PRC 2 unit
• D: Dobutamine iv drip
• E: Swan-Ganz PAOP
▪ Echocardiogram ▪ CO= ………………………
▪ hyperdynamic LV
▪ LV EF 75%
▪ Normal all valves
▪ No RV dilate
▪ LVOT diameter 2.0 cm.
▪ LVOTVTI 15.2 cm.
▪ HR 102 bpm
Although CO is normal, why does
P(v-a)CO2gap exceed 6 mmHg?
• A: inadequate DO2
• B: high VO2
• C: all above
DO2 VO2
▪ CO 5.0 L/M ▪ CO 5.0 L/M
▪ Hb 9.7 g/dL ▪ Hb 9.7 g/dL
▪ SaO2 97% ▪ SaO2 97%
▪ ScVO2 50.6%
▪ DO2 = ……………………. ▪ VO2 = ………………………
What should you do?
• A: hypothermia
• B: increase FiO2 for SaO2 100%
• C: PRC 2 unit
• D: Dobutamine iv drip
• E: sedate and paralyzed
VO2 DO2 >728
▪ CO 5.0 L/M ▪ Fix CO increase Hb
▪ Goal Hb > …………….
▪ Hb 9.7 g/dL
▪ SaO2 97% ▪ Fix Hb increase CO
▪ Goal CO > ……………
▪ ScVO2 50.6%
▪ VO2 = 363.9
Time CO SVR Hb SaO2 ScVO2 P(v-a)CO2 DO2 VO2 lactate
7.00 5.0 1146 9.7 97 40.7 25 630 363 153.5
15.00 5.7 650 9.7 97 50.2 10 740 348 119
DBT 2.5
22.00 7.0 502 10.7 98 76 7 1004 221 105.7
PRC 1 U
6.00 10.2 574 11.7 97 70 8 1551 432 81.1
PRC 1 U
6.00 9.2 594 9.4 95 - - 1,100 - 40.8
HP
Normal CO Adequate CO
