Evolution of Shock Monitoring and ICU Scoring

Evolution of
Shock Monitoring and ICU Scoring
NTUH Anesthesiology/SICU
Yu-Chang
Yeh

Shock
組 織 灌 流 不 足 (Hypoperfusion)
氧 氣 供 應 不 足 / 無 法 利 用岦
休峈 克 重 要 觀 念
• 血 壓 115/40 (65) mmHg, 有 沒 有 休峈 克
Usual BP 185/95
CAD
ICP = 30
mmHg
IAP = 30
mmHg
RR 33/min
HR 140/min
BT 39.5 ℃
Agitation
Analgesia
Precedex
Dopamine
Norepinephrine
Epinephrine
Vasopressin

Diagnosis of Shock
• Symptoms & signs
– Mental change ( 意 識 變 化 )
– Hyperventilation
– Tachycardia→→→hypotension
• Urine output < 0.5 mL/kg/h
• ABG (lactate > 4 mmol/L, base excess< -5, pH↓)
• SvO 2 < 65% and ScvO 2 < 70%
Intensive Care Med 2007;33:575–590
Differential diagnosis
Current Opinion in Critical Care 2007, 13:318–323

Hemodynamic monitoring
Ensure adequacy of perfusion
Titrate therapy to specific
endpoints of resuscitation
Predict prognosis
Parameters of hemodynamic monitoring
• Measured variables • Calculated variables
– Heart rate/rhythm – MAP
– SBP/DBP
– MPAP
– CVP
– Cardiac index
– PAP/PAOP
– SV / SVI
– Cardiac output
– LVEF/RVEF
– SpO 2 / ScvO 2 /SVO 2
– SVR / PVR
– RVEDV (100-160 ml)

Heart functions
• Rate/Rhythm – ECG
• Blood pressure – NIBP/Arterial blood pressure
• Preload – CVP/PAOP/Echo/CCO(Flo-Trac)/PiCCO
• Contractility – TTE/TEE
• Valvular function – TTE/TEE
• Cardiac output – PAC/CCO/PiCCO
• Afterload – PAC/CCO/PiCCO
• Myocardial ischemia and failure - Cardiac enzyme
(CK, CK-MB, Troponin-I) and proBNP
△CVP 觀 念
•CVP 絕 對 值 是 參 考 指 標 (8-12[12-15])
–PEEP 10 cmH 2 O 對 CVP 的 影 響
•△CVP 及 治 療 反 應 可屣 提 供 更 多峿 訊 息 ,
–EX: CVP 4,MAP 45 mmHg
x 0.3
• 輸 500 ml NS→CVP 6,MAP 55 mmHg→ 繼 續 輸 液
• 輸 500 ml NS→CVP 12,MAP 48 mmHg→ 小 心尚 輸 液 ,
注 意 心尚 臟 功屖 能 是 否 良 好崅 , 考 慮 給 強 心尚 藥 物
–EX: CVP 8,MAP 110 mmHg, 體 重 增 加展 9 kg,HD
•HD 脫 水尯 500 ml → CVP 8,MAP 105 → 繼 續 脫 水尯
•HD 脫 水尯 500 ml → CVP 2,MAP 50 → 停 止尩 脫 水尯 , 補 水尯

Systolic pressure variation
( 使 用岦 呼 吸 器 時 )
• If △ down > 10 mm Hg
• Or △ down + △ up >15 mm Hg
• → hypovolemia
• → response to fluid challenge
Flo-Trac
• Continuous cardiac output
• Stroke volume index
• Calculated SVR
• Stroke volume variation - fluid responsiveness
• ScvO 2 (Combined with PreSep CVP)

Stroke volume variation
• Prediction of fluid responsiveness
Eur J Anaesthesiol. 2004;21(2):132-8
Crit Care. 2008;12(3):R82
• May be influenced by
– Spontaneous ventilation
– Arrhythmias
– Tidal volume > 8 ml/kg (controlled mode)
Crit Care Med. 2008;36(10):2858-62
– Pressure support ventilation
Acta Anaesthesiol Scand. 2006;50(9):1068-73
CCO (FloTrac sensor, Edwards)
Simplified Physiologic Protocol
Developed by W.T. McGee, MD, MHA, Tufts University Medical School

Normal Range
Others
• Transthoracic echo (TTE)
• Transesophageal echo (TEE)
• NICO - partial CO 2 re-breathing cardiac output
• Echo – SVC/IVC collapsibility – Preload
• Distribution volume of glucose – Preload
• Pulse pressure variations – Fluid responsiveness
• Whole-body electrical bioimpedance – Cardiac output

Goal-directed treatment
Goal directed treatment for Septic Shock
• ScvO2 CVP + Artery line (CCO)
– CVP > 8-12 (12-15) mm Hg
– MAP > 65 mm Hg
– Urine output > 0.5 ml/kg/h
– ScvO 2 > 70%
• Hct > 30%
• Cardiac output
•↓Systemic oxygen consumption.
NEJM 2001;345:1368-77
Crit Care Med 2008; 36:296–327

Is everything ok when ScvO2 > 70%
ICU Scoring
Severity
Prognosis
Work loading
Quality control / assurance
Research
Others

Scoring system
• APACHE (Acute Physiologic and Chronic Health Evaluation)
• TISS (Therapeutic Intervention Scoring System)
• SOFA (Sequential Organ Failure Assessment)
• SAPS (Simplified Acute Physiologic Score)
• MPM (Mortality Prediction Model)
• ISS (Injury Severity Score)
• Organ specific scoring
APACHE I-IV
• 1981 – APACHE I
• 1985 - APACHE II
– Acute physiology score
– Age adjustment
– Chronic health evaluation
• 1991 – APACHE III (1999-I, 2002-J)
• 2006 – APACHE IV
Curr Opin Crit Care 2008;14:491–497

APACHE IV
– Acute physiology score/Age adjustment
– Chronic health evaluation
– Diagnosis
– Prior treatment location
– Logistical regression equation
• Predict mortality and ICU length of stay
– Provide daily updates of prognosis
http://www.mecriticalcare.net/icu_scores/apacheIV.php
Critical care medicine 2006;34(5):1297-310
Organ specific scoring
• Neurology – GCS, WFNS, Fisher scale (SAH)
• Cardiovascular surgery – EuroScore
• Lung – Lung injury score
• Liver – Child’s classification, MELD
• Kidney - RIFLE
• Pancreas – Ranson score
• DIC score

結 論
Shock monitoring
目岰 的 – 確 保 組 織 灌 流 足 夠
使 用岦 適 當 的 監 視 器
快 速 診 斷 / 快 速 處 理 / 調 整 治 療 達 到 目岰 標
避 免 器 官 衰 竭 / 改 善 預 後 減 少 死 亡 率
善 用岦 Scoring system
判 斷 嚴 重 度 及 預 後
決 定 治 療 方尣 向峭
提 升 照 護 品 質
研 究 新 的 治 療
Thanks for your attention
Have a nice weekend!