La valutazione dell emodinamica in corso di insufficienza renale acuta

Transcription

1 U.O. Nefrologia, Dialisi, Ipertensione Policlinico S.Orsola-Malpighi Bologna - ITALY La valutazione dell emodinamica in corso di insufficienza renale acuta Elena Mancini, Antonio Santoro La Sindrome Cardio-Renale nel Paziente Critico Cuneo, 16 maggio 2012

2 Volume state and AKI Volume status Patient & Kidney volume responsiveness Cardiac Output Cardiac Output = Kidney function improves Kidney function does not improves Non volume responsive AKI due to accumulation of fluid in the extravascualr space Volume-responsive AKI pre-renal azotemia

3 Distant (heart) effects of renal experimental ischemia-reperfusion injury Animal model of bilateral renal ischemia Functional changes of heart 48 h after renal ischemia to identify apoptotic nuclei Kelly KJ, JASN 2003

4 AKI-induced heart injury

5 Hypovolemia : the classical model for AKI (volume-responsive)

6 The volume status and volume-status induced complications

7 The volume status and volume-status induced complications!!! Avoid hypovolemia, but be aware that hypervolemia could be harmful and associated with adverse outcome!!!

8 Fluid resuscitation in sepsis SSC guidelines for fluid resuscitation : l l l l as early as the condition is recognized (especially in septic shock) approximately 20 cc/kg of isotonic crystalloid, followed by boluses of up to 1000 ml of crystalloid or 500 ml of colloid solution given over 30 minutes to achieve adequate resuscitation. the general resuscitation targets are a central venous pressure of 8-12 mm Hg, a mean arterial pressure (MAP) of at least 65 mm Hg, urine output of at least 0.5 cc/kg/hour and a central venous oxygen level of 70%.[6] Surviving Sepsis Campaign. Rivers E, et al.. N Engl J Med

9 Volume and volumeresponsiveness

10 Consequences of congestion Renal Perfusion Pressure Net filtration pressure Prowle JR, Nat Rev Nephrol 2010

11 Pressure balance at the glomerular capillary level

12 Fluid accumulation and worse aoutcome The PICARD Study: 618 critically ill pts with AKI (North america) Fluid accumulation at 1 peak in s Creatinine: Survivors: % Non survivivors: % P=0.03 adjusted for APACHE III OR for death associated with fluid overload 1.36 (95%CI ) Bouchard J, Kidney Int 2009

13 Fluid accumulation and worse outcome 3147 pts (SAOPS Study), 194 ICUs, 24 UE countries ANOVA p<0.05 Key messages.. In patients with ARF, mean daily fluid balance was significantly more positive among nonsurvivors than among survivors ( versus L/24 hours; p<0.001). Payen D, Crit Care 2008

14 Fluid balance and renal outcome in the ICU: liberal vs restrictive fluid management No renal worsening from restrictive volume management Prowle JR, Nat Rev Nephrol 2010

15 Positive fluid balance An independent risk for mortality even after adjustment for severity of illness and the need for dialysis

16 Central Venous Pressure and Renal Function in cardiovascular disease Dammam K et al. JACC 2009

17 Central Venous Pressure and Renal Function in cardiovascular disease CI>3.2 l/min/m2 CI< l/min/m2 CI<2.5 l/min/m2 Increased Central Venous Pressure Is Associated With Impaired Renal Function and Mortality in a Broad Spectrum of Patients With Cardiovascular Disease Dammam K et al. JACC 2009

18 Central Venous Pressure and the risk of worsening renal function Worsening renal function (WRF) 145 consecutive patients admitted with advanced heart failure. WRF= increase in s creat >0.3 mg/dl during hospitalisation Congestion rather than hypotension! ROC curves for CVP and CI on admission for the development of worsening renal function Mullens W, JACC 2009

19 Fluid therapy in sepsis: late critiques A critique of fluid bolus resuscitation in severe sepsis A K Hilton, R Bellomo. Crit Care 2012 Resuscitation of septic patients by means of one or more fluid boluses is recommended by guidelines from multiple relevant organizations and as a component of surviving sepsis campaigns...in the present article, we contend that the concept of large fluid bolus resuscitation in sepsis needs to be investigated further.

20 Fluid volume assessment Ensuring the right intravascular volume is the only way to guarantee effective tissue perfusion Overexpansion of intravascualr volume is not useful, may be dangerous Fluid volume assessment / hemodynamic monitoring: to help clinicians to meet the goal of adequate tissue oxygenation & select pts who might benefit from volume load Positive response to volume load: CO > 15% with kidney function improvment

21 Vena cava diameter variations as a guide to fluid therapy Mech ventilated pts with septic shock; volume load with 8 ml/kg Inferior vena cava diameter ultrasound ü Compliant vessel, very sensitive to changes of CVO, and blood volume ü Changes in intra-thoracic pressures can modify diameter ü Studies demonstrate poor correlation between absolute value of diameter and RA pressure ü Respiratory variations of IVC diameter highly correlated with fluid responsivenes (p<0.001) ü Threshold value at 12% Volume loaded induced changes in CO Feissel M, Int Care med 2004 Pre-infusion variation in inf VC diameter

22 100 cm/sec TRANSMITRAL FLOW SPECTRUM Peack rapid filling velocity Rapid filling spectrum Atrial filling spectrum Peack atrial filling velocity Rapid filling period Atrial filling period msec Diastolic filling period

23 Hemodynamic monitoring in a Nephrological ward Clinical parameters TTBI: Body weight BP / HR Fluid balance (water / plasma, RBC ) SatO Body temp 2 SV,CO,CI Instrumentale evaluations TSVR TTBI (transthoracic bioimpedance) Inferior Vena Cava diameter ultrasound (collapsibility) Echocardiogram (to exclude severe hypovolemia) Dynamic measurements ΔCO in response to: volume load or raising legs ΔIVC diameter in response to volume load

24 LiMon (Liver Monitor) l l l LiMON provides an easy, fast and noninvasive monitoring of liver and splanchnic perfusion. Plasma disappearance rate of indocyanine green, that is influenced by liver function and perfusion It can estimate blood volume knowing the cardiac output ICG-PDR target : >16%/min

25 ICG-PDR (indocyanine green plasma disappearance rate) : a prognostic parameter ICG-PDR: parameter for prognosis of survival of surgical intensive care patients compared to the complex scores SAPS II and APACHE II. Sakka S. Chest 2002

26 Advanced hemodynamic monitoring (PiCCO) Continuous monitoring Cardiac output stroke volume Systemic vascular resistance Blood pressure Heart rate Central venous line Femoral artery catheter (4Fr.) with the thermistor for CCO stroke volume variation contractility (dpmax) Volumetric monitoring Preload: intrathoracic blood volume Extravascular lung water

27 Transpulmonary thermodilution volumes Transpulmonary thermodilution Pulse contour analysis

28 Volumetric monitoring Intravascular volume Lung water EVLW RAEDV RVEDV PBV LAEDV LVEDV Cold water bolus EVLW thermistor ITTV = CO * MTT TD PTV = CO * DST TD GEDV = ITTV - PBV MTt DSt

29 Non invasive dynamic parameters: Aortic velocity time integral

30 Lung ultrasound for pulmonary congestion Mallamaci, F. et al. J Am Coll Cardiol Img

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