7Tissue Hypoxia O2 reserves DO2/VO2 imbalance Decrease in O2 delivery Increase in O2 ConsumptionO2 reserves25% of the Ο2 delivered in theperiphery is usedIs it reasonable?- CaO2 =20 ml/dl- (a-v)DO2 = 5 ml/dl- SvO2 75%,Marathon RunnersDeep Divers (mammals, Birds)
8Tissue Hypoxia -The Concept of Supra-normal Values ICU patientsTraumaSevere SepsisExtensive SurgeryIf we increase DO2MortalityGoals of the hemodynamic optimizationDO2 ?SvO2 ?, ScvO2 ?C.I ?
9The first randomized controlled trial Shoemaker et al The first randomized controlled trial Shoemaker et al. Chest 1988;94:1176General surgery high risk patients.trauma, vascular, acute abdominal catastrophe, extensive ablative surgeryThree groups 1. CVP control group2. PAC control group3. PAC protocol group.Goals of therapy C.I > 4,5 lit/min/m2, DO2>600ml/min/m2,Reduction in mechanical ventilation (9,4 vs 2.3) and ICU days (15,8 vs 10,2)146 patients, 55 non randomized, 45 not ill enough, non consecutive enrolled,severity illness score not employed for baseline comparability, Co-interventions,hemodynamic and oxygen transport values for each group not reported.
10The beneficial effect of supranormalization of oxygen delivery with dopexamine hydrochloride on perioperative mortality Boyd et al. JAMA 1993;270:Dopexamine as the pharmacologic agent to increase DO2The intervention was initiated preoperativePatients comparable at baselinePre and post op DO2 values were higher in the treatment group28 days mortality was lower in the treatment group6% vs 22% p< 0,015ButThe median duration of ICU stay were 40 and 46 hoursIn other studies ICU stay ranged from 5 to 24 daysThe population in the study of Boyd at al was less critically ill.
11Elevation of systemic oxygen delivery in the treatment of critically ill patients Hayes et al. N Engl J Med 1994;330:100 patientsDobutamine as the pharmacologic agent to increase DO2Randomization after standard fluid resuscitationMortality was higher in the treatment group 48% vs 30%ButDelay to start the protocolMore seriously ill patients, higher APACHE score in the protocol groupPatients in the protocol group received more aggressive treatment50 mcg/kg/min Dobutamine and more than 68% Norepinephrine70% of the patients did not reach the supranormal value
13Control group MAP > 60 mmHg Large (762 patients) multi-center randomized trialThree groupsControl groupSupranormal C.I groupNormal SvO2 group (>70%)Standard clinical care in all three groupsMAP > 60 mmHgCVP=8-12PAOP≤18mmHgUrine output≥0.5ml/kgpH ≥ 7,3-7,5- 55% of the CI group failed to achieve a supranormal value
15The negative results of these study may be due to failure to achieve treatment goals rather than failure of treatment to influence outcome
167 randomized trials 1016 patients included Maximizing Oxygen delivery in critically ill patients: A methodologic appraisal of the evidence. Heyland et al. Crit Care Med 1996;24:517-247 randomized trials 1016 patients includedMajor problem:crossover of the patientsTime of interventionPre or postoperative in the ICUTiming of inotropic support
17Treatment of SepsisHemodynamic OptimizationAppropriate ATB treatment
35Conclusion Sepsis related mortality and ICU-hospital LOS depends of: Early detection or screening for high-risk patientsEarly detection and treatment of tissue hypoxiaEarly administration of appropriate antibiotic treatmentProviding education of all involved personnel