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How Hight Should MAP Be ? C Martin MD,FCCM,FCCP ICU and Trauma Center Nord University Marseilles France.

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Presentation on theme: "How Hight Should MAP Be ? C Martin MD,FCCM,FCCP ICU and Trauma Center Nord University Marseilles France."— Presentation transcript:

1 How Hight Should MAP Be ? C Martin MD,FCCM,FCCP ICU and Trauma Center Nord University Marseilles France

2 Organ Artery Pressure (mmHg) Organ Blood Flow (% baseline) Subautoregulatory slope Autoregulatory threshold Autoregulation in Health and Disease Below their autoregulatory thresholds, organ flows are linearly dependent on perfusion pressure.

3 What about settings where organ autoregulation is lost ?

4 Organ Artery Pressure (mmH g) Organ Blood Flow (% baseline) Autoregulation in Disease Control 3 weeks 1 week

5 Any increase in organ perfusion is likely to augment organ blood flow

6 Ogan Artery Pressure (mmH g) Organ Blood Flow (% baseline) Autoregulation in Disease Control 3 weeks 1 week

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8 Norepinephrine and Regional Blood Giantomasso ICM 2004 MAP (mmHg) PlaceboNE PlaceboNE CO L/min Flow during Hyperdynamic Sepsis (p < 0.05) (p<0.05 )  Merino ewes IV bolus of E. coli (3x10 9 )  Norepinephrine 0.4  g/kg/min or placebo

9 Norepinephrine and Regional Blood Giantomasso ICM 2004 UF (ml/h) Placebo NEPlaceboNE CrCL mlL/min Flow during Hyperdynamic Sepsis p < 0.05) (p<0.05 )

10 What is the relevance of these experimental studies to clinical practice ???

11 Norepinephrine and Renal Blood Flow Urine Flow ml/h MAPressure Desjars CCM 1983, 1987 Meadows CCM 1988 Hesselvik CCM 1989 Martin CCM 1990 Martin Chest 1994 ………. Time

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13 Norepinephrine in Septic and Non- Septic Patients Septic shock Head trauma Creatinine before24hrbefore24hr before p < p < Cr CL Albanese et al Chest 2004,126,

14 MAP : mmHg ???

15 Organ Artery Pressure (mmH g) Organl Blood Flow (% baseline) Autoregulation in Disease Control 3 weeks 1 week

16 Organ Artery Pressure (mmH g) Organ Blood Flow (% baseline) Autoregulation in Disease Control 3 weeks 1 week

17 Organ Artery Pressure (mmH g) Organ Blood Flow (% baseline) Autoregulation in Disease Control 3 weeks 1 week

18 * * * Increasing MAP ? 10 septic shock patients treated by NE LeDoux et al Crit Care Med 2000, 28, 2729 CI VO2 DO2

19 Increasing MAP ? 10 septic shock patients treated by NE LeDoux et al Crit Care Med 2000, 28, 2729 UF

20 65 85

21 A Bourgoin et al CCM 2005,33, Increasing MAP ? Lactate DO2 VO

22 Increasing MAP ? UF Creatinine Cr Cl A Bourgoin et al CCM 2005,33,

23 MAP : 65 mmHg

24 Unresolved issues : Formerly hypertensive patients ? Elderly patients ? Atherosclerotic patients ? Others ????

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27 Coronary Artery flow

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29

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31 Cardiogenic Shock Management of Hypotension SBP > 90 mmHg ESC Guidelines. Eur Heart J 2005, 26, CI > 2 l.min -1.m -2

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33 Prehospital Hypotension and Outcome in Trauma Arbabi et al J Trauma 2004, Register of Ann Arbor Seattle USA patients 2373 hypotension SAP Mortality Prehospital Hypotension = Predictive Factor of Mortality in Trauma

34 Uncontrolled Hemorrhage : Is Normal Blood Pressure the Target ? Roberts et al Lancet 2001 Normal blood pressure is not the target ! Bleeding or Re-bleeding Hemodilution Coagulation disorders Agressive Volume Loading Anemia Hypothermia Hypoxemia SAP Increase Mechanic effect on vascular clot

35 Is Normalisation of blood Pressure Dangerous ????? Fluid resuscitation interferes with the physiological response to hemorrhage Elevated blood pressure favors bleeding by a mechanical effect Hemodilution aggavates bleeding Bickell et al NEJM 1994

36 The effect of vigorous fluid resuscitation in uncontrolled hemorrhagic shock after massive splenic injury Solomonov E, Krausz M CRIT CARE MED 2000;28: Uncontrolled Hemorrhage in Rats After FR ( LVNS ) : Fall of BP, increase in blood losses and mortality Survival MAP No fluids LVNS No fluids LVNS

37 Should We Raise Blood Pressure in Case of Uncontrolled Hemorrhage ????? Meta-analysis of clinical randomized studies –3 studies on survival –2 studies on coagulation Maximal heterogeneity Kwan I, Bunn F, Roberts I; WHO Pre-Hospital Trauma Care Steering Committee Cochrane group 2003.

38 Timing and volume of fluid administration for patients with bleeding 1.« We found no evidence from randomised controlled trials for or against early or larger volume of intravenous fluid administration in uncontrolled haemorrhage. There is continuing uncertainty about the best fluid administration strategy in bleeding trauma patients. Further randomised controlled trials are needed to establish the most effective fluid resuscitation strategy » Kwan I, Bunn F, Roberts I; WHO Pre-Hospital Trauma Care Steering Committee Cochrane group 2003.

39 Should We Raise Blood Pressure in Case of Uncontrolled Hemorrhage ????? Meta-analysis of clinical randomized studies –3 studies on survival –2 studies on coagulation Maximal heterogeneity ==> No conclusion !!!!! ==> Experimental data Kwan I, Bunn F, Roberts I; WHO Pre-Hospital Trauma Care Steering Committee Cochrane group 2003.

40 Uncontrolled hemorrhage and fluid resuscitation with HSS+HEA or LR in Rats Burris et Col J Trauma 1999 Permissive hypotension rather than the type of fluid reduces re bleeding REBLEEDING

41 Stern et al Ann Emerg Med mmHg 60 mmHg 80 mmHg

42 Burris et al J Trauma 1999; 46 : Aortotomy (rat) NONE MAP 80 mmHg MAP 40 mmHg MAP 100 mmHg

43 Improved Outcome with Hypotensive Resuscitation ? Uncontrolled Hemorrhagic shock in a Swine Model Kowalenko T, et Al J. Trauma, 33, 349, immature swines - Aortotomy - Saline Infusion % Survival Time ( min ) MAP = 40 mmHg MAP = 80 mmHg NO RESUSCITATION 100

44 Normotensive or hypotensive resuscitation ? A meta analysis 9 randomized studies Improvement Pooled Risk ratio : 0.37 ( ) Permissive hypotension improve survival ! Mapstone J, Roberts I, Evans PH, J TRAUMA 2003, 55, 571 Favour hypotensiveFavour normotensive

45 Immediate Versus Delayed Fluid Resuscitation for Hypotensive Patients with Penetrating Torso Injuries. 598 patients with torso or cervical injury. SAP ≤ 90 mmHg at the scene. No fluid survival 70 %. Fluid at the scene survival 62 % * Bickell WH, Wall MJ, N. Engl. J. Med. 1994, 331, p < 0.04 (level I)

46 Hemorrhagic shock (rat) Capone et al J Am Coll Surg 1995; 180 : 49-5 A = « prehospital » period (1 hour) B = « hospital period (72 h) Group 1 : 0 VL Group 2 : A = No VL ; B = VL for MAP = 80 mmHg Group 3 : A = VL for MAP = 40 mmHg ; B MAP = 80 mmHg Group 4 : A = VL for MAP = 80 mmHg ; B = MAP=80 mmHg Must We Perform Vascular Loading in Multiple Trauma Patients ?

47 Hypotensive Resuscitation during Active Hemorrhage: Impact on In-Hospital Mortality Clinical study at Trauma Centrer arrival SBP ≤ 90 mmHg and uncontrolled hemorrhage Randomisation: SBP 100 (n = 55) SBP 70 (n = 55) Survival 92.7 % in each group Dutton R, Mackenzie CF, et Al J trauma 2002, 52, 1141

48 Penetrating Trauma and Hemorrhagic Shock A military Point of View American Armed Forces Medical Services Combat Fluids Conference July 2001 Fluid for –Radial pulse SBP  80 mmHg –If impossible, carotide pulse SBP # 60 mmHg Or keep the patients conscious !!!!

49 Permissive Hypotension for Uncontrollde Hemorrhage Strong clinical arguments Less clinical evidences Indirect arguments – SBP : mmhg

50 SBP < 90 mmHg MORTALITY x 3 (level III) Hypotension and Prognosis in Head Trauma Patients The role of secondary brain injury in determining outcome from severe head injury Chesnut et al J Trauma 1993, 34 : Prospective study in 717 severe brain trauma patients

51 Fluid resuscitation of patients with multiple injuries and severe closed head injury Experience with an aggressive fluid resuscitation strategy 34 patients ISS> 16 CGS < 8 PPC > 80 mmHg, York et al J Trauma 2000; 48 : % of patients with no cerebral sequellae 6 % mortality

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54 Hemorrhagic Shock Goals for Blood Pressure SBP : mmHg if no head trauma (modulate according to age and underlying disease). MAP : 40 mmHg until bleeding is controlled and then 80 mmHg SBP : 120 mmHg in case of head and / or medullar trauma

55 How High Should M(S)AP Be ? Septic shock MAP : 65 mmHg 1 controlled study (30 patients) 1 open study (10 patients) Cardiogenic shock SAP : > mmHg expert opinion Hemorrhagic shock SBP : mmHg MAP : 40 mmHg in case of TBI : SBP 120 mmHg expert opinion

56 THE END

57 Vasoconstrictors Arterial bed Increased venous return with less volume loading Increased preload Increased blood pressure Edema ? Venous bed Vasoconstrictor Effets in Hemorrhagic Shock From De La Coussaye

58 Prehospital volume loading and vasoconstrictors for severe trauma SBP < 90mmHg Volume loading Crystalloids Colloids < 20 ml/kg Transport and direct admission to trauma center + First priority surgical hemostasis - Stop volume loading Vasoconstrictor - + SBP unstable or target non reached From Carli P, 2005 Blunt trauma + TBI GCS < 8 Target: SBP = 120, Ht = 30% Penetrating injury Target: SBP = 70 90

59 Hypovolemia Hemorrhage Vasoplegia Myocardial Depression Surgery Vascular loading ? Transfusion ? Vasopressors ? Inotropic support ? Hemorrhagic Shock

60 Meta- analysis of Fluid Challenge on Survival in Rat Tail resection Favour fluidsFavour NO fluids 2.88 ( ) 0.25 ( ) 0.86 ( ) Section ≤ 50% Section ≥ 50% Roberts I et Al, BMJ , 474

61 Animal models and Uncontrollded Hemorrhage Literature Analysis Large Heterogeneity: Stratification by Model and Severity Mapstone J, Roberts I, Evans PH, J TRAUMA 2003, 55, 571 Model Adjusted Risk Ratio p Aortotomy 0.48 ( ) < Organ Injury 0.76 ( ) Tail resection > 50 % 0.69 ( ) Tail resection < 50 % 1.86 ( ) Other vascular Injury 1.70 ( ) experimental studies Massive Hemorrhage: Fluid resuscitation improves the mortality rate Massive Hemorrhage: Fluid resuscitation improves the mortality rate Moderate Hemorrhage : Fluid resuscitation worsens the mortality rate Moderate Hemorrhage : Fluid resuscitation worsens the mortality rate

62 FAUT IL CORRIGER LA PRESSION ARTERIELLE A LA PHASE AIGUE DU CHOC HEMORRAGIQUE ?? Occult hypoperfusion is associated with increased morbidity in patients undergoing early femur fixation Crowl et al J Trauma 2000, 48 : Adultes avec fracture(s) fémorale(s) nécessitant ostéosynthèse Groupe 1 : 20 patients avec lactate < 2,5 Groupe 2 : 37 patients avec lactate > 2,5 (hypoperfusion occulte) Score de gravité identique Complications post opératoires : Groupe 1 : 20 % Groupe 2 : 50 %

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64 Norepinephrine and Renal Flow (Endotoxemic Dogs) Bellomo et al AJRCCM, 1999, 159, PA (mmHg) CO RVR (dynes) Qr/ml/min contNEendoEndo + NE contNEendoEndo + NE * contNEendoEndo + NE * contNEendoEndo + NE * * * * *

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66 Cardiogenic Shock : Management of Hypotension Use Norepinephrine to raise SBP > 80 mmHg Change to dopamine (5-15 mcg/kg/min) ACC/AHA Guidelines 2004 Dobutamine may be given when SBP > 90 mmHg

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68 Norepinephrine and Regional Blood Giantomasso ICM 2004 UF (ml/h) Placebo NE PlaceboNE Cr CL ml/min Flow in the Normal Mammalian Circulation (p<0.05 ) (p<0.05 )

69 Norepinephrine and Regional Blood  Merino ewes  Placebo or NE : 0.4  g/kg/min Giantomasso ICM 2004 MAP (mmHg) PlaceboNE PlaceboNE CO L/min Flow in the Normal Mammalian Circulation (p< 0.05) (p<0.05)


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