1. How and when should we monitor CO and SV in shock? When would I want to measure CO or SV in shock ? Alexandre Mebazaa, MD, PhD University Paris 7 Anesthesiology and Critical care medicine Hôpital Lariboisière, Paris, France

2. SHOCK MAP < 65mmHg Oliguria (<0.5ml/Kg/hour) Clinical signs of tissue hypoperfusion Volemia Vessel tone Heart function If shock is prolonged, mechanisms of shock are combined

3. Hochman JS Circulation 2003, 107: 2998-3002

4. Here is the summary of my talk!

5. SHOCK MAP < 65mmHg Oliguria (<0.5ml/Kg/hour) Clinical signs of tissue hypoperfusion 1) Clinical approach -HR/BP -Peripheral perfusion -Impact of volume loading -Urine output 2) CVP/SvcO 2 3) Echocardiography should preceed any CO monitoring Predominant RVF or global F PAC catheter Predominant LVF any CO monitoring First step Second step Third step Fourth step

6. Hemodynamic management of shock: first step- clinical evaluation

7. Heart rate Normal / high Heart rate < 40 bpm Isoprenaline or pacemaker as necessary Give fluid challenge of 250 ml over 5 min Improvement? No SHOCK MAP < 65mmHg Oliguria (<0.5ml/Kg/hour) Clinical signs of tissue hypoperfusion Yes, repeat if needed CVP/SvcO 2

8. Hemodynamic management of shock: second step

9. Hemodynamic management of shock: second step- CVP/ScvO 2

10. Insert CVP/SvcO 2 SvO2 >70% SvO2 <70% Sepsis ? Repeat Fluid challenge 250ml/ 5mins Haemodynami c improvement ? Consider global/right ventricular failure Echocardiography that preceeds cardiac output monitoring Yes Continue until normal values obtained NoNo Vasopressors Hypovolaemic/ Haemorrhagic/ cause? No response Continue until normal values obtained Haemodynami c improvement Repeat fluid challenge (250ml/5mins) or transfusion if necessary. Echocardiography that preceeds CO monitoring CVP N or low CVP high CVP low

11. Hemodynamic management of shock: third step- echocardiography

12. The « pyramid » of echocardiography skills in ICU Cholley,Vieillard-baron, Mebazaa, ICM 2006

13. Echocardiography Predominent right ventricular failure Predominent left ventricular failure TAMPONADE ? Yes Echocardiographic guided pericardiocentesis or surgical intervention Massive mitral regurgitation ? Global heart failure PA catheter No Pulmonary hypertension? Pulmonary vasodilators RV ischaemia? Reduce RV afterload, avoid excess volume, use inotropes if CO low Mebazaa et al. Intensive Care Med, 2004;30:185-96 LV dysfunction No Any CO Monitoring, ideally non invasive Optimise LV pre- and afterload, Inotropes if required

14. Hemodynamic management of shock: fourth step- CO monitoring

15. Why/when would I want to measure CO or SV in shock? Failure hemodynamic management based on clinical signs and CVP-ScvO2; this should always direct to echocardiography Echocardiography should, ideally, always preceed CO monitoring CO monitoring shoud be a PAC catheter in case of RV dysfunction while any CO monitoring, less invasive than PAC, should be favored for LV dysfunction

16. SHOCK MAP < 65mmHg Oliguria (<0.5ml/Kg/hour) Clinical signs of tissue hypoperfusion 1) Clinical approach -HR/BP -Peripheral perfusion -Impact of volume loading -Urine output 2) CVP/SvcO 2 3) Echocardiography should preceed any CO monitoring Predominant RVF or global F PAC catheter Predominant LVF any CO monitoring