INTERPRETATION OF CARDIAC OUTPUT

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INTERPRETATION OF CARDIAC OUTPUT
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INTERPRETATION OF CARDIAC OUTPUT
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INTERPRETATION OF CARDIAC OUTPUT
70 Y/O / 70 kg / MAP 70 mmHg
Under 70 mcg / min of norepinephrine
CO
7 L/min 5.5 L/min 4
L/min
First type of response
It depends on

• Urine output
• Cutaneous perfusion
• Mental status
• Blood lactate concentration

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INTERPRETATION OF CARDIAC OUTPUT
mEq/L
BLOOD LACTATE LEVELS
6 5 4 3 2 1 0
Rule out

• Recent seizures
• Shivering
• Hyperventilation
• (Advanced malignancy)

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INTERPRETATION OF CARDIAC OUTPUT
HEMORRHAGIC SHOCK
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INTERPRETATION OF CARDIAC OUTPUT
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INTERPRETATION OF CARDIAC OUTPUT
70 Y/O / 70 kg / MAP 70 mmHg
Under 70 mcg / min of norepinephrine
CO
7 L/min 5.5 L/min 4
L/min
First type of response
It depends on

• Urine output
• Cutaneous perfusion
• Mental status
• Blood lactate concentration

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INTERPRETATION OF CARDIAC OUTPUT
70 Y/O / 70 kg / MAP 70 mmHg
Under 70 mcg / min of norepinephrine
Second type of response
CO
7 L/min 5.5 L/min 4
L/min
?
Breathing spontaneously Agitated Hyperthermic
Mechanically ventilated Deeply comatose Hypothermi
c
Hb 7.8 g/dL
Hb 13.0 g/dL
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INTERPRETATION OF CARDIAC OUTPUT
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INTERPRETATION OF CARDIAC OUTPUT
Anemia Hypoxemia Polyglobulism
Convulsions Agitation Anxiety Calm Sedation A
nesthesia
Sepsis Inflammation Hypothermia
Jogging Walking Standing Resting Sleeping
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INTERPRETATION OF CARDIAC OUTPUT
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INTERPRETATION OF CARDIAC OUTPUT
70 Y/O / 70 kg / MAP 70 mmHg
Under 70 mcg / min of norepinephrine
CO
What do you do ?
6 L/min 4 L/min
75 65 55 45
Nothing Nothing ? Fluids ? Dobutamine ? WOW
! Fluids, dobutamine, etc !
75 65 55 45
SvO2
SvO2
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INTERPRETATION OF CARDIAC OUTPUT
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INTERPRETATION OF CARDIAC OUTPUT
SvO2 low
SaO2 low (hypoxemia)
SaO2 normal
Increased O2 extraction
CO high CO low
Hemoglobin
PAOP high PAOP low
Normal
Low (Anemia)
Heart failure
Hypovolemia
Elevated VO2
exercise, stress, anxiety
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INTERPRETATION OF CARDIAC OUTPUT
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INTERPRETATION OF CARDIAC OUTPUT
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INTERPRETATION OF CARDIAC OUTPUT
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INTERPRETATION OF CARDIAC OUTPUT
We must be less invasive
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INTERPRETATION OF CARDIAC OUTPUT
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INTERPRETATION OF CARDIAC OUTPUT
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INTERPRETATION OF CARDIAC OUTPUT
PRELOAD
HEART RATE
CONTRACTILITY
AFTERLOAD
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INTERPRETATION OF CARDIAC OUTPUT
IV fluids
Isoproterenol Pacemaker
PRELOAD
HEART RATE
CONTRACTILITY
AFTERLOAD
Dobutamine
Vasodilators
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INTERPRETATION OF CARDIAC OUTPUT
The price to pay
CO 3.5 L/min SvO2 45
85 Y/O Myocardial infarction RAP / PAOP 20 mmHg
25 Y/O Peritonitis RAP / PAOP 10 mmHg
?
Fluids (Transfusion ?) Dobutamine ?
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INTERPRETATION OF CARDIAC OUTPUT
FLUIDS ?
Obviously yes
Not sure
Traumatic shock GI bleeding
85 Y/O patient Severe cardiomyopathy
Fluid loading
Fluid challenge
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INTERPRETATION OF CARDIAC OUTPUT
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INTERPRETATION OF CARDIAC OUTPUT
Do we have a problem ?
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INTERPRETATION OF CARDIAC OUTPUT
FLUIDS ?
DOBUTAMINE ?
Do we need to measure cardiac output ?
Increase in cardiac output
Faster information ?

• Arterial hypotension
• Tachycardia
• Oliguria

Do we have a problem ?
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INTERPRETATION OF CARDIAC OUTPUT
Is the patient on vasopressor agents ?
Yes No
Adequate tissue perfusion ? (skin perfusion,
urine output, mental status, blood lactate)
Fluid challenge ? (Transfusion ?)
No Yes
Dobutamine
AIM
Do nothing !
Definitive restoration of adequate perfusion
Weaning from vasopressor agents
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Persistent microcirculatory alterations are
associated with organ failure and death in
patients with septic shock Sakr Y, Dubois MJ, De
Backer D, Creteur J, Vincent JL
Crit Care Med 32 1825-31, 2004
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INTERPRETATION OF CARDIAC OUTPUT
ARTERIAL PRESSURE
MENTAL STATUS
URINE OUTPUT
CUTANEOUS PERFUSION
BLOOD LACTATE
CARDIAC OUTPUT
SvO2
OPS / SDF NIRS
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INTERPRETATION OF CARDIAC OUTPUT