238 SECTION IV Pediatric Critical Care Cardiovascular SVRI usually is 800 to 1600 dyne • s/m2 per cm5 in children72,73 and 2180 6 210 in adults 81 Calculation of Intracardiac Shunt If the oxygen satur[.]
238 S E C T I O N I V Pediatric Critical Care: Cardiovascular SVRI usually is 800 to 1600 dyne • s/m2 per cm5 in children72,73 and 2180 210 in adults.81 Calculation of Intracardiac Shunt If the oxygen saturations throughout the cardiopulmonary circulation are known, derivation of the values for the ratio of pulmonary to systemic blood flow or intracardiac shunt (Qp/Qs) is possible: Vo2/(1.34 10 Hb[Spvo2 Spao2]) Qp Eq 26.28 Vo2/(1.34 10 Hb[Sao2 Svo2]) Qs Eq 26.29 Qp/Qs (Sao2 Svo2)/(Spvo2 Spao2) Eq 26.30 where Spvo2 is oxygen saturation in the pulmonary vein and Spao2 is oxygen saturation in the pulmonary artery In the absence of severe intrapulmonary shunt, Spvo2 approaches 98% to 100% In a complete mixing lesion, Spao2 and Sao2 should be equal by definition, enabling Sao2 to be substituted for Spao2 Novel Monitoring Strategies As PAC use has fallen dramatically and familiarity with it has waned, providers have been replacing it with many innovative techniques, often used in concert with one another, to obtain similar information Many of these investigations can be performed noninvasively Pulse wave Doppler (PWD) has shown promise82 as an assessment of left ventricular function, as has esophageal Doppler,83 although the latter requires a transesophageal echocardiogram probe Thermodilution from PACs may be supplanted by lithium dilution and/or transpulmonary thermodilution methods.84,85 Although the long-term utilization of such techniques is not yet routine in children, the relative ease of use or placement, often using in situ CVCs and arterial lines, in comparison with the PAC, and additional monitoring capabilities, make them attractive Conclusions Invasive hemodynamic monitoring provides the intensivist with valuable information regarding the condition of critically ill children Correct interpretation of this information is important to aid in the management of these patients, but these data must be integrated with the rest of the patients’ assessments When pieces of data conflict with one another, the invasive origin of one does not necessarily suggest its superiority New noninvasive monitoring modalities are emerging that may eventually supplant the need for these invasive measurements Thus far, however, invasive monitoring remains a cornerstone of pediatric critical care medicine Key References Baloglu O, Aluquin VP, Tamburro RF, et al Assessing pulmonary arterial hypertension in infants with severe chronic lung disease of infancy: a role for a pulmonary artery catheter? Pediatr Cardiol 2013;34: 1330-1334 Cohn JN, Luria MH Studies in clinical shock and hypotension; the value of bedside hemodynamic observations JAMA 1964;190: 891-896 Eskesen TG, Wetterslev M, Perner A Systematic review including reanalyses of 1148 individual data sets of central venous pressure as a predictor of fluid responsiveness Intensive Care Med 2016;42: 324-332 Marik PE, Cavallazzi R, Vasu T, Hirani A Dynamic changes in arterial waveform derived variables and fluid responsiveness in mechanically ventilated patients: a systematic review of the literature Crit Care Med 2009;37:2642-2647 Marik PE Noninvasive cardiac output monitors: a state-of the-art review J Cardiothorac Vasc Anesth 2013;27:121-134 Mercier JC, Beaufils F, Hartmann JF, Azema D Hemodynamic patterns of meningococcal shock in children Crit Care Med 1988;16:27-33 Pagnamenta A, Lador F, Azzola A, Beghetti M Modern invasive hemodynamic assessment of pulmonary hypertension Respiration 2018; 95:201-211 Perez AC, Eulmesekian PG, Minces PG, Schnitzler EJ Adequate agreement between venous oxygen saturation in right atrium and pulmonary artery in critically ill children Pediatr Crit Care Med 2009;10: 76-79 Ruth A, McCracken CE, Fortenberry JD, Hall M, Simon HK, Hebbar KB Pediatric severe sepsis: current trends and outcomes from the Pediatric Health Information Systems database Pediatr Crit Care Med 2014;15:828-838 Walkey, AJ, Wiener RS, Lindenauer, PK Utilization patterns and outcomes associated with central venous catheter in septic shock – a population-based study Crit Care Med 2013;41:1450-1457 Yang X, Du B Does pulse pressure variation predict fluid responsiveness in critically ill patients? A systematic review and meta-analysis Crit Care 2014;18:650 The full reference list for this chapter is available at ExpertConsult.com e1 References Hales S Statical Essays: Containing Haemastaticks; or, an Account of Some Hydraulick and Hydrostatical Experiments Made on the Blood and Blood-Vessels of Animals London: Innis, Manby, and Woodward; 1733 Tobin M Principles and Practice of Intensive Care Monitoring New York: McGraw-Hill; 1998 Webster J Medical Instrumentation Boston: Houghton Mifflin Company; 1978 Bronzino J The Biomedical Engineering Handbook Boca Raton, FL: CRC Press; 1995 Lowrie L, Difiore J, Martin R Monitoring in the pediatric and neonatal intensive care units In: Tobin JMM, ed Principles and Practice of Intensive Care Monitoring San Francisco, CA: McGrawHill; 1998 Heitmiller EWR Hemodynamic monitoring considerations in pediatric critical care In: Rogers M, ed Textbook Pediatric Intensive Care Baltimore: William & Wilkins; 1996 Carcillo JA, Fields AI Clinical practice parameters for hemodynamic support of pediatric and neonatal patients in septic shock Crit Care Med 2002;30:1365-1378 Eskesen TG, Wetterslev M, Perner A Systematic review including re-analyses of 1148 individual data sets of central venous pressure as a predictor of fluid responsiveness Intensive Care Med 2016;42: 324-332 Cecconi M, Aya HD, Geisen M, et al Changes in the mean systemic filling pressure during a fluid challenge in postsurgical intensive care patients Intensive Care Med 2013;39:1299-1305 10 Edwards Lifesciences PediaSat Oximetry Catheter 2008 http:// ht.edwards.com/resourcegallery/products/presep/pdfs/ar03176.pdf 11 Rivers E, Nguyen B, Havstad S, et al Early goal-directed therapy in the treatment of severe sepsis and septic shock N Engl J Med 2001;345: 1368-1377 12 Yealy DM, Kellum JA, Huang DT, et al A randomized trial of protocol-based care for early septic shock N Engl J Med 2014; 370:1683-1693 13 Peake SL, Delaney A, Bailey M, et al Goal-directed resuscitation for patients with early septic shock N Engl J Med 2014;371: 1496-1506 14 Mouncey PR, Osborn TM, Power GS, et al Trial of early, goaldirected resuscitation for septic shock N Engl J Med 2015;372: 1301-1311 15 Ruth A, McCracken CE, Fortenberry JD, Hall M, Simon HK, Hebbar KB Pediatric severe sepsis: current trends and outcomes from the Pediatric Health Information Systems database Pediatr Crit Care Med 2014;15:828-838 16 Marik PE Noninvasive cardiac output monitors: a state-of the-art review J Cardiothorac Vasc Anesth 2013;27:121-134 17 Perez AC, Eulmesekian PG, Minces PG, Schnitzler EJ Adequate agreement between venous oxygen saturation in right atrium and pulmonary artery in critically ill children Pediatr Crit Care Med 2009;10:76-79 18 Berthiaume LR, Peets AD, Schmidt U, et al Time series analysis of use patterns for common invasive technologies in critically ill patients J Crit Care 2009;24:471.e9-e14 19 Walkey, AJ, Wiener RS, Lindenauer, PK Utilization patterns and outcomes associated with central venous catheter in septic shock – a population-based study Crit Care Med 2013;41:1450-1457 20 Roberts LN, Smiley JR, Manning GW A comparison of direct and indirect blood-pressure determinations Circulation 1953;8: 232-242 21 Van Bergen FH, Weatherhead DS, Treloar AE, et al Comparison of indirect and direct methods of measuring arterial blood pressure Circulation 1954;10:481-490 22 Cohn JN, Luria MH Studies in clinical shock and hypotension; the value of bedside hemodynamic observations JAMA 1964;190: 891-896 23 Kaye W Invasive monitoring techniques: arterial cannulation, bedside pulmonary artery catheterization, and arterial puncture Heart Lung 1983;12:395-427 24 Vargo T Cardiac catheterization: hemodynamic measurements In: Garson A, Fisher D, Neish S, eds Science and Practice of Pediatric Cardiology Baltimore, MD: Williams & Wilkins; 1998 25 Murgo JP, Westerhof N, Giolma JP, Altobelli SA Aortic input impedance in normal man: relationship to pressure wave forms Circulation 1980;62:105-116 26 Mignini M, Piacentini E, Dubin A Peripheral arterial blood pressure monitoring adequately tracks central arterial blood pressure in critically ill patients: an observational study Crit Care 2006; 10(2):R43 27 Compton F, Zukunft B, Hoffmann C, Zidek W, Schaefer J Performance of a minimally invasive uncalibrated cardiac output monitoring system (Flotrac/Vigileo) in haemodynamically unstable patients Br J Anaesth 2008;100(4):451-456 28 Galluccio S, Chapman M, Finnis M Femoral-radial arterial pressure gradients in critically ill patients Crit Care Resusc 2009;11(1):34-38 29 Kim W, Jun J, Huh J, Hong S, Lim C, Koh Y Radial to femoral arterial blood pressure differences in septic shock patients receiving high-dose norepinephrine therapy Shock 2013;40(6): 527-531 30 Magder S, Guerard B Heart-lung interactions and pulmonary buffering: lessons from a computational modeling study Respir Physiol Neurobiol 2012;182:60-70 31 Marik PE, Cavallazzi R, Vasu T, Hirani A Dynamic changes in arterial waveform derived variables and fluid responsiveness in mechanically ventilated patients: a systematic review of the literature Crit Care Med 2009;37:2642-2647 32 Michard F, Boussat S, Chemla D, et al Relation between respiratory changes in arterial pulse pressure and fluid responsiveness in septic patients with acute circulatory failure Am J Respir Crit Care Med 2000;162:134-138 33 Yang X, Du B Does pulse pressure variation predict fluid responsiveness in critically ill patients? A systematic review and meta-analysis Crit Care 2014;18:650 34 Auler Jr JO, Galas F, Hajjar L, Santos L, Carvalho T, Michard F Online monitoring of pulse pressure variation to guide fluid therapy after cardiac surgery Anesth Analg 2008;106:1201-1206 35 Fye WB Jean-Baptiste Auguste Chauveau Clin Cardiol 2003;26: 351-353 36 Chaveau J, Ej M Determination graphique des rappats de la pulsation cardiaque avee les mouvements de l’ oriellette et du ventrucule, obtenu au moyen d’un appareil enregistecur CR Mear Soc Biol 1861;3:3-11 37 Chaveau J, Ej M De la force deployee par la contraction de differentes cavites du coeur CR Mear Soc Biol 1862;3:151-154 38 Chaveau A, Marey E Apparells at Experiences cardiographiques Demonsration Nouvelle du mechanisme des mouvement du mechanisme des mouvements du Coeur par l’Emploi des Instruments Enregistreurs a Indications Continuees Paris: JB Balliere; 1863 39 Forssman W Die Sondierung des rechten herzens Klin Wochenschr 1929;8:2085-2087 40 Fontenot C, O’Leary JP Dr Werner Forssman’s self-experimentation Am Surg 1996;62:514-515 41 Cournand A, Ranges H Catheterization of the right auricle in man Proc Soc Exp Biol Med 1941;46:462-466 42 Richards D, Cournand A, Darling R, et al Pressure of blood in the right auricle in animals and man: under normal conditions and in right heart failure Am J Physiol 1941;136:115-123 43 Cournand A Measurement of the cardiac output in man using the right heart catheterization Fed Proc 1945;4:207-212 44 Hellems H, Haynes F, Dexter L, et al Pulmonary capillary pressure in animals estimated by venous arterial catheterization Am J Physiol 1948;155:98-105 45 Mukhopadhyay M A biographical sketch of Lewis Dexter Tex Heart Inst J 2001;28:133-138 e2 46 Lategola M, Rahn H A self-guiding catheter for cardiac and pulmonary arterial catheterization and occlusion Proc Soc Exp Biol Med 1953;84:667-668 47 Swan HJ, Ganz W, Forrester J, et al Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter N Engl J Med 1970;283:447-451 48 Connors AF Jr, Speroff T, Dawson NV, et al The effectiveness of right heart catheterization in the initial care of critically ill patients SUPPORT Investigators JAMA 1996;276:889-897 49 Sandham JD, Hull RD, Brant RF, et al A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients N Engl J Med 2003;348:5-14 50 Richard C, Warszawski J, Anguel N, et al Early use of the pulmonary artery catheter and outcomes in patients with shock and acute respiratory distress syndrome: a randomized controlled trial JAMA 2003;290:2713-2720 51 Hadian M, Pinsky MR Evidence-based review of the use of the pulmonary artery catheter: impact data and complications Crit Care 2006;10:S8 52 Shah MR, Hasselblad V, Stevenson LW, et al Impact of the pulmonary artery catheter in critically ill patients: meta-analysis of randomized clinical trials JAMA 2005;294:1664-1670 53 Friese RS, Shafi S, Gentilello LM Pulmonary artery catheter use is associated with reduced mortality in severely injured patients: a National Trauma Data Bank analysis of 53,312 patients Crit Care Med 2006;34:1597-1601 54 Taylor R, Ahrens T, Yaakov B, PACCCP Pulmonary artery catheter consensus conference: consensus statement Crit Care Med 1997; 25:910 55 Perkin RM, Anas N Pulmonary artery catheters Pediatr Crit Care Med 2011;12:S12-S20 56 Carcillo JA, Davis AL, Zaritsky A Role of early fluid resuscitation in pediatric septic shock JAMA 1991;266:1242-1245 57 Mercier JC, Beaufils F, Hartmann JF, Azema D Hemodynamic patterns of meningococcal shock in children Crit Care Med 1988;16:27-33 Pollack MM, Reed TP, Holbrook PR, Fields AI Bedside pulmonary artery catheterization in pediatrics J Pediatr 1980;96: 274-276 59 Reynolds EM, Ryan DP, Sheridan RL, Doody DP Left ventricular failure complicating severe pediatric burn injuries J Pediatr Surg 1995;30:264-269; discussion 269-270 60 Baloglu O, Aluquin VP, Tamburro RF, et al Assessing pulmonary arterial hypertension in infants with severe chronic lung disease of infancy: a role for a pulmonary artery catheter? Pediatr Cardiol 2013;34:1330-1334 61 Pagnamenta A, Lador F, Azzola A, Beghetti M Modern invasive hemodynamic assessment of pulmonary hypertension Respiration 2018;95:201-211 62 Thompson AE Pulmonary artery catheterization in children New Horiz 1997;5:244-250 63 Singh S, Nasa V, Tandon M Perioperative monitoring in liver transplant patients J Clin Exp Hepatol 2012;2:271-278 64 DeBruin W, Notterman DA, Magid M, et al Acute hypoxemic respiratory failure in infants and children: clinical and pathologic characteristics Crit Care Med 1992;20:1223-1234 65 Wheedon D, Shore DF, Lincoln C Continuous monitoring of pulmonary artery pressure after cardiac surgery in infants and children J Cardiovasc Surg (Torino) 1981;22:307-311 66 Damen J, Wever JE The use of balloon-tipped pulmonary artery catheters in children undergoing cardiac surgery Intensive Care Med 1987;13:266-272 67 Hopkins RA, Bull C, Haworth SG, et al Pulmonary hypertensive crises following surgery for congenital heart defects in young children Eur J Cardiothorac Surg 1991;5:628-634 68 Atz AM, Adatia I, Jonas RA, Wessel DL Inhaled nitric oxide in children with pulmonary hypertension and congenital mitral stenosis Am J Cardiol 1996;77:316-319 69 Adatia I, Atz AM, Jonas RA, Wessel DL Diagnostic use of inhaled nitric oxide after neonatal cardiac operations J Thorac Cardiovasc Surg 1996;112:1403-1405 70 Morray JP, Lynn AM, Mansfield PB Effect of pH and PCO2 on pulmonary and systemic hemodynamics after surgery in children with congenital heart disease and pulmonary hypertension J Pediatr 1988;113:474-479 71 Cayler GG, Rudolph AM, Nadas AS Systemic blood flow in infants and children with and without heart disease Pediatrics 1963;32:186-201 72 Krovetz LJ, McLoughlin TG, Mitchell MB, Schiebler GL Hemodynamic findings in normal children Pediatr Res 1967;1:122-130 73 Gottschall CA The greatest medical discovery of the millennium (Fundamental steps to the understanding of cardiac performance) Arq Bras Cardiol 1999;73:320-330 74 Stewart G The output of the heart in dogs Am J Physiol 1921;57: 27-50 75 Moise SF, Sinclair CJ, Scott DH Pulmonary artery blood temperature and the measurement of cardiac output by thermodilution Anaesthesia 2002;57:562-566 76 Fegler G A thermocouple method of determination of heart output in anaesthetized dogs Montreal: XIX International Physiological Congress Proceedings p 341;1953 77 Fegler G Measurement of cardiac output in anesthetized animals by a thermodilution method Q J Exp Physiol 1954;39:153-164 78 Stetz CW, Miller RG, Kelly GE, Raffin TA: Reliability of the thermodilution method in the determination of cardiac output in clinical practice Am Rev Respir Dis 1982;126:1001-1004 79 Dhingra VK, Fenwick JC, Walley KR, Chittock DR, Ronco JJ Lack of agreement between thermodilution and Fick cardiac output in critically ill patients Chest 2002;122:990-997 80 Phillips RA, Hood SG, Jacobson BM, West MJ, Wan L, May CN Pulmonary artery catheter (PAC) accuracy and efficacy compared with flow probe and transcutaneous Doppler (USCOM): an ovine cardiac output validation Crit Care Res Pract 2012;62:1494 81 Shoemaker W, Chang P, Bland R, Al E Cardiorespiratory monitoring in postoperative patients: Pulmonary Artery Catheter Consensus Conference: consensus statement Crit Care Med 1979;7:243-249 82 Teboul JL, Saugel B, Cecconi M, et al Less invasive hemodynamic monitoring in critically ill patients Intensive Care Med 2016;42: 1350-1359 83 Huttemann E, Schelenz C, Kara F, Chatzinikolaou K, Reinhart K The use and safety of transoesophageal echocardiography in the general ICU—a minireview Acta Anaesthesiol Scand 2004;48:827-836 84 Monnet X, Teboul JL Transpulmonary thermodilution: advantages and limits Crit Care 2017;21:147 85 Monnet X, Anguel N, Osman D, Hamzaoui O, Richard C, Teboul JL Assessing pulmonary permeability by transpulmonary thermodilution allows differentiation of hydrostatic pulmonary edema from ALI/ARDS Intensive Care Med 2007;33:448-453 e3 Abstract: Hemodynamic monitoring refers to measurement of the functional characteristics of the heart and circulatory system that affect the perfusion of tissues with oxygenated blood Hemodynamic monitoring can be performed invasively or noninvasively and can be used for diagnosis, surveillance, or titration of therapy The central venous waveform is composed of three waves (a, c, and v) and two wave descents (x and y) The arterial waveform has three components: rapid upstroke, dicrotic notch, and runoff Pulse pressure variation has excellent specificity as an indicator of fluid responsiveness in many critically ill patients Cardiac output can be calculated using the Fick method or measured directly via thermodilution A pulmonary artery catheter can be used to measure cardiac output and indices of oxygen delivery and extraction Key words: pulmonary artery catheter, Swan-Ganz, arterial line, central venous catheter, pulse pressure, hemodynamics 10 27 Chapter Titleof Cardiovascular Function Assessment CHAPTER AUTHOR NATHANIEL R SZNYCER-TAUB, THOMAS J KULIK, JOHN R CHARPIE, AND MELVIN C AL MODOVAR PEARLS Again R L Sbasic knowledge of the development of the eye •P ETo •• • • • To develop essential understanding how abnormalities at inCardiovascular assessment and monitoring in the pediatric various stages of development can arrest or hamper normal tensive care unit require careful integration of physical findings, formation the ocular structures data and visual pathways laboratory of studies, and electronic to make appropriate therapeutic decisions Noninvasive monitoring includes physical examination, chest radiography, echocardiography, blood pressure monitoring, and pulse oximetry Invasive monitoring includes intravascular and intracardiac monitoring, cardiac output measurements (thermodilution or Fick method), and laboratory studies It is important to appreciate the quantity of therapy needed to achieve and sustain adequate systemic oxygen delivery and • To acquire adequate information about normal anatomy of the eye and related ifstructures and is develop a strong the foundation perfusion pressure the clinician to understand pafor the understanding of common ocular problems and tient’s overall condition, discern the patient’s trajectory,their and consequences anticipate associated consequences of current management choices Management of patients with single-ventricle physiology (such as the neonate with hypoplastic left heart syndrome) poses several unique challenges to the cardiac intensivist, including optimization of pulmonary-to-systemic blood flow ratios for best systemic oxygen delivery Pediatric patients undergoing surgical treatment for congenital heart disease (CHD) or those with severe systemic illnesses such as sepsis and other causes of multiple-organ system failure commonly have impaired cardiovascular function.1,2 In addition to treating the primary disease process, the pediatric intensivist should use strategies to reliably assess and monitor cardiovascular function, which specifically involve assessing adequacy of oxygen delivery (Do2) and systemic perfusion pressure, the primary determinants of tissue oxygenation O2, the ease with which these demands can be increased by small environmental changes, and the apparently limited reserve for augmenting cardiac output (CO) or O2 extraction acutely.7,8 Thus, it is crucial that cardiovascular assessment and monitoring in the pediatric intensive care unit (PICU) involve continuous and reliable evaluation of the adequacy of systemic perfusion and Do2 to select appropriate hemodynamic support strategies Cardiovascular Function If one considers hemodynamic monitoring not only in terms of Do2 and perfusion pressure but also in terms of what therapy is required to produce a given level of tissue oxygenation, one gains a much better understanding of the overall condition of the patient It is therefore important to monitor not only Do2 and perfusion pressure but also the quantity of therapy (QOT) needed to procure and maintain adequate tissue oxygenation Consider two hypothetical 6-month-old infants, Destiny and Dakota, hours after repair of tetralogy of Fallot They have identical (and adequate) Do2 and perfusion pressure, but Destiny has a left atrial (LA) pressure of mm Hg and a right atrial (RA) pressure of mm Hg, whereas Dakota has received volume infusion to achieve an LA pressure of mm Hg and an RA pressure of 15 mm Hg Assuming that the levels of intravascular volume provided are exactly those needed to achieve the identical Do2 values and perfusion pressures, it is clear that the physiologies of these two patients are different The clinician who has learned what to expect relative to the QOT in any given set of circumstances will find Dakota’s sufficient tissue oxygenation only mildly reassuring and asks: is there substantial residual right ventricular (RV) outflow The function of the heart and vasculature is to deliver oxygen (O2) and other nutrients to various tissues in order to meet the metabolic demands of the organism Mild to moderate depression of Do2 is normally compensated by augmented O2 extraction at the tissue level, thereby maintaining a stable level of oxygen consumption (Vo2) When Do2 falls below some critical level, this compensatory mechanism fails, and a state of O2 supply dependency exists3 such that any further drop in Do2 leads to a parallel fall in Vo2.4–6 Under a state of supply-dependent Vo2, affected tissues and organs attempt to maintain homeostasis partly through anaerobic metabolism Several studies suggest that the initial metabolic response to hypoxemia or decreased Do2 differs between the newborn and older ages and varies among different vascular beds In adults at rest, Do2 is in great excess of Vo2 This “O2 surplus” means that moderate reductions of O2 transport are generally well tolerated without compromise of Vo2 In contrast to the adult, the metabolism of the newborn may be particularly susceptible to modest alterations in O2 transport because of the high resting demands for Quantity of Therapy 239 ... atrium and pulmonary artery in critically ill children Pediatr Crit Care Med 2009;10:76-79 18 Berthiaume LR, Peets AD, Schmidt U, et al Time series analysis of use patterns for common invasive... maintaining a stable level of oxygen consumption (Vo2) When Do2 falls below some critical level, this compensatory mechanism fails, and a state of O2 supply dependency exists3 such that any further... ages and varies among different vascular beds In adults at rest, Do2 is in great excess of Vo2 This “O2 surplus” means that moderate reductions of O2 transport are generally well tolerated without