Central blood volume: maintenance of cardiac output and blood - PowerPoint PPT Presentation

Central blood volume: • maintenance of cardiac output and blood pressure during surgery Niels H. Secher Department of Anaesthesia Rigshospitalet The Copenhagen Muscle research center University of Copenhagen Department of Anesthesia, Rigshospital

The ether dome (Anesthesi 1846)

Operation Theatre

Anesthesia spread rapidly • First anesthesia in Denmark 1847 • But the death rate was approximately 5% until 1950 • At our part of the RH we conduct app. 6000 procedures meaning that we should experience an anesthesia-rated death almost every day • Anesthesiologists are not hired to provide anesthesia, but to maintain ventilation • Death is now related to circular problems rather than to handling of the ventilation

Department of Anesthesia, Rigshospitalet What is the volume deficit? (Ruptured aortic aneurysm)

(Cholera victim)

Department of Anesthesia, Rigshospitalet

Department of Rheumatology, Rigshospitalet

Department of Anesthesia, Rigshospitalet Irreversible chock Wiggers 1950

Department of Anesthesia, Rigshospitalet 19 year old dead in the dentist’s chair

Department of Rheumatology, Rigshospitalet Inferior calval vein diameter during HUT and HDT HUT: 1.2 cm 2 Supine: 1.7 cm 2 HDT: 2.2 cm 2

William Harvey discovered that blood is circulating But we measure typically • Heart rate and • Blood pressure

Hjertefrekvens og blodtryk under anæstesi

Department of Anesthesia, Rigshospitalet Cardiaovacular Variables During Hypovolemic shock Sander-Jensen et al. 1986.

Hjertemassage

Department of Anesthesia, Rigshospitalet HR response to hemorrhage Jacobsen & Secher 1992

Department of Anesthesia, Rigshospitalet The barorecptors do not work during a vasovagal episode Ogoh et al. 2004

Department of Rheumatology, Rigshospitalet Ernest Starling Otto Frank

Krogh & Lindhard

Department of Anesthesia, Rigshospitalet

Department of Anesthesia, Rigshospitalet Cardiac stroke volume decreases with filling of the heart HUT / HDT [degrees] 90 60 30 0 -30 -60 -90 20 dSV <30 y.o. R 2 = 0,93 dSV >30 y.o. 10 0 -10 R 2 = 0,97 -20 -30 -40 -50 -60 Bundgaard-Nielsen et al. 2009

J.J. Van Lieshout University of Amsterdam

Department of Rheumatology, Rigshospitalet How much fluid? Define normovolæmia ! Jans: Acta Anaesthesiol Scand.52:536-40 (2008)

Department of Anesthesia, Rigshospitalet Harms et al 2003

Registrering af hjernens oxygenering med nær infrarød spektroskopi (NIRS)

Department of Anesthesia, Rigshospitalet The heart is filled when SvO2 reaches a maximal value Tollund et al. 2009

TI reflects chances in blood volume Department of Anesthesia, Rigshospitalet rho accurately 4 TI2.5 (Ohm) 2 -0,97 0 -2 4 TI90 (Ohm) 2 -0,98 0 -2 HR (beats min-1) 125 -0,59 100 75 80 MAP (mm Hg) 60 0,70 40 CO (l min-1) 4 0,57 2 -25 -20 -15 -10 -5 0 5 Volume deficit (ml kg-1) Krantz et al. Acta Anaest Scand 44:598-604 (2000)

Department of Anesthesia, Rigshospitalet Cai et al. 2002

30 y = 8,8565x - 8,7409 25 R² = 0,8813 20 CO (l/min) y = -8,1954x - 22,618 15 R² = 0,5442 10 5 0 -6 -4 -2 0 2 4 CVP (mmHg) Rowing Running Lineær (Running)

30 y = 35,542ln(x) - 140,29 R² = 0,9414 25 20 y = 21,891ln(x) - 86,804 R² = 0,9471 CO (l/min) 15 10 5 0 60 70 80 90 100 110 120 130 140 150 160 Plasma ANP (pg/ml)

Pro-atrial natriuretic peptide ProANP in relation to intraoperative blood loss and fluid balance. Kirsten C Rasmussen et al. BMJ Open 2016;6:e010323

Department of Rheumatology, Rigshospitalet

The RH-test

Department of Anesthesia, Rigshospitalet Individual goal directed fluid volume therapy and postoperative outcome (M Bundgaard-Nielsen) • Review of 9 (10) randomized studies (877 patients) • Abdominal, orthopedic, gynecological, urological, and cardiac surgery • Intra- or early post-operative individualized fluid ”optimization” • Hospital stay • PONV • Complications • Ileus

Department of Rheumatology, Rigshospitalet

Department of Rheumatology, Rigshospitalet

Central blood volume • How to define CBV • How to monitor CBV

August og Marie Krogh

Department of Anesthesia, Rigshospitalet Kety- Schmidt method for “global” CBF: a measure of internal jugular venous flow

Department of Anesthesia, Rigshospitalet

Birgitte Hanel finds reduced CBV after exercise by pulmonary diffusion capacity

Department of Anesthesia, Rigshospitalet Clinical evaluation of cerebral blood flow • Dubrovnik 2017 Niels H. Secher Department of Anaesthesia Rigshospitalet The Copenhagen Muscle research center University of Copenhagen

Alternative evaluation of CBV • Pulmonary diffusion capacity • Thoracic electrical impedance • Echocardiography • Monitoring plasma atrial natiuretic peptide

Department of Anesthesia, Rigshospitalet TI predicts Hypotension during dialysis Cai et al. 2002

Department of Anesthesia, Rigshospitalet Brain function and blood flow. Lassen NA, Ingvar DH, Skinhøj E. N A Lassen Regional CBF increases during exercise but not after regional anaesthesia

Cerebral autoregulation

Secure filling of the heart before other interventions are considered

Arnold Mærsk Mc-Kinney Møller son of a Danish father, Arnold Peter Møller, founder of the A.P. Moller – 13 July 1913 Hellerup, Denmark Maersk Group, and an American mother, Chastine Estelle Roberta (née McKinney) Møller. Died 16 April 2012 (aged 98)