Lessons from the ICU Under the Auspices of the European Society of Intensive Care Medicine

Maurizio Cecconi, Head Dept Anesthesia and ICU, Humanitas Research Hospital, Rozzano, Milano, Italy Series Editor Daniel De Backer, Dept Intensive Care Erasme University, Université Libre de Bruxelles, Bruxelles, Brussels Hoofdst.ge., Belgium Series Editor Lessons from the ICU is a Book Series published by Springer under the auspices of the European Society of Intensive Care Medicine (ESICM). The aim of the Series is to provide focused and state-of-the-art reviews of central topics in Intensive Care. Ultimately, its mission is to transfer the latest knowledge to the bedside in order to improve patient outcomes. Accordingly, the ESICM has also developed Lessons from the ICU with the vision or providing the best resources for everyone working in Intensive Care. Each volume presents a comprehensive review of topical issues in Intensive Care. The volumes are intended to cover the majority of aspects that intensive care professionals are likely to encounter in the course of their career. Books offer an excellent guide for residents who are new to the ICU, and for allied professionals, senior consultants as well as nurses and allied healthcare professionals. The chapters are organized in a way that allows the reader to quickly familiarize or reacquaint them- selves with the pathophysiological background before moving on to diagnosis and treatment. Each chapter includes a list of Take Home Messages, as well as practical examples that apply theoretical knowledge in real clinical scenarios. Each volume in the Series is edited by international Key Opinion Leaders in Intensive Care, and each chapter is written by experts in the field. In summary, this Series represents a valuable contribution to fill the gap in the current Intensive Care literature by providing top-quality literature reviews that can be easily digested and used at the bedside to improve patient outcomes.

More information about this series at http://www.springer.com/series/15582 Michael R. Pinsky Jean-Louis Teboul Jean-Louis Vincent Editors Hemodynamic Monitoring Editors Michael R. Pinsky Jean-Louis Teboul Critical Care Medicine Dept. Bicetre University Hospital University of Pittsburgh Paris South University Pittsburgh, PA Le Kremlin-Bicêtre USA France

Jean-Louis Vincent Department of Intensive Care Erasme University Hospital Brussels Belgium

ISSN 2522-5928 ISSN 2522-5936 (electronic) Lessons from the ICU ISBN 978-3-319-69268-5 ISBN 978-3-319-69269-2 (eBook) https://doi.org/10.1007/978-3-319-69269-2

Library of Congress Control Number: 2019930093

© European Society of Intensive Care Medicine 2019 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recita- tion, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland V

The editors wish to dedicate this volume to all our teachers who through hard work and dedication mentored us through our careers, our colleagues who have been with us always on this journey of shared patient care, and to our patients, for whose optimal care and comfort is our never-ending goal. Foreword

Critical illness often presents problems of such complexity that the bedside clinician is forced to integrate information from many data streams into the management decision. As the ‘evidence-based’ investigational paradigm gained traction and eventual dominance in medicine, initial hope was entertained by many intensivists that solid evidence from trials, together with advanced imaging and the laboratory data, would generate effective ‘rules’ to guide practice. In fact, well-designed and conducted clinical trials (RCTs) do characterize general behaviors and may provide defensible starting points for making some choices, especially if positive. To this point however, we have been disappointed by RCT output; fundamentally, such problems are too imprecisely defined, complicated, interactive, and labile to allow RCTs, ‘snapshot’ imaging, and biomarkers – even considered together – to reliably direct the next best step for the individual patient.

Effective life support needs a more ‘personalized’ approach that adheres to established principles aimed at supporting the patient’s own efforts to recover homeostasis and viability. Our decisions must remain flexible; within the physical boundaries of the ICU, the principles of therapeutic challenge, frequent reassessment, continual re-eval- uation, and timely mid-course correction remain fundamental elements of the inten- sivist’s art. Moment-by-moment access to key information relevant to the patient’s status is central to well-timed interventions. Successful management still depends upon having a firm grasp of the physiology of critical illness, coupled with the ability to expertly integrate and act upon monitored information from key indicators that reflect cardiopulmonary functioning. A few foundational elements of critical care physiology share precedence over the others, but none is more important than the circulation.

This important volume, written by the foremost experts of our field and directed toward bedside management, is a wide-ranging compendium of in-depth chapters that address essential cardiovascular physiology as well as the pragmatics of diagnosing, monitoring, and supporting the circulatory system. The mechanistic basis for clinical decision making is emphasized throughout. Cardio-respiratory management of the critically ill has advanced rather impressively in recent decades, and such progress is clearly evident in the attention given to such up-to-date topics as bedside ultrasound, assessment of the microcirculation and perfusion adequacy, advanced monitoring options, and extracorporeal circulatory assistance and gas exchange. The chapters of this book are not meant to be read sequentially from cover to cover (even though such an exercise might prove highly rewarding), but rather to be accessed in a focused man- ner as specific clinical issues arise in patient care or when knowledge gaps need to be filled.

In this current exciting age of rapidly expanding knowledge of genetic and molecular sciences, exhaustive statistical analyses, empirical evidence gathering, RCTs and meta- analysis, it sometimes seems that our attention as practitioners has been diverted from VII Foreword understanding the ‘why?’ to the ‘what and how’?. I congratulate the editors and authors for addressing both in admirable fashion. It is refreshing and most welcome to see a definitive work based upon the often neglected but invaluable middle ground of applied pathophysiology. Mastery of physiology will always be needed to unravel our most dif- ficult clinical challenges and remains the foundation of intelligent critical care.

John J. Marini Minneapolis/St. Paul, MN, USA Preface

An essential aspect of the care of the critically ill patient is to identify cardiovascular insufficiency, treat it, and know when to stop over resuscitation while also attending to the various other aspects of pathology that each patient brings to the clinical environ- ment. No two patents are alike in their presentation of acute illness, response to therapy, or potential for a good outcome from the treatment of disease and a minimal amount of treatment-associated morbidities. Furthermore, most people, if they live long enough, will experience some acute potentially life-taking process that if not treated correctly and rapidly will result in death or morbidity before their time. These realities make the practice of critical care medicine one of the most demanding of all medical specialties, and also one of its greatest attractions in the recruitment of dedicated and passionate bedside clinicians.

Within this context, this volume has been crafted to systematically address all aspects of hemodynamic monitoring-related cardiovascular diagnosis and management. Part I of this volume addresses the essential aspects of the physiology and pathophysiology of cardiovascular insufficiency. The authors of these eleven chapters are some of the leading clinical investigators in the field with many years of bedside clinical experience and an impressive publication record of clinical trials and basic science companion studies. Although these chapters are arranged in a progressive sequence to supplement each other, the reader can pick and choose specific chapters of interest based on their per- ceived knowledge gaps or focused areas of interest.

Part II of this volume assumes the reader is cognizant of the underlying physiology and pathophysiology and goes directly into their use in clinical assessment. Because once a basic understanding of physiology is present, real-time knowledge of the patient allows diagnosis to become personalized by addressing the unique aspects of each patient as they face life-threatening disease processes. These five integrated chapters require an understanding of the underlying physiology but then take that plane and elevate it to clinical decision making and prognosis. This section in the volume represents a unique series of chapters relative to other critical care medicine textbooks, and we hope its util- ity to direct patient care will be innately obvious to the reader.

Part III addresses the specific measures made by various monitoring devices because at the end of the day hemodynamic monitoring is monitoring with specific devices that report specific information over time. Thus the focus on specific monitoring modality and physiologic parameter discussed in these twelve chapters bring the physiology of Part I and the pathophysiologic assessments in Part II into reality at the bedside.

Part IV addresses the very real question of what to do and why. Targeting specific therapeutic end points assumes that their achievement will reduce morbidity and mortality. But what therapies to give and why? These questions are addressed in these three very focused chapters. IX Preface

Finally, in Part V, patients usually fit into broad groupings of acute illness based on the fundamental pathophysiologic processes that initiated their instability. Acute heart failure, septic shock, ARDS, neurologic emergencies, postoperative problems, and recently the need for extracorporeal support. They reflect the present-day disease state/processes commonly seen in the intensive care unit. These chapters serve to solidify the prior chapters into a complete set, leaving the bedside clinician with insight and hopeful perspec- tive as to what to expect, to monitor, and how to apply that monitoring.

The editors are profoundly grateful to the authors of this book for their excellent contri- butions and knowledge base that made these chapters what they are; the senior editors of the European Society of Intensive Care Medicine, who oversaw the creation of this book within their series; and the publisher, Springer, for their support and dedication to this very important and clinically relevant opus.

Michael R. Pinsky Pittsburgh, PA, USA

Jean-Louis Teboul Le Kremlin-Bicêtre, France

Jean-Louis Vincent Brussels, Belgium XI

Contents

I Physiology and Pathophysiology

1 Introduction to “Hemodynamic Monitoring”...... 3 Jukka Takala

2 Shock: Definition and Recognition...... 7 Antonio M. Dell’Anna, Flavia Torrini, and Massimo Antonelli

3 Assessing the Adequacy of Cardiac Output...... 21 Jean-Louis Vincent

4 Determinants of Venous Return...... 27 Hollmann D. Aya and Maurizio Cecconi

5 Arterial Blood Pressure Regulation...... 39 Alexander Kobzik and Michael R. Pinsky

6 Pulmonary Circulation...... 49 Marco Maggiorini

7 The Pulse: An Essential Vital Sign...... 65 Paul E. Marik

8 Autonomic Dysfunction in Shock...... 71 Gareth L. Ackland

9 Oxygen Delivery...... 81 Eleonora Duscio, Francesco Vasques, Federica Romitti, Francesco Cipulli, and Luciano Gattinoni

10 Mitochondrial Function...... 97 Mervyn Singer

11 Perioperative Haemodynamics...... 107 Katherine McAndrew, Maurizio Cecconi, and Andrew Rhodes

12 Hemodynamics and Extracorporeal Circulation...... 117 Maxime Coutrot, Alain Combes, and Nicolas Bréchot

II Clinical Assessment and Measurements

13 Clinical Assessment of Hemodynamic Instability...... 131 Jan Bakker XII Contents

14 Assessment of the Microcirculation...... 147 Daniel De Backer

15 SvO 2/ScvO2...... 157 Zsolt Molnar and Marton Nemeth

16 The PCO2 Gaps...... 173 Gustavo A. Ospina-Tascón

17 Lactate ...... 191 Ricardo Castro, David Carpio, and Glenn Hernández

III The Techniques

18 Cardiac Ultrasound Examination in Shock...... 205 Guillaume Geri and Antoine Vieillard-Baron

19 Non-cardiac Ultrasound Signs in Shock...... 215 Becky X. Lou and Paul H. Mayo

20 Central Venous Pressure...... 223 Sheldon Magder

21 Arterial Blood Pressure...... 233 Bernd Saugel, Thomas W. L. Scheeren, and Jean-Louis Teboul

22 Cardiac Output Monitors...... 247 Daniel A. Reuter and Sebastian A. Haas

23 Volumetric Monitoring in Critically Ill Patients...... 253 Manu L. N. G. Malbrain

24 Assessment of Fluid Responsiveness...... 283 Xavier Monnet and Jean-Louis Teboul

25 Pulmonary Artery Catheter...... 301 Ina Filipović-Grčić and Didier Payen

26 Arterial Pressure Waveform Analysis on Cardiac Output Monitoring...... 313 Manuel Ignacio Monge García and Arnoldo Santos

27 Oesophageal Doppler...... 323 Jonathan Lacey and Monty Mythen

28 Bioimpedance and Bioreactance...... 339 Lee S. Nguyen and Pierre Squara XIII Contents

IV Basic Goals in Clinical Practice

29 Blood Pressure Targets in the Initial Stabilization...... 359 Julien Demiselle, Peter Radermacher, and Pierre Asfar

30 Lessons from the ICU: Choosing the Right Vasopressor...... 367 Francesco Fiorini, David Antcliffe, and Anthony C. Gordon

31 Fluid Resuscitation...... 379 Peter Buhl Hjortrup and Anders Perner

V Choosing the Right Hemodynamic Therapy

32 Choosing the Ideal Hemodynamic Therapy in Acute Right and Left Heart Failure...... 393 Alexa Hollinger and Alexandre Mebazaa

33 Cardiopulmonary Monitoring of Septic Shock...... 411 Claude Martin, Gary Duclos, and Marc Leone

34 In ARDS...... 419 Giacomo Grasselli, Nadia Corcione, and Antonio Pesenti

35 In Neurological Emergencies...... 439 Ilaria Alice Crippa and Fabio Silvio Taccone

36 Perioperative Haemodynamic Optimisation...... 457 Mark R. Edwards and Rupert M. Pearse

37 In a Patient Under ECMO...... 469 Darryl Abrams and Matthieu Schmidt Contributors

Darryl Abrams Daniel De Backer Division of Pulmonary, Allergy, and Critical Care Department of Intensive Care Columbia University College of Physicians CHIREC Hospitals, Université Libre de Bruxelles and Surgeons/New York-Presbyterian Hospital Brussels, Belgium New York, NY, USA [email protected] [email protected] Jan Bakker, MD, PhD, FCCP, FCCM Gareth L. Ackland Department of Pulmonary and Critical Care Translational Medicine and Therapeutics, New York University William Harvey Research Institute, Barts and New York, NY, USA The London School of Medicine and Dentistry Division of Pulmonary, Allergy, Queen Mary University of London and Critical Care Medicine John Vane Science Centre Columbia University Medical Center London, UK New York, NY, USA [email protected] Department of Intensive Care Adults Erasmus MC University Medical Center David Antcliffe Rotterdam, The Netherlands Imperial College London Department of Intensive Care London, UK Pontificia Universidad Católica de Chile [email protected] Santiago, Chile Massimo Antonelli, MD [email protected] Department of Anesthesiology Nicolas Bréchot, MD, PhD and Intensive Care Medicine Medical–Surgical ICU, Hôpital Pitié–Salpêtrière, Fondazione Policlinico Universitario Assistance Publique–Hôpitaux de Paris A.Gemelli- Università Cattolica Paris Cedex, France del Sacro Cuore – Roma INSERM U1050, Centre for Interdisciplinary Rome, [email protected] Research in Biology (CIRB), College de France CNRS, INSERM, PSL Research University Pierre Asfar Paris, France Medical Intensive Care Department [email protected] University Hospital of Angers Angers, France David Carpio, MD [email protected] Departamento de Medicina Intensiva Facultad de Medicina, Pontificia Universidad Hollmann D. Aya Católica de Chile Critical Care Department Santiago, Chile St Bartholomew’s Hospital – Heart Center [email protected] Barts Health NHS Trust London, UK Ricardo Castro, MD, MPH [email protected] Departamento de Medicina Intensiva Facultad de Medicina, Pontificia Universidad Católica de Chile Santiago, Chile [email protected] XV Contributors

Maurizio Cecconi Antonio M. Dell’Anna, MD IRCCS Istituto Clinico Humanitas Department of Anesthesiology Rozzano, MI, Italy and Intensive Care Medicine Humanitas University Fondazione Policlinico Universitario Pieve Emanuele, MI, Italy A.Gemelli- Università Cattolica del Sacro [email protected] Cuore – Roma Rome, Italy Francesco Cipulli [email protected] Department of Anesthesiology, Emergency and Intensive Care Medicine Julien Demiselle University of Göttingen Medical Intensive Care Department Göttingen, Germany University Hospital of Angers [email protected] Angers, France [email protected] Alain Combes, MD, PhD Medical–Surgical ICU, Hôpital Pitié–Salpêtrière Gary Duclos Assistance Publique–Hôpitaux de Paris Aix-Marseille Université Paris Cedex, France Marseille, France [email protected] Sorbonne University, UPMC Univ Paris 06, INSERM, UMRS_1166-iCAN, Eleonora Duscio Institute of Cardiometabolism and Nutrition Department of Anesthesiology, Paris Cedex, France Emergency and Intensive Care Medicine [email protected] University of Göttingen Göttingen, Germany Nadia Corcione [email protected] Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Mark R. Edwards Milan, Italy University Hospital Southampton NHS [email protected] Foundation Trust and University of Southampton Southampton, UK Maxime Coutrot, MD [email protected] Medical–Surgical ICU, Hôpital Pitié–Salpêtrière Assistance Publique–Hôpitaux de Paris Ina Filipović-Grčić, MD Paris Cedex, France Department of Anesthesiology and Intensive Care [email protected] European Medical Center-General Hospital Dubrovnik Ilaria Alice Crippa, MD Dubrovnik, Croatia Department of Intensive Care [email protected] Hopital Erasme, Université Libre de Bruxelles (ULB) Francesco Fiorini Brussels, Belgium Imperial College London [email protected] London, UK [email protected] XVI Contributors

Manuel Ignacio Monge García Peter Buhl Hjortrup Unidad de Cuidados Intensivos, Department of Intensive Care Hospital SAS de Jerez de la Frontera Copenhagen University Hospital Rigshospitalet Jerez de la Frontera, Spain Copenhagen, Denmark [email protected] [email protected]

Luciano Gattinoni Alexa Hollinger Department of Anesthesiology, Emergency The University Hospital of Basel and Intensive Care Medicine Basel, Switzerland University of Göttingen [email protected] Göttingen, Germany [email protected] Alexander Kobzik, MD Department of Critical Care Medicine Guillaume Geri University of Pittsburgh Medico-Surgical ICU, Pittsburgh, PA, USA Ambroise Paré Hospital, APHP [email protected] Boulogne-Billancourt, France Jonathan Lacey Versailles Saint Quentin University University College London INSERM U1018, Team 5 London, UK Paris, France [email protected] [email protected] Marc Leone Anthony C. Gordon Aix-Marseille Université Imperial College London Marseille, France London, UK [email protected] [email protected] Becky X Lou, MD Giacomo Grasselli Zucker School of Medicine at Hofstra/ University of Milan Northwell Health Milan, Italy New Hyde Park, NY, USA [email protected] [email protected]

Sebastian A. Haas Sheldon Magder Department of Anesthesiology Department of Critical Care and Intensive Care Medicine McGill University Health Centre Rostock University Medical Center Montreal, QC, Canada Rostock, Germany [email protected] [email protected] Marco Maggiorini Glenn Hernández, MD, PhD University Hospital Zürich Departamento de Medicina Intensiva Zürich, Switzerland Facultad de Medicina [email protected] Pontificia Universidad Católica de Chile Santiago, Chile Manu L. N. G. Malbrain [email protected] Vrije Universiteit Brussel (VUB) Ixelles, Belgium [email protected] XVII Contributors

Paul E. Marik, MD, FCCM, FCCP Monty Mythen Division of Pulmonary and Critical University College London Care Medicine London, UK Eastern Virginia Medical School [email protected] Norfolk, VA, USA [email protected] Marton Nemeth, MD, PhD Department of Anesthesiology Claude Martin and Intensive Therapy Aix-Marseille Université University of Szeged Marseille, France Szeged, Hungary [email protected] [email protected]

Paul H. Mayo, MD Lee S. Nguyen Zucker School of Medicine at Hofstra/ Critical Care Medicine Department Northwell Health CMC Ambroise Paré New Hyde Park, NY, USA Neuilly-sur-Seine, France [email protected] [email protected]

Katherine McAndrew Gustavo A. Ospina-Tascón Department of Intensive Care Medicine Department of Intensive Care Medicine St George’s University Hospitals NHS Fundación Valle del Lili - Universidad ICESI Foundation Trust Cali, Colombia London, UK [email protected] [email protected] Didier Payen, MD, PhD Alexandre Mebazaa University Paris 7 Denis Diderot, Sorbonne Cité Hôpitaux Lariboisière Saint Louis UMR INSERM 1109, Hôpital Lariboisière, AP-HP University Hospitals Paris, France Paris, France [email protected] [email protected] Rupert M. Pearse Zsolt Molnar, MD, PhD Queen Mary’s University of London Barts & Department of Anesthesiology The London School of Medicine and Dentistry and Intensive Therapy London, UK University of Szeged Adult Critical Care Unit, Royal London Hospital Szeged, Hungary London, UK [email protected] [email protected]

Xavier Monnet Anders Perner Medical Intensive Care Unit, Bicêtre Hospital Department of Intensive Care Paris-Sud University Hospitals Copenhagen University Hospital Rigshospitalet Inserm UMR_S999, Paris-Sud University Copenhagen, Denmark Le Kremlin-Bicêtre, France [email protected] Service de réanimation médicale Hôpital de Bicêtre Antonio Pesenti Le Kremlin-Bicêtre, France University of Milan [email protected] Milan, Italy [email protected] XVIII Contributors

Michael R. Pinsky, MD Bernd Saugel Department of Critical Care Medicine Department of Anesthesiology University of Pittsburgh Center of Anesthesiology and Intensive Care Pittsburgh, PA, USA Medicine, University Medical Center [email protected] Hamburg-Eppendorf Hamburg, Germany Peter Radermacher [email protected] Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung Thomas W. L. Scheeren Universitätsklinikum Department of Anaesthesiology Ulm, Germany University of Groningen [email protected] University Medical Center Groningen Groningen, The Netherlands Daniel A. Reuter [email protected] Department of Anesthesiology and Intensive Care Medicine Matthieu Schmidt Rostock University Medical Center Medical-Surgical Intensive Care Unit Rostock, Germany Hôpital Pitié-Salpêtrière, Assistance [email protected] Publique-Hôpitaux de Paris Paris, France Andrew Rhodes Sorbonne University Paris, INSERM Department of Intensive Care Medicine Institute of Cardiometabolism and Nutrition St George’s University Hospitals NHS UMRS_1166-ICAN Foundation Trust Paris, France London, UK [email protected] [email protected] Mervyn Singer Federica Romitti Bloomsbury Institute of Intensive Care Department of Anesthesiology, Emergency Medicine, University College London and Intensive Care Medicine London, UK University of Göttingen [email protected] Göttingen, Germany [email protected] Pierre Squara Critical Care Medicine Department Arnoldo Santos CMC Ambroise Paré CIBER de enfermedades respiratorias (CIBERES) Neuilly-sur-Seine, France Madrid, Spain [email protected] Surgical Sciences Department, Hedenstierna Laboratory, Uppsala University Uppsala, Sweden [email protected] XIX Contributors

Fabio Silvio Taccone, MD, PhD Cuore – Roma Department of Intensive Care Rome, Italy Hopital Erasme [email protected] Université Libre de Bruxelles (ULB) Brussels, Belgium Francesco Vasques [email protected] Department of Anesthesiology, Emergency and Intensive Care Medicine Jukka Takala, MD, PhD University of Göttingen Department of Intensive Care Medicine Göttingen, Germany Inselspital, Bern University Hospital [email protected] University of Bern Bern, Switzerland Antoine Vieillard-Baron [email protected] Medico-Surgical ICU Ambroise Paré Hospital, APHP Jean-Louis Teboul Boulogne-Billancourt, France Medical Intensive Care Unit, Bicêtre Hospital, Versailles Saint Quentin University Paris-Sud University Hospitals INSERM U1018, Team 5 Inserm UMR_S999, Paris-Sud University Paris, France Le Kremlin-Bicêtre, France [email protected] [email protected] Jean-Louis Vincent Flavia Torrini, MD Department of Intensive Care Department of Anesthesiology Erasme University Hospital and Intensive Care Medicine Université Libre de Bruxelles Fondazione Policlinico Universitario Brussels, Belgium A.Gemelli- Università Cattolica del Sacro [email protected]