Management

Post operative
Low Cardiac Output Syndrome

Bundit Mokarat, MD

Queen Sirikit Heart centre, Khonkaen University

Two Days 2020

Demand
Shock
1. Systemic arterial hypotension: Typically, in adults, SBP < 90 mm Hg or MAP < 70 mmHg, with
associated tachycardia.

2. Clinical signs of tissue hypoperfusion: Cutaneous (skin that is cold and clammy, with
vasoconstriction and cyanosis)
Circulatory
Failure ▬ Renal (urine output of <0.5 ml/kg/hr)
▬ Neurologic (altered mental state, disorientation)
Inadequate cellular Oxygen
3. Hyperlactatemia: >1.5 mmol/L
perfusion
 Type to Shock
Non septic Distributive Shock
Obstructive

2% Low CO High CO
Hypovolumic 4% ▬ Narrow pulse pressure ▬ Wild pulse pressure
16% ▬ Cool, blue skin ▬ Warm, pink skin
▬ Delayed capillary refill ▬ Rapid capillary refill
16% 62%
Jugular veins Distributive Shock
Septic
Empty Full
Cardiogenic
Hypovolumic Shock Breath sound

De Backer D, N EngJ Med. 2010;362:779-89

Clear Crackle
Obstructive Shock Cardiogenic Shock
Principle of critical care. 4thed. New York: McGraw-Hill, 2015:249-62.
Low Cardiac Output Syndrome : Definition

LCOS Cardiac index <2.2 l/min/m

without relative hypovolemia
secondary to LV, RV failure
+/- systemic, pulmonary congest

Clinical malperfusion Oliguria (diuresis <0.5 ml/kg/h)

SvO2 <60%
Lactate >3 mmol/l

Cardiogenic shock Cardiac index <2.0 l/min/m

SBP <90 mmHg
 Complication
Relate LCOS

CO & Hospital DEAD

Med Intensiva. 2018;42(3):159—167

Cardiac Surgery risk for LCOS
Incident : 3 - 5 %, Post Adult Cardiac Operation
25 %, Post Congenital Cardiac Operation

Decrease Oxygen delivery q Surgical manipulations

q Arrhythmias / Valvular dysfunction
LCOS Reduce Cardiac output q Impaired preload
q Myocardial depression / dysfunction
Organ/Tissue poor perfusion q Vascular resistance / tone
Preoperative factors -Age>65 years / Female
Peri-operative -CPB duration
-LVEF<50%
factors -Emergency / Redo surgery
-On-pump CABG
-Incomplete revascularization
-Recent MI
-Complex congenital Surgery Multifactorial -CPB with cardioplegic arrest: myocardial dysfunction
-Severe PHT cause -Inadequate myocardial protection
-DM and CKD -Systemic inflammatory responses
-Malnutrition -ischemic / Reperfusion injury
Laboratory predictors -Hemoglobin -Alteration in signal transduction system
-TLC 2,000 cells per microliter -Uncorrected pre-existing cardiac conditions
-NT-proBNP
-BNP
-hFABP

* TCL : Total lymphocyte count , hFABP : Heart fatty acid binding protein
LCOS Risk factors
 Cardiogenic Shock
Patient risk factors

▬EuroSCORE II
▬Diabetes
▬CCS class 4
▬Preoperative critical condition
▬Previous cardiac surgery
▬Emergency surgery
▬CPB > 120 min
▬CPB re-entry

Med Intensiva. 2018;42(3):159—167

Common Cardiac pathophysiologic mechanism

LV Systolic RV Systolic
Dysfunction Dysfunction

LV Diastolic
Dysfunction
 LCOS Management
Early recognition /
Treatment Prevention
monitor
Diagnosis LCOS

Signs / Symptoms / Clinical assessment

Early recognition
Timely intervention / Management
Hemodynamic monitoring

Diagnostic studies / Laboratory tests / Serologic variables

Hemodynamic Monitor and Early
Detection
Principle of Hemodynamic Monitor
Balance Oxygen delivery (DO2) vs Oxygen consumption (VO2)

Real time measurement Less invasive

Monitor Depend on

• Type of Surgery
• Patients relative risks
 25

Curr Opin Crit Care 21:395-401, 2015

 Hemodynamic Monitor
BASIC PRELOAD MEASUREMENT
ECG MONITORING
HR, Rhythm , Arrhythmia , Ischemic pattern

BLOOD PRESSURE MONITORING

MAP, SVR : CO

Cuff (sphygmomanometer), Catheter

SPO2 MONITORING
Peripheral skin perfusion, O2 dissociation curve

Oxygen saturation, SpO2 should be maintained >92%

SERUM LACTATE
resting humans ~1 mmol/L (0.7-2.0)

^ serum lactate : Poor tissue perfusion; circulatory failure, anaerobic metabolism and tissue
hypoxia
 Static Measurement
CVP / RAP PAP / PAOP

▬ Assume right ventricular output is proportionate to left ventricular preload ▬ Measure LV preload Equivalent to LVEDP
▬ myocardial compliance (sepsis, myocardial ischemia),Right ventricular overload, Pericardial disease,
▬ Inaccurate and unreliable predictor of fluid responsiveness Increase intrathoracic pressure

▬ RAP is a measure pressure not volume

▬ Variation in vascular tone, intra-thoracic, and cardiac function directly affect RAP,
without change of preload
Ann Intensive Care

-RAP, , RVEDV, and LVEDA were not significantly lower in responders than in non-responders
- no threshold value could discriminate

Correlation PAOP and CO , AUC 0.63

N=2015, 20 studies Osman D. Crit Care Med. 2007
 Dynamic Hemodynamic Monitor
‐ SPV
A. mechanical ventilation (MV) induced cyclic variation ‐ PPV
‐ SVV
‐ Aortic blood flow

‐ Vena Cava Diameter

B. hemodynamic parameters based on MV ‐ Ventricular‐pre‐ejection period

‐ Passive leg raising

C. hemodynamic parameters based on preload redistribution manoeuvres ‐ Valsalva manoeuvre
 HOW DO CHOOSE THE APPROPRIATE HAEMODYNAMIC
I

MONITORING ?

29

Haemodynamic monitoring per se has no favourable impact on outcome.

Only the interventions based on haemodynamic data will impact outcome.

Decision matrix for
intraoperative hemodynamic monitoring

30
 Pulse pressure, Stroke volume Variation
predict volume responsiveness

PPV (%) = (PPmax –PPmin)/ (Ppmax+Ppmin)/2

SVV = SV max – SV min

SV mean

Crit Care Med 2009 Vol. 37, No. 9

 Ann Intensive Care

PPV, SVV limitation

Pulse pressure Analysis

33
Arterial Wave form

34

▬ Systolic upstroke
▬ Systolic peak pressure
▬ Systolic decline
▬ Dicrotic notch
▬ Diastolic runoff
▬ End-diastolic pressure
 Arterial wave form

35
Full cardiac cycle Stroke volume Vascular tone

Contractility Aortic compliance Afterload

Arterial Waveform

37
 Advance Arterial wave form
LV

Critical Care (2018) 22:325

Femoral
38

Radial

Maximal left ventricular (LV) pressure rise (LV dP/dtmax) : marker of LV systolic function
 AI Analysis

39

>15 min

85

HPI : Hypotension prediction index

Anesthesiology 2018; XXX:00-00
 Preventive LCOS
Monitor Application

40
 AUC 0.926 AUC 0.895 AUC 00.879
(95% CI, 0.925–0.926; (95% CI, 0.894–0.895; (95% CI, 0.879–0.880;
sensitivity, 86%; specificity, 86%) sensitivity, 82%; specificity, 82%) sensitivity, 81%; specificity, 81%)
February 17, 2020.

0.957
0.919
0.934

20 patients : CABG, CABG + valve surgery

A-wave form and HPI

Treatment LCOS
 Initial Management
q Adequate ventilation management
Identify correctable causes
q Normothermia
• Graft dysfunction
• Valvular incompetence
q Maintain acid-base balance
• Pericardial tamponade
• Pneumothorax
q Correct electrolyte abnormalities
LCOS: Treatments
LCOS Treatment Guide
Preload : Passive leg raising

Suitable for the critically ill ICU population

Limitation
Need to assess real time direct measurement of CO

Increase in risk of aspiration

Increased Intracranial pressure (limit use in traumatic brain injury)

Fracture of lower extremities (painful )

Intensive Care Med (2010) 36:1475–1483 Limit use in operating room

Preload : PGDT

PCWP
Perioperative Goal‐Directed Therapy
(PGDT)

▬ GDT : hemodynamic optimization algorithm based on the use of fluids,

inotropes, and/or vasopressors to achieve normal or supranormal
hemodynamic values (hemodynamic goals)”.

▬ PGDT -> GDT initiated in the intraoperative period and maintained in

the immediate postoperative period
 PGDT Benefit - Cardiac Surgery
British Journal of Anaesthesia 110 (4): 510–17 (2013)

Post operative complication

▬ PGDT protocol 24Hr preoperative

▬ RCT 5 studies 722 patients
▬ Adult (>18y) cardiac surgery

Hospital length of Stay

Mortality
Medication Treatment : Inotropic
Lovosimendan vs Dobutamine
Rev Esp Cardiol. 2006;59(4):338-45
 56

ECMO
Hemodynamic
Medication / Mechanical Support & Hemodynamic
 Take Home message
▬ Low cardiac output syndrome make severe complication after cardiac surgery
▬ Hemodynamic monitor in high risk patients and and high risk procedure
▬ Peri-operative Goal‐Directed Therapy (PGDT) is very important to management patient to prevent low cardiac output syndrome
▬ Early recognition , Timely intervention / treatment, less sequence LCOS complications.
Management
Post operative
Low Cardiac Output Syndrome

Bundit Mokarat, MD

Queen Sirikit Heart centre, Khonkaen University

Two Days 2020