Presentazione sul tema: "IL MONITORAGGIO EMODINAMICO NELLO SCOMPENSO CARDIACO"— Transcript della presentazione:
1 IL MONITORAGGIO EMODINAMICO NELLO SCOMPENSO CARDIACO a cura diFabrizio OlivaAREA SCOMPENSOA.N.M.C.O.
2 Pulmonary Artery Catheter (PAC) Introduction in 1970sPAC is often considered a cornerstone of critical care and a hallmark of the ICUAppoximately 1 million PACs are used annualy in USPhysician, equipment and hospital cost in US over $ 2 billion per yearWidspread application in the ICU and perioperative setting, despite a lack of high-quality evidence supporting such useAREA SCOMPENSOA.N.M.C.O.
3 Pulmonary Artery Catheter (PAC) Conflicting Data The majority of nonrandomized study in critically ill pts have suggested that PAC is associated with increased morbidity and mortalityConversely some studies showed improved quality of life when the PAC was used to direct a specific therapeutic approachLimits: small sample sizes in heterogeneous populationsClinicians continue to use the PAC in ICUs based on personal experience and the belief that careful monitoring will improve decision making and clinical outcome.AREA SCOMPENSOA.N.M.C.O.,
4 ADHERE Registry Procedure All patients (N= 105.388) ICU patients Defibrillation (%)16Mechanical ventilation (%)523Intraaortic baloon pump (%)<12Pulmonary artery catheter (%)17Dialisys (%)9AREA SCOMPENSOA.N.M.C.O.AREA SCOMPENSOA.N.M.C.O.Kirkwood et al Am Heart J 2005
6 Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness The ESCAPE Trial433 pts56 y (SD14)74% maleischemic 51%EF 20% (SD 6)Creat 1.5 mg/dl (SD0.6)AREA SCOMPENSOA.N.M.C.O.JAMA 2005; 294:
7 The ESCAPE TrialImpact of Intervention on Primary End Point Across Demographic SubgroupsJAMA 2005; 294:
8 Inotrope and Vasodilators Use After Randomization The ESCAPE TrialPrimary Outcomes Mortality and Hospitalizations and Primary End Point Results byInotrope and Vasodilators Use After Randomization
9 2005 ESC Guidelines on the Diagnosis and Treatment of Acute Heart Failure Pulmonary Artery Catheter (PAC)The insertion for diagnosis of AHF is usually unnecessaryIt can be use to distinguish between a cardiogenic and a non-cardiogenic mechanism in complex pts with concurrent cardiac and pulmonary diseaseIt is also used to estimate haemodynamic variable in the presence of severe diffuse pulmonary pathology or ongoing haemodynamic compromise not resolved by initial therapy.
10 2005 ESC Guidelines on the Diagnosis and Treatment of Acute Heart Failure Pulmonary Artery Catheter (PAC)Its use is reccomended in haemodinamically unstable pts who are not responding in a predictable fashion to traditional treatments and in pts with a combination of congestion and hypoperfusion.It is inserted in order to ensure optimal fluid loading of the ventricles and to guide vasoactive therapies and inotropic agents.Because the complications increase with the duration of its use, it is critical to insert the PAC when specific data are neeeded and to remove it as soon as it is of no further help.Class IIb reccomandation, level of evidence C
11 Monitoraggio Emodinamico nello S.C. acuto CONCLUSIONI: E’ utilizzato in una bassa percentuale di pz. ricoverati per ICUn impiego estensivo non è in grado di migliorare la gestione e il destino nella maggior parte questi pz.La procedura è esente da rischi rilevanti, soprattutto presso centri con ampia esperienza.Utilizzo oculato per rispondere a una precisa esigenza diagnostica e/o terapeutica:diagnosi dubbiapersistenza di sintomi nonostante terapiacombinazione di congestione ed ipoperfusionedifficoltà allo svezzamento da terapia infusivaIpertensione polm. non reversibile a test acuto in candidato a Txc