25th Symposium Intensive Care Bremen - Germany
19 Feb 2015
Is hyperventilation during general anesthesia potentially hazardous? F. Grüne Erasmus MC Dept. of Anesthesiology
[email protected] https://www.researchgate.net/profile/Frank_Gruene 1
No conflict of interests
ABP 120 mmHg
No conflicts of interest!
flow = resistance * driving pressure CBF = CVR * CPP driving pressure = EUP – EDP EUP = MAP EDP
ICP or ZFP
No problem ! But why not ????
MAP 200 mmHg
Dr. Frank Grune - Erasmus MC Rotterdam
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25th Symposium Intensive Care Bremen - Germany
19 Feb 2015
Epilepsy when drinking?
? No problem ! But why not ???? 4
Jugular'venous'pooling'during'lowering'of'the'head'' affects'blood'pressure'above'the'heart.'' V. jug.
Brondum E et al.: Am J Physiol Regul Integr Comp Physiol 2009
A. car.
V. jug. A. car.
Dr. Frank Grune - Erasmus MC Rotterdam
MAP= 193 mmHg CBF = 700 ml/min
MAP= 131 mmHg CBF = 500 ml/min
CPPe 120 mmHg
CPPe = 100 mmHg5
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25th Symposium Intensive Care Bremen - Germany
19 Feb 2015
Blood'8low'uphill'and'downhill:' Does'a'siphon'faciliate'circulation'above'the'heart?' Seymour R, Johansen K. Comp Biochem Physiol 1987
6
Inside nature’s giants
Inside Nature’s Giants National Geographic - TV 2009 (DVD/Book) 7
Dr. Frank Grune - Erasmus MC Rotterdam
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25th Symposium Intensive Care Bremen - Germany
19 Feb 2015
Hydrostatic'pressure'is'challenging'human’s'brain:' Humans'='giraffes?'
n=1
TCD in steep Trendelenburg
A mm Hg Vmca = 39 MAP = 89 ZFP = 51
Vmca = ABP = ZFP =
CPPe = 38 mmHg
CPPe
40 41 35 10430 6225 20 = 42 15 10 5 0
CVP
ZFP
ZFPCzosnyka
ZFPSchmidt
PE¢CO2
Vmca = 46 ABP = 133 ZFP = 94
mmHg
Pre
T1
B mm Hg
CPPe = 39 mmHg
T2
T3
T4
T5
Pulsatility Index
T6
T7
T8
8
T9 T10 T11 T12 T13 T14 T15 T16 T17
Resistivity Index
S1
S2
S1
S2
S1
S2
PE¢CO2
1
Cerebral'haemodynamic'physiology'during'steep' Trendelenburg'position'and'CO2'pneumoperitoneum.'' TCD in steep Trendelenburg
Pre
A mm Hg
CVP
C mm Hg ZFPCzosnyka 120
ZFP
40 35 30 25 20 15 10 5 0 Pre
T1
T2
T3
T4
T5
T6
T7
T8
T1
T2
CVP ZFPSchmidt
T3
T4
T5
T6
MAPPE¢CO2 CPP
T7
T8
T9 T10 T11 T12 T13 T14 T15 T16 T17
eCPPBelfort
kPa 6
100
5
80
4
60
3
40
2
20
1
0 T9 Pre T10 T1 T11 T12 T2 T13 T3 T14 T4 T15 T5 T16 T6 T17 T7 T8
0 S1 T10 S2 T11 S3 T12 T13 T14 T15 T16 T17 T9
Fig 3 (AIndex ) CVP, ZFP calculated by linear regression (ZFP), ZFP as described by Czosnyka and colleagues6 and Schmidt and colleag kPa Resistivity PE¢CO end-tidal CO2 pressure (P2E′CO2 ). (B) PI, RI, and PE′CO2 . (C) The course of the CVP, invasive MAP, CPP determined as (CPP¼MAP2CVP), an 6 15 by Belfort and colleagues (eCPPMAP The variables are shown as mean values at 10 min intervals. Pre-values are d Belfort). changes ZFP described proportional changes to CVP and 5 induction of anaesthesia. All data are synchr average of the 30 s interval at 5 min before steep Trendelenburg repositioning, after moment of initiating Trendelenburg positioning and resynchronized at resumption4 of the supine position. The variables are sho CPP nearly constant values at 10 min intervals from 5 min before to 165 min after institution of the Trendelenburg position. At reassuming the sup 3 the curves are resynchronized and values are shown for another 20 min. 2
Pulsatility Index
1
⇒ ⇒
9
0 Pre
T1
C mm Hg
T2
T3
CVP
T4 MAP
120
Dr. Frank Grune - Erasmus MC 100 Rotterdam 80 60 40 20
while in a further three patients, adequate signals were not obtainable in the Trendelenburg position. Data of the remainT5 T6ingT7 T8 T9 were T10 T11 T12 T13 T14 T15and T16are T17 S1 14 patients normally distributed presented as mean (SD). The age of the patients was 63 (8) yr. The total timeeCPP spent in the steep Trendelenburg position was 149 (83) CPP Belfort min. All patients left the post-anaesthesia care with an Aldrete13 score of 10/10 and were discharged from hospital after an uneventful postoperative period. CVP and ZFP calculated using linear regression and the Czosnyka formula, but not the Schmidt formula, increased in the Trendelenburg position (Table 1). MAP, CPP, and eCPP were lower in the post-Trendelenburg phase (Table 1). CVP
1 reg increased significantly after T0. and ZFP between 0 these variables remained stable— S2 was S3 2.8 (8.6) mm Hg, greater than CVP during T positioning (P.0.05). Neither variable changed during the period of Trendelenburg positioning The ZFPCzosnyka increased significantly after T0 a closely with ZFPreg (Fig. 3A). After resumption of th ition, it was not significantly different from the Trendelenburg. The ZFPSchmidt did not change after T0 and showed poor correlation with the Z Over the course of the operation, eCPP valu sistently lower than the calculated CPP (
T5
S2
0 Pre
T1
T2
T3
T4
Downloaded from http://bja.oxfordjournals.org/ at Erasmus Universiteit Rotterdam on
B mm Hg
BJA
Kalmar A et al. Brit0 J Anaesth 2012
T6
T7
T8
T9 T10 T11 T12 T13 T14 T15 T16 T17
S1
S3
4
25th Symposium Intensive Care Bremen - Germany
19 Feb 2015
Threshold cerebral perfusion: Beachchair position J Clin Anesth 2005
Anesth Analg 2003
Cullen DJ , APSF Newsletter 2007
Panevicius M , APSF Newsletter 2008
Threshold cerebral perfusion: high ICP => low CPP
Dr. Frank Grune - Erasmus MC Rotterdam
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11
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25th Symposium Intensive Care Bremen - Germany
19 Feb 2015
in
Q ≈ IN – OUT
PP
IN
OUT
Zero Flow
ICP
MAP
Vascular waterfall
12
Resistormodel Ohm resistor
upstream
Pv
Pa
downstream
CVR = (MAP-ICP) / CBF
Starling resistor
Ps upstream
Pa
PV
downstream
13
Dr. Frank Grune - Erasmus MC Rotterdam
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25th Symposium Intensive Care Bremen - Germany
19 Feb 2015
Vascular waterfall Weyland A et al.: Anaesthesist 1995; 44:893 Kottenberg-Assenbacher et al.:Anesthesiology 2009; 110: 379
26,3 mmHg
14,6
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PressureFFlow'plot'after'cardiac'arrest'(cerebral'circulation)' Weyland A et al. (1995) 55 50 45 Relation of ABP and VMCA during cardial arrest van 15 s
VMCA [cm s-1]
40 35 30 25 20 15
ZFP
10 5 0 0
20
40
60
80
AP [mmHg]
Dr. Frank Grune - Erasmus MC Rotterdam
100
120 15
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25th Symposium Intensive Care Bremen - Germany
19 Feb 2015
Aortic valve insufficiency grade 4 Prior OK
100
ZFP
50
cm/s
0
Post OK 100
50
cm/s
0 16
Zero'Flow'Pressure'estimation'(LR)' Weyland A et al (1997)
VMCA
80
t [s]
VMCA [cm s-1]
60
40
ZFP = EDP
Part
20
0 t [s]
0
25
50
75
100
AP [mmHg] 17
Dr. Frank Grune - Erasmus MC Rotterdam
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25th Symposium Intensive Care Bremen - Germany
19 Feb 2015
Zero'Flow'Pressure'estimation'(LR)'
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CO2
!
Dr. Frank Grune - Erasmus MC Rotterdam
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25th Symposium Intensive Care Bremen - Germany
19 Feb 2015
Cerebral autoregulation: MAP, CO2, O2
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ICP vs. ZFP Influence of PaCO2 Weyland A et al. (2000) J. Neurosurg Anesthesiol; 12: 210-216
• 16 ICU patients after T • ICP epidural transduce • Variation in PaCO2 (R
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Dr. Frank Grune - Erasmus MC Rotterdam
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25th Symposium Intensive Care Bremen - Germany
19 Feb 2015
Cerebrovascular tone rather than ICP determines the effective downstream pressure of the cerebral circulation in the absence of intracranial hypertension
• 16 ICU patients after T • ICP epidural transduce • Variation in PaCO2 (R
Weyland A et al. (2000) J. Neurosurg Anesthesiol; 12: 210-216
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Adapted model of cerebral cerebral vasculation
PCSF/ICP PA
PCV
CCP1
PV
CCP2
Part CCPart CCPven (ICP) Weyland A et al. (2000) J. Neurosurg Anesthesiol; 12: 210-216
Dr. Frank Grune - Erasmus MC Rotterdam
Pven 23
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25th Symposium Intensive Care Bremen - Germany
19 Feb 2015
Adapted model of cerebral vasculation Ein modifiziertes Konzept dercerebral zerebralen Zirkulation: Vaskuläre Wasserfälle in serieller Verbindung ICB
CPP
Part CCPart CCPven (ICP)
Pven
Weyland A et al. (2000) J. Neurosurg Anesthesiol; 12: 210-216
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y = b*x
Flow
Ohm / Darcey
Pressure
Pressure
Resistance & Tone
y = b*x + a
Flow
CCP concept 26
Dr. Frank Grune - Erasmus MC Rotterdam
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25th Symposium Intensive Care Bremen - Germany
19 Feb 2015
General anaesthesia: What happens?!
Normal CBF" " 50 mL / 100g / min!
Lassen NA J Cereb Blood Flow Metabol 1985; 5: 347-9
Dr. Frank Grune - Erasmus MC Rotterdam
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25th Symposium Intensive Care Bremen - Germany
19 Feb 2015
Awake versus Anesthesia: CBF Weyland A et al. (2000) J. Neurosurg Anesthesiol; 12: 210-216
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Awake versus Anesthesia: CMRO2
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Dr. Frank Grune - Erasmus MC Rotterdam
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25th Symposium Intensive Care Bremen - Germany
19 Feb 2015
Awake versus Anesthesia: CVR
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Anesthesia & CO2
!
Dr. Frank Grune - Erasmus MC Rotterdam
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25th Symposium Intensive Care Bremen - Germany
19 Feb 2015
Anesthesia: CBF versus PaCO2
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Anesthesia: CMRO2 versus PaCO2
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Dr. Frank Grune - Erasmus MC Rotterdam
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25th Symposium Intensive Care Bremen - Germany
19 Feb 2015
Anesthesia: SjvO2 versus PaCO2
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Anesthesia: AjvD-Lactate
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25th Symposium Intensive Care Bremen - Germany
19 Feb 2015
Anesthesia: CMR-lactate versus PaCO2
? 37
Is Hyperventilation perhaps dangerous?!
Dr. Frank Grune - Erasmus MC Rotterdam
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25th Symposium Intensive Care Bremen - Germany
19 Feb 2015
Moderate'hyperventilation'during'intravenous'anesthesia' increases'net'cerebral'lactate'ef8lux.''' Grüne F, Kazmaier S, (Sonntag H #), Stolker RJ, Weyland A. Anesthesiology 2014;120:335-42
- 30 cardiovascular patients - ANE = Fe / Mi - CBF = Kety Schmidt (Argon) - ZFP = TCD (LR) - PaCO2 changes = 30 vs 50 mmHg - Endpoints= CBF, VMCA, CMRO2, CMR-Gluc, CMR-Lac
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Moderate'hyperventilation'during'intravenous'anesthesia' increases'net'cerebral'lactate'ef8lux.''' Grüne F, Kazmaier S, (Sonntag H #), Stolker RJ, Weyland A. Anesthesiology 2014;120:335-42
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Dr. Frank Grune - Erasmus MC Rotterdam
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25th Symposium Intensive Care Bremen - Germany
19 Feb 2015
Moderate'hyperventilation'during'intravenous'anesthesia' increases'net'cerebral'lactate'ef8lux.''' Grüne F, Kazmaier S, (Sonntag H #), Stolker RJ, Weyland A. Anesthesiology 2014;120:335-42
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Astrocyte-neuron lactate shuttle hypothesis ?
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Dr. Frank Grune - Erasmus MC Rotterdam
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25th Symposium Intensive Care Bremen - Germany
19 Feb 2015
Hyperventilation and clinical outcome Wax et al. Eur J Anaesthesiol 2010;27:819 – 823
Cases = 3421 colorectal surgery, open n= 975 colorectal surgery, scopic n= 763 Hysterectomy, open n= 1127
median PetCO2 = 31 mmHg
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Comparison'of'cerebral'vascular'reactivity'measures' obtained'using'breathFholding'and'CO2'inhalation' Nagata et al. Annals of the New York Academy of Sciences, 826: 272–81
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Dr. Frank Grune - Erasmus MC Rotterdam
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25th Symposium Intensive Care Bremen - Germany
19 Feb 2015
Misery'perfusion'with'preserved'vascular'reactivity' in'Alzheimer's'Disease' Nagata et al. Annals of the New York Academy of Sciences, 826: 272–81
10 AD patients vs. 15 healthy controls hyper vs. hypocapnia CBF 77% ! CMRO2 88% ! OEF 12% "" Regional differences - supramarginal ! - superior temporal ! 45
Rotterdam 46
Dr. Frank Grune - Erasmus MC Rotterdam
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25th Symposium Intensive Care Bremen - Germany
Eramus MC - Rotterdam
19 Feb 2015
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Erasmus MC – multiculti-working 48
Dr. Frank Grune - Erasmus MC Rotterdam
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25th Symposium Intensive Care Bremen - Germany
19 Feb 2015
Erasmus MC – Central OR 49
Next week on the OR!!
Normal !
Dr. Frank Grune - Erasmus MC Rotterdam
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25th Symposium Intensive Care Bremen - Germany
19 Feb 2015
How to improve patients outcome?! • • • • • •
Optimal medical treatment WHO - Sign In / Sign Out Antibiotics 30 min before incision Protocols-adherence (Pain/PONV/ERAS) Hygienic protocols Double-checks medication
• • • • • •
Temp control HR control MAP control PPV SpO2 control PetCO2 control
36-37°C 60-80/min >65 mmHg 96% 35-40 mmHg
Do not hyperventilate patients ! CBF / CPPe / cDO2 / pvO2 / CPPe " cerebral Lactate efflux
Hyperventilation - special indications
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Dr. Frank Grune - Erasmus MC Rotterdam
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25th Symposium Intensive Care Bremen - Germany
19 Feb 2015
Epilepsy when drinking?
Questions?
No problem ! But why not ???? 53
Dr. Frank Grune - Erasmus MC Rotterdam
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