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Identifing the risk factors of LCOS is necessary to optimize preoperative risk factors and to use of myocardial protection strategies, hemodynamic support in operating and to indicate support cardiovascular equipment (eg: Intra-aortic Balloon Pump) for pa

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1.Using the PiCCO for hemodynamic monitoring showed the

changes of cardiac index, global end-diastolic volume and extravascular

lung water in patients after cardiac surgery.

2.The PiCCO is high valuable in accurate preload measurement

and treatment guidelines. Global end diastolic volume and Stroke

volume variation are more reliable predictors of fluid responsiveness

and preload measurement than CVP and heart rate. Goal-directed

therapy by PiCCO has been shown to reduce duration and dependence

of catecholamin, shortened duration of mechanical ventilation and

duration of extubation.

3. Four pre- and post-operation independent predictors of low

cardiac output syndrome were preoperation cardiac index ≤ 2,5 l/min/m,

NYHA class III - IV, intraoperation tranfusion red blood cell ≥ 750 ml,

the aortic clamping time ≥ 90 minus and preoperation pulmonary artery

systolic pressure ≥ 50 mmHg.

THE STRUCTURE OF THE THESIS

The reseach consists of 131 pages: 2 pages of introduction, 35

page of overview, 21 pages of subjects and methods, 33 pages of

research results, 37 pages of discussion, 2 pages of conclusions and 1

page of suggestion; The reserch consist of 177 references (18 sources in

Vietnamese and 159 sources in English)

Chapter 1 – OVERVIEW

1.1. SOME CONCEPTS OF HEMODYNAMIC PARAMETER AND

EXTRA-VASCULAR LUNG WATER



1.1.2. Preload

1.1.2.3. The parameters of preload

Cardiac Filling pressures monitoring: Central venous pressure

(CVP) and pulmonary artery occlusion pressure (PAOP) does not assess

preload accurately. PAOP may not be valid in some cases: mitral valve

disease, the cause of ventricular compliance’s adjustment such as

myocardial ischemia or heart failure, dilated cardiomyopathy or

hypertrophy, valve aorta disease, pericardiac disease, and the location of

the catheter tip according to the West zone ...



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Global end - diastolic volume index (GEDVI) and intrathoracic

blood volume index (ITBVI): Many studies have confirmed that GEDVI,

ITBVI are more accurate in assessing preload than cardiac chamber

filling pressures. On the other hand, CVP and PAOP are affected by

mechanical ventilation, neither do GEDVI, ITBVI.

Predict fluid responsiveness

Static indicators of fluid responsiveness

CVP and PAOP poorly predict the hemodynamic

response to fluid challenge.

Predicting fluid responsiveness of GEDVI is very different,

depended on the researchs: arcording to Preisman and et al, area under

the receiver operating characteristic curves of GEDVI were 0,71 while

it was 0,593 in Hofer’ research and 0,56 in Marik’s one.

The dynamic indicator of fluid responsiveness

Stroke volume variation (SVV) and pulse pressure variation

(PPV) increase in inspiratory time and decrease expiratory time in the

patients using sedation and supporting positive pressure mechanical

ventilation. This influence will be more clear in hypovolemia patients.

Many studies have shown that these parameters are high value in

assessing fluid responsiveness: study of Lopes on the severe patients,

the meta-analyzed study of Marik based on 29 studies in critically ill

patients. This technique, however, is limited to patients who receive

controlled ventilation and who are not breathing spontaneously.

1.1.5. Extravascular lung water

1.1.5.1.Definition

Extravascular lung water (EVLW) is the volume of water that is

contained in the interstitium, intracellular compartment, lymphatic fluid,

surfactant, and the alveoli. The EVLW volume does not include the

intravascular volume or any pleural effusion.

1.1.5.4. Clinical utility of EVLW

Diagnosis of Pulmonary Edema. Guidance of fluid therapy

Dentification of the mechanism of pulmonary edema



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Prognostic evaluation of mortality, duration of mechanical

ventilation, length of stay in intensive care and monitoring and

evaluation of effectiveness of treatment...

1.2. PiCCO

1.2.1.The current trend of selecting hemodynamic monitoring

Since its introduction in the 1970s, the pulmonary artery catheter

(PAC) has indeed become the reference standard for advance

hemodynamic monitoring and measurement of cardiac output. However,

many studies have showed that the absence of a clear evidence-based

survival benefit of PAC critically ill patients, in cardiac patients and in

high risk of surgery patients. Therefore, the current trend is to select

non-invasive or less- invanse hemodynamic monitoring. PiCCO is one

of hemodynamic monitoring equipment has many advantages such as

less invasive, more accurately measured hemodynamic parameters.

1.4. GOAL DIRECT THERAPY AND LOW CARDIAC OUTPUT

SYNDROME IN CARDIAC SURGERY



1.4.1. Goal direct therapy (GDT)

Goal direct therapy (GDT) is a term used to describe the

including monitoring and the adjustment hemodynamics in high risk

patients complications and death. The aim is to ensure organ perfusion

and oxygen delivery contribute.

CI, GEDVI, EVLWI are inportant parameters in GDT. Goeperf’s

study has shown that GDT with these parameters reduced the length of

stay in intensive care, reduces the need and duration for vasopressor and

inotropic in cardiac surgery patients. Smetkin has showed that in the

GDT’s group with ITBVI, cardiac index (CI), mean blood pressure

(MAP), ScvO2 decreased length of stay in hospital and intensive care,

compared to control group with CVP, heart rate and MAP .

1.4.2. Low cardiac output syndrome

1.4.2.3. The risk factors of LCOS

The risk factors of LCOS included: high age, low preoperative

left ventricular function, poor myocardial protection, preoperative

myocardial infarction, or the aortic clamping time, reoperation surgery,

combined valve replacement and coronary, chronic kidney disease ...



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Chapter 2 - SUBJECTS AND METHODS

2.1. Studying subjects

we conducted prospective study description data on cardiac

surgery patients with cardiopulmonary bypass at central Military

hospital 108 between 12/2009 to 8/2012

2.2.1. Selection criteria for study patients

Patients underwent cardiac surgery with cardiopulmonary bypass,

their age were over 18 years old.

2.2.1. Exclusion criteria:

- The patient did not agree to participate in research.

- Patient with traumatic cardiac surgery, atrial myxoma.

- Patient with congenital heart surgery patients,

- Patients died during surgery.

- Patients with lung or lobar ectomy or pulmonary embolism.

2.2. Reseach methodology

2.2.1.Study Design: a prospective, observational, analyzes and

randomized controlled clinical trials study.

2.2.2. Sample size

Sample size is determined by formula:



p: the incident of LCOS, p = 0.147 (arcording to Sa MP et al, ε:

relative error = 0,45; Z 1-α/22 = 1,96, we have n = 99.

Sampling method: randomized into 2 groups

- Group 1 (PiCCO’s group): Monitoring and adjusting hemodynamic

based on postoperative PiCCO’s parameters.

- Group 2 (Control group): Monitoring and adjusting hemodynamic

based on “fundamental parameters”.

2.2.3 . Research content and assessment criteria

2.2.3.1. Assessment dynamic changes of GEDVI, CI and EVLWI in

cardiac surgery patients with CPB (Objective 1)

* Research Content

- Determine dynamic changes of CI , EVLWI, GEDVI, SRVI at the

some time: TM: preoperation, T0: at the first time admission to ICU,



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T2, T4, T6, T8, T12, T16, T20, T24, T30, T36, T42, T48, T56, T64 ,

T72 respectively postoperative period : 2, 4, 6, 8, 12, 16, 20, 24, 30, 36,

48, 56, 64, 72h. Dx, Dy: time before and after volume challenge,

adjusting vasopressor dosage.

- Evaluate CI, GEDVI, vascular resistance system index (SVRI) at the

first time admission to ICU (T0) and 6 hours after surgery (T6) .

- Evaluation the association between EVLWI and the duration of

mechanical ventilation and extubation.

* The assessment criteria for target 1

- The parameters (CI, GEDVI, ITBVI, EVLWI) were determined by

thermal dilution method , normal values in Table 2.1 .

- Preload: Evaluation based on GEDVI, was divided into 3 groups:

GEDVI > 800 ml/m2 (high preload), GEDVI: 680-800 ml/m2 (normal)

GEDVI < 680 ml/m2 (low preload)

- Afterload: based on systemic vascular resistance index (SVRI) .

2.2.3.2. Evaluate the value PiCCO’s parameters in determining preload and

effects of hemodynamic adjustment following the guidance of PiCCO

(Objective 2 )

* Evaluate the value PiCCO’s parameters in determining preload



- Compare the change of parameters: heart rate, MAP, CVP, SVI,

GEDVI, SVV, SVRI, EVLWI before and after fluid challenge (HAES –

sterin 6 % x 7ml/kg in 20 - 30 minutes) .

- Evaluate the correlation between change of CVP , GEDVI, SVV and

the change of stroke volume index (SVI) after fluid challenge.

- Comparison characteristics diagnostic of positive fluid response

(hypovolemia) of heart rate , MAP , CVP , GEDVI , SVV .

* The evaluation criteria

- Standard hemodynamic response after fluid challenge:

+ Hypovolemia (positive response): When SVI or CI increased

compared with the previous fluid transfusion > 15 %.

+ No hypovolemia (negative response): SVI or CI increased compared

with the previous fluid transfusion ≤ 15 %

* Effects of adjustment method following the guidance of PiCCO

+ Comparison of parameters before, during surgery: Medical history and

kind of operation, EuroSCORE score, body mass index (BMI), the

NYHA, hepatomegaly, PAPS (systolic pressure of the pulmonary



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artery), left ventricular EF, anesthesia time, circulation time outside the

body, aortic clamp time, the amount of transfused blood and fluid

balance in surgery.

+ Compare adjust hemodynamic characteristics: number of times using

a diuretic, time of using vasoactive drugs, the total amount of fluids and

fluid balance in the first 24 hours.

+ Compare the treatment effect: mortality rate, duration of mechanical

ventilation, extubation, length of stay in ICU, duration of use and

dosage of vasopressin/inotrope

2.2.3.3. Identify the preoperative and intraoperative predictors of low

cardiac output syndrome after cardiac surgery (Objective 3)

The evaluation criteria .

* Low cardiac output syndrome :

o According to Sa M.P. applied to both groups, include:

- Need for inotropic support with vasoactive drugs (dopamine ≥ 4

μg/kg/min at least for a minimum of 12 hours and/or dobutamine) to

maintain systolicblood pressure greater than 90 mmHg or need for

mechanical circulatory support with intraaortic balloon to maintain

systolic blood pressure greater than 90 mmHg and signs of impairment

of body perfusion – cold extremities, hypotension, oliguria/ anuria,

lowered level of consciousness or a combination of these signs.

According to author Rao et al (1996): the requirement for intraaortic

balloon counterpulsation or inotropic support for longer than 30 minutes

after the patient was returned to the intensive care unit to maintain the

systolic blood pressure higher than 90 mm Hg and the cardiac index

greater than 2.2 L/min per square meter. Eliminate caused by pre- and

afterload: Adjustable preload (GEDVI: 680-800 ml/m 2) and afterload

(SVRI: 1700 - 2400 dyne.s.cm-5.m-2) and adjusted abnormal electrolytes,

blood gases.

* Pre-operative factors of LCOS: Age, gender (male or female); obesity

(BMI > 30 kg/m2); CI, PAPS, left ventricular EF, NYHA

* Intra-operative factors: surgery (Emergency), concomitant cardiac

surgery; cardiopulmonary bypass time, the aortic clamping time

intraoperation tranfusion red blood cell.



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* Goal-directed hemodynamic treatment algorithm of the

goal-directed therapy group1.

Postoperation patients



< 640



≥ 640

GEDVI



EVLWI ≤ 10 

HAES 6% 7ml/kg



CI; MAP

CI < 2,5 or/and MAP ≤ 70



GEDVI > 800 or/and

EVLWI > 10

 catecholamin until CI >

2,5



GEDVI ≤ 800 and

EVLWI ≤ 10  HAES

6% 7ml/kg



CI ≥ 2,5 or/and MAP ≥ 70



GEDVI ≤ 800 and

EVLWI ≤ 10

HAES 6% 7ml/kg



< 70

GEDVI > 800 or/and

EVLWI > 10  performe

pacing or give chronotropes



Heart

rate

>110

Sedation

Hematocrit > 27 %

Pharmaco-therapy



Hình 2.4. Goal-directed hemodynamic algorithm - Goepfert

680-850

GEDVI:

680-850

2

ml/mlasix 20 mg IV

Notes: EVLWI > 12ml/kg give

HAES-sterin 6% x 7ml/kg intravenous transfusion in 20-30

minus.

2.2.6. Data analysis

The results were processed by statistical software SPSS 16.0.



GEDVI:

(2007)

ml/m2



Chapter 3 - FINDINGS

3.1. Clinical faetures

The study included 125 patients, group 1 (PiCCO group) had 62

patients, group 2 (control group) had 63 patients. Mean age was 49.1 ±

12.4. The two groups did not different in age, gender (p> 0.05).

Table 3.3 to Table 3.6 shows there were different between 2

groups about medical history, Euroscore, the operating characteristics,

BMI, NYHA level, symptoms of enlarged liver, PAPS average (p>

0.05)



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CPB time, the aortic clamping time group in group 1 higher than

group 2 (p< 0.05). Duration of anesthesia, red blood transmission in

operation, fluid balance during surgery were no difference between the

2 groups (p> 0.05).

3.1. Change of cardiac index, global end-diastolic volume and

extravascular lung water in patients of group 1.

Table 3.9. changes of CI, GEDVI, EVLWI and SVRI before and 24 hours after surgery.

Parameter

Time



CI (l/min/m2)

n = 62

X ± SD



GEDVI (ml/m2)

n = 62

X ± SD



EVLWI

(ml/kg)

n = 62

X ± SD



SVRI

(dyne.s.cm-5.m-2)

n = 62

X ± SD



TM



2,64 ± 0,31



763,9 ± 130,6



12,5 ± 3,4b 2005,8± 250,9



T0



2,68 ± 0,44



749,2 ± 120,1



14,0 ± 4,4a 1997,3± 215,4



T2



2,67 ± 0,45



714,2 ± 135,6a



12,6 ± 3,8 1920,7± 257,6



a,b



12,0 ± 5,1b 1810,7±213,3a,b



T4



2,53 ± 0,34



T6



2,42 ± 0,27a,b



684,2±136,6a,b



12,3 ± 4,8b 1722,7±247,3a,b



T8



2,52 ± 0,30a,b



697,1±134,2a,b



12,1 ± 5,6b 1765,2±250,7a,b



T10



2,71 ± 0,44



718,0 ± 126,0a



12,2 ± 4,2b 1935,4 ± 230,9



T12



2,78 ± 0,45



727,0 ± 110,2



12,0 ± 4,7b 1987,3 ± 225,7



T16



2,84 ± 0,43a,b



760,2 ± 147,2



12,2 ± 5,0b 2007,2 ± 237,6



T20



2,91 ± 0,51a,b



775,3 ± 139,3



12,1 ± 4,4b 2002,7 ± 231,5



T24



2,98 ±0,47a, b



789,8 ± 152,1



12,2 ± 5,1b 1972,2 ± 251,6



a



705,1±122,2



a,b



a



p < 0,05

p < 0,05

pb < 0,05

pb < 0,05

Note: pa: (a) and TM ; pb: b and T0

p



pa < 0,05

pb < 0,05



pa < 0,05

pb < 0,05



CI at the right time after surgery was similar to before surgery, then CI

decreased steadly, and was lowest from 4 to 8 hour and recoveried at 10 hours

after surgery, increased from 16 hours after surgery (p< 0.05). GEDVI, SVRI

from 4 to 8 hour after surgery was lower than preoperation and T0 (p<0.05).

EVLWI increased immediately after surgery compared to before surgery

(p<0.05), decreased from 4 hours after surgery.

Table 3.10. Changes of CI, GEDVI, EVLWI and SVRI from 24 to 72 hours after surgery.



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SVRI

(dyne.s.cm-5.m-2)

n = 62

X ± SD

2005,8 ± 250,9

1997,3 ± 215,4



2,65 ± 0,31



763,9 ± 130,6



EVLWI

(ml/kg)

n = 62

X ± SD

12,5 ± 3,4



T0



2,68 ± 0,44



749,2 ± 120,1



14,0 ± 4,4



T24



2,98 ± 0,47



789,8 ± 152,1



12,2 ± 5,1



1972,2 ± 251,6



T30



3,02 ± 0,53



776,5 ± 137,0



12,0 ± 4,6



2005,6 ± 270,4



T36



3,01 ± 0,57



766,5 ± 147,4



12,4 ± 5,0



2060,4 ± 240,5



T42



3,09 ± 0,56



754,3 ± 125,0



11,9 ± 5,3



1998,7 ± 255,4



T48



3,09 ± 0,51



766,5 ± 131,5



11,7 ± 5,2



2017,6 ± 265,5



T56



3,18 ± 0,54



764,1 ± 131,6



11,8 ± 5,6



2038,5 ± 274,7



T64



3,19 ± 0,49



766,0 ± 137,4



11,8 ± 5,4



2020,7 ± 247,3



Parameter

Time

TM



CI (l/min/m2)

n = 62

X ± SD



GEDVI (ml/m2)

n = 62

X ± SD



T72



3,27 ± 0,49

755,9 ± 114,5

11,6 ± 4,3

2010,7 ± 243,5

p*< 0,05

p* > 0,05

p* > 0,05

p* > 0,05

p

p†< 0,05

p† > 0,05

p† < 0,05

p† > 0,05

Notes (*): Between time from 24-72 hours post operation compared to TM. (†):Between

time from 24-72 hours post operation compared to T0



CI increased in the period in 24-72 hours after surgery compared to

T0(p <0.05). GEDVI was stable in 24 -72 hour after surgery compared

with T0 (p> 0.05). SVRI was stable in 24 -72 hour after surgery

compared with T0 (p> 0.05). EVLWI decreased in 24-72 h after surgery

compared with T0 (p <0.05).



p* < 0,05



n = 42

n = 20



Chart 3.7. Comparison groups EVLW between mechanical ventilation time ≤

6 hours and duration of mechanical ventilation group > 6 hours

EVLWI in groups with duration of mechanical ventilation ≤ 6h lower than

duration of mechanical ventilation > 6 h (p <0.05).



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p * < 0,05



n = 38

n =24

Chart 3.8. Comparison groups EVLW between extubate time ≥ 8 hours and

duration of extubate > 8 hours

EVLWI in groups with duration of exutubate ≥ 8h much lower than duration of

exutubate < 8 hours (p <0.05).



3.3. The value of PiCCO’s parameters in determining preload and

effects of adjustment method following the guidance of PiCCO

3.3.1. The value of PiCCO’s parameters in determining preload

Fluid challenge was conducted in 62 patients with hemodynamic

monitoring by PiCCO after surgery, total time of insfusion HAES - 6%

x 7ml/kg body weight were 139 times.

Table 3.16. Change of strock volume variation before and after fluid

challenge.

value (n = 139)



Parameter

(SVI2 – SVI1) (ml/m2)



23,6 ± 8,9



Min ÷ Max



4,0 ÷ 58,3



> 15% (số lần, %)



120 (86,3%)



≤ 15% (số lần, %)



x100(%)



6,1 ± 1,6



( X ± SD)

∆SVI =



( X ± SD)



19 (13,7%)



Positive response rate (ΔSVI> 15%) is 120/139 (accounting for 86.3%).

Negative response rates (ΔSVI ≤ 15%) seen in 19/139 (13.7%).



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Chart 3.12. The rate of positive response to extended fluid challenge with GEDVI



The group with GEDVI <600 ml/m 2 had a highest positive response rate,

followed by group with 600 ml/m 2 ≤ GEDVI ≤ 679 ml/m 2 and lowest in the

group 680 ml/m2 ≤ GEDVI ≤ 800 ml/m2

Biến đổi GEDVI

variation GEDVI (%)



40



r = - 0,643; p < 0,01

Y = - 0,037 X + 30,631



30



20



10



0

400



GEDV befor transfusion



500

600

700

GEDVI trước khi truyền dịch (ml/m2)



800



Chart 3.13. Correlations between GEDVI before fluid insfusion and change

GEDVI after fluid insfusion

Biến đổi SVI (%)



Biến đổi của SVI (%)



r = 0,084; p > 0,05

Y= 0,022 X + 23,12



60



60



r = 0,863; p < 0,01

Y= 1,382 X + 2,114



50



50



40



40



30



30



20



20



10



10



0



0

0



10



20

30

Biến đổi của GEDVI (%)



40



Chart 3.15. Correlations between

change SVI and GEDVI after

transfusion fluid



-50



0



50

100

Biến đổi của CVP (%)



150



200



Chart 3.16. Correlations between

change SVI

and CVP after

transfusion fluid



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