1. Sepsis and Cardiac Output Measurement S Gower Consultant Anaesthetist

2. Aim Glimpse of history of sepsis management Overview of pathophysiology Comment on cardiac output measurement Update on sepsis treatment, particularly early management.

3. History Swan Ganz catheter, 1970 Bp=COxSVR Shoemaker, 1979 DO 2 =(SaO 2 xHb)xCO Supranormal values

4. PA Catheter

5. Cardiac Output Measurement

6. Swan song for the Swan Ganz? Soni 1996 Connors, JAMA 1996 Retrospective study of 5735 patients Increased mortality with swan.  PiCCO Lithium Dilution Thoracic electrical bioimpedance Oesophageal doppler CCCombo Edwards lifesciences

7. Clinical Assessment of C.O. Palazzo BJA 2001 BP maintained at expense of CO Poor cerebral perfusion, agitation and confusion Metabolic acidosis and increased resp rate Diminished renal and splanchnic flow Decreased urine output and ileus Clinical assessment all you have on the ward

8. Recognise decreased CO before it’s too late

10. Pathophysiology of sepsis Margination of leukocytes Induction of nitric oxide synthetase Impaired anticoagulation Microvascular thrombosis DIC

11. Activated Protein C

14. Timing of the intervention is vital

15. Summary of management Aggressive goal orientated treatment of sepsis Fluids and dobutamine Restore effective blood volume and CO Sepsis and two organ failure give Activated protein C

16. Summary of sepsis and Cardiac Output Very Exciting! Early recognition of hypovolaemia of sepsis Rapid restitution of effective CO Appropriate usage of Xigris Experience teaches that to place reliance upon a single sign is precarious. Compare this sign and that, and confident recognition of the patients state grows. Sir Thomas Lewis 1942