JOURNAL PRESENTATION

CENTRAL VENOUS PRESSURE AFTER

CORONARY ARTERY BYPASS SURGERY: DOES
IT PREDICT POSTOPERATIVE MORTALITY OR
RENAL FAILURE?
Prima artya k.

Pembimbing:
Dr. April Retno susilo, Sp. An. Kakv kic
CENTRAL VENOUS PRESSURE AFTER
CORONARY ARTERY BYPASS SURGERY: DOES IT
PREDICT POSTOPERATIVE MORTALITY OR
RENAL FAILURE?

Judson B. Williams, MD MHS, Eric D.

Peterson, MD MPH, Daniel Wojdyla,
MSca, T. Bruce Ferguson, MD, Peter K.
Smith, MD, Carmelo A. Milano, MDb, and
Renato D. Lopes, MD PhD

Published in final edited form as: J Crit Care.

2014 December ; 29(6): 1006–1010.
doi:10.1016/j.jcrc.2014.05.027.
 INTRODUCTION

Operasi CABG memerlukan monitoring

hemodinamik untuk memastikan pasien
memperoleh cardiac output dan indeks yang
adekuat

CVP adalah parameter hemodinamik yang

mudah dan simple pada periode pemulihan
akut

Apakah CVP dapat berhubungan dengan

kejadian kematian dan renal failure pada kasus
paska operasi CABG?
 METHODS

CAPS-care registry Populasi Pasien Pengukuran CVP Clinical Outcomes

• Pasien risiko • Menjalani operasi • Dilakukan saat: • Menilai mortalitas

tinggi dari the CABG antara kedatangan di in-hospital dan
Society of Januari 2004 – ICU dan 6 jam 30-hari
Thoracic Juni 2005 paska operasi • Menilai renal
Surgeons Adult • EF <40% atau • Perubahan CVP failure in-hospital
Cardiac Surgery umur >65 th selama paska operasi,
Database (STS dengan diabetes kedatangan ICU new-onset
ACSD) mellitus atau GFR hingga 6 jam dialysis, atau
• 50 sites diambil <60 mL/mnt tiap paska operasi readmisi dari
dan dari 55 RS 1.73 m2 juga renal failure
diikutkan dalam diperhitungkan
studi ini
 RESULTS
• 2001 pasien CABG
dengan CVP tersimpan di
CAPS-Care Registry
• Umur rata-rata 72 th
dengan 54% menderita
diabetes mellitus dan
waktu rerata
cardiopulmonary bypass
105 menit
Relationship between central
venous pressure (CVP) at 6 hours
and predicted probability of
death through 30 days or in-
hospital. Solid dark blue line
represents point estimates and
light blue shaded area represents
95% confidence interval.
• Relationship between central
venous pressure (CVP) and
predicted probability of death
according to cardiac index (CI)
≥ 2 or < 2 L/min/m2 at 6
hours. The shapes of the
curves are approximately the
same indicating that the
relationship between CVP and
mortality is independent of
cardiac index. Solid dark blue
line represents point estimates
and light blue shaded area
represents 95% confidence
interval.
Models, unadjusted and risk-adjusted, estimating the odds of in-hospital / 30-
day death and death or renal complications based on central venous pressure
in the intensive care unit at 6 hours postoperatively
 DISCUSSION

• CVP memberikan informasi right ventricular end-diastolic pressure dapat menjadi variable bagi left
ventricular preload
• Pada studi ini, CVP yang diukur 6 jam setelah operasi berhubungan dengan mortalitas dan gagal ginjal
di antara kohort observasional dari berbagai institusi yang menjalani operasi CABG
• Pada rutinitas lainnya, pasien post CABG dengan cardiac index >2 dengan CVP meningkat memerlukan
perhatian khusus
• CVP pada 6 jam berhubungan kuat dengan outcome berbeda dengan CVP yang diukur secara langsung
saat kedatangan di ICU.
• Sementara perhatian tetap pada cardiac index, CVP menyediakan informasi tambahan terhadap fungsi
ventrikel g kanan.
• Pada beberapa studi perhatian klinis, nilai CVP tinggi berpengaruh terhadap pertimbangan dari volume
resusitasi yang berlebihan dan agresif, tamponade pericardial, regurgitasi valvular, disfungsi jventrikel
kanan, dan etiologi potensial lainnya
CVP - KIDNEY FAILURE
• CVP must be lower than renal venous pressure
(RVP)in order to allow an adequate venous renal
blood flow (RBF) to the heart.
• Kidney perfusion is pressure and flow dependent
• The difference between mean system filling pressure
(MSFP) and CVP is the driving force behind venous
return. Thus, with increasing CVP, a venous return
will drop.
• With the heart functioning on the steep portion of the
Starling curve, volume expansion will increase MSFP
more than CVP
• If fluid administration fails to obtain a higher MSFP,
CVP must be kept low to enhance venous return,
cardiac preload and CO
 KESIMPULAN

• Nilai CVP dipengaruhi dari beberapa kondisi termasuk disfungsi ventrikel,

penyakir disfungsi katup tricuspid, tamponade jantung, pemberian cairan
perioperative, pericarditis, dan gagal ginjal.
• CVP pada prosedur CABG dapat menjadi prediksi dari mortalitas awal dan
gagal ginjal, cardiac indeks dan beberapa variable penting lainnya.
• Studi ini menunjukkan pentingnya CVP yang diukur rutin pada 6 jam dan
setelah kedatangan di ICU, sebuah alat yang simple dan mudah, untuk
mengakses risiko awal dari kematian dan gagal ginjal pada pasien operasi
CABG.
 REFERENCES
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TERIMA KASIH
 GUYTON MODEL

• Guyton menunjukkan bahwa aliran balik vena tergantung pada

 sirkulasi perifer (MCFP),
 tekanan atrium kanan (Pra/CVP)
 resistensi aliran balik vena (Rvr)
 WHAT DETERMINES CARDIAC OUTPUT?

CARDIAC OUTPUT

RETURN FUNCTION CARDIAC FUNCTION

STROKE VOLUME X HR
AFTERLOAD
CVP
CENTRAL VENOUS
PRESSURE 1 PRELOAD
CONTRACTILITY

RVR 3
RESISTANCE TO VENOUS RETURN
DIAMETER VEIN CAVA AND BLOOD
VISCOSITY
2
GRADIENT PRESSURE
MCFP-CVP

MCFP
MEAN SYSTEMIC FILLING PRESSURE
 STRESSED VOLUME (NON-SPLANCHNIC
CIRCULATION)

Circulatory Physiology: Cardiac Output And Its Regulation. A.C. Guyton.W.B. Saunders
Co. Philadelphia 1963
GUYTON COMBINED VENOUS RETURN CURVE WITH STARLING’S CARDIAC

FUNCTION CURVE

A R LIN G ’S CA R DIAC FUNCTION

ST
CURVE
WORKING
ABILITY
POINT
VENOUS RETURN AND CARDIAC OUTPUT

GU
liters/m2/min

Y
RE TON
AV TUR ’S VE
A I N C NO
LA UR US
BIL VE
ITY

0
RIGHT ARTERIAL PRESSURE
mmHg
 GUYTON MODEL
• Pada pendekatan Guyton, pemberian cairan, inotropik dan
vasopressor mempertimbangkan tidak hanya faktor jantung namun
juga sirkulasi sistemik yang mempengaruhi aliran balik vena

ALIRAN BALIK CURAH FUNGSI JANTUNG

VENA JANTUNG
MCFP – Stroke
X HR
Pra volume
Rvr

MCF Preloa
Preloa Afterlo
Afterlo
MCF Pra Rvr
P Pra Rvr d
d ad
ad
P
Kontraktilit
Kontraktilit
as
as
Cairan/vas Inotropik/ Venodilat
opressor Inodilator or
Cairan/vas Inotropik/ Vasopressor/ Inotropik/
opressor Inodilator vasodilator pacing
APPROACH TO MANAGEMENT OF HYPOTENSION
GUYTON VS STARLING:
SIMILAR THERAPY DIFFERENT PATHOPHYSIOLOGY

STARLING’S LAW: CO = MAP – CVP

SVR

HYPOTENSION =  CARDIAC OUTPUT x  SYSTEMIC VASCULAR RESISTANCE

VASODILATORY SHOCK
 HEART RATE  STROKE VOLUME
IC
AORT
NO EASE
DIS
BRADYCARDIA  PRELOAD  CONTRACTILITY AFTERLOAD

ATROPINE, PACING FLUID INOTROPE VASOPRESSOR

TRANSFUSION

GEORGE 2016
APPROACH TO MANAGEMENT OF HYPOTENSION
GUYTON VS STARLING:
SIMILAR THERAPY DIFFERENT PATHOPHYSIOLOGY

GUYTON’S THEORY: VR = CO = MCFP – CVP

RVR

HYPOTENSION =  VENOUS RETURN x  RESISTANCE TO VENOUS

RETURN (RVR)

 CVP GRADIENT  MCFP  VENOUS RETURN

PRESSURE

HEART HYPOVOLEMIA VASODILATORY SHOCK

FAILURE Low total blood VENODILATATION
volume Normal total blood
volume

INOTROPE FLUID VASOPRESSOR VASODILATOR

TRANSFUSION

GEORGE 2016