Transcript Monitoring

Haemodynamic Monitoring
Theory and Practice
Haemodynamic Monitoring
2
A.
Physiological Background
B.
Monitoring
C.
Optimising the Cardiac Output
D.
Measuring Preload
E.
Introduction to PiCCO Technology
F.
Practical Approach
G.
Fields of Application
H.
Limitations
Physiological Background
Task of the circulatory system
Pflüger 1872: ”The cardio-respiratory system fulfils the
physiological task of ensuring cellular oxygen supply”
3
Goal Reached?
Yes
Assessment of
oxygen supply and
demand
No
Uni Bonn
OK
What is the problem?
Diagnosis
Therapy
Physiological Background
Processes contributing to cellular oxygen supply
Aim: Optimal Tissue Oxygenation
Direct Control
Pulmonary gas exchange
Macrocirculation
Indirect
Microcirculation
Volume
4
Catecholamines
Oxygen Absorption
Oxygen Transportation
Oxygen Delivery
Lungs
Blood
Tissues
Oxygen carriers
Cell function
Ventilation
Oxygen Utilisation
Cells / Mitochondria
Physiological Backgound
Organ specific differences in oxygen extraction
SxO2 in %
Oxygen delivery must always be
greater than consumption!
5 modified from:
Reinhart K in: Lewis, Pfeiffer (eds): Practical Applications of Fiberoptics in Critical Care Monitoring, Springer Verlag Berlin - Heidelberg - NewYork 1990, pp 11-23
Physiological Background
Dependency of Oxygen Demand on delivery
Behaviour of oxygen consumption and the oxygen extraction rate with
decreasing oxygen supply
Oxygen consumption
Oxygen extraction rate
DO2-independent area
DO2- dependent area
Decreasing Oxygen Supply
6
DO2: Oxygen Delivery
Physiological Background
Determinants of Oxygen Delivery and Consumption
Central role of the mixed venous oxygen saturation
CO
SaO2
Delivery DO2:
Hb
CO: Cardiac Output
Hb: Haemoglobin
SaO2: Arterial Oxygen Saturation
SvO2: Mixed Venous Oxygen Saturation
DO2: Oxygen Delivery
VO2: Oxygen Consumption
7
DO2 = CO x Hb x 1.34 x SaO2
Physiological Background
Determinants of Oxygen Delivery and Consumption
Central role of mixed central venous oxygen saturation
CO
SaO2
Delivery DO2:
DO2 = CO x Hb x 1.34 x SaO2
Consumption VO2: VO2 = CO x Hb x 1.34 x (SaO2 - SvO2)
Hb
S(c)vO
SvO2 2
Mixed Venous Saturation SvO2
CO: Cardiac Output
Hb: Haemoglobin
SaO2: Arterial Oxygen Saturation
SvO2: Mixed Venous Oxygen Saturation
DO2: Oxygen Delivery
VO2: Oxygen Consumption
8
Physiological Background
Oxygen delivery and its influencing factors
DO2 = CaO2 x CO = Hb x 1.34 x SaO2 x CO
Transfusion
• Transfusion
CO: Cardiac Output
Hb: Haemoglobin
SaO2: Arterial Oxygen Saturation
CaO2: Arterial Oxygen Content
9
Physiological Background
Oxygen delivery and its influencing factors
DO2 = CaO2 x CO = Hb x 1.34 x SaO2 x CO
Ventilation
• Transfusion
• Ventilation
CO: Cardiac Output
Hb: Haemoglobin
SaO2: Arterial Oxygen Saturation
CaO2: Arterial Oxygen Content
10
Physiological Background
Oxygen delivery and its influencing factors
DO2 = CaO2 x CO = Hb x 1.34 x SaO2 x CO
Volume
Catecholamines
• Transfusion
• Ventilation
• Volume
• Catecholamines
11
CO: Cardiac Output
Hb: Haemoglobin
SaO2: Arterial Oxygen Saturation
CaO2: Arterial Oxygen Content
Physiological Background
Assessment of Oxygen Delivery
Supply
DO2 = CO x Hb x 1.34 x SaO2
SaO2
CO, Hb
Oxygen Absorption
Oxygen Transport
Oxygen Delivery
Oxygen Utilization
Lungs
Blood
Tissues
Cells / Mitochondria
CO: Cardiac Output; Hb: Hemoglobin; SaO2: Arterial Oxygen Saturation
12
Physiological Background
Assessment of Oxygen Delivery
Supply
Monitoring the CO, SaO2 and Hb is essential!
SaO2
CO, Hb
Oxygen Absorption
Oxygen Transport
Oxygen Delivery
Oxygen Utilization
Lungs
Blood
Tissues
Cells / Mitochondria
CO: Cardiac Output; Hb: Haemoglobin; SaO2: Arterial Oxygen Saturation
13
Physiological Background
Assessment of Oxygen Delivery
Supply
Monitoring the CO, SaO2 and Hb is essential!
SaO2
CO, Hb
Oxygen Absorption
Oxygen Transport
Oxygen Delivery
Oxygen Utilization
Lungs
Blood
Tissues
Cells / Mitochondria
SvO2
VO2 = CO x Hb x 1.34 x (SaO2 – SvO2)
Consumption
CO: Cardiac Output; Hb: Haemoglobin; SaO2: Arterial Oxygen Saturation
14
Physiological Background
Assessment of Oxygen Delivery
Supply
Monitoring CO, SaO2 and Hb is essential
SaO2
CO, Hb
Oxygen Absorption
Oxygen Transport
Oxygen Delivery
Oxygen Utilization
Lungs
Blood
Tissues
Cells / Mitochondria
SvO2
Monitoring the CO, SaO2 and Hb does not give
information re O2-consumption!
Consumption
CO: Cardiac Output; Hb: Haemoglobin; SaO2: Arterial Oxygen Saturation
15
Physiological Background
Balance of Oxygen Delivery and Consumption
The adequacy of CO and SvO2 is affected by many factors
Older Age
Body weight /height
Current Medical History
Previous Medical History
General Factors
Microcirculation Disturbances
Volume status
Tissue Oxygen Supply
Oxygenation / Hb level
Situational Factors
16
Physiological Background
Extended Haemodynamic Monitoring
Monitoring
Therapy
17
Optimisation
O2 supply
O2 consumption
Physiological Background
Summary and Key Points
• The purpose of the circulation is cellular oxygenation
• For an optimal oxygen supply at the cellular level the macro and micro-circulation
as well as the pulmonary gas exchange have to be in optimal balance
• Next to CO, Hb and SaO2 is SvO2 which plays a central role in the assessment of
oxygen supply and consumption
• No single parameter provides enough information for a full assessment of oxygen
supply to the tissues.
18
Haemodynamic Monitoring
19
A.
Physiological Background
B.
Monitoring
C.
Optimizing the Cardiac Output
D.
Measuring Preload
E.
Introduction to PiCCO Technology
F.
Practical Approach
G.
Fields of Application
H.
Limitations
Monitoring
Monitoring the Vital Parameters
Respiration Rate
Temperature
20
Monitoring
Monitoring the Vital Parameters
Respiration Rate
Temperature
ECG
• Heart Rate
• Rhythm
21
Monitoring
Monitoring the Vital Parameters
Respiration Rate
Temperature
ECG
22
Blood Pressure (NiBP)
• no correlation with CO
• no correlation with oxygen delivery
Monitoring
Monitoring the Vital Parameters
MAP mmHg
150
The Mean Arterial Pressure does not correlate with Oxygen Delivery!
120
90
60
n= 1232
30
23
100
300
500
MAP: Mean Arterial Pressure, DO2: Oxygen Delivery
700
DO2 ml*m-2*min-1
Reinhart K in: Lewis, Pfeiffer (eds): Practical Applications of Fiberoptics in Critical Care Monitoring, Springer Verlag Berlin - Heidelberg - NewYork 1990, pp 11-23
Monitoring
Monitoring the Vital Parameters
Respiration Rate
Temperature
ECG
Blood Pressure (NiBP)
• No correlation with CO
• No correlation with oxygen delivery
• No correlation with volume status
24
Monitoring
Monitoring the Vital Parameters
80% of blood volume is found in the venous
blood vessels,
only 20% in the arterial blood vessels!
25
Monitoring
Monitoring the Vital Parameters
Respiration Rate
Temperature
ECG
Blood Pressure (NiBP)
• No correlation with CO
• No correlation with oxygen delivery
• No correlation with volume status
• No evidence of what is the ‘right’ perfusion pressure
26
Monitoring
Standard Monitoring
Respiration Rate
Temperature
ECG
NIBP
27
Oxygen Saturation
• No information re the O2 transport capacity
• No information re the O2 utilisation in the tissues
Monitoring
Standard Monitoring
Respiration Rate
Temperature
ECG
NIBP
Oxygen Saturation
Urine Production
Blood Circulation
(clinical assessment)
28
Monitoring
Advanced Monitoring
The standard parameters do not give
enough information in unstable patients.
What other parameters do I need?
29
Monitoring
Advanced Monitoring
Invasive Blood Pressure (IBP)
• Continuous blood pressure recording
• Arterial blood extraction possible
• Limitations as with NiBP
30
Monitoring
Advanced Monitoring
IBP
Arterial BGA
Information re:
• Pulmonary Gas exchange
• Acid Base Balance
No information re oxygen supply at the cellular level
31
Monitoring
Advanced Monitoring
IBP
Lactate
Arterial BGA
Marker for global metabolic situation
Significant limitations due to:
• Liver metabolism
• Reperfusion effects
32
Monitoring
Advanced Monitoring
IBP
Arterial BGA
CVP
• central venous blood gas analysis possible
• When low: hypovolaemia probable
Lactate
• When high: hypovolaemia not excluded
• Not a reliable parameter for volume status
33
Monitoring
Advanced Monitoring
IBP
Arterial BGA
ScvO2
• Good correlation with SvO2 (oxygen consumption)
• Surrogate parameter for oxygen extraction
34
Lactate
• Information on the oxygen consumption situation
CVP
• When compared to SvO2 less invasive
(no pulmonary artery catheter required)
Monitoring
Monitoring of the central venous oxygen saturation
The ScvO2 correlates well with the SvO2!
ScvO2 (%)
SvO2
90
90
85
80
80
70
75
60
70
50
r = 0.945
40
30
n = 29
r = 0.866
ScvO2 = 0.616 x SvO2 + 35.35
65
60
30
40
50
60
70
80
90
ScvO2
Reinhart K et al: Intensive Care Med 60, 1572-1578, 2004;
40
50
60
70
80
90
SvO2 (%)
Ladakis C et al: Respiration 68, 279-285, 2000
Monitoring
Monitoring of the central venous oxygen saturation
avDO2 ml/dl
A low ScvO2 is a marker for increased global
oxygen extraction!
7.0
6.0
7.0
4.0
3.0
r= -0.664
2.0
n= 1191
1.0
avDO2= 12.7 -0.12*ScvO2
0
30
40
50
60
70
80
90
100
ScvO2 %
avDO2: arterial-venous oxygen content difference, ScvO2: central venous oxygen saturation
36
Reinhart K in: Lewis, Pfeiffer (eds): Practical Applications of Fiberoptics in Critical Care Monitoring, Springer Verlag Berlin - Heidelberg - NewYork 1990, pp 11-23
Monitoring
Monitoring of the central venous oxygen saturation
avDO2 ml/dl
7.0
CO
6.0
SaO2
Delivery DO2:
DO2 = CO x Hb x 1.34 x SaO2
Consumption VO2: VO2 = CO x Hb x 1.34 x (SaO2 - S(c)vO2)
7.0
Hb
Mixed / Central Venous Saturation S(c)vO2
4.0
3.0
2.0
1.0
r= -0.664
n= 1191
avDO2= 12,7 -0.12*ScvO2
0
30
40
50
60
70
80
avDO2: arterial-venous oxygen content difference, ScvO2: central venous oxygen saturation
37
90
100
ScvO2 %
Reinhart K in: Lewis, Pfeiffer (eds): Practical Applications of Fiberoptics in Critical Care Monitoring, Springer Verlag Berlin - Heidelberg - NewYork 1990, pp 11-23
Monitoring
Monitoring of the central venous oxygen saturation
Early goal-directed therapy
O2- Therapy and Sedation
Intubation + Ventilation
Rivers E et al. New Engl J Med 2001;345:1368-77
Cardiovascular Stabilisation
CVP
< 8 mmHg
Volume therapy
Mortality
Central Venous Catheter
Invasive Blood Pressure Monitoring
8-12 mmHg
MAP
< 65 mmHg
Vasopressors
Hospital
65 mmHg
ScVO2
< 70%
Blood transfusion to
Haematocrit 30%
>70%
no
38
Goal achieved?
ScVO2
 70%
yes
Therapy maintenance,
regular reviews
< 70%
Inotropes
60 days
Monitoring
Monitoring of the ScvO2 – Clinical Relevance
Significance of the ScvO2 for therapy guidance
39
Monitoring
Monitoring of the ScvO2 – Clinical Relevance
Early monitoring of ScvO2 is crucial for fast and effective
hemodynamic management!
40
Monitoring
Monitoring ScvO2 – therapeutic consequences in the example of sepsis
Pt unstable
ScvO2 < 70%
Volume bolus
(when absence of contraindications)
ScvO2 > 70% or < 80%
ScvO2 < 70%
Continuous ScvO2 monitoring – CeVOX
Advanced Monitoring - PiCCO
Re - evaluation
Volume / Catecholamine
Erythrocytes
41
Monitoring
Monitoring ScvO2 – Limitations
Tissue hypoxia despite ”normal“ or high ScvO2?
SxO2 in %
?
Microcirculation disturbances
in SIRS / Sepsis
42 modified from:
Reinhart K in: Lewis, Pfeiffer (eds): Practical Applications of Fiberoptics in Critical Care Monitoring, Springer Verlag Berlin - Heidelberg - NewYork 1990, pp 11-23
Monitoring
Monitoring ScvO2 – therapeutic consequences in the example of sepsis
Tissue hypoxia despite „normal“ or high ScvO2?
ScvO2
Pt unstable ScvO2 < 70%
ScvO2 > 80%
Volume administration
(when absence of
contraindications)
ScvO2 > 70% but < 80%
Re- evaluation
ScvO2 < 70%
Advanced Monitoring
cont. ScvO2 monitoring
Volume / Catecholamine / Erythrocytes
?
Monitoring
Monitoring ScvO2 – therapeutic consequences in the example of sepsis
Tissue hypoxia despite ”normal“ or high ScvO2?
Pt unstable
ScvO2 > 80%
Volume bolus
(when absence of contraindications)
ScvO2 < 80% but > 70%
ScvO2 > 80%
Microcirculation?
Re-evaluation
Organ perfusion?
Further information needed
44
Macro-haemodynamics (PiCCO)
Liver function (PDR – ICG)
Renal function
Neurological assessment
Monitoring
Summary and Key Points
• Standard monitoring does not give information re the volume status or the
adequacy of oxygen delivery and consumption.
• The CVP is not a valid parameter to measure volume status
• The measurement of central venous oxygen saturation gives important
information re global oxygenation balance and oxygen extraction
• Measuring the central venous oxygenation can reveal when more
advanced monitoring is indicated
45
Haemodynamic Monitoring
46
A.
Physiological Background
B.
Monitoring
C.
Optimising the Cardiac Output
D.
Measuring Preload
E.
Introduction to PiCCO Technology
F.
Practical Approach
G.
Fields of Application
H.
Limitations
Optimisation of CO
Monitoring – what is the point?
The haemodynamic instability is identified.
What can be done for the patient (sepsis example)?
1. Step: Volume Management
Aim?
Optimisation of CO
Recommendation of the SSC
How can you optimise CO?
47
Optimisation of CO
Monitoring – what is the point?
Optimisation of CO
Preload
Contractility
Frank-Starling mechanism
48
Afterload
Chronotropy
Optimisation of CO
Preload, CO and Frank-Starling Mechanism
SV
V
SV
V
SV
Normal contractility
SV
V
volume responsive
target area
volume overloaded
Preload
49
Optimisation of CO
Preload, CO and Frank-Starling Mechanism
SV
SV
V
Normal contractility
SV
V
volume responsive
Poor contractility
target area
volume overloaded
Preload
50
Optimisation of CO
Preload, CO and Frank-Starling Mechanism
SV
High contractility
SV
V
Normal Contractility
SV
V
volume responsive
Poor contractility
target area
volume overloaded
Preload
51
Optimisation of CO
Preload, CO and Frank-Starling Mechanism
SV
V
V
SV
SV
SV
V
volume responsive
target area
volume overloaded
Preload
In order to optimise the CO you must know what the preload is!
52
Optimisation of CO
Summary and Key Points
• The goal of fluid management is the optimisation of cardiac output
• An increase in preload leads to an increase in cardiac output, within certain
limits. This is explained by the Frank-Starling mechanism.
• The measurement of cardiac output does not show where the patient’s heart is
located on the Frank-Starling curve.
• For optimisation of the CO a valid preload measurement is indispensable.
53
Haemodynamic Monitoring
54
A.
Physiological Background
B.
Monitoring
C.
Optimising the Cardiac Output
D.
Measuring Preload
E.
Introduction to PiCCO Technology
F.
Practical Approach
G.
Fields of Application
H.
Limitations
Measuring Preload
Volumetric Preload Parameters, Volume Responsiveness and Filling Pressures
Preload
Filling Pressures
CVP / PCWP
55
Volumetric
Preload parameters
GEDV / ITBV
Volume
Responsiveness
SVV / PPV
Measuring Preload
Role of the filling pressures CVP / PCWP
Correlation between Central Venous Pressure CVP and Stroke Volume
Kumar et al., Crit Care Med 2004;32: 691-699
56
Measuring Preload
Role of the filling pressures CVP / PCWP
Correlation between Pulmonary Capillary Wedge Pressure PCWP and
Stroke Volume
Kumar et al., Crit Care Med 2004;32: 691-699
57
Measuring Preload
Role of the filling pressures CVP / PCWP
The filling pressures CVP and PCWP do not give an adequate
assessment of cardiac preload.
The PCWP is, in this regard, not superior to CVP
(ARDS Network, N Engl J Med 2006;354:2564-75).
Pressure is not volume!
Influencing Factors:
-Ventricular compliance
-Position of catheter (PAC)
-Mechanical ventilation
-Intra-abdominal hypertension
58
Measuring Preload
Role of the volumetric preload parameters GEDV / ITBV
Preload
Filling Pressures
CVP / PCWP
59
Volumetric
Preload parameters
Volume
Responsiveness
GEDV / ITBV
SVV / PPV
Measuring Preload
Role of the volumetric preload parameters GEDV / ITBV
GEDV = Global Enddiastolic Volume
Lungs
Pulmonary
Circulation
Right Heart
Left heart
Body Circulation
Total volume of blood in all 4 heart chambers
60
Measuring Preload
Role of the volumetric preload parameters GEDV / ITBV
GEDV shows good correlation with the stroke volume
Michard et al., Chest 2003;124(5):1900-1908
61
Measuring Preload
Role of the volumetric preload parameters GEDV / ITBV
ITBV = Intrathoracic Blood Volume
Lungs
Pulmonary
Circulation
Right heart
Left heart
Body Circulation
ITBV =GEDV + PBV
Total volume of blood in all 4 heart chambers plus the pulmonary blood volume
62
Measuring Preload
Role of the volumetric preload parameters GEDV / ITBV
ITBV is normally 1.25 times the GEDV
ITBVTD (ml)
3000
2000
1000
0
ITBV = 1.25 * GEDV – 28.4 [ml]
0
1000
GEDV vs. ITBV in 57 Intensive Care Patients
Sakka et al, Intensive Care Med 2000; 26: 180-187
63
2000
3000 GEDV (ml)
Measuring Preload
Role of the volumetric preload parameters GEDV / ITBV
The static volumetric preload parameters GEDV and ITBV
• Are superior to filling pressures for assessing cardiac preload
(German Sepsis Guidelines)
• Are, in contrast to cardiac filling pressures, not falsified by other pressure
influences (ventilation, intra-abdominal pressure)
64
Measuring Preload
Role of the dynamic volume responsiveness parameters SVV / PPV
Preload
Filling Pressures
CVP / PCWP
65
Volumetric
Preload
parameters
GEDV / ITBV
Volume Responsiveness
SVV / PPV
Measuring Preload
Physiology of the dynamic parameters of volume responsiveness
Fluctuations in blood pressure during the respiration cycle
Early Inspiration
Intrathoracic pressure
„Squeezing “ of the pulmonary blood
Left ventricular preload
Left ventricular stoke volume
Late Inspiration
Intrathoracic pressure
Venous return to left and right ventricle
Left ventricular preload
Left ventricular stroke volume
Systolic arterial blood pressure
Inspiration
PPmax
66 Reuter
Expiration
PPmin
et al., Anästhesist 2003;52: 1005-1013
Systolic arterial blood pressure
Inspiration
PPmax
Expiration
PPmin
Measuring Preload
Physiology of the dynamic parameters of volume responsiveness
Fluctuations in stroke volume throughout the respiratory cycle
SV
SV
SV
V
V
Preload
Mechanical Ventilation
Intrathoracic pressure fluctuations
Changes in intrathoracic blood volume
Preload changes
Fluctuations in stroke volume
67
Measuring Preload
Role of the dynamic volume responsiveness parameters SVV / PPV
SVV = Stroke Volume Variation
SVmax
SVmin
SVmean
• The variation in stroke volume over the respiratory cycle
• Correlates directly with the response of the cardiac ejection to
preload increase (volume responsiveness)
68
mean
Measuring Preload
Role of the dynamic volume responsiveness parameters SVV / PPV
SVV is more accurate for predicting volume responsiveness than CVP
Sensitivity 1
0,8
0,6
0,4
- - - CVP
___ SVV
0,2
0
0
Berkenstadt et al, Anesth Analg 92: 984-989, 2001
69
0,5
Specificity 1
Measuring Preload
Role of the dynamic volume responsiveness parameters SVV / PPV
PPV = Pulse Pressure Variation
PPmean
PPmax
PPmin
• The variation in pulse pressure amplitude over the respiration cycle
• Correlates equally well as SVV for volume responsiveness
70
Measuring Preload
Role of the dynamic volume responsiveness parameters SVV / PPV
A PPV threshold of 13% differentiates between responders
and non-responders to volume administration
respiratory
changes in arterial
pulse pressure (%)
Non – Responders
n = 24
Responders
n = 16
Michard et al, Am J Respir Crit Care Med 162, 2000
71
Measuring Preload
Role of the dynamic volume responsiveness parameters SVV / PPV
The dynamic volume responsiveness parameters SVV and PPV
- are good predictors of a potential increase in CO due to volume administration
- are only valid with patients who are fully ventilated and who have no cardiac
arrhythmias
72
Extra
Role of extravascular lung water EVLW
EVLW = Extravascular Lung Water
Lungs
Pulmonary
circulation
Left Heart
Right Heart
Body circulation
Extravascular water content of the lung
73
Extra
Role of extravascular lung water EVLW
The Extravascular Lung Water EVLW
- is useful for differentiating and quantifying lung oedema
- is, for this purpose, the only parameter available at the bedside
- functions as a warning parameter for fluid overload
74
Measuring Preload
Summary and Key Points
• The volumetric parameters GEDV / ITBV are superior to the filling pressures
CVP / PCWP for measuring cardiac preload.
• The dynamic parameters of volume responsiveness (SVV and PPV) can predict
whether CO will respond to volume administration.
• GEDV and ITBV show what the actual volume status is, whilst SVV and PPV reflect
the volume responsiveness of the heart.
• For optimal control of volume therapy simultaneous monitoring of both the static
preload parameters and the dynamic parameters of volume responsiveness is
sensible (F. Michard, Intensive Care Med 2003;29: 1396).
75
Haemodynamic Monitoring
76
A.
Physiological Background
B.
Monitoring
C.
Optimising the Cardiac Output
D.
Measuring Preload
E.
Introduction to PiCCO Technology
F.
Practical Approach
G.
Fields of Application
H.
Limitations
Haemodynamic Monitoring
E. Introduction to PiCCO Technology
1.
Principles of function
2.
Thermodilution
3.
Pulse contour analysis
4.
Contractility parameters
5.
Afterload parameters
6.
Extravascular lung water
7.
Pulmonary permeability
Introduction to the PiCCO-Technology
Parameters for guiding volume therapy
Volumetric preload
Contractility
- static
- dynamic
Differentiated Volume Management
CO
EVLW
PiCCO Technology
Introduction to the PiCCO-Technology – Function
Principles of Measurement
PiCCO Technology is a combination of transpulmonary thermodilution and pulse contour analysis
CVC
Lungs
Pulmonary Circulation
central venous
bolus injection
Right Heart
PULSIOCATH
PULSIOCATH
Left Heart
Body Circulation
PULSIOCATH
arterial thermodilution
catheter
Introduction to the PiCCO-Technology – Function
Principles of Measurement
After central venous injection the cold bolus sequentially passes through the
various intrathoracic compartments
Bolus injection
EVLW
RA
RV
PBV
LA
LV
concentration changes
over time
EVLW
(Thermodilution curve)
Right heart
Lungs
Left heart
The temperature change over time is registered by a sensor at the tip of the arterial catheter
Introduction to the PiCCO-Technology – Function
Intrathoracic Compartments (mixing chambers)
Intrathoracic Thermal Volume (ITTV)
Pulmonary Thermal
Volume (PTV)
EVLW
RA
RV
PBV
EVLW
Largest single
mixing chamber
Total of mixing chambers
LA
LV
Haemodynamic Monitoring
E. Introduction to PiCCO Technology
1.
Principles of function
2.
Thermodilution
3.
Pulse contour analysis
4.
Contractility parameters
5.
Afterload parameters
6.
Extravascular Lung Water
7.
Pulmonary Permeability
Introduction to the PiCCO-Technology – Thermodilution
Calculation of the Cardiac Output
The CO is calculated by analysis of the thermodilution curve using the modified
Stewart-Hamilton algorithm
Tb
Injection
t
COTD a
(Tb - Ti) x Vi x K
=
∫ D Tb x dt
Tb = Blood temperature
Ti = Injectate temperature
Vi = Injectate volume
∫ ∆ Tb . dt = Area under the thermodilution curve
K = Correction constant, made up of specific weight and specific heat of blood and injectate
Introduction to the PiCCO-Technology – Thermodilution
Thermodilution curves
The area under the thermodilution curve is inversely proportional to the CO.
Temperature
36,5
Normal CO: 5.5l/min
37
Temperature
Time
36,5
low CO: 1.9l/min
37
Temperature
Time
36,5
High CO: 19l/min
37
5
10
Time
Introduction to the PiCCO –Technology – Thermodilution
Transpulmonary vs. Pulmonary Artery Thermodilution
Transpulmonary TD (PiCCO)
Pulmonary Artery TD (PAC)
Aorta
Pulmonary
Circulation
PA
Lungs
central venous
bolus injection
LA
RA
Right Heart
Left heart
PULSIOCATH
arterial thermodilution catheter
RV
LV
Body Circulation
In both procedures only part of the injected indicator passes the thermistor.
Nonetheless the determination of CO is correct, as it is not the amount of the detected
indicator but the difference in temperature over time that is relevant!
Introduction to the PiCCO –Technology – Thermodilution
Validation of the Transpulmonary Thermodilution
Comparison with Pulmonary Artery Thermodilution
n (Pts / Measurements)
bias ±SD(l/min)
r
Friedman Z et al., Eur J Anaest, 2002
17/102
-0,04 ± 0,41
0,95
Della Rocca G et al., Eur J Anaest 14, 2002
60/180
0,13 ± 0,52
0,93
Holm C et al., Burns 27, 2001
23/218
0,32 ± 0,29
0.98
Bindels AJGH et al., Crit Care 4, 2000
45/283
0,49 ± 0,45
0,95
Sakka SG et al., Intensive Care Med 25, 1999
37/449
0,68 ± 0,62
0,97
Gödje O et al., Chest 113 (4), 1998
30/150
0,16 ± 0,31
0,96
9/27
0,19 ± 0,21
-/-
Pauli C. et al., Intensive Care Med 28, 2002
18/54
0,03 ± 0,17
0,98
Tibby S. et al., Intensive Care Med 23, 1997
24/120
0,03 ± 0,24
0,99
McLuckie A. et a., Acta Paediatr 85, 1996
Comparison with the Fick Method
Introduction to the PiCCO-Technology – Thermodilution
Extended analysis of the thermodilution curve
From the characteristics of the thermodilution curve it is possible to determine certain time
parameters
Tb
Injection
Recirculation
In Tb
e-1
MTt
DSt
MTt: Mean Transit time
the mean time required for the indicator to reach the detection point
DSt: Down Slope time
the exponential downslope time of the thermodilution curve
Tb = blood temperature; lnTb = logarithmic blood temperature; t = time
t
Introduction to the PiCCO-Technology – Thermodilution
Calculation of ITTV and PTV
By using the time parameters from the thermodilution curve and the CO ITTV and
PTV can be calculated
Tb
Injection
Recirculation
In Tb
e-1
MTt
DSt
t
Intrathoracic Thermal Volume
Pulmonary Thermal Volume
ITTV = MTt x CO
PTV = Dst x CO
Einführung in die PiCCO-Technologie – Thermodilution
Calculation of ITTV and PTV
Intrathoracic Thermal Volume (ITTV)
Pulmonary Thermal
Volume (PTV)
EVLW
RA
RV
PBV
EVLW
PTV = Dst x CO
ITTV = MTt x CO
LA
LV
Introduction to the PiCCO –Technology – Thermodilution
Volumetric preload parameters – GEDV
Global End-diastolic Volume (GEDV)
ITTV
PTV
EVLW
RA
RV
PBV
LA
LV
EVLW
GEDV
GEDV is the difference between intrathoracic and pulmonary thermal volumes
Introduction to the PiCCO –Technology – Thermodilution
Volumetric preload parameters – ITBV
Intrathoracic Blood Volume (ITBV)
GEDV
EVLW
RA
RV
PBV
PBV
LA
LV
EVLW
ITBV
ITBV is the total of the Global End-Diastolic Volume and the blood volume in
the pulmonary vessels (PBV)
Introduction to the PiCCO-Technology – Thermodilution
Volumetric preload parameters – ITBV
ITBV is calculated from the GEDV by the PiCCO Technology
Intrathoracic Blood Volume (ITBV)
ITBVTD (ml)
3000
2000
1000
0
ITBV = 1.25 * GEDV – 28.4 [ml]
0
1000
GEDV vs. ITBV in 57 Intensive Care Patients
Sakka et al, Intensive Care Med 26: 180-187, 2000
2000
3000 GEDV (ml)
Introduction to the PiCCO-Technology
Summary and Key Points - Thermodilution
• PiCCO Technology is a less invasive method for monitoring the
volume status and cardiovascular function.
• Transpulmonary thermodilution allows calculation of various volumetric parameters.
• The CO is calculated from the shape of the thermodilution curve.
• The volumetric parameters of cardiac preload can be calculated through advanced
analysis of the thermodilution curve.
• For the thermodilution measurement only a fraction of the total injected indicator
needs to pass the detection site, as it is only the change in temperature over time that
is relevant.
Haemodynamic Monitoring
E. Introduction to PiCCO Technology
1.
Principles of function
2.
Thermodilution
3.
Pulse contour analysis
4.
Contractility parameters
5.
Afterload parameters
6.
Extravascular Lung Water
7.
Pulmonary Permeability
Introduction to the PiCCO-Technology – Pulse contour analysis
Calibration of the Pulse Contour Analysis
The pulse contour analysis is calibrated through the transpulmonary thermodilution
and is a beat to beat real time analysis of the arterial pressure curve
Transpulmonary Thermodilution
Pulse Contour Analysis
Injection
COTPD
HR
T = blood temperature
t = time
P = blood pressure
= SVTD
Introduction to the PiCCO-Technology – Pulse contour analysis
Parameters of Pulse Contour Analysis
Cardiac Output
dP
 P(t)
PCCO = cal • HR • (
+ C(p) •
) dt
 SVR
dt
Systole
Patient- specific calibration
factor (determined by thermodilution)
Heart rate
Area under the
pressure curve
Aortic compliance
Shape of the pressure
curve
Introduction to the PiCCO-Technology – Pulse contour analysis
Validation of Pulse Contour Analysis
Comparison with pulmonary artery thermodilution
n (Pts / Measurements)
bias ±SD (l/min)
r
Mielck et al., J Cardiothorac Vasc Anesth 17 (2), 2003
22 / 96
-0,40 ± 1,3
-/-
Rauch H et al., Acta Anaesth Scand 46, 2002
25 / 380
0,14 ± 0,58
-/-
Felbinger TW et al., J Clin Anesth 46, 2002
20 / 360
-0,14 ± 0,33
0,93
Della Rocca G et al., Br J Anaesth 88 (3), 2002
62 / 186
-0,02 ± 0,74
0,94
Gödje O et al., Crit Care Med 30 (1), 2002
24 / 517
-0,2 ± 1,15
0,88
Zöllner C et al., J Cardiothorac Vasc Anesth 14 (2), 2000
19 / 76
0,31 ± 1,25
0,88
Buhre W et al., J Cardiothorac Vasc Anesth 13 (4), 1999
12 / 36
0,03 ± 0,63
0,94
Introduction to the PiCCO-Technology – Pulse Contour Analysis
Parameters of Pulse Contour Analysis
Dynamic parameters of volume responsiveness – Stroke Volume Variation
SVmax
SVmin
SVmean
SVV =
SVmax – SVmin
SVmean
The Stroke Volume Variation is the variation in stroke volume over the ventilatory cycle,
over the previous 30 second period.
measur
Introduction to the PiCCO-Technology – Pulse Contour Analysis
Parameters of Pulse Contour Analysis
Dynamic parameters of volume responsiveness – Pulse Pressure Variation
PPmax
PPmin
PPmean
PPV =
PPmax – PPmin
PPmean
The pulse pressure variation is the variation in pulse pressure over the ventilatory cycle,
measured over the previous 30 second period.
Introduction to the PiCCO-Technology – Pulse contour analysis
Summary pulse contour analysis - CO and volume responsiveness
• The PiCCO technology pulse contour analysis is calibrated by transpulmonary
thermodilution
• PiCCO technology analyses the arterial pressure curve beat by beat
thereby providing real time parameters
• Besides cardiac output, the dynamic parameters of volume responsiveness
SVV (stroke volume variation) and PPV (pulse pressure variation) are determined
continuously
Haemodynamic Monitoring
E. Introduction to PiCCO Technology
1.
Principles of function
2.
Thermodilution
3.
Pulse contour analysis
4.
Contractility parameters
5.
Afterload parameters
6.
Extravascular Lung Water
7.
Pulmonary Permeability
Introduction to the PiCCO-Technology – Contractility parameters
Contractility
Contractility is a measure for the performance of the heart muscle
Contractility parameters of PiCCO technology:
- dPmx (maximum rate of the increase in pressure)
- GEF (Global Ejection Fraction)
- CFI (Cardiac Function Index)
kg
Introduction to the PiCCO-Technology – Contractility parameters
Contractility parameter from the pulse contour analysis
dPmx = maximum velocity of pressure increase
The contractility parameter dPmx represents the maximum velocity of left
ventricular pressure increase.
Introduction to the PiCCO-Technology – Contractility parameters
Contractility parameter from the pulse contour analysis
dPmx = maximum velocity of pressure increase
n = 220
y = -120 + (0,8* x)
r = 0,82
p < 0,001
femoral dP/max 2000
[mmHg/s]
1500
1000
500
0
0
500
1000
1500
2000
LV dP/dtmax
[mmHg/s]
de Hert et al., JCardioThor&VascAnes 2006
dPmx was shown to correlate well with direct measurement of velocity of left
ventricular pressure increase in 70 cardiac surgery patients
Introduction to the PiCCO-Technology – Contractility parameters
Contractility parameters from the thermodilution measurement
GEF = Global Ejection Fraction
LA
RA
LV
GEF =
4 x SV
GEDV
RV
• is calculated as 4 times the stroke volume divided by the global end-diastolic
volume
• reflects both left and right ventricular contractility
Introduction to the PiCCO-Technology – Contractility parameters
Contractility parameters from the thermodilution measurement
GEF = Global Ejection Fraction
sensitivity
1
15
18
0,8
8
12
16
19
10
5
0,6
20
0,4
-20
22
-10
10
20
D FAC, %
-5
0,2
-10
0
0
0,2
0,4
0,6
0,8
1 specifity
-15
r=076, p<0,0001
n=47
D GEF, %
Combes et al, Intensive Care Med 30, 2004
Comparison of the GEF with the gold standard TEE measured contractility in
patients without right heart failure
Introduction to the PiCCO-Technology – Contractility parameters
Contractility parameters from the thermodilution measurement
CFI = Cardiac Function Index
CFI =
CI
GEDVI
• is the CI divided by global end-diastolic volume index
• is - similar to the GEF – a parameter of both left and right ventricular
contractility
Introduction to the PiCCO-Technology – Contractility parameters
Contractility parameters from the thermodilution measurement
CFI = Cardiac Function Index
sensitivity
1
3
4
15
2
3,5
10
0,8
5
0,6
5
-20
0,4
-10
10
20
D FAC, %
-5
6
0,2
-10
0
0
0,2
0,4
0,6
0,8
1 specificity
-15
r=079, p<0,0001
n=47
D GEF, %
Combes et al, Intensive Care Med 30, 2004
CFI was compared to the gold standard TEE measured contractility in patients
without right heart failure
Haemodynamic Monitoring
E. Introduction to PiCCO technology
1.
Functions
2.
Thermodilution
3.
Pulse contour analysis
4.
Contractility parameters
5.
Afterload parameters
6.
Extravascular Lung Water
7.
Pulmonary Permeability
Introduction to the PiCCO –Technology – Afterload parameter
Afterload parameter
SVR = Systemic Vascular Resistance
SVR =
(MAP – CVP) x 80
CO
• is calculated as the difference between MAP and CVP divided by CO
• as an afterload parameter it represents a further determinant of the
cardiovascular situation
• is an important parameter for controlling volume and catecholamine therapies
MAP = Mean Arterial Pressure
CVP = Central Venous Pressure
CO = Cardiac Output
80 = Factor for correction of units
Introduction to the PiCCO –Technology – Contractility and Afterload
Summary and Key Points
• The parameter dPmx from the pulse contour analysis as a measure of the left
ventricular myocardial contractility gives important information regarding
cardiac function and therapy guidance
• The contractility parameters GEF and CFI are important parameters for
assessing the global systolic function and supporting the early diagnosis of
myocardial insufficiency
• The Systemic Vascular Resistance SVR calculated from blood pressure and
cardiac output is a further parameter of the cardiovascular situation, and gives
additional information for controlling volume and catecholamine therapies
Haemodynamic Monitoring
E. Introduction to PiCCO technology
1.
Principles of function
2.
Thermodilution
3.
Pulse contour analysis
4.
Contractility parameters
5.
Afterload parameters
6.
Extravascular Lung Water
7.
Pulmonary Permeability
Introduction to the PiCCO –Technology – Extravascular Lung Water
Calculation of Extravascular Lung Water (EVLW)
ITTV
– ITBV
= EVLW
The Extravascular Lung Water is the difference between the intrathoracic thermal volume and
the intrathoracic blood volume. It represents the amount of water in the lungs outside the blood
vessels.
Introduction to the PiCCO –Technology – Extravascular Lung Water
Validation of Extravascular Lung Water
EVLW from the PiCCO technology has been shown to have a good correlation with
the measurement of extravascular lung water via the gravimetry and dye dilution
reference methods
Gravimetry
Dye dilution
ELWI by PiCCO
ELWIST (ml/kg)
Y = 1.03x + 2.49
40
25
n = 209
r = 0.96
20
30
15
20
10
10
0
R = 0,97
P < 0,001
0
10
20
30
ELWI by gravimetry
Katzenelson et al,Crit Care Med 32 (7), 2004
5
0
0
5
10
15
20
25
ELWITD (ml/kg)
Sakka et al, Intensive Care Med 26: 180-187, 2000
Introduction to the PiCCO –Technology – Extravascular Lung Water
EVLW as a quantifier of lung edema
High extravascular lung water is not reliably identified by blood gas analysis
ELWI (ml/kg)
30
20
10
0
0
50
150
250
350
450
PaO2 /FiO2
Boeck J, J Surg Res 1990; 254-265
550
Introduction to the PiCCO –Technology – Extravascular Lung Water
EVLW as a quantifier of lung oedema
ELWI = 19 ml/kg
ELWI = 14 ml/kg
Extravascular lung
water index
(ELWI)
normal range:
3 – 7 ml/kg
ELWI = 7 ml/kg
ELWI = 8 ml/kg
Introduction to the PiCCO –Technology – Extravascular Lung Water
EVLW as a quantifier of lung oedema
Chest x ray – does not reliably quantify pulmonary oedema and is difficult to judge,
particularly in critically ill patients
D radiographic score
r = 0.1
p > 0.05
80
60
40
20
0
-15
-10
10
-20
-40
-60
-80
Halperin et al, 1985, Chest 88: 649
15
D ELWI
Introduction to the PiCCO –Technology – Extravascular Lung Water
Relevance of EVLW Assessment
The amount of extravascular lung water is a predictor for mortality in the intensive
care patient
Mortality (%)
Mortality(%
)
100
n = 81
90
80
70
70
60
60
50
n = 373
40
50
30
40
20
30
20
*p = 0.002
80
10
0
4 - 6 6 - 8 8 - 10 10 - 12 - 16 16 - > 20
12
20
ELWI (ml/kg)
Sturm J in: Lewis, Pfeiffer (eds): Practical Applications of Fiberoptics in
Critical Care Monitoring, Springer Verlag Berlin - Heidelberg - NewYork
1990, pp 129-139
0
0
<7
n = 45
7 - 14
n = 174
Sakka et al , Chest 2002
14 - 21
n = 100
> 21
n = 54
ELWI (ml/kg)
Introduction to the PiCCO –Technology – Extravascular Lung Water
Relevance of EVLW Assessment
Volume management guided by EVLW can significantly reduce time on ventilation and
ICU length of stay in critically ill patients, when compared to PCWP oriented therapy,
Ventilation Days
* p ≤ 0,05
n = 101
Intensive Care
days
* p ≤ 0,05
22 days
9 days
15 days
7 days
PAC Group
EVLW Group
PAC Group
EVLW Group
Mitchell et al, Am Rev Resp Dis 145: 990-998, 1992
Haemodynamic Monitoring
E. Introduction to PiCCO Technology
1.
Principles of function
2.
Thermodilution
3.
Pulse contour analysis
4.
Contractility parameters
5.
Afterload parameters
6.
Extravascular Lung Water
7.
Pulmonary Permeability
Introduction to PiCCO Technology – Pulmonary Permeability
Differentiating Lung Oedema
PVPI = Pulmonary Vascular Permeability Index
PVPI =
EVLW
EVLW
PBV
PBV
• is the ratio of Extravascular Lung Water to Pulmonary Blood Volume
• is a measure of the permeability of the lung vessels and as such can
classify the type of lung oedema (hydrostatic vs. permeability caused)
Introduction to PiCCO Technology – Pulmonary Permeability
Classification of Lung Oedema with the PVPI
Difference between the PVPI with hydrostatic and permeability lung oedema:
Lung oedema
hydrostatic
permeability
PBV
PBV
EVLW
EVLW
EVLW
EVLW
PBV
PBV
PVPI normal (1-3)
PVPI raised (>3)
Introduction to PiCCO Technology – Pulmonary Permeability
Validation of the PVPI
PVPI can differentiate between a pneumonia caused and a cardiac failure caused
lung oedema.
PVPI
4
3
2
Cardiac insufficiency
Pneumonia
16 patients with congestive heart failure and acquired pneumonia. In both
groups EVLW was 16 ml/kg.
Benedikz et al ESICM 2003, Abstract 60
Introduction to PiCCO Technology – Pulmonary Permeability
Clinical Relevance of the Pulmonary Vascular Permeability Index
EVLWI answers the question:
How much water is in the lungs?
PVPI answers the question:
Why is it there?
and can therefore give valuable aid for therapy guidance!
Introduction to PiCCO Technology – EVLW and Pulmonary Permeability
Summary and Key Points
• EVLW as a valid measure for the extravascular water content of the lungs is
the only parameter for quantifying lung oedema available at the bedside.
• Blood gas analysis and chest x-ray do not reliably detect and measure lung
edema
• EVLW is a predictor for mortality in intensive care patients
• The Pulmonary Vascular Permeability Index can differentiate between
hydrostatic and a permeability caused lung oedema
Haemodynamic Monitoring
126
A.
Physiological Background
B.
Monitoring
C.
Optimising the Cardiac Output
D.
Measuring Preload
E.
Introduction to PiCCO Technology
F.
Practical Approach
G.
Fields of Application
H.
Limitations
Practical Approach
PiCCO Technology Set-Up
PiCCO monitoring uses vascular accesses that are already existing or required
anyway.
Central venous catheter
Injectate temperature
sensor housing
PULSIOCATH
Arterial thermodilution catheter
(femoral, axillary, brachial)
Practical Approach
Clinical Case
Patient with secondary myeloid leukemia due to non-Hodgkin’s lymphoma
Currently: aplasia as a result of ongoing chemotherapy.
Transfer from the oncology ward to intensive care unit due to development of septic
status
Status on transfer to the Intensive Care Unit
Hemodynamic
Respiration
Abdomen
Renal
Laboratory
BP 90/50mmHg, HR 150bpm SR, CVP 11mmHg
SaO2 99% on 2L O2 via nasal prongs
Severe diarrhoea, probably associated with chemotherapy
Retention values already increasing, cumulative 24h diuresis 400ml
Hb 6.7g/dl, Leuco <0.2/nl, Thrombo 25/nl
High fluid loss because of severe diaphoresis
Initial Therapy
Given 6500 ml crystalloids and 4 PBC
Practical Approach
Clinical Case
Ongoing Development
Haemodynamics • despite extensive volume therapy during the first 6 hours,
catecholamines had to be commenced
• requirement for catecholamines steadily increased
• echocardiography showed good pump function
• CVP increased from 11 to 15mmHg
Respiration
• respiratory deterioration with volume therapy:
SaO2 90% on 15L O2/min, pO2 69mmHg, pCO2 39mmHg, RR 40/min
• radiological signs of pulmonary edema
• started on intermittent non-invasive BIPAP ventilation
Renal
• ongoing poor quantitative function despite the use of diuretics (frusemide)
Infection Status • evidence of E.Coli in the blood culture
Diagnosis: Septic Multiorgan Failure
Practical Approach
Clinical Case
Therapeutic Problems and Issues
Haemodynamics • further requirement for volume? (rising catecholamine needs
despite good pump function)
• problematic assessment of volume status
(CVP initially raised, patient diaphoretic / diarrhoea)
Respiration
• evidence of lung edema (deterioration in pulmonary function)
• danger of need for intubation and ventilation with high risk of ventilatorassociated pneumonia (VAP) because of immunosuppression
Renal
• impending anuric renal failure
Practical Approach
Clinical Case
Therapeutic Problems and Questions
Haemodynamics
Volume Administration
Respiration
Renal
?
Haemodynamics
Volume Restriction
Respiration
Renal
Practical Approach
Clinical Case
Application of the PiCCO system
Initial measurement
Normal values
Cardiac Index
3.4
3.0 – 5.0 l/min/m2
GEDI
760
680 - 800 ml/m2
ELWI
14
3.0 – 7.0 ml/kg
SVRI
950
1700 - 2400 dyn*s*cm 5 m2
CVP
16
2 - 8 mmHg
- continuation of the noradrenaline infusion
- careful GEDI guided volume therapy
Practical Approach
Clinical Case
PiCCO values the following day
Actual values
Normal range
CI
3.5
3.0 – 5.0 l/min/m2
GEDI
780
680 - 800 ml/m2
ELWI
14
3.0 – 7.0 ml/kg
SVRI
990
1700 - 2400 dyn*s*cm 5 m2
CVP
16
2 - 8 mmHg
GEDI with volume therapy persistently within the high normal range, however
no increase in ELWI
Practical Approach
Clinical Case
Other therapy
- non-invasive ventilation
- targeted antibiotic therapy
- administration of hydrocortisone / GCSF
Further course
- stabilization of haemodynamics
- steady noradrenaline requirement
- start of negative fluid balance, guided by the PiCCO parameters
Practical Approach
Clinical Case
PiCCO values the next day
Actual values
Normal values
CI
3.2
3.0 – 5.0 l/min/m2
GEDVI
750
680 - 800 ml/m2
EVLWI
8
3.0 – 7.0 ml/kg
SVRI
1810
1700 - 2400 dyn*s*cm 5 m2
CVP
14
2 - 8 mmHg
- stabilization of pulmonary function
- cessation of catecholamines
- good diuresis with frusemide
Practical Approach
Clinical Case
Progression of PiCCO values
30
25
CVP
10
GEDVI
ITBIRemained within normal range under
monitoring
EVLWI
GEDVI
EVLW
Regular monitoring of the lung water
SVRI
EVLWI
5
0
Despite significant volume
administration/ removal remains
relatively constant, thus on its own
HI not an indicator for volume status
Nor
20
15
CI
increase of lung oedema
CI
Day 1
allowed titration of the volume therapy
SVR
whilst simultaneously avoiding further
Day 2
Day 3
Day 4
Time Course
Day 5
CVP
Initially raised, despite volume
Nordepletion and thus not of use
Practical Approach
Clinical Case
Actual advantages of using PiCCO with this patient
Optimisation of the intravascular
volume status
Monitoring of lung oedema
Stabilisation of the haemodynamics
Reduction
in catecholamine requirements
Pulmonary stabilisation
Avoidance of intubation
No acute renal failure
No invasive ventilation
Avoidance of complications
Efficient use of resources
Practical Approach
Clinical Case
Potential problems without PiCCO use in this patient
Diarrhoea
Severe diaphoresis
difficult
clinical assessment
of volume deficit
Poor Diuresis
High CVP
Volume
?
Volume
?
Constant CI
Volume
?
Practical Approach
Therapy Guidance with PiCCO Technology
PiCCO allows the establishment of an adequate cardiac output through optimisation
of volume status whilst avoiding lung oedema
Optimisation of stroke volume
The
haemodynamic triangle
Optimisation
of preload
Avoidance of
lung oedema
Practical Approach
Therapy Guidance with PiCCO Technology
Evaluation of
therapy success
PiCCO monitoring
CI, Preload, Contractility,
Afterload, Volume
responsiveness
Therapy
Volume / Catecholamines
if necessary:
additional information
Oxygen extraction ScvO2
Organ perfusion PDR-ICG
Practical Approach
Therapy Guidance with PiCCO Technology
5
Cardiac Output
Inadequate preload should initially be
treated with volume administration
3
EVLW
7
3
Preload
Practical Approach
Therapy Guidance with PiCCO Technology
5
Cardiac Output
Inadequate preload should be treated
initially with volume administration
3
Continue volume administration until
EVLW increases
EVLW
7
3
Preload
Practical Approach
Therapy Guidance with PiCCO Technology
5
Cardiac Output
Inadequate preload should be treated
initially with volume administration
3
Volume administration causes an
increase in EVLW
Volume removal until EVLW stops
decreasing or decreases only slowly
(preload monitoring!)
EVLW
Always check measurements for
plausibility.
7
3
Preload
Volume administration must lead to
an increase in preload, or increase in
lung oedema (reflected by increase in
EVLW)
Costs and Resources
Economic Aspects of PiCCO Technology
Is it possible to reduce treatment costs through
PiCCO Technology guided optimisation of therapy?
How high are the financial costs in comparison to the
pulmonary artery catheter?
Costs and Resources
Economic Aspects of PiCCO Technology
Direct costs in comparison to the PAC
Percentage
Costs
230%
PiCCO - Kit
Pulmonary catheter
Chest X-Ray
Introducer
CVC
Arterial catheter
Pressure transducer
Injection accessories
140%
100%
100%
PiCCO Kit
CCO - PAC
Day 1 to 4
PiCCO Kit
CCO - PAC
Day 5 to 8
Efficient and economically priced monitoring with PiCCO technology is possible because of
the low costs for materials and efficient use of staff time
Costs and Resources
Economic Aspects of PiCCO Technology
Indirect costs in comparison to the PAC
Ventilation days
* p ≤ 0.05
n = 101
Intensive care
days
* p ≤ 0.05
22 days
9 days
15 days
7 days
PAC group
EVLW group
PAC group
EVLW group
Mitchell et al, Am Rev Resp Dis 1992;145: 990-998
By reducing the ventilation days and subsequent days in intensive care the costs can be
effectively reduced (average cost per day currently 1,318.00€) (Moerer et al., Int Care Med 2002; 28)
Practical Approach
Summary and Key Points
• PiCCO technology as a less invasive monitoring method utilizes only vascular
accesses that already exist or are required anyway in ICU patients
• PiCCO technology provides all the parameters essential for complete
haemodynamic management
• Through valid and rapidly available PiCCO parameters optimal haemodynamic
therapy guidance is possible
• Through the optimisation of therapies with PiCCO technology complications
can be reduced and resources used more efficiently
Haemodynamic Monitoring
148
A.
Physiological Background
B.
Monitoring
C.
Optimising the Cardiac Output
D.
Measuring Preload
E.
Introduction to PiCCO technology
F.
Practical Approach
G.
Fields of Application
H.
Limitations
Applications
Indications for PiCCO Technology
Applications in intensive care (early use)
-
Severe sepsis
Septic shock/SIRS reaction
ARDS
Cardiogenic shock (myocardial infarction / ischaemia, decompensated heart failure)
Heart failure (e.g. due to cardiomyopathy)
Pancreatitis
Poly-trauma including haemorrhagic shock
Sub-arachnoid haemorrhage
Decompensated liver cirrhosis / hepatorenal syndrome
Severe burns
Perioperative Applications
- Cardiac surgery
- High risk surgery and high risk patients
- Transplantation
Applications
Indications for PiCCO Technology
Recommendation:
The use of PiCCO technology is indicated in all patients
with haemodynamic instability and for those with complex
cardiocirculatory conditions.
By early use, PiCCO-directed therapy optimisation can
prevent complications.
Application
Summary and Key Points
• PiCCO technology is able to be used in a wide group of patients, both in
Intensive Care Medicine and peri-operatively
• The use should always be taken into consideration in haemodynamically unstable
patients as well as in those with complex cardiocirculatory conditions
• As well as directing therapy, the PiCCO parameters can also provide important
diagnostic information
• PiCCO technology supports decision making in unstable patients
Haemodynamic Monitoring
152
A.
Physiological Background
B.
Monitoring
C.
Optimising the Cardiac Output
D.
Measuring Preload
E.
Introduction to PiCCO Technology
F.
Practical Approach
G.
Fields of Application
H.
Limitations
Limitations
Limitations of the PiCCO parameters - thermodilution
Knowledge of the limitations is essential for correct interpretation of the data!
GEDV
- data will give false-high with large aortic aneurysm
- is not usable with intracardiac left-right shunt
- can be overestimated in severe valvular insufficiency
EVLW
- data will be falsely high with gross pulmonary
perfusion failure (macro-embolism)
- is not usable with intracardiac left-right shunt
Limitations
Limitations of PiCCO parameters – pulse contour analysis
Knowledge of the limitations is essential for correct interpretation of the data!
SVV / PPV
All parameters of
pulse contour
analysis
can only be used with fully controlled mechanical
ventilation (minimal tidal volume 6-8ml/kg) and absence
of cardiac arrhythmias (otherwise may give false high
reading)
not valid when an IABP is in use
(thermodilution is unaffected)
Special clinical situations
PiCCO Technology in special situations
Renal replacement
therapy
normally no interference with the PiCCO parameters
Prone positioning
all parameters are measured correctly
Peripheral venous
injection
not recommended, measurements possibly incorrect
Limitations
Limitations of application of PiCCO Technology
PiCCO Technology has no specific limitations of
application
Because of the use of normal saline as indicator, PiCCO measurements are
possible at virtually any desired frequency, even in children (over 5kg) and
pregnant women.
Limitations
Contraindications to PiCCO Technology
Because of the low invasiveness there are no absolute
contraindications
The usual precautions are required when puncturing larger blood vessels:
• coagulation disorders
• vascular prosthesis (use other puncture site, e.g. axillary)
Limitations
Complications of PiCCO Technology
The complications of PiCCO technology are confined to the usual risks of arterial
puncture
• injuries associated with the puncture
• infection
• perfusion disturbances
PULSION recommends that the PiCCO catheter be
removed after 10 days at the latest
None the less …..