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PiCCO plus Standalone Monitor
PiCCO-Technology
PiCCO ...
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Contents
1. What is the PiCCO-Technology?.................................................................................... 3
2. What are the advantages of the PiCCO-Technology?.................................................... 4
3. How does the PiCCO-Technology work?....................................................................... 6
4. How to use the PiCCO-Technology?............................................................................. 19
5. Which disposables do I need for the PiCCO-Technology?............................................ 22
6. References…………………………………………………………………………………….. 24
7. Where can I get what I need?.......................................................................................... 25
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1. What is the PiCCO-Technology?
The PiCCO Technology is a combination of 2 techniques for advanced
hemodynamic and volumetric management without the necessity of a
pulmonary artery catheter in most patients:
a. Transpulmonary thermodilution
b. Arterial pulse contour analysis
-∆T
-∆T
see also page 8
t
see also page 16
t
3
2. What are the advantages of the PiCCO-Technology?
The PiCCO measures the following main parameters:
Thermodilution Parameters
• Cardiac Output
• Global Enddiastolic Volume
• Intrathoracic Blood Volume
• Extravascular Lung Water
CO
GEDV
ITBV
EVLW*
Pulse Contour Parameters
• Pulse Continuous Cardiac Output PCCO
• Systemic Vascular Resistance
SVR
• Stroke Volume Variation
SVV
* not available in USA
4
2. What are the advantages of the PiCCO-Technology?
Less Invasiveness
- Only central venous and arterial access required
- No pulmonary artery catheter required
- Applicable also in small children
Short Set-up Time
- Can be installed within minutes
Dynamic, Continuous Measurement - Cardiac Output, Afterload and Volume Responsiveness
are measured beat-by-beat
No Chest X-ray
- To confirm correct catheter position no x-ray is necessary
Cost Effective
- Less expensive than pulmonary artery catheter technique
- Arterial PiCCO catheter can be in place for 10 days or more
- Potential to reduce ICU stay and costs
More Specific Parameters
- PiCCO parameters are easy to use and interpret even
for less experienced clinical staff
Extravascular Lung Water*
- Lung edema can be excluded or quantified at the bed-side
* not available in USA
5
3. How does the PiCCO-Technology work?
Most of hemodynamic unstable and/or severely hypoxemic patients are instrumented with:
Central venous line
Arterial line
(e.g. for vasoactive agents administration…)
(accurate monitoring of arterial pressure, blood samples…)
The PiCCO-Technology uses any standard CV-line and a thermistor-tipped arterial
PiCCO-catheter instead of the standard arterial line.
6
Configuration
Central venous line (CV)
CV
A
Thermodilution catheter with lumen for
arterial pressure measurement
• Axillary (A)
• Brachial (B)
• Femoral (F)
• Radial (R), long catheter
B
R
F
Arterial pressure transducer
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a. Transpulmonary Thermodilution
Transpulmonary thermodilution measurement simply requires the central
venous injection of a cold (< 8°C) or room-tempered (< 24°C) saline bolus…
CV Bolus
Injection
Lungs
Right Heart
Left Heart
PiCCO Catheter
e.g. in femoral artery
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PiCCO Thermodilution Cardiac Output
After central venous injection of the indicator, the thermistor in the tip of the arterial
catheter measures the downstream temperature changes
The cardiac output is calculated by analysis of the thermodilution curve using a
modified Stewart-Hamilton algorithm:
-Tb Injection
t
9
PiCCO Volumetric Parameters
Global Enddiastolic Volume
GEDV
Intrathoracic Blood Volume ITBV
Extravascular Lung Water
EVLW*
These volumetric parameters are obtained by advanced analysis of the thermodilution curve.
(Detailed information and formulas available on request.)
Advanced Thermodilution Curve Analysis
Tb
injection
recirculation
ln Tb
e -1
At
MTt
DSt
t
* not available in USA
10
Global Enddiastolic Volume
Global Enddiastolic Volume (GEDV) is the volume of blood contained in the 4 chambers
of the heart.
11
Intrathoracic Blood Volume
Intrathoracic Blood Volume (ITBV) is the volume of the 4 chambers of the heart + the
blood volume in the pulmonary vessels.
12
Extravascular Lung Water*
Extravascular Lung Water (EVLW)* is the amount of water content in the lungs. It
allows bedside quantification of the degree of pulmonary edema.
* not available in USA
13
PiCCO Preload Indicators
Intrathoracic Blood Volume, ITBV and Global Enddiastolic Volume, GEDV have
shown to be far more sensitive and specific to cardiac preload than the standard
cardiac filling pressures CVP + PCWP but also than right ventricular enddiastolic
volume. 2,3,5,6,8,9,12,13,22
The striking advantage of ITBV and GEDV is that they are not wrongly influenced by
mechanical ventilation and give correct information on the preload status under any
condition. 2,3,6,7,8,9,12,13, 22
14
Extravascular Lung Water*
Extravascular Lung Water, EVLW* assessment by transpulmonary thermodilution has
been validated against dye dilution and the reference gravimetric method. 11,16,21,23
Extravascular Lung Water, EVLW* has shown to have a clear correlation to severity
of ARDS, length of ventilation days, ICU-Stay and Mortality and to be superior to
assessment of lung edema by chest x-ray.7,8,15,20,23,24
* not available in USA
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b. Arterial Pulse Contour Analysis
Arterial pulse contour analysis provides continuous beat-by-beat parameters obtained
from the shape of the arterial pressure wave.
The algorithm is capable of computing each single stroke volume (SV) after being
calibrated by an initial transpulmonary thermodilution.
-∆T
-∆T
t
P [mm Hg]
t
Calibration
SV
t [s]
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Cardiac Output and Systemic Vascular Resistances
As pulse contour analysis continuously measures stroke volume and arterial pressure,
cardiac output (CO) and systemic vascular resistance (SVR) are computed as follows:
CO is calculated as stroke volume x heart rate
SVR is calculated as (mean arterial pressure - central venous pressure) / CO
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Stroke Volume Variation (SVV)
In mechanically ventilated patients without arrhythmia,
SVV reflects the sensitivity of the heart to the cyclic changes in cardiac preload induced by
mechanical ventilation.1,14,17,18,19
SVV can predict whether stroke volume will increase with volume expansion.1,14,17,18,19
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4. How to use the PiCCO-Technology?
1. Connect the injectate-temperature sensor housing to the CV line already in place.
2. Insert a PiCCO arterial thermistor catheter into a large artery, preferable femoral
artery, but also brachial / axillary artery and radial artery (with long catheter).
3. Connect the injectate sensor, the arterial catheter’s thermistor and pressure line to
your PiCCO monitor.
4. For blood pressure transfer to any bedside monitoring system, connect the cable at
the back side of the PiCCO monitor.
5. Now the system is ready to work.
6. For information how to handle your PiCCO monitor, please refer to your
accompanying PiCCO Operator’s Manual.
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How to manage my patient with the PiCCO-Technology?
Management of a patients hemodynamic situation is easily possible by following the
therapeutic guideline shown below.+
It was developed out of daily clinical practice, has shown to be successful in over a
hundred thousand patients and refers to below listed normal values of indices:
Cardiac Index
Global Enddiastolic Blood Volume Index
Intrathoracic Blood Volume Index
Stroke Volume Variation
Extravascular Lung Water Index*
+without
guarantee
CI
GEDI
ITBI
SVV
ELWI*
3.0 – 5.0
680 – 800
850 – 1000
 10
3.0 – 7.0
l/min/m2
ml/m2
ml/m2
%
ml/kg
* not available in USA
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Decision tree for hemodynamic / volumetric monitoring**
CI (l/min/m2 )
R
E
S
U
L
T
S
T
H
E
R
A
P
Y
<3.0
GEDI (ml/m2 )
<700
<850
2
or ITBI (ml/m )
ELWI (ml/kg)
1.
GEDI (ml/m2 )
2
or ITBI (ml/m )
T
+
A 2. Optimise to SVV (%)
R
G
CFI (1/min)
E
or GEF (%)
T
ELWI (ml/kg) *
>3.0
<700
<850
>700
>850
>700
>850
<10
>10
<10
>10
<10
>10
V+
V+!
Cat
Cat
Cat
V-
V+
V+!
V-
>700
>850
700-800
850- 1000
>700
>850
700- 800
850- 1000
>700
>850
700- 800
850- 1000
700- 800
850- 1000
<10
<10
<10
<10
<10
<10
>4.5
>25
>5.5
>30
>4.5
>25
>5.5
>30
10
10
<10
<10
>10
<10
OK!
10
10
(slowly responding)
V + = volume loading (! = cautiously)
V - = volume contraction
+SVV only applicable in ventilated patients without cardiac arrhythmia
**without guarantee
Cat = catecholamine / cardiovascular agents
*not available in USA
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5. Which disposables do I need with the PiCCO-Technology?
PULSIOCATH arterial thermodilution catheter
• Specifically designed for less invasive volumetric, hemodynamic monitoring
• To be placed with Seldinger Technique
• Several sizes available for pediatric and adult patients
• Can remain within the patient up to 10 days or longer
Injectate temperature sensor housing
Any standard central venous catheter
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PULSIOCATH arterial thermodilution catheters product range
PULSIOCATH arterial thermodilution catheters are specifically designed for less invasive volumetric
hemodynamic monitoring with the PiCCO Technology. The catheters are placed with Seldinger Technique.
Several versions and sizes are available. They can remain within the patient up to 10 days or even longer.
Article number
PV2013L07
PV2014L08
PV2015L20
PV2014L50LGWA
Outer diameter
3F
(~20G) / 0,9mm
4F
4F
(~18G) / 1,4mm (~18G) / 1,4mm
5F
(~16G) / 1,7mm
4F
(~18G) / 1,4mm
Usable length
7cm
8cm
20cm
50cm
Common feature
PV2014L16
16cm
Latex free
Technical specifications are subject to change without further notice
The catheters are also available as complete kits (e.g. PVPK2015L20-46), including a disposable pressure
transducer and the injectate temperature sensor housing. These kits can optionally be ordered with an
additional pressure line for intermittent central venous pressure monitoring.
Catheters have to be selected depending on patient size, weight and insertion site.
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6. References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
Berkenstadt H et al., Anesth Analg, 2001
Bindels A et al., Crit Care 4, 2000
Boussat S et al., Int Care Med 2002
Brock H et al., Eur J Anaesth 19 (4), 2002
Della Rocca G et al., Eur J Anaesth 19, 2002
Della Rocca G et al., Anesth Analg 95, 2002
Eisenberg PR et al., Am Rev Respir Dis 136 (3), 1987
Gödje O et al., Chest 118, 2000
Gödje O et al., Eur J of Cardio-thoracic Surgery 13, 1998
Haperlin et al., Chest, 1985
Katzenelson et al., SCCM 2001, San Diego
Lichtwarck-Aschoff M et al., Journal of Critical Care 11 (4), 1996
Lichtwarck-Aschoff M et al., Intensive Care Med 18, 1992
Michard F et al., Yearbook of Intensive Care Med, 2002
Mitchell JP et al., Am Rev Respir Dis 145 (5), 1992
Neumann et al., Intensive Care Med 1999
Reuter DA et al., Crit Care Med, 2003
Reuter DA et al., Intensive Care Med, 2002
Reuter DA et al., Brit J Anaesth, 2002
Sakka SG et al., Chest 122, 2002
Sakka S et al., Intensive Care Med 2000
Sakka S et al., Journal of Critical Care 14 (2), 1999
Sturm JA, Practical Applications of Fiberoptics in Critical Care Monitoring, 1990
Takeda A et al., J Vet Med Sci 57, 1995
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7. Where can I get what I need?
For further information or ordering, please contact your local PULSION Office:
PULSION Medical Systems AG
Stahlgruberring 28
D- 81829 München
Germany
Tel.: +49 (0)1805 PULSION
+49 (0)89 4599140
Fax: +49 (0)89 45991418
[email protected]
PULSION Medical U.K., Ltd.
P.O. Box 315
Arundel Road
Uxbridge, Middlesex
GB- UB8 2US, England
Great Britain
Tel.: +44 (0) 1895 455255
Fax: +44 (0) 1895 274035
[email protected]
Seda S.p.A.
Via Tolstoi, 7/B
I- 20090 Trezzano sul Naviglio
(MI)
Italy
Tel.: +39 02 48424219
Fax: +39 02 48424290
[email protected]
PULSION Benelux nv/sa
Maaltecenter, Blok G
Derbystraat 341
B- 9051 Gent (SDW)
Belgium
Tel. : +32 (0)9 242 99 10
Fax : +32 (0)9 242 99 11
[email protected]
PULSION France sarl
6, Place Jeanne d´Arc
F- 13100 Aix en Provence
France
Tél. : +33 (0)4 42 27 67 19
Fax : +33 (0)4 42 27 44 90
[email protected]
PULSION Pacific Pty. Ltd.
P.O. Box 823
AUS- Randwick, NSW Australia,
2031
Australia
Tel.: +61 (0) 2 9340 5525
Fax: +61 (0) 2 9340 5515
[email protected]
PULSION Medical Systems
Ibérica S.L.
Pol. Ind. Las Nieves, C/ Puerto
Canencia 21
E- 28935 Móstoles, Madrid
Spain
Tel.: +34 91 665 73 12
Fax: +34 91 616 94 27
[email protected]
If your country is not
listed above, please
contact
PULSION Germany
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The PiCCO-Technology is also available as a module for
Philips IntelliVue / CMS patient monitoring systems.
For more information please refer to your local PULSION representative (page 25) or visit www.pulsion.com
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For further information, please visit
www.pulsion.com
There you will find also information on other revolutionary PULSION products:
LiMON
ICG-PULSION
VoLEF
IC-VIEW
@ PULSION 07/2003
MPI812205
- noninvasive bedside liver function monitor
- indocyanine green dye for diagnostics
- PiCCO plus add-on monitor for cardiac sub-volumes and RVEF
- laser fluorescence makes tissue perfusion visible
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