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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 …..