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NURSE DRIVEN
FLUID OPTIMIZATION
Using Non-Invasive Hemodynamic Monitoring
Cheetah Medical
Fluid Optimization Machines™
TM
THE CHEETAH NICOM®
The Cheetah NICOM® provides continuous non-invasive tracking of Cardiac Output
and other key hemodynamic parameters of cardiac function including: Stroke Volume,
Vascular Resistance, Non-Invasive Blood Pressure, Stroke Volume Variation, Heart
Rate and Thoracic Fluid Content. The system is based on the NICOM® BIOREACTANCE®
platform which has been used to enhance fluid management and drug titration in multiple
clinical applications. These include Critical Care (MICU, SICU, NICU), Anesthesia, PACU,
ED and Rapid Response Team.
Main Applications
Advantages
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•
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1. 100% non-invasive fluid management
Peri-Operative Patients
Sepsis
Shock
Trauma
Subarachnoid Hemorrhage
Acute heart failure
2. Highly accurate
3. Quick and easy application, nurse driven
4. Enables standardization across patients
5. Available without capital expenditure
6. Helps reduce invasive lines
7. Cost effective
8. Flexible sensor placement
9. Continuous real-time data
10. Compact & portable
TM
Cheetah
Cheetah Medical
Cheetah
Medical
Medical
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Cheetah Medical
TM
1OO% Non- Invasive
Guided Fluid
Management
Managemen
™
A
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s
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C r i t i c a l
Emergency
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C a r e
Medicine
Cheetah Medical
TM
www.cheetahnicom.com
PASSIVE LEG RAISE (PLR) TEST
Estimation of Fluid Responsiveness
First Step Baseline
45°
Patient position: Lying in a semi-recumbent position
Stroke Volume Index (SVI)
Obtain 3 readings (equals to 3 minutes)
Second Step Challenge
45°
Patient position: Passive leg raise (about 45 degrees)
Obtain 3 readings (equals to 3 minutes). In fluid responsive*
patients look for the following anticipated stroke volume index
response:
SVI
) 10%
Fluid Responsive: SVI will increase by >15% in response to 500 mL IV fluid
administration
*
Test is positive: SVI rise ) 10% ; Patient is Fluid Responsive
Test is negative: SVI rise < 10% ; Patient is not Fluid Responsive
3
4
<70%
**
ScvO2
CI
3080
1.3 L/min/m2
Diuretics, Nitrates, Cardiac inotropes
2270
3.0 L/min/m2
TREATMENT
RESPONSE TO PLR
TPRI
CI
Restless, Cool, Clammy
150
90
HR
VA
70/40
110/70
PATIENT 1 CARDIOGENIC SHOCK
BP
CASE
CI
680
5.9 L/min/m2
<
> 70%
IV Fluids, Antibiotics, Pressors
2270
3.0 L/min/m2
150
70/40
Restless, Warm Skin
90
110/70
PATIENT 2 SEPTIC SHOCK
150
70/40
2270
3.0 L/min/m2
www.cheetah-medical.com
Cheetah Medical
<70%***
IV Fluids
CI
2500
1.6 L/min/m2
Restless, Cool, Clammy
90
110/70
PATIENT 3 HYPOVOLEMIC SHOCK
CASE IN POINT : CI , TPRI IN CONTEXT
A 250 mL IV bolus infusion can substitute the PLR if given in under 10 minutes | **The ScvO2 parameter is obtained via an invasive sensor | ***May be >75% in severe sepsis
*
*
PARAMETER
Differential Diagnosis
Cheetah NICOM®
TM
Chest. 2002 Jun;121(6):2000-8
Predicting fluid responsiveness in ICU patients: a critical analysis
of the evidence
Michard F, Teboul JL
Medical ICU, CHU de Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre,
Université Paris XI, France. [email protected]
Abstract
STUDY OBJECTIVE: To identify and critically review the published peer-reviewed,
English-language studies investigating predictive factors of fluid responsiveness in ICU
patients. DESIGN: Studies were collected by doing a search in MEDLINE (from 1966)
and scanning the reference lists of the articles. Studies were selected according to
the following criteria: volume expansion performed in critically ill patients, patients
classified in two groups (responders and nonresponders) according to the effects
of volume expansion on stroke volume or on cardiac output, and comparison of
responder and nonresponder patients' characteristics before volume expansion.
RESULTS: Twelve studies were analyzed in which the parameters tested were as
follows: (1) static indicators of cardiac preload (right atrial pressure [RAP], pulmonary
artery occlusion pressure [PAOP], right ventricular end-diastolic volume [RVEDV], and
left ventricular end-diastolic area [LVEDA]); and (2) dynamic parameters (inspiratory
decrease in RAP [Delta RAP], expiratory decrease in arterial systolic pressure [Delta
down], respiratory changes in pulse pressure [Delta PP], and respiratory changes in
aortic blood velocity [Delta Vpeak]). Before fluid infusion, RAP, PAOP, RVEDV, and
LVEDA were not significantly lower in responders than in nonresponders in three
of five studies, in seven of nine studies, in four of six studies, and in one of three
studies, respectively. When a significant difference was found, no threshold value
could discriminate responders and nonresponders. Before fluid infusion, Delta RAP,
Delta down, Delta PP, and Delta Vpeak were significantly higher in responders, and
a threshold value predicted fluid responsiveness with high positive (77 to 95%)
and negative (81 to 100%) predictive values. CONCLUSION: Dynamic parameters
should be used preferentially to static parameters to predict fluid responsiveness in
ICU patients.
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Chest 2008;134;172-178
Does Central Venous Pressure Predict Fluid Responsiveness?:
A Systematic Review of the Literature and the Tale of Seven Mares
Marik PE, Baram M, Vahid B
Abstract
BACKGROUND: Central venous pressure (CVP) is used almost universally to guide
fluid therapy in hospitalized patients. Both historical and recent data suggest that this
approach may be flawed. OBJECTIVE: A systematic review of the literature to determine
the following: (1) the relationship between CVP and blood volume, (2) the ability of
CVP to predict fluid responsiveness, and (3) the ability of the change in CVP ([CVP) to
predict fluid responsiveness. DATA SOURCES: MEDLINE, Embase, Cochrane Register
of Controlled Trials, and citation review of relevant primary and review articles. STUDY
SELECTION: Reported clinical trials that evaluated either the relationship between CVP
and blood volume or reported the associated between CVP/[CVP and the change in
stroke volume/cardiac index following a fluid challenge. From 213 articles screened,
24 studies met our inclusion criteria and were included for data extraction. The studies
included human adult subjects, healthy control subjects, and ICU and operating room
patients. DATA EXTRACTION: Data were abstracted on study design, study size, study
setting, patient population, correlation coefficient between CVP and blood volume,
correlation coefficient (or receive operator characteristic [ROC]) between CVP/[CVP
and change in stroke index/cardiac index, percentage of patients who responded
to a fluid challenge, and baseline CVP of the fluid responders and nonresponders.
Metaanalytic techniques were used to pool data. DATA SYNTHESIS: The 24 studies
included 803 patients; 5 studies compared CVP with measured circulating blood
volume, while 19 studies determined the relationship between CVP/[CVP and change
in cardiac performance following a fluid challenge. The pooled correlation coefficient
between CVP and measured blood volume was 0.16 (95% confidence interval [CI],
0.03 to 0.28). Overall, 56±16% of the patients included in this review responded to a
fluid challenge. The pooled correlation coefficient between baseline CVP and change in
stroke index/cardiac index was 0.18 (95% CI, 0.08 to 0.28). The pooled area under the
ROC curve was 0.56 (95% CI, 0.51 to 0.61). The pooled correlation between [CVP and
change in stroke index/cardiac index was 0.11 (95% CI, 0.015 to 0.21). Baseline CVP
was 8.7±2.32 mm Hg [mean ± SD] in the responders as compared to 9.7±2.2 mm Hg in
nonresponders (not significant). CONCLUSIONS: This systematic review demonstrated
a very poor relationship between CVP and blood volume as well as the inability of
CVP/[CVP to predict the hemodynamic response to a fluid challenge. CVP should not
be used to make clinical decisions regarding fluid management.
6
Am J Respir Crit Care Med 183;2011:A6440
Evaluation Of Noninvasively Measured Cardiac Output In Patients
With Pulmonary Hypertension
Rich JD, Archer SL, Rich S
University of Chicago Medical Center, Department of Medicine, Section of Cardiology, Chicago, IL
Abstract
RATIONALE: Pulmonary hypertension (PH) is characterized by right ventricular
dysfunction and a progressive decline in cardiac output (CO), which requires
invasive hemodynamic monitoring to evaluate. NICOM® is a new Bioreactance®based technology that has been broadly validated, but its specific application
in isolated RV failure is unknown. We sought to determine the precision and
accuracy of NICOM to measure CO in patients with PH. METHODS: Right
heart catheterization (RHC) was performed in 24 consecutive patients with
confirmed PH. Simultaneous CO measurements were performed using three
different methods (thermodilution, estimated Fick, and NICOM) at baseline
(n=24) and after adenosine vasodilator challenge (n=15). The average of
three consecutive CO measurements was calculated for both thermodilution
and NICOM methods. We compared the precision (coefficient of variation) and
accuracy of NICOM as compared to thermodilution and Fick, respectively,
using a student’s t-test and Bland-Altman analysis (bias±95% limits of
agreement). RESULTS: The mean age of the patients was 54±16 yrs, 54% were
female, and most had severe PH (mean pulmonary artery systolic pressure
71.2±25 mm Hg). At baseline, there were no significant differences in CO
measured with NICOM as compared to thermodilution and Fick: 4.96±1.14
L/min, 5.33±1.56 L/min and 4.69±1.04 L/min, respectively (p=NS). CO
measured by NICOM was significantly more precise than by thermodilution
(3.6±1.7 % vs. 9.9±5.7 %, p<0.001). Bland-Altman analyses comparing
NICOM to thermodilution and Fick revealed mean bias and limits of agreement
of -0.37±2.6 L/min and 0.21±2.3 L/min, respectively, which were comparable
to those of the Bland-Altman analysis comparing Fick to thermodilution
(-0.91±2.1 L/min). Adenosine challenge (mean dose 106.7±37.2 μg/kg · min-1)
resulted in a similar mean % increase in CO according to each method
(NICOM=18.8%, TD=29.0%, Fick=21.0%; p=NS). CONCLUSIONS: CO measured
noninvasively via Bioreactance provides precise and accurate CO measurements
and reliably detects increases in CO with adenosine challenge in patients with
PH as compared to thermodilution and estimated Fick. NICOM may allow for
the acute and chronic assessment of response to therapy noninvasively in
patients with PH, thus avoiding serial RHC.
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American Society of Anesthesiologists 2011
NICOM versus EDM Guided Goal Directed Fluid Therapy in the
Perioperative Period
Waldron NH, Miller TE, Nardiello J, Manchester AK, Gan TJ
Duke University, Durham, North Carolina, United States
Abstract
INTRODUCTION: Goal-directed fluid therapy GDFT has been associated with
improved outcomes following moderate to major surgery1. The esophageal
Doppler monitor (EDM), is widely used as a minimally invasive cardiac output
(CO) monitor to guide fluid administration2. The National Institute for Health
and Clinical Excellence (NICE), a UK governmental body, recently recommended
the use of EDM in patients undergoing major or high-risk surgery or other surgical
patients in whom a clinician would consider using invasive cardiovascular
monitoring. However, it has several limitations3. The non-invasive cardiac
output monitor (NICOM-Cheetah Medical), a bioreactance-based CO assessment,
is a sensitive and specific method for assessing fluid responsiveness4. It is
non-invasive, tolerable in awake patients, and is potentially applicable in a wide
variety of patient populations. There are no prospective studies comparing
the NICOM and the EDM for GDFT. It is our hypothesis that the NICOM will
be equivalent to the EDM in assessing baseline stroke volume (SV) and fluid
response after colloid bolus. METHODS: Baseline SV and changes in SV after
colloid bolus were compared between NICOM and EDM. Patients whose SV
increased >10% after a colloid bolus were declared “fluid responsive” based
on an established GDFT algorithm5. Data on >20% increase in SV following a
fluid bolus was also collected. Baseline SV was compared using correlations,
and the proportion of patients who were “fluid responsive” at each time
point were compared using agreement statistics and McNemar’s test. P<0.05
was considered statistically significant. RESULTS: Data from 61 patients, with
234 fluid challenges, were available for analysis. There was a consistent and
significant correlation of baseline SV between monitors (Pearson Correlation
Coefficient 0.48138, p=0.0002). Information on agreement between monitors
is shown in Table1. Hemodynamic variables were not displayed by the NICOM
for 35/936 (3.74%) measurements and by the EDM for 73/676 (7.80%)
measurements due to a number of reasons. DISCUSSION: In this preliminary
analysis, there was a good correlation of baseline SV measurements between
monitors. Both monitors demonstrate about 50% of patients were “fluid
responsive” (10% increase in SV). Agreement on “fluid responsiveness”
between the two monitors was highest at 15 min. However, there were no
systematic differences in disagreement between the two monitors (McNemar’s
statistic 0.0123 to 2.5128, p>0.05 at all points). NICOM performs similarly
to the esophageal Doppler monitor and may be a viable alternative to guide
fluid administration.
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NICOM CASE STUDY
Differential Diagnosis and Volume Status Assessment
Wet vs Dry – Osteomyelitis/Acute Renal Failure
Magrieta Brandt RN, BSN, CCRN
Case Background
A 48-year-old female was admitted with osteomyelitis and cellulitis. Past history
remarkable only for morbid obesity with weight of 255 lb.
The patient was admitted to the ICU and received Vancomycin and fluids. Her
condition deteriorated, with progressive hemodynamic instability, oliguria and renal
failure with creatinine of 7.4.
In the face of hemodynamic instability and ARF the clinical team was unclear as to her
fluid status and was deliberating between two differential diagnosis:
A. Pre-renal azotemia. Volume expansion with IV fluids might be the right treatment
B. Acute renal failure. Volume reduction with CRRT or hemodialysis might be the
best choice.
Nephrology was consulted for dialysis. A NICOM test was requested.
A passive leg raise challenge indicated that the patient was highly fluid responsive
with a cardiac output increase of 34% following the fluid challenge. This indicated that
the patient was fluid responsive.
As a result, IV fluids were given. The patient responded very well to IV fluid alone, did
not require dialysis and began to produce urine. She later went home with a Creatinine
level of 0.8.
Starling curve
CO/CI
Approx. position implied by PLR challenge
10
SVI
Significant increase
in cardiac output
with PLR
8
6
09:08
09:05
09:01
08:58
08:54
08:51
08:47
2
08:44
4
9
Time
LVEDV*
*Left Ventricular End Diastolic Volume
NICOM CASE STUDY
Differential diagnosis of respiratory distress, drug selection
and titration: A case of acute decompensated heart failure (ADHF)
vs. chronic obstructive pulmonary disease (COPD)
Magrieta Brandt RN, BSN, CCRN
Case Background
A dyspneic patient with known COPD and CHF was evaluated with a differential diagnosis
of acute decompensated heart failure (ADHF) vs. pulmonary disease. Her Pulmonologist
felt it was heart failure exacerbation, while her Cardiologist felt it was due to the patient’s
pulmonary disease and stopped her diuretics. The patient was on 100% non-rebreather
with O2 saturation of 90-91%, at times diving below 90%. Urine output was low. A
NICOM test was ordered.
NICOM Test and Actions
NICOM supported a cardiac problem, showing poor cardiac function with CI 1.6-1.8,
SVI 28-30 and increased peripheral resistance (TPRI). Moreover, the passive leg raise
challenge (PLR) indicated that the patient cannot increase CI in response to fluids, or
in other words that she is in heart failure.
PLR Protocol
#
10
11
12
13
14
15
Starling curve
Start Time: 10:01:41AM Date: 1/25/2012
Stage
CO CI
3.4
Baseline
2
3.6 2.2
Baseline
3.5 2.1
Baseline
3.4
Challenge
2
3.4
Challenge
2
3.5 2.1
Challenge
Results [[%] -2.7% -2.7%
HR NIBP MAP TPR
69 129/66 87 2033
69
--/---69
--/---68 127/64 85 2002
69
--/---68
--/----1% -2%/-3% -2% -2%
Approx. position implied by PLR challenge
TPRI SV
3424 49.4
-- 52.6
-- 50.6
3370 49.7
-- 49.4
-51
-2% -1.6%
SVI
29.3
31.3
30
29.5
29.4
30.3
-1.6%
SVV
13.4%
14.5%
12.9%
13.2%
12.8%
11.8%
-7.1%
TFC
47.5
47.1
47.3
47.4
47.3
47.3
0.1%
SVI
LVEDV*
*Left Ventricular End Diastolic Volume
Actions: Low dose diuretics and inotropic support with dobutamine were started.
Dobutamine was not very effective possibly due to its peripheral vasoconstricting
effects. It increased the patient’s BP as well as her TPRI and did not improve her cardiac
index or urine output much. Therefore, dobutamine was stopped and Primacor, another
inotropic agent, which also acts as a potent afterload reducer (reduces TPRI) was
started. As a result, TPRI decreased and CI increased markedly (see figure below).
Patient Outcome
The patient’s urine output picked up, O2 saturation improved significantly and her
dyspnea was resolved. Intubation and possible code were avoided.
3
2.5
CI
Dobutamine 2.5
mcg/kg/min
Note:
Primacor 0.375
mcg/kg/min
•Primacor causes a significant increase in
Cardiac Index (from 1.6 to 2.4)
2
•There was a simultaneous decrease in
Total Peripheral Resistance (from 3880
to 2700)
1.5
1
11:55pm 12:15am 12:35am 12:57am 1:17am 1:39am
Time
2:00am
10
NORMAL HEMODYNAMIC PARAMETERS - ADULT
Parameter
Equation
Normal Range
Cardiac Output (CO)
HR x SV/1000
4.0-8.0 l/min
Cardiac Index (CI)
CO/BSA
2.5-4.0 l/min/m2
Stroke Volume (SV)
CO/HR x 1000
60-100 ml/beat
Stroke Volume Index (SVI)
SV/BSA
33-47 ml/m2/beat
Mean Arterial Pressure (MAP)
Directly from the oscillometric profile
70-105 mmHg
Total Peripheral Resistance (TPR)
80 x (MAP)/CO
800-1200 dynes . sec/cm5
Total Peripheral Resistance
Index (TPRI)
80 x MAP/CI
1970-2390 dynes . sec/cm5/m2
Stroke Volume Variation (SVV)*
*
During positive pressure mechanical
ventilation and normal sinus rhythm
SVmax-SVmin/[(SVmax+SVmin)/2] x 100
< 10% Unlikely to be preload
responsive
> 12% Likely to be preload
responsive
Cheetah Medical, Inc 600 SE Maritime Avenue Suite 220, Vancouver, WA 98661 USA
Tel: (+1) 360-828-8685 | Fax: (+1) 360-718-8154 | www.cheetah-medical.com
11
Cheetah Medical
Fluid Optimization Machines™
TM