01 tuong phan

Advances in haemodynamic monitoring in Anaesthesia and ICU

Dr Tuong PhanStaff Specialist Anaesthetist

Dept Anaesthesia and Pain MedicineSt Vincent’s Hospital Melbourne

the technologyBeyond standard monitoringKeys to understanding

Recommendations and summary

utilityAccuracyTrending ability

utilityClinical studies

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Method Proprietary device Invasive elements Parameters

Oesophageal Doppler

CardioQTM, Deltex Medical Oesoph. Doppler probe

CO, SV, Ftc

CardioQ PLUS OD plus arterial line

CO, SV

Transcutaneous Doppler

Ultrasound CO monitor, USCOMTM

Nil CO, SV

APCO uncalibrated

Vigileo/FloTracTM, Edwards Lifesciences (1)

Arterial line CO, SV, SVV

LiDCO Rapide, LiDCO Ltd Arterial line CO, SV, SVV, PPV

Finepress, Nexfin, Edwards Finger cuff CO, SV, SVV

Arterial Pressure CO calibrated

LiDCO Plus, LiDCO Ltd (2) Arterial line CO, SV, SVV, PPV

PiCCOplusTM, Pulsion Medical Systems

Central Venous catheter and femoral arterial line

CO, SV, ITBV, EVLW

Plethysmography Masimo Rainbow SET Pulse CO, Masimo Corp.

Pulse oximeter dPOPPVI

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Method Proprietary device Invasive elements Parameters

Oesophageal Doppler

CardioQTM, Deltex Medical Oesoph. Doppler probe

CO, SV, Ftc

CardioQ PLUS OD plus arterial line

CO, SV

Transcutaneous Doppler

Ultrasound CO monitor, USCOMTM

Nil CO, SV

APCO uncalibrated

Vigileo/FloTracTM, Edwards Lifesciences (1)

Arterial line CO, SV, SVV

LiDCO Rapide, LiDCO Ltd Arterial line CO, SV, SVV, PPV

Finepress, Nexfin, Edwards Finger cuff CO, SV, SVV

Arterial Pressure CO calibrated

LiDCO Plus, LiDCO Ltd (2) Arterial line CO, SV, SVV, PPV

PiCCOplusTM, Pulsion Medical Systems

Central Venous catheter and femoral arterial line

CO, SV, ITBV, EVLW

Plethysmography Masimo Rainbow SET Pulse CO, Masimo Corp.

Pulse oximeter dPOPPVI

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V = ∆f c .

2 ft cosθ

the technology

Oesophageal Doppler Monitor

Stroke Distance

SV = VTI x Area

SV = VTI/0.7 x est desc Aortic area

∆CO ∝ ∆VTI

Afterload Increase Afterload Reduction

Positive InotropyMyocardial Depression

Preload Reduction Preload Increase Predominant Change

Keys to

Oesophageal Doppler Monitor

• ∆CO ∝ ∆VTI– Good diagnostic and trend ability– Uncoupled from pressure entirely

• Continuously available• Learning curve

Method Proprietary device Invasive elements Parameters

Oesophageal Doppler

CardioQTM, Deltex Medical Oesoph. Doppler probe

CO, SV, Ftc

CardioQ PLUS OD plus arterial line

CO, SV

Transcutaneous Doppler

Ultrasound CO monitor, USCOMTM

Nil CO, SV

APCO uncalibrated

Vigileo/FloTracTM, Edwards Lifesciences (1)

Arterial line CO, SV, SVV

LiDCO Rapide, LiDCO Ltd Arterial line CO, SV, SVV, PPV

Finepress, Nexfin, Edwards Finger cuff CO, SV, SVV

Arterial Pressure CO calibrated

LiDCO Plus, LiDCO Ltd (2) Arterial line CO, SV, SVV, PPV

PiCCOplusTM, Pulsion Medical Systems

Central Venous catheter and femoral arterial line

CO, SV, ITBV, EVLW

Plethysmography Masimo Rainbow SET Pulse CO, Masimo Corp.

Pulse oximeter dPOPPVI

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CO-from-ABP

• MAP positively but imperfectly correlates with CO– Variable changes in SVR make

MAP unreliable– ABP waveform analysis

assumes other features are less affected by confounders such as Vascular resistance

• MAP is a control in Sun et al

CO-from-ABP

• All 8 methods superior to MAP as directional qualitative indicators of major changes in CO-Thermodilution

• Differ drastically in magnitude. Only one method was superior than MAP when comparing limits of agreement cf CO.

8 different algorithms8 different algorithms

Cardiac Index: 95% limits of agreement l/min

Liljestrand*** -1.76 1.41Corr Impedance -1.91 1.57Pulse Pressure -2.07 1.73Systolic Area -2.07 1.73Sys Area with Kouchoukos corr -2.08 1.71AC power RMS -2.09 1.73Diastolic decay -2.23 1.77MAP -2.20 1.82Herd -2.66 1.89

SPV

Respiratory coupled parameters

Inspiration- blood squeezed from lung- ↑LV preload ↑systemic BP

↑intrathoracic pressure ↓ RV preload ↓ RV stroke vol

Respiratory coupled parametersPerel, CCM 2009

SPV SVVPPV

© 2011 International Anesthesia Research Society . Published by International Anesthesia Research Society.2

Respiratory Variation in Pulse Pressure and Plethysmographic Waveforms: Intraoperative Applicability in a North American Academic Center.Maguire, Sinead; Rinehart, Joseph; Vakharia, Shermeen; Cannesson, Maxime; MD, PhD

Anesthesia & Analgesia. 112(1):94-96, January 2011.DOI: 10.1213/ANE.0b013e318200366b

Respiratory coupled parameters

the technologyPiCCO injection

t

T

P

t

Transpulmonary thermodilution calibrationPulse contour analysis

the keys

PiCCO

• Requires femoral arterial line• Requires central line• Calibrated• Provides additional

haemodynamic variables• Continuous CO

LiDCOplusTM

Proprietary algorithm - PulseCOTM

the technology

LiDCOrapidTM

Proprietary algorithm - PulseCOTM

Uncalibrated

Cardiac Index

SVV

PPV - Pulse Pressure Variation

the keys to

LiDCO Plus and Rapid

• Fick principle Lithium dilution calibration• Pulse power algorithm

– “Morphology independent”

• Arterial line required but utilises data cable from standard monitoring system. No specific transducer is needed

the technology

Vigeleo Flotrac

• Arterial pulsatility - sd of pressure wave

• K• sex, age, ht and wgt• Waveform characteristics

(skewness and kurtosis)

the technologyVigeleo Flotrac

• Graphic User Interface: • “Drive screen”

• Graphic User Interface: • “Trend screen”

• GUI– Additional

functionality– ScvO2– GEDI and ELWI

the technology

Vigeleo Flotrac

the keys to

Vigeleo Flotrac

• Equipment: arterial line• Flow sensor connected directly to arterial line• Accuracy has been dependent on software

upgrades/version.– Previously struggled with changes in compliance,

low SVR states– version 4 being released.

the technology

Nexfin, aka Finepress • Volume clamp with finger cuff• HRS: heart reference system

– measures and corrects pressure difference btw finger and heart•200Hz sampling rate

• Stroke Volume – 3 element Windkessel model• Up to 12% may have inadequate signal

Fischer M O et al. Br. J. Anaesth. 2012;109:514-521

© The Author [2012]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com

• Nexfin and arterial pressure– MAP

correlates well– SBP

underestimates

– CI has looser agreement

the technology

Finepress

Edwards EV1000

• EV1000– Flotrac– Nexfin– VolumeView– ScVO2

– PAC thermodilution

the technologyMasimo• Pulse oximetry• Plethysmographic

variability index (PVI)– It measures the dynamic

changes in perfusion index (PI) over respiratory cycles and calculated as follows:

– PVI = [(PImax – PImin)/PImax] x 100%.

• ∆POP• COHb• Continuous Hb

utilityAccuracy

• Peyton and Chong– Anesthesiology 2010

• Metaanalysis 4 CO monitor types

• Mean bias, precision, percentage error cf thermodilution

• All 40%• Limitation of BA is the

reference TD

limitations Accuracy

↘

TD vs OD TD vs FT TD vs Li

limitations Accuracy

Lorsomradee, JCVA 2009

Truly Not Fluid Responsive

Accuracy: “functional” vs static, receiver operating curves

Trul

y Fl

uid

Resp

onsi

ve

22%

12%

5%

utilityAccuracy• Marik et al, CCM 2009

Summative ROC area

PPV (n=19)0.94 (0.92-0.96)

SVV 0.84 (n=5) (0.81-0.87)

CVP 0.55GEDI 0.56

Limitations : comparison of SVV

• LiDCO SVV cf FT SVV• Large percentage

error• Different methods of

calculating SV• Not interchangeable

utilityClinical Application

Stroke volume based parameters

utilityClinical Application

Respiratory coupled parameters

Survey of tools for GDT

Oesoph dopplerClinical Application

↘

↘

Oesoph Doppler

(1) Use the Stroke Volume Index (SVI); average over 10 cycles(2) Hypotension can be absolute or relative(3) A large change in the SV, ie. >10%, represents the fluid responsiveness(4) A small change in the SV, ie <10% represents the plateau phase and represents an optimised preload(5) Once an optimised phase is reached, a fluid bolus should be given if the SVI falls >10% * The Doppler values will vary from measurement to measurement. However, a trend over several measurements will be more informative.

Arterial Pressure CO algorithm

“Optimal Fluid therapy”

Opt

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HypervolemiaHypovolemia

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Editorial “Wet, dry or something else?”

Bellamy, BJA 97 (6), Dec2006

my observations

• Mythen and Hamilton 1995 ICM

• Exanguinate 6 healthy volunteers– BP drops modestly– SV drops markedly

the technologyDoppler, APCO, Plethysmography

recommendations and summaryThey are just monitors. Outcomes will be dependent on how they

are utilised to make decisions

utility: Accuracy and Trending abilityKeep in mind the key parameters, their underlying assumptions and be critical. Nevertheless estimations of stroke volume, respiratory coupled parameters do represent a significant addition to standard monitoring eg. Arterial pressure, urine output, CVP

utility: Clinical studiesDevices can be used to target the delivery of fluids and inotropes

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