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Haemodynamic Monitoring Theory and Practice

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Haemodynamic Monitoring. Theory and Practice. Haemodynamic Monitoring. Physiological Background Monitoring Optimizing the Cardiac Output Measuring Preload Introduction to PiCCO Technology Practical Approach Fields of Application Limitations. Monitoring. Monitoring the Vital Parameters. - PowerPoint PPT Presentation

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Page 1: Haemodynamic Monitoring

Haemodynamic Monitoring

Theory and Practice

Page 2: Haemodynamic Monitoring

2

Haemodynamic Monitoring

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

Page 3: Haemodynamic Monitoring

3

Monitoring the Vital Parameters

Monitoring

Respiration Rate

Temperature

Page 4: Haemodynamic Monitoring

4

Monitoring the Vital Parameters

Monitoring

ECG

• Heart Rate

• Rhythm

Respiration Rate

Temperature

Page 5: Haemodynamic Monitoring

5

Monitoring the Vital Parameters

Monitoring

Blood Pressure (NiBP)

• no correlation with CO

• no correlation with oxygen deliveryECG

Respiration Rate

Temperature

Page 6: Haemodynamic Monitoring

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DO2 ml*m-2*min-1100 300 500 70030

60

90

120

150

MAP mmHg

n= 1232

Monitoring the Vital Parameters

Monitoring

MAP: Mean Arterial Pressure, DO2: Oxygen Delivery

The Mean Arterial Pressure does not correlate with Oxygen Delivery!

Reinhart K in: Lewis, Pfeiffer (eds): Practical Applications of Fiberoptics in Critical Care Monitoring, Springer Verlag Berlin - Heidelberg - NewYork 1990, pp 11-23

Page 7: Haemodynamic Monitoring

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Monitoring the Vital Parameters

Monitoring

Blood Pressure (NiBP)

• No correlation with CO

• No correlation with oxygen delivery

• No correlation with volume status

ECG

Respiration Rate

Temperature

Page 8: Haemodynamic Monitoring

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Monitoring the Vital Parameters

80% of blood volume is found in the venous blood vessels,

only 20% in the arterial blood vessels!

Monitoring

Page 9: Haemodynamic Monitoring

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Monitoring the Vital Parameters

Monitoring

Blood Pressure (NiBP)

ECG

Respiration Rate

Temperature • No correlation with CO

• No correlation with oxygen delivery

• No correlation with volume status

• No evidence of what is the ‘right’ perfusion pressure

Page 10: Haemodynamic Monitoring

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Standard Monitoring

Monitoring

Oxygen Saturation

NIBP

ECG

Respiration Rate

Temperature• No information re the O2 transport capacity

• No information re the O2 utilisation in the tissues

Page 11: Haemodynamic Monitoring

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Standard Monitoring

Monitoring

Respiration Rate

NIBP

ECG

Temperature

Urine Production

Oxygen Saturation

Blood Circulation(clinical assessment)

Page 12: Haemodynamic Monitoring

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What other parameters do I need?

Advanced Monitoring

Monitoring

The standard parameters do not give enough information in unstable patients.

Page 13: Haemodynamic Monitoring

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Advanced Monitoring

Monitoring

Invasive Blood Pressure (IBP)

• Continuous blood pressure recording• Arterial blood extraction possible• Limitations as with NiBP

Page 14: Haemodynamic Monitoring

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Advanced Monitoring

Monitoring

IBP Arterial BGA

Information re:

• Pulmonary Gas exchange

• Acid Base Balance

No information re oxygen supply at the cellular level

Page 15: Haemodynamic Monitoring

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Advanced Monitoring

Monitoring

IBP Lactate

Marker for global metabolic situation

Significant limitations due to:

• Liver metabolism

• Reperfusion effects

Arterial BGA

Page 16: Haemodynamic Monitoring

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Advanced Monitoring

Monitoring

IBP CVP

Arterial BGA

Lactate

• central venous blood gas analysis possible

• When low: hypovolaemia probable

• When high: hypovolaemia not excluded

• Not a reliable parameter for volume status

Page 17: Haemodynamic Monitoring

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Advanced Monitoring

Monitoring

IBP ScvO2

• Good correlation with SvO2 (oxygen consumption)

• Surrogate parameter for oxygen extraction

• Information on the oxygen consumption situation

• When compared to SvO2 less invasive (no pulmonary artery catheter required)

Arterial BGA

Lactate

CVP

Page 18: Haemodynamic Monitoring

Reinhart K et al: Intensive Care Med 60, 1572-1578, 2004; Ladakis C et al: Respiration 68, 279-285, 2000

Monitoring

n = 29r = 0.866ScvO2 = 0.616 x SvO2 + 35.35

ScvO2

SvO2

r = 0.945

30

50

70

90

70 9050

SvO2 (%)

65

70

85

70 90

90

30 6040 80

80

ScvO2 (%)

40

60

80

806040

75

6050

Monitoring of the central venous oxygen saturation

The ScvO2 correlates well with the SvO2!

Page 19: Haemodynamic Monitoring

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avDO2 ml/dl

Monitoring

Monitoring of the central venous oxygen saturation

30 40 50 60 70 80 90 100

7.0

6.0

7.0

4.0

3.0

2.0

1.0

0

r= -0.664

n= 1191

avDO2= 12.7 -0.12*ScvO2

ScvO2 %

A low ScvO2 is a marker for increased global oxygen extraction!

avDO2: arterial-venous oxygen content difference, ScvO2: central venous oxygen saturation

Reinhart K in: Lewis, Pfeiffer (eds): Practical Applications of Fiberoptics in Critical Care Monitoring, Springer Verlag Berlin - Heidelberg - NewYork 1990, pp 11-23

Page 20: Haemodynamic Monitoring

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Monitoring

Monitoring of the central venous oxygen saturation

avDO2 ml/dl

7.0

6.0

7.0

4.0

3.0

2.0

1.0

r= -0.664

n= 1191

avDO2= 12,7 -0.12*ScvO2

Consumption VO2: VO2 = CO x Hb x 1.34 x (SaO2 -  S(c)vO2)

Delivery DO2: DO2 = CO x Hb x 1.34 x SaO2

CO

Hb

Mixed / Central Venous Saturation S(c)vO2

SaO2

avDO2: arterial-venous oxygen content difference, ScvO2: central venous oxygen saturation 30 40 50 60 70 80 90 100

0 ScvO2 %

Reinhart K in: Lewis, Pfeiffer (eds): Practical Applications of Fiberoptics in Critical Care Monitoring, Springer Verlag Berlin - Heidelberg - NewYork 1990, pp 11-23

Page 21: Haemodynamic Monitoring

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Early goal-directed therapyRivers E et al. New Engl J Med 2001;345:1368-77

O2- Therapy and SedationIntubation + Ventilation

Central Venous CatheterInvasive Blood Pressure Monitoring

CVP

MAP

ScVO2

Cardiovascular Stabilisation

Volume therapy

8-12 mmHg

< 8 mmHg

65 mmHg

Inotropes

>70%70%

< 70%

no Therapy maintenance,regular reviews

< 65 mmHgVasopressors

Blood transfusion to Haematocrit 30%

Monitoring

Monitoring of the central venous oxygen saturation

< 70%

Goal achieved?yes

ScVO2

Hospital 60 days

Mo

rtal

ity

Page 22: Haemodynamic Monitoring

Monitoring

Monitoring of the ScvO2 – Clinical Relevance

Significance of the ScvO2 for therapy guidance

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Page 23: Haemodynamic Monitoring

Monitoring of the ScvO2 – Clinical Relevance

Monitoring

Early monitoring of ScvO2 is crucial for fast and effective

hemodynamic management!

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Page 24: Haemodynamic Monitoring

Monitoring ScvO2 – therapeutic consequences in the example of sepsis

Pt unstable

ScvO2 < 70%

Volume bolus

(when absence of contraindications)

ScvO2 > 70% or < 80%

Re - evaluation

Continuous ScvO2 monitoring – CeVOX

Advanced Monitoring - PiCCO

Volume / Catecholamine

Erythrocytes

Monitoring

ScvO2 < 70%

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Page 25: Haemodynamic Monitoring

Tissue hypoxia despite ”normal“ or high ScvO2?

?Microcirculation disturbances

in SIRS / Sepsis

Monitoring ScvO2 – Limitations

Monitoring

25

SxO2 in %

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

Page 26: Haemodynamic Monitoring

Monitoring ScvO2 – therapeutic consequences in the example of sepsis

ScvO2

Pt unstable ScvO2 < 70%

Re- evaluation

Monitoring

ScvO2 > 80%

Tissue hypoxia despite „normal“ or high ScvO2?

?

Volume administration (when absence of

contraindications)

ScvO2 > 70% but < 80% ScvO2 < 70%

Advanced Monitoring

cont. ScvO2 monitoring

Volume / Catecholamine / Erythrocytes

Page 27: Haemodynamic Monitoring

Pt unstable

ScvO2 > 80%

ScvO2 < 80% but > 70%

Re-evaluation

Monitoring

ScvO2 > 80%

Tissue hypoxia despite ”normal“ or high ScvO2?

Microcirculation?

Organ perfusion?

Further information neededMacro-haemodynamics (PiCCO)

Liver function (PDR – ICG)Renal function

Neurological assessment

Volume bolus

(when absence of contraindications)

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Monitoring ScvO2 – therapeutic consequences in the example of sepsis

Page 28: Haemodynamic Monitoring

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

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