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Haemodynamic Monitoring. Theory and Practice. 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. - PowerPoint PPT Presentation

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  • Haemodynamic MonitoringTheory and Practice

  • PiCCO Technology is a combination of transpulmonary thermodilution and pulse contour analysisPrinciples of MeasurementLeft HeartRight HeartPulmonary CirculationLungsBody CirculationPULSIOCATHPULSIOCATHCVCPULSIOCATH arterial thermodilution cathetercentral venous bolus injectionIntroduction to the PiCCO-Technology Function

  • Bolus injectionconcentration changes over time(Thermodilution curve)After central venous injection the cold bolus sequentially passes through the various intrathoracic compartments The temperature change over time is registered by a sensor at the tip of the arterial catheter Introduction to the PiCCO-Technology FunctionLeft heartRight heartLungsPrinciples of Measurement

  • Intrathoracic Compartments (mixing chambers)Introduction to the PiCCO-Technology FunctionPulmonary Thermal Volume (PTV)Intrathoracic Thermal Volume (ITTV)Total of mixing chambersLargest single mixing chamber

  • Haemodynamic MonitoringE. Introduction to PiCCO TechnologyPrinciples of functionThermodilutionPulse contour analysisContractility parametersAfterload parametersExtravascular Lung WaterPulmonary Permeability

  • Tb x dt(Tb - Ti) x Vi x K TbInjectiontD=COTD a

    Tb = Blood temperatureTi = Injectate temperatureVi = Injectate volume Tb . dt = Area under the thermodilution curveK = Correction constant, made up of specific weight and specific heat of blood and injectateThe CO is calculated by analysis of the thermodilution curve using the modified Stewart-Hamilton algorithm Calculation of the Cardiac OutputIntroduction to the PiCCO-Technology Thermodilution

  • The area under the thermodilution curve is inversely proportional to the CO. 36,537510Thermodilution curvesNormal CO: 5.5l/minIntroduction to the PiCCO-Technology Thermodilution36,53736,537Timelow CO: 1.9l/minHigh CO: 19l/minTimeTimeTemperatureTemperatureTemperature

  • Transpulmonary vs. Pulmonary Artery ThermodilutionLeft heartRight HeartPulmonary CirculationLungsBody CirculationPULSIOCATH arterial thermo-dilution cathetercentral venous bolus injectionRARVPALALVAortaTranspulmonary TD (PiCCO)Pulmonary Artery TD (PAC)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

  • MTt: Mean Transit time the mean time required for the indicator to reach the detection pointDSt: Down Slope time the exponential downslope time of the thermodilution curveRecirculationte-1TbFrom the characteristics of the thermodilution curve it is possible to determine certain time parameters Extended analysis of the thermodilution curve Introduction to the PiCCO-Technology ThermodilutionInjectionIn TbMTtDStTb = blood temperature; lnTb = logarithmic blood temperature; t = time

  • Pulmonary Thermal VolumePTV = Dst x COBy using the time parameters from the thermodilution curve and the CO ITTV and PTV can be calculated Calculation of ITTV and PTVIntroduction to the PiCCO-Technology ThermodilutionRecirculationte-1TbInjectionIn TbIntrathoracic Thermal VolumeITTV = MTt x COMTtDSt

  • Pulmonary Thermal Volume (PTV)Intrathoracic Thermal Volume (ITTV)Calculation of ITTV and PTVEinfhrung in die PiCCO-Technologie ThermodilutionITTV = MTt x COPTV = Dst x CO

  • GEDV is the difference between intrathoracic and pulmonary thermal volumesGlobal End-diastolic Volume (GEDV)Volumetric preload parameters GEDVITTVGEDVPTVIntroduction to the PiCCO Technology Thermodilution

  • Volumetric preload parameters ITBVIntrathoracic Blood Volume (ITBV)GEDVITBVPBVIntroduction to the PiCCO Technology ThermodilutionITBV is the total of the Global End-Diastolic Volume and the blood volume in the pulmonary vessels (PBV)

  • ITBVTD (ml)ITBV = 1.25 * GEDV 28.4 [ml]GEDV vs. ITBV in 57 Intensive Care PatientsIntrathoracic Blood Volume (ITBV)Volumetric preload parameters ITBVIntroduction to the PiCCO-Technology ThermodilutionITBV is calculated from the GEDV by the PiCCO Technology GEDV (ml)Sakka et al, Intensive Care Med 26: 180-187, 2000

  • Intrathoracic Compartments (mixing chambers)Introduction to the PiCCO-Technology FunctionPulmonary Thermal Volume (PTV)Intrathoracic Thermal Volume (ITTV)Total of mixing chambersLargest single mixing chamber

  • ITTV

    ITBV

    = EVLWThe 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.Calculation of Extravascular Lung Water (EVLW)Introduction to the PiCCO Technology Extravascular Lung Water

  • Katzenelson et al,Crit Care Med 32 (7), 2004 Sakka et al, Intensive Care Med 26: 180-187, 2000GravimetryDye dilutionEVLW 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 methodsValidation of Extravascular Lung Watern = 209r = 0.96ELWI by gravimetryELWI by PiCCOR = 0,97P < 0,001Y = 1.03x + 2.49010203020304010ELWITD (ml/kg)051020152525501002015ELWIST (ml/kg)Introduction to the PiCCO Technology Extravascular Lung Water

  • Haemodynamic MonitoringE. Introduction to PiCCO TechnologyPrinciples of functionThermodilutionPulse contour analysisContractility parametersAfterload parametersExtravascular Lung WaterPulmonary Permeability

  • Transpulmonary ThermodilutionThe pulse contour analysis is calibrated through the transpulmonary thermodilution and is a beat to beat real time analysis of the arterial pressure curveCalibration of the Pulse Contour AnalysisIntroduction to the PiCCO-Technology Pulse contour analysisInjectionPulse Contour AnalysisT = blood temperature t = timeP = blood pressure COTPD= SVTDHR

  • PCCO = cal HR P(t)SVR+ C(p) dPdt()dtCardiac OutputHeart rateSystoleIntroduction to the PiCCO-Technology Pulse contour analysisParameters of Pulse Contour Analysis

  • SVmax SVminSVV =SVmeanThe Stroke Volume Variation is the variation in stroke volume over the ventilatory cycle, measured over the previous 30 second period.Parameters of Pulse Contour AnalysisIntroduction to the PiCCO-Technology Pulse Contour AnalysisDynamic parameters of volume responsiveness Stroke Volume Variation

  • PPmax PPminPPV =PPmeanThe pulse pressure variation is the variation in pulse pressure over the ventilatory cycle, measured over the previous 30 second period.Parameters of Pulse Contour AnalysisIntroduction to the PiCCO-Technology Pulse Contour AnalysisDynamic parameters of volume responsiveness Pulse Pressure VariationPPmaxPPmeanPPmin

  • Summary pulse contour analysis - CO and volume responsivenessThe 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 continuouslyIntroduction to the PiCCO-Technology Pulse contour analysis

    **PiCCO technology is a complete haemodynamic monitoring system based on the transpulmonary thermodilution technique. An indicator (cold) is injected into the circulation and the course of its concentration downstream is recorded.In the case of PiCCO technology, this means central venous injection of a cold bolus and detection of the temperature course in a peripheral large artery (femoral, axillary, brachial) through a special thermodilution catheter.The second component of PiCCO technology is pulse contour analysis, which is calibrated from the results of the thermodilution measurement and delivers continuous haemodynamic parameters in contrast to intermittent thermodilution.*This is a diagram of the pathway followed by the indicator following injection: following central venous injection, first through the right heart (atrium and ventricle), then through the lung, then through the left heart (atrium and ventricle) and the aorta as far as the detection site (location of the thermodilution catheter).

    The individual cardiac chambers and the lung with the extravascular lung water are thus mixing chambers in which the cold bolus is distributed.*The totality of all mixing chambers, that is, all four cardiac chambers, the pulmonary circulation and the extravascular lung water forms the total intrathoracic thermal volume. This designates the total intrathoracic distribution volume for cold.

    The largest single mixing chamber in this system is the pulmonary thermal volume, which consists of the blood volume of the pulmonary circulation and the extravascular lung water.

    **Various volume parameters can be calculated from the thermodilution curve, which is recorded via the thermodilution catheter (PiCCO catheter). One of the main parameters of thermodilution measurement is the cardiac output, which is calculated using the modified Stewart-Hamilton algorithm from the area under the thermodilution curve.

    The Stewart Hamilton algorithm is not specific for PiCCO but is already relatively old and well validated. It is also the basis, e.g., for measuring CO by means of pulmonary arterial thermodilution with the pulmonary artery catheter.*Important conclusions about the level of the CO can be drawn from the shape of the thermodilution curve.The area under the thermodilution curve is inversely proportional to the CO, i.e. when the CO is high, the area is small and vice versa.

    When the CO is high, the cold bolus arr

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