haemodynamic monitoring

Haemodynamic Monitoring

Theory and Practice

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

3

Task of the circulatory system

Pflüger 1872: ”The cardio-respiratory system fulfils the physiological task of ensuring cellular oxygen supply”

Physiological Background

Uni Bonn

Goal Reached?Assessment of oxygen supply and demand

OK

No

Yes

What is the problem?

Diagnosis Therapy

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4


Processes contributing to cellular oxygen supply

Aim: Optimal Tissue Oxygenation

Pulmonary gas exchange Macrocirculation Microcirculation Cell function

Direct Control Indirect

Oxygen AbsorptionLungs

Oxygen TransportationBlood

Oxygen DeliveryTissues

Oxygen Utilisation Cells / Mitochondria

Volume Catecholamines

Oxygen carriers Ventilation

5

Organ specific differences in oxygen extraction

Physiological Backgound

Oxygen delivery must always be greater than consumption!

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

6


Dependency of Oxygen Demand on delivery

Behaviour of oxygen consumption and the oxygen extraction rate with decreasing oxygen supply

Oxygen consumption

DO2-independent area DO2- dependent area

Oxygen extraction rate

Decreasing Oxygen SupplyDO2: Oxygen Delivery

7

Central role of the mixed venous oxygen saturation


Determinants of Oxygen Delivery and Consumption

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

CO: Cardiac OutputHb: HaemoglobinSaO2: Arterial Oxygen SaturationSvO2: Mixed Venous Oxygen SaturationDO2: Oxygen DeliveryVO2: Oxygen Consumption

SaO2CO

Hb

8

Central role of mixed central venous oxygen saturation


Determinants of Oxygen Delivery and Consumption

SaO2

S(c)vO2

Consumption VO2: VO2 = CO x Hb x 1.34 x (SaO2 - SvO2)Delivery DO2: DO2 = CO x Hb x 1.34 x SaO2

CO

Hb

Mixed Venous Saturation SvO2

SvO2

CO: Cardiac OutputHb: HaemoglobinSaO2: Arterial Oxygen SaturationSvO2: Mixed Venous Oxygen SaturationDO2: Oxygen DeliveryVO2: Oxygen Consumption

9

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

10




Ventilation

• Transfusion• Ventilation

CO: Cardiac Output

Hb: Haemoglobin



11




VolumeCatecholamines

• Transfusion• Ventilation• Volume• Catecholamines

CO: Cardiac Output

Hb: Haemoglobin



12

Assessment of Oxygen Delivery


CO: Cardiac Output; Hb: Hemoglobin; SaO2: Arterial Oxygen Saturation

CO, HbSaO2

DO2 = CO x Hb x 1.34 x SaO2


Oxygen TransportBlood


Oxygen UtilizationCells / Mitochondria

Supply

13



CO, HbSaO2

Monitoring the CO, SaO2 and Hb is essential!





CO: Cardiac Output; Hb: Haemoglobin; SaO2: Arterial Oxygen Saturation

Supply

14



SvO2

SaO2 CO, HbMonitoring the CO, SaO2 and Hb is essential!

VO2 = CO x Hb x 1.34 x (SaO2 – SvO2)






Supply

Consumption

15



SvO2

SaO2 CO, Hb

Monitoring CO, SaO2 and Hb is essential

Monitoring the CO, SaO2 and Hb does not give information re O2-consumption!






Supply

Consumption

16

Situational Factors

Balance of Oxygen Delivery and Consumption

The adequacy of CO and SvO2 is affected by many factors

Microcirculation Disturbances

Volume status Tissue Oxygen Supply

Oxygenation / Hb level

Older Age

Body weight /heightCurrent Medical HistoryPrevious Medical History


General Factors

17


Extended Haemodynamic Monitoring

TherapyOptimisationO2 supplyO2 consumption

Monitoring

18

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.

19



B. Monitoring

C. Optimizing the Cardiac Output





H. Limitations

20

Monitoring the Vital Parameters

Monitoring

Respiration Rate

Temperature

21


Monitoring

ECG

• Heart Rate

• Rhythm

Respiration Rate

Temperature

22


Monitoring

Blood Pressure (NiBP)

• no correlation with CO

• no correlation with oxygen deliveryECG

Respiration Rate

Temperature

23

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

60

90

120

150

MAP mmHg

n= 1232


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

24


Monitoring


• No correlation with CO

• No correlation with oxygen delivery

• No correlation with volume status

ECG

Respiration Rate

Temperature

25


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

only 20% in the arterial blood vessels!

Monitoring

26


Monitoring


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

27

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

28

Standard Monitoring

Monitoring

Respiration Rate

NIBP

ECG

Temperature

Urine Production

Oxygen Saturation

Blood Circulation(clinical assessment)

29

What other parameters do I need?

Advanced Monitoring

Monitoring

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

30

Advanced Monitoring

Monitoring

Invasive Blood Pressure (IBP)

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

31

Advanced Monitoring

Monitoring

IBP Arterial BGAInformation re:

• Pulmonary Gas exchange

• Acid Base Balance

No information re oxygen supply at the cellular level

32

Advanced Monitoring

Monitoring

IBP Lactate

Marker for global metabolic situation

Significant limitations due to:

• Liver metabolism

• Reperfusion effects

Arterial BGA

33

Advanced Monitoring

Monitoring

IBP CVPArterial BGA

Lactate

• central venous blood gas analysis possible

• When low: hypovolaemia probable

• When high: hypovolaemia not excluded

• Not a reliable parameter for volume status

34

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

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!

36

avDO2 ml/dl

Monitoring


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


37

Monitoring


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 %


38

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


< 70%

Goal achieved?yes

ScVO2

Hospital 60 days

Mor

talit

y

Monitoring

Monitoring of the ScvO2 – Clinical Relevance

Significance of the ScvO2 for therapy guidance

39

Monitoring of the ScvO2 – Clinical Relevance

Monitoring

Early monitoring of ScvO2 is crucial for fast and effective

hemodynamic management!

40

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%

41

Tissue hypoxia despite ”normal“ or high ScvO2?

?Microcirculation disturbances in SIRS / Sepsis

Monitoring ScvO2 – Limitations

Monitoring

42

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


ScvO2

Pt unstable ScvO2 < 70%

Re- evaluation

Monitoring

ScvO2 > 80%

Tissue hypoxia despite „normal“ or high ScvO2?

?Volume administration


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

Advanced Monitoring

cont. ScvO2 monitoring

Volume / Catecholamine / Erythrocytes

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


44


Monitoring


• 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

46



B. Monitoring






H. Limitations

The haemodynamic instability is identified.

What can be done for the patient (sepsis example)?

1. Step: Volume Management Aim?

Monitoring – what is the point?

Optimisation of CO

Recommendation of the SSC

How can you optimise CO?

Optimisation of CO

47

Optimisation of CO

Preload Contractility Afterload Chronotropy

Frank-Starling mechanism

Monitoring – what is the point?

Optimisation of CO

48

SV

Preload

V

V

V

SV

SVSV

Normal contractility

Preload, CO and Frank-Starling Mechanism

Optimisation of CO

target areavolume responsive volume overloaded

49

V

V

SV

SV

SV

Preload

Poor contractility

Normal contractility


50


Optimisation of CO

V

V

SV

SV

SV

Preload


Optimisation of CO

High contractility

Normal Contractility


Poor contractility

51

V

V

V

SV

SVSV


In order to optimise the CO you must know what the preload is!

Optimisation of CO


52

Preload

SV


Optimisation of CO

• 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

54



B. Monitoring






H. Limitations

Preload

Filling Pressures

CVP / PCWP

Volumetric Preload Parameters, Volume Responsiveness and Filling Pressures

Measuring Preload

Volume Responsiveness

SVV / PPV

Volumetric

Preload parameters

GEDV / ITBV

55

Kumar et al., Crit Care Med 2004;32: 691-699

56

Role of the filling pressures CVP / PCWP

Correlation between Central Venous Pressure CVP and Stroke Volume

Measuring Preload

Kumar et al., Crit Care Med 2004;32: 691-699

57

Correlation between Pulmonary Capillary Wedge Pressure PCWP and Stroke Volume

Measuring Preload


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


Measuring Preload

58

Role of the volumetric preload parameters GEDV / ITBV

Measuring Preload

Preload

Filling Pressures

CVP / PCWP


SVV / PPV

Volumetric Preload parameters

GEDV / ITBV

59

Total volume of blood in all 4 heart chambers

Left heartRight Heart

Measuring Preload

Pulmonary Circulation

Lungs

Body Circulation

GEDV = Global Enddiastolic Volume

60


Measuring Preload

GEDV shows good correlation with the stroke volume

Michard et al., Chest 2003;124(5):1900-1908

61


ITBV = Intrathoracic Blood Volume

Total volume of blood in all 4 heart chambers plus the pulmonary blood volume

Left heartRight heart

Measuring Preload

Pulmonary Circulation

Lungs

Body Circulation

ITBV =GEDV + PBV

62


Sakka et al, Intensive Care Med 2000; 26: 180-187

Measuring Preload

63

ITBVTD (ml)

ITBV = 1.25 * GEDV – 28.4 [ml]

GEDV vs. ITBV in 57 Intensive Care Patients

0

1000

2000

3000

0 1000 2000 3000 GEDV (ml)

ITBV is normally 1.25 times the GEDV


The static volumetric preload parameters GEDV and ITBV

Measuring Preload

• 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


SVV / PPV

Volumetric Preload parameters

GEDV / ITBV

65

Intrathoracic pressure

Venous return to left and right ventricle

Left ventricular preload

Left ventricular stroke volume

Systolic arterial blood pressure

Intrathoracic pressure

„Squeezing “ of the pulmonary blood

Left ventricular preload

Left ventricular stoke volume

Systolic arterial blood pressure

PPPPmaxmax PPPPminmin

PPPPmaxmax

PPPPminmin

Inspiration

Reuter et al., Anästhesist 2003;52: 1005-1013

Measuring Preload

Physiology of the dynamic parameters of volume responsiveness

Expiration Inspiration Expiration

Early Inspiration Late Inspiration

66

Fluctuations in blood pressure during the respiration cycle

SV

PreloadV

SV

V

SV

Mechanical Ventilation

Measuring Preload

Fluctuations in stroke volume

Intrathoracic pressure fluctuationsChanges in intrathoracic blood volume

Preload changes

67

Fluctuations in stroke volume throughout the respiratory cycle

Physiology of the dynamic parameters of volume responsiveness

SVSVmaxmax

SVSVminmin

SVSVmeanmean

Measuring Preload

SVV = Stroke Volume Variation

• 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


Sensitivity

- - - CVP___ SVV

SVV is more accurate for predicting volume responsiveness than CVP

Measuring Preload

Berkenstadt et al, Anesth Analg 92: 984-989, 2001

Specificity 1 0,5 00

0,2

0,4

0,6

0,8

1

69


Measuring Preload

PPV = Pulse Pressure Variation

• The variation in pulse pressure amplitude over the respiration cycle • Correlates equally well as SVV for volume responsiveness

PPPPmaxmax

PPPPmeanmean

PPPPminmin

70


Measuring Preload

A PPV threshold of 13% differentiates between responders and non-responders to volume administration

Michard et al, Am J Respir Crit Care Med 162, 2000

71

Respondersn = 16

Non – Respondersn = 24


respiratory changes in arterial pulse pressure (%)

The dynamic volume responsiveness parameters SVV and PPV

Measuring Preload

- 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


Extravascular water content of the lung

Pulmonary circulation

Left Heart

Right Heart

Lungs

Role of extravascular lung water EVLW

Extra

EVLW = Extravascular Lung Water

Body circulation

73

Role of extravascular lung water EVLW

Extra

- 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

The Extravascular Lung Water EVLW

74

• 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).

Measuring Preload

75


76



B. Monitoring






H. Limitations


1. Principles of function

2. Thermodilution

3. Pulse contour analysis

4. Contractility parameters

5. Afterload parameters

6. Extravascular lung water

7. Pulmonary permeability


PiCCO Technology

Parameters for guiding volume therapy

Introduction to the PiCCO-Technology

CO

Volumetric preload

EVLW

Contractility

Differentiated Volume Management

- static - dynamic

PiCCO Technology is a combination of transpulmonary thermodilution and pulse contour analysis

Principles of Measurement

Left HeartRight Heart

Pulmonary CirculationLungs

Body CirculationPULSIOCATHPULSIOCATH

CVC

PULSIOCATH arterial thermodilution catheter

central venous bolus injection

Introduction to the PiCCO-Technology – Function

Bolus injection

concentration 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


Left heartRight heart Lungs

RA RV LA LVPBV

EVLW

EVLW

Principles of Measurement

Intrathoracic Compartments (mixing chambers)


Pulmonary Thermal Volume (PTV)

Intrathoracic Thermal Volume (ITTV)

Total of mixing chambers

RA RV LA LVPBV

EVLW

EVLW

Largest single mixing chamber




2. Thermodilution




6. Extravascular Lung Water

7. Pulmonary Permeability

Tb x dt(Tb - Ti) x Vi

x K

Tb

Injection

t

∫ =COTD a

Tb = Blood temperatureTi = Injectate temperatureVi = Injectate volume∫ ∆ Tb

. dt = Area under the thermodilution curve

K = Correction constant, made up of specific weight and specific heat of blood and injectate

The CO is calculated by analysis of the thermodilution curve using the modified Stewart-Hamilton algorithm

Calculation of the Cardiac Output

Introduction to the PiCCO-Technology – Thermodilution

The area under the thermodilution curve is inversely proportional to the CO.

36,5

37

5 10

Thermodilution curves

Normal CO: 5.5l/min


36,5

37

36,5

37

Time

low CO: 1.9l/min

High CO: 19l/min

Time

Time

Temperature

Temperature

Temperature

Transpulmonary vs. Pulmonary Artery Thermodilution

Left heartRight Heart

Pulmonary Circulation Lungs

Body Circulation

PULSIOCATH arterial thermo-dilution catheter

central venous bolus injection RA

RV

PA

LA

LV

Aorta

Transpulmonary 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

Comparison with the Fick Method

0,970,68 ± 0,6237/449Sakka SG et al., Intensive Care Med 25, 1999

- / - 0,19 ± 0,219/27McLuckie A. et a., Acta Paediatr 85, 1996

0,960,16 ± 0,3130/150Gödje O et al., Chest 113 (4), 1998

0.980,32 ± 0,2923/218Holm C et al., Burns 27, 2001

0,930,13 ± 0,5260/180Della Rocca G et al., Eur J Anaest 14, 2002

0,95-0,04 ± 0,4117/102Friedman Z et al., Eur J Anaest, 2002

0,950,49 ± 0,4545/283Bindels AJGH et al., Crit Care 4, 2000

0,980,03 ± 0,1718/54Pauli C. et al., Intensive Care Med 28, 2002

24/120

n (Pts / Measurements)

0,990,03 ± 0,24Tibby S. et al., Intensive Care Med 23, 1997

r bias ±SD(l/min)

Comparison with Pulmonary Artery Thermodilution

Validation of the Transpulmonary Thermodilution


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

Recirculation

t

e-1

Tb

From the characteristics of the thermodilution curve it is possible to determine certain time parameters

Extended analysis of the thermodilution curve


Injection

In Tb

MTt DSt

Tb = blood temperature; lnTb = logarithmic blood temperature; t = time

Pulmonary Thermal Volume

PTV = Dst x CO

By using the time parameters from the thermodilution curve and the CO ITTV and PTV can be calculated

Calculation of ITTV and PTV


Recirculation

t

e-1

Tb

Injection

In Tb

Intrathoracic Thermal Volume

ITTV = MTt x CO

MTt DSt

Pulmonary Thermal Volume (PTV)

Intrathoracic Thermal Volume (ITTV)

Calculation of ITTV and PTV

Einführung in die PiCCO-Technologie – Thermodilution

ITTV = MTt x CO

PTV = Dst x CO

RA RV LA LVPBV

EVLW

EVLW

GEDV is the difference between intrathoracic and pulmonary thermal volumes

Global End-diastolic Volume (GEDV)

Volumetric preload parameters – GEDV

RA RV LA LVPBV

EVLW

EVLW

ITTV

GEDV

PTV


Volumetric preload parameters – ITBV

Intrathoracic Blood Volume (ITBV)

GEDV

ITBV

PBVRA RV LA LVPBV

EVLW

EVLW


ITBV 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 Patients

IIntrantratthoracic horacic BBlood lood VVolume (olume (ITBVITBV))

Volumetric preload parameters – ITBV


ITBV is calculated from the GEDV by the PiCCO Technology

0

1000

2000

3000

0 1000 2000 3000 GEDV (ml)

Sakka et al, Intensive Care Med 26: 180-187, 2000

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.

Introduction to the PiCCO-Technology




2. Thermodilution






Transpulmonary Thermodilution

The pulse contour analysis is calibrated through the transpulmonary thermodilution and is a beat to beat real time analysis of the arterial pressure curve

Calibration of the Pulse Contour Analysis

Introduction to the PiCCO-Technology – Pulse contour analysis

Injection

Pulse Contour Analysis

T = blood temperature t = timeP = blood pressure

COCOTPDTPD= SV= SVTDTD

HRHR

PCCO = cal • HR •P(t)SVR + C(p) • dP

dt( ) dt

Cardiac Output

Patient- specific calibration factor (determined by thermodilution)

Heart rate Area under the pressure curve

Shape of the pressure curve

Aortic compliance

Systole


Parameters of Pulse Contour Analysis

n (Pts / Measurements)

0,940,03 ± 0,6312 / 36Buhre W et al., J Cardiothorac Vasc Anesth 13 (4), 1999

19 / 76

24 / 517

62 / 186

20 / 360

25 / 380

22 / 96 - / --0,40 ± 1,3Mielck et al., J Cardiothorac Vasc Anesth 17 (2), 2003

0,880,31 ± 1,25Zöllner C et al., J Cardiothorac Vasc Anesth 14 (2), 2000

0,88-0,2 ± 1,15Gödje O et al., Crit Care Med 30 (1), 2002

0,94-0,02 ± 0,74Della Rocca G et al., Br J Anaesth 88 (3), 2002

0,93-0,14 ± 0,33Felbinger TW et al., J Clin Anesth 46, 2002

- / - 0,14 ± 0,58Rauch H et al., Acta Anaesth Scand 46, 2002

r

bias ±SD (l/min)

Comparison with pulmonary artery thermodilution

Validation of Pulse Contour Analysis


SVSVmaxmax – SV – SVminminSVV =SVV =

SVSVmeanmean

SVSVmaxmax

SVSVminmin

SVSVmeanmean

The Stroke Volume Variation is the variation in stroke volume over the ventilatory cycle, measured over the previous 30 second period.


Introduction to the PiCCO-Technology – Pulse Contour Analysis

Dynamic parameters of volume responsiveness – Stroke Volume Variation

PPPPmaxmax – PP – PPminminPPV =PPV =

PPPPmeanmean

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

Dynamic parameters of volume responsiveness – Pulse Pressure Variation

PPPPmaxmax

PPPPmeanmean

PPPPminmin

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





2. Thermodilution






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)

Contractility

Introduction to the PiCCO-Technology – Contractility parameters

kg

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.

Contractility parameter from the pulse contour analysis


femoral dP/max [mmHg/s]

LV dP/dtmax [mmHg/s]

dPmx was shown to correlate well with direct measurement of velocity of left ventricular pressure increase in 70 cardiac surgery patients

de Hert et al., JCardioThor&VascAnes 2006

n = 220y = -120 + (0,8* x)r = 0,82p < 0,001

0

500

1000

1500

0 1000 1500

2000

2000500

dPmx = maximum velocity of pressure increase

• is calculated as 4 times the stroke volume divided by the global end-diastolic volume

• reflects both left and right ventricular contractility

GEF = Global Ejection Fraction

Contractility parameters from the thermodilution measurement


4 x SVGEF =GEDV

LA

LVRA

RV

Combes et al, Intensive Care Med 30, 2004

GEF = Global Ejection Fraction

Comparison of the GEF with the gold standard TEE measured contractility in patients without right heart failure

sensitivity

0

0,4

0,6

0,8

0

1

0,2

0,2

0,4 0,6 0,81 specifity

22

20

19

18

16

12 8

FAC, %

GEF, %

5

10

-5

-20 -10 10 20

15

-15

-10

r=076, p<0,0001n=47



• is the CI divided by global end-diastolic volume index

• is - similar to the GEF – a parameter of both left and right ventricular contractility

CFI = Cardiac Function Index

CICFI =

GEDVI



Combes et al, Intensive Care Med 30, 2004

sensitivity

0

0,4

0,6

0,8

0

1

0,2

0,2

0,4 0,6 0,81 specificity

6

5

43,5

3 2

FAC, %

GEF, %

5

10

-5

-20 -10 10 20

15

-15

-10

r=079, p<0,0001n=47

CFI = Cardiac Function Index


CFI was compared to the gold standard TEE measured contractility in patients without right heart failure



E. Introduction to PiCCO technology

1. Functions

2. Thermodilution






• 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 – CVP) x 80SVR =

CO

Afterload parameter

SVR = Systemic Vascular Resistance

MAP = Mean Arterial PressureCVP = Central Venous PressureCO = Cardiac Output80 = Factor for correction of units

Introduction to the PiCCO –Technology – Afterload parameter

• 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


Introduction to the PiCCO –Technology – Contractility and Afterload




2. Thermodilution






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.

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, 2000

Gravimetry Dye dilution

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

Validation of Extravascular Lung Water

n = 209r = 0.96

ELWI by gravimetry

ELWI by PiCCO

R = 0,97P < 0,001

Y = 1.03x + 2.49

0

10

20

30

20 30

40

10

ELWITD (ml/kg)

0

5

10

20

15 25

25

50 100 20

15

ELWIST (ml/kg)


Boeck J, J Surg Res 1990; 254-265

High extravascular lung water is not reliably identified by blood gas analysis

EVLW as a quantifier of lung edema

PaO2 /FiO2

10

20

550

30

150 2500 450

ELWI (ml/kg)

050 350


ELWI = 7 ml/kg

ELWI = 8 ml/kgELWI = 14 ml/kg

ELWI = 19 ml/kg

Extravascular lung water index

(ELWI) normal range:

3 – 7 ml/kg

Pulmonary oedem

a Normal rangeEVLW as a quantifier of lung oedema


40

Halperin et al, 1985, Chest 88: 649

Chest x ray – does not reliably quantify pulmonary oedema and is difficult to judge, particularly in critically ill patients

r = 0.1p > 0.05

0

20

80

15-10-15 10

60

radiographic score

-80

-60

-40

-20 ELWI

EVLW as a quantifier of lung oedema


ELWI (ml/kg)

> 21 n = 54

14 - 21 n = 100

7 - 14 n = 174

< 7 n = 45

Mortality(%)

10

00

n = 373*p = 0.002

20

30

40

50

60

70

80

Sturm J in: Lewis, Pfeiffer (eds): Practical Applications of Fiberoptics in Critical Care Monitoring, Springer Verlag Berlin - Heidelberg - NewYork 1990, pp 129-139

Relevance of EVLW Assessment

The amount of extravascular lung water is a predictor for mortality in the intensive care patient

ELWI (ml/kg) 4 - 6

30

0

Mortality (%)

20

n = 81

40

50

60

70

80

6 - 8 8 - 10 10 - 12 12 - 16 16 - 20 > 20

90

100

Sakka et al , Chest 2002


Intensive Care days

Mitchell et al, Am Rev Resp Dis 145: 990-998, 1992

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

PAC Group

n = 101* p ≤ 0,05

PAC GroupEVLW Group EVLW Group22 days 15 days9 days 7 days

* p ≤ 0,05





2. Thermodilution






Differentiating Lung Oedema

PVPI = Pulmonary Vascular Permeability Index

• 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)

EVLWPVPI =

PBVPBV

EVLW

Introduction to PiCCO Technology – Pulmonary Permeability

permeability

PVPI normal (1-3) PVPI raised (>3)

Classification of Lung Oedema with the PVPI

Difference between the PVPI with hydrostatic and permeability lung oedema:

Lung oedema

hydrostatic

PBV

EVLW

PBV

EVLW

PBV

EVLW

PBV

EVLW


16 patients with congestive heart failure and acquired pneumonia. In both groups EVLW was 16 ml/kg.

Validation of the PVPI

PVPI can differentiate between a pneumonia caused and a cardiac failure caused lung oedema.

Benedikz et al ESICM 2003, Abstract 60

Cardiac insufficiency

PVPI

Pneumonia

4

3

2


EVLWI answers the question:

Clinical Relevance of the Pulmonary Vascular Permeability Index

PVPI answers the question:

and can therefore give valuable aid for therapy guidance!

How much water is in the lungs?

Why is it there?



• 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

Introduction to PiCCO Technology – EVLW and Pulmonary Permeability

126



B. Monitoring






H. Limitations

PiCCO monitoring uses vascular accesses that are already existing or required anyway.

PiCCO Technology Set-Up

Practical Approach

Central venous catheter

PULSIOCATHArterial thermodilution catheter (femoral, axillary, brachial)

Injectate temperature sensor housing

Patient with secondary myeloid leukemia due to non-Hodgkin’s lymphomaCurrently: aplasia as a result of ongoing chemotherapy.Transfer from the oncology ward to intensive care unit due to development of septic status

Clinical Case

Practical Approach

Status on transfer to the Intensive Care Unit

Initial Therapy Given 6500 ml crystalloids and 4 PBC

Hemodynamic BP 90/50mmHg, HR 150bpm SR, CVP 11mmHgRespiration SaO2 99% on 2L O2 via nasal prongsAbdomen Severe diarrhoea, probably associated with chemotherapyRenal Retention values already increasing, cumulative 24h diuresis 400mlLaboratory Hb 6.7g/dl, Leuco <0.2/nl, Thrombo 25/nl

High fluid loss because of severe diaphoresis

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

Ongoing Development

Practical Approach

Clinical Case

Therapeutic Problems and Issues

Practical Approach

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 ventilator-

associated pneumonia (VAP) because of immunosuppression

Renal • impending anuric renal failure

Clinical Case

Volume Administration Respiration

Haemodynamics

Renal

?

Practical Approach

Therapeutic Problems and Questions

Volume Restriction Respiration

Haemodynamics

Renal

Clinical Case

Practical Approach

Application of the PiCCO system

- continuation of the noradrenaline infusion- careful GEDI guided volume therapy

Initial measurement

3.4

760

14

950

16

Normal values

3.0 – 5.0 l/min/m2

680 - 800 ml/m2

3.0 – 7.0 ml/kg

1700 - 2400 dyn*s*cm 5 m2

2 - 8 mmHg

Cardiac Index

GEDI

ELWI

SVRI

CVP

Clinical Case

Actual values

3.5

780

14

990

16

Normal range

3.0 – 5.0 l/min/m2

680 - 800 ml/m2

3.0 – 7.0 ml/kg

1700 - 2400 dyn*s*cm 5 m2

2 - 8 mmHg

CI

GEDI

ELWI

SVRI

CVP

PiCCO values the following day

Practical Approach

GEDI with volume therapy persistently within the high normal range, however no increase in ELWI

Clinical Case

Other therapy

Practical Approach

- stabilization of haemodynamics- steady noradrenaline requirement- start of negative fluid balance, guided by the PiCCO parameters

Further course

- non-invasive ventilation- targeted antibiotic therapy - administration of hydrocortisone / GCSF

Clinical Case

PiCCO values the next day

Practical Approach

Actual values

3.2

750

8

1810

14

Normal values

3.0 – 5.0 l/min/m2

680 - 800 ml/m2

3.0 – 7.0 ml/kg

1700 - 2400 dyn*s*cm 5 m2

2 - 8 mmHg

CI

GEDVI

EVLWI

SVRI

CVP

- stabilization of pulmonary function- cessation of catecholamines- good diuresis with frusemide

Clinical Case

HI

ITBI

EVLW

SVR

Nor

Despite significant volume administration/ removal remains relatively constant, thus on its own not an indicator for volume status

CI

CVP

Progression of PiCCO values

Practical Approach

GEDVI Remained within normal range under monitoring

EVLWIRegular monitoring of the lung water allowed titration of the volume therapy whilst simultaneously avoiding further increase of lung oedema

Initially raised, despite volume depletion and thus not of useTime Course

SVRI

0

5

10

15

20

25

30

Day 5Day 4Day 3Day 2Day 1

Nor

CVPEVLWIGEDVI

CI

Clinical Case

Stabilisation of the haemodynamics

Avoidance of complications

Efficient use of resources

Practical Approach

Actual advantages of using PiCCO with this patient

Optimisation of the intravascular volume status

Reductionin catecholamine requirements

No acute renal failure

Monitoring of lung oedema

Avoidance of intubation

Pulmonary stabilisation

No invasive ventilation

Clinical Case

Volume ?Volume ?

Practical Approach

Potential problems without PiCCO use in this patient

Diarrhoea Severe diaphoresis

difficult clinical assessment

of volume deficit

High CVP

Volume ?

Poor Diuresis Constant CI

Clinical Case

The

haemodynamic triangleOptimisation

of preload

Optimisation of stroke volume

Therapy Guidance with PiCCO Technology

Practical Approach

PiCCO allows the establishment of an adequate cardiac output through optimisation of volume status whilst avoiding lung oedema

Avoidance of lung oedema

if necessary: additional information

Oxygen extraction ScvO2

Organ perfusion PDR-ICG


Practical Approach

PiCCO monitoring CI, Preload, Contractility,

Afterload, Volume responsiveness

Evaluation of therapy success

TherapyVolume / Catecholamines

7

Cardiac Output

Preload


Practical Approach

EVLW

3

5

3

Inadequate preload should initially be treated with volume administration

7

Cardiac Output

Preload


Practical Approach

EVLW

3

5

3

Inadequate preload should be treated initially with volume administration

Continue volume administration until EVLW increases

7

Cardiac Output

Preload


Practical Approach

EVLW

3

5

3

Inadequate preload should be treated initially with volume administration

Volume administration causes an increase in EVLW

Volume removal until EVLW stops decreasing or decreases only slowly (preload monitoring!)

Always check measurements for plausibility.

Volume administration must lead to an increase in preload, or increase in lung oedema (reflected by increase in EVLW)

Economic Aspects of PiCCO Technology

Costs and Resources

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

Direct costs in comparison to the PAC

Day 1 to 4 Day 5 to 8

CCO - PACPiCCO Kit CCO - PACPiCCO Kit

Percentage Costs

PiCCO - KitPulmonary catheterChest X-RayIntroducerCVCArterial catheterPressure transducerInjection accessories

100% 100%

140%

230%

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

Indirect costs in comparison to the PAC

Intensive care days

Mitchell et al, Am Rev Resp Dis 1992;145: 990-998

Ventilation days

PAC group

n = 101* p ≤ 0.05

PAC groupEVLW group EVLW group

22 days 15 days9 days 7 days

* p ≤ 0.05

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

• 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

148



B. Monitoring






H. Limitations

Applications in intensive care (early use)

Indications for PiCCO Technology

Applications

- 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

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.

Recommendation:

Indications for PiCCO Technology

Applications


Application

• 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

152



B. Monitoring






H. Limitations

Knowledge of the limitations is essential for correct interpretation of the data!

Limitations of the PiCCO parameters - thermodilution

Limitations

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

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)

Knowledge of the limitations is essential for correct interpretation of the data!

Limitations of PiCCO parameters – pulse contour analysis

Limitations

SVV / PPV

not valid when an IABP is in use (thermodilution is unaffected)

All parameters of pulse contour

analysis

PiCCO Technology in special situations

Special clinical situations

normally no interference with the PiCCO parametersRenal replacement therapy

Prone positioning all parameters are measured correctly

Peripheral venous injection

not recommended, measurements possibly incorrect

Limitations of application of PiCCO Technology

Limitations

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.

PiCCO Technology has no specific limitations of application

Contraindications to PiCCO Technology

Limitations

The usual precautions are required when puncturing larger blood vessels:• coagulation disorders• vascular prosthesis (use other puncture site, e.g. axillary)

Because of the low invasiveness there are no absolute contraindications

The complications of PiCCO technology are confined to the usual risks of arterial puncture

Complications of PiCCO Technology

Limitations

• 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 …..

haemodynamic monitoring

Documents

oxygen deliveryvo2

arterial oxygen saturationcao2

arterial oxygen saturationsvo2

arterial oxygen saturationco

oxygen deliverycentral

cellular oxygen supplyaim

assessment of oxygen

cardiac outputhb