haemodynamic monitoring theory and practice. 2 haemodynamic monitoring a.physiological background...

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Haemodynamic Monitoring Theory and Practice Slide 2 2 Haemodynamic Monitoring 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 Slide 3 Preload Filling Pressures CVP / PCWP Volumetric Preload Parameters, Volume Responsiveness and Filling Pressures Measuring Preload Volume Responsiveness SVV / PPV Volumetric Preload parameters GEDV / ITBV 3 Slide 4 Kumar et al., Crit Care Med 2004;32: 691-699 4 Role of the filling pressures CVP / PCWP Correlation between Central Venous Pressure CVP and Stroke Volume Measuring Preload Slide 5 Kumar et al., Crit Care Med 2004;32: 691-699 5 Correlation between Pulmonary Capillary Wedge Pressure PCWP and Stroke Volume Measuring Preload Role of the filling pressures CVP / PCWP Slide 6 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 Role of the filling pressures CVP / PCWP Measuring Preload 6 Slide 7 Role of the volumetric preload parameters GEDV / ITBV Measuring Preload Preload Filling Pressures CVP / PCWP Volume Responsiveness SVV / PPV Volumetric Preload parameters GEDV / ITBV 7 Slide 8 Total volume of blood in all 4 heart chambers Left heart Right Heart Measuring Preload Pulmonary Circulation Lungs Body Circulation GEDV = Global Enddiastolic Volume 8 Role of the volumetric preload parameters GEDV / ITBV Slide 9 Measuring Preload GEDV shows good correlation with the stroke volume Michard et al., Chest 2003;124(5):1900-1908 9 Role of the volumetric preload parameters GEDV / ITBV Slide 10 ITBV = Intrathoracic Blood Volume Total volume of blood in all 4 heart chambers plus the pulmonary blood volume Left heart Right heart Measuring Preload Pulmonary Circulation Lungs Body Circulation ITBV =GEDV + PBV 10 Role of the volumetric preload parameters GEDV / ITBV Slide 11 Sakka et al, Intensive Care Med 2000; 26: 180-187 Measuring Preload 11 ITBV TD (ml) ITBV = 1.25 * GEDV 28.4 [ml] GEDV vs. ITBV in 57 Intensive Care Patients 0 1000 2000 3000 0100020003000 GEDV (ml) ITBV is normally 1.25 times the GEDV Role of the volumetric preload parameters GEDV / ITBV Slide 12 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) 12 Role of the volumetric preload parameters GEDV / ITBV Slide 13 Measuring Preload Role of the dynamic volume responsiveness parameters SVV / PPV Preload Filling Pressures CVP / PCWP Volume Responsiveness SVV / PPV Volumetric Preload parameters GEDV / ITBV 13 Slide 14 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 PP max PP min PP max PP min Inspiration Reuter et al., Ansthesist 2003;52: 1005-1013 Measuring Preload Physiology of the dynamic parameters of volume responsiveness Expiration InspirationExpiration Early InspirationLate Inspiration 14 Fluctuations in blood pressure during the respiration cycle Slide 15 SV Preload V SV V Mechanical Ventilation Measuring Preload Fluctuations in stroke volume Intrathoracic pressure fluctuations Changes in intrathoracic blood volume Preload changes 15 Fluctuations in stroke volume throughout the respiratory cycle Physiology of the dynamic parameters of volume responsiveness Slide 16 SV max SV min SV mean 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) 16 mean Role of the dynamic volume responsiveness parameters SVV / PPV Slide 17 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 0,50 0 0,2 0,4 0,6 0,8 1 17 Role of the dynamic volume responsiveness parameters SVV / PPV Slide 18 Measuring Preload PPV = Pulse Pressure Variation The variation in pulse pressure amplitude over the respiration cycle Correlates equally well as SVV for volume responsiveness PP max PP mean PP min 18 Role of the dynamic volume responsiveness parameters SVV / PPV Slide 19 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 19 Responders n = 16 Non Responders n = 24 Role of the dynamic volume responsiveness parameters SVV / PPV respiratory changes in arterial pulse pressure (%) Slide 20 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 20 Role of the dynamic volume responsiveness parameters SVV / PPV Slide 21 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 21 Slide 22 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 22 Slide 23 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 23 Summary and Key Points