The PiCCO system - Koolitused

1 1 The PiCCO systemThe PiCCO systemHOW TO PRACTICALLY USE THE VARIOUS HOW TO PRACTICALLY USE THE VARIOUS MONITORING SYSTEMS?MONITORING SYSTEMS?The PiCCO systemThe PiCCO systemAzriel PerelAzriel PerelProfessor and ChairmanProfessor and ChairmanRome 2009 Professor and Chairman Professor and Chairman Department of Anesthesiology and Intensive Care Department of Anesthesiology and Intensive Care Sheba Medical Center, Tel Aviv UniversitySheba Medical Center, Tel Aviv UniversityIsraelIsraelDisclosureThktith th f lliiThe speaker cooperates with the following companiesBMeyeDrager-SiemensPulsion PiCCOThe PiCCOA multiA multi--parametric parametric approach to advanced approach to advanced hemodynamichemodynamichemodynamic hemodynamic monitoringmonitoringCentral venous catheterCentral venous catheterThe PiCCO The PiCCO FemoralFemoral AxillaryAxillary BrachialBrachial Radial (long)Radial (long)

2 ThermistorThermistor--tipped tipped arterial catheterarterial catheter{3 Preload &Preload &Clinical examination, vital signs, urine output, Hb, responsivenessFluid responsivenessCardiac OutputEVLWScvO2dP/dT, CFI, GEF, PVPIP reload &Preload &Clinical examination, vital signs, urine output, Hb, responsivenessFluid responsivenessCardiac OutputEVLWScvO2dP/dT, CFI, GEF, PVPI4 ScvO272%CVP 9 mmHg A man with fever and shortness of breathgLactate 48 PaO2/FiO275 (PEEP 10) ITBVI950 (normaI) EVLWI15 (high) SVR1100P [mm Hg]Real-time CCO by the pulse contour methodPCCO = cal HR P(t)SVR+ C(p) dPdt()dtt [s]Area of pressure curveShape of pressure curve SystoleSVR(p)dt()ComplianceHeart ratePatient-specific calibration factor (determined with thermodilution) Arterial compliance and resistance are updated beat-to-beat according to a proprietary algorithm that depends particularly on the arterial pressure and on dP/dt.}

3 5 Measurements recorded when SVR changed > 15%Whole set of CI pairsAfter a 1-hr calibration-free period, recalibration may be encouraged since it provides helpful information drawn from other thermodilution-derived &Preload &Clinical examination, vital signs, urine output, Hb, responsivenessFluid responsivenessCardiac OutputEVLWScvO2dP/dT, CFI, GEF, PVPI6 Preload &Preload &Clinical examination, vital signs, urine output, Hb, responsivenessFluid responsivenessCardiac OutputEVLWScvO2dP/dT, CFI, GEF, PVPIITBV = CO mtt50cICGmttcentIntra-thoracic blood volume (ITBV)203040[mg l-1]70%33%0 102030405060010[s]tRAEDVRVEDVLAEDVLVEDVR AEDVRVEDVLAEDVLVEDVPBVITBVGEDV7 Global End-Diastolic Volume as an Indicator of Cardiac Preload in patients With Septic Shock F Michard et al, ;124:1900-1908% of fluid -responders720740760780800 PrePre--infusioninfusionGEDViGEDVi(mL/m( mL/m22))600620640660680700 Responders Non-respondersITBV and its changes correlates to CI and its changes significantly better than the CVPCrit Care Med 2008; 36: 23488 Intravascular volume depletion in a Intravascular volume depletion in a 2424--hour porcine model of hour porcine model of intraintra--abdominal hypertensionabdominal hypertensionSchachtrupp A et al, J Trauma.

4 Schachtrupp A et al, J Trauma. 5555: : 734734--740740, , 20032003 Should we monitor preload andShould we monitor preload and fluid responsivenessin shock?9 Functional hemodynamic parameters Functional hemodynamic parameters (SPV, PPV, SVV) are the most sensitive (SPV, PPV, SVV) are the most sensitive parameters for the assessment of parameters for the assessment of fluid responsiveness in mechanically fluid responsiveness in mechanically SPV PPV SVVSPV PPV SVVpypyventilated patientsventilated patientsPreload &Preload &Clinical examination, vital signs, urine output, Hb, responsivenessFluid responsivenessCardiac OutputEVLWScvO2dP/dT, CFI, GEF, PVPI10 Sturm JA 1990 High EVLW content is associated with increased mortality (65-80% when EVLW>20 ml/kg)Sakka S et al Chest 2002.

5 1232:2080-6 EVLWI and Mortality (Highest measurement)N=37320304050607080902_66_88 _1010_1212_1616_20>20 EVLWI (ml/kg)Mortality (%)Beale R 2001N=241FT Chung et al , respiratory Medicine 200811 EVLW was markedly elevated ( ml/kg) in patients with early ARDS, was significantly higher in non-survivors and correlated with Vd/Vt. 15 dogs; EVLW measured by PiCCO and, following sacrifice, by gravimetrics. Control (n=5) Non-cardiogenic203040 PiCCO (m l/kg) Non-cardiogenic pulmonary edema (oleic acid) (n=5) Cardiogenic pulmonary edema (lt. atrial balloon) (n=5)0100 1020 3040 EVLW-grav. (m l/kg)EVLW-R2= 63 yrs old patient with pulmonary edema after TURT24 hours later20 20 ml/kgml/kg10 10 ml/kgml/kgSevere respiratory failure in a 33 yrs old patient following ruptured hematoma of the liver and multiple transfusions EVLW is only 5 ml/kg 13BP70/40 mmHgHR155 bpmA patient with head injury, severe ARDS and septic shock CO=1215L/minCVP5 cmH2 OPaO2/FiO280 (PEEP 16)Hi h !

6 !!Would you give fluids to this patient?Noradrenaline + aggressive diuresis! CO = 12-15 L/min SVR = 400-500 ITBVI = 1200 ml/m2 (800-1000) EVLW = 19-23 ml/kg (4-7)Low !!!High !!!High !!!High !!!An old patient with chronic heart failure, sepsis, severe respiratory failure and hemodynamic instability. l/minl/minLOWITBVi600 ml/m600 ml/m22 LOWLOWEVLWi15 ml/kg15 ml/kgHIGHHIGHSVV2525--30%30%HIGHHIGHA classic therapeutic (heart vs. lungs) fluid loading!3030 Stop fluid loading!A 63 years old male patient; developed fulminant pulmonary edema 4 hours into a re-total hip replacement. Hypoxemia (SaO2<80%), hemodynamic instability and ST changes. In the PACU hypotensive, tachycardic, on vasopressors and - COITBVI779 ml/m2850 -1000 Low preloadpSVV22 %<10 High fluid responsiveness!

7 !EVLW23 ml/kg3 - 7 Severe pulmonary edema15 Decision tree for hemodynamic / volumetric monitoring**CI (l/min/m2)> < (ml/m2)orITBI (ml/m2)>700>850<700<850>700>850<700<850 RESUCO (L)GEDV (L) +ELWI (ml/kg)GEDI (ml/m2)orITBI (ml/m2)<10>10<10<10<10>10>10>10V+V+!V+!V+CatCatV->700>850700-80 0850-1000700-800850- 1000 Cat>700>850700-800850-1000700-800850- 1000V->700>850<10 Optimise toSVV (%)<10<10< <10<10<10<10()EVLW (H)Fluids cautiously + catecholaminesCI (l/m2) ITBVI (ml/m2)779 Start fluid loading!29*not available in USA**without guarantee*+ELWI (ml/kg)(slowly responding)CFI (1/min)orGEF (%)OK!> >25> >30> >25> >30 10 10 10 10V+= volume loading (! = cautiously)V-= volume contractionCat = catecholamine / cardiovascular agentsSVV only applicable in ventilated patients without cardiac arrhythmiaGETPY(ml/m)SVV %22 EVLW (ml/kg)23 Decision tree for hemodynamic / volumetric monitoring**CI (l/min/m2)> < (ml/m2)orITBI (ml/m2)>700>850<700<850>700>850<700<850 RESUCO (H)GEDV (H) +ELWI (ml/kg)GEDI (ml/m2)orITBI (ml/m2)<10>10<10<10<10>10>10>10V+V+!

8 V+!V+CatCatV->700>850700-800850-1000700- 800850- 1000 Cat>700>850700-800850-1000700-800850- 1000V->700>850<10 Optimise toSVV (%)<10<10< <10<10<10<10 EVLW (H)DiuresisCI (l/m2) ITBVI (ml/m2)1444 !!!Stop fluid loading!30*not available in USA**without guarantee*+ELWI (ml/kg)(slowly responding)CFI (1/min)orGEF (%)OK!> >25> >30> >25> >30 10 10 10 10V+= volume loading (! = cautiously)V-= volume contractionCat = catecholamine / cardiovascular agentsSVV only applicable in ventilated patients without cardiac arrhythmiaGETPY(ml/m2)!!!SVV %15 EVLW (ml/kg)1516 This flash permeability of uncertain etiology (TRALI?) was associated with severe hypovolemia and improved spontaneously even though fluids were liberally administeredPostop Day 2 Postop Day 1 fluid 8 SVV %9721444 !!!ITBVI (ml/m2) (l/m2)Postop Day 2 Postop Day 1 fluid 8 SVV %9721444 !

9 !!ITBVI (ml/m2) (l/m2)Table 2y451523 EVLW (ml/kg) / ITBV815 SVV %451523 EVLW (ml/kg) / ITBV815 SVV %**PEF/plasma TP ratio=1 Preload &Preload &Clinical examination, vital signs, urine output, Hb, responsivenessFluid responsivenessCardiac OutputEVLWScvO2dP/dT, CFI, GEF, PVPI17BP113 / l/min/m234 yr female; Very severe respiratory failure; Hemodynamic collapse; on / 67 mmHgHR91 bpmUrine GoodSaO286% !!! l/min/mITBVi578 ml/m2 EVLWi 20 ml/kgICG PDR (LiMON)(1825%)(LiMON) (18-25%)ScvO280% !!!Have we achieved initial resuscitation goals in this patient?18A Perel, M Maggiorini, M Malbrain, JL Teboul, J Belda, E Fern ndez-Mond jar, M Kirov, J WendonThe PiCClin StudyThe PiCClin StudyThe patient population included The patient population included 206 206 patients , patients , which were evaluated by which were evaluated by 166 166 residents and residents and 146 146 specialists (total of specialists (total of 315 315 questionnaires).)

10 Questionnaires).Ptii tkdtditddPtii tkdtditddParticipants were asked to predict advanced Participants were asked to predict advanced hemodynamic parameters and decide on a hemodynamic parameters and decide on a therapeutic plan prior to PiCCO plan prior to PiCCO Perel, M Maggiorini, M Malbrain, JL Teboul, J Belda, E Fern ndez-Mond jar, M Kirov, J WendonThe PiCClin StudyThe PiCClin StudyThe main reasons for using the PiCCO The main reasons for using the PiCCO monitoring system included:monitoring system included: Unclear fluid status (Unclear fluid status (136136)) Suspected sepsis / septic shock (Suspected sepsis / septic shock (8989)) Respiratory failure (Respiratory failure (5959)) Respiratory failure (Respiratory failure (5959)) Cardiogenic shock (Cardiogenic shock (2424)) Renal failure (Renal failure (3232)) Other (Other (2121))19 EVLWi(n=304)GEDVi(n=314)SVR(n=312)CO(n=3 15)The accuracy of predicted cardiopulmonary parametersThe accuracy of predicted cardiopulmonary parameters()()()()83 ( )97 ( )46 ( )170 (54%)Underestimation>20%124 ( )154 (49%)107 ( )110 ( )Within 20% ( )(49%)( )( )97 ( )63 ( )159 (51%)35( )