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PiCCO, CeVOX & LiMON Technology Training in methodology, operation, application and safety.

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Presentation on theme: "PiCCO, CeVOX & LiMON Technology Training in methodology, operation, application and safety."— Presentation transcript:

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2 PiCCO, CeVOX & LiMON Technology Training in methodology, operation, application and safety

3 2 Icons & Navigation More information (external documents) More information (within the presentation) i Video Back to start position Start animation

4 3Overview A. Introduction B. Disposables C. Start-Up D. Measurement E. Parameters F. PiCCO Strategies

5 4 User orientated presentation Basic nurse training Basic medical training Intensive care nurse training Intensive care medical training

6 5 A. Introduction

7 6 History of the PiCCO-Technology COLD System 1990 PiCCO 1997 PiCCO plus 2002 Philips PiCCO Module 2003 Dräger Smart Pod 2005 Intelligent hemodynamic monitoring Paradigm shift in hemodynamic monitoring Integration into patient monitoring monitors Most widely used less-invasive method PiCCO PulsioFlex™ 2010

8 7 PULSION – Made in Germany Medical device manufacturer based in Munich, founded in 1990 Production, development, management, marketing and distribution in Munich Subsidiaries in USA, France, Spain, United Kingdom, Benelux, Poland, Austria and Switzerland Distribution and licensing worldwide PULSION Head Office Production Clean Room

9 8 What are hemodynamics? When is hemodynamic monitoring indicated? What types of hemodynamic monitoring are there? Why do you need the PiCCO-Technology? Why Monitor Hemodynamics? Illustrative case

10 9 Key questions Is the O 2 supply sufficient? Volume or catecholamine's ? Is there Pulmonary edema?

11 10 What are Hemodynamics? O 2 consumption O 2 delivery O 2 transportO 2 uptake Gas exchangeMacro-circulation Micro-circulation Cellular O 2 consumption (Cardiac Output, Hb) (ScVO 2, PDR ICG *) Maintenance of oxygen extraction! * Parameter is not available in the USA

12 11 Intervention Options Vasopressors? Vasodilators? Inotropes? Vasopressors? Vasodilators? Inotropes? Volume loading? Volume withdrawal? Diuretics? Volume loading? Volume withdrawal? Diuretics? Volume Catecholamines Hemoglobin Respiration The correct decision, early!

13 12 Anatomy and physiology of the circulatory system Preload: - Blood volume, blood available for pumping Contractility: - Performance of the heart muscle Determinants of cardiac output: Afterload: - Resistance, against which the heart must pump Heart rate Flow is the result of: preload, afterload, contractility & heart rate Circulatory model 

14 13 Hemodynamic Parameters O 2 Delivery DO 2 Gas exchange? SaO 2 O 2 Transport? Hb Flow? CI O 2 Consumption VO 2 Mixed- / Central- Venous O 2- Saturation ScVO 2 x Stroke Volume SVI Frequency HR Lung ELWI PVPI* Preload GEDI SVV Afterload MAP SVRI Contractility dPmx, CPI* CFI*, GEF* DO 2 VO 2   ! * Parameters are not available in the USA

15 14 Sepsis Cardiac surgery Cardiology Neurosurgery/ Neurology /Stroke Burns Trauma Treatment strategies

16 15 Monitoring and Diagnostic systems Diagnostics & Advanced Monitoring CO - Monitoring Diagnostics TTE/TEE CT/ MRI Vigilance / PACPiCCO 2 Bioimpendance Vigileo LiDCO rapid Doppler PulsioFlex

17 16 B. Disposables

18 17 For advanced hemodynamic monitoring with the PiCCO-Technology Temperature sensor at the catheter tip for transpulmonary thermodilution Pressure lumen for arterial pressure measurement For use with PiCCO 2 PiCCO plus Philips PiCCO technology module and Draeger Infinity ® PiCCO SmartPod ®. PiCCO Catheter

19 18 PiCCO Catheter Placement Options A.Radial Adult4F - 50cm* A. Axilla Adult4F - 08cm Children/peds3F - 07cm A. Brachial Proximal 4F - 16cm Adult distal (cubital) 4F - 22cm A.Femoral Adult5F - 20cm * Product is not available in the USA

20 19 Catheter handling according to hospital hygiene policy Latex and DEHP free Remove catheter if there are any signs of inflammation/infection PiCCO Catheter Safety Tips

21 20 Continuous monitoring of ScvO 2 Convenient application Access via already placed standard CVC Easy application Continuous ScvO 2 within minutes CeVOX Probe* * Product is not available in the USA

22 21 CeVOX Probe Selection and Placement CeVOX-probe indicator Insert probe through the distal lumen of your CVC Secure CeVOX probe Luer lock to CVC distal Luer lock Tip of CeVOX probe is positioned 2.5 ± 0.5 cm past the tip of the CVC Connect the CeVOX probe to the optical module and perform an in-vivo calibration Remove slide clamp from CeVOX lumen No stopcock / 3 way tap in-between probe and CVC! Remove slide clamp from CeVOX lumen! * Product is not available in the USA

23 22 Blood samples for in-vivo calibration are withdrawn from the Y-connector at the end of the CeVOX probe. (if not possible then from the next (medial) lumen from the same CVC) In-vitro calibration (pre-calibration) is not validated and raises hygiene issues Keep the CeVOX lumen open by continuous flow Online CVP via pressure transducer 3ml/h flush solution via syringe pump Infusions and medication can be administered via the CeVOX-CVC lumen No catecholamines! CeVOX* CVC-lumen * Product is not available in the USA

24 23 CeVOX probe and CVC handling according to hospital policy Latex and DEHP- free Remove CeVOX probe together with CVC if there are signs of inflammation at the injection site or signs of catheter related infection Remove slide clamp from CeVOX lumen! Do not place a stopcock (3 way tap) between probe and CVC CeVOX* probe safety tips * Product is not available in the USA

25 24 PiCCO Pressure Transducer

26 25 PV8215PiCCO transducer incl. PV 4046 PV in1 PiCCO transducer with continuous AP and CVP incl. PV4046 PV8215CVP PiCCO transducer with discontinuous CVP incl. PV4046 PV8615 CVP online transducer DPT-100In-Line transducer PV4046Injectate sensor housing PV82xx transducers are not available in all markets. Alternative products are available on request. PiCCO Pressure Transducer Movie

27 26 Change transducer according to hospital policy (usually around every 96 hours) PV82XX is Latex and DEHP free Use only PULSION approved transducers for PiCCO monitoring (CE-Conformity). Transducer Safety Tips

28 27 Measures the temperature of injectate at time of injection Included in PiCCO transducer kits Also available separately Injectate Sensor Housing PV4046

29 28 C. Start-UP

30 29 Connectivity PiCCO 2 PiCCO plus Philips IntelliVue Model Dräger Infinity PiCCO SmartPod

31 30 Connectivity PiCCO 2 CeVOX Module (Art. No. PC3015) LiMON Module* (Art. No. PC5100) Injectate-Sensor cable (Art. No. PC80109) Temperature cable (Art. No. PC80150) Pressure cable (Art. No. PMK-206) Flush bag PiCCO catheter PiCCO monitoring kit CeVOX probe via standard CVC 1a LiMON Sensor * Product is not available in the USA

32 31 Connectivity Philips IntelliVue Module Flush bag PiCCO catheter PiCCO monitoring Kit Injectate -Sensor cable (Art. No. PC80109) Temperature cable (Art. No. PC80150) Pressure transducer cable (Art. No. PMK-206)

33 32 Connectivity Dräger Infinity PiCCO SmartPod ® Flush bag PiCCO catheter PiCCO monitoring kit To bedside monitor Connected to the back Injectate Sensor cable (Art. No. PC80109) Temperature cable (Art. No. PC80150) Pressure transducer cable (Art. No. PMK-206)

34 33 Connectivity PiCCO plus PV8215 PV2015L20N

35 34 Conectivity Philips IntelliVue Model PiCCO 2 PiCCO plusDräger Infinity PiCCO SmartPod

36 35 PiCCO 2 Connectivity CeVOX - ScvO 2 Module PiCCO – Thermodilution PiCCO – arterial pressure Online - CVP Input AUX port for connection to bedside monitoring Output CVP AP

37 36 PiCCO 2 Connectivity Interface 2x USB LAN RS 232 Mains Lead Mains connection Potential- Equilization

38 37 Operation PiCCO 2 Information Philips IntelliVue Model PiCCO 2 PiCCO plus Dräger Infinity PiCCO SmartPod

39 38 1.Power Switch 2.On/Off button 3.Alarm indicator 4.Charge warning light Start-Up PiCCO Blinking = charging Permanently on = Fully charged

40 39 Screen layout Touch screen

41 40 1.On / Off 2.Help 3.Print 4.Suspend alarm 5.Back (to previous level) 6.Back (to main screen) Direct Access Buttons and Navigation Dial

42 41 Help Function - Press Help button to open the help screen Setup scheme

43 42 Help Function Parameter - information

44 43 Therapy algorithm Help Function

45 44 Help Function Help funktion Physiological parameter model with intervention options

46 45 Help Function How to contact PULSION and the PiCCO 2 serial number

47 46 Press „Exit“ or “Next” to proceed to next screen Help Function

48 47 Zero pressures once per shift and as required Manually enter CVP in mmHg Continuous CVP can be monitored via a second transducer Zeroing of AP and CVP

49 48 System Check Systole identified? AP plausible? (PiCCO and patient monitor) 3.. Blood temp (TB) plausible? 1 2 3

50 49 Configuration PiCCO 2

51 50 PiCCO 2 Supports Your Decisions Spider Vision View the patient status at a glance Profile Detailed insight at a parameter level Trends Clinical course & treatment success

52 51 Configuration of Parameters Press on the parameter field on the right side of the screen to go to parameter configuration

53 52 Configuration of Alarms 80 65

54 53 Switch to target mode via Selection “Target Values” Enter your target values It is possible to adjust target ranges for each individual patient Configuration of Normal and Target Values Target valuesNormal values

55 54 Configuration SpiderVision Select the number of required arms Place the parameters onto the arms by: 1. Selecting a SpiderVision parameter 2. Touching the parameter label onto the Spider arm

56 55 Customizable trend screen with up to 8 parameters Select: -Trend period -Trend graphic or -Trend table Configuration Trend Screen

57 56 D. Thermodilution

58 57 Principles of the PiCCO-Technology Calibration Injection t T P t The PiCCO-Technology is a unique combination of two methods; Firstly the hemodynamic and volumetric status is determined by transpulmonary thermodilution (TD). Secondly arterial pulse contour is calibrated. Thermodilution Pulse contour analysis

59 58 Thermodilution The indicator passes through heart and lungs. CO, Preload and Lung water are measured. Injection Detection PiCCO 2 Booklet

60 59 Pulse Contour Analysis Calibration The second step is that arterial pulse contour is calibrated by TD - CO The systolic part of the curve, representing stroke volume, is calibrated. Each new TD automatically recalibrates the pulse contour PiCCO-PCCI is “beat to beat” Calibration also integrates the patients aortic compliance Injection t T P t

61 60 Workflow - Thermodilution PiCCO 2 Philips IntelliVue Model PiCCO plus Dräger Infinity PiCCO SmartPod

62 61 Start thermodilution Select the injectate volume For an adult 15mls saline is recommended In the „Measurement“ menu you will find the recommended volume Press „Start“ Auto – Thermodilution mode (x in a row)

63 62 Thermodilution When „Wait“ is displayed in the TD window the blood temperature profile is being calculated. 1Once the message ‘Inject xx ml’ appears, inject the saline bolus rapidly past the injectate sensor housing. 2The word ‘Injection’ indicates that the monitor has recognized the bolus injection. 3The thermodilution curve appears in the TD window. 4The results are highlighted in green in the table above the thermodilution curve

64 63 Selection of results The TD results are averaged from the set of TD measurements. CI, GEDI and ELWI should be within 10% of each other Results that are outside this range should be excluded from the set of measurements. Measurements can be excluded by double clicking on the results. Excluded results are crossed out

65 64 Quality of the thermodilution 37° 36,7° 36,9° 36,8° ∆T =0.3°C 37° 36,7° 36,9° 36,8° ∆T =0.14°C Optimize the thermodilution by: -More injection volume -Colder injection -Faster injection -Raising blood temperature if hypothermic (after surgery) Quality of thermodilution: -Optimized when∆T >0.3°C -Good when∆T >0.2°C -Weak when ∆T <0.15°C -∆T = change in temperature

66 65 ScvO 2 Calibration PiCCO 2

67 66 ScvO 2 Calibration Press to start calibration The quality indicator should show a medium to high signal Withdraw blood from the Y- connector of the CeVOX probe. Ensure that you get only blood and no infusion fluid. Do a venous blood gas sample and flush the lumen with saline afterwards. Press “Sample drawn” after withdrawing blood. Enter the results of the BGA. Press „Confirm“ If DO 2 and VO 2 are enabled you need to enter the SaO 2 (SpO 2 ) value DO 2 & VO 2 Measurement ScVO 2 CAL

68 67 LiMON – PDR ICG * Press to go to LiMON calibration. Attach the LiMON sensor to a well perfused finger. Wait 3 minutes until the finger perfusion becomes adapted to the sensor. Ensure that the sensor is not subjected to strong direct light. If necessary cover the sensor during the measurement of the PDR ICG SpO 2 and perfusion level will be displayed. The signal should be stable. Press to calculate the ICG dose. Select target concentration: 0.25mg/Kg or 0.5mg/Kg Select the number and size of vials Use XX mls ‘water for injection’ ICG quantity: dose in mgs to inject Volume: Volume in mls to inject Calc * Parameter is not available in the USA

69 68 LiMON – PDR ICG * 1.Prepare the calculated ICG bolus 2.Press ‘START’ 3.“Wait” will be displayed until the signal is stable. 4.Inject calculated volume of ICG. 5.Curve detected will be displayed 6.PDR ICG reading will be displayed after 5 – 8 mins 7.Time of next possible measurement will be displayed * Parameter is not available in the USA

70 69 E. - Parameters

71 70 Therapy control O 2 consumption O 2 delivery O 2 transport O 2 uptake Gas exchange Macro-hemodynamics Micro-circulation Cellular O 2 consumption Volume Catecholamine Hemoglobin Respiration Maintenance of oxygen extraction Options for Intervention

72 71 Main Parameters ScvO 2 : Adequate global tissue oxygenation? CI: Adequate flow? GEDI:Adequate cardiac preload? SVV/PPV:Volume responsiveness? SVRI: Vasopressor therapy necessary? ELWI:Lung edema?

73 72 Monitoring Strategy 1. Identification of the problem 2. Identification of the cause 3. Coordination of suitable interventions 4. Goal directed therapy 5. Quality check

74 73 Hemodynamic parameters O 2 Delivery DO 2 Gas exchange? SaO 2 O 2 Transport? Hb Flow? CI O 2 Consumption VO 2 Mixed- / Central- Venous O 2- Saturation ScVO 2 x Stroke Volume SVI Frequency HR Lung ELWI PVPI* Preload GEDI SVV/PPV Afterload MAP SVRI Contractility dPmx, CPI* CFI*, GEF* DO 2 VO 2   ! Organ function? If ScVO 2 >75% PDR ICG * - Liver * Parameters are not available in the USA

75 74 ScvO 2 - Indicates insufficient tissue oxygenation ScvO % SvO % ScvO 2 O 2 Delivery O 2 Consumption ScvO 2 – Central venous oxygen saturation Imbalance between O 2 delivery and O 2 consumption? Measurement via standard CVC ScvO 2 (via CVC) correlates with SvO 2 (via Pulmonary Artery Catheter) Fever Stress Muscle work (shivering) CO Hemoglobin Arterial O 2 saturation 

76 75 Cardiac Output – Blood volume, amount of blood pumped by the heart per minute CI – Cardiac Index (Thermodilution) PCCI – Pulse Contour Cardiac Index (Cont. Pulse Contour) SVI – Stroke Volume Index Cardiac Index indicates the global blood flow Cardiac Index is Heart Rate x Stroke Volume Index Stroke Volume depends on preload, afterload and contractility Cardiac Index is indexed to the Body Surface Area (BSA) PCCI 3-5 l/min/m 2 SVI ml/m 2  CO Heart rate Afterload Contractility Stroke volume Preload

77 76 Preload Volume – Blood volume which fills the heart just prior to beating GEDI – Global End-diastolic Volume Index Filling volume of all 4 heart chambers Adequate preload volume is necessary for an adequate CO GEDI is indexed to the PBSA* Volumetric preload assessment GEDI ml/m 2  * Predicted Body Surface Area (normalized body surface area)

78 77 Direct correlation between GEDI and CO GEDI (ml/m 2 ) CI (l/min/m 2 ) Preload increase Inotropes Preload optimization (GEDI) will increase Cardiac Index (CI) to a defined maximum (top of the Frank-Starling-Curve) After preload optimization CI can be increased further by inotropes Frank-Starling-Curve

79 78 Volume responsiveness – predicts the response of cardiac output to volume loading SVV – Stroke Volume Variation PPV – Pulse Pressure Variation Respiratory fluctuations in the arterial pressure curve in fully controlled ventilated patients. High SVV/PPV (>10%) indicates the stroke volume will increase following preload volume loading At values >10% volume replacement can be useful SVV < 10% PPV < 10%  SVV > 10% PPV > 10% SVV 0-10% PPV 0-10% Preload (GEDI) Stroke volume (SV)

80 79 SVV / PPV – can only be used as a volume responsive parameter under controlled conditions.  Is the patient on fully controlled ventilation? Spontaneous breathing or assisted breathing may cause incorrect measurements.  Is the patient in sinus rhythm? The arterial pressure curve cannot be used in arrhythmic patients.  Is the arterial pressure curve free from artifacts? Artifacts such as coughing or dys-synchronisation with the ventilator.  Sufficiently high tidal volume? In cases of low tidal volume, the effect of ventilation on the arterial pressure curve is inadequate. (usable with a tidal volume >= 8ml/KG* PBW). * Muller et al. The influence of the airway driving pressure on pulsed pressure variation as a predictor of fluid responsiveness. ICM 2010; 36: De Backer et al. Pulse pressure variations to predict fluid responsiveness: influence of tidal volume. ICM 2005; 31:517–523 SVV / PPV – Safety Tips

81 80 Lung water – water content of the lungs ELWI – Extravascular Lung Water Index Measurement of the intracellular, interstitial and intra-alveolar water content of the lungs (not pleural effusion) Direct and easy bedside quantification and tracking of pulmonary edema ELWI 3-7 ml/kgPBW  ELWI = 8 ml/kg ELWI = 14 ml/kg ELWI = 19 ml/kg ELWI = 7 ml/kg

82 81 Predicted Body Weight (PBW) Absolute values (cardiac output, GEDV, EVLW) are indexed to the body surface area (BSA) and body weight (BW indexed) to make values comparable between patients. Cardiac output is indexed to the current BSA in order to ensure comparability to other systems. GEDV and EVLW are indexed to ‘ideal’ BSA (PBSA) and ‘ideal’ weight (PBW). In order to avoid an underestimation of values in obese patients The size of the heart and lungs are proportional to ‘ideal’ BSA and ‘ideal’ weight, but not to actual BSA and weight KG

83 82 Hydrostatic volume shift 1.If preload is low, volume is given. 2.Preload loading can increase CI to its maximum. 3.Excessive preload loading will also increase the hydrostatic pressure in the vascular system. This can lead to an increase in lung water. 7 CI ELWI GEDI GEDI

84 83 Hydrostatic vs. osmotic edema Infusion Osmotically active particle (protein & salt)H2OH2O Normal tissue permeability Disturbed tissue permeability IntravascularExtravascular Osmotic EdemaHydrostatic Edema

85 84 Differentiate between types of pulmonary edema PVPI* – Pulmonary Vascular Permeability Index Provides a differentiated view of pulmonary edema: cardiac osmotic Corresponds to the ratio between lung water (EVLW) and pulmonary blood volume (PBV) PVPI* 1-3  Normal situation PVPI 1-3 EVLW PBV EVLW PBV EVLW PBV PVPI =1 PVPI = Cardiac lung edema PVPI 1-3 Osmotic lung edema PVPI 3-5 Intravascular fluid / PBV Extravascular fluid / EVLW * Parameter is not available in the USA

86 85 Afterload – Resistance against which the heart must overcome to eject blood SVRI - Systemic Vascular Resistance Index Measurement of the resistance against which the heart must pump Depends on the degree of vasoconstriction Increased: Centralization, Vasopressor therapy, Cardiogenic shock Decreased: Septic shock, Anaphylactic shock. SVRI dyn/sec/m 2  Vasoconstriction: Flow (CO) Pressure (RR) Vasodilation: Flow (CO) Pressure (RR) Resistance = Pressure Flow (CO)

87 86 Contractility - Performance of the heart muscle GEF* – Global Ejection Fraction Ratio of ejection to ventricular filling Measures global cardiac contractility GEF correlates well with LVEF (Echocardiography) GEF* % LVEF 50 – 70 % 4 x SV GEF* = GEDV  * Parameter is not available in the USA

88 87 Contractility - Performance of the heart muscle CFI* – Cardiac Function Index Index of the relationship between flow and cardiac preload Measures global cardiac performance * Parameter is not available in the USA CFI* 4,5 – 6,5  GEDI CI 3,5 400ml 700ml 900ml 5 1,5 2 4,9 7 High contractility Low contractility Normal contractility CO CFI* = GEDV

89 88 Contractility - Performance of the heart muscle dPmx – Left Ventricular (LV) contractility Measures the contractility of the left ventricle to afterload Maximum pressure increase over time in the aorta (∆P max / ∆t) Trending parameter, no normal range NB: Preload and afterload both influence dPmx dPmx for a healthy heart  Steep pressure increaseFlatter pressure increase High LV ContractilityLow LV Contractility

90 89 Contractility - Performance of the heart muscle Power = Watt 1 Watt = 1 Joule/Second Power (Watt) = Current (V) x Amps (A) (x conversion factor) CPI* = MAP x CI (x ) CPI* – Cardiac Power Index CPI is the left ventricular cardiac output (W) as a product of flow and pressure The strongest independent predictor of hospital mortality in cardiogenic shock * Parameter is not available in the USA CPI* 0.5 – 0.7 W/m² 

91 90 The relationship between DO 2 and VO 2 DO 2 I ml/min/m 2 VO 2 I ml/min/m 2 - DO 2 and VO 2 indicate the relationship between O 2 supply and O 2 consumption - If DO 2 falls below a critical point, tissue hypoxia will occur  S(c)vO 2 CO, Hb Oxygen uptakeOxygen transportOxygen releaseOxygen consumption VO 2 I = CI x Hb x 1.34 x (SaO 2 – S(c)vO 2 ) DO 2 I = CI x Hb x 1.34 x SaO 2 SaO 2 Consumption: Delivery: Enough Too low! O 2 transport capacity DO 2 ml/min/m² O 2 supply VO 2 ml/min/m²

92 91 Liver perfusion / Splanchnic perfusion PDR ICG * – Plasma Disappearance Rate of Indocyanine Green (ICG) Shows the excretion of ICG dye from the blood by the liver Is a marker of global liver function and perfusion The value is decreased if: the liver cell function is impaired. the liver has insufficient perfusion. Highly prognostic regarding mortality * Parameter is not available in the USA PDR ICG * %/min  Distribution in blood Transport to the liver Excretion by the liver ICG Injection Liver Gall bladder Portal vein Colon Hepatocyte

93 92 F. PiCCO strategies

94 93 Therapy control

95 94 Plan Planning Phase Doctor: Examination and diagnosis Doctor: Treatment Decisions Do Implementation Phase Nurse: Execution of the treatment plan Check Control Phase Nurse: Monitoring ongoing situation Act Evaluation Phase Doctor: Follow up or redefinition of treatment Doctor & Nurse Communication

96 95 Contact: PULSION Medical Systems AG Joseph-Wild-Str Munich Germany Tel: +49 (0) – 0 Fax: +49 (0) – 18 I. Summary Thank you for your attention!

97 96

98 97 Auto Thermodilution mode  In the configuration screen the Auto thermodilution function can be activated Option to select 3 – 5 measurements in a row, without having to press the start button each time

99 98 Visualization of DO 2 and VO 2 in real-time to monitor oxygen delivery and oxygen consumption (CI and ScvO 2 must be monitored continuously) *Physically dissolved oxygen is ignored. Selection of oxygen parameters Oxygenation

100 99 Admission from a general ward: 5 days post-operative after a colon resection, no CVC, no A-line Vital signs GCS:somnolent Respiration:tachypnea Pulse:120 NIBP90/50 Temperature39.8°C Patient admission

101 100 ECG Monitor heart rhythmSR Monitor heart rate120/min SpO 2 > O 2 mask with 5l/min Awareness of respiratory failure95% Monitor O 2 -supply and respiration> Intubation Patient admission

102 101 Basic Monitoring Can we identify the source of the shock? Can we control the patients circulation with this level of monitoring? Electrocardiogram (ECG) Pulse oximetry (SpO 2 ) NIBP (RR)

103 102 Standard Monitoring Invasive blood pressure monitoring A. Axilla A. Brachial A. Radial A. Femoral Differentiation Central perfusion (Femoral, Brachial and Axilla) Peripheral perfusion (Radial)

104 103 Compensation mechanism AP The blood pressure gives only a delayed picture when a circulatory problem is occurring. Continuous CI responds to problems much earlier. Conventional parameters for monitoring circulation (RR + HR) may be meaningless or even misleading MAP 55mmHg MAP 65mmHg 10:0010:30 CI 2L/min CI 3L/min CI 10:30 RR is decreasing! 10:22 Flow decreasing!

105 104 Physiological model of the circulatory system Pump


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