Haemodynamic Monitoring

Haemodynamic Monitoring
Theory and Practice

Physiological Background Monitoring Optimising the Cardiac Output Measuring Preload Introduction to PiCCO Technology Practical Approach Fields of Application Limitations Division of the talk into two parts: A - D: general part with basic principles of the physiology, the need for haemodynamic monitoring, the connection between preload and cardiac output and presentation of different methods of measuring preload E - H: special part on PiCCO technology with technical explanations, basic principles of thermodilution and pulse contour analysis, explanation of calculation of parameters, technical setup, physiology of PiCCO parameters and presentation of the advantages of therapy guidance by means of PiCCO using a clinical case example, also presentation of the limitations and sources of error of the individual parameters

Task of the circulatory system
Physiological Background Task of the circulatory system Pflüger 1872: ”The cardio-respiratory system fulfils the physiological task of ensuring cellular oxygen supply” Goal Reached? Yes OK Assessment of oxygen supply and demand What is the problem? Diagnosis No Therapy Why haemodynamic monitoring anyway? The task of the circulation is to supply the tissue with oxygen (recognised by Pflüger as long ago as 1872) Haemodynamic monitoring is therefore monitoring of whether the circulation is performing its task of supplying oxygen to the tissues. If it is, no further intervention is necessary. If not, haemodynamic monitoring is required for diagnosis, treatment of the disorder and monitoring the effect of therapy (in the sense of the “circulation“ referred to above). Uni Bonn

Aim: Optimal Tissue Oxygenation
Physiological Background Processes contributing to cellular oxygen supply Aim: Optimal Tissue Oxygenation Direct Control Indirect Pulmonary gas exchange Macrocirculation Microcirculation Cell function Volume Catecholamines What processes are involved in tissue oxygenation? What processes have to be optimised so that the cellular oxygen supply is optimised? For the best possible cellular oxygen supply, pulmonary gas exchange, the macrocirculation and microcirculation must be optimised. Pulmonary function and macrocirculation can be influenced specifically but this applies only partially for the microcirculation. The individual processes that have to be optimised are pulmonary gas exchange (lung), oxygen transport via the blood and oxygen delivery in the tissues. Only limited means are available for influencing these processes: ventilation, volume, catecholamines, oxygen carriers Oxygen Absorption Lungs Oxygen Transportation Blood Oxygen Delivery Tissues Oxygen Utilisation Cells / Mitochondria Oxygen carriers Ventilation

Organ specific differences in oxygen extraction
Physiological Backgound Organ specific differences in oxygen extraction SxO2 in % What happens if the need is not met? Oxygen extraction increases until an organ-specific maximum is reached. 100% extraction of the oxygen content of the blood is not possible so the oxygen supply must always be greater than consumption. If this is not the case, the tissues are undersupplied with oxygen, visible, for instance, through marked peripheral cyanosis (picture) Oxygen delivery must always be greater than consumption! 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

Physiological Background
Dependency of Oxygen Demand on delivery Behaviour of oxygen consumption and the oxygen extraction rate with decreasing oxygen supply Oxygen consumption Oxygen extraction rate What is the relationship between oxygen supply and oxygen consumption? Physiologically (when the supply is adequate), consumption is independent of the supply (left-hand part of the upper graph). If the oxygen supply diminishes, the rate of oxygen extraction can be increased to a certain degree (left-hand part of the lower graph) so that oxygen consumption remains constant initially. If the oxygen supply diminishes to a critical point (marked by the vertical dotted line), the extraction rate can no longer be increased further (right-hand part of the lower graph) and oxygen consumption falls (right-hand part of the upper graph). Since the oxygen requirement of the tissues can therefore no longer be met even with maximum oxygen extraction, tissue hypoxia occurs. DO2-independent area DO2- dependent area Decreasing Oxygen Supply DO2: Oxygen Delivery

Central role of the mixed venous oxygen saturation
Physiological Background Determinants of Oxygen Delivery and Consumption Central role of the mixed venous oxygen saturation CO SaO2 Delivery DO2: DO2 = CO x Hb x 1.34 x SaO2 Hb What factors determine the level of oxygen supply and consumption? The determinants of oxygen supply are the cardiac output, Hb level and arterial oxygen saturation (disregarding the dissolved oxygen) CO: Cardiac Output Hb: Haemoglobin SaO2: Arterial Oxygen Saturation SvO2: Mixed Venous Oxygen Saturation DO2: Oxygen Delivery VO2: Oxygen Consumption

Central role of mixed central venous oxygen saturation
Physiological Background Determinants of Oxygen Delivery and Consumption Central role of mixed central venous oxygen saturation CO SaO2 Delivery DO2: DO2 = CO x Hb x 1.34 x SaO2 Consumption VO2: VO2 = CO x Hb x 1.34 x (SaO2 - SvO2) Hb S(c)vO2 SvO2 Mixed Venous Saturation SvO2 Exactly the same parameters also determine oxygen consumption but the mixed venous oxygen saturation is also involved. In other words, when the oxygen supply remains constant (i.e. When CO, Hb and SaO2 or their product remain constant), the SvO2 is the only parameter that provides information about the relationship between oxygen supply and consumption. The SvO2 level is thus an indicator of the degree of oxygen extraction and the adequacy of the oxygen supply. CO: Cardiac Output Hb: Haemoglobin SaO2: Arterial Oxygen Saturation SvO2: Mixed Venous Oxygen Saturation DO2: Oxygen Delivery VO2: Oxygen Consumption

Oxygen delivery and its influencing factors
Physiological Background 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 The level of the oxygen supply can be influenced by various measures: Hb by transfusion of oxygen carriers

Physiological Background Oxygen delivery and its influencing factors DO2 = CaO2 x CO = Hb x 1.34 x SaO2 x CO Ventilation • Transfusion • Ventilation CO: Cardiac Output Hb: Haemoglobin SaO2: Arterial Oxygen Saturation CaO2: Arterial Oxygen Content SaO2 by ventilation / increase of inspiratory oxygen concentration

Physiological Background Oxygen delivery and its influencing factors DO2 = CaO2 x CO = Hb x 1.34 x SaO2 x CO Volume Catecholamines • Transfusion • Ventilation • Volume • Catecholamines CO: Cardiac Output Hb: Haemoglobin SaO2: Arterial Oxygen Saturation CaO2: Arterial Oxygen Content CO by administration of volume and/or catecholamines

Assessment of Oxygen Delivery
Physiological Background Assessment of Oxygen Delivery Supply DO2 = CO x Hb x 1.34 x SaO2 SaO2 CO, Hb Oxygen Absorption Lungs Oxygen Transport Blood Oxygen Delivery Tissues Oxygen Utilization Cells / Mitochondria How can the different processes that are important for tissue oxygenation be monitored from the supply and consumption aspect? Supply aspect: Oxygen absorption (lung) through SaO2 Oxygen transport (blood) and (very limited) oxygen delivery in the tissue through CO and Hb Oxygen utilisation in the tissue / cells cannot be measured using the parameters of oxygen supply. CO: Cardiac Output; Hb: Hemoglobin; SaO2: Arterial Oxygen Saturation

Physiological Background Assessment of Oxygen Delivery Supply Monitoring the CO, SaO2 and Hb is essential! SaO2 CO, Hb Oxygen Absorption Lungs Oxygen Transport Blood Oxygen Delivery Tissues Oxygen Utilization Cells / Mitochondria This means that monitoring of SaO2, Hb and CO, though essential for estimating the oxygen supply, does not allow conclusions about oxygen consumption. CO: Cardiac Output; Hb: Haemoglobin; SaO2: Arterial Oxygen Saturation

Physiological Background Assessment of Oxygen Delivery Supply Monitoring the CO, SaO2 and Hb is essential! SaO2 CO, Hb Oxygen Absorption Lungs Oxygen Transport Blood Oxygen Delivery Tissues Oxygen Utilization Cells / Mitochondria SvO2 VO2 = CO x Hb x 1.34 x (SaO2 – SvO2) When the processes involved in tissue oxygenation are considered from the consumption aspect, it becomes clear that only the mixed venous oxygen saturation can provide information (the other parameters are identical with the supply aspect) Consumption CO: Cardiac Output; Hb: Haemoglobin; SaO2: Arterial Oxygen Saturation

Physiological Background Assessment of Oxygen Delivery Supply Monitoring CO, SaO2 and Hb is essential SaO2 CO, Hb Oxygen Absorption Lungs Oxygen Transport Blood Oxygen Delivery Tissues Oxygen Utilization Cells / Mitochondria SvO2 Monitoring the CO, SaO2 and Hb does not give information re O2-consumption! That is, the systemic relationship of oxygen supply and oxygen consumption can be estimated only by additional monitoring of venous oxygen saturation. Consumption CO: Cardiac Output; Hb: Haemoglobin; SaO2: Arterial Oxygen Saturation

The adequacy of CO and SvO2 is affected by many factors
Physiological Background Balance of Oxygen Delivery and Consumption The adequacy of CO and SvO2 is affected by many factors Older Age Body weight /height Current Medical History Previous Medical History General Factors Microcirculation Disturbances Volume status Tissue Oxygen Supply Oxygenation / Hb level It is difficult to give absolute normal values for the parameters of oxygen supply and oxygen consumption, especially for CO. Whether a given CO value is adequate for the particular patient is influenced by many factors. The same holds for SvO2. It is therefore important not to consider the parameters in isolation but only in conjunction with various general and situational factors (e.g. absolute CO low but SvO2 normal: CO probably adequate for the patient but exceptions are possible, e.g. in sepsis, but the patient‘s disease is also important when assessing the parameters) Situational Factors

Therapy Extended Haemodynamic Monitoring Monitoring Optimisation
Physiological Background Extended Haemodynamic Monitoring Monitoring Optimisation O2 supply O2 consumption Therapy The purpose of extended haemodynamic monitoring thus consists of delivering parameters, which, considered together, help to identify a mismatch between oxygen supply and consumption, optimise systemic oxygen balance and confirm the effect of the therapeutic measures that have been adopted (identification of disturbances – therapy guidance – monitoring of therapy effect)

Physiological Background
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.

Physiological Background Monitoring Optimizing the Cardiac Output Measuring Preload Introduction to PiCCO Technology Practical Approach Fields of Application Limitations Introduction to the basic principles of monitoring Explanation of the need for extended haemodynamic monitoring First, presentation of standard monitoring and the limitations of the parameters with regard to assessment of oxygen metabolism

Monitoring the Vital Parameters
Respiration Rate Temperature Scenario: patient, obviously ill and without any monitoring, is in front of you. What do you do to obtain information? First, the vital parameters are recorded without using devices: respiratory rate, temperature, (pulse)

Respiration Rate ECG Temperature • Heart Rate • Rhythm Further procedure: ECG This gives information about the heart rate and rhythm, but no functional information about the circulation and oxygen transport

Respiration Rate Blood Pressure (NiBP) Temperature • no correlation with CO • no correlation with oxygen delivery ECG Application of a blood pressure cuff for non-invasive blood pressure Information about the perfusion pressure but not about the associated flow and thus not about oxygen delivery either. The blood pressure is not correlated with oxygen delivery.

MAP mmHg The Mean Arterial Pressure does not correlate with Oxygen Delivery! 150 120 90 Adequate oxygen delivery can be present even with relatively low mean arterial perfusion pressures (e.g. 50mmHg) but conversely, a “normal“ MAP of e.g. 80mmHg is no guarantee for adequate oxygen delivery 60 n= 1232 100 300 500 700 DO2 ml*m-2*min-1 30 MAP: Mean Arterial Pressure, DO2: 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

Respiration Rate Blood Pressure (NiBP) Temperature • No correlation with CO • No correlation with oxygen delivery • No correlation with volume status ECG Besides the lack of information about oxygen delivery, the MAP does not provide reliable information about the patient‘s volume status either

80% of blood volume is found in the venous blood vessels, only 20% in the arterial blood vessels! The MAP is measured in the arterial system where only approx. 20% of the entire blood volume is located. MAP thus usually reflects only 20% of total blood volume. No conclusion about the remaining 80% is possible.

Respiration Rate Blood Pressure (NiBP) • No correlation with CO • No correlation with oxygen delivery • No correlation with volume status No evidence of what is the ‘right’ perfusion pressure Temperature ECG The measured blood pressure level does not tell us if this is adequate for the indivual patient and ensures adequate tissue perfusion. (e.g. young healthy patient: MAP of 50mmHg fully adequate, elderly vascular patient may need a MAP of 80mmHg or more)

Standard Monitoring Oxygen Saturation
Respiration Rate Oxygen Saturation Temperature • No information re the O2 transport capacity • No information re the O2 utilisation in the tissues ECG NIBP Another standard monitoring parameter: arterial oxygen saturation via pulse oxymetry Important value but tells us nothing about oxygen utilisation in the tissues. Is included in calculation of oxygen delivery but allows this to be quantified only in conjunction with other parameters.

Standard Monitoring Monitoring Respiration Rate Temperature ECG NIBP
Oxygen Saturation Urine Production Blood Circulation (clinical assessment) Other elements of standard monitoring: Urine production and clinical assessment of perfusion With these two elements, only a rough qualitative estimate, if any, of tissue oxygenation is possible. No precise information and many sources of error: e.g. polyuric renal failure or pre-existing vascular disease can falsify the assessment of urine volume and tissue perfusion.

What other parameters do I need?
Monitoring Advanced Monitoring The standard parameters do not give enough information in unstable patients. What other parameters do I need? In unstable patients, the standard monitoring parameters are not sufficient for assessing tissue oxygen supply for the reasons presented. Additional parameters are required. How does one proceed?

Advanced Monitoring Invasive Blood Pressure (IBP)
• Continuous blood pressure recording • Arterial blood extraction possible • Limitations as with NiBP Insertion of an arterial cannula, invasive blood pressure measurement This allows continuous pressure measurement and arterial blood sampling for BGA but the limitations listed for non-invasive blood pressure measurement also apply here.

Advanced Monitoring Arterial BGA Information re:
IBP Information re: • Pulmonary Gas exchange • Acid Base Balance No information re oxygen supply at the cellular level Possibility of measuring arterial BGA is beneficial as the pulmonary gas exchange and acid-base balance can be assessed. However, only very limited information about the oxygen supply and use at cellular level is obtained.

Advanced Monitoring Lactate Marker for global metabolic situation
IBP Lactate Marker for global metabolic situation Significant limitations due to: • Liver metabolism • Reperfusion effects Arterial BGA The lactate level as an indicator of anaerobic glycolysis is an interesting parameter in the assessment of tissue oxygen supply. However, the validity of this parameter is limited by its dependence on liver metabolism (a rise in lactate is possible not only through the increased production of lactate but also by diminished breakdown when liver function is impaired). Moreover: rise in lactate due to diminished perfusion is often only measurable after reperfusion, that is, when the problem has already been solved (and thus too late!)

Advanced Monitoring CVP central venous blood gas analysis possible
IBP CVP central venous blood gas analysis possible When low: hypovolaemia probable When high: hypovolaemia not excluded Not a reliable parameter for volume status Arterial BGA Lactate Usually, insertion of a central venous catheter and CVP measurement in unstable patients Advantage of CVC: central venous BGA sampling possible However, value of conventional CVP measurement doubtful with regard to guiding therapy. CVP is often used to assess volume status but is often misleading in this regard: many studies show a lack of correlation between CVP and cardiac preload Conclusion possible only when CVP low: the patient is then very probably hypovolaemic Conversely, hypovolaemia is not ruled out when the CVP is high. CVP is therefore not a reliable parameter for volume status.

Advanced Monitoring ScvO2
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 CVC provides a possibility for central venous BGA sampling and measurement of central venous oxygen saturation As mentioned above, the SvO2 is a central parameter in estimating whether oxygen supply and oxygen extraction are adequate but can only be obtained through a highly invasive pulmonary artery catheter (oxygen saturation of pulmonary arterial blood). Alternatively: measurement of ScvO2 from the central venous catheter. In recent years increasingly important and used instead of SvO2, even in studies (e.g. Rivers). Measures only the blood from the upper half of the body (superior vena cava), but the level of the ScvO2 nevertheless shows good correlation with mixed venous oxygen saturation for clinical purposes. Thus a less invasive, more useful parameter for the systematic balance between oxygen supply and consumption.

Monitoring of the central venous oxygen saturation
The ScvO2 correlates well with the SvO2! ScvO2 (%) SvO2 90 90 85 80 80 70 75 60 70 50 n = 29 r = 0.866 ScvO2 = x SvO r = 0.945 65 40 30 60 Different studies show the good correlation between central and mixed venous oxygen saturation. For clinical purposes, the SvO2 can be omitted for estimating the systemic oxygenation status (if a pulmonary arterial catheter is not indicated anyway) and the ScvO2 can be used. 30 40 50 60 70 80 90 40 50 60 70 80 90 ScvO2 SvO2 (%) Reinhart K et al: Intensive Care Med 60, , 2004; Ladakis C et al: Respiration 68, , 2000

avDO2 ml/dl 7.0 6.0 4.0 3.0 2.0 1.0 r= n= 1191 avDO2= *ScvO2 ScvO2 % A low ScvO2 is a marker for increased global oxygen extraction! The significance of the ScvO2 as a parameter of the extent of oxygen extraction is also apparent from the good inverse correlation with the arteriovenous difference in oxygen content. The greater the difference between arterial and venous oxygen content – that is, oxygen extraction - the lower the ScvO2 30 40 50 60 70 80 90 100 avDO2: arterial-venous oxygen content difference, ScvO2: central venous oxygen saturation Reinhart K in: Lewis, Pfeiffer (eds): Practical Applications of Fiberoptics in Critical Care Monitoring, Springer Verlag Berlin - Heidelberg - NewYork 1990, pp 11-23

avDO2 ml/dl 7.0 CO SaO2 6.0 Delivery DO2: DO2 = CO x Hb x 1.34 x SaO2 Consumption VO2: VO2 = CO x Hb x 1.34 x (SaO2 - S(c)vO2) 7.0 Hb 4.0 Mixed / Central Venous Saturation S(c)vO2 3.0 2.0 r= n= 1191 avDO2= 12, *ScvO2 A reminder of the central role of the ScvO2 or mixed venous oxygen saturation in the assessment of the ratio between oxygen supply and consumption Because of the good correlation, the ScvO2 is given here in the formulae as an alternative to the SvO2. 1.0 ScvO2 % 30 40 50 60 70 80 90 100 avDO2: arterial-venous oxygen content difference, ScvO2: central venous oxygen saturation Reinhart K in: Lewis, Pfeiffer (eds): Practical Applications of Fiberoptics in Critical Care Monitoring, Springer Verlag Berlin - Heidelberg - NewYork 1990, pp 11-23

O2- Therapy and Sedation Intubation + Ventilation Early goal-directed therapy Rivers E et al. New Engl J Med 2001;345: Central Venous Catheter Invasive Blood Pressure Monitoring Cardiovascular Stabilisation Mortality < 8 mmHg CVP Volume therapy 8-12 mmHg < 65 mmHg MAP Vasopressors Hospital 60 days 65 mmHg The clinical significance of the central venous oxygen saturation has already been shown in several studies. The most well-known example is the Rivers study which demonstrated a clear mortality advantage in septic patients for a therapy algorithm that included the ScvO2. Both hospital and 60-day mortality was significantly lower in those patients in whom the ScvO2 was used for guiding therapy along with the CVP and MAP. < 70% Blood transfusion to Haematocrit 30% < 70% ScVO2 ScVO2 Inotropes >70%  70% yes no Therapy maintenance, regular reviews Goal achieved?

Monitoring of the ScvO2 – Clinical Relevance
However, the ScvO2 has major significance in guiding therapy not only in septic patients but also in many other disease conditions. Numerous publications about SvO2/ScvO2 in various indications (cardiogenic shock, cardiac surgery, polytrauma, intraoperative) confirm this. Significance of the ScvO2 for therapy guidance 39

Monitoring of the ScvO2 – Clinical Relevance
ScvO2 is used for early identification of disturbances of the cardiocirculatory system with impairment of tissue oxygen delivery. ScvO2 is a very rapidly reacting parameter, that can provide important evidence about disturbed global oxygen delivery very early in the disease course. 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% ScvO2 < 70% Continuous ScvO2 monitoring – CeVOX Advanced Monitoring - PiCCO The level of the ScvO2 is an important indicator for identifying a haemodynamic disturbance and can provide early evidence of disordered tissue oxygenation, for instance in sepsis. This enables correctly timed therapeutic consequences: When the ScvO2 is reduced, the oxygen supply must be increased as soon as possible (in sepsis typically by volume administration initially). Extended monitoring also necessary for monitoring therapy Re - evaluation Volume / Catecholamine Erythrocytes 41

? Tissue hypoxia despite ”normal“ or high ScvO2?
Monitoring Monitoring ScvO2 – Limitations Tissue hypoxia despite ”normal“ or high ScvO2? SxO2 in % ? Low ScvO2 indicates increased oxygen extraction but: normal ScvO2 does not always mean a good oxygen supply Especially in sepsis/SIRS, disturbances can occur in the microcirculation that interfere with oxygen extraction and utilisation in the tissues. The result is an apparently normal or even raised ScvO2, although the oxygen supply to the tissues is inadequate. ScvO2 is falsely high in these cases and does not allow any reliable conclusions about oxygen balance in the tissues. Microcirculation disturbances in SIRS / Sepsis 42 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

? Tissue hypoxia despite „normal“ or high ScvO2?
Monitoring Monitoring ScvO2 – therapeutic consequences in the example of sepsis Tissue hypoxia despite „normal“ or high ScvO2? ScvO2 Pt unstable ScvO2 < 70% ScvO2 > 80% Volume administration (when absence of contraindications) ScvO2 > 70% but < 80% ScvO2 < 70% ? Raised ScvO2 in sepsis should be regarded as a sign of disturbance of the microcirculation. What should be done when ScvO2 is raised? Re- evaluation Advanced Monitoring cont. ScvO2 monitoring Volume / Catecholamine / Erythrocytes

(when absence of contraindications) Further information needed
Monitoring Monitoring ScvO2 – therapeutic consequences in the example of sepsis Tissue hypoxia despite ”normal“ or high ScvO2? Pt unstable ScvO2 > 80% Volume bolus (when absence of contraindications) ScvO2 < 80% but > 70% ScvO2 > 80% Microcirculation? Organ perfusion? Re-evaluation First, administration of a volume bolus as with reduced ScvO2. If the ScvO2 tends to fall after this, this indicates an improvement of oxygen supply. If the raised ScvO2 persists despite administration of volume, this indicates continuing disturbances of the microcirculation and organ perfusion. In this case, further information is needed in addition to the ScvO2 to assess haemodynamics: monitoring of volume status and cardiac function (e.g. by means of PiCCO), quantification of liver function and hepatosplanchnic perfusion (ICG plasma disappearance rate), renal function. Clinical neurological assessment can also be helpful. Further information needed Macro-haemodynamics (PiCCO) Liver function (PDR – ICG) Renal function Neurological assessment 44

Monitoring Summary and Key Points 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

Physiological Background Monitoring Optimising the Cardiac Output Measuring Preload Introduction to PiCCO Technology Practical Approach Fields of Application Limitations

How can you optimise CO? Monitoring – what is the point?
Optimisation of CO Monitoring – what is the point? The haemodynamic instability is identified. What can be done for the patient (sepsis example)? 1. Step: Volume Management Aim? Optimisation of CO Recommendation of the SSC How can you optimise CO? Using monitoring, haemodynamic instability with inadequate tissue oxygen delivery has been identified. What is the aim of the therapy? The main aim is usually to optimise CO (possibly also to increase the perfusion pressure) While it is relatively easy to increase and measure the perfusion pressure, optimising the CO proves more difficult. How can CO be optimised? 47

Frank-Starling mechanism
Optimisation of CO Monitoring – what is the point? Optimisation of CO Preload Contractility Afterload Chronotropy To optimise the CO, four determinants must be taken into account. The preload and contractility are the primary determinants of cardiac ejection (stroke volume). The association between these two parameters is described by the Frank-Starling mechanism. Frank-Starling mechanism 48

Preload, CO and Frank-Starling Mechanism
Optimisation of CO Preload, CO and Frank-Starling Mechanism SV V SV SV V Normal contractility SV V Representation of the association between cardiac preload (ventricular end-diastolic filling volume) and stroke volume: up to a certain limit, the stroke volume increases with increasing preload (area of volume responsiveness). The optimal filling volume is reached when a further increase of the preload leads to no further or only a slight increase in stroke volume (target area). If there is a further increase in preload beyond this point, there is then a fall in the stroke volume as the cardiac muscle is over-stretched and so loses some of its contractility (volume overload). This curve can demonstrate different slopes and different areas for volume responsiveness and volume overload depending on the contractility of the ventricle. volume responsive target area volume overloaded Preload 49

Optimisation of CO Preload, CO and Frank-Starling Mechanism SV SV V Normal contractility SV V Poor contractility With low contractility, the Frank-Starling curve is flatter, i.e. when contractility is low, the same increase in preload leads to a smaller increase in stroke volume than with normal contractility. The ventricle with impaired contractility usually requires a higher preload volume to achieve its maximum ejection, but reacts more sensitively to volume overload so that the target area overall is usually narrower and shifted to the right compared to a ventricle with normal contractility. volume responsive target area volume overloaded Preload 50

Optimisation of CO Preload, CO and Frank-Starling Mechanism SV High contractility SV V Normal Contractility SV V Poor contractility When contractility is high, the course of the curve is steeper so that an identical increase in preload leads to a greater increase in stroke volume compared to normal contractility. The maximal stroke volume is reached at a low end-diastolic filling volume and the ventricle is less sensitive to volume overload so when the preload is increased excessively, it reacts later with a fall in stroke volume than the normally contractile ventricle. volume responsive target area volume overloaded Preload 51

In order to optimise the CO you must know what the preload is!
Optimisation of CO Preload, CO and Frank-Starling Mechanism SV V SV SV V SV V volume responsive target area volume overloaded Preload Measurement of CO on its own does not allow the location on the Frank-Starling curve to be determined. In order to estimate the area where the individual patient‘s heart is located, the preload must be measured. In order to optimise the CO you must know what the preload is! 52

Optimisation of CO Summary and Key Points 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

Volume Responsiveness
Measuring Preload Volumetric Preload Parameters, Volume Responsiveness and Filling Pressures Preload Volumetric Preload parameters GEDV / ITBV Volume Responsiveness SVV / PPV Filling Pressures CVP / PCWP What parameters are available for measuring the preload? - classical parameters: cardiac filling pressures CVP (via CVC) and PCWP (via pulmonary arterial catheter) - static volumetric preload parameters: GEDV (global end-diastolic volume and ITBV (intrathoracic blood volume) - dynamic parameters SVV (stroke volume variation) and PPV (pulse pressure variation). In the narrower sense, these are not preload parameters but parameters of the heart‘s preload responsiveness (reaction of cardiac stroke volume to volume administration) 55

Correlation between Central Venous Pressure CVP and Stroke Volume
Measuring Preload Role of the filling pressures CVP / PCWP Correlation between Central Venous Pressure CVP and Stroke Volume The relevance of the filling pressures for assessing cardiac preload has long been disputed and has been refuted in numerous publications. Neither the absolute level of the CVP (shown on left) nor the changes in CVP (shown on right) correlate with stroke volume. CVP therefore not suitable for assessing volume status. Kumar et al., Crit Care Med 2004;32: 56

Measuring Preload Role of the filling pressures CVP / PCWP Correlation between Pulmonary Capillary Wedge Pressure PCWP and Stroke Volume The pulmonary capillary wedge pressure (PCWP) and alterations of this do not show any correlation with cardiac ejection either. Thus measurement of cardiac preload is not possible by means of the traditionally employed PCWP either. Kumar et al., Crit Care Med 2004;32: 57

Measuring Preload Role of the filling pressures CVP / PCWP 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: ). Pressure is not volume! Influencing Factors: Ventricular compliance Position of catheter (PAC) Mechanical ventilation Intra-abdominal hypertension FACCT study by the ARDS Networks, published in the New England Journal of Medicine: no difference in the outcome of ARDS patients with CVP-guided fluid management and those with volume therapy guided by the PCWP. Better: measure volumes directly instead of estimating them from the pressure measurement. The level of the filling pressures is subject to many influencing factors so a valid statement about volume status is not possible. Only exception: low filling pressures indicate hypovolaemia 58

Volume Responsiveness Volumetric Preload parameters
Measuring Preload Role of the volumetric preload parameters GEDV / ITBV Preload Volume Responsiveness SVV / PPV Filling Pressures CVP / PCWP Volumetric Preload parameters GEDV / ITBV Introduction to the volumetric preload parameters. These allow direct measurement of the cardiac filling volume so that this does not have to be estimated through a pressure measurement. 59

GEDV = Global Enddiastolic Volume
Measuring Preload Role of the volumetric preload parameters GEDV / ITBV GEDV = Global Enddiastolic Volume Lungs Pulmonary Circulation Left heart Right Heart The global end-diastolic volume consists of the end-diastolic volumes of all four cardiac chambers. Even if this volume does not exist physiologically (diastole of all four cardiac chambers is not simultaneous), it does reflect the filling status of the heart and is a valid parameter of cardiac preload compared to the filling pressures. Body Circulation Total volume of blood in all 4 heart chambers 60

GEDV shows good correlation with the stroke volume
Measuring Preload Role of the volumetric preload parameters GEDV / ITBV GEDV shows good correlation with the stroke volume The correlation of the global end-diastolic volume with the cardiac stroke volume is considerably better than with CVP or PCWP. GEDV is thus much better suited for measuring the cardiac preload. Michard et al., Chest 2003;124(5): 61

ITBV = Intrathoracic Blood Volume
Measuring Preload Role of the volumetric preload parameters GEDV / ITBV ITBV = Intrathoracic Blood Volume Lungs Pulmonary Circulation Left heart Right heart Body Circulation The intrathoracic blood volume corresponds to the global end-diastolic blood volume plus the blood in the pulmonary circulation. ITBV =GEDV + PBV Total volume of blood in all 4 heart chambers plus the pulmonary blood volume 62

ITBV is normally 1.25 times the GEDV
Measuring Preload Role of the volumetric preload parameters GEDV / ITBV ITBV is normally 1.25 times the GEDV ITBVTD (ml) 1000 2000 3000 ITBV = 1.25 * GEDV – 28.4 [ml] The intrathoracic blood volume is usually 25% higher than the global end-diastolic blood volume. A linear association has been demonstrated for the two parameters. The ITBV can therefore be calculated from the GEDV. GEDV (ml) GEDV vs. ITBV in 57 Intensive Care Patients Sakka et al, Intensive Care Med 2000; 26: 63

The static volumetric preload parameters GEDV and ITBV
Measuring Preload Role of the volumetric preload parameters GEDV / ITBV The static volumetric preload parameters GEDV and ITBV 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) The German Sepsis Society confirms in its official guidelines that volumetric parameters are superior to the classical filling pressures for assessing cardiac preload. GEDV and ITBV are not falsified by extravascular pressure influences, in contrast to CVP and PCWP. 64

Volumetric Preload parameters Volume Responsiveness
Measuring Preload Role of the dynamic volume responsiveness parameters SVV / PPV Preload Filling Pressures CVP / PCWP Volumetric Preload parameters GEDV / ITBV Volume Responsiveness SVV / PPV The parameters stroke volume variation (SVV) and pulse pressure variation (PPV) are not preload parameters in the narrower sense but parameters of the heart‘s preload responsiveness. They thus provide information on whether the heart will respond to volume administration with an increase in cardiac stroke volume. They can help to determine whether volume administration is useful to increase cardiac output. 65

Fluctuations in blood pressure during the respiration cycle
Measuring Preload Physiology of the dynamic parameters of volume responsiveness Fluctuations in blood pressure during the respiration cycle Early Inspiration Late Inspiration Intrathoracic pressure „Squeezing “ of the pulmonary blood Left ventricular preload Left ventricular stoke volume Systolic arterial blood pressure Intrathoracic pressure Venous return to left and right ventricle Left ventricular preload Left ventricular stroke volume Systolic arterial blood pressure Inspiration Expiration Inspiration Expiration Everyone knows the “fluctuation“ of the arterial pressure curve in hypovolaemic patients, that is, the fluctuation in pulse pressure amplitude with the respiratory cycle. This is due to ventilation-induced preload changes, which are more marked, the more hypovolaemic the patient is. PPmax PPmin PPmax PPmin 66 Reuter et al., Anästhesist 2003;52:

Fluctuations in stroke volume throughout the respiratory cycle
Measuring Preload Physiology of the dynamic parameters of volume responsiveness Fluctuations in stroke volume throughout the respiratory cycle SV SV SV Preload V V An identical preload change (x-axis) leads to different changes in the stroke volume (y-axis) depending on the area of the Frank-Starling curve in which the heart is working. The more hypovolaemic the patient, the greater the stroke volume variation and pulse pressure variation. The SVV and PPV can be measured correctly only if the induced preload changes are always the same and no other fluctuations in the stroke volume occur. For correct measurement of SVV and PPV the patient‘s ventilation must be completely controlled (no spontaneous breathing) and there has to be a regular sinus rhythm. Mechanical Ventilation Intrathoracic pressure fluctuations Changes in intrathoracic blood volume Preload changes Fluctuations in stroke volume 67

SVV = Stroke Volume Variation
Measuring Preload Role of the dynamic volume responsiveness parameters SVV / PPV SVV = Stroke Volume Variation SVmax SVmin SVmean mean The variation in stroke volume over the respiratory cycle Correlates directly with the response of the cardiac ejection to preload increase (volume responsiveness) 68

SVV is more accurate for predicting volume responsiveness than CVP
Measuring Preload Role of the dynamic volume responsiveness parameters SVV / PPV SVV is more accurate for predicting volume responsiveness than CVP Sensitivity 1 0,8 0,6 0,4 - - - CVP ___ SVV 0,2 The illustration shows that the SVV has considerably greater sensitivity and specificity for assessing volume responsiveness than CVP. According to the graph, the probability of predicting volume responsiveness correctly with the CVP is 50%, thus equivalent to tossing a coin. 0,5 Specificity 1 Berkenstadt et al, Anesth Analg 92: , 2001 69

PPV = Pulse Pressure Variation
Measuring Preload Role of the dynamic volume responsiveness parameters SVV / PPV PPV = Pulse Pressure Variation PPmean PPmax PPmin The variation in pulse pressure amplitude over the respiration cycle Correlates equally well as SVV for volume responsiveness 70

Measuring Preload Role of the dynamic volume responsiveness parameters SVV / PPV A PPV threshold of 13% differentiates between responders and non-responders to volume administration respiratory changes in arterial pulse pressure (%) Non – Responders n = 24 This study showed how the PPV can distinguish the reaction of cardiac ejection to volume administration (preload increase). A value of 13% differentiates between responders (PPV>13%) and non-responders (PPV<13%) to volume administration. Responders n = 16 Michard et al, Am J Respir Crit Care Med 162, 2000 71

The dynamic volume responsiveness parameters SVV and PPV
Measuring Preload Role of the dynamic volume responsiveness parameters SVV / PPV The dynamic volume responsiveness parameters SVV and PPV 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 Despite the limitations, PPV and SVV are valuable parameters for optimising the patient‘s volume status. 72

EVLW = Extravascular Lung Water
Role of extravascular lung water EVLW EVLW = Extravascular Lung Water Lungs Pulmonary circulation Left Heart Right Heart Brief presentation of another parameter that is not a preload parameter but is nevertheless highly important for guiding volume management: Extravascular lung water signifies the water content of the lungs outside the blood vessels. The EVLW therefore consists of the interstitial, intracellular and intraalveolar water of lung tissue. Body circulation Extravascular water content of the lung 73

The Extravascular Lung Water EVLW
Role of extravascular lung water EVLW The Extravascular Lung Water EVLW 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 Pulmonary oedema can be diagnosed with certainty and its severity determined with the extravascular lung water. The parameter can be measured at the bedside using thermodilution, in contrast to conventional methods such as chest X-ray. The level of lung water and changes in this can provide important information for guiding volume therapy, as the point of time from which volume therapy leads to the development of pulmonary oedema can be identified. 74

Measuring Preload Summary and Key Points 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). 75

E. Introduction to PiCCO Technology Principles of function Thermodilution Pulse contour analysis Contractility parameters Afterload parameters Extravascular lung water Pulmonary permeability

Differentiated Volume Management
Introduction to the PiCCO-Technology Parameters for guiding volume therapy Contractility Volumetric preload static - dynamic Differentiated Volume Management CO EVLW For differentiated volume management of the patient, knowledge of a number of haemodynamic and volumetric parameters is required. Only one monitoring method is available currently that allows measurement of all these parameters: PiCCO. PiCCO Technology

Principles of Measurement
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 PULSIOCATH arterial thermodilution catheter 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. Right Heart Left Heart PULSIOCATH PULSIOCATH Body Circulation

Principles of Measurement
Introduction to the PiCCO-Technology – Function Principles of Measurement After central venous injection the cold bolus sequentially passes through the various intrathoracic compartments Bolus injection RA RV LA LV PBV EVLW concentration changes over time (Thermodilution curve) 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. Right heart Lungs Left heart The temperature change over time is registered by a sensor at the tip of the arterial catheter

Intrathoracic Thermal Volume (ITTV) Pulmonary Thermal Volume (PTV)
Introduction to the PiCCO-Technology – Function Intrathoracic Compartments (mixing chambers) Intrathoracic Thermal Volume (ITTV) Pulmonary Thermal Volume (PTV) RA RV LA LV PBV EVLW 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. Largest single mixing chamber Total of mixing chambers

E. Introduction to PiCCO Technology Principles of function Thermodilution Pulse contour analysis Contractility parameters Afterload parameters Extravascular Lung Water Pulmonary Permeability

(Tb - Ti) x Vi x K COTD a = D Tb x dt
Introduction to the PiCCO-Technology – Thermodilution Calculation of the Cardiac Output The CO is calculated by analysis of the thermodilution curve using the modified Stewart-Hamilton algorithm Tb Injection t (Tb - Ti) x Vi x K COTD a = D Tb x dt ∫ 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. Tb = Blood temperature Ti = Injectate temperature Vi = Injectate volume ∫ ∆ Tb . dt = Area under the thermodilution curve K = Correction constant, made up of specific weight and specific heat of blood and injectate

Thermodilution curves
Introduction to the PiCCO-Technology – Thermodilution Thermodilution curves The area under the thermodilution curve is inversely proportional to the CO. Temperature 36,5 Normal CO: 5.5l/min 37 Temperature Time 36,5 low CO: 1.9l/min 37 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 arrives sooner at the thermistor so the curve is shifted to the left compared to the normal and reduced CO. The reverse applies for a reduced CO, so the curve is shifted to the right. Temperature Time 36,5 High CO: 19l/min 37 5 10 Time

Transpulmonary TD (PiCCO) Pulmonary Artery TD (PAC)
Introduction to the PiCCO –Technology – Thermodilution Transpulmonary vs. Pulmonary Artery Thermodilution Transpulmonary TD (PiCCO) Pulmonary Artery TD (PAC) Aorta PA Pulmonary Circulation Lungs LA central venous bolus injection RA LV PULSIOCATH arterial thermo-dilution catheter RV Right Heart Left heart The principle of thermodilution with the PiCCO technology is identical to the pulmonary artery catheter (PAC), However, while the temperature bolus is detected in the pulmonary artery with the PAC, this takes place in a large peripheral artery (femoral, axillary or brachial) with the PiCCO system after passage through the heart and lungs. With both methods, not the entire injected indicator flows past the thermistor since this is in a branch of the pulmonary artery. This has no influence on the validity of the result with either measurement method as the detected amount of the indicator is not relevant but rather the difference in temperature over time. Pictorial comparison: a stone falls into smooth water and generates a wave that spreads in all directions. The height of the wave can be measured at any location but the same result will always be obtained. Body Circulation 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!

Validation of the Transpulmonary Thermodilution
Introduction to the PiCCO –Technology – Thermodilution Validation of the Transpulmonary Thermodilution Comparison with Pulmonary Artery Thermodilution n (Pts / Measurements) r bias ±SD(l/min) Friedman Z et al., Eur J Anaest, 2002 17/102 -0,04 ± 0,41 0,95 Della Rocca G et al., Eur J Anaest 14, 2002 60/180 0,13 ± 0,52 0,93 Holm C et al., Burns 27, 2001 23/218 0,32 ± 0,29 0.98 Bindels AJGH et al., Crit Care 4, 2000 45/283 0,49 ± 0,45 0,95 Sakka SG et al., Intensive Care Med 25, 1999 37/449 0,68 ± 0,62 0,97 Gödje O et al., Chest 113 (4), 1998 30/150 0,16 ± 0,31 0,96 McLuckie A. et a., Acta Paediatr 85, 1996 9/27 0,19 ± 0,21 - / - The thermodilution measurement of CO with the PiCCO system has been validated in numerous studies against the established methods, pulmonary artery thermodilution and direct Fick method (gold standard). All of these studies indicate the accuracty of PiCCO measurement of CO by thermodilution. Comparison with the Fick Method Pauli C. et al., Intensive Care Med 28, 2002 18/54 0,03 ± 0,17 0,98 Tibby S. et al., Intensive Care Med 23, 1997 24/120 0,03 ± 0,24 0,99

Extended analysis of the thermodilution curve
Introduction to the PiCCO-Technology – Thermodilution Extended analysis of the thermodilution curve From the characteristics of the thermodilution curve it is possible to determine certain time parameters Tb Injection Recirculation In Tb e-1 MTt DSt t However, not only the CO but other volume parameters can be calculated from the thermodilution curve. The curve undergoes extended analysis and two time parameters are determined: MTt Mean transit time, time from injection to the point at which the thermodilution curve has fallen to 75% of its maximum. This corresponds to the average time that the indicator requires from injection to detection. DST: Downslope time, time in which the thermodilution curve falls from 75% of its maximum to 25% of its maximum. This period represents the mixing behaviour of the indicator in the largest single mixing chamber. The theoretical principles of indicator dilution are very complex but already long familiar (Newman 1951) and validated. 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 Tb = blood temperature; lnTb = logarithmic blood temperature; t = time

Intrathoracic Thermal Volume Pulmonary Thermal Volume
Introduction to the PiCCO-Technology – Thermodilution Calculation of ITTV and PTV By using the time parameters from the thermodilution curve and the CO ITTV and PTV can be calculated Tb Injection Recirculation In Tb e-1 MTt DSt t If the cardiac output is multiplied by the mean transit time, the intrathoracic thermal volume (ITTV) is obtained. This is the total distribution volume for cold in the thorax. The volume of the biggest single mixing chamber for cold in the thorax, the pulmonary thermal volume (PTV), is obtained by multiplying the CO by the downslope time. Intrathoracic Thermal Volume ITTV = MTt x CO Pulmonary Thermal Volume PTV = Dst x CO

Intrathoracic Thermal Volume (ITTV) Pulmonary Thermal Volume (PTV)
Einführung in die PiCCO-Technologie – Thermodilution Calculation of ITTV and PTV Intrathoracic Thermal Volume (ITTV) Pulmonary Thermal Volume (PTV) RA RV LA LV PBV EVLW Repeat of the diagram of the individual compartments. The ITTV refers to the sum of all the mixing chambers in the thorax, that is, the total intrathoracic distribution volume for cold. The PTV represents the largest single mixing chamber in the thorax, the pulmonary theramal volume, which consists of the blood volume of the pulmonary circulation (pulmonary blood volume, PBV) and the extravascular lung water (EVLW). PTV = Dst x CO ITTV = MTt x CO

Global End-diastolic Volume (GEDV)
Introduction to the PiCCO –Technology – Thermodilution Volumetric preload parameters – GEDV Global End-diastolic Volume (GEDV) ITTV PTV RA RV LA LV PBV EVLW GEDV If the pulmonary thermal volume is now subtracted from the intrathoracic thermal volume, the total blood volume in all 4 cardiac chambers is obtained. This is also called the global end-diastolic volume. This is a volumetric parameter that gives information about the filling condition of the heart and thus about cardiac preload. GEDV is the difference between intrathoracic and pulmonary thermal volumes

Intrathoracic Blood Volume (ITBV)
Introduction to the PiCCO –Technology – Thermodilution Volumetric preload parameters – ITBV Intrathoracic Blood Volume (ITBV) GEDV RA RV LA LV PBV EVLW PBV ITBV If the blood volume present in the pulmonary circulation (pulmonary blood volume, PBV) is now added to the global end-diastolic volume, the intrathoracic blood volume is obtained. This thus represents the total blood volume present in the heart and pulmonary circulation. ITBV is the total of the Global End-Diastolic Volume and the blood volume in the pulmonary vessels (PBV)

ITBV is calculated from the GEDV by the PiCCO Technology
Introduction to the PiCCO-Technology – Thermodilution Volumetric preload parameters – ITBV ITBV is calculated from the GEDV by the PiCCO Technology Intrathoracic Blood Volume (ITBV) ITBVTD (ml) 1000 2000 3000 ITBV = 1.25 * GEDV – 28.4 [ml] The intrathoracic blood volume can be measured either directly by double indicator dilution or – as with PiCCO technology – calculated reliably from the GEDV. The ITBV is usually 25% higher than the GEDV. GEDV (ml) GEDV vs. ITBV in 57 Intensive Care Patients Sakka et al, Intensive Care Med 26: , 2000

Summary and Key Points - Thermodilution
Introduction to the PiCCO-Technology 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.

Calibration of the Pulse Contour Analysis
Introduction to the PiCCO-Technology – Pulse contour analysis Calibration of the Pulse Contour Analysis The pulse contour analysis is calibrated through the transpulmonary thermodilution and is a beat to beat real time analysis of the arterial pressure curve Transpulmonary Thermodilution Pulse Contour Analysis Injection The continuous pulse contour analysis is calibrated by transpulmonary thermodilution measurement. The stroke volume obtained with thermodilution is placed in relation to the area under the systolic part of the arterial pulse curve. Using this calibration, the cardiac output can then be determined continuously from the arterial pressure curve (pulse contour). COTPD = SVTD HR T = blood temperature t = time P = blood pressure

( Parameters of Pulse Contour Analysis   P(t) dP PCCO = cal • HR •
Introduction to the PiCCO-Technology – Pulse contour analysis Parameters of Pulse Contour Analysis Cardiac Output   Area under the pressure curve P(t) Shape of the pressure curve dP Patient- specific calibration factor (determined by thermodilution) PCCO = cal • HR • ( + C(p) • Aortic compliance ) dt SVR dt Besides the area under the pressure curve and other factors, calculation of the continuous PiCCO pulse contour cardiac output also involves the aortic compliance measured by thermodilution, which represents an important advantage compared to systems that cannot be calibrated. Systole Heart rate

Validation of Pulse Contour Analysis
Introduction to the PiCCO-Technology – Pulse contour analysis Validation of Pulse Contour Analysis Comparison with pulmonary artery thermodilution n (Pts / Measurements) bias ±SD (l/min) r Mielck et al., J Cardiothorac Vasc Anesth 17 (2), 2003 22 / 96 -0,40 ± 1,3 - / - Rauch H et al., Acta Anaesth Scand 46, 2002 25 / 380 0,14 ± 0,58 - / - Felbinger TW et al., J Clin Anesth 46, 2002 20 / 360 -0,14 ± 0,33 0,93 Della Rocca G et al., Br J Anaesth 88 (3), 2002 62 / 186 -0,02 ± 0,74 0,94 Gödje O et al., Crit Care Med 30 (1), 2002 24 / 517 -0,2 ± 1,15 0,88 The PiCCO pulse contour cardiac output has been validated in numerous studies against the gold standard of pulmonary artery thermodilution All of these studies demonstrate the accuracy of continuous CO measurement using the PiCCO pulse contour algorithm. Zöllner C et al., J Cardiothorac Vasc Anesth 14 (2), 2000 19 / 76 0,31 ± 1,25 0,88 Buhre W et al., J Cardiothorac Vasc Anesth 13 (4), 1999 12 / 36 0,03 ± 0,63 0,94

Parameters of Pulse Contour Analysis
Introduction to the PiCCO-Technology – Pulse Contour Analysis Parameters of Pulse Contour Analysis Dynamic parameters of volume responsiveness – Stroke Volume Variation SVmax SVmin SVmean SVmax – SVmin Besides CO, the PiCCO also measures the dynamic parameters of volume responsiveness from the arterial pressure curve. To do this, the stroke volumes are measured over a period of 30 seconds and the stroke volume variation is calculated from this. This gives very reliable information on whether the heart will respond to an increase in preload with an increase in ejection. SVV = SVmean The Stroke Volume Variation is the variation in stroke volume over the ventilatory cycle, measured over the previous 30 second period.

Parameters of Pulse Contour Analysis
Introduction to the PiCCO-Technology – Pulse Contour Analysis Parameters of Pulse Contour Analysis Dynamic parameters of volume responsiveness – Pulse Pressure Variation PPmax PPmin PPmean PPmax – PPmin The pulse pressure variation is determined similarly to the stroke volume variation. This too is a reliable parameter of volume responsiveness. PPV = PPmean The pulse pressure variation is the variation in pulse pressure over the ventilatory cycle, measured over the previous 30 second period.

Summary pulse contour analysis - CO and volume responsiveness
Introduction to the PiCCO-Technology – Pulse contour analysis 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

Introduction to the PiCCO-Technology – Contractility parameters
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) kg Besides the static and dynamic preload parameters, contractility is a measure of the performance of the heart muscle and is a further important determinant of cardiac output. PiCCO technology provides several parameters: Continuous measurement of the maximum rate of pressure increase of the arterial pulse curve (dPmx) Determination of the global ejection fraction (GEF) and cardiac function index (CFI) from the thermodilution.

Contractility parameter from the pulse contour analysis
Introduction to the PiCCO-Technology – Contractility parameters Contractility parameter from the pulse contour analysis dPmx = maximum velocity of pressure increase The maximum slope of the arterial pressure rise can be determined from the pulse contour curve. This represents a preload-dependent gauge for the contractility of the heart. With a very low (defective filling) and very high preload (overstretching), the rise in pressure will be slower than with a normal filling state even when the contractility itself is the same. The contractility parameter dPmx represents the maximum velocity of left ventricular pressure increase.

Contractility parameter from the pulse contour analysis
Introduction to the PiCCO-Technology – Contractility parameters Contractility parameter from the pulse contour analysis dPmx = maximum velocity of pressure increase femoral dP/max [mmHg/s] 2000 n = 220 y = (0,8* x) r = 0,82 p < 0,001 1500 1000 500 500 1000 1500 2000 LV dP/dtmax [mmHg/s] The parameter dPmx was validated in cardiac surgery patients against direct left ventricular pressure measurement. The correlation between the two methods was very good so that dPmx represents an ideal, less invasive and continuous possibility for assessing left ventricular contractility. de Hert et al., JCardioThor&VascAnes 2006 dPmx was shown to correlate well with direct measurement of velocity of left ventricular pressure increase in 70 cardiac surgery patients

Contractility parameters from the thermodilution measurement GEF = Global Ejection Fraction LA 4 x SV GEF = GEDV RA LV RV PiCCO measures other contractility parameters from the thermodilution measurement. The quotient of four times the stroke volume and the total preload volume GEDV is called the global ejection fraction (GEF). GEF thus gives the theoretical relationship between the total stroke volume and total preload volume of the heart. This parameter does not exist physiologically so the normal range (25-35%) deviates from the physiologically normal left ventricular ejection fraction (50-60%). The GEF is a parameter of global myocardial contractility; this means that no differentiation between a left ventricular and right ventricular reduction in contractility is possible. is calculated as 4 times the stroke volume divided by the global end-diastolic volume reflects both left and right ventricular contractility

Contractility parameters from the thermodilution measurement
Introduction to the PiCCO-Technology – Contractility parameters Contractility parameters from the thermodilution measurement GEF = Global Ejection Fraction sensitivity 1 15 18 12 8 0,8 19 16 10 5 0,6 20 D FAC, % 0,4 22 -20 -10 10 20 -5 0,2 -10 r=076, p<0,0001 n=47 0,2 0,4 0,6 0,8 1 specifity -15 The PiCCO GEF was validated against the gold standard TEE and good correlation was demonstrated in patients without isolated right heart failure. D GEF, % Combes et al, Intensive Care Med 30, 2004 Comparison of the GEF with the gold standard TEE measured contractility in patients without right heart failure

Contractility parameters from the thermodilution measurement CFI = Cardiac Function Index CI CFI = GEDVI is the CI divided by global end-diastolic volume index is - similar to the GEF – a parameter of both left and right ventricular contractility Another contractility parameter obtained from thermodilution measurement is the cardiac function index (CFI). As with the GEF, the ejection volume (cardiac index, CI) is brought into relation with the preload volume. For calculating the CFI, unlike the GEF, the heart rate is taken into account so that the CFI is a somewhat more global parameter of cardiac performance than GEF. As with the GEF, the CFI does not allow differentiation between left ventricular and right ventricular contractility.

Contractility parameters from the thermodilution measurement
Introduction to the PiCCO-Technology – Contractility parameters Contractility parameters from the thermodilution measurement CFI = Cardiac Function Index sensitivity 1 4 3 2 15 3,5 0,8 10 5 0,6 5 D FAC, % 0,4 -20 -10 10 20 6 -5 0,2 -10 r=079, p<0,0001 n=47 0,2 0,4 0,6 0,8 -15 1 specificity Like the GEF, the CFI was validated against echocardiography, where good correlation was found with contractility as measured by echocardiography. Both GEF and CFI reflect the global contractility of the heart. In this function, both parameters can be used well as an indicator of the need for echocardiographic investigations: If the GEF and/or CFI are normal, the left and right ventricular contractility of the heart is probably normal If the GEF and/or CFI are reduced, echocardiography is indicated to differentiate between a left and right ventricular disturbance of contractility. D GEF, % Combes et al, Intensive Care Med 30, 2004 CFI was compared to the gold standard TEE measured contractility in patients without right heart failure

E. Introduction to PiCCO technology Functions Thermodilution Pulse contour analysis Contractility parameters Afterload parameters Extravascular Lung Water Pulmonary Permeability

(MAP – CVP) x 80 SVR = CO Afterload parameter
Introduction to the PiCCO –Technology – Afterload parameter Afterload parameter SVR = Systemic Vascular Resistance (MAP – CVP) x 80 SVR = CO 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 A further important haemodynamic parameter, which is helpful for differentiated volume and catecholamine therapy, is calculation of the systemic vascular resistance by PiCCO. This requires input of the central venous pressure. MAP = Mean Arterial Pressure CVP = Central Venous Pressure CO = Cardiac Output 80 = Factor for correction of units

Introduction to the PiCCO –Technology – Contractility and Afterload
Summary and Key Points 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

E. Introduction to PiCCO technology Principles of function Thermodilution Pulse contour analysis Contractility parameters Afterload parameters Extravascular Lung Water Pulmonary Permeability

ITTV – ITBV = EVLW Calculation of Extravascular Lung Water (EVLW)
Introduction to the PiCCO –Technology – Extravascular Lung Water Calculation of Extravascular Lung Water (EVLW) ITTV – ITBV = EVLW To detect and quantify pulmonary oedema, PiCCO technology measures the extravascular lung water, which represents the water content of the lungs outside the blood vessels. It corresponds to the difference between the total intrathoracic distribution volume for cold (ITTV) and the blood volume in the thorax (ITBV). 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.

Validation of Extravascular Lung Water
Introduction to the PiCCO –Technology – Extravascular Lung Water Validation of Extravascular Lung Water 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 Gravimetry Dye dilution ELWI by PiCCO ELWIST (ml/kg) Y = 1.03x 40 25 30 20 n = 209 r = 0.96 15 20 10 PiCCO measurement of the extravascular lung water was validated against the reference methods, gravimetry (in sheep) and dye dilution. Correlation excellent for clinical purposes was demonstrated between the much simpler PiCCO thermodilution measurement and the reference methods. 10 5 R = 0,97 P < 0,001 10 20 30 5 10 15 20 25 ELWI by gravimetry ELWITD (ml/kg) Katzenelson et al,Crit Care Med 32 (7), 2004 Sakka et al, Intensive Care Med 26: , 2000

EVLW as a quantifier of lung edema
Introduction to the PiCCO –Technology – Extravascular Lung Water EVLW as a quantifier of lung edema High extravascular lung water is not reliably identified by blood gas analysis ELWI (ml/kg) 30 20 10 The extravascular lung water cannot be assessed reliably with conventional clinical methods. Blood gas analysis, which is frequently used in routine clinical practice for quantification does not correlate in any way with the extravascular lung water. i.e. the presence or extent of pulmonary oedema cannot be concluded from an impairment of oxygenation and vice versa. 50 150 250 350 450 550 PaO2 /FiO2 Boeck J, J Surg Res 1990;

Extravascular lung water index (ELWI) normal range: 3 – 7 ml/kg
Introduction to the PiCCO –Technology – Extravascular Lung Water EVLW as a quantifier of lung oedema Extravascular lung water index (ELWI) normal range: 3 – 7 ml/kg Pulmonary oedema Normal range ELWI = 19 ml/kg ELWI = 7 ml/kg X-ray of the lung is also often difficult to interpret, especially in the supine patient. Pulmonary shadowing is not the same as pulmonary oedema (right) but can also be due e.g. to a pleural effusion. Conversely, severe pulmonary oedema can be present (top left) without this being particularly obvious on the X-ray. As the pictures on the left show, the degree of radiographic shadowing does not correlate with the severity of the pulmonary oedema. ELWI = 14 ml/kg ELWI = 8 ml/kg

EVLW as a quantifier of lung oedema
Introduction to the PiCCO –Technology – Extravascular Lung Water EVLW as a quantifier of lung oedema Chest x ray – does not reliably quantify pulmonary oedema and is difficult to judge, particularly in critically ill patients D radiographic score r = 0.1 p > 0.05 80 60 40 20 -15 -10 10 15 -20 D ELWI It was shown as long ago as 1985 that the degree of pulmonary shadowing in supine patients determined by radiographic scores does not correlated with the water content of the lungs. -40 -60 -80 Halperin et al, 1985, Chest 88: 649

Relevance of EVLW Assessment
Introduction to the PiCCO –Technology – Extravascular Lung Water 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 Mortality (%) 20 n = 81 40 50 60 70 80 6 - 8 8 - 10 > 20 90 100 Mortality(%) 10 n = 373 *p = 0.002 20 30 40 50 60 70 80 Measurement of the extravascular lung water is important not only for quantification of pulmonary oedema and thus for guiding therapy. The relevance of the parameter EVLW is also apparent in the good correlation with the mortality of intensive care patients. EVLW is thus a good predictor for the patient‘s prognosis. < 7 n = 45 n = 174 n = 100 > 21 n = 54 ELWI (ml/kg) Sturm J in: Lewis, Pfeiffer (eds): Practical Applications of Fiberoptics in Critical Care Monitoring, Springer Verlag Berlin - Heidelberg - NewYork 1990, pp Sakka et al , Chest 2002

Relevance of EVLW Assessment
Introduction to the PiCCO –Technology – Extravascular Lung Water 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 Intensive Care days * p ≤ 0,05 n = 101 * p ≤ 0,05 Inclusion of lung water in the therapeutic strategy has a great influence on the patient‘s outcome. In this study, PCWP-guided therapy was compared with EVLW-guided management in a mixed intensive care patient population. The patients in the EVLW group had a significantly shorter ventilation time and length of ICU stay. Besides the improved patient outcome, this also means a high potential for cost savings. 22 days 9 days 15 days 7 days PAC Group EVLW Group PAC Group EVLW Group Mitchell et al, Am Rev Resp Dis 145: , 1992

EVLW PVPI = PBV Differentiating Lung Oedema
Introduction to PiCCO Technology – Pulmonary Permeability Differentiating Lung Oedema PVPI = Pulmonary Vascular Permeability Index EVLW EVLW PVPI = PBV PBV 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) Not only the degree of pulmonary oedema but also identification of its cause is important for guiding treatment. PiCCO technology measures the pulmonary vascular permeability index (PVPI), which provides information about the ratio between extravascular lung water and pulmonary blood volume. This ratio is a measure of the permeability of the pulmonary vascular bed, thus allowing differentiation between pulmonary oedema due to permeability (e.g. in sepsis) and hydrostatic pulmonary oedema (e.g. in cardiogenic shock). The PVPI can therefore provide important additional information for guiding treatment.

Classification of Lung Oedema with the PVPI
Introduction to PiCCO Technology – Pulmonary Permeability Classification of Lung Oedema with the PVPI Difference between the PVPI with hydrostatic and permeability lung oedema: Lung oedema hydrostatic permeability PBV PBV EVLW EVLW EVLW EVLW Differences in the PVPI occur in permeability and hydrostatic pulmonary oedema because of the different ratio of extravascular lung water and pulmonary blood volume. While the extravascular lung water and pulmonary blood volume are increased in hydrostatic pulmonary oedema (cardiac congestion) so that the ratio between the two is relatively unchanged, lung water increases in permeability oedema and the pulmonary blood volume remains unchanged or can even become smaller. This leads to a higher PVPI value. A precondition for a valid PVPI value is an adequate preload, as the pulmonary blood volume is diminished in hypovolaemia and the PVPI can appear falsely elevated. PBV PBV PVPI normal (1-3) PVPI raised (>3)

Cardiac insufficiency
Introduction to PiCCO Technology – Pulmonary Permeability Validation of the PVPI PVPI can differentiate between a pneumonia caused and a cardiac failure caused lung oedema. PVPI 4 3 This study showed that the PVPI can provide reliable information in practice about the cause of pulmonary oedema. 2 Cardiac insufficiency Pneumonia 16 patients with congestive heart failure and acquired pneumonia. In both groups EVLW was 16 ml/kg. Benedikz et al ESICM 2003, Abstract 60

How much water is in the lungs?
Introduction to PiCCO Technology – Pulmonary Permeability Clinical Relevance of the Pulmonary Vascular Permeability Index EVLWI answers the question: How much water is in the lungs? PVPI answers the question: Why is it there? The combination of EVLW and PVPI is a valuable instrument for diagnosing, quantifying and guiding therapy of pulmonary oedema. and can therefore give valuable aid for therapy guidance!

Introduction to PiCCO Technology – EVLW and Pulmonary Permeability
Summary and Key Points 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

PiCCO Technology Set-Up
Practical Approach PiCCO Technology Set-Up PiCCO monitoring uses vascular accesses that are already existing or required anyway. Central venous catheter Injectate temperature sensor housing A major advantage of PiCCO technology is its simple and rapid use, which means that the results of measurement are quickly available. PiCCO monitoring uses only vascular accesses that are already present or required anyway in critically ill patients. No special training, such as that needed for a pulmonary artery catheter, is required for placing the PiCCO catheter. Use of isotonic saline as indicator is a further simplification compared to other indicator dilution methods (lithium, dye). PULSIOCATH Arterial thermodilution catheter (femoral, axillary, brachial)

Practical Approach Clinical Case Patient with secondary myeloid leukemia due to non-Hodgkin’s lymphoma Currently: aplasia as a result of ongoing chemotherapy. Transfer from the oncology ward to intensive care unit due to development of septic status Status on transfer to the Intensive Care Unit Hemodynamic BP 90/50mmHg, HR 150bpm SR, CVP 11mmHg Respiration SaO2 99% on 2L O2 via nasal prongs Abdomen Severe diarrhoea, probably associated with chemotherapy Renal Retention values already increasing, cumulative 24h diuresis 400ml Laboratory Hb 6.7g/dl, Leuco <0.2/nl, Thrombo 25/nl High fluid loss because of severe diaphoresis Clinical case illustrating use of PiCCO technology in a septic patient Initial Therapy Given 6500 ml crystalloids and 4 PBC

Diagnosis: Septic Multiorgan Failure
Practical Approach Clinical Case Ongoing Development 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

Clinical Case Therapeutic Problems and Issues
Practical Approach Clinical Case Therapeutic Problems and Issues 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

Volume Administration
Practical Approach Clinical Case Therapeutic Problems and Questions Haemodynamics Volume Administration Respiration ? Renal Haemodynamics Volume Restriction Respiration Renal

Clinical Case Application of the PiCCO system Initial measurement 3.4
Practical Approach Clinical Case Application of the PiCCO system Initial measurement 3.4 760 14 950 16 Normal values 3.0 – 5.0 l/min/m2 ml/m2 3.0 – 7.0 ml/kg dyn*s*cm 5 m2 2 - 8 mmHg Cardiac Index GEDI ELWI SVRI CVP The first PiCCO values in this patient show a preload volume in the mid normal range, markedly raised extrapulmonary lung water and drastically reduced peripheral resistance. Because of the low peripheral resistance, the noradrenaline therapy is continued. To improve cardiac output, the volume therapy is continued with monitoring of the GEDI and ELWI in view of the still relatively low preload volume despite the increased lung water continuation of the noradrenaline infusion careful GEDI guided volume therapy

Clinical Case Actual values 3.5 780 14 990 16 Normal range
Practical Approach Clinical Case PiCCO values the following day Actual values 3.5 780 14 990 16 Normal range 3.0 – 5.0 l/min/m2 ml/m2 3.0 – 7.0 ml/kg dyn*s*cm 5 m2 2 - 8 mmHg CI GEDI ELWI SVRI CVP On the following day it is apparent that the preload could be kept in the upper normal range with repeated PiCCO measurement without aggravating the pulmonary oedema. Despite giving noradrenaline, the peripheral resistance continues to be very low (vasoplegia) GEDI with volume therapy persistently within the high normal range, however no increase in ELWI

Clinical Case Other therapy - non-invasive ventilation
Practical Approach Clinical Case Other therapy - non-invasive ventilation targeted antibiotic therapy administration of hydrocortisone / GCSF Further course - stabilization of haemodynamics - steady noradrenaline requirement - start of negative fluid balance, guided by the PiCCO parameters In the further course, haemodynamic stabilisation was achieved so that the noradrenaline requirement did not increase further and cautious negative volume balance could be begun.

Clinical Case Actual values 3.2 750 8 1810 14 Normal values
Practical Approach Clinical Case PiCCO values the next day Actual values 3.2 750 8 1810 14 Normal values 3.0 – 5.0 l/min/m2 ml/m2 3.0 – 7.0 ml/kg dyn*s*cm 5 m2 2 - 8 mmHg CI GEDVI EVLWI SVRI CVP The patient‘s stabilisation and negative volume balance are reflected in the markedly reduced extravascular lung water with continuing normal preload volume. Despite stopping the vasopressor therapy, the peripheral resistance is now within the normal range. stabilization of pulmonary function cessation of catecholamines good diuresis with frusemide

Clinical Case Progression of PiCCO values HI ITBI EVLW SVR Nor
Practical Approach Clinical Case Progression of PiCCO values Despite significant volume administration/ removal remains relatively constant, thus on its own not an indicator for volume status CI 30 25 Nor HI 20 GEDVI Remained within normal range under monitoring CVP ITBI 15 EVLWI GEDVI 10 EVLW Regular monitoring of the lung water allowed titration of the volume therapy whilst simultaneously avoiding further increase of lung oedema SVRI EVLWI SVR 5 CI The course of the measurements shows on the one hand how the PiCCO parameters GEDI and ELWI were used to guide therapy. On the other hand, it is also apparent that the CVP, which is often used in clinical practice for guiding volume management, was raised initially although clinically there was marked volume depletion. Measurement of the cardiac output on its own without taking preload volume and lung water into account would not have been useful as a guide since the cardiac index remained relatively constant despite administration and removal of volume. Day 1 Day 2 Day 3 Day 4 Day 5 CVP Initially raised, despite volume depletion and thus not of use Nor Time Course

Avoidance of complications Efficient use of resources
Practical Approach Clinical Case Actual advantages of using PiCCO with this patient Optimisation of the intravascular volume status Monitoring of lung oedema Stabilisation of the haemodynamics Pulmonary stabilisation Reduction in catecholamine requirements Avoidance of intubation No acute renal failure PiCCO technology in this case enabled optimisation of intravascular volume status on the one hand while on the other hand further deterioration of lung function could be avoided by simultaneous monitoring of the pulmonary oedema. In this way, the PiCCO parameters supported prompt haemodynamic stabilisation, so that further complications were avoided in this high-risk patient (underlying malignant disease, immunosuppression). This results in a relevant cost-saving potential in intensive care medicine. No invasive ventilation Avoidance of complications Efficient use of resources

Clinical Case Potential problems without PiCCO use in this patient
Practical Approach Clinical Case Potential problems without PiCCO use in this patient Diarrhoea Severe diaphoresis High CVP Poor Diuresis Constant CI difficult clinical assessment of volume deficit Volume ? Volume ? Volume ? Without the use of PiCCO assessment of the baseline status and therapy guidance would have been much more problematic in this patient: Difficult assessment of the existing volume deficit due to diarrhoea and diaphoresis, the CVP as assumed indicator was raised initially Contradictory indicators on volume management due to high CVP and low diuresis The course of the CI does not provide information on the ideal volume management

haemodynamic triangle
Practical Approach Therapy Guidance with PiCCO Technology PiCCO allows the establishment of an adequate cardiac output through optimisation of volume status whilst avoiding lung oedema Optimisation of stroke volume The haemodynamic triangle The possibility of optimising preload and thus cardiac output with the aid of the PiCCO parameters and at the same time identifying and quantifying pulmonary oedema predestines this technology for the volume and catecholamine management of haemodynamically unstable patients or patients at increased risk of haemodynamic instability. Optimisation of preload Avoidance of lung oedema

additional information Volume / Catecholamines
Practical Approach Therapy Guidance with PiCCO Technology Evaluation of therapy success if necessary: additional information Oxygen extraction ScvO Organ perfusion PDR-ICG PiCCO monitoring CI, Preload, Contractility, Afterload, Volume responsiveness Therapy Volume / Catecholamines PiCCO parameters are helpful in choosing the therapeutic measures and also facilitate or enable reliable monitoring of the success of therapy. Other available information such as central venous oxygen saturation and ICG plasma disappearance rate are ideal supplements to the PiCCO parameters and complete the haemodynamic picture of the patient.

Therapy Guidance with PiCCO Technology
Practical Approach Therapy Guidance with PiCCO Technology Cardiac Output Inadequate preload should initially be treated with volume administration 5 3 EVLW 7 The following diagrams illustrate how the interplay of the PiCCO parameters can be used for volume management. The upper part of the diagram shows the connection between preload and stroke volume (Frank-Starling curve), and the lower part shows the interaction between extravascular lung water and preload. The hatched areas are the normal ranges. The ideal preload range is thus where the stroke volume is in the normal range without excess lung water. Accordingly, when the preload is low, volume should first be given to increase the stroke volume until the preload volume is in the normal range. 3 Preload

Practical Approach Therapy Guidance with PiCCO Technology Cardiac Output Inadequate preload should be treated initially with volume administration 5 3 Continue volume administration until EVLW increases EVLW 7 At the same time, check whether the extravascular lung water is increasing with the volume administration. Ideally, this enables optimisation of the stroke volume, at the same time avoiding pulmonary oedema. 3 Preload

Practical Approach Therapy Guidance with PiCCO Technology Cardiac Output Inadequate preload should be treated initially with volume administration 5 3 Volume administration causes an increase in EVLW Volume removal until EVLW stops decreasing or decreases only slowly (preload monitoring!) EVLW Always check measurements for plausibility. Volume administration must lead to an increase in preload, or increase in lung oedema (reflected by increase in EVLW) 7 The PiCCO parameters can used not only to guide volume administration but also to monitor volume removal. Simultaneous measurement of lung water and preload enables effective monitoring of volume removal. The pulmonary oedema can thus be reduced as far as possible without reducing the cardiac preload volume too greatly. Thus, optimal negative balance can be achieved in the patient while maintaining adequate organ perfusion. It is always important to check the measurements for plausibility. In case of doubt, a further thermodilution measurement is recommended. 3 Preload

Costs and Resources Economic Aspects of PiCCO Technology 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? Nowadays, not only medical but also economic aspects are of great importance. A monitoring method, like other diagnostic and therapeutic methods, is also judged against this background.

Economic Aspects of PiCCO Technology
Costs and Resources Economic Aspects of PiCCO Technology Direct costs in comparison to the PAC Percentage Costs 230% PiCCO - Kit Pulmonary catheter Chest X-Ray 140% Introducer CVC 100% 100% Arterial catheter Pressure transducer Injection accessories Compared with the pulmonary arterial catheter used traditionally for haemodynamic monitoring, PiCCO technology has clear advantages with regard to the direct costs. Positive effects are that it can remain in situ for a long period and X-ray checking of its position is not required. The graph above does not include the added costs due to the more time-consuming aspect of the pulmonary arterial catheter. PiCCO Kit CCO - PAC PiCCO Kit CCO - PAC Day 1 to 4 Day 5 to 8 Efficient and economically priced monitoring with PiCCO technology is possible because of the low costs for materials and efficient use of staff time

Economic Aspects of PiCCO Technology
Costs and Resources Economic Aspects of PiCCO Technology Indirect costs in comparison to the PAC Ventilation days Intensive care days * p ≤ 0.05 n = 101 * p ≤ 0.05 Therapy guidance using PiCCO parameters can potentially lead to a reduction of the indirect costs also. As this study showed, EVLW-guided therapy can lead to a significantly shorter ventilation and intensive care period compared with management with the pulmonary artery catheter. Depending on the respective treatment costs per day (current average approx. 1300€), there is thus a considerable potential for cost savings. 22 days 9 days 15 days 7 days PAC group EVLW group PAC group EVLW group Mitchell et al, Am Rev Resp Dis 1992;145: 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 Summary and Key Points 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

Physiological Background Monitoring Optimising the Cardiac Output Measuring Preload Introduction to PiCCO technology Practical Approach Fields of Application Limitations

Indications for PiCCO Technology
Applications Indications for PiCCO Technology Applications in intensive care (early use) - 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 Haemodynamic monitoring with PiCCO technology can be used in a large number of intensive care conditions. Early use is particularly beneficial so that the causes of the haemodynamic disorder can be identified as soon as possible and organ damage can be avoided as far as possible. PiCCO is also ideally suited for perioperative monitoring of high risk patients and/or high risk surgery. Perioperative Applications - Cardiac surgery - High risk surgery and high risk patients Transplantation

Indications for PiCCO Technology
Applications Indications for PiCCO Technology Recommendation: 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.

Application Summary and Key Points 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

Limitations of the PiCCO parameters - thermodilution
Knowledge of the limitations is essential for correct interpretation of the data! data will give false-high with large aortic aneurysm is not usable with intracardiac left-right shunt can be overestimated in severe valvular insufficiency GEDV data will be falsely high with gross pulmonary perfusion failure (macro-embolism) is not usable with intracardiac left-right shunt PiCCO technology provides valid results in nearly all clinical situations. Nevertheless, there are a few limitations inherent in the method, knowledge of which is very important for correct use and interpretation. Indicator dilution is a flow-dependent method, i.e. when there are disturbances of blood flow such as intracardiac left-right shunts or perfusion deficits in the lung, the results may be of limited or no use. EVLW

All parameters of pulse contour analysis
Limitations Limitations of PiCCO parameters – pulse contour analysis Knowledge of the limitations is essential for correct interpretation of the data! 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) SVV / PPV All parameters of pulse contour analysis not valid when an IABP is in use (thermodilution is unaffected) The pulse contour analysis parameters also have limitations inherent in the method. For example, the parameters of volume responsiveness deliver valid results only when ventilation induces precisely constant preload fluctuations and the stroke volume is not influenced by other factors such as arrhythmias. When an intra-aortic balloon pump is used, a classical pulse wave is not generated so pulse contour analysis is not possible in this case.

PiCCO Technology in special situations
Special clinical situations PiCCO Technology in special situations Renal replacement therapy normally no interference with the PiCCO parameters Prone positioning all parameters are measured correctly Peripheral venous injection not recommended, measurements possibly incorrect

Limitations of application of PiCCO Technology
PiCCO Technology has no specific limitations of application 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 is a method with few complications and is not subject to any special limitations of use, in contrast to other monitoring methods such as lithium dilution and the pulmonary arterial catheter. The method can also be used without restriction in children (above 5kg) and pregnant women.

Contraindications to PiCCO Technology
Limitations Contraindications to PiCCO Technology 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 Since PiCCO requires only conventional central venous and arterial access and isotonic saline is used as indicator, there are no absolute contraindications. If a certain puncture site is contraindicated, an alternative insertion site can be chosen.

Complications of PiCCO Technology
Limitations Complications of PiCCO Technology The complications of PiCCO technology are confined to the usual risks of arterial puncture • injuries associated with the puncture • infection • perfusion disturbances PULSION recommends that the PiCCO catheter be removed after 10 days at the latest The risks include the usual risks of puncturing arteries or central veins. Since intensive care patients usually require these vascular accesses anyway, use of PiCCO does not involve any additional risk. In general, the same principles apply regarding the duration the catheter can be left in situ or should be removed if infection is suspected as for other intravascular catheters. For safety reasons, the manufacturer recommends that it should remain in situ for a maximum of 10 days.

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Haemodynamic Monitoring

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Haemodynamic Monitoring

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