Hemodynamic monitoring Prof. Jean-Louis TEBOUL University Paris-South in septic patients Prof. Jean-Louis TEBOUL Medical ICU Bicetre hospital University Paris-South France

Conflicts of interest Member of the Medical Advisory Board of Pulsion

hypovolemia vascular tone myocardial depression depression Hemodynamic failure in septic patients: 3 components vascular tone depression myocardial depression hypovolemia Importance of assessing the degree of each component to select and apply the best therapeutic option fluids vasopressors inotropes presence of associated lung injury

Methods currently available to assess hemodynamics in ICU pts Echocardiography non invasive  Esophageal Doppler less invasive  Central Venous Catheter Systemic Artery Catheter FloTrac/Vigileo LidCO PiCCO / VolumeView  invasive  Pulmonary Artery Catheter 4

non invasive Echocardiography Esophageal Doppler Methods currently available to assess hemodynamics in ICU pts Echocardiography intermittent measurements of several cardiac function variables non invasive  Esophageal Doppler 5

Esophageal Doppler Advantages non-invasive real-time monitoring of descending aorta blood flow prediction of fluid responsiveness (variability or PLR)

real-time monitoring of descending aorta blood flow Esophageal Doppler Advantages non-invasive real-time monitoring of descending aorta blood flow prediction of fluid responsiveness (variability or PLR) assessment of LV systolic function Br. J. Anaesth. (2013) 111 (5): 743-749

Esophageal Doppler Advantages non-invasive real-time monitoring of descending aorta blood flow prediction of fluid responsiveness (variability or PLR) assessment of LV systolic function Inconveniences aortic diameter is not fixed and changes with MAP

utility in case of circulatory failure with associated lung injury? Esophageal Doppler Advantages non-invasive real-time monitoring of descending aorta blood flow utility in case of circulatory failure with associated lung injury? prediction of fluid responsiveness (variability or PLR) assessment of LV systolic function Inconveniences aortic diameter is not fixed blood flow partition upper/lower part of the body may vary

Hemodynamic failure in septic patients: 3 components Echocardiography non invasive  Esophageal Doppler less invasive  Central Venous Catheter 10

CVP and SvcO2 Central venous catheter (with or without fiberoptic probe) Configuration What is needed to accomplish art. thermodilution cardiac output & pulse contour cardiac output? Any central venous line. Injectate temperature sensor for detection of the cold bolus. The injectate temperature sensor (PV4045) is included in the monitoring kit (e.g. PV8015) 22G - 5F Thermodilution catheter with lumen for arterial pressure, placed in the Femoral artery or the Axillary artery. The reason that a large artery needs to be accessed is that the catheter needs to have blood flow around it to detect a temperature change. Are you aware that a traditional radial arterial line does not have blood flow? Only 30% of the patients with a radial artery line have blood flow around catheter. 70 % do not have flow. Arterial pressure transducer

(mostly through elevation of CO) SvO2 = SaO2 - VO2 CO x Hb x 13.4 SvO2 indicator of VO2 / DO2 balance a low SvO2 may incite to elevate DO2 (mostly through elevation of CO) 12

Methods currently available to assess hemodynamics in ICU pts Echocardiography non invasive  Esophageal Doppler less invasive  Central Venous Catheter Systemic Artery Catheter 13

radial arterial catheter AP monitoring radial arterial catheter Configuration What is needed to accomplish art. thermodilution cardiac output & pulse contour cardiac output? Any central venous line. Injectate temperature sensor for detection of the cold bolus. The injectate temperature sensor (PV4045) is included in the monitoring kit (e.g. PV8015) 22G - 5F Thermodilution catheter with lumen for arterial pressure, placed in the Femoral artery or the Axillary artery. The reason that a large artery needs to be accessed is that the catheter needs to have blood flow around it to detect a temperature change. Are you aware that a traditional radial arterial line does not have blood flow? Only 30% of the patients with a radial artery line have blood flow around catheter. 70 % do not have flow. Arterial pressure transducer femoral arterial catheter

Monitoring blood pressure…. … is not only monitoring Arterial Pressure (mmHg) SAP 140 PP Monitoring blood pressure…. … is not only monitoring systolic blood presssure 120 100 MAP 80 DAP 60 40 A lot of useful pieces of information can be drawn from MAP, DAP, PP and from analysis of the AP waveform 20 Time

MAP: driving pressure for perfusion Arterial Pressure (mmHg) 140 120 100 MAP 80 60 MAP: driving pressure for perfusion of important organs (e.g. brain, kidney) 40 20 Time

MAP: important hemodynamic target of resuscitation of shock states Arterial Pressure (mmHg) 140 120 100 MAP 80 60 MAP: important hemodynamic target of resuscitation of shock states 40 20 Time

DAP: reflection of vasomotor tone Arterial Pressure (mmHg) 140 120 100 80 DAP 60 DAP: reflection of vasomotor tone 40 20 Time

DAP: reflection of vasomotor tone Arterial Pressure (mmHg) 140 120 100 80 DAP 60 DAP: reflection of vasomotor tone 40 DAP: driving pressure for left coronary circulation 20 Time

Arterial Pressure (mmHg) 140 PP 120 100 80 60 40 20 Time

suggests that the stroke volume is low Pulse pressure Aortic PP = k. SV . aortic stiffness Chemla et al AJP 1998 If aorta is stiff (elederly, ateriosclerosis, hypertension, diabetes, etc) A low PP (30-40 mmHg) suggests that the stroke volume is low 21

Methods currently available to assess hemodynamics in ICU pts Echocardiography non invasive  Esophageal Doppler less invasive  Central Venous Catheter Systemic Artery Catheter PPV Pulse Pressure Variation dynamic index of fluid responsiveness 22

Methods currently available to assess hemodynamics in ICU pts Echocardiography non invasive  Esophageal Doppler less invasive  Central Venous Catheter Systemic Artery Catheter FloTrac/Vigileo 23

radial arterial catheter Configuration What is needed to accomplish art. thermodilution cardiac output & pulse contour cardiac output? Any central venous line. Injectate temperature sensor for detection of the cold bolus. The injectate temperature sensor (PV4045) is included in the monitoring kit (e.g. PV8015) 22G - 5F Thermodilution catheter with lumen for arterial pressure, placed in the Femoral artery or the Axillary artery. The reason that a large artery needs to be accessed is that the catheter needs to have blood flow around it to detect a temperature change. Are you aware that a traditional radial arterial line does not have blood flow? Only 30% of the patients with a radial artery line have blood flow around catheter. 70 % do not have flow. Arterial pressure transducer radial arterial catheter

FloTrac/VigileoTM Technology Real-time CO monitoring from AP waveform Complex algorithm based on statistical analysis of the AP signal No need of calibration Any type of arterial catheter and any site including the radial site Validation studies?

surgical pts 26

3rd generation Percentage Error = 54%

induced by fluid infusion induced by norepinephrine septic pts 3rd generation Concordance: 73% Concordance: 60% Changes in CI (%) induced by fluid infusion Changes in CI (%) induced by norepinephrine

FloTrac/VigileoTM Technology Real-time CO monitoring from AP waveform Complex algorithm based on statistical analysis of the AP signal No need of calibration Any type of arterial catheter and any site including the radial site Validation studies? seems valid in the absence of changes in vascular tone serious doubts on its validity in cases of changes in vascular tone (sepsis, vasopressor use)

Methods currently available to assess hemodynamics in ICU pts Echocardiography non invasive  Esophageal Doppler less invasive  Central Venous Catheter Systemic Artery Catheter FloTrac/Vigileo LidCO 30

Central Venous Catheter (Lithium bolus injection) Configuration What is needed to accomplish art. thermodilution cardiac output & pulse contour cardiac output? Any central venous line. Injectate temperature sensor for detection of the cold bolus. The injectate temperature sensor (PV4045) is included in the monitoring kit (e.g. PV8015) 22G - 5F Thermodilution catheter with lumen for arterial pressure, placed in the Femoral artery or the Axillary artery. The reason that a large artery needs to be accessed is that the catheter needs to have blood flow around it to detect a temperature change. Are you aware that a traditional radial arterial line does not have blood flow? Only 30% of the patients with a radial artery line have blood flow around catheter. 70 % do not have flow. Arterial pressure transducer Radial arterial catheter

LidCOplus continuous CO Two proprietary algorithms a continuous arterial waveform analysis system coupled to a single point lithium indicator dilution calibration system continuous CO dynamic preload responsiveness parameters (PPV/SVV) 32

Methods currently available to assess hemodynamics in ICU pts Echocardiography non invasive  Esophageal Doppler less invasive  Central Venous Catheter Systemic Artery Catheter FloTrac/Vigileo LidCO LidCOrapid Trends in CO PPV, SVV 33

Methods currently available to assess hemodynamics in ICU pts Echocardiography non invasive  Esophageal Doppler less invasive  Central Venous Catheter Systemic Artery Catheter FloTrac/Vigileo LidCO PiCCO / VolumeView 34

Central Venous Catheter (cold bolus injection) Thermodilution femoral arterial catheter Configuration What is needed to accomplish art. thermodilution cardiac output & pulse contour cardiac output? Any central venous line. Injectate temperature sensor for detection of the cold bolus. The injectate temperature sensor (PV4045) is included in the monitoring kit (e.g. PV8015) 22G - 5F Thermodilution catheter with lumen for arterial pressure, placed in the Femoral artery or the Axillary artery. The reason that a large artery needs to be accessed is that the catheter needs to have blood flow around it to detect a temperature change. Are you aware that a traditional radial arterial line does not have blood flow? Only 30% of the patients with a radial artery line have blood flow around catheter. 70 % do not have flow. Arterial pressure transducer

Transpulmonary thermodilution monitors allow measurements of cardiac output

Transpulmonary thermodilution monitors are not only CO monitoring devices

GEDV marker of cardiac preload Transpulmonary thermodilution 1- Cardiac output 2- Global end-diastolic volume (GEDV)

cardiac systolic function CFI Index of cardiac systolic function Transpulmonary thermodilution 1- Cardiac output 2- Global end-diastolic volume (GEDV) 3- Cardiac function index (CFI) = CO/GEDV

EVLW quantitative measure of pulmonary edema Transpulmonary thermodilution 1- Cardiac output 2- Global end-diastolic volume (GEDV) 3- Cardiac function index 4- Extravascular lung water (EVLW)

200 pts D28 mortality: 54% Odds Ratio ( CI 95%) p value Maximal blood lactate 1.29 (1.14 - 1.46) 0.0001 Mean PEEP 0.78 (0.67 – 0.91) 0.002 Minimal PaO2 / FiO2 0.98 (0.97 - 0.99) 0.006 SAPS II 1.03 (1.01 - 1.05) 0.02 EVLWmax 1.07 (1.02 - 1.12) 0.007 Mean fluid balance 1.0004 (1.0001 – 1.0008) 0.02

EVLW: safety parameter during fluid management

* * * * Time (hours) Cumulative fluid balance (L) 7 WP group 5 5 3 1 EVLW group -1 -3 * p < 0.0001 vs temps 0 -5 0 12 24 36 48 60 72 Time (hours)

25 20 15 * WP group * 10 EVLW group 5 MV days ICU days 44

pulmonary vascular permeability PVPI marker of pulmonary vascular permeability Transpulmonary thermodilution 1- Cardiac output 2- Global end-diastolic volume (GEDV) 3- Cardiac function index 4- Extravascular lung water (EVLW) 5- Pulmonary vascular permeability index

200 pts D28 mortality: 54% Odds Ratio ( CI 95%) p value Maximal blood lactate 1.27 (1.12 - 1.45) 0.0002 Mean PEEP 0.78 (0.67 – 0.91) 0.002 Minimal PaO2 / FiO2 0.98 (0.97 - 0.99) 0.0009 SAPS II 1.03 (1.01 - 1.05) 0.008 PVPImax 1.07 (1.02 - 1.12) 0.03 Mean fluid balance 1.0004 (1.0000 – 1.0007) 0.03

predictors of volume responsiveness SVV and PPV predictors of volume responsiveness Transpulmonary thermodilution 1- Cardiac output 2- Global end-diastolic volume (GEDV) 3- Cardiac function index 4- Extravascular lung water (EVLW) 5- Pulmonary vascular permeability index Pulse contour analysis 1- Continuous cardiac output (CCO) 2- Stroke volume variation (SVV) 3- Pulse pressure variation (PPV)

Complete picture of the patient’s hemodynamic status Transpulmonary thermodilution 1- Cardiac output 2- Global end-diastolic volume (GEDV) 3- Cardiac function index (CFI) 4- Extravascular lung water (EVLW) 5- Pulmonary vascular permeability index Pulse contour analysis 1- Continuous cardiac output (CCO) 2- Stroke volume variation (SVV) 3- Pulse pressure variation (PPV) ScvO2

PiCCO or VolumeView monitoring useful tools to deal with fluid loading and/or depletion … especially if associated respiratory and circulatory failures SVV and PPV to predict fluid responsiveness What to do if PPV or SVV are not interpretable? GEDV to check that preload actually increases with fluid loading CO to assess the real hemodynamic response to fluid infusion EVLW and PVPI to assess lung tolerance to fluid infusion SVV/PPV GEDV CO EVLW to help to decide To start fluid infusion To continue fluid infusion To stop fluid infusion

PiCCO or VolumeView monitoring useful tools to deal with fluid loading and/or depletion … especially if associated respiratory and circulatory failures PLR and EOT to predict fluid responsiveness SVV and PPV to predict fluid responsiveness GEDV to check that preload actually increases with fluid loading CO to assess the real hemodynamic response to fluid infusion EVLW and PVPI to assess lung tolerance to fluid infusion SVV/PPV GEDV CO EVLW PLR/EOT GEDV CO EVLW to help to decide To start fluid infusion To continue fluid infusion To stop fluid infusion

non invasive less invasive invasive Echocardiography Methods currently available to assess hemodynamics in ICU pts Echocardiography non invasive  Esophageal Doppler less invasive  Central Venous Catheter Systemic Artery Catheter FloTrac/Vigileo LidCO PiCCO / VolumeView Continuous CO and SvO2 monitoring + Intermittent measurements RAP, PAOP and PAP  invasive  PAC 51

non invasive Echocardiography Methods currently available to assess hemodynamics in ICU pts intermittent but repeatable measurements of cardiac function variables Echocardiography non invasive  availability of a device? availability of a skilled operator? not a continuous method 52

non invasive Esophageal Doppler Methods currently available to assess hemodynamics in ICU pts Real-time monitoring of aortic blood velocity, Vpeak and Acc non invasive  Esophageal Doppler aortic diameter changes with arterial pressure blood flow partition between upper and lower body can change with therapy 53

Methods currently available to assess hemodynamics in ICU pts less invasive  Central Venous Catheter CVP and ScvO2 Systemic Artery Catheter AP and PPV No access to CO or to any other important variables 54

Methods currently available to assess hemodynamics in ICU pts reliability in cases of changes in vasomotor tone? no access to other hemodynamic variables less invasive  FloTrac/Vigileo Real-time CO, SVV and ScvO2 monitoring Poor reliability of other uncalibrated CO monitors in ICU pts ProAqt-Pulsioflex Mostcare Nexfin 55

less invasive PiCCO / VolumeView Methods currently available to assess hemodynamics in ICU pts Real-time CO, PPV, SVV and ScvO2 monitoring + Intermittent measurements GEDV, CFI, EVLW, PVPI less invasive  PiCCO / VolumeView femoral artery access 56

Methods currently available to assess hemodynamics in ICU pts invasiveness need of experience for correct data interpretation Continuous CO and SvO2 monitoring + Intermittent measurements RAP, PAOP and PAP  invasive  PAC 57

Which monitoring technique is suitable in the ICU? Echocardiography non invasive  Esophageal Doppler less invasive  Central Venous Catheter Systemic Artery Catheter FloTrac/Vigileo LidCO PICCO/ VolumeView  invasive  PAC 58

Which monitoring technique is suitable in the ICU? current clinical situation (lung injury?) history of cardiovascular disease - clinical questions you want to answer - your experience with either technique The ideal monitoring device is not yet your choice will depend on: Try to early perform echocardiography, chest X-ray and blood gases, which should help selecting the best monitoring strategy

hypovolemia vascular tone myocardial depression depression fluids Hemodynamic failure in septic patients: 3 components vascular tone depression myocardial depression hypovolemia fluids vasopressors inotropes presence of associated lung injury

myocardial depression inotropes Hemodynamic failure in septic patients: 3 components myocardial depression Echocardiography + CFI (PiCCO) inotropes

vascular tone depression vasopressors Hemodynamic failure in septic patients: 3 components vascular tone depression Arterial catheter (DAP ++) vasopressors

hypovolemia fluids presence of associated lung injury Hemodynamic failure in septic patients: 3 components hypovolemia Prediction of fluid responsiveness PPV, SVV PLR or end-expiratory occlusion test if SB, arrhythmias, low TV or low lung compliance Evaluation: real-time CO fluids Lung tolerance PAOP EVLW presence of associated lung injury

Patient with circulatory failure First, try to perform echocardiography to assess cardiac function Normal cardiac fonction Abnormal cardiac function Lung injury ? ABG, Chest X-ray If no response to initial therapy yes no Basic monitoring advanced monitoring yes no PiCCO only PAC VolumeView CVC + Art cath CO PAOP RAP, PAP SvO2 CO GEDV, EVLW, CFI PPV, SVV ScvO2 CVP SvcO2 AP PPV considered valid? 64

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Thank you 66