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

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

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

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

5. A. Introduction

6. History of the PiCCO-Technology
Intelligent hemodynamic monitoring
Paradigm shift in hemodynamic monitoring
Integration into patient monitoring monitors
Most widely used less-invasive method
PulsioFlex™ 2010
PiCCO2 2007
Dräger Smart Pod 2005
Philips PiCCO Module 2003
PiCCO plus 2002
PiCCO 1997
COLD System 1990

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

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

9. Key questions
Is the O2 supply sufficient? Volume or catecholamine's ? Is there Pulmonary edema?
Focus Therapeutische Konflikte / Explizit Indikationen statt Fachrichtungen 9

10. What are Hemodynamics? Maintenance of oxygen extraction! O2 uptake
O2 transport
O2 delivery
O2 consumption
Gas exchange Macro-circulation Micro-circulation Cellular O2 consumption
(Cardiac Output, Hb) (ScVO2, PDRICG*)
Maintenance of oxygen extraction!
* Parameter is not available in the USA

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

12. Anatomy and physiology of the circulatory system
Determinants of cardiac output:
Preload:
- Blood volume, blood available for pumping
Afterload:
- Resistance, against which the heart must pump
Contractility:
- Performance of the heart muscle
Zuordnung Parameter zu Gruppen, Was ist erw. Häm Mon
Heart rate 
Circulatory model
Flow is the result of: preload, afterload, contractility & heart rate

13. Hemodynamic Parameters
O2 Delivery
DO2
Gas exchange?
SaO2
O2 Transport? Hb
Flow? CI
Mixed- / Central-
Venous O2-Saturation
ScVO2
O2 Consumption
VO2  
DO2
VO2 ! x
Stroke Volume
SVI
Frequency HR
Basisworkshop
Differenzierung der Picco Parameter zu den Hämodynamischen bzw. Volumetrischen Eckdaten.
Position der Wichtigsten Parameter Interaktionsmechanismen.
Preload
GEDI
SVV
Afterload
MAP
SVRI
Contractility
dPmx, CPI*
CFI*, GEF*
Lung
ELWI
PVPI*
* Parameters are not available in the USA

14. Treatment strategies Sepsis Cardiac surgery Cardiology
Neurosurgery/ Neurology /Stroke
Burns
Trauma
Focus Therapeutische Konflikte / Explizit Indikationen statt Fachrichtungen

15. Monitoring and Diagnostic systems
CO - Monitoring
Diagnostics
Doppler
TTE/TEE
CT/ MRI
LiDCO rapid
Diagnostics & Advanced Monitoring
Vigileo
Bioimpendance
PulsioFlex
Vigilance / PAC
PiCCO2

16. B. Disposables

17. PiCCO Catheter
For advanced hemodynamic monitoring with the PiCCO-Technology
Temperature sensor at the catheter tip for transpulmonary thermodilution
Pressure lumen for arterial pressure measurement
For use with
PiCCO2
PiCCO plus
Philips PiCCO technology module and
Draeger Infinity® PiCCO SmartPod®.

18. PiCCO Catheter Placement Options
A. Axilla Adult 4F - 08cm
A. Brachial Proximal 4F - 16cm Adult distal (cubital) 4F - 22cm
Femoral Adult 5F - 20cm
Children/peds 3F - 07cm
Radial Adult 4F - 50cm*
* Product is not available in the USA

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

20. CeVOX Probe* Continuous monitoring of ScvO2 Convenient application
Access via already placed standard CVC
Easy application
Continuous ScvO2 within minutes
Botschaft Nachrüsten einer Sonde im Cava
* Product is not available in the USA

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

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

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

24. PiCCO Pressure Transducer

25. PiCCO Pressure Transducer
PV8215 PiCCO transducer incl. PV 4046
PV in1 PiCCO transducer
with continuous AP and CVP
incl. PV4046
PV8215CVP PiCCO transducer with discontinuous CVP incl. PV4046
PV CVP online transducer
DPT-100 In-Line transducer
PV4046 Injectate sensor housing
PV82xx transducers are not available in all markets. Alternative products are available on request.
Movie

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

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

28. C. Start-UP

29. Philips IntelliVue Model Dräger Infinity PiCCO SmartPod
Connectivity
Philips IntelliVue Model
PiCCO2
PiCCO plus
Dräger Infinity PiCCO SmartPod 29

30. Connectivity PiCCO2 1a 1 2 3 4 1 1a 2 3 4 CeVOX Module LiMON Module*
LiMON Sensor
Flush bag 1
CeVOX Module
(Art. No. PC3015)
LiMON Module*
(Art. No. PC5100)
Injectate-Sensor cable
(Art. No. PC80109)
Temperature cable
(Art. No. PC80150)
Pressure cable
(Art. No. PMK-206) 1a 1a
CeVOX probe via standard CVC 2 1 3 2 3 4 4
PiCCO catheter
PiCCO monitoring kit
* Product is not available in the USA 30

31. Connectivity Philips IntelliVue Module
Flush bag 1
Injectate -Sensor cable
(Art. No. PC80109)
Temperature cable
(Art. No. PC80150)
Pressure transducer cable
(Art. No. PMK-206) 2 3 1 2 3
PiCCO catheter
PiCCO monitoring Kit 31

32. Connectivity Dräger Infinity PiCCO SmartPod®
Flush bag 1
Injectate Sensor cable
(Art. No. PC80109)
Temperature cable
(Art. No. PC80150)
Pressure transducer cable
(Art. No. PMK-206) 2 1 3 2
To bedside monitor
Connected to the back 3
PiCCO catheter
PiCCO monitoring kit 32

33. Connectivity PiCCO plus
PV8215
PV2015L20N 33

34. Philips IntelliVue Model Dräger Infinity PiCCO SmartPod
Conectivity
Philips IntelliVue Model
PiCCO2
PiCCO plus
Dräger Infinity PiCCO SmartPod

35. PiCCO2 Connectivity Input Output CeVOX - ScvO2 Module
PiCCO – Thermodilution
PiCCO – arterial pressure
Online - CVP
AUX port for connection to bedside monitoring
CVP AP

36. PiCCO2 Connectivity Interface Mains Lead 2x USB LAN RS 232
Mains connection
Potential- Equilization

37. Philips IntelliVue Model Dräger Infinity PiCCO SmartPod
Operation
Philips IntelliVue Model
PiCCO2
PiCCO2 Information
PiCCO plus
Dräger Infinity PiCCO SmartPod

38. Start-Up Power Switch On/Off button Alarm indicator
Charge warning light
PiCCO2 2 4 3 1
Blinking = charging
Permanently on = Fully charged

39. Innovative visualizations Direct access buttons & dial knob
Screen layout
Information bar
Touch screen
Real-time
arterial waveform
Parameter
fields
Innovative visualizations
Graphical User Interface
The screen is divided into different screen areas:
Patient information bar
Real Time Curve
Parameter fields
Direct Access Buttons
Display Tabs
Display Range
Real time curve and parameter fields are always visible
Direct access buttons & dial knob

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

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

42. Help Function
Parameter - information

43. Help Function
Therapy algorithm

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

45. and the PiCCO2 serial number
Help Function
How to contact PULSION
and the PiCCO2 serial number

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

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

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

49. Configuration
PiCCO2

50. PiCCO2 Supports Your Decisions
Spider Vision View the patient status at a glance
Profile Detailed insight at a parameter level
Spider: arms
Setup of the spider in the Configuration screen
Normal ranges: grey areas
Continuous indexed parameters
No scale
Display
Green - all parameters in normal range
Orange - one parameter out of normal range
Red - more than one parameter out of normal range
Trends Clinical course & treatment success

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

52. Configuration of Alarms
80 65

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

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

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

56. D. Thermodilution

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

58. Thermodilution The indicator passes through heart and lungs.
Detection
Injection
The indicator passes through heart and lungs.
CO, Preload and Lung water are measured.
PiCCO2 Booklet

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

60. Workflow - Thermodilution
Philips IntelliVue Model
PiCCO2
PiCCO plus
Dräger Infinity PiCCO SmartPod

61. Start thermodilution Select the injectate volume
For an adult 15mls saline is recommended
In the „Measurement“ menu you will find the recommended volume
Press „Start“ 1 1 2 2
Auto – Thermodilution mode (x in a row)

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

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

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

65. ScvO2 Calibration
PiCCO2

66. ScvO2 Calibration Press to start calibration
The quality indicator should show a medium to high signal
Withdraw blood from the Y- connector of the CeVOX probe. Ensure that you get only blood and no infusion fluid.
Do a venous blood gas sample and flush the lumen with saline afterwards.
Press “Sample drawn” after withdrawing blood.
Enter the results of the BGA .
Press „Confirm“
If DO2 and VO2 are enabled you need to enter the SaO2 (SpO2) value
ScVO2 CAL
DO2 & VO2 Measurement

67. LiMON – PDRICG* Press to go to LiMON calibration.
Attach the LiMON sensor to a well perfused finger.
Wait 3 minutes until the finger perfusion becomes adapted to the sensor.
Ensure that the sensor is not subjected to strong direct light. If necessary cover the sensor during the measurement of the PDRICG
SpO2 and perfusion level will be displayed. The signal should be stable.
Press to calculate the ICG dose.
Select target concentration:
0.25mg/Kg or 0.5mg/Kg
Select the number and size of vials
Use XX mls ‘water for injection’
ICG quantity: dose in mgs to inject
Volume: Volume in mls to inject
Calc
* Parameter is not available in the USA

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

69. E. - Parameters

70. Therapy control - + - + - + - + Maintenance of oxygen extraction
O2 uptake
O2 transport
O2 delivery
O2 consumption
Gas exchange Macro-hemodynamics Micro-circulation Cellular O2 consumption
Options for Intervention - + - + - + - +
Respiration
Volume
Catecholamine
Hemoglobin

71. Main Parameters ScvO2: Adequate global tissue oxygenation?
CI: Adequate flow?
GEDI: Adequate cardiac preload?
SVV/PPV: Volume responsiveness?
SVRI: Vasopressor therapy necessary?
ELWI: Lung edema?

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

73. Hemodynamic parameters
O2 Delivery
DO2
Gas exchange?
SaO2
O2 Transport? Hb
Flow? CI
Mixed- / Central-
Venous O2-Saturation
ScVO2
O2 Consumption
VO2  
DO2
VO2 !
Organ function?
If ScVO2 >75%
PDRICG* - Liver x
Stroke Volume
SVI
Frequency HR
Preload
GEDI
SVV/PPV
Afterload
MAP
SVRI
Contractility
dPmx, CPI*
CFI*, GEF*
Lung
ELWI
PVPI*
* Parameters are not available in the USA

74. ScvO2 - Indicates insufficient tissue oxygenation
ScvO2 – Central venous oxygen saturation
Imbalance between O2 delivery and O2 consumption?
Measurement via standard CVC
ScvO2 (via CVC) correlates with SvO2 (via Pulmonary Artery Catheter)
O2 Delivery
When oxygen supply does not match oxygen demand, the oxygen deficit rapidly causes cell and organ injury leading to organ failure and subsequent complications
ScvO2 values outside the normal range indicates a threat to tissue oxygenation and necessitates advanced hemodynamic monitoring to verify the cause. CO
Hemoglobin
Arterial O2 saturation
O2 Consumption
Fever
Stress
Muscle work (shivering)
ScvO2 
ScvO % SvO %

75. Cardiac Output – Blood volume, amount of blood pumped by the heart per minute
CI – Cardiac Index (Thermodilution)
PCCI – Pulse Contour Cardiac Index (Cont. Pulse Contour)
SVI – Stroke Volume Index
Cardiac Index indicates the global blood flow
Cardiac Index is Heart Rate x Stroke Volume Index
Stroke Volume depends on preload, afterload and contractility
Cardiac Index is indexed to the Body Surface Area (BSA) CO
Heart rate
Afterload
Contractility
Stroke volume
Preload 
PCCI 3-5 l/min/m2 SVI ml/m2

76. Preload Volume – Blood volume which fills the heart just prior to beating
GEDI – Global End-diastolic Volume Index
Filling volume of all 4 heart chambers
Adequate preload volume is necessary for an adequate CO
GEDI is indexed to the PBSA*
Volumetric preload assessment
* Predicted Body Surface Area (normalized body surface area) 
GEDI ml/m2

77. Direct correlation between GEDI and CO
CI (l/min/m2)
7.5
Frank-Starling-Curve
5.0
Inotropes
2.5
Preload increase
200
400
600
800
1000
1200
1400
GEDI (ml/m2)
Preload optimization (GEDI) will increase Cardiac Index (CI) to a defined maximum (top of the Frank-Starling-Curve)
After preload optimization CI can be increased further by inotropes

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

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

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

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

82. Hydrostatic volume shiftCI 5
If preload is low, volume is given.
Preload loading can increase CI to its maximum.
Excessive preload loading will also increase the hydrostatic pressure in the vascular system. This can lead to an increase in lung water. 3
ELWI
GEDI 7 3
GEDI

83. Hydrostatic vs. osmotic edema
Infusion
Hydrostatic Edema
Osmotic Edema
Intravascular
Extravascular
Normal tissue permeability
Disturbed tissue permeability
Osmotically active particle (protein & salt)
H2O

84. Differentiate between types of pulmonary edema
PVPI* – Pulmonary Vascular Permeability Index
Provides a differentiated view of pulmonary edema:
cardiac
osmotic
Corresponds to the ratio between lung water (EVLW) and pulmonary blood volume (PBV)
* Parameter is not available in the USA
Normal situation PVPI 1-3
EVLW
PBV 1
PVPI =1
Cardiac lung edema PVPI 1-3
EVLW
PBV 3
PVPI =1 
Osmotic lung edema PVPI 3-5
PVPI* 1-3
Extravascular fluid / EVLW
EVLW
PBV 4 1
PVPI =4
Intravascular fluid / PBV

85. Afterload – Resistance against which the heart must overcome to eject blood
SVRI - Systemic Vascular Resistance Index
Measurement of the resistance against which the heart must pump
Depends on the degree of vasoconstriction
Increased:
Centralization, Vasopressor therapy, Cardiogenic shock
Decreased:
Septic shock, Anaphylactic shock .
Pressure Flow (CO)
Resistance =
Vasoconstriction: Flow (CO)
Pressure (RR)
Vasodilation: Flow (CO)
Pressure (RR) 
SVRI dyn/sec/m2

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

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

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

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

90. The relationship between DO2 and VO2
Delivery:
DO2I = CI x Hb x 1.34 x SaO2
SaO2
CO, Hb
Oxygen uptake
Oxygen transport
Oxygen release
Oxygen consumption
S(c)vO2
Consumption:
VO2I = CIxHbx1.34x(SaO2 – S(c)vO2)
DO2 and VO2 indicate the relationship between O2 supply and O2 consumption
If DO2 falls below a critical point, tissue hypoxia will occur
O2 supply VO2 ml/min/m²
Enough
Too low! 
DO2I ml/min/m2 VO2I ml/min/m2
O2 transport capacity DO2 ml/min/m²

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

92. F. PiCCO strategies

93. Therapy control

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

95. Thank you for your attention!
I. Summary
Thank you for your attention!
Contact:
PULSION Medical Systems AG
Joseph-Wild-Str. 20
81829 Munich
Germany
Tel: +49 (0) – 0
Fax: +49 (0) – 18

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

98. Selection of oxygen parameters
Visualization of DO2 and VO2 in real-time to monitor oxygen delivery and oxygen consumption (CI and ScvO2 must be monitored continuously)
*Physically dissolved oxygen is ignored.
Oxygenation

99. Patient admission Admission from a general ward:
5 days post-operative after a colon resection, no CVC, no A-line
Vital signs
GCS: somnolent
Respiration: tachypnea
Pulse: 120
NIBP 90/50
Temperature 39.8°C

100. Patient admission ECG Monitor heart rhythm SR
Monitor heart rate /min
SpO2 > O2 mask with 5l/min
Awareness of respiratory failure 95%
Monitor O2-supply and respiration > Intubation

101. Basic Monitoring Can we identify the source of the shock?
Electrocardiogram (ECG)
NIBP (RR)
Pulse oximetry (SpO2)
Can we identify the source of the shock?
Can we control the patients circulation with this level of monitoring?

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

103. Compensation mechanism
10:30 RR is decreasing! AP
MAP 55mmHg
MAP 65mmHg CI
CI 3L/min
CI 2L/min
10:00
10:30
10:22 Flow decreasing!
The blood pressure gives only a delayed picture when a circulatory problem is occurring.
Continuous CI responds to problems much earlier.
Conventional parameters for monitoring circulation (RR + HR) may be meaningless or even misleading

104. Physiological model of the circulatory system
Pump