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Pulsion Work

Booklet
Bucarest hemodynamic Monitoring
Workshop
Overview
Work booklet

Ongoing training is important: This work booklet was designed for training of medical and nursing staff in the
hospital. It should help to increase user confidence as well as getting more detailed information about the
PiCCO® and other PULSION Technologies.

Topics:
• Basic haemodynamic monitoring
• Measuring cardiac output
• Parameter calculation
• Parameters
• PULSION Technologies
• Literature

Please note: This work booklet has been provided as a template for adaption at the local hospital site and
should not in any way replace the operators manuals of PULSION products.
All information is provided without warranty. It is not for use in the USA.
Basics of haemodynamic
monitoring
Bucarest 2017

October 2017, Dr. Mark Konrad


Basic physiology
Advanced haemodynamic monitoring

Oxygen Oxygen Oxygen Oxygen


Uptake Transport Extraction Utilisation
Lungs Blood flow Vessels & tissues Cells

Oxygen Supply Oxygen Consumption

A balance between oxygen supply and oxygen consumption


is necessary to avoid severe organ damage
Haemodynamic parameters
Advanced haemodynamic monitoring
Typical reasons for ICU admission
Advanced haemodynamic monitoring

Cardiac Output measurement with PiCCO is indicated in cases of unstable


haemodynamics, unclear volume status and therapeutic conflicts.

Those situations are usually present in:

• Shock (septic, cardiogenic, haemorrhagic)


• Acute Respiratory Distress Syndrome
• Severe organ dysfunction or failure
• Intra-cerebral bleeds
• Multiple trauma (accidents, fractures)
• Severe burn injury
• High risk surgical procedures (abdominal, vascular)
Measuring cardiac output
Bucarest 2017

Bucarest Hemodynamic Monitoring Workshop


31 March 2019
Page 7
Transpulmonary thermodilution
Measuring cardiac output

• Discontinuous information but more accurate calculation of parameters

• Defined bolus injected via a temperature sensor placed in the distal lumen of
the central venous catheter
Arterial pulse contour analysis
Measuring cardiac output

• Provides continuous information based on the arterial pressure line

• Calibration done automatically done via transpulmonary thermodilution


Set up
Transpulmonary Thermodilution – PiCCO Technology

CVC

Injectate sensor cable

Injectate sensor
housing and bolus

PulsioFlex, PiCCO2
or OEM Module

Arterial connection cable

Pressure transducer
Arterial pressure sensor
cablel
Recommendations for catheter positions
PiCCO Catheter

A. axillaris
PiCCO Catheter 4F 8cm

A. brachialis
PiCCO Catheter 4F 16cm
PiCCO Catheter 4F 22cm

A. radialis
PiCCO Catheter 4F 50cm

A. femoralis
PiCCO Catheter 5F 20cm
PiCCO Catheter 3F 7cm (paediatric)
Thermodilution measurement
Transpulmonary Thermodilution
Parameter calculation
Bucarest 2017

Bucarest Hemodynamic Monitoring Workshop


31 March 2019
Page 13
Cardiac output via transpulmonary thermodilution
PiCCO Technology
Cardiac output via pulse contour analysis
PiCCO Technology and ProAQT Technology

Godje O et al. Accuracy of beat-to-beat cardiac output monitoring by pulse contour analysis in hemodynamical unstable patients.
Med Sci Monit 2001;7(6):1344-1350
Assessment of volumes
Transpulmonary Thermodilution

• Every patient has a different amount of volume in the chest – determination of


different transit times enable individual evaluation of parameters
• Based on a publication by Newman et al.1
1Newman et al. The dye dilution method for describing the central circulation. An analysis of factors shaping the time-
concentration curves Circulation 1951; 4: 735-46.
Mean Transit time and Exponential Down-Slop time
Transpulmonary Thermodilution

Mean Transit time (MTt) Exponential Down-Slope time (DSt)


• Time when half of the indicator • Wash-out function of indicator
passes the detection point
• Used for calculation of the
(central artery).
pulmonary thermal volume
• Used for calculation of the
intrathoracic thermal volume
Intrathoracic thermal volume and pulmonary
thermal volume

Intrathoracic thermal volume (ITTV) Pulmonary thermal volume (PTV)

ITTV = COTD x MTt PTV = COTD x DSt


Quantification preload
Parameter calculation

Intrathoracic thermal
volume
ITTV

Pulmonary thermal
volume
PTV

Global Enddiastolic
Volume

GEDV GEDV = ITTV - PTV


Quantification of extravascular lung water
Parameter calculation

Intrathoracic thermal
volume
ITTV

Intrathoracic blood volume

ITBV ITBV = GEDV x 1,25

Extravascular lung water

EVLW = ITTV - ITBV


EVLW
Parameters
Bucarest 2017

Bucarest Hemodynamic Monitoring Workshop


31 March 2019
Page 21
Overview
Parameters
Cardiac index and its determinants
Parameters
Cardiac Index (CI) & Stroke Volume Index (SVI)
PiCCO Parameters

CI:
• Amount of blood pumped by the heart
per minute indexed to the body surface

• Represents global blood flow

SVI:
• CI is the product of SVI and heart rate

• Output of left ventricle per heart beat


Global Enddiastolic Volume Index (GEDI)
Preload

• Initial stretching of the heart muscle prior to contraction


• Estimated as the end diastolic volume or pressure
• Filling volume of all four heart chambers
• GEDI found to be a better indicator for preload than CVP or PCWP1
(1 Michard F et al. Chest 2003; 124(5):1900-1908)
Stroke Volume Variation (SVV) & Pulse Pressure Variation
(PPV)
Volume responsiveness
• Cyclic changes of the blood in the chest cavity, caused by mechanical
ventilation
• Changes in aortic blood flow are reflected by swings in the blood pressure
curve – causing variations in stroke volume and blood pressure
• Magnitude of variations is dependent on the volume responsiveness of
patient
• The higher the variations in SV and PP, the more likely the patient is to be
volume responsive
Stroke Volume Variation (SVV) & Pulse Pressure Variation
(PPV)

For proper use of the parameters, the following preconditions must be fulfilled:

• Fully controlled mechanical ventilation with tidal volume (≥ 8ml/KG PBW*)


• Sinus rhythm
• Pressure curves free of artifacts

*PBW – predicted body weight


Frank-Starling curve
Preload status and volume responsiveness

SV
SVV and PVV
<10 – 12%

SVV and PVV


>10 – 12%

Volume responsive Optimal preload Volume overload


Preload
(GEDI)
The power of the heart muscle depends on its initial load before the start of contraction
Systemic Vascular Resistance Index (SVRI)
Afterload

• Pressure that builds up in the wall of the left ventricle during ejection

• Simplified: resistance the heart has to pump against

• When afterload is high – Cardiac output is low and vice versa


Global Ejection Fraction (GEF) & Cardiac Function
Index (CFI)

GEF: CFI:
• Percentage of volume in a heart • Used to estimate cardiac
chamber which is ejected with a contractility
single contraction
• Relation of flow and preload
• Picture of overall cardiac
contractility
Cardiac Power Index (CPI) & Left Ventricular Contractility
(dPmx)

CPI: dPmx:
• Power of left ventricular output in • Pressure changes during the systolic
watts phase (left ventricle) can be analysed
via the arterial pressure curve
• Strong independent predictor of
mortality in cardiogenic shock1 • Pressure increase over time (speed) is
calculated – trend information

• The steeper the upslope of the curve,


the higher the contractility of the left
ventricle

1 Mendoza DD et al. Am Heart J 2007;153(3):366-70


Extravascular Lung Water (EVLW)
Pulmonary oedema

• In clinical routine chest x-ray is used to estimate the amount of pulmonary


oedema. This has consistently been shown to be inaccurate

• With EVLW underestimation of lung water is avoided

• Includes intra-cellular, interstitial and intra-alveolar fluid

Reference: unpublished data: Azriel Perel, MD, Department of Anaestesiology and Intensive Care, Sheba Medical Center, Tel Aviv University, Tel
Hashomer, Israel
Pulmonary Vascular Permeability Index (PVPI)
Pulmonary oedema

• Helps to identify the source of pulmonary oedema


• Cardiogenic pulmonary oedema: PVPI 1.0 -3.0
• Permeability pulmonary oedema: > 3.0

• Relation between EVLW and pulmonary blood volume (PBV)

Cardiogenic pulmonary oedema Permeability pulmonary oedema


Normal values
Parameters
Decision model
Parameters
Getinge Monitoring
Technologies
Bucarest 2017

Bucarest Hemodynamic Monitoring Workshop


31 March 2019
Page 36
Overview of technologies and parameters
PULSION Technologies

*This parameter will not be available by the PulsioFlex monitor from software version 5.0.Not every technology and parameter is available globally.
Please contact your local MAQUET sales representative to clarify approved technologies in your country
Overview
PiCCO Technology

PiCCO …

• gives the complete picture of the haemodynamic


situation (preload, afterload, contractility &
lung water)

• around 1,000 scientific publications on


validation and clinical use

• is clinically accepted as the standard for


advanced haemodynamic monitoring

• requires only the standard vascular access in


intensive care patients
Overview
ProAQT Technology

ProAQT offers…
• CITrend via any arterial standard catheter (including radial)
• Automatic (internal) and manual (external) calibration procedure
• ProAQT sensor with signal quality indicator LED
• For use in perioperative haemodynamic optimisation of high risk patients, with
high risk procedures or early recognition of unstable patients
Continuous Central Venous Oxygen Saturation
(ScvO2)

• Based on spectophotometry
• Fibreoptic probe for standard-CVC
• LED-signal is reflected by red blood cells and detected by a sensor
• Indications for use include patients in the Emergency Department, septic shock,
early goal directed therapy, cardiogenic shock

CeVOX Module CeVOX Probe Standard - CVC


Liver function
LiMON Technology

• Indocyanine green (ICG) dye is injected intravenously and excreted into the bile
via the liver
• LiMON finger clip sensor detects ICG concentration in the blood
• Elimination rate measured within 5 - 7 mins
• Parameter: PDR (plasma disappearance rate)
• Includes ICG calculator for the correct amount of dye according to patients
weight
• Indications for use include: liver surgery / transplantation, diagnosis and
monitoring in intensive care, hepatology / gastroenterology
Literature
Bucarest 2017

Bucarest Hemodynamic Monitoring Workshop


31 March 2019
Page 42