The PiCCO system - Anest The PiCCO system HOW TO PRACTICALLY USE THE VARIOUS MONITORING SYSTEMS? The PiCCO system Azriel Perel Professor and Chairman Rome 2009 Professor and Chairman

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The PiCCO systemThe PiCCO system

HOW TO PRACTICALLY USE THE VARIOUS HOW TO PRACTICALLY USE THE VARIOUS MONITORING SYSTEMS?MONITORING SYSTEMS?

The PiCCO systemThe PiCCO system

Azriel PerelAzriel Perel

Professor and ChairmanProfessor and Chairman

Rome 2009

Professor and Chairman Professor and Chairman Department of Anesthesiology and Intensive Care Department of Anesthesiology and Intensive Care

Sheba Medical Center, Tel Aviv UniversitySheba Medical Center, Tel Aviv UniversityIsraelIsrael

Disclosure

Th k t ith th f ll i iThe speaker cooperates with the following companies

BMeye

Drager-Siemens

Pulsion

[email protected]

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The PiCCOThe PiCCOA multiA multi--parametric parametric

approach to advanced approach to advanced hemodynamichemodynamichemodynamic hemodynamic

monitoringmonitoring

Central venous catheterCentral venous catheter

The PiCCO The PiCCO

• FemoralFemoral

•• AxillaryAxillary

•• BrachialBrachial

• Radial (long)Radial (long)

ThermistorThermistor--tipped tipped arterial catheterarterial catheter

{

3

Preload &Preload &

Clinical examination, vital signs, urine output, Hb, lactate...

Fluid responsivenessFluid responsiveness

Cardiac OutputEVLW

ScvO2dP/dT, CFI, GEF, PVPI

Preload &Preload &



Cardiac OutputEVLW


4

ScvO2 72%CVP 9 mmHg

A man with fever and shortness of breath

gLactate 48

PaO2/FiO2 75 (PEEP 10)

• CO 3.8• ITBVI 950 (normaI)• EVLWI 15 (high)• SVR 1100

P [mm Hg]

Real-time CCO by the pulse contour method

PCCO = cal • HR •⌠⌡P(t)SVR + C(p) • dP

dt( ) dt

t [s]

Area of pressure curve

Shape of pressure curve

⌡Systole

SVR (p) dt( )

ComplianceHeart rate

Patient-specific calibration factor (determined with thermodilution)

Arterial compliance and resistance are updated beat-to-beat according to a proprietary algorithm that depends particularly on the arterial pressure and on dP/dt.

5

Measurements recorded when SVR changed > 15%

Whole set of CI pairs

After a 1-hr calibration-free period, recalibration may be encouraged since it provides helpful information drawn from other thermodilution-derived variables.

Preload &Preload &



Cardiac OutputEVLW


6

Preload &Preload &



Cardiac OutputEVLW


ITBV = CO • mtt50cICG

mttcent

Intra-thoracic blood volume (ITBV)

20

30

40[mg l-1]

70%

33%

0 10 20 30 40 50 60

0

10

[s]tRAEDV RVEDV LAEDV LVEDV RAEDV RVEDV LAEDV LVEDVPBV

ITBVGEDV

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Global End-Diastolic Volume as an Indicator of Cardiac Preload in Patients With Septic Shock

F Michard et al, Chest. 2003;124:1900-1908

% of fluid-responders

720

740

760

780

800PrePre--infusioninfusionGEDViGEDVi(mL/m(mL/m22))

600

620

640

660

680

700

Responders Non-responders

ITBV and its changes correlates to CI and its changes significantly better than the CVP

Crit Care Med 2008; 36: 2348

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Intravascular volume depletion in a Intravascular volume depletion in a 2424--hour porcine model of hour porcine model of intraintra--abdominal hypertensionabdominal hypertension

Schachtrupp A et al, J Trauma. Schachtrupp A et al, J Trauma. 5555: : 734734--740740, , 20032003

Should we monitor preload andShould we monitor preload and fluid responsiveness in shock?

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Functional hemodynamic parameters Functional hemodynamic parameters (SPV, PPV, SVV) are the most sensitive (SPV, PPV, SVV) are the most sensitive

parameters for the assessment of parameters for the assessment of fluid responsiveness in mechanically fluid responsiveness in mechanically

SPV PPV SVVSPV PPV SVV

p yp yventilated patientsventilated patients

Preload &Preload &



Cardiac OutputEVLW


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Sturm JA 1990High EVLW content is

associated with increased mortality

(65-80% when EVLW>20 ml/kg)

Sakka S et al Chest 2002; 1232:2080-6

EVLWI and Mortality (Highest measurement)

N=373

20

3040

50

60

7080

90

2_6 6_8 8_10 10_12 12_16 16_20 >20EVLWI (ml/kg)

Mor

talit

y (%

)

Beale R 2001

N=241

FT Chung et al , respiratory Medicine 2008

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EVLW was markedly elevated (13.5 ml/kg) in patients with early ARDS, was significantly higher in non-survivors and correlated with Vd/Vt.

• 15 dogs; EVLW measured by PiCCO and, following sacrifice, by gravimetrics.

• Control (n=5)

• Non-cardiogenic20

30

40

PiC

CO

(ml/k

g)

• Non-cardiogenic pulmonary edema (oleic acid) (n=5)

• Cardiogenic pulmonary edema (lt. atrial balloon) (n=5)

0

10

0 10 20 30 40

EVLW-grav. (ml/kg)

EVLW

-

R2 = 0.9758

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A 63 yrs old patient with pulmonary edema after TURT

24 hours later

20 20 ml/kgml/kg 10 10 ml/kgml/kg

Severe respiratory failure in a 33 yrs old patient following ruptured hematoma of the liver and multiple transfusions

EVLW is only 5 ml/kg

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BP 70/40 mmHg

HR 155 bpm

A patient with head injury, severe ARDS and septic shock

CO = 12 15 L/min

CVP 5 cmH2OPaO2/FiO2 80 (PEEP 16)

Hi h !!!

Would you give fluids to this patient?Noradrenaline + aggressive diuresis!

CO = 12-15 L/minSVR = 400-500ITBVI = 1200 ml/m2 (800-1000)

EVLW = 19-23 ml/kg (4-7)

Low !!!

High !!!

High !!!

High !!!

An old patient with chronic heart failure, sepsis, severe respiratory

failure and hemodynamic instability.

CO 1.8 l/minl/min LOW

ITBVi 600 ml/m600 ml/m22 LOWLOW

EVLWi 15 ml/kg15 ml/kg HIGHHIGHSVV 2525--30%30% HIGHHIGH

A classic therapeutic (heart vs. lungs) conflict

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17.5EVLWEVLW

Start fluid loading!

3030

Stop fluid loading!

A 63 years old male patient; developed fulminant pulmonary edema 4 hours into a re-total hip replacement. Hypoxemia (SaO2<80%), hemodynamic instability and ST changes. In the PACU – hypotensive, tachycardic, on vasopressors and inotropes.

Parameter Normal range Interpretation

CI 1.9 l/m2 3.5 - 5.0 Low CO

ITBVI 779 ml/m2 850 -1000 Low preloadp

SVV 22 % <10 High fluid responsiveness!!

EVLW 23 ml/kg 3 - 7 Severe pulmonary edema

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Decision tree for hemodynamic / volumetric monitoring**

CI (l/min/m2) >3.0<3.0

GEDI (ml/m2)or ITBI (ml/m2)

>700>850

<700<850

>700>850

<700<850

RESU

CO (L)

GEDV (L)

+

ELWI (ml/kg)


<10 >10 <10 <10 <10>10 >10 >10

V+ V+! V+!V+Cat Cat V-

>700>850

700-800850-1000

700-800850-1000

Cat

>700>850

700-800850-1000

700-800850-1000

V-

>700>850

<10Optimise toSVV (%) <10 <10 <10

ULTS

TAR

THERAP

1.

2. <10 <10 <10 <10

( )

EVLW (H)

Fluids cautiously + catecholamines

CI (l/m2) 1.9

ITBVI (ml/m2)

779 Start fluid loading!

29*not available in USA**without guarantee

*

+

ELWI (ml/kg)(slowly responding)

CFI (1/min)or GEF (%) OK!

>4.5>25

>5.5>30

>4.5>25

>5.5>30

≤10 ≤10 ≤10 ≤10

V+= volume loading (! = cautiously) V-= volume contraction Cat = catecholamine / cardiovascular agentsSVV only applicable in ventilated patients without cardiac arrhythmia

GET

PY

(ml/m )

SVV % 22

EVLW (ml/kg)

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Decision tree for hemodynamic / volumetric monitoring**

CI (l/min/m2) >3.0<3.0


>700>850

<700<850

>700>850

<700<850

RESU

CO (H)

GEDV (H)

+

ELWI (ml/kg)


<10 >10 <10 <10 <10>10 >10 >10

V+ V+! V+!V+Cat Cat V-

>700>850

700-800850-1000

700-800850-1000

Cat

>700>850

700-800850-1000

700-800850-1000

V-

>700>850

<10Optimise toSVV (%) <10 <10 <10

ULTS

TAR

THERAP

1.

2. <10 <10 <10 <10

EVLW (H)

DiuresisCI (l/m2) 3.75

ITBVI (ml/m2)

1444 !!!

Stop fluid loading!

30*not available in USA**without guarantee

*

+

ELWI (ml/kg)(slowly responding)

CFI (1/min)or GEF (%) OK!

>4.5>25

>5.5>30

>4.5>25

>5.5>30

≤10 ≤10 ≤10 ≤10

V+= volume loading (! = cautiously) V-= volume contraction Cat = catecholamine / cardiovascular agentsSVV only applicable in ventilated patients without cardiac arrhythmia

GET

PY(ml/m2) !!!

SVV % 15

EVLW (ml/kg)

15

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This ‘flash’ permeability of uncertain etiology (TRALI?) was associated with

severe hypovolemia and improved spontaneously even though fluids were

liberally administered

Postop Day 2Postop Day 1Fluid loadingPACU

7

1093

3.47

22

779

1.9

8SVV %

9721444 !!!ITBVI (ml/m2)

2.893.75CI (l/m2)

Postop Day 2Postop Day 1Fluid loadingPACU

7

1093

3.47

22

779

1.9

8SVV %

9721444 !!!ITBVI (ml/m2)

2.893.75CI (l/m2)

Table 2

y

451523EVLW (ml/kg)

0.26

7

1.82

22

0.360.73EVLW / ITBV

815SVV %

451523EVLW (ml/kg)

0.26

7

1.82

22

0.360.73EVLW / ITBV

815SVV %

*

*PEF/plasma TP ratio=1

Preload &Preload &



Cardiac OutputEVLW


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BP 113 / 67 mmHg CI 2.7 l/min/m2

34 yr female; Very severe respiratory failure; Hemodynamic collapse; on noradrenaline.

BP 113 / 67 mmHg

HR 91 bpm

Urine GoodSaO2 86% !!!

CI 2.7 l/min/m

ITBVi 578 ml/m2

EVLWi 20 ml/kgICG PDR 6.7%(LiMON) (18 25%)(LiMON) (18-25%)ScvO2 80% !!!

Have we achieved initial resuscitation goals in this patient?

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A Perel, M Maggiorini, M Malbrain, JL Teboul, J Belda, E Fernández-Mondéjar, M Kirov, J Wendon

The PiCClin StudyThe PiCClin Study

The patient population included The patient population included 206 206 patients, patients, which were evaluated by which were evaluated by 166 166 residents and residents and 146 146 specialists (total of specialists (total of 315 315 questionnaires).questionnaires).

P ti i t k d t di t d dP ti i t k d t di t d dParticipants were asked to predict advanced Participants were asked to predict advanced hemodynamic parameters and decide on a hemodynamic parameters and decide on a therapeutic plan prior to PiCCO insertion.therapeutic plan prior to PiCCO insertion.

A Perel, M Maggiorini, M Malbrain, JL Teboul, J Belda, E Fernández-Mondéjar, M Kirov, J Wendon

The PiCClin StudyThe PiCClin Study

The main reasons for using the PiCCO The main reasons for using the PiCCO monitoring system included:monitoring system included:

Unclear fluid status (Unclear fluid status (136136))Suspected sepsis / septic shock (Suspected sepsis / septic shock (8989))Respiratory failure (Respiratory failure (5959))Respiratory failure (Respiratory failure (5959))Cardiogenic shock (Cardiogenic shock (2424))Renal failure (Renal failure (3232))Other (Other (2121))

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EVLWi(n=304)

GEDVi(n=314)

SVR(n=312)

CO(n=315)

The accuracy of predicted cardiopulmonary parametersThe accuracy of predicted cardiopulmonary parameters

( )( )( )( )

83 (27.3%)

97 (30.9%)

46 (14.7%)

170 (54%)

Underestimation>20%

124 (40.8%)

154 (49%)

107 (34.3%)

110 (34.9%)Within ± 20% (40.8%)(49%)(34.3%)(34.9%)

97 (31.9%)

63 (20.1%)

159 (51%)

35(11.1%)

Overestimation>20%

The PiCClin Study

The PiCClin Study The PiCClin Study II: Change of therapeutic plan following advanced II: Change of therapeutic plan following advanced

rdiopulmonary monitoring in critically ill patientsrdiopulmonary monitoring in critically ill patients

In the absence of further hemodynamic information, what would be your

therapeutic decision?

OtherDialysis/ filtration

DiureticVaso-constrictor

Inotropic agent

Red blood cells

Fluid loading

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The PiCClin Study The PiCClin Study II: Change of therapeutic plan following advanced II: Change of therapeutic plan following advanced

rdiopulmonary monitoring in critically ill patients.rdiopulmonary monitoring in critically ill patients.

Original therapeutic plan

ChangedPursued(n=315)

32.4%67.6%Fluids

21 6%78 4%Inotropes 21.6%78.4%Inotropes

22.5%77.5%Vasoconstrictors

13.9%86.1%Diuretics

Forty-six patients with SAH treated within 24 hours of the ictus were investigated.

A fluid management protocol emphasizing supplemental colloid administration was used to attain the following targets:

CI - 3.0 L/min/m2

GEDVi - 700-900 mL/m2

EVLW < 14 mL/kg

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Initially the CI was high (5.3 L/min/m2) and the GEDVi low (555 mL/m2), with elevations of plasma adrenaline noradrenaline andadrenaline, noradrenaline, and cortisol. CI progressively decreased and GEDVi was normalized by fluid administration aimed at normovolemia.

Mutoh et al

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NorepinephrineGuiding therapy by an algorithm based on GEDVI leads to a shortened and reduced need for vaso-pressors, catecholamines, mechanical ventilation,and ICU therapy in

Goepfert et al, ICM 2007

Epinephrine

and ICU therapy in patients undergoing cardiac surgery.

The use of PiCCO resulted in:The use of PiCCO resulted in:

1.1. Early recognition of Early recognition of hypovolemia and hypovolemia and myocardial depression.myocardial depression.

2.2. Better titration of fluid and Better titration of fluid and inotrope / vasopressor inotrope / vasopressor therapy.therapy.

3.3. Shorter hospital length of Shorter hospital length of stay after OPCAB.stay after OPCAB.

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22 days* *

n=101

Targeting EVLW in ARDS

22 days

15 days

9 days7 days

RHC group RHC groupEVLW group EVLW group

After: Mitchell et al, Am Rev Resp Dis 145: 990-998, 1992

RHC group RHC groupEVLW group EVLW group

Ventilation days ICU days

When EVLW is high

C. Philips et al

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“This protocol allows aggressive diuresis of excess preload even during periods of shock –something not done in the FACTT trial and rarely done clinically. This is accomplished by y y p ybetter identifying preload state using superior metrics of preload and cardiovascular status –GEDI, CI, and EVLW.” C. Philips (with permission)

1. Is there a problem?

How should the PiCCO be used?How should the PiCCO be used?

1. Is there a problem?

2. Identify the problem(s)

3. Which seems to be the most critical problem?

4. Is there a therapeutic conflict?

5. Out of your potential therapeutic options, which y p p pdecision will cause most/least damage in case of error?

6. Make your decision and follow results

7. Go back to (1)

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When do I use the PiCCO? When do I use the PiCCO?

CHF + major surgeryCHF + major surgeryCHF + major surgery CHF + major surgery Sepsis Sepsis ARDS, MOFARDS, MOFPulmonary edema Pulmonary edema Therapeutic conflictsTherapeutic conflictsTherapeutic conflictsTherapeutic conflictsExpected hemodynamic instabilityExpected hemodynamic instabilityWhen the patient cannot afford to pay When the patient cannot afford to pay

the price of my mistakethe price of my mistake

Critically ill patients do often have complexCritically ill patients do often have complex

Conclusion

Critically ill patients do often have complex Critically ill patients do often have complex hemodynamics and may hemodynamics and may often present us with often present us with heartheart--lung and other therapeutic conflicts.lung and other therapeutic conflicts.

Since aSince all individual hemodynamic ll individual hemodynamic parameters have limitations and confounding parameters have limitations and confounding factors a multifactors a multi parametric hemodynamicparametric hemodynamicfactors, a multifactors, a multi--parametric hemodynamic parametric hemodynamic approach that includes EVLW reduces the approach that includes EVLW reduces the chance of erroneous critical decisions.chance of erroneous critical decisions.

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Preload &Fluid responsiveness


Cardiac OutputEVLW


Thank you!

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Cardiac output 6.77 L/minScvO2 is 60%!

Is this CO adequate?

ScvOScvO22==6363ScvOScvO22==7676

ScvOScvO22==7474CO

Patient is given dobutamine

CO was high, but not high enough!CO was high, but not high enough!

The CO and the ScvOThe CO and the ScvO22 complement each other!complement each other!

Documents

The PiCCO system - Anest The PiCCO system HOW TO PRACTICALLY USE THE VARIOUS MONITORING SYSTEMS? The PiCCO system Azriel Perel Professor and Chairman Rome 2009 Professor and Chairman