Transcript Folie 1 - PULSION Medical Systems SE: Startseite
Haemodynamic Monitoring
Theory and Practice
2
Haemodynamic Monitoring
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Physiological Background Monitoring Optimising the Cardiac Output Measuring Preload
Introduction to PiCCO Technology
Practical Approach Fields of Application Limitations
Haemodynamic Monitoring
E. Introduction to PiCCO Technology 1.
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Principles of function Thermodilution Pulse contour analysis Contractility parameters Afterload parameters Extravascular lung water Pulmonary permeability
Introduction to the PiCCO-Technology
Parameters for guiding volume therapy
Volumetric preload - static - dynamic
Differentiated Volume Management
CO Contractility EVLW
PiCCO Technology
Introduction to the PiCCO-Technology – Function
Principles of Measurement
PiCCO Technology is a combination of transpulmonary thermodilution and pulse contour analysis CVC central venous bolus injection Lungs
Pulmonary Circulation
Right Heart Left Heart
Body Circulation PULSIOCATH
arterial thermodilution catheter
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 EVLW PBV EVLW
Lungs
LA LV concentration changes over time
(Thermodilution curve) Right heart Left heart The temperature change over time is registered by a sensor at the tip of the arterial catheter
Introduction to the PiCCO-Technology – Function
Intrathoracic Compartments (mixing chambers)
RA RV Intrathoracic Thermal Volume (ITTV) Pulmonary Thermal Volume (PTV) EVLW PBV EVLW
Largest single mixing chamber Total of mixing chambers
LA LV
Haemodynamic Monitoring
E. Introduction to PiCCO Technology 1.
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Principles of function Thermodilution Pulse contour analysis Contractility parameters Afterload parameters Extravascular Lung Water Pulmonary Permeability
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
T b Injection t
CO
TD a
= (T
b
- T
i
)
x ∫
D
T
b x
V
i x
K dt
T b T i = Blood temperature = Injectate temperature V i = Injectate volume ∫ ∆ T b .
dt = Area under the thermodilution curve K = Correction constant, made up of specific weight and specific heat of blood and injectate
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 36,5 Time
low CO: 1.9l/min
37 Temperature 36,5 Time 37 5 10 Time
High CO: 19l/min
Introduction to the PiCCO –Technology – Thermodilution
Transpulmonary vs. Pulmonary Artery Thermodilution
Transpulmonary TD (PiCCO) Pulmonary Artery TD (PAC)
Aorta central venous bolus injection
Pulmonary Circulation
Lungs RA LA PA LV Right Heart Left heart
PULSIOCATH
arterial thermo dilution catheter RV
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!
Introduction to the PiCCO –Technology – Thermodilution
Validation of the Transpulmonary Thermodilution
Comparison with Pulmonary Artery Thermodilution
n (Pts / Measurements)
Friedman Z et al., Eur J Anaest, 2002 Della Rocca G et al., Eur J Anaest 14, 2002 Holm C et al., Burns 27, 2001 Bindels AJGH et al., Crit Care 4, 2000 Sakka SG et al., Intensive Care Med 25, 1999 Gödje O et al., Chest 113 (4), 1998 McLuckie A. et a., Acta Paediatr 85, 1996 17/102 60/180 23/218 45/283 37/449 30/150 9/27 Comparison with the Fick Method Pauli C. et al., Intensive Care Med 28, 2002 Tibby S. et al., Intensive Care Med 23, 1997 18/54 24/120
bias
±
SD(l/min)
-0,04 ± 0,41 0,13 ± 0,52 0,32 ± 0,29 0,49 ± 0,45 0,68 ± 0,62 0,16 ± 0,31 0,19 ± 0,21 0,03 ± 0,17 0,03 ± 0,24
r 0,95 0,93 0.98
0,95 0,97 0,96 - / 0,98 0,99
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 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 T b = blood temperature; lnTb = logarithmic blood temperature; t = time t
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
Intrathoracic Thermal Volume ITTV = MTt x CO Pulmonary Thermal Volume PTV = Dst x CO
Einführung in die PiCCO-Technologie – Thermodilution
Calculation of ITTV and PTV
RA RV Intrathoracic Thermal Volume (ITTV) Pulmonary Thermal Volume (PTV) EVLW LA PBV EVLW PTV = Dst x CO ITTV = MTt x CO LV
Introduction to the PiCCO –Technology – Thermodilution
Volumetric preload parameters – GEDV
Global End-diastolic Volume (GEDV)
ITTV
RA RV EVLW PBV EVLW LA LV
PTV GEDV GEDV is the difference between intrathoracic and pulmonary thermal volumes
Introduction to the PiCCO –Technology – Thermodilution
Volumetric preload parameters – ITBV
Intrathoracic Blood Volume (ITBV)
GEDV
RA RV EVLW PBV EVLW LA LV
PBV ITBV ITBV is the total of the Global End-Diastolic Volume and the blood volume in the pulmonary vessels (PBV)
Introduction to the PiCCO-Technology – Thermodilution
Volumetric preload parameters – ITBV
ITBV is calculated from the GEDV by the PiCCO Technology
Intrathoracic Blood Volume (ITBV)
ITBV TD (ml)
3000 2000 1000 0 0 1000
GEDV vs. ITBV in 57 Intensive Care Patients
Sakka et al, Intensive Care Med 26: 180-187, 2000 2000
ITBV = 1.25 * GEDV – 28.4 [ml]
3000
GEDV (ml)
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.
Haemodynamic Monitoring
E. Introduction to PiCCO Technology 1.
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Principles of function Thermodilution Pulse contour analysis Contractility parameters Afterload parameters Extravascular Lung Water Pulmonary Permeability
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 CO TPD HR = SV TD
T = blood temperature t = time P = blood pressure
Introduction to the PiCCO-Technology – Pulse contour analysis
Parameters of Pulse Contour Analysis
Cardiac Output PCCO = cal • HR •
Systole ( P(t) SVR + C(p) • dP dt ) dt Patient- specific calibration factor
(determined by thermodilution)
Heart rate Area under the pressure curve Aortic compliance Shape of the pressure curve
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) Mielck
et al., J Cardiothorac Vasc Anesth 17 (2), 2003
Rauch H
et al., Acta Anaesth Scand 46, 2002
Felbinger TW
et al., J Clin Anesth 46, 2002
Della Rocca G
et al., Br J Anaesth 88 (3), 2002
Gödje O
et al., Crit Care Med 30 (1), 2002
Zöllner C
et al., J Cardiothorac Vasc Anesth 14 (2), 2000
Buhre W
et al., J Cardiothorac Vasc Anesth 13 (4), 1999
22 / 96 25 / 380 20 / 360 62 / 186 24 / 517 19 / 76 12 / 36 -0,40
±
1,3 0,14
±
0,58 -0,14
±
0,33 -0,02
±
0,74 -0,2
±
1,15 0,31
±
1,25 0,03
±
0,63 r - / - / 0,93 0,94 0,88 0,88 0,94
Introduction to the PiCCO-Technology – Pulse Contour Analysis
Parameters of Pulse Contour Analysis
Dynamic parameters of volume responsiveness – Stroke Volume Variation SV max SV min SV mean SVV = SV max – SV min SV mean
The Stroke Volume Variation is the variation in stroke volume over the ventilatory cycle, measured over the previous 30 second period.
Introduction to the PiCCO-Technology – Pulse Contour Analysis
Parameters of Pulse Contour Analysis
Dynamic parameters of volume responsiveness – Pulse Pressure Variation PP max PP min PP mean PPV = PP max – PP min PP mean
The pulse pressure variation is the variation in pulse pressure over the ventilatory cycle, measured over the previous 30 second period.
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
Haemodynamic Monitoring
E. Introduction to PiCCO Technology 1.
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Principles of function Thermodilution Pulse contour analysis Contractility parameters Afterload parameters Extravascular Lung Water Pulmonary Permeability
Introduction to the PiCCO-Technology – Contractility parameters
Contractility
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
Introduction to the PiCCO-Technology – Contractility parameters
Contractility parameter from the p
ulse contour analysis
dPmx = maximum velocity of pressure increase
The contractility parameter dPmx represents the maximum velocity of left ventricular pressure increase.
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 1500 1000 500
n = 220 y = -120 + (0,8* x) r = 0,82 p < 0,001
0 0 500 1000 1500 2000
LV dP/dtmax [mmHg/s]
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
Introduction to the PiCCO-Technology – Contractility parameters
Contractility parameters from the thermodilution measurement GEF = Global Ejection Fraction LA RA LV
GEF = 4 x SV GEDV
RV
• is calculated as 4 times the stroke volume divided by the global end-diastolic volume • reflects both left and right ventricular contractility
Introduction to the PiCCO-Technology – Contractility parameters
Contractility parameters from the thermodilution measurement GEF = Global Ejection Fraction sensitivity
1 0,8
19 18 16
0,6 0,4
22 20
0,2
12 8
0 0 0,2 0,4 0,6 0,8
1 specifity
Combes et al, Intensive Care Med 30, 2004 -20 15 10 5 -10 10 20 D
FAC, %
-5 -10 -15 D
GEF, % r=076, p<0,0001 n=47
Comparison of the GEF with the gold standard TEE measured contractility in patients without right heart failure
Introduction to the PiCCO-Technology – Contractility parameters
Contractility parameters from the thermodilution measurement CFI = Cardiac Function Index
CFI = CI 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
Introduction to the PiCCO-Technology – Contractility parameters
Contractility parameters from the thermodilution measurement CFI = Cardiac Function Index sensitivity
1
4 3,5 3 2
15 10 0,8 5 0,6
5
0,4 0,2
6
-20 -10 -5 10 20 D
FAC, %
0 0 0,2 0,4 0,6 0,8
1 specificity
-10 -15 D
GEF, % r=079, p<0,0001 n=47
Combes et al, Intensive Care Med 30, 2004 CFI was compared to the gold standard TEE measured contractility in patients without right heart failure
Haemodynamic Monitoring
E. Introduction to PiCCO technology 1.
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Functions Thermodilution Pulse contour analysis Contractility parameters Afterload parameters Extravascular Lung Water Pulmonary Permeability
Introduction to the PiCCO –Technology – Afterload parameter
Afterload parameter SVR = Systemic Vascular Resistance
SVR = (MAP – CVP) x 80 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 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
Haemodynamic Monitoring
E. Introduction to PiCCO technology 1.
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Principles of function Thermodilution Pulse contour analysis Contractility parameters Afterload parameters Extravascular Lung Water Pulmonary Permeability
Introduction to the PiCCO –Technology – Extravascular Lung Water
Calculation of Extravascular Lung Water (EVLW)
ITTV – ITBV = EVLW
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.
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 ELWI by PiCCO
40 Y = 1.03x + 2.49
Dye dilution ELWI ST (ml/kg)
30 20 25 20 15 10 5
n = 209 r = 0.96
10
R = 0,97 P < 0,001
0 0 10 20 30
ELWI by gravimetry
Katzenelson et al,Crit Care Med 32 (7), 2004 0 0 5 10 15 20 25
ELWI TD (ml/kg)
Sakka et al, Intensive Care Med 26: 180-187, 2000
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 0 0 50 150 250 350 450
PaO 2 /FiO 2
550 Boeck J, J Surg Res 1990; 254-265
Introduction to the PiCCO –Technology – Extravascular Lung Water
EVLW as a quantifier of lung oedema
ELWI = 19 ml/kg
Extravascular lung water index (ELWI) normal range: 3 – 7 ml/kg
ELWI = 7 ml/kg ELWI = 14 ml/kg ELWI = 8 ml/kg
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 0 -15 -10 -20 -40 -60 -80 10 D 15
ELWI
Halperin et al, 1985, Chest 88: 649
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
Mortality (%) ) Mortality(%
100 90 80 70 60 50 40 30
n = 81
20 0 4 - 6 > 20
ELWI (ml/kg)
Sturm J in: Lewis, Pfeiffer (eds): Practical Applications of Fiberoptics in Critical Care Monitoring, Springer Verlag Berlin - Heidelberg - NewYork 1990, pp 129-139 80 70 60 50 40 30 20 10 0 0 < 7 n = 45 7 - 14 n = 174
*p = 0.002
Sakka et al , Chest 2002 14 - 21 n = 100
n = 373
> 21 n = 54
ELWI (ml/kg)
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 * p ≤ 0,05 Intensive Care days n = 101 * p ≤ 0,05 22 days PAC Group 9 days EVLW Group
Mitchell et al, Am Rev Resp Dis 145: 990-998, 1992
15 days PAC Group 7 days EVLW Group
Haemodynamic Monitoring
E. Introduction to PiCCO Technology 1.
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Principles of function Thermodilution Pulse contour analysis Contractility parameters Afterload parameters Extravascular Lung Water Pulmonary Permeability
Introduction to PiCCO Technology – Pulmonary Permeability
Differentiating Lung Oedema
PVPI = Pulmonary Vascular Permeability Index
PVPI = EVLW PBV
EVLW 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)
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
PBV EVLW EVLW PBV
permeability
PBV EVLW EVLW PBV PVPI normal (1-3) PVPI raised (>3)
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 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
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?
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