PiCCO Technology Train the Trainer Folder

Tips & tricks

Tips & tricks

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Tips & tricks Error Cause Arterial pressure measurement Pressure curve • Pressure line not correctly attached absent • Pressure line blocked • Cable or device defect Abnormal pressure • Catheter malpositioned curve • Blocked catheter lumen • Arrhythmia, extra systole • Tachycardia (> 240 bpm) Flat pressure curve • Inappropriate scale settings • Failed connection of pressure system • Flush has insufficient pressure • None or wrong zero adjustment • Damped pressure transducer transmission from: --Airbubbles --Modifications of pressure line --Malposition of stop cocks --Kinked catheter or pressure line • Hypotonia Indicator injection Injection was not • CVC malpositioned detected • 3-way-stopcock incorrectly adjusted • Temperature sensor housing pin clotted • Temperature sensor housing / sensor not connected correctly • Defective temperature sensor Thermodilution results Results implausible Amount injected does not match amount to be injected displayed by device Pulse contour results Calibration PCCO Arterial pressure curve absent or faulty not possible Large variation in Arrhythmia, extra systoles values

Remedy • Check pressure line, stop-cock, cable and plug • Flush pressure line • Connect pressure transducer directly to the bedside monitor for testing • Check or change catheter position • Flush catheter • Regulate therapeutically • Regulate therapeutically • Set scale of pressure curve • Check and ensure pressure system connected correctly • Increase the flush pressure to 250-300 mmHg • Carry out / repeat zero adjustment -- Disconnect from patient and remove air bubble -- Remove any additional lines and or stop cocks -- Adjust stop cocks correctly -- Remove kinks, possibly change patient position • Regulate therapeutically • Correct position • Adjust 3-way-stopcock • Change temperature sensor housing • Check connection („click-sound“) • Check or change sensor Inject correct volume

Check / optimize arterial pressure measurement Regulate therapeutically

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Tips & tricks Error Cause Thermodilution curve Unstable • Rapid cooling or warming of patient temperature • Massive volume loading baseline • Arterial connection cable broken or not measurement correctly connected • Faulty thermistor on PiCCO catheter • Thermistor lying against vessel wall Thermodilution curve is not displayed

• Incorrect injection at central venous catheter • Faulty thermistor on PiCCO catheter • Broken or failed cable-connection of arterial connection cable

Remedy • Wait for stabilisation phase • Stop volume supply if possible • Check cable connection, replace if necessary • Check temperature change when flushing catheter, replace catheter if no temperature change seen • Change catheter or patient position • Perform central venous injection correctly • Check temperature change when flushing catheter, replace catheter if no temperature change seen • Check cable connection, change if necessary

Thermodilution • Injection too slow curve display is too • Very low cardiac output or very high late (Time out limit) lung water

• Inject faster (< 7s) • Use colder and/or more injectate

Thermodilution curve very flat

• Inappropriate scale settings • Injectate too warm • Very low cardiac output or very high lung water

• Adjust scaling • Use colder injectate • Use colder and/or more injectate

Thermodilution curve displays more than one peak

• Injection not smooth • Existing intracardiac shunts

• Ensure smooth injection • Perform shunt diagnosis

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PiCCO2 Guidelines 1.

Have you got a good arterial pressure waveform trace?

Height 70 inch Weight 182 lbs Arterial pressure

HR

86

AP 132/71 MAP 91 (CVP 9)

Time since

140

Flow

PCC

Pressure waveform

AP 70

SVRI 17

Press on the waveform to change the amplitude of the waveform. If the trace is absent or dampened, check position of patient and/or catheter, check for presence of air bubblesPCCI in blood pressure tubing, remove any additional pressure lines, check for kinks in tubing. Check that the transducer is open to catheter and pressure bag inflated. Check all cables are correctly attached (see operator manual for further details). Flush with saline using flush device. 2.

Have you got an arterial pressure appropriate for this patient? The arterial pressure numbers are located on the top left hand side of the display page (see above). If a false lowVolume or high measurement is suspected, check SVI level of transducer (it should be placed in line with the phlebostatic axis). MAP Check the machine was ‘zeroed’ correctly (see operator manual for further details).

3.

Have you got an adequate / appropriate Cardiac Output / Index for the patient’s clinical situation? If CO/CI appears inappropriate (too low or too high), check in the <Patient> screen that the patients correct weight and height have been entered. To enter this screen press the patient information bar at the top of the screen. NB the thermodilution measurement may not work in patients who have extremely low CO/ CI, for e.g. <1.2 l/min.

SVV

4.

Were you in the Thermodilution screen when you performed the injection? Press the grey Thermodilution screen button on the bottom left of the display. Press start and wait until the message "INJECT" appears on the screen. Inject as quickly and smoothly as possible. Previous thermodilution measurements SVV SVRI TD Results

3.47

3.11

3.15

3.76

AP/CVP 3.44

GEDI

705

626

678

764

698

ELWI

9

9

10

10

9

T

1.18

1.17

0.30

1.20

TD

CI

Press to go to Thermodilution Screen

10:18 am 10:20 am 10:22 am 10:26 am SEP 23 SEP 23 SEP 23 SEP 23

Press START when machine and you are ready to inject

START READY

10:26 am SEP 23

15 ml CVP 5

98.6 0s

10s

20s

30s

mmHg

Exit

Amount to be injected

4-4

9 %

Organ Function

Inj. Volume 98.1

dyn*

1/m

Thermodilution measurement

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5.

Did you inject the correct amount and correct temperature of injectate? Check the thermodilution screen. The amount of injectate can be changed depending o patients weight. In general 15cc is the appropriate amount for an adult patient. It is recommended that the temperature of injectate be ≤ 46,4°F in all instances. Change injectate volume in configuration ‘Measurement Screen’ if necessary.

6.

Did you inject as quickly (under 7 secs) and steadily as possible? The device will ignore or reject injections under 0.5 sec or over 10 seconds. If necessary inject again, injecting as quickly and as smoothly as possible. Make sure you do not touch the end of the plunger UNTIL you are ready to inject.

7.

Was the bolus cold enough? The temperature of the injectate (Tinj) is displayed on the Thermodilution screen in the summary data above each completed thermodilution curve. There must be a difference in temperature of at least 0.15 °C (32,27°F) for the thermodilution measurement to be recognized (shown as ΔT).To display this information go into the ‘Measurement Screen’ and ensure ‘Display Vinj & Tinj ‘ says <Yes>.

8.

Did the device display ‘Injection’ whilst you were injecting? The device will detect if you have performed a correct thermodilution measurement (the word “injection” appears below the start button). If this did not happen, check the device was ready (see section above), check amount and temperature of injectate (see section above) and try again.

9.

Is there only one three way tap between the patient and the injectate temperature sensor housing? The point of injection must be a close as possible to the injectate temperature sensor housing which must be as close as possible to the patient. Remove any additional 3 way taps. Temperature sensor housing Infusion

Thermodilution

CVP Line – 3 way tap to remain switched off until after Thermodilution measurement completed.

Distal Lumen of CVC

10. When you injected did the injectate pass through the injectate temperature sensor housing? Check the position of the three way tap is only open to the patient not other infusions (see above). If this is not the case, correct and re-inject. 11. Were all other infusions switched off during the injection? To ensure the injectate remains in a bolus and as cold as possible other infusions that are running through the same lumen should be temporarily suspended during the thermodilution injection. Do not turn the 3 way tap back until the thermodilution curve has been completed. This includes the pressure line for the CVP. 12. Is the injectate temperature sensor cable connected correctly? Ensure the cable is connected to both the sensor at the CVC port and the arterial PiCCO catheter.

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Special clinical situations General Hypothermia • There is no influence on the thermodilution measurements as long as the patient’s temperature is stable. Cooled injectate should be used. Fluctuating blood temperature • Temperature fluctuations from baseline are compensated by the device. Thermodilution measurement is not recommended in the event where a stable baseline is not possible. Basic requirements for the assessment of the volume responsiveness parameters (SVV, PPV) • Controlled mechanical ventilation with no spontaneous breaths • Sinus rhythm without arrhythmias or artefacts

Contraindications and complications No absolute contraindications • Usual precautions should be considered when accessing larger blood vessels. For example presence of coagulation problems, grafts etc. Other sites such as the axillary artery can be used. No increased complication rate • Usual risks associated with arterial puncture: puncture injury, infection (extremely rare), impaired blood flow, hematoma. • The maximum recommended placement period for the PiCCO catheter is 10 days. No specific application restrictions • As it is possible to use normal saline for the thermodilution measurements, there are no restrictions on the number of measurements possible, including in pregnancy and with children

Specific Therapies Vasoconstrictors / Inotropes / Volume Therapy • All parameters are correctly calculated. During periods of unstability where there are significant changes in the catecholamine requirements, or volume therapy, recalibration of the pulse contour analysis is recommended Intra-aortic Balloon Pump (IABP) • The thermodilution parameters (CO, GEDI, EVLW) are measured correctly. • Pulse contour analysis is not always accurate. Renal Replacement Therapy (continuous hemofiltration / dialysis) • All the parameters are measured correctly provided the dialysis out- and inflow catheters are not in the path of the indicator

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 Heart Valvular Insufficiency • Regurgitation of the thermodilution injectate can prolong the transit time of the indicator, or interfere with the thermodilution curve. However, where a thermodilution curve is possible, the calculation of the cardiac output is correct. The extended mean transit time of the injectate can result in an overestimation in the GEDI / ITBI. Aortic Stenosis • All parameters are correctly measured Intra-cardiac Shunts • Due to the marked alteration in the thermodilution curve, no valid values are able to be calculated. In less severe shunts, measurements may be possible. In left-to-right shunts, the CO is determined correctly. Aortic aneurysms • GEDI / ITBI is increased due to the volume of the aortic aneurysm, this can be avoided by placement of the PiCCO catheter in the axillary artery. Cardiac Arrhythmia • The thermodilution parameters are measured correctly. • The pulse contour analysis is correct in mild to moderate rhythm disturbances (normal rate atrial flutter / fibrillation, bigeminal –, trigeminal or incidental extra systoles) • In severe cardiac rhythm disturbances (tachyarhythmias, supraventricular tachycardia), pulse contour analysis may be inaccurate. It is recommended to recalibrate with 3-5 thermodilution measurements.

Lung Partial Lung Resection • Correct calculation of the cardiac output and GEDI. The degree of potential under-estimation of the ELWI is dependent on the amount of lung resected. The trend of the ELWI remains accurate. Pulmonary perfusion disturbances (e.g. pulmonary embolism) • The ELWI is underestimated when there are significant perfusion disturbances. Pleural effusion • There is no influence on the ELWI measurement because the contact area between the indicator and pleural fluid is minimal.

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PiCCO2 Demo mode ®

For training and demonstration purposes, a fully functional demo mode is available from version 8.1.0.3 onwards. • All procedures are able to be demonstrated in demo mode, including Admission, Zeroing, Thermodilution Measurement and Calibration of the Pulse Contour Analysis, and Basic Monitoring. • The demo mode is marked with "DEMO DEMO DEMO" at the top of the screen • Under no circumstances should the PiCCO2® Monitor be connected to the patient whilst it is in Demo Mode

Switch to Demo Mode 1. Remove all cables from the patient and the device 2. Press the parameter field on the right hand side of the screen

3. Press the 'SERVICE'-button in the 'Monitor' configuration tab

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 4. Enter the password 'EDUCATION' and confirm with return

5. Choose 'PiCCO' mode

6. The PiCCO2 now switches to the 'DEMO' Mode

7. To switch the 'DEMO' off, simply switch the device off and then on again. 8. Please ensure after switching the device off and on again that the DEMO mode warning is no longer present at the top of the display.

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Tips & tricks - summary • Injecting as smoothly and quickly as possible (under 7 seconds) is essential for correct thermodilution measurement. As normal saline is used there are no restrictions on the number of possible measurements. • Patients with very low cardiac output, or very high extravascular lung water may require more and / or colder injectate. • All other infusions must remain turned off during the duration of the thermodilution measurement. • The usual precautions when accessing larger blood vessels should be considered when inserting the PiCCO catheter. • All PiCCO2® monitors can be put into demo mode for training purposes.

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PULSION Medical Inc. • 2445 Gateway Drive • Suite 110 • TX 75063 Irving, USA Tel. +1 (214) 446 8500 • Fax +1 (214) 446 6702 • Toll free +1 877 655 8844 [email protected] • www.PULSION.com

Train the Trainer Folder US MPI851405US_R00 © PULSION 08/2009

See instructions for use and package insert for full prescribing information. Technical specifications are subject to change without further notice. © 2009 PULSION Medical Systems all rights reserved.