PiCCO2 Information for Nurses May 2010

PiCCO2 - A complete hemodynamic picture TM

• Continuous cardiac output • Volumetric preload • Afterload • Contractility • Volume responsiveness • Pulmonary edema / Lung water

PiCCO2TM 2

Table of contents Overview...

4-6

Fields of Application ...

7

PiCCO2TM Disposables and Set up ...

8 - 11

Principles of PiCCO2TM Technology... 12 - 14 Parameter Overview... 15 - 25 PiCCO2TM Monitor... 26 Normal Ranges... 27 Decision Tree Model... 28 Summary of Benefits... 29 Recommended Literature... 30 Contact Information... 32

3

Cardiac Output - Optimizing Oxygen delivery

O2 uptake

O2 transport

O2 extraction

O2 utilization

PiCCO-Technology Which therapy?

Volume?

Vasopressors?

Inotropes? 4

Is measuring just the CO enough? Cardiac output CO Stroke volume SV

Heart rate HR

Preload GEDV, SVV, PPV

Afterload SVR, MAP

Contractility CFI

Pulmonary edema EVLW

Volume?

Vasopressors?

Inotropes? 5

PiCCO2 – See more than others TM

Optimize CO

Protect the lungs

• Continuous cardiac output

• Monitor Pulmonary Edema (lung water) at the bedside.

• Volumetric preload • Afterload • Contractility

• Respond quickly • More reliable than Chest X Ray

• Volume responsiveness

6

Fields of Application Intensive Care

OR/Post surgery

• Septic Shock

• Cardiac Surgery

• Cardiogenic Shock

• Major Surgery

• Burns

• Neuro Surgery

• Trauma / Hypovolemic Shock

• Pediatrics

• ARDS / Acute Lung Injury • Pediatrics

7

Use your existing CVC and the PiCCO arterial line

Central venous line

(Standard CVC) Internal jugular, subclavian, femoral

Arterial line

(PiCCO Catheter available in different sizes) Brachial, axillary or femoral artery

8

PiCCO arterial catheters - The choice is yours Axillary artery Adults: 4F 8 cm / 3.15 in Small adults: 3F 7 cm / 2.76 in

Brachial artery Adults: 4F 16 cm / 6.29 in Adults: 4F 22 cm / 8.66 in

Femoral artery Adults: 5F 20 cm / 7.78 in Adults: 4F 22 cm / 8.66 in Small adults: 4F 16 cm / 6.29 in Children: 3F 7 cm / 2.76 in and 4F 8 cm / 3.15 in 9

PiCCO2 Setup TM

Thermodilution

C B CVP line

Flush bag

A

PiCCO Catheter

B

Distal lumen of CVC

C

Injectate sensor housing

D

Injectate sensor cable

E

Arterial connection cable

F

PiCCO thermistor plug Pressure connection cable

G

D

F

E

Pressure output adapter A

G 10

PiCCO - Two principles for reliable information Transpulmonary thermodilution

Pulse contour analysis

Calibration

Intermittent parameters from thermodilution technique • Thermodilution cardiac output (CO) / cardiac index (CI) • Volumetric preload (GEDV/GEDI) • Contractility (CFI) • Lung water (EVLW/ELWI)

Continuous parameters from analysis of the arterial waveform (pulse contour) • Pulse contour cardiac output (PCCO) / cardiac index (PCCI) • Afterload (SVR/SVRI) • Volume responsiveness (SVV, PPV) • Stroke volume (SV/SVI) 11

PiCCO - Transpulmonary Thermodilution (TD) Bolus injection

Bolus detection

• The bolus injection of cold saline is detected by the temperature sensor attached to the CVC • The saline bolus passes through the heart and lungs and is detected downstream by the thermistor on the tip of the PiCCO arterial line • The change in temperature between the two thermistors provides a TD curve • Mathematical analysis of the TD curve gives the cardiac output CO • Further analysis of the TD curve allows determination of preload volumes and lung water 12

PiCCO - Pulse Contour Analysis

• Stroke volume is the area under the systolic part of the pressure curve (red area) of one heart beat • Cardiac output is calculated and updated beat-by-beat: stroke volume x heart rate • In severely “shocked” patients organ perfusion pressure and pulse contour CO is more reliably represented by central arterial pressure (femoral / brachial / axillary) than by radial arterial pressure 13

CCI

Thermodilution (TD) Cardiac Output / Index Cardiac Output - Volume of blood pumped by the heart in one minute - Important determinant for oxygen delivery to the body

Time since TD 0 h 52 min 10:26 am TD Results

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

CI

3.47

3.11

3.15

3.76

3.44

GEDI

705

626

678

764

698

ELWI

9

9

10

10

9

T

1.18

1.17

0.30

1.20

Flow

Inj. Volume 98.1

START READY

10:26 am SEP 23

15 ml CVP 5

98.6 0s

10s

20s

30s

mmHg

PCCI

5.0 3.0

Exit

SVRI 1735

dyn*s*cm-5 m 2

4.52 l/min/m 2

SVI

ml/m 2

47

CO – Cardiac Output CI – Cardiac Index The Thermodilution CO is used to “calibrate“ the continuous CO obtained from 2the arterial waveform l/min/m (pulse contour) analysis. Volume

14

s

Pulse Contour Cardiac Output / Index Cardiac Output - Following thermodilution a “calibrated” continuous CO can be obtained Time since TD 0 h 52 min 10:26 am Flow

PCCI

PCCI

SVRI 1735

5.0 3.0

dyn*s*cm-5 m 2

PCCO – Pulse Contour Cardiac Output PCCI – Pulse Contour Cardiac Index Volume • Product of stroke volume and heart rate • Determination beat-by-beat MAP • Reliability and patient safety possible due to calibration technique

4.52 l/min/m 2

SVI

ml/m 2

47

l/min/m 2

ml/m 2

15

l/min/m 2

SVRIpressures 1735 Preload Volume instead of filling PCCI dyn*s*cm m -5

2

SVI

ml/m 2

47

Preload - Volume of blood in the heart, available to be pumped Volumetric preload parameters are superior to filling pressures (CVP / PCWP) Michard, YICM 2004 l/min/m 2

Volume

MAP ml/m 2

SVV

9 %

GEDV – Global End-Diastolic Volume / GEDI – Global Volume Index OrganEnd-Diastolic Function • Combined diastolic volume of all four heart chambers • Adequate preload is an important prerequisite for adequate cardiac output (Frank-Starling curve) • GEDI is indexed to “predicted body surface area” *

SVRI

* Indexing particular parameters i.g. to the predicted body weight (EVLW) or predicted body surface area (GEDV) rather than the actual body weight or body surface area is more accurate particularly in overweight patients. ml/kg 16

Volume

MAP edema assessment at the bedside Lung Water – Pulmonary EVLW – Extravascular Lung Water reflects pulmonary edema

SVV

ml/m 2

9 %

Organ Function

SVRI ml/kg

AP/CVP 1/minIndex EVLW – Extravascular Lung Water / ELWI – Extravascular Lung Water • Extravascular lung water (EVLW) represents the extravascular water content of the lung tissue • Includes intra-cellular, interstitial and intra-alveolar water (not pleural effusion) • ELWI is indexed to “Predicted Body Weight” *Predicted body weight is determined from the body height, gender and age 17

Fluid management using lung water (ELWI) Improved patient outcomes

Organ function - Lung water Ventilation days

Comparison of fluid therapy targeting lung water (protocol group) or wedge pressure (standard group)

ICU days

reduced by

reduced by

Days

59%

Control group PCWP

Protocol group EVLW

53%

Control group PCWP

Protocol group EVLW

Source: Improved outcome based on fluid management in critically ill patients requiring pulmonary artery catheterization Mitchell JP, Schuller D, Calandrino FS, Schuster DP, Am Rev Respir Dis 1992; 145(5): 990-8 18

Time since TD 0 h 52 min 10:26 am Flow resistance Afterload - the systemic vascular

PCCI

5.0

4.52

Systemic vascular resistance - Represents the vascular “tone” of the blood3.0 vessels.

SVRI 1735

PCCI

dyn*s*cm-5 m 2

l/min/m 2

SVI

ml/m 2

47

l/min/m 2 Volume

MAP

SVR - Systemic Vascular Resistance SVRI - Systemic Vascular Resistance Index • Helps to determine levels of vasodilation or vasoconstriction • Useful for guiding vasopressor management.

ml/m 2 19

ml/m 2

SVV

Heart Contractility

9

% Contractility – describes the performance of the cardiac muscle Organ Function

SVRI ml/kg

AP/CVP

1/min

CFI - Cardiac Function Index • Parameter of the global cardiac contractility • The cardiac function index is the ratio of flow and preload • CFI = CO (Cardiac Output) / GEDV (Global End-Diastolic Volume) 20