PiCCOplus Setup & Method Guide Dec 2005

The PiCCO-Technology initial setup

Central Venous Catheter (CVC)

Standard Central Venous Catheter (CVC)

Injectate temperature sensor housing

1. Connect the injectate-temperature sensor housing to the CV line already in place.

PULSIOCATH thermodilution catheter with lumen for arterial pressure measurement

2. Insert a PiCCO arterial thermodilution catheter into a large artery, preferable femoral artery, but also brachial / axillary artery or radial artery (with long catheter).

Injectate temperature sensor cable

A

Pressure cable

are specifically designed for less invasive volumetric hemodynamic monitoring with the PiCCO-Technology. The catheters are placed with Seldinger Technique. Several versions and sizes are available. They can remain in situ for up to 10 days.

R

F

Temperature interface cable

Article number Outer diameter

4. For blood pressure transfer to any bedside monitoring system, connect the cable at the back of the PiCCO Monitor.

Usable length Common feature

PULSION disposable pressure transducer

PULSIOCATH thermodilution catheter

5. Now the system is ready to work.

PV2014L16 4F (~18G) / 1,4 mm 16 cm

PV2014L22 4F (~18G) / 1,4 mm 22 cm

PV2015L20 5F (~16G) / 1,7 mm 20 cm

PV2014L50LGW 4F (~18G) / 1,4 mm 50 cm

Latex free / DEHP free

Latex free / DEHP free

Latex free / DEHP free

Latex free / DEHP free

Latex free / DEHP free

Latex free / DEHP free

1

2

3

4

5

6

7

8

Introduce the cannula at an angle of no more than 45° into a suitable artery.

Insert a part of the guidewire through the cannula into the artery.

Leave the guidewire in place and withdraw the cannula.

Enlarge the point of entry by performing a skin incision using a scalpel.

With a twisting motion, advance the dilator over the guidewire into the vessel.

Leave the guidewire in place and withdraw the dilator.

With a twisting motion, insert the catheter over the guidewire into the vessel.

Hold catheter at the desired position and withdraw guidewire.

Enter Height and Weight of the patient for calculation of the indexed parameters The Arterial Catheter Constant (ACC) will be detected automatically, if the PULSIOCATH is connected < 24° C = room temp. injectate < 8° C = cold injectate CVP should be manually updated when the CVP changes ± 5 to accurately calculate SVR

B

C

Open pressue transducer to atmosphere.

1

Press to perform a thermodilution measurement.

2

Wait until “STABLE“ appears

3

Injection of the indicator should be done as fast (< 7 sec) and steadily as possible.

PV4046

Press

for zeroing

C

A

B

A

Input Screen

B

AP zeroing

C

Thermodilution Screen

GEDV

GEF

SVV

SVR

➔ Pull the Snap Tab™ of the flush device and release immediately. ➔ Observe the pressure signal on the patient monitor. ➔ Compare the wave form with the figures to determine the dynamic response. If necessary repeat to verify maximum dynamic response.

CAUTION: An over- or under dampened wave may be the result of one or more of the following: - 3 way stopcock partially closed pressure line kinked or squeezed - Air in the pressure tubing and/or in the catheter - Loose connections in the system - Blood clots in catheter or in the pressure tubing - Catheter tip touching the vessel wall - Lumen too narrow - Use of foreign or addition pressure tubing or material

Under dampened > 2 oscillations

Over dampened

CI (l/min/m2)

> 3.0

< 3.0

Results

< 700 < 850

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

>10

< 10

> 10

< 10

> 10

< 10

> 10

Therapy

➔

➔

➔

➔

➔

➔

➔

V+

V+! Cat

Cat

Cat V-

V+

V+!

➔

➔

➔

➔

➔

> 700 > 850

700-800 850-1000

> 700 > 850

700-800 850-1000

> 700 > 850

700-800 850-1000

➔

700-800 850-1000

< 10

< 10

< 10

< 10

< 10

< 10

> 4.5 > 25

> 5.5 > 30

> 4.5 > 25

> 5.5 > 30

< – 10

ELWI (ml/kg)

< 10

< 10

➔

CFI (1/min) or GEF (%)

➔

2. Optimise SVV (%)*

V-

➔

or ITBI (ml/m2)

OK!

< – 10

< – 10

< – 10

(slowly responding)

V+ = volume loading (! = cautiously) Without guarantee

➔ The PiCCO-Technology is a unique combination of 2 techniques for advanced hemodynamic and volumetric management without the necessity of a right heart catheter in most patients:

V- = volume contraction

Cat = catecholamine / cardiovascular agents

Optimally dampened 1-2 oscillations

If ΔT < 0,2 % more/colder injectate might be necessary

Thermodilution Parameters Cardiac Output Global End-Diastolic Volume Intrathoracic Blood Volume Extravascular Lung Water* Pulmonary Vascular Permeability Index Cardiac Function Index Global Ejection Fraction Pulse Contour Parameters Pulse Continuous Cardiac Output Arterial Blood Pressure Heart Rate Stroke Volume Stroke Volume Variation Pulse Pressure Variation Systemic Vascular Resistance Index of Left Ventricular Contractility

... change to if you want to delete measurements

The PiCCO-Technology advantages: Index

Range

Unit

CO GEDV ITBV EVLW* PVPI CFI GEF

CI GEDI ITBI ELWI

3.0-5.5 680-800 850-1000 3.0-7.0 1.0-3.0 4.5-6.5 25-35

l/min/m2 ml/m2 ml/m2 ml/kg 1/min %

PCCO AP HR SV SVV PPV SVR dPmx

PCCI

3.0-5.5

l/min/m2

SVI

40-60 <10 <10 1700-2400

ml/m2 % % dyn*s*cm-5*m2 mmHg/sec

SVRI

➔ Less Invasiveness

Only central venous and arterial access required No pulmonary artery catheter required Also applicable in small children

➔ Short Set-up Time

Can be installed within minutes

➔ Dynamic, Continuous

Cardiac Output, Afterload and Volume Responsiveness are measured Beat by Beat

Measurement

➔ No Chest X-ray

To confirm correct catheter position

➔ Cost Effective

Less expensive than continuous pulmonary artery catheter Arterial PiCCO catheter can be in place for 10 days or more Potential to reduce ICU stay and costs

➔ More Specific Parameters PiCCO parameters are easy to use and interpret even for less experienced caregivers

➔ Extravascular Lung Water* Lung edema can be excluded or quantified at the bed-side

* SVV only applicable in ventilated patients without cardiac arrhythmia

➔ All volumetric parameters are obtained by advanced analysis of the thermodilution curve:

Tb = Blood temperature Ti = Injectate temperature Vi = Injectate volume ∫ Δ Tb · dt = Area under the thermodilution curve K = Correction constant

For the calculations of volumes…

Advanced Thermodilution Curve Analysis

MTt: Mean Transit time -̂- time when half of the indicator has passed the point of detection in the artery

➔ For correct calculation of CO, only a fraction of the total injected indicator needs to pass the detection site. Simplified, only the change of temperature over time is relevant. ➔ The algorithm is capable of computing each single stroke volume (SV) after being calibrated by an initial transpulmonary thermodilution. ➔ After calibration, the pulse contour algorithm is able to follow the cardiac output Beat by Beat.

CO Calculation: ➔ Area under the Thermodilution Curve

3 ml 3 ml 5 ml 10 ml 15 ml 20 ml

Press when performing further thermodilution measurements. Recalibrate 8 hourly or more frequently if patient condition unstable, if one measurement does not closely correspond to others, delete and re-perform.

➔ After central venous injection of the indicator, the thermistor at the tip of the arterial catheter measures the downstream temperature changes. ➔ Cardiac output is calculated by analysis of the thermodilution curve using a modified Stewart-Hamilton algorithm:

Transpulmonary Thermodilution

CV Bolus injection

> 700 > 850

< 10

1. GEDI (ml/m2)

What is the current situation?.………..……..…………...Cardiac Output What is the preload?.………………...…...Global End-Diastolic Volume Will volume increase CO?...………...….……...Stroke Volume Variation What is the afterload?……………..…...Systemic Vascular Resistance What about contractility?.………………...…...Global Ejection Fraction Are the lungs still dry?...…….….…...…..…...Extravascular Lung Water*

< 700 < 850

ELWI (ml/kg)

Target

Volume

> 700 > 850

➔

Drugs

2 ml 2 ml 3 ml 5 ml 10 ml 15 ml

Initially perform 3 thermodilution measurements

The PiCCO-Technology therapeutic decision tree and normal range table

EVLW*

< 3 kg < 10 kg < 25 kg < 50 kg < 100 kg _> 100 kg

3

(available as pocket guide)

CO

For roomtemp. injectate

Recommendation: 15 ml of cold NaCl 0,9 % as the default setting for adults.

Square Wave Test Procedure:

PiCCO answers all relevant questions:

For cold injectate

1

Perform zero adjustment initially on PiCCO plus then on bedside monitor!

.

Weight of pat.

2

☛

A

The minimal injectate volume is recommended by the PiCCO plus in brackets ( ). This parameter can be modified by highlighting the parameter using the inverse marker . The number can be changed by using the function keys

…and…

DSt: Down Slope time -̂- exponential downslope time of the thermodilution curve

➔

…are important.

CALIBRATION

➔ The intrathoracic compartments can be considered as a series of “mixing chambers” for the distribution of the injected indicator (intrathoracic thermal volume).

PULSIOCATH

➔ The largest mixing chamber in this series are the lungs, here the indicator (cold) has its largest distribution volume (largest thermal volume). Patient-specific calibration factor (determined by thermodilution)

Pulse Contour Analysis

Heart rate

Area under pressure curve

Aortic compliance

Shape of pressure curve

➔ ITBV and GEDV have been shown to be far more sensitive and specific to Cardiac Preload than the standard cardiac filling pressures CVP plus PCWP, and also right ventricular enddiastolic volume.

ITTV = CO * MTt

ITBV = 1.25 * GEDV

PTV = CO * DSt

GEDV = ITTV - PTV

➔ The striking advantage of ITBV and GEDV is that they are not adversely influenced by mechanical ventilation and give correct information regarding the preload status under any condition. ➔ Global End-Diastolic Volume (GEDV) is the volume of blood contained in the 4 chambers of the heart.

EVLW* = ITTV - ITBV

Troubleshooting: If the device shows an error message (E), please confirm with and check the system for correct setup and settings. Do a further Thermodilution Measurement. For detailed trouble shooting please refer to the PiCCO plus Operator’s Manual or contact your PULSION representative. In the case where you observe any product defect on disposables or accessories, please keep the product to be handed to your PULSION representative for further investigation.

E 0 1 2 3 4-6 7 8 9

PULSION Medical Systems AG • Stahlgruberring 28 • D-81829 Munich, Germany Tel. +49-(0)89-45 99 14-0 • Fax +49-(0)89-45 99 14-18 [email protected]

www.PULSION.com *Extravascular Lung Water (EVLW) is not yet available in the US, FDA clearance pending

PULSION Medical Inc., USA +1-760-295 1370 [email protected]

☎

➔ Extravascular Lung Water (EVLW)* is the amount of water content in the lungs. It allows bedside quantification of the degree of pulmonary edema.

➔ EVLW* has shown to have a clear correlation to severity of ARDS, length of ventilation days, ICU-Stay and Mortality and to be superior to assessment of lung edema by chest x-ray and CT scan.

Injectate temperature problem - Injection not detected - Injectate temperature sensor error

Possible cause - No signal transfer - Blocked sensor housing

Suggested remedy - Change injectate temp. sensor cable or housing - Change sensor housing

Thermodilution signal problem - TD curve does not appear - No TB (Blood Temperature) - TB incorrect

Possible cause - Defective catheter / cable - Defective catheter / cable - Catheter / calibration of system defective

Suggested remedy - Remove catheter / cable - Remove catheter / cable - Change cath. / call PULSION representative

Arterial blood pressure problem - Arterial pressure dampened - Arterial line flat or absent

PULSION Benelux nv/sa +32-9-242 99 10 [email protected]

☎

➔ SVV reflects the sensitivity of the heart to the cyclic changes in cardiac preload induced by mechanical ventilation. ➔ SVV can predict whether stroke volume will increase with volume expansion ➔ SVV is only applicable in fully ventilated patients with regular heart rhythm

➔ EVLW* assessed by transpulmonary thermodilution has been validated against dye dilution and the reference gravimetric method.

➔ Intrathoracic Blood Volume (ITBV) is the volume of the 4 chambers of the heart plus the blood volume in the pulmonary vessels.

Interpretation Technically good measurement Error in determination of Tinj. Injection error Inject faster than 10 s Error in calculation of thermodilution curve parameters Time out (Thermodilution curve longer than 90s) Blood temperature lower than injectate temperature Invalid PCCO calibration

➔ Stroke Volume Variation (SVV) represents the variation of stroke volume (SV) over the ventilatory cycle.

PULSION Medical System Iberica S.L. +34-91-665 73 12 [email protected]

☎

PULSION France sarl +33-4-42 27 67 19 [email protected]

☎

PULSION Medical UK Ltd. +44-1895-45 52 55 [email protected]

☎

- No pressure transfer - Invalid pressure values

PULSION Pacific Pty. Ltd., AUS +61-7-32 66 84 48 [email protected]

☎

Indications: Patients in whom cardiovascular and circulatory volume status monitoring are necessary. This includes patients in surgical, medical, cardiac and burn specialty units, as well as other specialty units where cardiovascular monitoring is desired, and patients undergoing major surgical interventions where cardiovascular monitoring is necessary. In short, every patient who requires a central venous and arterial catheter for monitoring. Contraindications: Patients in whom there are arterial access restrictions, for example due to femoral artery grafting or severe burns in areas where the arterial catheter would normally be placed. Note: The Axillary or Brachial artery can be used as an alternative site. Additionally a long radial artery catheter can also be placed for short term use. The PiCCO-Technology may give incorrect thermodilution measurements in patients with intracardiac shunts, aortic aneurysm, aortic stenosis, mitral or tricuspid insufficiency, pneumonectomy, macro lung embolism and extracorporeal circulation (if blood is either extracted from or infused back into the cardiopulmonary circulation). As is the case with all arterial catheters adequate perfusion downstream of the puncture site has to be assured. Adequacy of perfusion can be monitored using clinical inspection, surface temperature measurement, or by applying a pulse oximetry sensor to a digit downstream from the puncture site to continuously establish pulsatile flow.

Possible cause - Air in arterial line - Additional /foreign pressure line - Catheter kinked - Catheter clotted - No pressure in flush device - Defective cable - Defective pressure transducer - Calibration of system defective

Suggested remedy - Remove air from pressure line - Remove additional / foreign line - Avoid bending of catheter - Secure continuous flushing - Add pressure to flush device - Replace cable - Replace pressure transducer - Call PULSION representative

PULSION and PiCCO are registered tradenames of PULSION Medical Systems AG Munich.

Underlying Principles

PV2014L08 4F (~18G) / 1,4 mm 8 cm

SELDINGER TECHNIQUE

☛

Operation

Catheter Placement

PV2013L07 3F (~20G) / 0,9 mm 7 cm

The catheters are also available as complete kits (e.g. PVPK2015L20-46), including a disposable pressure transducer and the injectate temperature sensor housing. Optionally, these kits can be ordered with an additional pressure line for intermittent central venous pressure monitoring. Catheters should be selected depending on patient size, weight and insertion site.

6. For information how to operate your PiCCO Monitor, please refer to your accompanying PiCCO Operator’s Manual and Setup guide.

Clinical Use & Benefit

8 cm 22 cm 7-20 cm 50 cm

PULSIOCATH arterial thermodilution catheters

B

3. Connect the injectate sensor, the arterial catheter’s thermistor and pressure line to your PiCCO Monitor.

Troubleshooting

Axillary: 4F (1,4 mm) Brachial: 4F (1,4 mm) Femoral: 3-5F (0,9-1,7 mm) Radial: 4F (1,4 mm)

© PULSION 12/2005 MPI812605R0 081

Setup

PULSION PiCCO plus: Setup & Method