Professional Documents
Culture Documents
Gozde Demiralp, MD
Assistant Professor of Anesthesiology Department of Anesthesiology Division of Critical Care Medicine University of Oklahoma, College of Medicine Oklahoma City, Oklahoma
Disclosure
I have no affiliations to disclose. There will be display of new technologies and monitors
during this presentation. All the opinions that will be displayed here reflects scientific data that is supported by literature.
Outline:
Review of Basics: What have we been doing and Why? Cardiac Output Matters Invasive vs. Noninvasive Methods Old Monitors & New e T chnology Arterial Wave Form Analysis Venous Oximetry Why does it matter? How can we monitor it?
Hemodynamic Monitoring
Monitoring critically ill patients: What are we really worried about? Tissue Hypoperfusion What do we really want to monitor? Adequate Oxygen Delivery Definition of Shock: Inadequate tissue perfusion affecting multiple organ systems.
Arterial Oxygen Content (CaO2) = (0.0138 x Hgb x SaO2) + (0.0031 x PaO2 ) = 20.1 ml/dl
Cardiac Output (CO) = SV x HR =4-8 L/min
Why is he hypotensive?
(Preload)
(Contractility)
(Afterload)
That is why almost always the first step is to give fluids and
Central venous pressure (CVP) =Preload ? CVP can reflect a volume increase in RA pressures or decrease in RV contractility can be both.
CVP
Need to be monitored in conjunction with other monitors.(CVP&MAP) The main limitations of CVP monitoring: (a) it does not allow to measure cardiac output (b) it does not provide reliable information on the status of the pulmonary circulation in the presence of left ventricular dysfunction.
Why is he hypotensive?
CVP (Preload)
(Contractility)
(Afterload)
Measurement of Cardiac Output: Thermo Dilution Dye/Indicator Dilution Arterial Pulse Pressure Analysis**
1870-oldest defined CO measurement system Cold solution proximal port/RA distal port- thermistor Measures RV outflow, not systemic CO. Not perfect because Volume & temp of cold solution may vary. Baseline blood temperature changes Intracardiac shunts ( R_L ; L_R) Mechanical and Spontaneous Resp. Cycle effects.
Continuous Pulmonary Artery Thermodilution Technique: Same principle, New technology. Electric filament ( vigilance) vs. thermal coil(optiQ) Intermittently heating R heart Temp change is being detected at tip of PAC. Every 30 60 second data collection but Displayed value is average of 5-15 minutes of data collection. Advantage: 1. Continuous trend of CO 2. Decrease operator workload 3. Reduce infection risk ( no more boluses into system)
KEY advantage: Simultaneous measurements of other hemodynamic parameters: CO Pulmonary Artery Pressures ( PAD, PAOP) Right Sided Filling Left Sided Filling SvO2%
PACs3-6:
Studies overall the years had conflicting results: Increased Mortality ? Multiple RCTs were conducted in several RCTs. Conclusion: No difference in LOS in the ICU No difference in Mortality No benefit, no harm
There is no guided therapy tailored towards PAC use. PAC is a diagnostic tool, not a therapeutic one.
Transpulmonary Thermodilution Methods: PiCCO & PiCCO2 VolumeView Lithium Dilution Technique: LiDCO /LiDCOplus/LiDCOrapid limited) Ultrasound Indicator Dilution COstatus (Transonic Systems, Inc.) ( LiDCO (Pulsion Medical Systems) (Edwards Life Sciences)
VolumeView
FloTrac Vigileo
PiCCO2
PiCCO2
Pulse Contour Analysis Aline Wave Form matters ! Area under systolic area ( until dicrotic notch) on arterial
waveform is detected. **
External manual calibration for CO is necessary. This is done via transpulmonary TD every 8 hours or Hourly calibration is required, if patient is hemodynamically
unstable.
PiCCO2
System Requires: Thermistor Tipped Aline Catheter Femoral Aline ( longer cath, better signal)
Radial, Axillary, Brachial ok as well
Central Venous Catheter ( thermo indicator solution injection) Provides: Dynamic parameters of Preload: SVV, PPV, SPV. Other Volumetric parameters : GEDV, EVLW, ITBV. Global end diastolic volume Extravascular lung water Intrathoracic Blood Volume
picco2
Foto koy
LiDCOplus
Combination of two monitors
LiDCO PulseCO
(Indicator dilution CO calculation & monitor) (Software ,CO from aline waveform. )
Unlike PiCCO2, aline wave form is not important in pulse power analysis.
(This is why damping effect is also minimized in LiDCO system.) (No need to detect dicrotic notch.) Requires: Aline Peripheral or Central Access (to insert a lithium sensitive sensor) External CO calibration with lithium every 8 hours is necessary. Neuromuscular blockers within 30 min. (due to interactivity w lithium on sensor level) Lithium therapy receiving patients*
LiDCOrapid
No need for CO calibration with lithium. Replaced by nomogram which is derived form in vivo data to
estimate CO.
lidco
Foto koy
FloTrac Vigileo
FloTrac Algorithm integrates multiple characteristics of arterial
No external CO calibration is required. ( Unlike LiDCO, PiCCO) An arterial aline is adequate to use the monitor. No CVL is required.
( age, gender, height, weight to initiate the monitoring.) Advanced Arterial Waveform Analysis ( PRAM) by FloTrac Sensor. Pt to pt differences in vasculature. Real time changes in vascular tone. Different arterial sites are acceptable. Central Venous Oximetry (Scvo2) is available. (if used in conjunction with appropriate oximetry CVL.)*
accurate CO calculation.
During Arrhythmias For Hemodynamically Unstable Patients Intra Aortic Balloon Pump in use. Ventricular Assist Devices in use.
FloTRac Vigileo
FloTrac Sensor
http://www.edwards.com/products/mininvasive/Pages/flotracsystemanimation.aspx?wt.ac=flotrac
Vigileo Monitor: Can display: CCO CCI SV SVI SVV Every 20 seconds When used with FloTrac Sensor.
Stroke Volume Variations (SVV) Pulse Pressure Variations (PPV) Systolic Pressure Variations (SPV)
Can be used as a tool for volume responsiveness in low CO states. SVV > 13% = Volume Responsive SVV and PPV are more effective indicators for Volume
Limitations:
Pt needs to be on 100% Controlled MechanicalVentilation. SpontaneousVentilation & SVV ? Arrhythmias can affect SVV.
Venous Oximetry
Fick Principle
Oxygen Delivery (DaO2): Oxygen Consumption (VO2): Oxygen Extraction Ratio: Normal SvO2%: SvO2< 60% Svo2 > 75%
Increased VO2 will be compensated by increased CO. If this is not adequate, elevated oxygen extraction occurs in the peripheral tissues SvO2 will drop SvO2 thus reflects the balance between oxygen delivery and oxygen demand
Supranormal SvO2 (or ScvO2) values do not guarantee adequate tissue oxygenation.( SvO2%>80%) If tissue is not capable of extracting oxygen, venous return may have a high oxygen content despite persistent cellular hypoxia. E.g.: Sepsis, Burn Patients, Shunts etc.
Old Method, New Technology Advanced Technology Catheters: Swan-Ganz CCOmbo Pulmonary Artery Catheter: (Combo = Continuous CO + Venous Oximetry)
Swan-Ganz CCOmbo VIP Catheters:
Ref#2
References:
1) 2) 3)
Bigatello,L.M., George, E. Hemodynamic Monitoring. Minerva Anesthesiol 2002;68:219-25 Lee, A.J., Cohn Hochman J., Ranasinghe, J. Cardiac output assessed by invasive and minimally invasive techniques. Anesthesiology Research and Practice Volume 2011, Article ID 475151, 17 pages. Harvey S, Harrison DA, Singer M, Ashcroft J, Jones CM, Elbourne D, Brampton W, Williams D,Young D, Rowan K: Assessment of the clinical effectiveness of pulmonary artery catheters in management of patients in intensive care (PAC-Man): a randomized controlled trial. Lancet 2005, 366:472-477. Connors AF, Jr., Speroff T, Dawson NV, Thomas C, Harrell FE, Jr., Wagner D, Desbiens N, Goldman L, Wu AW, Califf RM, Fulkerson WJ, Jr., Vidaillet H, Broste S, Bellamy P, Lynn J, Knaus WA: The effectiveness of right heart atheterization in the initial care ofcritically ill patients. SUPPORT Investigators. JAMA1996, 276:889-897. Sandham JD, Hull RD, Brant RF, Knox L, Pineo GF, Doig CJ, Laporta DP, Viner S, Passerini L, Devitt H, Kirby A, Jacka M: A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med 2003, 348:5-14. Richard C, Warszawski J, Anguel N, Deye N, Combes A, Barnoud D, Boulain T, Lefort Y, Fartoukh M, Baud F, Boyer A, Brochard L, Teboul JL: Early use of the pulmonary artery catheter and outcomes in patients with shock and acute respiratory distress syndrome: a randomized controlled trial. JAMA 2003, 290:2713-2720 Michard, F. Changes in Arterial Pressure During Mechanical Ventilation, Anesthesiology 2005; 103:419-28. Rivers et al. Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock. New England Journal of Medicine 2001; 345(19): 1368-77 J. Mayer, J. Boldt, R. Poland, A. Peterson, and G. R. Manecke, Continuous arterial pressure waveform-based cardiac output using the FloTrac/Vigileo: a review and metaanalysis, Journal of Cardiothoracic andVascular Anesthesia, vol. 23, no. 3, pp. 401406, 2009 S. Sundar and P. Panzica, LiDCO systems, International Anesthesiology Clinics, vol. 48, no. 1, pp. 87100, 2010 Vincent, J., Rhodes,A., Perel, A.,Martin,G., Rocca, D., Vallet, B.,Pinsky,M., Hofer,C., Tebou,J., Pieter de Boode, W., Scolletta,S.,VieillardBaron,A.,De Backer,D., Walley,K., Maggiorini,M.,Singer,M. Clinical review: Update on hemodynamic monitoring - a consensus of 16. Critical Care 2011, 15:229 Van Beest et al. Clinical review: use of venous oxygen saturations as a goal a yet unfi nished puzzle. Critical Care 2011, 15:232
4)
5) 6)
7) 8) 9) 10) 11)
12)
Contact Info:
Gozde Demiralp, MD
Gozde-Demiralp@ouhsc.edu
Assistant Professor of Anesthesiology Department of Anesthesiology Division of Critical Care Medicine University of Oklahoma, College of Medicine