Less invasive advanced haemodynamic monitoring
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PiCCO 2. Less Invasive Advanced Haemodynamic Monitoring. Training. Short. Content. PULSION Medical Systems See more than others – PiCCO 2 Medical concept and parameter PiCCO 2 – the technology. PULSION Medical Systems.

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Less Invasive Advanced Haemodynamic Monitoring

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Less invasive advanced haemodynamic monitoring

PiCCO2

Less Invasive Advanced Haemodynamic Monitoring

Training

Short


Content

Content

  • PULSION Medical Systems

  • See more than others – PiCCO2

  • Medical concept and parameter

  • PiCCO2 – the technology


Pulsion medical systems

PULSION Medical Systems

  • Manufacturer of medical equipment from Munich, Germany, established 1990

  • Production, development, administration, marketing and sales in Germany

  • Subsidiaries in USA, France, Spain, UK, Benelux and Australia

PULSION head quarters in Munich, Germany


Picco technology

PiCCO-Technology

  • Market leader for less invasive haemodynamic monitoring

  • Paradigm shift in haemodynamics by the PiCCO-Technology

  • Integration of the PiCCO-Technology into multi-parameterpatient monitoring systems

PiCCO22007

Draeger Smart Pod 2005

Philips PiCCO Module 2003

PiCCO plus 2002

COLD System 1990

PiCCO 1997


Less invasive advanced haemodynamic monitoring

PiCCO2 – See more than others

  • Continuous ScvO2

  • Cardiac output

  • Volumetric preload

  • Contractility

  • Afterload

  • Volume responsiveness

  • Pulmonary oedema – measured at the bedside


The more information the better

The more information the better?

6


The doctor s dream

The doctor’s dream?

recognize problems earlier…

I should

immediately know the reasons for it…

detect if the therapeutic decisions are correct…

7


Basis of success fast decision lanes

Basis of success – fast decision lanes

1. Quick overview!

2. Acquire details!

3. Follow trend!


Less invasive advanced haemodynamic monitoring

PiCCO2 – visualize decision lanes

1. SpiderVisionRisk assessment with one view

2. ProfileDetailed insight on parameter level

3. TrendsClinical course and therapy results

9


Less invasive advanced haemodynamic monitoring

Optimization of tissue oxygenation

O2 intake

O2 transport

O2 delivery

O2 consumption

PiCCO-Technology

CeVOX-Technology

Which therapy ?

- +

- +

- +

+

- +

Volume?

Vasopressors?

Inotropics?

Blood transfusion?

Ventilation

10


Less invasive advanced haemodynamic monitoring

PiCCO2 parameter visualize physiology

Global oxygenationScvO2

Oxygen delivery

Oxygen consumption

Cardiac output

Arterial oxygen content

Haemoglobine

Hb

Oxygenation

SaO2

Heart rate

Stroke volume

Afterload

SVRI; MAP

Preload

GEDI; SVV; PPV

Contractility

GEF; CFI; dPmx

Pulmonary Oedema

ELWI; PVPI

Vasopressors?

Inotropics?

Volume?

Blood transfusion?


Less invasive advanced haemodynamic monitoring

Parameter fields – from overview to details

Overview

Details

Cont. Cardiac Output

Cont. Cardiac Output TD Cardiac OutputAfterloadLeft Heart Contractility

Preload Volume

Preload VolumeVolume Responsiveness

Lung Water

Lung WaterPulmonary Vascular Permeability

Cardiac ContractilityCardiac Power

Central venous Oxygenation

Central venous Oxygenation

Oxygen Delivery

Oxygen Consumption


Less invasive advanced haemodynamic monitoring

Data visualization – PiCCO2 accompanies your decision process

SpiderVisionDynamic risk level indicator

ProfilesDetailed insight at parameter level

  • TrendsTrack the clinical trends & thera-peutic results


Picco 2

Distinguished by easy & intuitive handling

Structured and visualized information for fast recognition

Reflects the physiology of the patient

Based on medical processes and way of thinking

PiCCO2

PiCCO2 is physiologic…

for the patient

and the operator !!!

14


Less invasive advanced haemodynamic monitoring

CO

Heart Rate

Stroke volume

Prelaod

Contractility

Afterlaod

Cardiac Output

Cardiac Output – Volume of blood pumped by the heart in one minute

  • PCCO – Pulse Contour Cardiac Output

  • PCCI – Pulse Contour Cardiac Index

  • Stroke Volume depends on Preload, Contractility and Afterload

  • Index (PCCI) related to body surface area


Less invasive advanced haemodynamic monitoring

CO Measurement

  • Transpulmonary Thermodilution

  • Discontinuous

Combination of two measurement techniques for maximum precision of continuous CO determination

Calibration

  • Pulse Contour Analysis

    Continuous (Beat-by-Beat)


Less invasive advanced haemodynamic monitoring

Preload – Volume instead of filling pressures

Preload – Blood volume in the heart, available to be pumped

  • GEDV – Global End-diastolic Volume

  • GEDI – Global End-diastolic Volume Index

  • Filling volume of all four heart chambers

  • Preload volume is necessary for an adequate CO

  • GEDI is indexed to “predicted body surface area”


Less invasive advanced haemodynamic monitoring

ITBV900 ml/m²

Preload – Volume instead of filling pressures

Preload – Blood volume in the heart, available to be pumped

  • ITBV – Intrathoracic Blood Volume

  • ITBI – Intrathoracic Blood Volume Index

  • Filling volume of all four heart chambers and pulmonary blood volume

  • Preload volume is necessary for an adequate CO

  • ITBV is indexed to “Predicted Body Surface Area”


Less invasive advanced haemodynamic monitoring

Differenzierung: Volumen /Katecholamine

Preload – direct correlation of preload and CO

CI (l/min/m2)

7.5

5.0

Inotropic drugs

2.5

Preload increased / Volume recruitment

GEDI (ml/m2)

200

400

600

800

1000

1200

1400

Frank-Starling curve

  • Volume substitution increases cardiac output to the maximum

  • After preload optimization further increase is only possible by an increase of the contractility by inotropic drugs


Less invasive advanced haemodynamic monitoring

Contractility

Contractility – Performance of the cardiac muscle

Changes of cardiac performance during constant preload, afterload and heart rate are caused by changes of contractility

dPmx – Left Heart Contractility

  • Maximum of pressure increase in the aorta (P/tmax)

  • Excellent correlation to the maximum pressure increase speed in the left ventricle


Less invasive advanced haemodynamic monitoring

Contractility

GEF - Global Ejection Fraction

  • Parameter of the global cardiac contractility

  • Global Stroke Volume divided by Global End-diastolic Volume

  • GEF = 4 x SV / GEDV


Less invasive advanced haemodynamic monitoring

V

V

V

V

V

Contractility

CFI - Cardiac Function Index

  • Parameter of the global cardiac contractility

  • Fraction of the preload volume, which is pumped in one minute

  • Cardiac Index divided by Global End-diastolic Volume CFI = CI / GEDI

CI

SV

V

High Contractility

SV

SV

NormalContractility

SV

SV

LowContractility

SV

Volume Overload

Preload

Target Area

Volume Responders


Less invasive advanced haemodynamic monitoring

Cardiac Power

CPI - Cardiac Power (Index)

  • Surrogate parameter of the global cardiac capability

  • Unspecific indicator of cardiac malfunctioning

  • Mean Arterial Pressure multiplied by Cardiac Index:CPI = MAP x CI

  • Best predictor of mortality in patients with cardiogenic shock


Less invasive advanced haemodynamic monitoring

Flow (CO) =

Vasoconstriction: Flow (CO)

Pressure Resistance

Vasodilation: Flow (CO)

Afterload

Afterload – Pressure the heart has to overcome to eject blood

If other variables are unchanged cardiac output decreases when afterload increases.

SVRI -Systemic Vascular Resistancemost important factor of afterload


Less invasive advanced haemodynamic monitoring

O2 Delivery

O2 Consumption

  • CO (Cardiac Output)

  • Hb (Haemoglobine)

  • SaO2 (Arterial Oxygen Saturation)

ScvO2

  • Temperature (fever)↑

  • Muscle work (tremor) ↑

  • Stress ↑

70-80 %

ScvO2 - Indicator for insufficient tissue oxygenation

  • ScvO2 – Central Venous Oxygen Saturation

  • Measurement via Standard CVC

  • SvO2 (Mixed Venous Oxygen Saturation) only possible by high invasive measurement with a PA catheter

  • good clinical correlation between ScvO2 and SvO2

  • Normal ranges:ScvO270-80%SvO265-75%


Less invasive advanced haemodynamic monitoring

Delivery

DO2I = CI x Hb x 1,34 x SaO2

CO, Hb

SaO2

Oxygen intake

Oxygen transport

Oxygen delivery

Oxygen consumption

S(c)vO2

VO2I = CI x Hb x 1,34 x (SaO2 – S(c)vO2)

Consumption

Oxygen Delivery and Oxygen Consumption

  • DO2I – Oxygen Delivery (Index)

  • calculated from Cardiac Index, Haemoglobine and Arterial Oxygen Saturation

  • VO2I– Oxygen Consumption (Index)

  • calculated from Cardiac Index, Haemoglobine, Arterial and Mixed Venous Oxygen Saturation

  • Normal ranges:DO2400 - 650 ml/min/m2VO2125 - 175 ml/min/m2


Less invasive advanced haemodynamic monitoring

SVmax

PPmax

PPmin

SVmin

Volume Responsiveness

Volume Responsiveness

  • Volume Responsiveness predicts if volume administration (e.g. for preload increase) will result in an increase of Cardiac Output

SVV – Stroke Volume Variation

PPV – Pulse Pressure Variation

  • During inspiration blood volume shifts in the circulation resulting in a change of preload

  • Significant changes of Stroke Volume are called Stroke Volume Variation

  • Significant changes of Pulse Pressure are called Pulse Pressure Variation

Attention: Only applicable in patients under controlled mechanical ventilation and with sinus rhythm.


Less invasive advanced haemodynamic monitoring

SVV/PPV – Volume demand predicted

Volume Responsiveness = CO increase by preload increase

SV

∆ SV2

SVV > 10%

PPV > 13%

SVV 0-10% PPV 0-13%

∆ SV1

∆ EDV1

∆ EDV2

EDV

Frank-Starling curve


Svv and ppv limitations

SVV and PPV - Limitations

Check list for the correct use of the parameters of Volume Responsiveness:

  • Is the patient under controlled mechanical ventilation?

  • Does the patient have sinus rhythm without arrhythmia?

     Is the arterial pressure curve free from artefacts?


Less invasive advanced haemodynamic monitoring

Lung Water

EVLW – Extravascular Lung water

  • Direct and easy quantification and monitoring of lung oedema at the bedside

  • Includes intra-cellular, interstitial and intra-alveolar water (not pleural effusion)

  • ELWI is indexed to “Predicted Body Weight” (theoretical body weight)


Less invasive advanced haemodynamic monitoring

ELWI 21 ml/kg BW

ELWI 11 ml/kg BW

ELWI 5 ml/kg BW

severely increased Lung Water

moderately increased Lung Water

no Lung Water increase

Pulmonary Oedema

Pulmonary Oedema

  • Infiltration of water into the lung tissue caused by inflammatory or cardiac processes disables the gas exchange (oxygenation of blood) and is difficult to quantify by conventional methods


Less invasive advanced haemodynamic monitoring

Alveolus wall

Alveolus wall

Cardiogenic Lung OedemaIncreased hydrostatic pressure with normal permeability

Permeability Lung OedemaNormal hydrostatic pressure with increased permeability

Capillary

Capillary

Alveolus

Pulmonary Vascular Permeability

PVPI – Pulmonary Vascular Permeability Index

  • Differentiation of the origin of pulmonary oedema (inflammatory or cardiogenic)

  • Relation between extra- und intra-vascular fluid (EVLW/PBV)


Less invasive advanced haemodynamic monitoring

Parameter - Interaction during volume administration

  • Insufficient preload volume is treated with volume administration

  • Optimizing preload may increase CO to the maximum

  • Further volume administration beyond this point will not improve CO but increase Lung Water

CO

5

3

EVLW

7

3

Preload


Less invasive advanced haemodynamic monitoring

Parameter - Interaction during volume withdrawal

  • Volume withdrawal to decrease Lung Water may influence preload volume and thus CO

  • The target is balancing sufficient preload volume for adequate CO and Lung Water as low as possible

CO

5

3

EVLW

7

3


Less invasive advanced haemodynamic monitoring

More information – less invasiveness

Central venous access (Standard CVC)

Only standard accesses necessary

Femoral arterial access

(PiCCO Catheter)

alternative:

axillary arterial, brachial arterial


Less invasive advanced haemodynamic monitoring

Fields of application

  • Intensive Care

  • Septic Shock

  • Cardiogenic Shock

  • Burns

  • Trauma / Hypovolaemic Shock

  • ARDS

  • Pancreatitis

  • Paediatrics

  • Intra-operative

  • Cardiac Surgery

  • Mayor Surgery

  • Neuro Surgery

  • Paediatrics


Less invasive advanced haemodynamic monitoring

PiCCO2 – The new haemodynamic monitor

  • 13,3“ colour wide screen

  • Touch-screen, navigation dial

  • Elegant, light housing

  • Solid foil

  • Protected Connectors

  • Small footprint

  • Compatible to standard mounting systems

  • Lithium-Ion battery

37


Less invasive advanced haemodynamic monitoring

PiCCO2

248 mm

328 mm

180 mm


Less invasive advanced haemodynamic monitoring

Information bar

Real-time pressure curve

Parameter fields

Innovative data visualization

Direct access buttons

Innovative operation via touch-screen or navigation dial


Less invasive advanced haemodynamic monitoring

Front

On/Off

Help

Print

Mute

Main

Back

Navigation dial


Less invasive advanced haemodynamic monitoring

Rear

ScvO2 (optical module)

CO (temperature)

Mains switch

Mains connector

AP (Pressure)

Grounding

CVP (Pressure)


Less invasive advanced haemodynamic monitoring

Interface connections

Interfaces for current and future demand

AP Out

CVP Out

Serial

Interface

LAN

2 x USB


Less invasive advanced haemodynamic monitoring

Mounting systems

  • Cart

  • Wall mounting

Horizontal standard bar

ITD support system

GCX support system


Less invasive advanced haemodynamic monitoring

PiCCO2

  • Distinguished by easy and intuitive handling

  • Structured and visualized information for fast recognition- SpiderVision, Profile, Trends

  • Reflects the physiology of the patient- only monitor with preload volume and lung water

    - integrated ScvO2 monitoring

  • Based on medical processes and way of thinking

44


Less invasive advanced haemodynamic monitoring

Contact

PULSION Medical Systems AGJoseph-Wild-Str. 20D-81829 MunichGermanyTel. +49-(0)[email protected]

w w w . P i C C O 2 . com


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