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Haemodynamic Monitoring PowerPoint PPT Presentation


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Haemodynamic Monitoring. Theory and Practice. Haemodynamic Monitoring. Physiological Background Monitoring Optimising the Cardiac Output Measuring Preload Introduction to PiCCO Technology Practical Approach Fields of Application Limitations. Practical Approach. PiCCO Technology Set-Up.

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Haemodynamic Monitoring

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Haemodynamic Monitoring

Theory and Practice


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Haemodynamic Monitoring

Physiological Background

Monitoring

Optimising the Cardiac Output

Measuring Preload

Introduction to PiCCO Technology

Practical Approach

Fields of Application

Limitations


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Practical Approach

PiCCO Technology Set-Up

PiCCO monitoring uses vascular accesses that are already existing or required anyway.

Central venous catheter

Injectate temperature sensor housing

PULSIOCATH

Arterial thermodilution catheter (femoral, axillary, brachial)


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Practical Approach

Clinical Case

Patient with secondary myeloid leukemia due to non-Hodgkin’s lymphoma

Currently:aplasia as a result of ongoing chemotherapy.

Transfer from the oncology ward to intensive care unit due to development of septic status

Status on transfer to the Intensive Care Unit

HemodynamicBP 90/50mmHg, HR 150bpm SR, CVP 11mmHg

RespirationSaO2 99% on 2L O2 via nasal prongs

Abdomen Severe diarrhoea, probably associated with chemotherapy

RenalRetention values already increasing, cumulative 24h diuresis 400ml

LaboratoryHb 6.7g/dl, Leuco <0.2/nl, Thrombo 25/nl

High fluid loss because of severe diaphoresis

Initial Therapy

Given 6500 ml crystalloids and 4 PBC


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Practical Approach

Clinical Case

Ongoing Development

Haemodynamics •despite extensive volume therapy during the first 6 hours,

catecholamines had to be commenced

•requirement for catecholamines steadily increased

•echocardiography showed good pump function

•CVP increased from 11 to 15mmHg

Respiration •respiratory deterioration with volume therapy: SaO2 90% on 15L O2/min, pO2 69mmHg, pCO2 39mmHg, RR 40/min

•radiological signs of pulmonary edema

•started on intermittent non-invasive BIPAP ventilation

Renal•ongoing poor quantitative function despite the use of diuretics (frusemide)

Infection Status •evidence of E.Coli in the blood culture

Diagnosis: Septic Multiorgan Failure


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Practical Approach

Clinical Case

Therapeutic Problems and Issues

Haemodynamics •further requirement for volume? (rising catecholamine needs

despite good pump function)

•problematic assessment of volume status

(CVP initially raised, patient diaphoretic / diarrhoea)

Respiration •evidence of lung edema (deterioration in pulmonary function)

•danger of need for intubation and ventilation with high risk of ventilator-associated pneumonia (VAP) because of immunosuppression

Renal•impending anuric renal failure


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Practical Approach

Clinical Case

Therapeutic Problems and Questions

Haemodynamics

Volume Administration

Respiration

?

Renal

Haemodynamics

Volume Restriction

Respiration

Renal


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Practical Approach

Clinical Case

Application of the PiCCO system

  • continuation of the noradrenaline infusion

  • careful GEDI guided volume therapy


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Practical Approach

Clinical Case

PiCCO values the following day

GEDI with volume therapy persistently within the high normal range, however no increase in ELWI


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Practical Approach

Clinical Case

Other therapy

  • -non-invasive ventilation

  • targeted antibiotic therapy

  • administration of hydrocortisone / GCSF

Further course

-stabilization of haemodynamics

-steady noradrenaline requirement

-start of negative fluid balance, guided by the PiCCO parameters


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Practical Approach

Clinical Case

PiCCO values the next day

  • stabilization of pulmonary function

  • cessation of catecholamines

  • good diuresis with frusemide


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Practical Approach

Clinical Case

Progression of PiCCO values

Despite significant volume administration/ removal remains relatively constant, thus on its own not an indicator for volume status

CI

30

25

Nor

HI

20

Remained within normal range under monitoring

GEDVI

CVP

ITBI

15

EVLWI

GEDVI

EVLW

Regular monitoring of the lung water allowed titration of the volume therapy whilst simultaneously avoiding further increase of lung oedema

10

SVRI

EVLWI

SVR

5

CI

0

Initially raised, despite volume depletion and thus not of use

CVP

Day 1

Day 2

Day 3

Day 4

Day 5

Nor

Time Course


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Practical Approach

Clinical Case

Actual advantages of using PiCCO with this patient

Optimisation of the intravascular

volume status

Monitoring of lung oedema

Stabilisation of the haemodynamics

Pulmonary stabilisation

Reduction

in catecholamine requirements

Avoidance of intubation

No acute renal failure

No invasive ventilation

Avoidance of complications

Efficient use of resources


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Practical Approach

Clinical Case

Potential problems without PiCCO use in this patient

Diarrhoea

Severe diaphoresis

Poor Diuresis

Constant CI

High CVP

difficult

clinical assessment

of volume deficit

Volume ?

Volume ?

Volume ?


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Practical Approach

Therapy Guidance with PiCCO Technology

PiCCO allows the establishment of an adequate cardiac output through optimisation of volume status whilst avoiding lung oedema

Optimisation of stroke volume

The

haemodynamic triangle

Optimisation

of preload

Avoidance of lung oedema


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Practical Approach

Therapy Guidance with PiCCO Technology

if necessary:

additional information

Oxygen extraction ScvO2 Organ perfusion PDR-ICG

Evaluation of

therapy success

PiCCO monitoring

CI, Preload, Contractility, Afterload, Volume responsiveness

Therapy

Volume / Catecholamines


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Practical Approach

Therapy Guidance with PiCCO Technology

Cardiac Output

Inadequate preload should initially be treated with volume administration

5

3

EVLW

7

3

Preload


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Practical Approach

Therapy Guidance with PiCCO Technology

Cardiac Output

Inadequate preload should be treated initially with volume administration

5

Continue volume administration until EVLW increases

3

EVLW

7

3

Preload


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Practical Approach

Therapy Guidance with PiCCO Technology

Cardiac Output

Inadequate preload should be treated initially with volume administration

5

Volume administration causes an increase in EVLW

3

Volume removal until EVLW stops decreasing or decreases only slowly (preload monitoring!)

EVLW

Always check measurements for plausibility.

Volume administration must lead to an increase in preload, or increase in lung oedema (reflected by increase in EVLW)

7

3

Preload


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Costs and Resources

Economic Aspects of PiCCO Technology

Is it possible to reduce treatment costs through PiCCO Technology guided optimisation of therapy?

How high are the financial costs in comparison to the pulmonary artery catheter?


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Costs and Resources

Economic Aspects of PiCCO Technology

Direct costs in comparison to the PAC

Percentage Costs

230%

PiCCO - Kit

Pulmonary catheter

Chest X-Ray

140%

Introducer

CVC

100%

100%

Arterial catheter

Pressure transducer

Injection accessories

PiCCO Kit

CCO - PAC

PiCCO Kit

CCO - PAC

Day 5 to 8

Day 1 to 4

Efficient and economically priced monitoring with PiCCO technology is possible because of the low costs for materials and efficient use of staff time


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Costs and Resources

Economic Aspects of PiCCO Technology

Indirect costs in comparison to the PAC

Ventilation days

Intensive care days

* p ≤ 0.05

n = 101

* p ≤ 0.05

22 days

7 days

9 days

15 days

PAC group

EVLW group

PAC group

EVLW group

Mitchell et al, Am Rev Resp Dis 1992;145: 990-998

By reducing the ventilation days and subsequent days in intensive care the costs can be effectively reduced (average cost per day currently 1,318.00€) (Moerer et al., Int Care Med 2002; 28)


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Practical Approach

Summary and Key Points

  • PiCCO technology as a less invasive monitoring method utilizes only vascular accesses that already exist or are required anyway in ICU patients

  • PiCCO technology provides all the parameters essential for complete haemodynamic management

  • Through valid and rapidly available PiCCO parameters optimal haemodynamic therapy guidance is possible

  • Through the optimisation of therapies with PiCCO technologycomplications can be reduced and resources used more efficiently


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