PiCCO monitor indication, contraindications, how does it work and how to interpret

1. OSAMA ELAZZOUNY
PGY 3 ANESTHESIA RESIDENT
HMC, April 2019

2. I have no conflict of interest in relation to this
lecture

3. Objectives
• Introduction
• Indications and contraindications for PiCCO
• How does PiCCO work?
• Parameters measured by PiCCO : definitions & normal values
• Decision tree for hemodynamic monitoring using PiCCO

4. Objectives
• Introduction
• Indications and contraindications for PiCCO
• How does PiCCO work?
• Parameters measured by PiCCO : definitions & normal values
• Decision tree for hemodynamic monitoring using PiCCO

6. INTRODUCTION
• PiCCO is an acronym for Pulse Contour Cardiac Output.
• It enables assessment of the patient’s haemodynamic status to guide
fluid or vasoactive drug therapy
• Requires the insertion of a central venous pressure (CVP) catheter
and a thermodilution arterial line.

8. Objectives
• Introduction
• Indications and contraindications for PiCCO
• How does PiCCO work?
• Parameters measured by PiCCO : definitions & normal values
• Decision tree for hemodynamic monitoring using PiCCO

9. INDICATIONS FOR PiCCO
• Shock: cardiogenic, hypovolaemic, septic
• Sepsis
• Trauma
• Pulmonary oedema
• Acute lung injury
• Burns
• Any condition that requires assessment of haemodynamic and/ or
volumetric function

10. Contraindications for use of PiCCO:
• Conditions that distort the arterial wave form:
• Atrial or ventricular arrhythmia
• IABP
• ECMO
• Conditions that affect pulmonary vasculature:
• Pneumonectomy
• Massive pulmonary embolism
• Intracardiac shunt

11. Objectives
• Introduction
• Indications and contraindications for PiCCO
• How does PiCCO work?
• Parameters measured by PiCCO : definitions & normal values
• Decision tree for hemodynamic monitoring using PiCCO

12. HOW DOES PiCCO WORK?
• The PiCCO technology is based on two physical principles
• Transpulmonary thermodilution : calculates volumetric measurements of
preload and cardiac output
• Pulse contour analysis: continuous cardiac output and stroke volume
variation.

13. TRANSPULMONARY THERMODILUTION
• Injection of cold saline through a CVC.
• Mixes with the blood volume & passes through the Rt heart, through
the pulmonary vessels & back through the Lt heart
• Just after the Lt heart the arterial line measures the drop in blood
temperature & from this we obtain a Thermodilution Curve.
Transpulmonary Thermodilution

15. Transpulmonary thermodilution: Volumetric
parameters
• All volumetric parameters are obtained by advanced analysis of the thermodilution curve
• Below shows the graph of change in temp (inverted) against time

16. • Firstly cardiac output is calculated from the Stewart Hamilton
equation
• The product of volume/unit time x time= volume.
• The product of CO X MTt represents the total volume traversed by
the indicator i.e. total volume between site of injection and
detection.
• The greater the volume the bolus has to travel through the longer it will take.
• The product of CO x DSt represents the largest individual mixing
volume( Lungs) in a series of indicator mixing chambers.

18. • The pulse contour analysis provides continuous information
• while transpulmonary thermodilution provides static
measurements.
• Transpulmonary thermodilution is used to calibrate the
continuous pulse contour parameters.
Arterial pulse contour analysis

19. PULSE CONTOUR ANALYSIS:
• The PiCCO system continually estimates the SV from the arterial
waveform, using an arterial catheter.
• CO is then estimated from the SV & HR
• Beat by beat parameters are obtained from the shape of the arterial
pressure wave
• The initial transpulmonary thermodilution calibrates the parameters
& the algorithm is then capable of computing each single stroke
volume

20. PULSE CONTOUR ANALYSIS:

21. Objectives
• Introduction
• Indications and contraindications for PiCCO
• How does PiCCO work?
• Parameters measured by PiCCO : definitions & normal values
• Decision tree for hemodynamic monitoring using PiCCO

22. PARAMETERS MEASURED: DEFINITIONS &
NORMAL VALUES
• Preload:
• Global End Diastolic Volume (GEDV)
• The volume of blood contained in the 4 chambers of the heart
• 680- 800ml/m₂
• Intrathoracic Blood Volume (ITBV) :
• The volume of the 4 chambers of the heart plus the blood volume in the pulmonary
vessels
• 850-1000ml/m₂
• Stroke Volume Variation (SVV) :
• Reflects the sensitivity of the heart to the cyclic changes in cardiac preload induced by
respiration
• 3.0 L/min/m2 or less than 10%

25. • Contractility:
• Cardiac Function Index :
• The ratio of the index of cardiac output to the index of the GEDV.
• A measure of how well the CO is doing in relation to its preload.
• 4.5- 6.5%
• Global ejection fraction (GEF) :
• A % of total blood expelled from the heart every beat to the total amount of blood estimated
to be present just prior to ventricular systole.
• 25- 35%
• Lung function/?Pulmonary Edema:
• Pulmonary Vascular Permeability Index(PVPI) :
• Indication of pulmonary oedema in relation to preload
• 1.0- 3.0
• Extravascular Lung Water (EVLW) :
• Measures the fluid in the interstitial space outside of the pulmonary blood volume
• 3-7mls/kg
• Afterload:
• Systemic vascular resistance :
• SVR : MAP - CVP/CO

26. Objectives
• Introduction
• Indications and contraindications for PiCCO
• How does PiCCO work?
• Parameters measured by PiCCO : definitions & normal values
• Decision tree for hemodynamic monitoring using PiCCO