"Less invasive " monitoring
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1) Bioreactance and non-invasive arterial pressure curve analysis require more validation, especially in critically ill patients. 2) Non-calibrated pulse contour analysis is unreliable in critically ill patients receiving vasopressors. 3) Transpulmonary thermodilution devices using techniques like PiCCO can provide valuable information to clinical questions regarding shock such as fluid management and contractility through measurements of extravascular lung water, pulmonary vascular permeability index, and cardiac function index.
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"Less invasive " monitoring
- 1. Prof. Xavier MONNET Medical Intensive Care Unit Paris-Sud University Hospitals xavier.monnet@bct.aphp.fr "Less invasive " monitoring
- 2. Link of interest Member of the medical advisory board Pulsion Medical Systems
- 3. Which one should I choice ? PA catheterPiCCO EV 1000Eso DopplerPulsioflex VigileoNicomNexfin Invasive deviceLess invasive devicesNon invasive devices It depends on what you are waiting from monitoring ! What we are waiting from monitring depends on the setting
- 4. The questions asked to a hemodynamic monitoring device Peri-op monitoring ICU monitoring Is my treatment effective ? Should I give fluid ? Is the patient deteriorating ? Should I not give fluid ? Should I give an inotrope ? Should I give a vasopressor ? ? ?
- 5. Which one should I choice ? PA catheterPiCCO EV 1000Eso DopplerPulsioflex VigileoNicom Nexfin Invasive deviceLess invasive devicesNon invasive devices Are these devices reliable for measuring and monitoring cardiac output ? Well established
- 6. Is bioreactance reliable to monitor cardiac output ? Is it reliable ?
- 7. % of error = 33% OK but comparison with Vigileo No comparison with a reference technique ICU patients, vs. TP thermodilution ICU patients, vs. standard thermodilution Is bioreactance reliable to monitor cardiac output ?
- 8. % error = 82% 48 patients with circulatory failure ICU setting 63% under norepinephrine NiCOM vs. transpulmonary thermodilution Is bioreactance reliable to monitor cardiac output ?
- 9. 140 measurements in 11 ICU patients NiCOM vs. PAC % error ≈ 180% Is bioreactance reliable to monitor cardiac output ? Bioreactance seems to be unreliable in critically ill patients
- 10. Which one should I choice ? PA catheterPiCCO EV 1000Eso DopplerPulsioflex VigileoNicom Nexfin Invasive deviceLess invasive devicesNon invasive devices Are these devices reliable for measuring and monitoring cardiac output ?
- 11. Non invasive arterial pressure curve analysis 1st step measurement of finger blood pressure Photoplethysmography measures the diameter of the finger arteries The cuff inflates and relaxes to keep the diameter constant throughout the cardiac cycle The pressure that is needed to keep the diameter constant is continuously recorded generating a real- time pressure waveform. AP 110/70 mmHg
- 12. 2nd step Pulse contour analysis Is it reliable ?→ Non invasive arterial pressure curve analysis 1st step measurement of finger blood pressure AP 110/70 mmHg AP 110/70 mmHgCO 3.3 L/min for measuring blood pressure ?
- 13. PAni PAi Pairway 38 septic shock patients monitored with CNAP® device Non invasive arterial pressure curve analysis
- 14. 0 5 10 15 20 25 30 35 40 0 5 10 15 20 25 30 35 40 PPVni(%) PPVi (%) 38 septic shock patients monitored with CNAP® device 0 20 40 60 80 100 0 20 40 60 80 100 100-Specificity Sensitivity PPVi PPVni Non invasive arterial pressure curve analysis
- 15. The questions asked to a hemodynamic monitoring device Peri-op monitoring ICU monitoring Is my treatment effective ? Should I give fluid ? Is the patient deteriorating ? Should I not give fluid ? Should I give an inotrope ? ? ? ? Is it reliable ?→ for measuring cardiac output?
- 16. 1st author Year of pub. Reliability Bogart 2005 Cardiac surgery after stopping inot. Broch 2011 Operating room Chen 2012 Operating room Von Geldorp Resynchronization treatment Bartels 2011 Normal subjects Fischer 2012 ICU patients Monnet 2011 ICU patients Setting/Patients x x Non invasive arterial pressure curve analysis
- 17. 38 patients with circulatory failure ICU setting 45% under norepinephrine Nexfin vs. transpulmonary thermodilution % error = 57% Non invasive arterial pressure curve analysis
- 18. 50 patients after cardiac surgery 93% under vasoactive drugs Nexfin vs. transpulmonary thermodilution % error = 50% Non invasive arterial pressure curve analysis It seems to be unreliable out of the operating room setting
- 19. Bioreactance and non-invasive arterial pressure curve analysis need some more validation, at least in critically ill patients 1 2 3 The 3key-messages
- 20. Which one should I choice ? PA catheterPiCCO EV 1000Eso DopplerPulsioflex VigileoNicom Nexfin Invasive deviceLess invasive devicesNon invasive devices Are these devices reliable for measuring and monitoring cardiac output ?
- 21. Uncalibrated pulse contour analysis CO 6.5 L/min
- 22. 20 40 60 80 100 120 0 = k . SV Uncalibrated devices estimate SV from the arterial pressure curve estimate arterial compliance by analysing the arterial waveform Is it still valuable when the properties of the arterial curve change to a large extent (sepsis, vasopressors) ? Uncalibrated pulse contour analysis
- 23. t AP Initial estimation of cardiac output Pulse contour analysis Uncalibrated pulse contour analysis
- 24. Which one should I choice ? PA catheterPiCCO EV 1000Eso DopplerPulsioflex VigileoNicom Nexfin Invasive deviceLess invasive devicesNon invasive devices Calibrated devices
- 26. cold bolus inj Température du sang (Ts) Ttm Transpulmonary thermodilution
- 27. t AP Initial value provided by transpulmonary dilution Transpulmonary thermodilution
- 28. bolus froid 3.5 L/min Transpulmonary thermodilution
- 29. t AP Initial value provided by transpulmonary dilution Pulse contour analysis Transpulmonary thermodilution
- 30. 51 pts, 401 measurements Vigileo2 vs.Vigileo3 vs. PAC Vigileo3 is more accurate and as precise than Vigileo2 Calibrated vs. non calibrated devices Percentage error: 30%
- 31. Changes in norepinephrine doseVolume expansion r2 = 0.26 r2 = 0.11 20 volume expansions, 20 decreases and 20 increases in norepinephrine Vigileo3 vs. PAC Calibrated vs. non calibrated devices
- 32. Low SVR Normal SVR Percentage error: 26% Percentage error: 46% High SVR Percentage error: 61% 40 patients undergoing cardiac surgery Phenylephrine administration FloTrac (v3.02) vs. pulmonary artery catheter Uncalibrated devices are not reliable in case of vasopressors administration and septic shock Calibrated vs. non calibrated devices
- 33. Bioreactance, non-invasive arterial pressure curve analysis need some more validation, at least in critically ill patients Non-calibrated pulse contour analysis is not reliable in critically ill patients who receive vasopressors 1 2 3 The 3key-messages
- 34. Which one should I choice ? PA catheterPiCCO EV 1000Eso DopplerPulsioflex VigileoNicom Nexfin Invasive deviceLess invasive devicesNon invasive devices Suitable for the peri-operative setting Suitable for the ICU setting
- 35. The questions asked to a hemodynamic monitoring device Peri-op monitoring ICU monitoring Is my treatment effective ? Should I give fluid ? Is the patient deteriorating ? Should I not give fluid ? Should I give an inotrope ? ? ? ? ? ? ? ? ?
- 36. Cold bolus extravascular lung water PiCCO EV1000 Transpulmonary thermodilution
- 37. 0 20 40 60 80 100 EVLWImax > 21 mL/kg EVLWImax ≤ 21 mL/kg 70% 42% p = 0.0001 Day-28 mortality (%) Lung water measured by transpulmonary thermodilution has a real physiological significance → p value EVLWImax (1 unit = 1 mL/kg) 1.07 (1.02 - 1.12) 0.007 Maximum blood lactate (1 unit = 1 mmol/L) 1.29 (1.14 - 1.46) 0.0001 Minimum PaO2/FiO2 (1 unit = 1 mmHg) 0.98 (0.97 - 0.99) 0.006 Mean PEEP (1 unit = 1 cmH2O) 0.78 (0.67 - 0.91) 0.002 SAPS II (1 unit = 1 point) 1.03 (1.01 - 1.05) 0.02 Mean cumulative fluid balance (1 unit = 1 mL) 1.0004 ( 1.0001 - 1.0008) 0.02 Odds Ratio ( CI 95%) 200 pts with ARDS EVLW measured by PiCCO device Transpulmonary thermodilution
- 38. lung water Cold bolus pulmonary blood volume Pulmonary vascular permeability index =PVPI Transpulmonary thermodilution PiCCO EV1000
- 39. 0 1 2 3 4 5 6 7 8 9 10 PVPI ALI/ARDS Hydrostatic pulmonary edema * Cut-off : 3 Se = 85 % Sp = 100 % 48 patients with pulmonary edema inflammatory vs. hydrostatic discriminated by experts PVPI by the PiCCO device Transpulmonary thermodilution
- 40. EVLW = 12 EVLW = 22 ARDS AP = 90 / 40 mmHg Cardiac index = 2.0 L/min/m2 PaO2/FiO2 = 180 mmHg PLR test : positive ARDS AP = 90 / 40 mmHg Cardiac index = 2.0 L/min/m2 PaO2/FiO2 = 180 mmHg PLR test : positive volume expansion volume expansion? vasopressor ? Transpulmonary thermodilution PVPI = 4 PVPI = 7
- 41. The questions asked to a hemodynamic monitoring device Peri-op monitoring ICU monitoring Is my treatment effective ? Should I give fluid ? Is the patient deteriorating ? Should I not give fluid ? Should I give an inotrope ? ? ? ? ? ? ? ? ?
- 42. How to assess the contractile function? Echocardiography is the gold standard but requires a skilled operator does not allow continuous monitoring cardiogenic shock at 1st day How many echos? LVEF We need a more continuous estimation of the LV systolic function
- 43. How to assess the contractile function? cardiac index cold bolus global end-diastolic volume cardiac function index =CFI stroke volume LV end-diastolic volume LVEF PiCCO EV1000
- 44. 0 20 40 60 80 100 0 20 40 60 80 100 100 - specificity Sensitivity 3.2 min-1 CFI for detecting LVEF 35% 60 pts Monitoring with PiCCO and TTE CFI allows detecting a low LVEF→ How to assess the contractile function?
- 45. The questions asked to a hemodynamic monitoring device Peri-op monitoring ICU monitoring Is my treatment effective ? Should I give fluid ? Is the patient deteriorating ? Should I not give fluid ? Should I give an inotrope ? ? ? ? ? ? ? ? ?
- 46. Bioreactance, non-invasive arterial pressure curve analysis need some more validation, at least in critically ill patients Non-calibrated pulse contour analysis is not reliable in critically ill patients who receive vasopressors Transpulmonary thermodilution devices provide valuable answers to the questions that are asked by complex patients with shock 1 2 3 The 3key-messages