Manu Malbrain - Nursing thisisit final monitoring - IFAD 2012

2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 1
Hemodynamic Monitoring
Anno 2012
17th November 2012
2nd iFAD – Nursing Session
Manu Malbrain

Therapeutic Dilemma - Conflict

What I really need to know is…
When do I start giving fluids?
When do I stop giving fluids?
When do I start emptying?
When do I stop emptying?
SEE
MORE
THAN
OTHERS
benefit of fluid administration?
risk of fluid administration?
benefit of fluid removal?
risk of fluid removal?

Today’s Agenda
• Introduction
• From Invasive to Less invasive
• Results of PulsioFlex study
• Results of NexFin study
• Wrap it up

HD Monitoring
Anno 2012
Introduction

Disclosure
The speaker consults for the following companies:
BMEYE
Edwards
PULSION Medical Systems
manu.malbrain@skynet.be

 Cardiac output (CO) is the main determinant of
oxygen delivery
 Physical examination and vital signs alone often fail to
reflect significant derangements in CO
 Many of our therapeutic efforts are aimed at
increasing the CO
 The monitoring of CO is therefore very useful for
proper decision-making in critically ill and high-risk
surgical patients.
Some statements on CO measurement
Thanks to Azriel Perel

Bodies of two Air France
passengers found CNN.COM June
6, 2009
The airline had failed to replace a part that
monitors speed, as recommended by the
manufacturer, based on technological
developments and improvements.
The fact that this statement is not
supported by EBM tells us more about the
shortcomings of EBM than those of the
measurement of CO

The two main reasons to measure CO are:
 Identification of patients who have low (or high)
CO values that are not evident clinically
 Measurement of the response to diagnostic and
therapeutic interventions
It is time to consider
CARDIAC OUTPUT
as just another vital sign!

A Perel, M Maggiorini, M Malbrain, JL Teboul, J Belda, E
Fernández-Mondéjar, M Kirov, J Wendon
The PiCClin Study
206 critically ill patients were evaluated by 166
residents and 146 specialists.
EVLWiGEDViSVRCO
124
(40.8%)
154
(49%)
107
(34.3%)
110
(34.9%)
Within ±
20%
83
(27.3%)
97
(30.9%)
46
(14.7%)
170
(54%)
Under-
estimation
>20%

Because of the complexity of assessment of
clinical variables in septic patients, direct
measurement of CO by invasive hemodynamic
monitoring is advisable.

Perioperative optimization

Funk DJ, Moretti EW, Gan TJ. Anesth Analg 2009;108:887–97
 With the advancing age of the surgical population and the
increasing prevalence of ischemic heart disease, the need for
monitoring of organ flow is likely to increase.
 Clinicians (both in the OR and the critical care setting) are
looking more toward the use of minimally or noninvasive
monitors of CO.
 Of the available monitors, the ED and the arterial pulse
contour devices seem to have the greatest potential at
replacing the PAC for CO measurement.

What hemodynamic monitoring do you routinely
use for the management of high-risk surgery
patients?

HD Monitoring
Anno 2012
Less invasive
CO…

Real Time beat to beat CO
Real Time Preload + Afterload
Adequacy data
Minimally invasive
Widely applicable
Simple to Operate and Understand
Measured variables
Clear Data Display + Interpretation
Cardiac Output Monitoring
Nurse driven at the bedside
Neonates to adults
Ideal
System

• Fick
– Difficult, large room for
error, “Gold” standard
– NiCO2
• Bioimpedance
– Variable ICU accuracy
– Cardiodynamics
• Doppler
– Accurate, but user
dependent
– HemoSonic, Deltex, WAKI
• Pulse Contour Analysis
– PiCCO/EV 1000
– PulseCO
– Vigileo/ Pulsioflex
• Thermodilution
– Vigilance PAC, CEDVi
– (PiCCO)
• Indicator Dilution
– Invasive
– (LiDCO)
Available technologies for
continuous Cardiac Output

PA catheter
Advancedmonitoring Which device for monitoring cardiac output?
PiCCO EV 1000
cardiac output cardiac output cardiac output
PAP - PAOP GEDVi GEDVi
EVLWi - PVPI EVLWi - PVPI
GEF - dpmax GEF - dpmax

• Advantages
– ‘Simple’ catheter
– No added fluid
– No calibration
– “Operator independent”
– SVO2 / Volumetric measurements
• Disadvantages
– Invasive
– Non continuous (3-6 minutes)
– Slow response to change
– Poor signal to noise ratio
– Non verifiable data
Vigilance - CEDVI
Gold Standard
RV end-diastolic volume (RVEDV)
(pulmonary artery thermodilution)

1. Transpulmonary thermodilution
2. Arterial Pulse contour analysis
Algorithm after calibration
What is TPTD technology ?
Global end-diastolic volume (GEDV)
(transpulmonary thermodilution)
Intrathoracic blood volume (ITBV)
(thermo-dye transpulmonary dilution)
PiCCO
or
EV1000

Cardiac output measurement
by transpulmonary
thermodilution
RA LARV LVPBV
EVLW
Cardiac
output

1. Transpulmonary lithiumdilution
2. Pulse power analysis algorithm combined with
indicator dilution calibration
What is LiDCO/PulseCO
technology ?

•Indicator dilution technique
•Lithium chloride (0.15-0.3 mmol) marker
•Intravenous bolus (peripherally or centrally)
•Ion selective electrode attached to arterial line
•CO computed

Vigileo Eso Doppler
preload
dependance
(Δ aortic blood flow)
preload
(FTc)
Pulsioflex
preload
dependance
(VVE and Δ PP)
preload
dependance
(VVE and Δ PP)
LidCOrapid
preload
dependance
(SVV and Δ PP)
continuous
cardiac output
continuous
cardiac output
(cardiac output)(AP curve
analysis)
continuous
cardiac output
(AP curve
analysis)
continuous
cardiac output
(AP curve
analysis)
essInvasivemonitoring

1. CO estimation
2. Pulse Contour Analysis
What is Vigileo technology ?
CO = HR * SV
• Heart Rate
measurement
• Biometric and
dynamic
compensation for
the vasculature
• Pulse pressure
measurement
proportional to
Stroke Volume

Trending Stroke Volume
• Arterial pressure is sampled at 100 Hz
(i.e., 20sec x 100Hz = 2000 data points)
• An equivalent for pulse pressure is achieved by taking the
standard deviation (SD) of the 2000 sampled data points
• SD(Arterial pressure) - Pulse Pressure - Stroke Volume
• Changes in stroke volume will result in corresponding changes
in the pulse pressure
• SV estimates are updated over 20 seconds
20 sec.

SD is a measure of variation of the AP
↑ AP Variation ➔ ↑ SD(AP) ➔ ↑ SV
Therefore, with a constant vasculature …
↓ AP Variation ➔ ↓ SD(AP) ➔ ↓ SV
20 sec. 20 sec.20 sec.

PulsioFlex
• ProAqt sensor

Pram
• Pressure
• recording
• analytical
• method

NesCO
• Estimated
• Continuous
• CO

Cheetah - NICOM
• Bioreactance

ECOM

UsCOM
• ultrasound

Transonic
• COstatus

ImaCor
• Disposable TEE

1. Pulsed Doppler Velocity
2. M-mode aortic root diameter
What is HemoSonic technology ?
HemoSonic
Atys
Médical

Ø 7mm

MM 06/2006 – 39
Probe Positioning
correct
incorrect

Doppler Principles

1. Indirect Fick Principle
2. Respiratory Mechanics
What is NiCO2 technology ?

Arterial pressure
Esophageal Doppler
Flotrac/Vigileo
Pulsioflex
LidCOrapid
AP catheter
CVP
PiCCO
EV 1000
Basic monitoring Advanced monitoring

OR monitoring

Different panel of hemodynamic information
Arterial pressure
Esophageal Doppler
Vigileo/Pulsioflex
LidCOrapid
PAC
CVC / ScvO2
PiCCO/EV1000
vasomotor
tone
lung
water
cardiac
contractility
tissue
oxygenation
preloadCO/SV preload
dependance
Different monitoring devices

HD Monitoring
Anno 2012
How to compare
2 techniques?

1. Correlations…
Gold standard Gold standard
Inverse correlation
Not equivalent
Good correlation
Systematic
overestimation
Gold standard
Poor correlation
Systematic
underestimation

1. Correlations…
• Pearson correlation
(p<0.01)
• Line of identity
crosses “0”
• Linear relation
• R2>0.6
• R>0.75

COPA-COA
(COPA-COA)/2
Bias
Limits of Agreement = ± 2 SD
Normal HighLow
CO = 3 ± 1 l/min CO = 8 ± 1 l/min
± 12.5%
<35%
2. Bland and Altman…

3. Critchley

PRECISE
ACCURAT
E
IMPRECISE
ACCURAT
E
PRECISE
INACCURATE
IMPRECISE
INACCURATE

Are uncalibrated CO monitors
accurate enough to guide therapy?

Anesthesia Analgesia 2009, 108:707
 When evaluating the role of new CO devices in clinical care,
the fundamental question is whether the new device can
replace thermodilution CO measurement as a guide to clinical
decisions.
 Despite the large number of studies evaluating new CO
devices, few, if any, answer this fundamental question.

HD Monitoring
Anno 2012
PulsioFlex Study
ZNA Stuivenberg

PulsioFlex Escalation Study

Reference:
NEXFIN !left !right
Finger
Edema !yes !no Date
Hospital
Patient ID (anonym) Height cm Weight kg
Age Y Gender female. ! male !
Medication
Obs 6 PiCCO2 Pulsioflex Nexfin/radial NIV/Monitor Other
Time +8hrs ADsys SaO2:
ADdia Blood T°:
MAP Periph T°:
SVV Nex Hgb: CVP:
PPV dobu:
dPmax Rythm: levo:
SVRI ulti:
SVI dorm:
HR dipri:
Auto CI 1.* CCI 2. 3. 4. other:
Obs 7 ADsys SaO2:
Time + 2 hrs ADdia Blood T°:
MAP Periph T°:
SVV CVP:
PPV dobu:
dPmax Rythm: levo:
SVRI ulti:
SVI dorm:
HR dipri:
CCI other:
Obs 8 ADsys SaO2:
MAP Periph T°:
SVV CVP:
PPV dobu:
dPmax Rythm: levo:
SVRI ulti:
SVI dorm:
HR dipri:
CCI other:
Obs 9 ADsys SaO2:
MAP Periph T°:
SVV CVP:
PPV dobu:
dPmax Rythm: levo:
SVRI ulti:
SVI dorm:
HR dipri:
CCI other:
Obs10+16hrs ADsys SaO2:
MV Mode ADdia Blood T°:
RR MAP Periph T°:
TV SVV Nex Hgb: CVP:
IPAP PPV dobu:
PEEP dPmax Rythm: levo:
FiO2 SVRI GEF: ulti:
pO2/pCO2 / SVI GEDVi: dorm:
pH/lact / HR EVLWi: dipri:
HCO3/BE / CCI 1. 2. 3. TPTD CI(5): other:
Auto CI 4.
!Brachial/Axillar !Radial !Femoral
PiCCO2 !De-escalation Arm
PiCCO placement !left !right
Observation: PULSIOFLEX vs. PiCCO2 8 - 16 hrs (PulsioFlex AUTOcalibration*)
PiCCO2 !escalation Arm
Fluid Balance/8hrs
Pulsioflex placement !left !right
Reference:
NEXFIN !left !right
Finger
Edema !yes !no Date
Hospital
Patient ID (anonym) Height cm Weight kg
Age Y Gender female. ! male !
Medication
Time 0 PiCCO2 Pulsioflex Nexfin/radial NIV/Monitor Other
MV Mode ADsys SaO2:
RR ADdia Blood T°:
TV MAP Periph T°:
IPAP SVV Nex Hgb: CVP:
PEEP PPV dobu:
FiO2 dPmax Rythm: levo:
pO2/pCO2 / SVRI GEF: ulti:
pH/lact / SVI GEDVi: dorm:
HCO3/BE / HR EVLWi: dipri:
Auto CI 5. CCI 2. 3. 4. TPTD CI*(1): other:
Obs 2 ADsys SaO2:
MAP Periph T°:
SVV CVP:
PPV dobu:
dPmax Rythm: levo:
SVRI ulti:
SVI dorm:
HR dipri:
CCI other:
Obs 3 ADsys SaO2:
MAP Periph T°:
SVV CVP:
PPV dobu:
dPmax Rythm: levo:
SVRI ulti:
SVI dorm:
HR dipri:
CCI other:
Obs 4 ADsys SaO2:
MAP Periph T°:
SVV CVP:
PPV dobu:
dPmax Rythm: levo:
SVRI ulti:
SVI dorm:
HR dipri:
CCI other:
Obs 5 + 8hrs
ADsys SaO2:
MV Mode ADdia Blood T°:
RR MAP Periph T°:
TV SVV Nex Hgb: CVP:
IPAP PPV dobu:
PEEP dPmax Rythm: levo:
FiO2 SVRI GEF: ulti:
pO2/pCO2 / SVI GEDVi: dorm:
pH/lact / HR EVLWi: dipri:
HCO3/BE / CCI 1. 2. 3. TPTD CI(5): other:
Auto CI 4.
Pulsioflex placement !left !right
PiCCO2 !De-escalation Arm
Fluid Balance/8hrs
Observation: PULSIOFLEX vs. PiCCO2 0 - 8 hrs (PulsioFlex calibration with TPTD*)
PiCCO2 !escalation Arm
PiCCO placement !left !right

Patients
• So far, 37 mechanically ventilated ICU patients
included
• All Escalation
Age Gender height weight BMI APACHE SAPS SOFA
mean 53,2 20,0 172,8 84,1 28,3 26,0 51,1 9,8
SD 15,5 Male 9,4 22,4 7,9 6,4 11,9 2,7
8h time periods 1 2 3 4
PICCO2 Femoral
Pulsioflex Radial Femoral
Calibration TDCI AutoCI TDCI AutoCI

Regression PiCCI vs PulseCI

Correlation with TPTDCI
Pulsioflex
Pulse contour
PiCCO2
Pulse contour
ProAQT
Auto Calibration

Bland and Altman
PICCI-PULSECI TDCI-PICCI TDCI-PULSECI TDCI-AUTOCI
n 440 182 182 182
mean 3,7 0,00 3,7 0,04 3,7 0,04 3,7 0,03
SD 1,1 0,58 1,1 0,40 1,0 0,58 0,9 0,61
min/LLA 1,7 -1,16 1,5 -0,76 1,8 -1,13 2,0 -1,20
max/ULA 7,0 1,17 6,9 0,84 6,7 1,20 6,6 1,25
COVA 30% 29% 26% 24%
PE 8,0 31,5% 7,9 21,6% 7,7 31,4% 7,6 32,9%
PE 31.5%
PE 21.6%
PE 31.4% PE 32.9%

Concordance: Changes in CI

Effect of therapeutic
intervention
• In total 40 interventions
• Passive leg raising (n=13)
• Fluid bolus 500ml/30 minutes (n=11)
• Increase or decrease of vasopressor (n=10)
• Increase or decrease of dobutamine (n=5)
• Increase in sedation (n=1)

HD Monitoring
Anno 2012
NexFin Study
ZNA Stuivenberg

The Nexfin device

The Nexfin applies 3 major steps in the
non-invasive measurement of CCO.
The Nexfin: Principles of measurement

An inflatable cuff* is wrapped around the middle
phalanx of the 2nd, 3rd or 4th finger.
* 3 sizes
1. Measurement of continuous beat-by-beat finger BP

 The diameter of the finger
arteries is measured by a pair of
LED’s.
 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.
Volume Clamp Technology
1. Measurement of continuous beat-by-beat finger BP

2. Transformation of finger BP to brachial BP by a
transfer function based on a vast clinical database

3. Calculation of the CCO from the brachial BP waveform
Nexfin CO-Trek
The Nexfin CO-Trek method is based on the
hemodynamic version of Ohm's law
ΔP/Q = Zin
Thus, when the arterial input impedance (Zin) is
known, a given pressure (P) allows for the
calculation of the related flow (Q).

Poster @ISICEM

Patient Characteristics

CI evolution

MAP evolution

Final analysis CO (45 pats)
-5.0
-4.0
-3.0
-2.0
-1.0
0.0
1.0
2.0
3.0
4.0
5.0
0.5 2.5 4.5 6.5
Bland and Altman PiCCI vs CI NEXFIN
-5.0
-4.0
-3.0
-2.0
-1.0
0.0
1.0
2.0
3.0
4.0
5.0
0.5 2.5 4.5 6.5
Bland and Altman TDCI vs CI NEXFIN
%error = 36.9% %error = 37.1%
y = 0.8724x + 0.3928
R² = 0.6781
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
0.0 5.0 10.0 15.0
NexCO(l/min)
TDCO (l/min)
y = 0.877x + 0.5645
R² = 0.7091
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0
NexCO(l/min)
CCO (l/min)

Final Analysis MAP (45 pats)
-50.0
-40.0
-30.0
-20.0
-10.0
0.0
10.0
20.0
30.0
40.0
50.0
25.0 50.0 75.0 100.0 125.0 150.0
Bland and Altman PiCCO vs CO NEXFIN
y = 0.9417x + 3.1686
R² = 0.8846
25.0
50.0
75.0
100.0
125.0
150.0
25.0 50.0 75.0 100.0 125.0 150.0
Correlation MAP Nexfin vs MAP PiCCO
%error = 14.7%

• 35 year old
• suicide attempt (glucophage)
• Septic shock
• Metabolic (lactic) acidosis
Case study
Infusion pumps
dialysis
NEXFIN PiCCO2
Evita XL
CiMON

PiCCI
NEXCI
art rad MAP
NEXMAP
PiCCOMAP

• 35 year old man, suicide attempt, Levo 0.45y
Case study
Agitation, pain midazolam
Small drift
PiCCI
NEXCI

Case study
Agitation, pain
midazolam
MAP
NEXMAP
• 35 year old man, suicide attempt, Levo 0.45y

PiCCI

AUC (PiCCO) = 8752 vs AUC (NEXFIN) = 9847 = 88.9%
NEXCI
NEXFIN
PiCCO

Concordance Plot
y = 0.4056x - 0.0147
R² = 0.3693
-4
-3
-2
-1
0
1
2
3
4
-4 -3 -2 -1 0 1 2 3 4
DNEXCO(l/min)
DTDCO (l/min)
Exclusion zone: 35/90
Level of concordance:
50/55 (91%)

Conclusions
• TRULY non-invasive
• Reasonable results in a really critically ill
patient sample (n=45)
• Performs even better than other more
invasive techniques
• Correlates excellent with invasive MAP
• LA for CI acceptable although % error too big
• Better patient selection needed

The Future for NEXFIN
 Double Cuff for continuous CCI
 Hygienic properties
 Longer connectors
 Physiocal optimisation
 Quantification of SVV and PPV
 Could be used in ER (pattern
recognition) and OR setting

HD Monitoring
Anno 2012
Conclusions

Evidence Based Medicine
 Does my new monitoring device does as
well as the gold standard?
 Does my new monitoring device give
new or additional information?
 Does the interpretation of the data
change my treatment?
 Does the new-variable-driven treatment
change patient outcome?

The Parachute Study
Gordon C S Smith, Jill P Pell BMJ 2003; 327:1459-60
WHAT DO WE KNOW WHAT THIS STUDY ADDS
• No RCCT on parachute
• Basis for parachute use
 Purely observational
• Efficacy explained by
 Healthy cohort
• He who believes in EBM
 Comes down
 to earth
 with a bump…
• Widely used
• Gravitational challenge
 Prevent death
 Prevent injury
• Adverse effects
 Failure
 Iatrogenic
• Studies free fall
 no 100% mortality

No monitoring device can improve
patient-centered outcomes unless it
is coupled to a treatment that
improves outcome.

• Non invasive technologies offer useful
additional information
• This can alter our treatment strategy
• There is a learning curve with any new
technology
• Each technology is different and needs to
be assessed on its own merits
• By knowing the pitfalls we can obtain new
and important information
• This can also alter our treatment…
Summary
manu.malbrain@skynet.be

HD Monitoring
Anno 2012
Wrap it Up

What I really need to know
When do I start giving fluids?
When do I stop giving fluids?
When do I start emptying?
When do I stop emptying?
SEE
MORE
THAN
OTHERS
benefit of fluid administration?
risk of fluid administration?
benefit of fluid removal?
risk of fluid removal?
GEF/GEDVi↓ PPV↑ PLR+
GEF/GEDVi↑ PPV↓ PLR-
EVLW↑/PVPI↑ IAP↑/APP↓ FB+
ICG-PDR↓ APP↓ ScvO2↓ FB--

WGAP Meeting at ESICM
ACS Workshop at ISICEM

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Manu Malbrain - Nursing thisisit final monitoring - IFAD 2012

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Manu Malbrain - Nursing thisisit final monitoring - IFAD 2012