Xavier Monnet - Monitoring hd pi cco java porto - IFAD 2012
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Xavier Monnet - Monitoring hd pi cco java porto - IFAD 2012
- 1. Prof. Xavier MONNET Medical Intensive Care Unit Paris-Sud University Hospitals Hemodynamic monitoring with the PiCCO
- 2. Link of interest Pulsion Medical Systems
- 3. In a patient with hemodynamic failure 3 therapeutic options vasopressor volume expansion inotrope hemodynamic monitoring ? vasodilation? volume responsiveness? impaired contractility? Hemodynamic monitoring to guide treatment
- 4. 20 40 60 80 100 120 140 vasodilation vasoplegic shock 115 75 80 30 → vasopressors Arterial pressure provides a lot of hemodynamic information physiologically related to vasomotor tone diastolic AP
- 5. In a patient with hemodynamic failure Hemodynamic monitoring ? vasodilation? ↘ cardiac output? Hemodynamic monitoring to guide treatment diastolic AP vasopressor Do we need to measure cardiac output?→
- 6. PiCCO Echo ProAQT/PulsioFlex PAC FloTrac/Vigileo Nexfin 228 pts receiving volume expansion 145 patients with increase of NE Arterial pressure Esophageal Doppler
- 7. -50 0 50 100 150 200 250 300 -50 0 50 100 150 200 250 300 Changes in CI induced by VE (%) Changes in PP induced by VE (%) -50 0 50 100 150 200 250 300 -50 0 50 100 150 200 250 300 Changes in CI induced by NE (%) Changes in PP induced by NE (%) 228 pts receiving volume expansion 145 patients with increase of NE r = 0.56 n = 228 r = 0.21 n = 145 * We need a direct measure of cardiac output in patients receiving vasopressors →
- 8. Cardiac output monitoring transpulmonary thermodilution pulse contour analysis 2 different techniques for measuring CO
- 9. transpulmonary thermodilutionCardiac output monitoring
- 10. cold bolus inj Blood temperature (Ts) Ttm transpulmonary thermodilutionCardiac output monitoring
- 11. Least significant change in cardiac index (%) 0 10 20 30 40 1 2 3 4 5 number of injected cold boluses 12% 100 TPTD measurements in critically ill patients → Transpulmonary thermodilution is precise for measuring cardiac output precisiontranspulmonary thermodilutionCardiac output monitoring
- 12. pulse contour analysis Cardiac output monitoring transpulmonary thermodilution 2 different techniques for measuring CO reliable precise
- 13. pulse contour analysisCardiac output monitoring CO 6.5 L/min
- 14. 20 40 60 80 100 120 0 = k . SV The area under the systolic part of the arterial curve is proportional to stroke volume k is calibrated from transpulmonary thermodilution pulse contour analysisCardiac output monitoring
- 15. t AP Initial value provided by transpulmonary dilution Pulse contour analysis pulse contour analysisCardiac output monitoring
- 16. CAL CAL CAL t IC pulse contour analysisCardiac output monitoring
- 17. pulse contour analysisCardiac output monitoring → Pulse contour analysis requires a frequent recalibration
- 18. transpulmonary thermodilution reliable precise Cardiac output monitoring 2 different techniques for measuring CO continuous pulse contour analysis
- 19. PiCCO
- 20. In a patient with hemodynamic failure hemodynamic monitoring ? vasodilation ? ↘ cardiac output ? Hemodynamic monitoring to guide treatment volume responsiveness ? ↘ contractile function ? PPV, SVV…
- 21. 50 70 90 110 mmHg PPmax PPmin PPV = 32 % PPV = PPmax - PPmin (PPmax + PPmin) / 2 spontaneous breathing activity cardiac arrhythmias ARDS with low Vt / lung compliance Prediction of volume responsiveness 3 frequent situations in the ICU Cannot be used in case of :
- 22. Hemodynamic monitoring to guide treatment hemodynamic monitoring ? vasodilation ? volume expansion? ↘ contractile function? When to administer fluid? PPV, SVV EEO test arrhythmias, spontaneous breathing, ARDS ? yesno EEO test
- 23. systemic venous return How to predict fluid responsiveness? end-expiratory occlusion test
- 24. Easier with a continuous measurement of cardiac output How to predict fluid responsiveness? end-expiratory occlusion test
- 25. -10 0 10 20 30 40 50 Effects of end-expiratory pause on continuous cardiac index increase 5% Se = 91% Sp = 100 % 34 patients with acute circulatory failure monitored by PiCCO device NR R Assessment of volume responsiveness end-expiratory occlusion test
- 26. Hemodynamic monitoring to guide treatment hemodynamic monitoring ? vasodilation? volume expansion ? ↘ contractile function ? When to administer fluid? PPV, SVV EEO test arrhythmias, spontaneous breathing, ARDS ? yesno EEO test PLR test PLR test
- 27. → PLR is like a " self-volume challenge " Assessment of volume responsiveness passive leg raising
- 28. Eso Doppler echo echo echo and arterial flow Flotrac/vigileo USCOM PiCCO Eso Doppler PiCCO echo bioreactance Assessment of volume responsiveness passive leg raising
- 29. -40 -20 0 20 40 60 80 PLR-induced changes in arterial pulse pressure * RNR False-negative cases We need a real-time measurement of cardiac output for assessing the effects of the PLR test → Assessment of volume responsiveness passive leg raising
- 30. Hemodynamic monitoring to guide treatment hemodynamic monitoring ? vasodilation? volume expansion ? ↘ contractile function ? When to administer fluid? PPV, SVV EEO test arrhythmias, spontaneous breathing, ARDS ? yesno EEO test PLR test PLR test when to stop fluid?
- 31. Hemodynamic monitoring to guide treatment hemodynamic monitoring ? vasopdilation? volume expansion ? ↘ contractile function ? when to administer fluid? Lung water ? when to stop fluid? Negative indices of tests of fluid responsiveness
- 32. PiCCO Cold bolus How to avoid excessive fluid loading? lung water extravascular lung water
- 33. 30 pts EVLW measured by TPTD and by postmortem gravimetry First validation of EVLW-TPTD evaluation in humans Validated in humans→ How to avoid excessive fluid loading? lung water
- 34. Extra-vascular lung water and pulmonary vascular permeability index are independent prognostic factors in patients with acute respiratory distress syndrome or acute lung injury Crit Care Med in pressJozwiak M, Silva S, Persichini R, Anguel N, Osman D, Richard C, Teboul JL, Monnet X 0 20 40 60 80 100 EVLWImax > 21 mL/kg EVLWImax ≤ 21 mL/kg 70% 42% p = 0.0001 Day-28 mortality (%) 200 pts with ARDS EVLW measured by PiCCO device Lung water measured by transpulmonary thermodilution has a real physiological significance → How to avoid excessive fluid loading? lung water 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%)
- 35. Hemodynamic monitoring to guide treatment hemodynamic monitoring ? vasodilation ? volume expansion ? ↘ contractile function ? When to administer fluid? PAOP ? when to stop fluid? ↗ lung water Negative indices of tests of fluid responsiveness
- 36. PAOP group Time (hours) Cumulative fluid balance (L) 7 3 1 5 -1 -3 -5 0 12 24 36 48 60 72 * * * * * p < 0.0001 vs time 0 EVLW group lung water 101 ARDS patients randomized to EVLW-guided management vs. PAOP-guided management How to estimate the risk of fluid administration ?
- 37. 0 5 10 15 20 25 Ventilation days ICU days PAOP Group EVLW Group * * Management of fluid therapy with : Lung water may guide fluid therapy during ARDS→ 101 ARDS patients randomized to EVLW-guided management vs. PAOP-guided management lung waterHow to estimate the risk of fluid administration ?
- 38. Hemodynamic monitoring to guide treatment hemodynamic monitoring ? vasodilation? volume expansion ? ↘ contractile function ? when to administer fluid? when to stop fluid? ↗ lung water Negative indices of tests of fluid responsiveness ↗ lung permeability
- 39. lung water Cold bolus pulmonary blood volume Pulmonary vascular permeability index =PVPI PiCCO How to avoid excessive fluid loading?
- 40. 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 When to stop volume expansion?
- 41. Hemodynamic monitoring to guide treatment hemodynamic monitoring ? vasodilation? volume expansion ? ↘ contractile function ? when to administer fluid? when to stop fluid? ↗ lung water ↗ lung permeability negative tests of fluid responsiveness
- 43. 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
- 44. 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
- 45. 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?
- 46. Hemodynamic monitoring to guide treatment PLR test PLR test hemodynamic monitoring ? vasodilation? volume expansion? ↘ contractile function? fluid administration? PPV, SVV… arrhythmias, sp. breath., ARDS? yesno EEO testEEO test when to stop fluid? ↗ lung water ↘ CFI ↗ PAOP DAP
- 48. + 2SD - 2SD + 1.92 - 0.56 (COTP thermo + COPA thermo ) / 2 COTP thermo - COPA thermo (L/min) COPA thermo COTPthermo (L/min) (L/min) Percentage error = 2SD/mean ≈ 16%, < 30% transpulmonary thermodilutionInvasive techniques PiCCO device
- 49. 1,000 pts with ALI/ARDS Comparison of conservative vs. liberal fluid strategies When to stop volume expansion?
- 50. Cohort study 3,147 pts with sepsis When to stop volume expansion? How to avoid fluid overload ?→
- 51. Fluid overload is clearly deleterious in septic and ARDS patients and must be avoided Volume expansion does not always result in the expected increase in cardiac output Several tests are now available for predicting fluid responsiveness For a precise assessment of the response to fluid administration, we need a direct measurement of cardiac output 1 2 3 4 The 6key-messages Fluid administration does not always result in an improvement of tissue oxygenation 5 Markers of tissue hypoxia detect patients in whom fluid will improve tissue oxygenation 6