hemodynamic monitoring does one size fit all? - pulsion.com filefor example, applicable for heart...

Prof. JeanProf. Jean--Louis TEBOUL, Louis TEBOUL,

Medical ICUBicetre hospital

University Paris XIFrance

HemodynamicHemodynamic monitoring monitoring

Does one size fit all?Does one size fit all?

MemberMember ofof thethe MedicalMedical AdvisoryAdvisory BoardBoardofof Pulsion Pulsion MedicalMedical SystemsSystems

((GermanyGermany))

Conflicts of interestConflicts of interest

definition (s) of definition (s) of hemodynamichemodynamic monitoring? monitoring?

•• InitiallyInitially

monitoring monitoring warning systemwarning system ((““moneremonere””: : ““to warnto warn””))

For example, applicable for heart rateheart rate continuous monitoring

• Detection of sudden tachycardia, bradycardia or arrhythmias

•• Useful inUseful in stable patients stable patients butbut at risks of instability at risks of instability (operating room)(operating room)

•• The concept has evolved over timeThe concept has evolved over time considerable technologic development

availability of various invasiveinvasive and non invasivenon invasive hemodynamiccontinuouscontinuous or non continuousnon continuous monitoring systems

availability of numerous hemodynamic variables

• in relation to:

-- volume depletion or volume depletion or maldistributionmaldistribution

-- decreased vascular tonedecreased vascular tone

• often in association with acute lung injuryacute lung injury

• and that can result in peripheral peripheral hypoperfusionhypoperfusion and organ dysfunctionorgan dysfunction

22-- Because the patients areBecause the patients are hemodynamicallyhemodynamically unstableunstable

-- cardiac dysfunction or failurecardiac dysfunction or failure

Why to use Why to use hemodynamichemodynamic monitoring? monitoring?

11-- Because the patients areBecause the patients are at risks of at risks of hemodynamichemodynamic instabilityinstability

22-- Because the patients are Because the patients are hemodynamicallyhemodynamically unstableunstable

Why to use Why to use hemodynamichemodynamic monitoring? monitoring?

11-- Because the patients are at risks of Because the patients are at risks of hemodynamichemodynamic instabilityinstability

44-- Because weBecause we need:need:

-- toto identifyidentify cardiovascular disease patterns,cardiovascular disease patterns,

-- toto understandunderstand pathophysiogicalpathophysiogical processes,processes,

-- toto assessassess thethe degreedegree ofof eacheach hemodynamichemodynamic disorderdisorder

for for choosingchoosing thethe bestbest therapytherapy Fluids Fluids VasopressorsVasopressors InotropesInotropes

-- toto titrate titrate these therapiesthese therapies

33-- Because clinical assessment is insufficient Because clinical assessment is insufficient to adequately evaluate to adequately evaluate the the hemodynamichemodynamic statusstatus of ICU patientsof ICU patients

•• continuouscontinuous andand realreal--timetime display display ofof relevant relevant variablesvariables

•• or or repeatablerepeatable measurementsmeasurements atat frequentfrequent intervalsintervals

•• non invasivenon invasive

•• easyeasy to to learnlearn

•• easyeasy to useto use

•• non non operatoroperator--dependentdependent

•• nonnon expansiveexpansive

•• positive impact on positive impact on outcomeoutcome

thethe idealideal hemodynamichemodynamic monitoring monitoring tooltool…….. .. doesdoes notnot yetyet existexist

WhatWhatshould be?should be?

PiCCOPiCCO™™ monitormonitor

SystemicSystemic ArteryArtery CatheterCatheter

invasive

less invasive

Echocardiography

Esophageal Doppler

non invasive

MethodsMethods currentlycurrently availableavailable to to assessassess hemodynamichemodynamic statusstatus in ICU patients in ICU patients

VigileoVigileo™™ monitormonitor

Central Central VenousVenous CatheterCatheter

LiDCOLiDCO™™ monitormonitor

Basic Basic monitoringmonitoring

Intermediate Intermediate monitoringmonitoring

CVP and ScvOCVP and ScvO22

AP and PPVAP and PPV

RealReal--time CO and SVV time CO and SVV monitoringmonitoring

aortic blood flowaortic blood flow

intermittent intermittent but but easilyeasily repeatable repeatable measurements of measurements of numerousnumerous cardiac cardiac function function variablesvariables

RealReal--timetime CO, PPV, SVV CO, PPV, SVV and and ScVOScVO22 monitoringmonitoring

++IntermittentIntermittent measurements ofmeasurements of

GEDV, CFI GEDV, CFI and and EVLWEVLW

GEDV :GEDV :

measuremeasure of of cardiaccardiac preloadpreload

-2

2

6

10

14

Changes in COChanges in GEDV

% **

fluidfluid loadingloading dobutaminedobutamine

**

**

GEDV behaves as a marker of preload

Chest 2003; 124:1900-1908

CFI:CFI:

Index ofIndex of

cardiaccardiac systolicsystolic functionfunction

44

CFICFI

prediction of LV FAC < 40 %prediction of LV FAC < 40 %

0

20

40

60

80

100

0 20 40 60 80 100100 - specificity

Sens

itivi

ty3.5 min-1

CFI for detectingLVEF ≤ 35%

Cardiac function index provided by transpulmonary thermodilutionbehaves as an indicator of left ventricular contractility.Jabot J, Monnet X, Lamia B, Chemla D, Richard C, Teboul JL

Crit Care Med 2009 (in press)

-40

-20

20

40

60

80

100

120

-40 -20 20 40 60 80 100 120

% c

hang

e in

LV

EF

% change in CFI

Changes induced by- fluid infusion- dobutamine

r = 0.79r = 0.79



-15

-5

5

15

25

35

45

55

Volume expansionVolume expansion DobutamineDobutamine

*

% changes in CFI

CFI CFI behavesbehaves as a marker of as a marker of systolicsystolic functionfunction



EVLW:EVLW:

Index ofIndex of

pulmonarypulmonary edemaedema

PulmonaryPulmonary ArteryArtery CatheterCatheter

PiCCOPiCCO™™ monitormonitor

SystemicSystemic ArteryArtery CatheterCatheter

invasive

less invasive

Echocardiography

Esophageal Doppler

non invasive

MethodsMethods currentlycurrently availableavailable to to assessassess hemodynamichemodynamic statusstatus in ICU patients in ICU patients

VigileoVigileo™™ monitormonitor

Central Central VenousVenous CatheterCatheter

LiDCOLiDCO™™ monitormonitor

Basic Basic monitoringmonitoring

Intermediate Intermediate monitoringmonitoring

Advanced Advanced monitoringmonitoring

Continuous Continuous CO and SvOCO and SvO22

monitoringmonitoring+

IntermittentIntermittent measurements measurements PAOP, RAP and PAPPAOP, RAP and PAP

RealReal--timetime CO, PPV CO, PPV andand SVV SVV monitoringmonitoring

++IntermittentIntermittent measurements ofmeasurements of

GEDV, CFI GEDV, CFI and and EVLWEVLW

Continuous Continuous oror intermittent intermittent hemodynamichemodynamic assessment? assessment?

It depends on the clinical situationclinical situationand on the questionquestion you are asking

• for managing high risk patientshigh risk patients in the OROR, continuouscontinuous monitoring of CO CO is probably important.

In most OR patients, a sudden fall in CO witnesses a sudden volume depletion.

Coupling continuous monitoring of COmonitoring of CO and of pulse pressure variationpulse pressure variation (PPV) or of stroke volume variationstroke volume variation (SVV) is helpful since the meaning of such indicesis straightforward in this setting.

120 mmHg

40

ArterialArterial PressurePressure

PPPPmaxmax

PPPPminmin

PPPPmaxmax -- PPPPminmin

((PPPPmaxmax ++ PPPPminmin) /2) /2PPV =PPV =

A B Ventricular preload

Stroke volume

Sens

itivi

tySe

nsiti

vity

PPVPPV

SPVSPV

RAPRAP

PAOPPAOP

1 1 -- SpecificitySpecificity

Am J Am J RespirRespir CritCrit Care Med 2000; 162:134Care Med 2000; 162:134--88

Chest 2004, 126:1563-1568

Chest 2005;128;848-854

Crit Care Med 2005;33:2534-9

PPVPPV

M. Cannesson, J. Slieker, O. Desebbe, F. Fahdi,O. Bastien, JJ. Lehot

StrokeStroke Volume Variation Volume Variation

SV maxSV max

SV minSV min

SV SV meanmean

SV max + SV minSV max + SV min

22SVV =SVV =

0 0.5 10 0.5 1

11-- specificityspecificity

sens

itivi

tyse

nsiti

vity

SVVSVV

CVPCVP

00

0.60.6

0.40.4

11

0.80.8

0.20.2

10 %10 % sensitivitysensitivity = 79 %= 79 %

specificityspecificity = 93 %= 93 %

SVV

SV

V b

asel

ine

base

line (

%)

(%)

CardiacCardiac Output changes Output changes afterafter fluidfluid infusion infusion (%)(%)

r = 0.74r = 0.74

Chest 2005;128;848-854

CutCut--offoff valuesvaluesPPVPPV : 13.5 %: 13.5 %SVV: 12.5 %SVV: 12.5 %

SVVSVVPPVPPV

CVPCVP

PAOPPAOP

GEDVGEDV

LVEDALVEDA

SVVSVV

PVVPVV

PAOPPAOP

CVPCVP



• for managing severe septic ptssevere septic pts in the ERER, SvOSvO22 monitoringmonitoring is probably important(in addition to conventional hemodynamic parameters) (see Rivers’ study)

SvOSvO22 > 70%> 70% considered as a targettarget for hemodynamic therapy

At this early stage, a more sophisticated monitoring device is rarely mandatory

• for managing high risk patients in the OR, continuous monitoring of CO/PPV is probably important.



• for managing severe septic pts in the ER, SvO2 monitoring is probably important

• for managing complex septic shock patients in the ICU, SvOSvO22 monitoringmonitoring alone is probably insufficient (see Gatinnoni’s study)but repeatablerepeatable (even intermittent) measurements of pertinentpertinent hemodynamicvariables are important

- to diagnosediagnose the cardiovascular disorders - to perform testsperform tests aimed at unmasking CV characteristics-- to choose and titratechoose and titrate therapies

ex: passive leg raisingpassive leg raising for detecting preload responsiveness


VenousVenous bloodblood shiftshift

IncreaseIncrease in in leftleft ventricularventricular preloadpreload (Rocha 1987, De Hert 1999)

IncreaseIncrease in right in right ventricularventricular preloadpreload (Thomas 1965) ReversibleReversible andandtransienttransient effectseffects

PLR PLR couldcould bebe usedused as a test as a test

to to detectdetect fluidfluid responsivenessresponsiveness

ratherrather thanthan as a as a therapytherapy

«« ContinuousContinuous »» thermodilutionthermodilution COCO monitoringmonitoring cannotcannot bebe usedused

for a PLR test because for a PLR test because thethe timetime--responseresponse isis tootoo longlong

The hemodynamic response to PLR can predict the hemodynamic response to volume infusion

RealReal--timetime CO monitoringCO monitoring isis mandatorymandatory

RealReal--timetime responseresponse ofofaorticaortic bloodblood flowflow

RealReal--timetime responseresponse ofofPulse contour COPulse contour CO RealReal--timetime responseresponse ofof

VTIVTI

The hemodynamic response to PLR can predict the hemodynamic response to volume infusion

RealReal--timetime CO monitoringCO monitoring isis mandatorymandatory

0

20

40

60

80

100

0 20 40 60 80 100

100 - specific ity

sens

itivity

Effects of passive leg rais ing on pulse pressure

A UC 0.675 [0.497-0.829]

0

20

40

60

80

100

0 20 40 60 80 100

100 - specific ity

sens

itivity


0

20

40

60

80

100

0 20 40 60 80 100

100 - specific ity

sens

itivity


A UC 0.675 [0.497-0.829]AUC: 0.675AUC: 0.675 [0.497-0.829]

PredictionPrediction of volume of volume responsivenessresponsivenessby the by the responseresponse of of Pulse PressurePulse Pressure

to PLRto PLR

100 - specificity

Effects of passive leg raising Effects of passive leg raising on Pulse contour COon Pulse contour CO

RR-10

0

10

20

30

40

50

60

70

80

90

NR

%

-10

0

10

20

30

40

50

60

70

80

90

-10

0

10

20

30

40

50

60

70

80

90

NR

%



• for managing severe septic pts in the ER, SvO2 monitoring is probably important

• for managing septic shock patients, repeatablerepeatable (even intermittent) measurements of pertinentpertinent hemodynamic variables are important

- to diagnosediagnose the cardiovascular disorders - to perform testsperform tests aimed at unmasking CV characteristics-- to choose and titratechoose and titrate therapies


ex: septic patients with ALI/ARDS

Therapeutic conflictTherapeutic conflict

On the one hand, septic patients are likely to be hypovolemic….. and thus should need fluid.

On the other hand, in ALI/ARDS patients, who suffer from high permeability pulmonary edema, a “dry” therapeutic attitude is recommended.

septic patients with ALI/ARDS

Benefit/risk ratio ?Benefit/risk ratio ?

Predictors of fluid responsiveness (PPV, SVV, passive leg raising)are needed.

Quantitative indicators of pulmonary edema and of increased lung permeability are needed.

Central venous catheter

Thermodilution

femoral artery

catheter

EVLW a quantitative marker of lung edema

PVPI (EVLW/ PBV) a quantitative marker of pulmonary vascular permeability

Se = 85 %Se = 85 %SpSp = 100 %= 100 %

cutcut--offoffvaluevalue

= 3= 3

SVV/SVV/PPVPPVPVPIPVPICOCOEVLWEVLW

To give fluidTo give fluid

decisiondecision To continue fluidTo continue fluid

To stop fluidTo stop fluid

SVV and PPVSVV and PPV for predicting volume responsiveness

PVPI PVPI for anticipating the degree of lung fluid filtration

EVLWEVLW for judging lung tolerance to fluid infusion

CO CO for evaluating the actual response to fluid once infused

Usefulness of the Usefulness of the PiCCOPiCCO devicedevice

for guiding fluid resuscitation/restriction for guiding fluid resuscitation/restriction especially in patients with ALI/ARDS and circulatory shockALI/ARDS and circulatory shock

HRHR: 125125 beats/min

BPBP: 80 / 3580 / 35 mmHg

PPVPPV: 2323 %

A 30 yrs old patient admitted for self-poisoning who developed severe ARDS at D2and presented an acute episode of septic shock (nosocomial infection) at D7.The patient received rapidly 2 L of saline2 L of saline, norepinephrinenorepinephrine (NE) at increasing doses and hemisuccinatehemisuccinate of hydrocortisoneof hydrocortisone.

Urine flow remained low. P/FP/F was 1191193 µg/kg/min NE

An arterial line was set up


BPBP: 80 / 3580 / 35 mmHg

PPVPPV: 2323 %



An arterial line was set up Which Which hemodynamichemodynamic therapy therapy do you propose?do you propose?

A- Nothing else

B- Infuse again fluid first and then reevaluate

C- Increase vascular tone first and then reevaluate

D- Give dobutamine first and then reevaluate

E- More information is needed before taking a decision

Because of hypoxemic increased permeability lung edema,

infusing more fluid can killkill the patient



A PiCCOPiCCO monitoring system was set up to to knowknow EVLW EVLW andand PVPIPVPI


APAP: 80 / 3580 / 35 mmHg

PPVPPV:: 2323 %

CardiacCardiac IndexIndex: 3.853.85 L/min/m2

SVISVI: 3131 mL/m2

GEDViGEDVi:: 550550 mL/m2 (N: 650-850)

EVLWEVLW: 2121 mL/kg (N < 10)

PVPI:PVPI: 6.36.3

Which Which hemodynamichemodynamic therapy therapy do you propose?do you propose?

AA-- NothingNothing elseelse

BB-- Infuse Infuse againagain fluidfluid first first andand thenthen reevaluatereevaluate

CC-- IncreaseIncrease vascularvascular tonetone first and first and thenthen reevaluatereevaluate

DD-- GiveGive dobutaminedobutamine first and first and thenthen reevaluatereevaluate

EE-- More information More information isis neededneeded

Conclusion Conclusion

• for managing severe septicsevere septic pts in the ERER, SvOSvO22 monitoringmonitoring is probably important

• for managing septic shockseptic shock patients in the ICU, repeatablerepeatable measurements of pertinentpertinent hemodynamic variables are more important.

In the frequent case of combination of shockshock and lung injurylung injury, advanced monitoring device (like PICCO) can be helpful (PPV/SVV, CO, PVPI, EVLW)(PPV/SVV, CO, PVPI, EVLW).

--

• for managing high riskhigh risk patients in the OROR, continuouscontinuous monitoring of CO CO and PPVPPV (SVV) is probably important.

Hemodynamic monitoring: one size does not fit all

ThankThank youyou for for youryour attentionattention

hemodynamic monitoring does one size fit all? - pulsion.com filefor example, applicable for heart...

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