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PiCCO plus Standalone Monitor. PiCCO-Technology. PiCCO ... ...Simple – Safe – Speedy - Specific. Contents. What is the PiCCO-Technology?.................................................................................... - PowerPoint PPT PresentationTRANSCRIPT
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PiCCO ...
...Simple – Safe – Speedy - Specific
PiCCO-Technology
PiCCO plus Standalone Monitor
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Contents
1. What is the PiCCO-
Technology?....................................................................................
2. What are the advantages of the PiCCO-
Technology?....................................................
3. How does the PiCCO-Technology work?.......................................................................
4. How to use the PiCCO-Technology?.............................................................................
5. Which disposables do I need for the PiCCO-Technology?............................................
6. References……………………………………………………………………………………..
7. Where can I get what I
need?..........................................................................................
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6
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1. What is the PiCCO-Technology?
The PiCCO Technology is a combination of 2 techniques for advanced hemodynamic and volumetric management without the necessity of a pulmonary artery catheter in most patients:
a. Transpulmonary thermodilution b. Arterial pulse contour analysis
t
-∆T
t
-∆T
see also page 8 see also page 16
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2. What are the advantages of the PiCCO-Technology?
Thermodilution Parameters• Cardiac Output CO• Global Enddiastolic Volume GEDV• Intrathoracic Blood Volume ITBV• Extravascular Lung Water EVLW*
Pulse Contour Parameters• Pulse Continuous Cardiac Output PCCO• Systemic Vascular Resistance SVR• Stroke Volume Variation SVV
* not available in USA
The PiCCO measures the following main parameters:
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2. What are the advantages of the PiCCO-Technology?
Less Invasiveness - Only central venous and arterial access required- No pulmonary artery catheter required- Applicable also in small children
Short Set-up Time - Can be installed within minutes
Dynamic, Continuous Measurement - Cardiac Output, Afterload and Volume Responsiveness are measured beat-by-beat
No Chest X-ray - To confirm correct catheter position no x-ray is necessary
Cost Effective - Less expensive than pulmonary artery catheter technique - Arterial PiCCO catheter can be in place for 10 days or more
- Potential to reduce ICU stay and costs
More Specific Parameters - PiCCO parameters are easy to use and interpret even for less experienced clinical staff
Extravascular Lung Water* - Lung edema can be excluded or quantified at the bed-side* not available in USA
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3. How does the PiCCO-Technology work?
Most of hemodynamic unstable and/or severely hypoxemic patients are instrumented with:
The PiCCO-Technology uses any standard CV-line and a thermistor-tipped arterial PiCCO-catheter instead of the standard arterial line.
Central venous line (e.g. for vasoactive agents administration…)
Arterial line (accurate monitoring of arterial pressure, blood samples…)
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Central venous line (CV)
Thermodilution catheter with lumen for arterial pressure measurement
• Axillary (A)• Brachial (B)• Femoral (F)• Radial (R), long catheter
Arterial pressure transducer
Configuration
CV
A
B
F
R
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a. Transpulmonary Thermodilution
Transpulmonary thermodilution measurement simply requires the central venous injection of a cold (< 8°C) or room-tempered (< 24°C) saline bolus…
CV Bolus Injection
Right Heart
Lungs
Left Heart
PiCCO Catheter e.g. in femoral artery
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PiCCO Thermodilution Cardiac Output
After central venous injection of the indicator, the thermistor in the tip of the arterial catheter measures the downstream temperature changes
The cardiac output is calculated by analysis of the thermodilution curve using a modified Stewart-Hamilton algorithm:
Injection
t
-Tb
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Global Enddiastolic Volume GEDVIntrathoracic Blood Volume ITBVExtravascular Lung Water EVLW*
ln Tb
injection
At
recirculation
MTt t
e -1
DSt
Tb
* not available in USA
PiCCO Volumetric Parameters
These volumetric parameters are obtained by advanced analysis of the thermodilution curve. (Detailed information and formulas available on request.)
Advanced Thermodilution Curve Analysis
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Global Enddiastolic Volume
Global Enddiastolic Volume (GEDV) is the volume of blood contained in the 4 chambers of the heart.
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Intrathoracic Blood Volume
Intrathoracic Blood Volume (ITBV) is the volume of the 4 chambers of the heart + the blood volume in the pulmonary vessels.
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Extravascular Lung Water*
Extravascular Lung Water (EVLW)* is the amount of water content in the lungs. It allows bedside quantification of the degree of pulmonary edema.
* not available in USA
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Intrathoracic Blood Volume, ITBV and Global Enddiastolic Volume, GEDV have shown to be far more sensitive and specific to cardiac preload than the standard cardiac filling pressures CVP + PCWP but also than right ventricular enddiastolic volume. 2,3,5,6,8,9,12,13,22
The striking advantage of ITBV and GEDV is that they are not wrongly influenced by mechanical ventilation and give correct information on the preload status under any condition. 2,3,6,7,8,9,12,13, 22
PiCCO Preload Indicators
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Extravascular Lung Water, EVLW* assessment by transpulmonary thermodilution has been validated against dye dilution and the reference gravimetric method.11,16,21,23
Extravascular Lung Water*
* not available in USA
Extravascular Lung Water, EVLW* has shown to have a clear correlation to severity of ARDS, length of ventilation days, ICU-Stay and Mortality and to be superior toassessment of lung edema by chest x-ray.7,8,15,20,23,24
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Arterial pulse contour analysis provides continuous beat-by-beat parameters obtained from the shape of the arterial pressure wave.The algorithm is capable of computing each single stroke volume (SV) after being calibrated by an initial transpulmonary thermodilution.
b. Arterial Pulse Contour Analysis
t
-∆T
t
-∆T
Calibration
t [s]
P [mm Hg] SV
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CO is calculated as stroke volume x heart rate
Cardiac Output and Systemic Vascular Resistances
As pulse contour analysis continuously measures stroke volume and arterial pressure, cardiac output (CO) and systemic vascular resistance (SVR) are computed as follows:
SVR is calculated as (mean arterial pressure - central venous pressure) / CO
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SVV reflects the sensitivity of the heart to the cyclic changes in cardiac preload induced by mechanical ventilation.1,14,17,18,19
SVV can predict whether stroke volume will increase with volume expansion.1,14,17,18,19
Stroke Volume Variation (SVV)
In mechanically ventilated patients without arrhythmia,
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1. Connect the injectate-temperature sensor housing to the CV line already in place.
2. Insert a PiCCO arterial thermistor catheter into a large artery, preferable femoral artery, but also brachial / axillary artery and radial artery (with long catheter).
3. Connect the injectate sensor, the arterial catheter’s thermistor and pressure line to your PiCCO monitor.
4. For blood pressure transfer to any bedside monitoring system, connect the cable at the back side of the PiCCO monitor.
5. Now the system is ready to work.
6. For information how to handle your PiCCO monitor, please refer to your accompanying PiCCO Operator’s Manual.
4. How to use the PiCCO-Technology?
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How to manage my patient with the PiCCO-Technology?
Management of a patients hemodynamic situation is easily possible by following the therapeutic guideline shown below.+
It was developed out of daily clinical practice, has shown to be successful in over a hundred thousand patients and refers to below listed normal values of indices:
Cardiac Index CI 3.0 – 5.0 l/min/m2
Global Enddiastolic Blood Volume Index GEDI 680 – 800 ml/m2
Intrathoracic Blood Volume Index ITBI 850 – 1000 ml/m2
Stroke Volume Variation SVV 10 %Extravascular Lung Water Index* ELWI* 3.0 – 7.0 ml/kg
* not available in USA+without guarantee
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Decision tree for hemodynamic / volumetric monitoring**
*not available in USA**without guarantee
*
+
+
CI (l/min/m2)
GEDI (ml/m2 )or ITBI (ml/m2 )
ELWI (ml/kg)(slowly responding)
>3.0<3.0
>700>850
<700<850
>700>850
<700<850
ELWI (ml/kg)
GEDI (ml/m2)or ITBI (ml/m2)
CFI (1/min)or GEF (%)
<10 >10 <10 <10 <10>10 >10 >10
V+ V+! V+!V+Cat Cat
OK!
V-
>700>850
700-800850-1000
>4.5>25
>5.5>30
>4.5>25
700-800850- 1000
Cat
>5.5>30
>700>850
700-800850-1000
700-800850- 1000
10 10 10 10
V-
V+= volume loading (! = cautiously) V- = volume contraction Cat = catecholamine / cardiovascular agentsSVV only applicable in ventilated patients without cardiac arrhythmia
>700>850
<10Optimise to SVV (%) <10 <10 <10
RESULTS
TARGET
THERAPY
1.
2. <10 <10 <10 <10
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PULSIOCATH arterial thermodilution catheter
Injectate temperature sensor housing
Any standard central venous catheter
5. Which disposables do I need with the PiCCO-Technology?
• Specifically designed for less invasive volumetric, hemodynamic monitoring• To be placed with Seldinger Technique• Several sizes available for pediatric and adult patients• Can remain within the patient up to 10 days or longer
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PULSIOCATH arterial thermodilution catheters product range
Article number PV2013L07 PV2014L08 PV2014L16 PV2015L20 PV2014L50LGWA
Outer diameter 3F(~20G) / 0,9mm
4F(~18G) / 1,4mm
4F(~18G) / 1,4mm
5F(~16G) / 1,7mm
4F(~18G) / 1,4mm
Usable length 7cm 8cm 16cm 20cm 50cm
Common feature Latex free
The catheters are also available as complete kits (e.g. PVPK2015L20-46), including a disposable pressure transducer and the injectate temperature sensor housing. These kits can optionally be ordered with an additional pressure line for intermittent central venous pressure monitoring.Catheters have to be selected depending on patient size, weight and insertion site.
PULSIOCATH arterial thermodilution catheters are specifically designed for less invasive volumetric hemodynamic monitoring with the PiCCO Technology. The catheters are placed with Seldinger Technique. Several versions and sizes are available. They can remain within the patient up to 10 days or even longer.
Technical specifications are subject to change without further notice
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1. Berkenstadt H et al., Anesth Analg, 20012. Bindels A et al., Crit Care 4, 20003. Boussat S et al., Int Care Med 20024. Brock H et al., Eur J Anaesth 19 (4), 20025. Della Rocca G et al., Eur J Anaesth 19, 20026. Della Rocca G et al., Anesth Analg 95, 20027. Eisenberg PR et al., Am Rev Respir Dis 136 (3), 19878. Gödje O et al., Chest 118, 20009. Gödje O et al., Eur J of Cardio-thoracic Surgery 13, 199810. Haperlin et al., Chest, 198511. Katzenelson et al., SCCM 2001, San Diego12. Lichtwarck-Aschoff M et al., Journal of Critical Care 11 (4), 199613. Lichtwarck-Aschoff M et al., Intensive Care Med 18, 199214. Michard F et al., Yearbook of Intensive Care Med, 200215. Mitchell JP et al., Am Rev Respir Dis 145 (5), 199216. Neumann et al., Intensive Care Med 199917. Reuter DA et al., Crit Care Med, 200318. Reuter DA et al., Intensive Care Med, 200219. Reuter DA et al., Brit J Anaesth, 200220. Sakka SG et al., Chest 122, 200221. Sakka S et al., Intensive Care Med 200022. Sakka S et al., Journal of Critical Care 14 (2), 199923. Sturm JA, Practical Applications of Fiberoptics in Critical Care Monitoring,
199024. Takeda A et al., J Vet Med Sci 57, 1995
6. References
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7. Where can I get what I need?
For further information or ordering, please contact your local PULSION Office: PULSION Medical Systems AG
Stahlgruberring 28D- 81829 München
GermanyTel.: +49 (0)1805 PULSION
+49 (0)89 4599140Fax: +49 (0)89 45991418
PULSION Medical U.K., Ltd.P.O. Box 315Arundel Road
Uxbridge, MiddlesexGB- UB8 2US, England
Great BritainTel.: +44 (0) 1895 455255Fax: +44 (0) 1895 274035
PULSION France sarl6, Place Jeanne d´Arc
F- 13100 Aix en ProvenceFrance
Tél. : +33 (0)4 42 27 67 19Fax : +33 (0)4 42 27 44 90
PULSION Medical Systems Ibérica S.L.
Pol. Ind. Las Nieves, C/ Puerto Canencia 21
E- 28935 Móstoles, MadridSpain
Tel.: +34 91 665 73 12Fax: +34 91 616 94 27
Seda S.p.A.Via Tolstoi, 7/B
I- 20090 Trezzano sul Naviglio (MI)Italy
Tel.: +39 02 48424219Fax: +39 02 48424290
PULSION Benelux nv/saMaaltecenter, Blok G
Derbystraat 341B- 9051 Gent (SDW)
BelgiumTel. : +32 (0)9 242 99 10Fax : +32 (0)9 242 99 11
PULSION Pacific Pty. Ltd.P.O. Box 823
AUS- Randwick, NSW Australia, 2031
AustraliaTel.: +61 (0) 2 9340 5525Fax: +61 (0) 2 9340 5515
If your country is not listed above, please
contact
PULSION Germany
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The PiCCO-Technology is also available as a module for Philips IntelliVue / CMS patient monitoring systems.
For more information please refer to your local PULSION representative (page 25) or visit www.pulsion.com
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For further information, please visit
www.pulsion.com
There you will find also information on other revolutionary PULSION products:
LiMON - noninvasive bedside liver function monitor ICG-PULSION - indocyanine green dye for diagnostics VoLEF - PiCCO plus add-on monitor for cardiac sub-volumes and RVEF IC-VIEW - laser fluorescence makes tissue perfusion visible
@ PULSION 07/2003
MPI812205