methods of advanced hemodynamic monitoring

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Less invasive methods of advanced hemodynamic monitoring:

Less invasive methods of advanced hemodynamic monitoring DR GHALEB ALMEKHLAFI CONSULTANT CCM PSMMC 1

Introduction:

Introduction Hemodynamics is concerned with the forces generated in the cardiovascular system 2

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1-Intravascular volume 2-Myocardial contraction 3- heart rate 3-Vasoactivity 4 factors that affecting the hemodynamic conditions C.O.= HR x Stroke Volume (60-130 Ml/beat ) Stroke Volume has three components 1. Preload 2. Afterload 3.Contractility 3

Hemodynamic Monitoring Truth:

Hemodynamic Monitoring Truth No monitoring device will improve outcome, Unless coupled to a treatment , which improves outcome. Pinsky & Payen . Functional Hemodynamic Monitoring, Springer, 2004 4

Classic Hemodynamic Monitoring methods:

Classic Hemodynamic Monitoring methods Noninvasive Hemodynamic Monitoring methods : Pulse Rate and quality Blood Pressure Skin temperature/color Capillary Refill Pulse oximeter Mentation UOP-Normal is 1ml/kg/h Invasive and less invasive Hemodynamic Monitoring methods : PAC-CO CVL-CVP ARTERIAL CATHETER- I BP 5

Advanced hemodynamic assessment methods:

Advanced hemodynamic assessment methods COMMON TECHNEQUES Pulse contour analysis and transpulmonary dilution techneques Electrical bioimpedance/ bioreactance esophageal Doppler Echocardiogram Partial carbon dioxide rebreathing :NICO others 6

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PULSE WAVE-CONTOUR:

PULSE WAVE-CONTOUR Detected by the use of an arterially placed catheter with a pressure transducer, which can measure pressure tracings on a beat-to-beat basis 8

CO MEASURMENT BY PCA:

CO MEASURMENT BY PCA 9

Factors affecting accuracy of PCA:

Factors affecting accuracy of PCA arterial pressure waveform are affected by vascular compliance, aortic impedance Peripheral arterial resistance. Technical factors(i.e. eliminating damping or increased tubing resonance , zeroing) severe arrhythmias the use of an intra-aortic balloon pump precludes adequate performance of the devices. periods of hemodynamic instability, i.e., rapid changes in vascular resistance. Is a problem for uncalibrated pulse pressure analysis. So frequent re-calibration for accurate cardiac output estimation in these situations is mandatory 10

CALIBRATION FOR PCA:

CALIBRATION FOR PCA Because vascular impedance varies between patients, it had to be measured using another modality to initially calibrate the PCA system The calibration method is transpulmonary thermodilution for PiCCO (need cvp and a-line) and VolumeViewTM The LiDCO plus: requires calibration using the transpulmonary lithium indicator dilution technique , which can be performed via a peripheral venous line(need a-line) FLOTRAC/VIGILEO doesn't need calibration because it estimate cardiac output by the standard deviation of pulse pressure sampled during a time window of 20 seconds 11

PCA/TPD:

PCA/TPD Advantages Almost continuous data of CO / SV / SV variation Provide information of preload and EVLW Provide many other parameters which has potential clinical utilities Disadvantages STILL invasive but less than PAC arterial pulse signal is affected by many factors Arrhythmia Damping Use of IABP Need calibration 12

Transpulmonary thermodilution-PICCO and Edward / Volume ViewTM :

Transpulmonary thermodilution-PICCO and Edward / Volume ViewTM . 13

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T b injection t Transpulmonary thermodilution : 1-Cardiac Output estimation/ calibration T b = Blood temperature T i = Injectate temperature V i = Injectate volume ∫ ∆ T b . dt = Area under the thermodilution curve K = Correction constant, made up of specific weight and specific heat of blood and injectate CO Calculation:  Area under the Thermodilution Curve After central venous injection of the indicator, the thermistor at the tip of the arterial catheter measures the downstream temperature changes. Cardiac output is calculated by analysis of the thermodilution curve using a modified Stewart-Hamilton algorithm : 14

LiDCO:

LiDCO LiCl : 0.002mmol/l injected into central vein (peripheral administration possible as well) Arterial plasma conc. measured by withdrawing blood across lithium selective electrode at 4ml/min CO calculated from Li dose and area under primary concentration-time curve before re-circulation PCV is packed cell volume which may be calculated as hemoglobin concentration (g/dl) / 34 Cardiac Output = (Lithium Dose x 60)/(Area x (1-PCV)) 15

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Advanced Thermodilution Curve Analysis Transpulmonary thermodilution: 2-Volumetric parameters derivation Mtt : Mean Transit time time when half of the indicator has passed the point of detection in the artery DSt: Down Slope time exponential downslope time of the thermodilution curve For the calculations of volumes… ln Tb injection recirculation MTt t e -1 DSt Tb …are important. …and… All volumetric parameters are obtained by advanced analysis of the thermodilution curve: ITTV =CO X MTt PTV =CO X DSt 16

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RAEDV Thermodilution curve measured with arterial catheter CV Bolus Injection LAEDV LVEDV RVEDV Right Heart Left Heart Lungs After injection, the indicator passes the following Intrathoracic compartments: The intrathoracic compartments can be considered as a series of “mixing chambers” for the distribution of the injected indicator ( intrathoracic thermal volume ). ITTV PTV The largest mixing chamber in this series are the lungs, here the indicator (cold) has its largest distribution volume (largest thermal volume). Transpulmonary thermodilution: Volumetric parameters calculation 17

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ITTV = CO * MTt PTV = CO * DSt ITBV = 1.25 * GEDV EVLW* = ITTV - ITBV GEDV = ITTV - PTV RAEDV RVEDV LAEDV LVEDV RAEDV RVEDV LAEDV LVEDV PBV RAEDV RVEDV LAEDV LVEDV PTV PTV EVLW* EVLW* Calculation of thermal volumes 18

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Index of Left Ventricular Contractility* t [s] P [mm Hg] dPmx * = dP / dtmax of arterial pressure c urve dPmx * represents left ventricular pressure velocity increase and thus is a parameter of myocardial contractility

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Thermodilution Parameters Cardiac Output CO Global End-Diastolic Volume GEDV Intrathoracic Blood Volume ITBV Extravascular Lung Water EVLW* Pulmonary Vascular Permeability Index PVPI* Cardiac Function Index CFI Global Ejection Fraction GEF The PiCCO measures the following parameters: Pulse Contour Parameters Pulse Contour Cardiac Output PCCO Arterial Blood Pressure AP Heart Rate HR Stroke Volume SV Stroke Volume Variation SVV Pulse Pressure Variation PPV Systemic Vascular Resistance SVR Index of Left Ventricular Contractility dPmx * Parameters measured with the PiCCO -Technology

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Normal ranges PARAMETER RANGE UNIT CI 3.0 – 5.0 l/min/m 2 SVI 40 – 60 ml/m2 GEDI 680 – 800 ml/m 2 ITBI 850 – 1000 ml/m 2 ELWI* 3.0 – 7.0 ml/kg PVPI* 1.0 – 3.0 SVV  10 % PPV  10 % GEF 25 – 35 % CFI 4.5 – 6.5 1/min MAP 70 – 90 mmHg SVRI 1700 – 2400 dyn*s*cm-5*m 21

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What is the current situation?.………..……..…………. Cardiac Output! What is the preload?.……………….....… Global End-Diastolic Volume! Will volume increase CO? ....………...……….Stroke Volume Variation! What is the afterload?……………..….. Systemic Vascular Resistance! Are the lungs still dry?...…….……...…..…. Extravascular Lung Water !* What about the contractility?........................ dPmx * LV pressure velocity Clinical application 22

PowerPoint Presentation:

Decision tree for hemodynamic / volumetric monitoring CI (l/min/m 2 ) GEDI (ml/m 2 ) or ITBI (ml/m 2 ) ELWI* (ml/kg) (slowly responding) >3.0 <3.0 >700 >850 <700 <850 >700 >850 <700 <850 ELWI* (ml/kg) GEDI (ml/m 2 ) or ITBI (ml/m 2 ) CFI (1/min) or GEF (%) <10 >10 <10 <10 <10 >10 >10 >10 V+ V+! V+! V+ Cat Cat OK! V- >700 >850 700-800 850-1000 >4.5 >25 >5.5 >30 >4.5 >25 700-800 850-1000 Cat >5.5 >30 >700 >850 700-800 850-1000 700-800 850-1000  10  10  10  10 V- V + = volume loading (! = cautiously) V - = volume contraction Cat = catecholamine / cardiovascular agents ** SVV only applicable in ventilated patients without cardiac arrhythmia >700 >850 <10 Optimise to SVV** (%) <10 <10 <10 R E S U L T S T A R G E T T H E R A P Y 1. 2. <10 <10 <10 <10 23

A protocol for resuscitation of severe burn patients guided by transpulmonary thermodilution and lactate levels:

A protocol for resuscitation of severe burn patients guided by transpulmonary thermodilution and lactate levels A decision tree for the adjustment of fluid and catecholamine therapy according to a permissive hypovolemia protocol with lower preload targets and lactate measurements to ensure tissue perfusion is shown Sánchez et al. Critical Care 2013, 17:R176

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In conclusion:

In conclusion Hemodynamic monitoring enable early detection of change in patient’s conditions New techniques provide reasonably good results and less invasive Always correlate the readings / findings with clinical pictures in order to provide the best treatment options 26

HEMODYNAMIC MONITORING COURSE AND WORKSHOP:

HEMODYNAMIC MONITORING COURSE AND WORKSHOP One-day course 7 lectures 4-station workshop 8 CME hours On September 11/every 3 months In PSMMC rec. center 27

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