pulse contour cardiac output

1. Philips IntelliVue Patient Monitoring
Pulse Contour Cardiac Output Measurement - PiCCO®
and Advanced Haemodynamic Monitoring
Application Note
For IntelliVue Patient Monitors
About this Document
This Application Note provides a basic overview of the application and clinical benefits of the PiCCO1
measurement available in the M1012A option #C10, M3012A option #C10, or M3014A option #C10. For a more
in depth understanding of this measurement, additional reading and reference material can be found on the
PULSION Medical Systems SE website, www.pulsion.com.
PiCCO is available on the supported IntelliVue patient monitors.
The Application Note covers,
• A list of abbreviations used in the document and their definitions
• An overview of the PiCCO method
• The normal ranges of the PiCCO measurement results
• The PiCCO decision model
• How the PiCCO technology is implemented in IntelliVue Patient Monitors
• Frequently asked application questions regarding PiCCO implemented in IntelliVue Patient Monitors
This document does not replace the Instructions for Use.
1.PiCCO is a trademark of PULSION Medical Systems SE
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2. 2
Abbreviations and Definitions
This table lists the abbreviations and definitions of the labels and units used in this Application Note.
1
Not available in the USA and territories relying on FDA market
clearance.
Label Units
ABP Arterial Blood Pressure
ARDS Adult Respiratory Distress Syndrome
At Appearance time (beginning of the injection to time
of detection)
BSA Body Surface Area
CCI Continuous Cardiac Index
CCO Continuous Cardiac Output
CFI Cardiac Function Index
C.I. Cardiac Index
C.O. Cardiac Output
COpa Pulmonary artery Cardiac Output
COa PiCCO Cardiac Output
CPI Cardiac Power Index
CVP Central-Venous Pressure
CV Central Vein
dPmax1 Left-ventricular contractility
DSt Down slope time (exponential downslope time of
the thermodilution curve)
e natural logarithm
EVLW Extravascular Lung Water
EVLWI Extravascular Lung Water Index
GEDV Global Enddiastolic Volume
GEDVI
or GEDI
Global Enddiastolic Volume Index
GEF1 Global Ejection Fraction
HR Heart Rate
IBW Ideal Body Weight
IBSA Ideal Body Surface Area
ICU Intensive Care Unit
Label Units
IMV Intermittent Mandatory Ventilation
ITBV Intrathoracic Blood Volume
ITBVI Intrathoracic Blood Volume Index
ITTV Intrathoracic Thermal Volume
MAP Mean Arterial Pressure
MTt Mean transit time (time when half of the indicator
has passed the point of detection in the artery)
PCWP Pulmonary Capillary Wedge Pressure
PiCCO Trade name for a technology for advanced
hemodynamic monitoring (PCCO = pulse contour
cardiac output)
PP Pulse Pressure
PPV Pulse Pressure Variation
PTV Pulmonary Thermal Volume
PVPI1 Pulmonary Vascular Permeability Index
SV Stroke Volume
SVI Stroke Volume Index
SVR Systemic Vascular Resistance
SVRI Systemic Vascular Resistance Index
SVV Stroke Volume Variation
T Temperature
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3. 3
The PiCCO Method
Introduction
The PiCCO method is a combination of the Transpulmonary
Thermodilution Technique and Arterial Pulse Contour Analysis that
provides advanced hemodynamic and volumetric management
information.
The majority of hemodynamically unstable and/or severely hypoxemic
patients have a central venous line (e.g. for fluid and drugs
administration), and an arterial line (for arterial pressure monitoring).
The PiCCO method utilizes the standard CV line in combination with
a special PiCCO Catheter that has a thermistor located at its tip, to
measure the following parameters:
Thermodilution Parameters
• Cardiac Index (C.I.)
• Global End-diastolic Volume Index (GEDVI)
• Intrathoracic Blood Volume Index (ITBVI)
• Cardiac Function Index (CFI)
• Global Ejection Fraction (GEF)2
• Extravascular Lung Water Index (EVLWI)
• Pulmonary Vascular Permeability Index (PVPI)2
Pulse Contour Parameters
• Continuous Cardiac Index (CCI)
• Systemic Vascular Resistance Index (SVRI)
• Stroke Volume Variation (SVV)
• Pulse Pressure Variation (PPV)
• Left Ventricular Contractility (dPmax)2
Transpulmonary Thermodilution
This discontinuous measurement requires the central venous
injection of a cold (<7ºC; recommended by Philips), or room
temperature (<24ºC) saline bolus.
After injection of the indicator via the CV catheter, the thermistor
located at the tip of the PiCCO catheter, measures the downstream
temperature changes. The cardiac output is then calculated by analysis
of the thermodilution curve using a Stewart-Hamilton algorithm.
Volumetric Parameters
The volumetric parameters are obtained by an advanced analysis of the
thermodilution curve.
The upper curve displays the thermodilution curve. The lower graphic
is a logarithmic illustration of the thermodilution curve which allows to
define the Mean Transit time (MTt) and the Down Slope time (DSt).
• LN C° logarithmic thermodilution curve
• e-1 natural logarithm
• At Appearance time (beginning of injection to time of
detection)
• DSt Down Slope time (exponential downslope time of the
thermodilution curve)
• MTt Mean Transit time (time when half of the indicator has
passed the point of detection in artery)
2.Not available in the USA and territories relying on FDA market clearance.
Lungs
Left Heart
PiCCO Catheter
Right Heart
CV Catheter
Injection
LN C°
At
MTt DSt
e-1
C°
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4. 4
Global Enddiastolic Volume
Global Enddiastolic Volume (GEDV) is the calculated volume of the
blood contained in the four chambers of the heart.
Intrathoracic Blood Volume
Intrathoracic Blood Volume (ITBV) is the volume of the four chambers
of the heart and the blood volume in the pulmonary blood vessels.
Both the GEDV and ITBV have been shown to be far more sensitive
and specific to cardiac preload than the standard cardiac filling
pressures routinely used (CVP, PCWP). The main advantage with
these measurements is that they are not influenced by mechanical
ventilation and therefore provide more accurate information on the
preload status of your patient.
Extra Vascular Lung Water
Extra Vascular Lung Water (EVLW) is the amount of water content in
the lungs. It allows for bedside quantification of the degree of
pulmonary edema. EVLW has been shown to have a clear correlation
to the severity of ARDS, length of ventilator days, ICU days and
mortality. For additional information, refer to www.pulsion.com.
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5. 5
Arterial Pulse Contour Analysis
The arterial pulse contour analysis provides continuous beat-to-beat
measurement that is obtained from the shape of the arterial pressure
waveform and averaged over 12 seconds.
CCI
Continuous Cardiac Index (CCI) is cardiac output related to the body
surface area. The value represents the general blood flow. Cardiac
index is the product of heart rate and stroke volume index. Stroke
volume is the ejection of blood per heart beat. Stroke volume depends
on the preload, afterload and contractility.
SVV and PPV
The algorithm used is able to compute each single Stroke Volume (SV),
after the initial transpulmonary thermodilution. The Stroke Volume
Variation (SVV) can be calculated.
It reflects the sensitivity of the heart to the cyclic changes in cardiac
preload induced by mechanical ventilation. SVV can predict whether
volume expansion would lead to the desired effect of increased stroke
volume. The pulse contour analysis provides SV and arterial pressure
continuously.
The Stroke Volume Variation (SVV), or Pulse Pressure Variation
(PPV)3
can be calculated over a 30 second time frame by the following
formula:
• SVV = (SVmax - SVmin)/SVmean
• PPV = (PPmax - PPmin)/PPmean
For proper use of the parameters, the following preconditions must be
fulfilled:
• Fully controlled mechanical ventilation with a tidal volume equal or
greater than 8 ml/kg IBW
• Sinus rhythm
• Pressure curves free of artifacts
3.On IntelliVue, in combination with the PiCCO measurement, the Pulsion PPV is
available.
P
t
SV max SV min
PP max PP min
PP mean
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6. 6
Normal Ranges
These normal ranges apply for adult patients only.
1 Not available in the USA and territories relying on FDA market clearance.
Stroke Volume Determinants
Preload
The volume of blood filling the heart during diastole. It is determined
by the ventricular filling volume at the end of the stroke.
Contractility
The force, velocity of contraction and shortening ability of the
ventricular wall muscle.
1
Not available in the USA and territories relying on FDA market clearance.
Afterload
The resistance which the contracting ventricles must overcome to
empty. This is primarily caused by the aortic diastolic pressure and the
systemic vascular resistance.
Label Normal Ranges Unit
MAP 70 - 90 mmHg
CVP 2 - 10 mmHg
HR 60 - 90 1/min
C.I. 3.0 - 5.0 l/min/m2
SVI 40 - 60 ml/m2
GEDVI 680 - 800 ml/m2
ITBVI 850 - 1000 ml/m2
SVV 0 - 10 %
PPV 0 - 10 %
SVRI 1700 - 2400 dyn2
sec2
cm-5
m2
GEF1 25 - 35 %
CFI 4.5 - 6.5 1/min
dPmax1 no normal range mmHg/s
EVLWI 3.0 - 7.0 ml/kg
PVPI1 no normal range
1 - 3 cardiogenic edema
>3 permeability edema
GEDVI Global Enddiasstolic Volume Index (volume of
blood in the heart)
ITBVI Intrathoracic Blood Volume Index (volume of
blood in heart and lungs)
SVV Stroke Volume Variation (dynamic fluid
responsiveness)
PPV Pulse Pressure Variation (dynamic fluid
responsiveness)
GEF1 Global Ejection Fraction (ratio of stroke volume
and preload)
dPmax1 Index of left ventricular contractility
CFI Cardiac Function Index (increase of arterial
pressure over time)
SVRI Systemic Vascular Resistance Index (resistance of
the vascular system)
MAP Mean Arterial Pressure
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7. 7
Decision Model
The PiCCO method represents an inexpensive, less invasive
technology for continuous quantification of cardiac output, its
determinants preload, afterload, and contractility as well as
extravascular lung water.
The CCO module requires a central venous and an arterial access.
The PiCCO method represents for many fields of application an
alternative to the pulmonary artery catheter and is also applicable in
children and infants.
The following table shows the decision model for advanced
hemodynamic management using PiCCO. All recommendations are
given without guarantee. This decision model is not obligatory. It
cannot replace the individual therapeutic decisions of the treating
physician.
• V+ volume loading
• V- volume reduction
• Cat catecholamine / cardiovascular agents
1
Not available in the USA and territories relying on FDA market clearance.
Measured Values
C.I. (l/min/m²) < 3.0
ScvO2 /Lactate /
Perfusion (MAP)?
> 3.0
   
GEDVI (GEDI) (ml/m²) < 700 > 700 < 700 > 700
or ITBI (ml/m²) < 850 > 850 < 850 > 850
       
ELWI (ml/kg) < 10 > 10 < 10 > 10 < 10 > 10 < 10 > 10
Therapy Options        
V+? V+?
Cat?
Cat? Cat?
V-?
V+? V+? OK? V-?
Targeted Values
GEDVI (GEDI) (ml/min2) > 700
(if ELWI > 10 => 700 - 800)
GEF1(%) > 25
CFI (1/min) > 5
ELWI (ml/kg) (slow response) ≤ 10
Clinical Questions
Volume Responsiveness?
(Passive Leg Raising / End expiratory Occlusion Test / Volume
Challenge / SVV / PPV?)
Contractility Problem?
(GEF1 / CFI / Echo?)
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8. 8
PiCCO Technology in IntelliVue Patient Monitors
Setting up the PiCCO Measurement
General Setup of the PiCCO Technology
The figure gives a setup overview of PiCCO in IntelliVue patient monitors.
PiCCO Catheter Choice and Application
The PiCCO catheter selection is dependent on patient category,
weight and insertion site.
All accessories needed for the PiCCO measurement can be purchased
directly through PULSION Medical Systems SE. Ask your Philips Sales
Representative for contact information.
injectate
sensor
housing*
PiCCO
arterial pressure
transducer*
indicator for
thermodilution
PiCCO Cardiac
Output cable
M1643A
central venous
catheter
PiCCO catheter
e.g. PV2015L20*
PiCCO pressure
connection cable
PMK-206*
pressurized flush bag
PiCCO
temperature
probe
M1646A
* Only available through PULSION SE
PiCCO MMS extension or module:
M3012A #C10
M1012A #C10
M3014A #C10
Application Blood Vessel Size
Adults Femoral Artery 5 F, 20 cm
Adults Brachial Artery (cubital) 4 F, 22 cm
Adults Brachial Artery (proximal) 4 F, 16 cm
Adults Axillary Artery 4 F, 8 cm
Children Femoral Artery 3 F, 7 cm
Adults Radial Artery 4 F, 50 cm
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9. 9
The following graphic shows the recommended PiCCO catheter
placement sites:
1 Not available in the USA and territories relying on FDA market
clearance.
For detailed instructions on the setup and use of PiCCO, refer to your
patient monitor Instructions for Use.
Entering Patient Data
Some of the values are calculated, using the Ideal Body Weight (IBW),
the Ideal Body Surface Area (IBSA), and the Body Surface Area (BSA).
To calculate these values, the algorithm needs to know the height, the
weight, the gender of the patient, and the Patient Category.
You can enter this data via the Enter Patient Demographics window, or
in the BSA menu.
Select the BSA label in the Cardiac Output window to open the BSA
menu.
As soon as you enter all data, the monitor calculates and uses these
values.
Zeroing the Pressure Transducers
Zero the transducer in accordance with your hospital policy. You must
perform a zero:
• When you use a new transducer or tubing
• Every time you reconnect the transducer cable to the monitor
• If you think the monitor's pressure readings are not correct
When using a pressure module, the zero information is stored in the
module. When a pressure module, with the transducer connected, is
plugged into the monitor, the monitor will use the zero stored in the
module.
Axillary Artery
PiCCO catheter 4 F, 8 cm
Brachial Artery
PiCCO catheter 4 F, 16 cm
PiCCO catheter 4 F, 22 cm
Femoral Artery
PiCCO catheter 5 F, 20 cm
PiCCO catheter 3 F, 7 cm
Radial Artery
PiCCO catheter 4 F, 50 cm1
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10. 10
Configuring CCO
The configuration settings of the CCO measurement depend on your
hospitals’s policy.
• To open the Setup C.O. menu, press the C.O. hardkey on the
measurement module, or alternatively select Main Setup >
Measurements > C.O.
Setting the Measurement Mode
• Select Measuring Mode to switch to Auto mode.
In this mode, up to six measurements can be performed (if required)
without pressing Start C.O. again.
Setting the Alarm Source and Alarm Limits
• To open the Setup CCO menu, select CCO.
• Select Alarms from > CCO (absolute values), or Alarms from > CCI
(indexed values).
• Set the high and low alarm limits for CCO, or for CCI.
• With CCO from, select the correct source for the CCO measurement.
The default source is ABP.
• To open the Cardiac Output (Transpulmonary) window, press the Start
key on the PiCCO measurement module, or alternatively the Cardiac
Output SmartKey.
Setting the Injectate Volume
• If needed, select InjVol to adjust the injectate volume. Use the
recommended amount, or enter an individual amount of injectate.
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11. 11
Performing Thermodilution Measurements
• Wait for the message Ready for new measurement to appear. To start a
series of measurements, select the Start C.O. pop-up key.
• In Measuring Mode > Auto, the monitor will guide you through the
procedure.
• In Measuring Mode > Standard, select Start C.O. for each measurement.
• When Stable baseline, inject now appears, perform a quick, smooth
bolus injection.
The thermodilution curve should overlap the upper dotted line. This
indicates a temperature change of more than 0.2°C. If the
thermodilution curve is below the dotted line, more and/or colder
injectate is required.
• Perform at least three initial measurements in succession.
If EVLWI is higher than 10ml/kg body weight, use iced injectate
(<8°C) for further measurements.
• Use the Select Trial pop-up key to select measurements which deviate
widely from the mean value. Select the Accept - Reject pop-up key to
exclude these measurements from the calculation.
• Measurements older than 15 minutes are not used in the current
calculation of CCO and are deleted automatically.
• In Measurement Mode > Auto, select the Stop C.O. pop-up key to
complete the set of measurements.
Saving and Calibrating CCO
• To save the thermodilution / calibration results, select the
SaveC.O.&Cal CCO pop-up key.
The saved values are now displayed on the screen with a timestamp
of the last thermodilution measurement.
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12. 12
Hemodynamic Calculations
Select the Hemo Calcs SmartKey to open the Hemodynamic Calculations
window,
If you measure CVP manually, select CVPm in this window. This opens
an on-screen keyboard. Enter the most current CVP mean value.
During continuous CVP measurement the value will be updated
automatically.
To calculate the values, select the Perform Calc pop-up key.
To display the measurement value ranges, select the On/Off Ranges
pop-up key. Values outside these ranges are highlighted.
To display the timestamp of measurement values, select the On/Off
DateTime pop-up key.
The Systemic Vascular Resistance (SVR) is a derived measurement. To
open the Setup SVR menu, select Main Setup > Measurements > SVR.
The Label setting is only available when the measurement is enabled.
Select SVRI (indexed SVR) to display SVRI on the screen. It is not
possible to display both values at a time.
Note: PVPI, GEF, and dPmax are not available in the USA and
territories relying on FDA market clearance.
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13. 13
Using the PiCCO Screen
Consider using the specific PiCCO Screen from the Screen Library. This screen displays the values in a customized layout for continuous cardiac
output measurements. The values are clinically arranged (see below):
Ask your Philips representative to add the PiCCO Screen to the list of
your Screens.
For more details regarding the application refer to the IntelliVue
Patient Monitor Instructions for Use.
Note: PVPI, GEF, and dPmax are not available in the USA and
territories relying on FDA market clearance.
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14. 14
Frequently Asked Application Questions
General Questions
Indication and Contraindication
What are the indications and contraindications for PiCCO?
Indications
Monitoring and recording of, and generating alarms for, continuous
cardiac output of adults, pediatrics, and neonates in a hospital
environment.
Contraindications
Arterial access restriction due to femoral artery grafting or severe
burns in areas where the arterial catheter would normally have
been placed. Note: Axillary artery can be used as alternative site.
PiCCO: Measurement or Calculation
Does PiCCO measure or calculate volumes?
The PiCCO technology calculates the volumes based on the
thermodilution curve using mean transit time and down slope time
multiplied with cardiac output.
PiCCO Versus PA Catheter Cardiac Output
Which cardiac output is more accurate, the one measured by
PiCCO method or the one measured by pulmonary artery
catheter?
Both methods are using the Stewart-Hamilton algorithm and
thermodilution. In terms of accuracy the two methods are very
comparable.
However, the PiCCO method has a much lower coefficient of
variability, meaning that the PiCCO method is less user dependent
and gives more stable measurements. Compared to the gold
standard (Fick method), the PiCCO has excellent correlation (r2
=
0.9 or better with bias of approximately 130 ml/min). Even the
Pulse Contour Cardiac Output compares with high degree of
correlation and low bias to the arterial thermodilution cardiac
output.*
*This recommendation is based on a publication by Pauli C. et. al.,
Cardiac output determination in children: equivalence of the
transpulmonary thermodilution method to the direct Fick principle,
Intensive Care Med (2002) 28:947–952, DOI 10.1007/s00134-002-
1334-2
GEDVI (GEDI) - Indicator of Cardiac Preload
Why is GEDVI larger than one would expect physiologically?
GEDVI is the total volume of the heart divided by the time it takes
for the indicator to traverse the cardiopulmonary circulation. Thus,
it is not a value displaying the volume of the heart during a single
cardiac cycle. Indicator injected into a compartment will be diluted
into the largest available volume of that compartment. When
applying this to the heart, all four compartments must be
considered: the end-diastolic volume of the right atrium, right
ventricle, left atrium, and left ventricle.
The indicator dilution curves from each compartment are added
both individually and in time. GEDVI is thus a sum of several cardiac
cycles as opposed to a discrete value from one cardiac cycle.
Furthermore a small volume must be added. These include volumes
from the aorta and a small amount just prior to the right atrium.
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15. 15
Measurement Related Questions
Calibration
Only one calibration is needed. What if it is not done correctly?
There are criteria that need to be met during calibration. Both the
thermodilution curve and the arterial waveform must be
considered technically acceptable before the CCO is calibrated.
Catheter Change Interval
How long can a CCO thermodilution catheter remain in situ and
how often should tubing be changed?
The arterial line can be left in situ for ten days unless there are
signs of infection around the catheter. It is very rare that a patient
will get a systemic infection from the arterial catheter. Systemic
infections are more commonly associated with central venous
catheters. The monitoring kit and the inline injectate sensor
housing should be changed every three to five days.*
In general, follow your hospital policy.
*These recommendations are based on a publication by the
“Robert-Koch-Institut, Bundesgesundheitsbl - Gesundheitsforsch -
Gesundheitsschutz 2002, 45:907–924; DOI 10.1007/s00103-002-
0499-8”
Injection Values for the Thermodilution Measurement
What are the recommended volumes to be injected for arterial
thermodilution measurement?
The injection volume is dependent on the body weight. If the
patient has an increased amount of extravascular lung water
(EVLWI, more than 10 ml/kg body weight), the injection
temperature should be decreased (see following table).
Patient Weight
Cold Injectate
EVLWI < 10 EVLWI >= 10
< 3 kg 2 ml 2 ml
< 10 kg 2 ml 3 ml
< 25 kg 3 ml 5 ml
< 50 kg 5 ml 10 ml
< 100 kg 10 ml 15 ml
≥ 100 kg 15 ml 20 ml
PiCCO and Venous Catheter Placement
Is it possible to inject the cold bolus through a venous catheter
placed in the right atrium? Are the results obtained by this
thermodilution exactly the same as those obtained by a bolus
injection into the vena cava?
The catheter for indicator injection should be placed central
venously, either directly before the right heart or in the right
atrium to obtain correct volume measurements.
For calibration of the pulse contour analysis, injection of indicator
in a peripheral vein is possible, as long as the arterial catheter can
obtain a good quality thermal response curve. However, in this
peripheral vein position, volumetric measurements are inaccurate
(ITBV, GEDV, EVLW).
Is it possible to use a catheter placed into the Vena Basilica for the
indicator injection?
The Vena Basilica can be used for calibration of the Pulse Contour
Cardiac Output as long as the thermodilution curve is within the
time limits. However, in this Vena Basilica position, volumetric
measurements are inaccurate (ITBV, GEDV, EVLW).
What is the effect of injecting ice cold indicator for the PiCCO
method into the femoral vein instead of the superior vena cava/
right atrium. Does this make a clinically significant difference on the
GEDV, ITBV and EVLW?
If the venous catheter is placed into the femoral vein, the PiCCO
readings for ITBV and GEDV will be about 150 ml (as absolute
values) higher than the volumes really are. The reason for this is,
that the volume from the point of injection to the point of
detection will be higher, because the catheter for indicator
injection is not placed directly before or in the right atrium. The
value for EVLW will be correct.
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16. 16
Number of Injections for the Thermodilution
Measurement
How many times is the injection of iced-cold injectate
recommended to perform thermodilution measurements in a new
patient?
At least three cold boluses are necessary to obtain acceptable
precision and any measured C.O. should not deviate by more than
15% from the mean value.*
*This recommendation is based on a publication by Hofkens, P.-J.,
Common pitfalls and tips and tricks to get the most out of your
transpulmonary thermodilution device: results of a survey and
state-of-the-art review, Anaesthesiology Intensive Therapy, ISSN
1642–5758, DOI: 10.5603/AIT.a2014.0068
Thermodilution Measurement Intervals
What are the time intervals or under what circumstances is it
recommended to carry out new thermodilution measurements in
order to keep the monitoring results from Pulse Contour analysis
updated and reflecting the patient status?
In general, the PiCCO must be calibrated every 8 hours with a
thermodilution determination, or if there are large or sudden
changes in the patient's condition.
PULSION PiCCO Monitoring Kit
We want to standardize pressure-monitoring kits, why do we have
to use PULSION kits?
The PULSION kits have been tested for frequency response to give
us the best fidelity and are matched to the algorithm used in the
CCO. The most important factor to maintain fidelity is the
connection tubing used with the PULSION transducer. This tubing
is very stiff and with a certain length and inner diameter. If you use
another pressure transducer and connection tubing the Pulse
Contour Cardiac Output may not be accurate.
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17. 17
Troubleshooting Questions
External Factors, Pathological Situations and Illnesses
Which external factors, pathological situations and illnesses may
result in incorrectly measured parameters?
Air bubbles in the arterial pressure monitoring kit will dampen the
curve and possibly influence the Pulse Contour Cardiac Output.
Inadequate indicator (small volume or warm temperature) will
influence thermodilution and volume calculations. However, the
status line will alert you if the thermodilution is incorrect.
Clinical situations include arrhythmia (incorrect Pulse Contour
Cardiac Output), large EVLW (colder or more volume of indicator
necessary), aortic aneurysm (ITBV and GEDV will be overestimated
if you use femoral arterial line), rapidly changing body temperature
(malignant hyperthermia or rewarming influences blood
temperature baseline) and intracardiac shunts (recirculation of
indicator). In pediatric patients you may encounter patent ductus
botalli (recirculation of indicator).
Temperature Artifacts During Baseline Analysis
Can temperature artifacts appear during baseline analysis?
Sometimes temperature artifacts can be visible, if the thermistor of
the arterial catheter is in contact with the vessel wall. The artefacts
are more prominent if the artery is narrow. In general, blood
temperature does not change so fast that you will see spikes on the
baseline.
Abnormal Thermodilution Curve Detection
If the shape of the thermodilution curve is abnormal, is it detected
by the monitor?
Yes, the cardiac output module checks several parameters of the
thermodilution curve, and uses them to derive several curve alerts.
Pulse Contour and Changing Pressure Curves
What about Pulse Contour in case of changing pressure curves,
tamponade, registration of bad quality curves etc.?
Each pulse waveform is analyzed to detect large variations in the
shape. Certain criteria must be fulfilled for the waveform to be
accepted. If the Pulse Contour is deemed not plausible no values
will be displayed.
Cardiac Output Measurement Differences
Pulse Contour Cardiac Output shows vast differences compared to
the cardiac output determined by arterial thermodilution. What
are the possible reasons?
Possible reasons include, but are not limited to:
- Significant hemodynamic instability
- Errors in detection of the arterial waveform and therefore
errors in the waveform analysis
- Extreme arrhythmia or frequent extrasystole
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18. 18
Questions Regarding Specific Patient Conditions
PiCCO and Temperature
Is it possible to use PiCCO in patients with variations of blood
temperature or with hypothermia?
The PiCCO compensates for baseline temperature drifts. If the
baseline drift is higher than 0.05°C per minute, the display shows
the message Unstable baseline, injection not recommended, or
Excessive baseline drift, don’t inject now.
Hypothermia does not cause any problems, if the PiCCO detects a
stable baseline. Cooled injectate should be used in hypothermic
patients.
PiCCO Measurement and Respiration
Does the respiratory cycle influence the value of measured PiCCO
parameters?
No. The respiratory cycle does not influence the measurements
since the thermodilution curve is at least 20 seconds long. At least
three respiratory cycles occur under the curve.
Cardiac Output Measurement and Aortic Stenosis
Is the cardiac output measurement correct in case of aortic
stenosis?
In aortic stenosis the arterial thermodilution accurately reflects the
cardiac output. The arterial pressure waveform is basically normal
with possibly reduced systolic and elevated diastolic pressures. The
area under the arterial waveform still reflects the stroke volume.
Cardiac Output Measurement and Aortic Valve
Insufficiency
Is the cardiac output measurement correct in case of aortic valve
insufficiency
In aortic insufficiency the aortic valve does not close completely.
The thermodilution curve will be affected since the indicator will be
regurgitated which results in prolonged indicator decay time. In
severe aortic insufficiency the curve may time out. However, if a
thermodilution curve is obtained it accurately reflects the cardiac
output. The arterial waveform may be distorted and the lack of
dicrotic notch may influence the CCO accuracy.
In both cases, the pulmonary and arterial cardiac outputs are the
same.
PiCCO and Open-Heart Surgery
Can PiCCO be used in open-heart surgery?
The initial calibration of the PiCCO should be done by
thermodilution measurements after induction of anaesthesia but
before opening of the chest. During pulse contour calibration with
thermodilution measurements the patient should be
hemodynamically stable and have no significant change in body
temperature. During extracorporeal circulation the PiCCO cannot
give any valid results due to lack of arterial waveform.
Thermodilution measurements are not useful during
extracorporeal circulation. As soon as the heart is pumping again
the PiCCO will show the cardiac output from pulse contour
analysis. Immediate re-calibration of pulse contour is usually not
necessary.
Pulse Contour and Arrhythmia
What about pulse contour in case of arrhythmia?
In cases of severe arrhythmia (ventricular fibrillation, supra-
ventricular tachycardia), the Pulse Contour Cardiac Output will not
be accurate. However, in cases with mild to moderate arrhythmia
(atrial flutter/fibrillation, bigemini, trigemini or occasional extra
beats) the pulse contour will reflect current cardiac output. You
have to calibrate the Pulse Contour more frequently in case of
arrhythmia, and use 3 to 5 bolus injections each time.
PiCCO and Intra-Aortic Balloon Pump
Is it possible to use the PiCCO in combination with an intra-aortic
balloon pump (IABP)?
The thermodilution measurement with the PiCCO is not
influenced by IABP, but the pulse contour analysis is unable to
provide valid continuous output.
PiCCO and Liver Surgery
Is it possible to use PiCCO in patients undergoing liver surgery?
There are no restrictions to use of PiCCO during surgery as long
as an adequate arterial waveform is detectable.
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19. 19
References
For a complete up-to-date list of publications on the PiCCO
technology, refer to www.pulsion.com.
PiCCO and Continuous Hemofiltration
Is it possible to use the PiCCO in patients treated with continuous
hemofiltration?
In patients with hemodialysis/hemofiltration the measurements
with PiCCO will give accurate results as long as the hemodialysis
catheter is not placed in the cardiopulmonary circulation.
Long Thermodilution Curve with Cardiac Tamponade
In case of cardiac tamponade the thermodilution curve is very long.
What is the reason?
One reason why the thermodilution curve is very long is that
cardiac output is very low.
Cardiac tamponade is a situation where the pericardial sack is filled
with fluid and/or blood clots. Since the pericardial sack completely
envelopes the heart, any fluid in the sack will influence the function
of the heart. If enough fluid is in the pericardial sack, the heart
cannot fill and the cardiac output will drop. Another result of
cardiac tamponade is that the arterial waveform is significantly
dampened. When you see a very low heart rate during cardiac
tamponade the situation is very critical and measurement of cardiac
output is of no use.
PiCCO Measurement and Aortic Aneurysm
What is the level of error in case of aortic aneurysm?
To avoid influences due to an aortic aneurysm, the PiCCO catheter
should not be placed into the femoral artery, but alternatively e.g.
into the axillary artery.
PiCCO Measurement and Pleural Fluid
Does pleural fluid influence the measurement of extravascular lung
water (EVLW)?
Pleural fluid is not measured as EVLW for two reasons:
- The capillary surface that is in contact with the pleural fluid is very
small in comparison to the pulmonary capillary network. Thus, the
temperature loss to the pleural fluid is negligible.
- The distance for diffusion is very large requiring a long time for
equilibrium.
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20. © 2016 Koninklijke Philips N.V.
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Philips Healthcare reserves the right to make changes in specifications and/or to discontinue any product at any time without notice or
obligation and will not be liable for any consequences resulting from the use of this publication.
Published in The Netherlands.
4522 991 22211 October 2016
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