The document discusses various hemodynamic monitoring tools available, including pulmonary artery catheters, transpulmonary thermodilution monitors, lithium dilution monitors, Doppler methods, bioimpedance, bioreactance, CO2 rebreathing, and uncalibrated pulse contour methods. It provides details on the measurements and values provided by transpulmonary thermodilution monitors such as cardiac output, volumes, extravascular lung water, and indices. It also discusses the decreasing use of pulmonary artery catheters and increasing use of less invasive tools.
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The menagerie of monitoring tools by Professor Jean-Louis Teboul
1. The menagerie of monitoring tools
Prof. Jean-Louis TEBOUL
Medical ICU
Bicetre Hospital
University Paris-South
France
2. Member of the Medical Advisory Board of Pulsion
Conflicts of interest
3. Various and intricate mechanisms responsible for
hemodynamic instability in ICU patients
hypovolemia
vascular tone
depression
myocardial
depression
vasopressors inotropesfluids
Important to estimate the degree of each component
to select the most appropriate therapeutic option
Important to assess the response to treatment
presence of associated ARDS
4. Although clinical examination is valuable
to detect haemodynamic instability,
it is insufficient to accurately assess
the hemodynamic status and thus to well identify
each component of haemodynamic instability
2015
Additional haemodynamic
assessment is required
5. • PAC
• Transpulmonary thermodilution monitors
• Lithium dilution monitor
→ PiCCO2
→ FloTrac/Vigileo
→ VolumeView
→ MostCare
→ Nexfin/Clearsight
• Doppler methods
→ esophageal Doppler
→ echocardiography
→ USCOM
→ LiDCOrapid
→ ProAQT
• Bioimpedance
→ Thoracic Electrical Bioimpedance
→ Endotracheal Bioimpedance
• Bioreactance
• CO2 rebreathing
Available hemodynamic monitoring tools
• Uncalibrated Pulse Contour methods
→ LiDCOplus
non invasive
invasive
less invasive
less invasive
less invasive
non invasive
non invasive
non invasive
non invasive
• Pulse wave transit time non invasive
6. • PAC
• Transpulmonary thermodilution monitors
• Lithium dilution monitor
→ PiCCO2
→ FloTrac/Vigileo
→ VolumeView
→ MostCare
→ Nexfin/Clearsight
• Doppler methods
→ esophageal Doppler
→ echocardiography
→ USCOM
→ LiDCOrapid
→ ProAQT
• Bioimpedance
→ Thoracic Electrical Bioimpedance
→ Endotracheal Bioimpedance
• Bioreactance
• CO2 rebreathing
Available hemodynamic monitoring tools
• Uncalibrated Pulse Contour methods
→ LiDCOplus
non invasive
less invasive
less invasive
less invasive
non invasive
non invasive
non invasive
non invasive
• Pulse wave transit time non invasive
invasive
7. Continuous CO and SvO2 monitoring
+
Intermittent measurements of
RAP PAP PAOP
+
Intermittent calculation of
DO2, VO2, PCO2 gap
9. What are the reasons for the decline of the PAC?
• Large RCTs showing no beneficial effect of maximizing CO in ICU pts
• Large retrospective studies showing harmful effects of the PAC
• Large RCTs showing neutral effects of the PAC
• Development of bedside echocardiography in the ICU
• Emergence of other advanced hemodynamic monitoring systems
• Emergence of the « fluid responsiveness » concept and the
« functional hemodynamic monitoring » approach
• Evidence of insufficient physician’s knowledge in terms of
measurements and interpretation of the PAC data
• Emergence of less invasive hemodynamic CO monitoring devices
10. • PAC
• Transpulmonary thermodilution monitors
• Lithium dilution monitor
→ PiCCO2
→ FloTrac/Vigileo
→ VolumeView
→ MostCare
→ Nexfin/Clearsight
• Doppler methods
→ esophageal Doppler
→ echocardiography
→ USCOM
→ LiDCOrapid
→ ProAQT
• Bioimpedance
→ Thoracic Electrical Bioimpedance
→ Endotracheal Bioimpedance
• Bioreactance
• CO2 rebreathing
Available hemodynamic monitoring tools
• Uncalibrated Pulse Contour methods
→ LiDCOplus
non invasive
invasive
less invasive
less invasive
less invasive
non invasive
non invasive
non invasive
non invasive
• Pulse wave transit time non invasive
14. RA LARV LV
Central venous access
cold bolus injection
Arterial line
Temperature detection
PulmonarPulmonary
blood volume
EVLW
Temperature
injection
time
Transpulmonary thermodilution
15. + 2SD
- 2SD
+ 1.92
- 0.56
(COTP thermo + COPA thermo ) / 2
COTP thermo - COPA thermo (L/min)
COPA thermo
COTPthermo(L/min)
Percentage error = 2SD/mean ≈ 16%, thus < 30% (upper limit of acceptability)
17. PCCO = cal . HR . (P(t)/SVR + C(p) . dP/dt) dt
systole
Patient-specific
calibration factor
(determined with
thermodilution)
compliance shape of
pressure
curve
area of
pressure
curve
P (mmHg)
t (s)
19. We recommend to recalibrate
if the preceding calibration
was performed more than one hour before
20. Transpulmonary thermodilution
• Global end-diastolic volume (GEDV)
• Extravascular lung water (EVLW)
Pulse contour analysis
• Continuous cardiac output (CCO)
• Cardiac output
• Stroke volume variation (SVV)
• Pulse pressure variation (PPV)
• Pulmonary vascular permeability index (PVPI)
• Cardiac function index (CFI)
These systems
are not just
CO monitoring systems
21. Transpulmonary thermodilution
• Global end-diastolic volume (GEDV)
• Extravascular lung water (EVLW)
Pulse contour analysis
• Continuous cardiac output (CCO)
• Cardiac output
• Stroke volume variation (SVV)
• Pulse pressure variation (PPV)
• Pulmonary vascular permeability index (PVPI)
• Cardiac function index (CFI)
23. Transpulmonary thermodilution
• Global end-diastolic volume (GEDV)
• Extravascular lung water (EVLW)
Pulse contour analysis
• Continuous cardiac output (CCO)
• Cardiac output
• Stroke volume variation (SVV)
• Pulse pressure variation (PPV)
• Pulmonary vascular permeability index (PVPI)
• Cardiac function index (CFI)
EVLW
quantitative measure
of pulmonary edema
38. Arterial
Pressure
Arterial pressure waveform analysis Stroke volume
Stroke Volume Variation
Calculated automatically and displayed in real-time
by functional hemodynamic monitors
39. Use rather the response of PCCO to:
• Passive leg raising
• End-expiratory occlusion
• Tidal volume challenge
• Lung recruitment maneuver
40. Changes in CO
AUC: 0.95 ± 0.01
Threshold: 10%
21
clinical
studies
995 pts
41. We recommend using
dynamic over static variables
to predict fluid responsiveness,
when applicable
We suggest that
dynamic over static variables be used
to predict fluid responsiveness,
when available
42. • PAC
• Transpulmonary thermodilution monitors
→ PiCCO2
→ VolumeView
→ Nexfin/Clearsight
• Doppler methods
→ esophageal Doppler
→ echocardiography
→ USCOM
• Bioimpedance
→ Thoracic Electrical Bioimpedance
→ Endotracheal Bioimpedance
• Bioreactance
• CO2 rebreathing
Available hemodynamic monitoring tools
non invasive
invasive
less invasive
non invasive
non invasive
non invasive
non invasive
• Lithium dilution monitor → LiDCOplus
less invasive
→ FloTrac/Vigileo
→ MostCare
→ LiDCOrapid
→ ProAQT
• Uncalibrated Pulse Contour methods
less invasive
• Pulse wave transit time non invasive
44. • Real-time CO monitoring from AP waveform
• Complex algorithm based on statistical analysis of the AP signal
• No need for calibration
• Any type of arterial catheter and any site including the radial site
• Validation?
FloTrac/VigileoTM Technology
47. Changes in CI (%)
induced by fluid infusion
Changes in CI (%)
induced by norepinephrine
Concordance: 73% Concordance: 60%
3rd generation
ICU pts
Poor concordance in ICU pts
The concordance rate between changes in CItd and CIpw with fluids was 73%
meaning that in 73% of instances, CItd and CIpw changed in the same direction
The concordance rate between changes in CItd and CIpw with NE was 60%
meaning that in 60% of instances, CItd and CIpw changed in the same direction
48. • Real-time CO monitoring from AP waveform
• Complex algorithm based on statistical analysis of the AP signal
• No need for calibration
• Any type of arterial catheter and any site including the radial site
• Validation?
FloTrac/VigileoTM Technology
• seems valid in the absence of changes in vascular tone
• serious doubts on its validity in cases of changes in vascular tone
(sepsis, vasopressor use)
49. • PAC
• Transpulmonary thermodilution monitors
→ PiCCO2
→ VolumeView
→ Nexfin/Clearsight
• Doppler methods
→ esophageal Doppler
→ echocardiography
→ USCOM
• Bioimpedance
→ Thoracic Electrical Bioimpedance
→ Endotracheal Bioimpedance
• CO2 rebreathing
Available hemodynamic monitoring tools
non invasive
invasive
less invasive
non invasive
non invasive
non invasive
• Lithium dilution monitor → LiDCOplus
less invasive
→ FloTrac/Vigileo
→ LiDCOrapid
→ ProAQT
• Uncalibrated Pulse Contour methods
less invasive
→ MostCare
• CO
• PPV, SVV
• Bioreactance non invasive
• Pulse wave transit time non invasive
56. • PAC
• Transpulmonary thermodilution monitors
→ PiCCO2
→ VolumeView
→ Nexfin/Clearsight
• Doppler methods
→ esophageal Doppler
→ echocardiography
→ USCOM
• Bioimpedance
→ Thoracic Electrical Bioimpedance
→ Endotracheal Bioimpedance
• Bioreactance
• CO2 rebreathing
Available hemodynamic monitoring tools
non invasive
invasive
less invasive
non invasive
non invasive
non invasive
non invasive
• Lithium dilution monitor → LiDCOplus
less invasive
→ FloTrac/Vigileo
→ LiDCOrapid
→ ProAQT
• Uncalibrated Pulse Contour methods
less invasive
→ MostCare
CO and
CO trends
• Pulse wave transit time non invasive
57. The pulsatile finger artery is clamped to a constant volume by applying a counter pressure
equivalent to the AP resulting in a pressure waveform (volume clamp method)
Inflatable cuff
around the middle phalanx
of the finger.
Finger AP is then reconstructed into brachial AP waveform using a transfer correction
and a level correction based on clinical database
Real-time CO is derived by a novel pulse contour method based on the systolic pressure
area and a physiological three-element Windkessel model
61. Inflatable cuff
around the middle phalanx
of the finger.
• potentially useful for CO trends in the OR pts
• serious doubts on its validity in ICU pts, even for CO trends
62. • PAC
• Transpulmonary thermodilution monitors
• Lithium dilution monitor
→ PiCCO2
→ FloTrac/Vigileo
→ VolumeView
→ MostCare
→ Nexfin/Clearsight
• Doppler methods
→ esophageal Doppler
→ echocardiography
→ USCOM
→ LiDCOrapid
→ ProAQT
• Bioimpedance
→ Thoracic Electrical Bioimpedance
→ Endotracheal Bioimpedance
• Bioreactance
• CO2 rebreathing
Available hemodynamic monitoring tools
• Uncalibrated Pulse Contour methods
→ LiDCOplus
non invasive
invasive
less invasive
less invasive
less invasive
non invasive
non invasive
non invasive
non invasive
• Pulse wave transit time non invasive
63. Two access windows for measuring CO
• the suprasternal notch for the aortic valve
(simple probe positioning, image quick to acquire)
• the parasternal border at the 3th-4th intercostal spaces for the
pulmonic valve (less simple, few minutes more to acquire, but image
acquisition better tolerated)
64. Nonimaging transthoracic probe and continuous-wave Doppler ultrasound to obtain
a beat-to-beat flow profile that can provide a real-time velocity time integral (VTI)
The cross-sectional area of a vessel is predicted by a height- and
weight-based nomogram incorporated in the USCOM software
74. The concordance rate between changes in CItd and CINicom with fluids was 43%
meaning that in 43% of instances, CItd and CINicom changed in the same direction.
unacceptable concordance in ICU pts
75. • PAC
• Transpulmonary thermodilution monitors
• Lithium dilution monitor
→ PiCCO2
→ FloTrac/Vigileo
→ VolumeView
→ MostCare
→ Nexfin/Clearsight
• Doppler methods
→ esophageal Doppler
→ echocardiography
→ USCOM
→ LiDCOrapid
→ ProAQT
• Bioimpedance
→ Thoracic Electrical Bioimpedance
→ Endotracheal Bioimpedance
• Bioreactance
• CO2 rebreathing
• Uncalibrated Pulse Contour methods
→ LiDCOplus
non invasive
non invasive
non invasive
non invasive
non invasive
• Pulse wave transit time non invasive
Available hemodynamic monitoring tools
less invasive
Many tools, an abundant literature about their validity
… but in general more suitable
for the OR setting than for the ICU
77. • We suggest the use of transpulmonary thermodilution or PAC in patients
with severe shock especially in the case of associated ARDS
• We recommend that less invasive devices are used, instead of more invasive
devices, only when they have been validated in the context of shock