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The menagerie of monitoring tools
Prof. Jean-Louis TEBOUL
Medical ICU
Bicetre Hospital
University Paris-South
France
Member of the Medical Advisory Board of Pulsion
Conflicts of interest
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
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
• 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
• 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
Continuous CO and SvO2 monitoring
+
Intermittent measurements of
RAP PAP PAOP
+
Intermittent calculation of
DO2, VO2, PCO2 gap
2018
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
• 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
Central venous catheter
Thermodilution femoral arterial catheter
Transpulmonary thermodilution
The transpulmonary thermodilution
systems allow measurements
of cardiac output
Transpulmonary thermodilution
Intermittent cardiac output
Pulse contour analysis
Continuous cardiac output
Two different techniques of CO measurements
with only one device
RA LARV LV
Central venous access
cold bolus injection
Arterial line
Temperature detection
PulmonarPulmonary
blood volume
EVLW
Temperature
injection
time
Transpulmonary thermodilution
+ 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)
Transpulmonary thermodilution
Intermittent cardiac output
Pulse contour analysis
Continuous cardiac output
Two different techniques of CO measurements
with only one device
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)
One frequently asked question
How often do we need to recalibrate?
We recommend to recalibrate
if the preceding calibration
was performed more than one hour before
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
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)
The menagerie of monitoring tools by Professor Jean-Louis Teboul
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
The menagerie of monitoring tools by Professor Jean-Louis Teboul
nonsurvivors
survivors
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)
PVPI
measure of
lung capillary leak
PVPI = EVLW/Pulmonary blood volume
10
9
8
7
6
5
4
3
2
1
0
PVPI
ALI/ARDS Hydrostatic
pulmonary edema
*
Se = 85 %
Sp = 100 %
cut-off
value
= 3
Maximal blood lactate 1.27 (1.12 - 1.45) 0.0002
Mean PEEP 0.78 (0.67 – 0.91) 0.002
Minimal PaO2 / FiO2 0.98 (0.97 - 0.99) 0.0009
SAPS II 1.03 (1.01 - 1.05) 0.008
PVPImax 1.07 (1.02 - 1.12) 0.03
Mean fluid balance 1.0004 (1.0000 – 1.0007) 0.03
p valueOdds Ratio ( CI 95%)
200 pts D28 mortality: 54%
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)
Cardiac function index (CFI) = CO/GEDV
CFI
Index of
cardiac systolic function
0
20
40
60
80
100
0 20 40 60 80 100
100 - specificity
Sensitivity
3.2 min-1
LVEF  35%
A low CFI should incite the clinician
to perform an echo
Transpulmonary thermodilution
• Global end-diastolic volume (GEDV)
• Extravascular lung water (EVLW)
Pulse contour analysis
• Continuous cardiac output (PCCO)
• Cardiac output
• Stroke volume variation (SVV)
• Pulse pressure variation (PPV)
• Pulmonary vascular permeability index (PVPI)
• Cardiac function index (CFI)
Real-time CO monitoring
Useful to perform dynamic tests
• fluid challenge
• passive leg raising test
• end-expiratory occlusion test
Transpulmonary thermodilution
• Global end-diastolic volume (GEDV)
• Extravascular lung water (EVLW)
Pulse contour analysis
• Continuous cardiac output (PCCO)
• Cardiac output
• Stroke volume variation (SVV)
• Pulse pressure variation (PPV)
• Pulmonary vascular permeability index (PVPI)
• Cardiac function index (CFI)
Ventricular
preload
Stroke
volume
preload
responsiveness
preload
unresponsiveness
Sensitivity
PPV
CVP
PAOP
1 - Specificity
Threshold: 12%
AUC: 0.94
807 pts22 studies
Calculated automatically and displayed in real-time
by functional hemodynamic monitors
Pulse Pressure Variation
Arterial
Pressure
Arterial pressure waveform analysis Stroke volume
Stroke Volume Variation
Calculated automatically and displayed in real-time
by functional hemodynamic monitors
Use rather the response of PCCO to:
• Passive leg raising
• End-expiratory occlusion
• Tidal volume challenge
• Lung recruitment maneuver
Changes in CO
AUC: 0.95 ± 0.01
Threshold: 10%
21
clinical
studies
995 pts
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
• 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
radial arterial catheter
• 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
surgical pts
Relatively acceptable agreement in surgical patients
3rd generation
Percentage Error = 54%
Poor agreement in ICU pts
ICU pts
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
• 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)
• 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
radial arterial catheter
Initial estimation of CO Continuous re-evaluation using PCCO algorithm
or external calibration (echo…) validation studies are ongoing
Percentage Error = 31%
Relatively acceptable agreement
Polar concordance rate = 74%
Poor concordance
poor agreement
FloTrac/Vigileo
ProAQT/Pulsioflex
Fluids NE
73%
91%
41%
39%
Relatively acceptable
concordance
during fluid infusion
Poor
concordance
during NE infusion
• 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
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
40 pts
213
measurements
191
measurements
acceptable agreement in surgical pts
Percentage Error = 57%
poor agreement in ICU pts
r = 0.56
Concordance rate = 83%
poor concordance during fluid infusion
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
• 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
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)
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
Percentage Error = 23%...... <30% (upper limit of acceptability)
acceptable agreement
COth–COUSCOM
COth + COUSCOM
2
Percentage Error = 40%...... > 30% (upper limit of acceptability)
unacceptable agreement after cardiac surgery
Percentage Error = 51%...... > 30% (upper limit of acceptability)
unacceptable agreement during liver transplantation
Percentage Error = 105%...... > 30% (upper limit of acceptability)
unacceptable agreement in ICU pts
unacceptable agreement
• 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
• 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
• Pulse wave transit time non invasive
• Bioreactance non invasive
Bioreactance
r = 0.15 PE > 150%
unacceptable agreement in ICU patients
Percentage error: 82%
unacceptable agreement in ICU patients
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
• 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
The menagerie of monitoring tools by Professor Jean-Louis Teboul
• 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
The menagerie of monitoring tools by Professor Jean-Louis Teboul
Thank you

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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
  • 11. Central venous catheter Thermodilution femoral arterial catheter Transpulmonary thermodilution
  • 12. The transpulmonary thermodilution systems allow measurements of cardiac output
  • 13. Transpulmonary thermodilution Intermittent cardiac output Pulse contour analysis Continuous cardiac output Two different techniques of CO measurements with only one device
  • 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)
  • 16. Transpulmonary thermodilution Intermittent cardiac output Pulse contour analysis Continuous cardiac output Two different techniques of CO measurements with only one device
  • 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)
  • 18. One frequently asked question How often do we need to recalibrate?
  • 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
  • 26. 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) PVPI measure of lung capillary leak PVPI = EVLW/Pulmonary blood volume
  • 28. Maximal blood lactate 1.27 (1.12 - 1.45) 0.0002 Mean PEEP 0.78 (0.67 – 0.91) 0.002 Minimal PaO2 / FiO2 0.98 (0.97 - 0.99) 0.0009 SAPS II 1.03 (1.01 - 1.05) 0.008 PVPImax 1.07 (1.02 - 1.12) 0.03 Mean fluid balance 1.0004 (1.0000 – 1.0007) 0.03 p valueOdds Ratio ( CI 95%) 200 pts D28 mortality: 54%
  • 29. 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) Cardiac function index (CFI) = CO/GEDV CFI Index of cardiac systolic function
  • 30. 0 20 40 60 80 100 0 20 40 60 80 100 100 - specificity Sensitivity 3.2 min-1 LVEF  35% A low CFI should incite the clinician to perform an echo
  • 31. Transpulmonary thermodilution • Global end-diastolic volume (GEDV) • Extravascular lung water (EVLW) Pulse contour analysis • Continuous cardiac output (PCCO) • Cardiac output • Stroke volume variation (SVV) • Pulse pressure variation (PPV) • Pulmonary vascular permeability index (PVPI) • Cardiac function index (CFI)
  • 32. Real-time CO monitoring Useful to perform dynamic tests • fluid challenge • passive leg raising test • end-expiratory occlusion test
  • 33. Transpulmonary thermodilution • Global end-diastolic volume (GEDV) • Extravascular lung water (EVLW) Pulse contour analysis • Continuous cardiac output (PCCO) • Cardiac output • Stroke volume variation (SVV) • Pulse pressure variation (PPV) • Pulmonary vascular permeability index (PVPI) • Cardiac function index (CFI)
  • 37. Calculated automatically and displayed in real-time by functional hemodynamic monitors Pulse Pressure Variation
  • 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
  • 45. surgical pts Relatively acceptable agreement in surgical patients
  • 46. 3rd generation Percentage Error = 54% Poor agreement in ICU pts ICU pts
  • 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
  • 51. Initial estimation of CO Continuous re-evaluation using PCCO algorithm or external calibration (echo…) validation studies are ongoing
  • 52. Percentage Error = 31% Relatively acceptable agreement
  • 53. Polar concordance rate = 74% Poor concordance
  • 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
  • 59. Percentage Error = 57% poor agreement in ICU pts
  • 60. r = 0.56 Concordance rate = 83% poor concordance during fluid infusion
  • 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
  • 65. Percentage Error = 23%...... <30% (upper limit of acceptability) acceptable agreement
  • 66. COth–COUSCOM COth + COUSCOM 2 Percentage Error = 40%...... > 30% (upper limit of acceptability) unacceptable agreement after cardiac surgery
  • 67. Percentage Error = 51%...... > 30% (upper limit of acceptability) unacceptable agreement during liver transplantation
  • 68. Percentage Error = 105%...... > 30% (upper limit of acceptability) unacceptable agreement in ICU pts
  • 70. • 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 • 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 • Pulse wave transit time non invasive • Bioreactance non invasive
  • 72. r = 0.15 PE > 150% unacceptable agreement in ICU patients
  • 73. Percentage error: 82% unacceptable agreement in ICU patients
  • 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