LiMON in Intensive Care Medicine

1. LiMON in Intensive Care Medicine

2. Basics • The Plasma Disappearance Rate of ICG-PULSION (PDR) is influenced by liver function and liver perfusion. • Changes of ICG-PDR within a short period of time are reflecting liver respectively splanchnic perfusion, as the function of liver cells does not change rapidly. • LiMON provides an easy, fast and non-invasive monitoring of liver and splanchnic perfusion.

3. Scientific facts I PDR as parameter of prognosis of survival • ICG-PDR is perfectly suited as parameter for prognosis of survival of surgical intensive care patients compared to the complex scores SAPS II and APACHE II. Sakka S, Reinart K, Meier-Hellmann A: Chest 122 (5), 1715-1720, 2002

4. Scientific facts II PDR and mortality • 2/3 of surgical intensive care patients qualified for advanced hemodynamic monitoring exhibit reduced ICG-PDR values, accompanied with a significantly increased mortality. * * PDR threshold value • An ICG-PDR  16 %/min requires intervention. Sakka S, Reinart K, Meier-Hellmann A: Chest 122 (5), 1715-1720, 2002

5. Scientific facts III PDR in septic shock • Patients in septic shock will not survive if a reduced ICG elimination can not be increased within the first 120 hours. According to: Kimura S, Yoshioka T, Shibuya M, Sakano T, Tanaka R, Matsuyama S: Crit Care Med 29 (6), 1159-1163, 2001

6. Scientific facts IV Multi-Organ-Management • The combination of PiCCO and LiMON enables optimized volume therapy. In case of volume withdrawal due to increased lung water, splanchnic perfusion can be monitored and a cut-off point for volume withdrawal can be defined. Sakka S, Meier-Hellmann A: Int J Intensive Care 9 (2), 66-72, 2002

7. Recommendations for application in intensive care ICG-PDR monitoring: • In all critically ill patients: at least once per day • In patients undergoing volume withdrawal or inotropic/vasoactive therapy a more frequent monitoring is recommended Therapeutic recommendations (please refer to check list): • Reduction of hepatotoxic substances • Optimization of hemodynamics • Liver support therapy ICG-PDR target value: • ICG-PDR > 16%/min Measurement site: • Disposable sensor at the ear lobe ICG dosage: • 0.25 mg/kg body weight per measurement

8. LiMON Therapeutic check list ICG-PDR  16 %/min RESULT Optimize global hemodynamic situation Reduce/stop hepatotoxic drugs Liver support therapy ●Advanced hemodynamic monitoring (PiCCO Technology) ● Optimize splanchnic inflow by - Optimizing cardiac preload - Positive inotropic or vasoactive drugs1 ● Contact liver specialist T H E R A P Y ● Treatment of alcoholic hepatitis3 ● Optimize venous return by - Reduction of intrathoracic pressure - Reduction of intra abdominal pressure - Improvement of (right) heart function2 ● Install extracorporal support system (MARS) TARGET ICG-PDR > 16 %/min 1 dobutamine, phosphodiesterase III inhibitor, prostaglandin; 2 dobutamine, phosphodiesterase III inhibitor, adrenaline, prostaglandin, NO inhalation; 3 steroids, pentoxyfylline

9. Conclusion • Routine monitoring of ICG-PDR (minimum once daily) may contribute to an early detection or prevention of reduced liver/splanchnic perfusion. • Previous studies demonstrated that ICG-PDR values  16%/min are requiring intervention. Thus, a goal-directed therapy to achieve an ICG-PDR > 16%/min is recommended. • An early detection and, if necessary, a goal-directed therapy of a reduced splanchnic perfusion contributes to a prevention of complications and therewith to cost reduction.

10. Appendix ICG dosage • ICG-PDR can be measured accurately with a reduced ICG dosage of 0.25 mg/kg body weight. Sakka S, Koeck H, Meier-Hellmann A: Intensive Care Med 30 (3): 506-509, 2004