Haemodynamic Monitoring

1. Haemodynamic Monitoring Theory and Practice

2. Haemodynamic Monitoring Physiological Background Monitoring Optimising the Cardiac Output Measuring Preload Introduction to PiCCO Technology Practical Approach Fields of Application Limitations

3. Practical Approach PiCCO Technology Set-Up PiCCO monitoring uses vascular accesses that are already existing or required anyway. Central venous catheter Injectate temperature sensor housing PULSIOCATH Arterial thermodilution catheter (femoral, axillary, brachial)

4. Practical Approach Clinical Case Patient with secondary myeloid leukemia due to non-Hodgkin’s lymphoma Currently:aplasia as a result of ongoing chemotherapy. Transfer from the oncology ward to intensive care unit due to development of septic status Status on transfer to the Intensive Care Unit HemodynamicBP 90/50mmHg, HR 150bpm SR, CVP 11mmHg RespirationSaO2 99% on 2L O2 via nasal prongs Abdomen Severe diarrhoea, probably associated with chemotherapy Renal Retention values already increasing, cumulative 24h diuresis 400ml LaboratoryHb 6.7g/dl, Leuco <0.2/nl, Thrombo 25/nl High fluid loss because of severe diaphoresis Initial Therapy Given 6500 ml crystalloids and 4 PBC

5. Practical Approach Clinical Case Ongoing Development Haemodynamics • despite extensive volume therapy during the first 6 hours, catecholamines had to be commenced • requirement for catecholamines steadily increased • echocardiography showed good pump function • CVP increased from 11 to 15mmHg Respiration • respiratory deterioration with volume therapy: SaO2 90% on 15L O2/min, pO2 69mmHg, pCO2 39mmHg, RR 40/min • radiological signs of pulmonary edema • started on intermittent non-invasive BIPAP ventilation Renal • ongoing poor quantitative function despite the use of diuretics (frusemide) Infection Status • evidence of E.Coli in the blood culture Diagnosis: Septic Multiorgan Failure

6. Practical Approach Clinical Case Therapeutic Problems and Issues Haemodynamics • further requirement for volume? (rising catecholamine needs despite good pump function) • problematic assessment of volume status (CVP initially raised, patient diaphoretic / diarrhoea) Respiration • evidence of lung edema (deterioration in pulmonary function) • danger of need for intubation and ventilation with high risk of ventilator- associated pneumonia (VAP) because of immunosuppression Renal • impending anuric renal failure

7. Practical Approach Clinical Case Therapeutic Problems and Questions Haemodynamics Volume Administration Respiration ? Renal Haemodynamics Volume Restriction Respiration Renal

8. Practical Approach Clinical Case Application of the PiCCO system • continuation of the noradrenaline infusion • careful GEDI guided volume therapy

9. Practical Approach Clinical Case PiCCO values the following day GEDI with volume therapy persistently within the high normal range, however no increase in ELWI

10. Practical Approach Clinical Case Other therapy • - non-invasive ventilation • targeted antibiotic therapy • administration of hydrocortisone / GCSF Further course - stabilization of haemodynamics - steady noradrenaline requirement - start of negative fluid balance, guided by the PiCCO parameters

11. Practical Approach Clinical Case PiCCO values the next day • stabilization of pulmonary function • cessation of catecholamines • good diuresis with frusemide

12. Practical Approach Clinical Case Progression of PiCCO values Despite significant volume administration/ removal remains relatively constant, thus on its own not an indicator for volume status CI 30 25 Nor HI 20 Remained within normal range under monitoring GEDVI CVP ITBI 15 EVLWI GEDVI EVLW Regular monitoring of the lung water allowed titration of the volume therapy whilst simultaneously avoiding further increase of lung oedema 10 SVRI EVLWI SVR 5 CI 0 Initially raised, despite volume depletion and thus not of use CVP Day 1 Day 2 Day 3 Day 4 Day 5 Nor Time Course

13. Practical Approach Clinical Case Actual advantages of using PiCCO with this patient Optimisation of the intravascular volume status Monitoring of lung oedema Stabilisation of the haemodynamics Pulmonary stabilisation Reduction in catecholamine requirements Avoidance of intubation No acute renal failure No invasive ventilation Avoidance of complications Efficient use of resources

14. Practical Approach Clinical Case Potential problems without PiCCO use in this patient Diarrhoea Severe diaphoresis Poor Diuresis Constant CI High CVP difficult clinical assessment of volume deficit Volume ? Volume ? Volume ?

15. Practical Approach Therapy Guidance with PiCCO Technology PiCCO allows the establishment of an adequate cardiac output through optimisation of volume status whilst avoiding lung oedema Optimisation of stroke volume The haemodynamic triangle Optimisation of preload Avoidance of lung oedema

16. Practical Approach Therapy Guidance with PiCCO Technology if necessary: additional information Oxygen extraction ScvO2 Organ perfusion PDR-ICG Evaluation of therapy success PiCCO monitoring CI, Preload, Contractility, Afterload, Volume responsiveness Therapy Volume / Catecholamines

17. Practical Approach Therapy Guidance with PiCCO Technology Cardiac Output Inadequate preload should initially be treated with volume administration 5 3 EVLW 7 3 Preload

18. Practical Approach Therapy Guidance with PiCCO Technology Cardiac Output Inadequate preload should be treated initially with volume administration 5 Continue volume administration until EVLW increases 3 EVLW 7 3 Preload

19. Practical Approach Therapy Guidance with PiCCO Technology Cardiac Output Inadequate preload should be treated initially with volume administration 5 Volume administration causes an increase in EVLW 3 Volume removal until EVLW stops decreasing or decreases only slowly (preload monitoring!) EVLW Always check measurements for plausibility. Volume administration must lead to an increase in preload, or increase in lung oedema (reflected by increase in EVLW) 7 3 Preload

20. Costs and Resources Economic Aspects of PiCCO Technology Is it possible to reduce treatment costs through PiCCO Technology guided optimisation of therapy? How high are the financial costs in comparison to the pulmonary artery catheter?

21. Costs and Resources Economic Aspects of PiCCO Technology Direct costs in comparison to the PAC Percentage Costs 230% PiCCO - Kit Pulmonary catheter Chest X-Ray 140% Introducer CVC 100% 100% Arterial catheter Pressure transducer Injection accessories PiCCO Kit CCO - PAC PiCCO Kit CCO - PAC Day 5 to 8 Day 1 to 4 Efficient and economically priced monitoring with PiCCO technology is possible because of the low costs for materials and efficient use of staff time

22. Costs and Resources Economic Aspects of PiCCO Technology Indirect costs in comparison to the PAC Ventilation days Intensive care days * p ≤ 0.05 n = 101 * p ≤ 0.05 22 days 7 days 9 days 15 days PAC group EVLW group PAC group EVLW group Mitchell et al, Am Rev Resp Dis 1992;145: 990-998 By reducing the ventilation days and subsequent days in intensive care the costs can be effectively reduced (average cost per day currently 1,318.00€) (Moerer et al., Int Care Med 2002; 28)

23. Practical Approach Summary and Key Points • PiCCO technology as a less invasive monitoring method utilizes only vascular accesses that already exist or are required anyway in ICU patients • PiCCO technology provides all the parameters essential for complete haemodynamic management • Through valid and rapidly available PiCCO parameters optimal haemodynamic therapy guidance is possible • Through the optimisation of therapies with PiCCO technology complications can be reduced and resources used more efficiently