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I Like to Use a PiCCO Manu Malbrain, MD

08-Dec-04. I Like to Use a PiCCO Manu Malbrain, MD. Director Intensive Care Unit Ziekenhuis Netwerk Antwerpen Campus Stuivenberg B-2060 Antwerp BELGIUM. manu.malbrain@skynet.be. Best preload parameter in IAH?. PRELOAD ?. LVEDAI ?. CVP ? PAOP ?. other ?. RVEDVI ? LVEDVI ?.

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I Like to Use a PiCCO Manu Malbrain, MD

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  1. 08-Dec-04 I Like to Use a PiCCO Manu Malbrain, MD Director Intensive Care Unit Ziekenhuis Netwerk Antwerpen Campus Stuivenberg B-2060 Antwerp BELGIUM manu.malbrain@skynet.be

  2. Best preload parameter in IAH? PRELOAD ? LVEDAI ? CVP ? PAOP ? other ? RVEDVI ? LVEDVI ? GEDVI ? ITBVI?

  3. Best preload parameter? Filling Pressures ? Compliance? Lung, Cw ? Transmural Pressures ? CVP ? PAOP ? PEEP ? IAP ? PPV ? ITP, Ppleu ?

  4. Mean RAP (mmHg) before volume expansion in responders (blue) and non-responders (grey) * * Michard F and Teboul JL. Chest 2002; 121: 2000-8 Predicting fluid responsiveness in ICU patients. A critical analysis of the evidence

  5. Mean PAOP (mmHg) before volume expansion in responders (blue) and non-responders (grey) * * * Michard F and Teboul JL. Chest 2002; 121: 2000-8 Predicting fluid responsiveness in ICU patients. A critical analysis of the evidence

  6. RV end-diastolic volume (RVEDV) (pulmonary artery thermodilution) LV end-diastolic area (LVEDA) (echocardiography) Intrathoracic blood volume (ITBV) (thermo-dye transpulmonary dilution) Global end-diastolic volume (GEDV) (transpulmonary thermodilution) Volumetric assessment of cardiac preload Special thanks to F Michard

  7. Worst Case Scenario

  8. Baseline IAP-BL 30 25 20 15 10 5 0 Study Stages

  9. Abdominal Compression Baseline IAP-BL IAP-1 30 25 20 15 10 5 0 Study Stages

  10. Abdominal Compression PEEP set at IAP Baseline IAP-BL IAP-1 IAP-2 30 25 20 15 10 5 0 Study Stages

  11. Abdominal Compression PEEP set at IAP Abdominal Decompression Baseline IAP-BL IAP-1 IAP-2 IAP-3 30 25 20 15 10 5 0 Study Stages

  12. PEEP set at IAP Abdominal Compression Abdominal Decompression Return to Baseline Baseline IAP-BL IAP-1 IAP-2 IAP-3 IAP-4 30 25 20 15 10 5 0 Study Stages

  13. Intra-Abdominal Pressure Baseline: normal IAP at ZEEP Stage 1: increased IAP by banding (compression) at ZEEP Stage 2: increased IAP and PEEP set at IAP Stage 3: normal IAP (decompression) and same PEEP-level as stage 2 Stage 4: normal IAP and ZEEP 8.6 15.4 15.9 10.2 8.8 * P<0.001 for all comparisons, except * p=NS

  14. Effects on filling pressures 12.3 17.2 19.6 15.4 12.5 ** * 15.4 20.9 24.3 18.7 15.6 P<0.001 for all comparisons, except *p=0.002, **p=0.004

  15. Effects on perfusion pressures * 30.4 34.3 34.8 33.3 28.9 * * * 79.1 77.4 74.5 69.3 79.2 P<0.05 for all comparisons, except *p=NS

  16. Effects on Cardiac Output 3.8 3.5 3.1 3.3 3.6 3.4 3.3 2.8 3 3.4 * * * * P<0.002 for all comparisons, except *p=NS

  17. 871 918 810 847 887 12.7 12.8 12.5 12.7 12.2 * Effects on Blood Volume PAOP GEDVI EVLWI P<0.05 for all comparisons, except *p=NS P=NS for all comparisons

  18. Optimal Preload Markers in IAH Paired CO-PCWP and CO-ITBVI measurements in an individual patient

  19. Hemodynamic Monitoring in IAH r = - 0.33 r = - 0.32 r = 0.69 r = 0.60 Special thanks to Michael Cheatham

  20. Filling Pressures in IAH Malbrain. Current Opinion Crit Care 2004; 10(2): 132-145

  21. Volumes in IAH Malbrain. Current Opinion Crit Care 2004; 10(2): 132-145

  22. If you don’t take a temperature you can’t find a fever S Shem in “The House of God” Dell Publishing, ISBN: 0-440-13368-8

  23. If you want to givefluids, you need to measure volume ! Volume Management Requires Volume Measurement!

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