Gozde Demiralp, MD
Assistant Professor of Anesthesiology
Department of Anesthesiology
Division of Critical Care Medicine
University of Oklahoma, College of Medicine
Oklahoma City, Oklahoma
Disclosure
I have no affiliations to disclose.
There will be display of new technologies and monitors
Outline:
Review of Basics: What have we been doing and Why?
Cardiac Output Matters
Invasive vs. Noninvasive Methods
Old Monitors & New eT chnology
Arterial Wave Form Analysis
Venous Oximetry
Hemodynamic Monitoring
Monitoring critically ill patients:
What are we really worried about?
Tissue Hypoperfusion
What do we really want to monitor?
Adequate Oxygen Delivery
Definition of Shock:
Inadequate tissue perfusion affecting multiple organ systems.
Hemodynamic Monitoring:
Review of Basics
Oxygen Delivery (DaO2)
= CaO2 x CO x 10
= 1000 ml/min
Tachycardia
Diaphoresis
Tachypnea
Cool Peripheries
Prolonged Capillary Refill
Increased Temperature Difference
Reduced Level of Consciousness
Decreased Urine Output
Lab Values
Measurement of
CO and/or
SvO2%
Lactate
Base Excess
Invasive &
Noninvasive
New vs. Old
Why is he hypotensive?
(Preload)
(Contractility)
(Afterload)
That is why almost always the first step is to give fluids and
Volume Responsiveness:
Frank Starling Curve
CVP
increase in RA pressures or
decrease in RV contractility
can be both.
Why is he hypotensive?
CVP (Preload)
(Contractility)
(Afterload)
KEY advantage:
Simultaneous measurements of
other hemodynamic parameters:
CO
Pulmonary Artery Pressures ( PAD, PAOP)
Right Sided Filling
Left Sided Filling
SvO2%
PACs3-6:
Studies overall the years had conflicting results:
Increased Mortality ?
Multiple RCTs were conducted in several RCTs.
Conclusion:
No difference in LOS in the ICU
No difference in Mortality
No benefit, no harm
There is no guided therapy tailored towards PAC use.
PAC is a diagnostic tool, not a therapeutic one.
( LiDCO
VolumeView
FloTrac Vigileo
LiDCOplus
Pulse Power Analysis
LiDCOrapid
PiCCO2
PiCCO2
Pulse Contour Analysis Aline Wave Form matters !
Area under systolic area ( until dicrotic notch) on arterial
waveform is detected. **
unstable.
PiCCO2
System Requires:
Thermistor Tipped Aline Catheter Femoral Aline ( longer cath, better signal)
Radial, Axillary, Brachial ok as well
picco2
Foto koy
LiDCOplus
Combination of two monitors
LiDCO
PulseCO
Unlike PiCCO2, aline wave form is not important in pulse power analysis.
LiDCOrapid
estimate CO.
lidco
Foto koy
FloTrac Vigileo
FloTrac Algorithm integrates multiple characteristics of arterial
accurate CO calculation.
During Arrhythmias
For Hemodynamically Unstable Patients
Intra Aortic Balloon Pump in use.
Ventricular Assist Devices in use.
FloTRac Vigileo
FloTrac Sensor
http://www.edwards.com/products/mininvasive/Pages/flotracsystemanimation.aspx?wt.ac=flotrac
Vigileo Monitor:
Can display:
CCO
CCI
SV
SVI
SVV
Every 20 seconds
When used with
FloTrac Sensor.
FloTrac Vigileo
Stroke Volume Variation
Limitations:
Venous Oximetry
Fick Principle
1000 ml/min
200-250 ml/min
25%
65-75%.
More O2 Extraction
Inadequate O2 Utilization
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Ref#2
References:
1)
2)
Lee, A.J., Cohn Hochman J., Ranasinghe, J. Cardiac output assessed by invasive and minimally invasive techniques. Anesthesiology Research and
Practice Volume 2011, Article ID 475151, 17 pages.
3)
Harvey S, Harrison DA, Singer M, Ashcroft J, Jones CM, Elbourne D, Brampton W, Williams D,Young D, Rowan K: Assessment of the clinical
effectiveness of pulmonary artery catheters in management of patients in intensive care (PAC-Man): a randomized controlled trial. Lancet 2005,
366:472-477.
4)
Connors AF, Jr., Speroff T, Dawson NV, Thomas C, Harrell FE, Jr., Wagner D, Desbiens N, Goldman L, Wu AW, Califf RM, Fulkerson WJ, Jr.,
Vidaillet H, Broste S, Bellamy P, Lynn J, Knaus WA: The effectiveness of right heart atheterization in the initial care ofcritically ill patients.
SUPPORT Investigators. JAMA1996, 276:889-897.
5)
Sandham JD, Hull RD, Brant RF, Knox L, Pineo GF, Doig CJ, Laporta DP, Viner S, Passerini L, Devitt H, Kirby A, Jacka M: A randomized,
controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med 2003, 348:5-14.
6)
Richard C, Warszawski J, Anguel N, Deye N, Combes A, Barnoud D, Boulain T, Lefort Y, Fartoukh M, Baud F, Boyer A, Brochard L, Teboul JL:
Early use of the pulmonary artery catheter and outcomes in patients with shock and acute respiratory distress syndrome: a randomized controlled
trial. JAMA 2003, 290:2713-2720
7)
Michard, F. Changes in Arterial Pressure During Mechanical Ventilation, Anesthesiology 2005; 103:419-28.
8)
Rivers et al. Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock. New England Journal of Medicine 2001; 345(19):
1368-77
9)
J. Mayer, J. Boldt, R. Poland, A. Peterson, and G. R. Manecke, Continuous arterial pressure waveform-based cardiac output using the
FloTrac/Vigileo: a review and metaanalysis, Journal of Cardiothoracic andVascular Anesthesia, vol. 23, no. 3, pp. 401406, 2009
10)
S. Sundar and P. Panzica, LiDCO systems, International Anesthesiology Clinics, vol. 48, no. 1, pp. 87100, 2010
11)
Vincent, J., Rhodes,A., Perel, A.,Martin,G., Rocca, D., Vallet, B.,Pinsky,M., Hofer,C., Tebou,J., Pieter de Boode, W., Scolletta,S.,VieillardBaron,A.,De Backer,D., Walley,K., Maggiorini,M.,Singer,M. Clinical review: Update on hemodynamic monitoring - a consensus of 16. Critical
Care 2011, 15:229
12)
Van Beest et al. Clinical review: use of venous oxygen saturations as a goal a yet unfi nished puzzle. Critical Care 2011, 15:232
Contact Info:
Gozde Demiralp, MD
Gozde-Demiralp@ouhsc.edu