Get the complete picture ...

PiCCO2

TM

Advanced Hemodynamic Monitoring

Complete hemodynamic picture without PA catheter

Continuous cardiac output Volumetric preload Afterload, contractility Volume responsiveness Pulmonary edema / Lung water
PiCCO2TM


Table of contents
PULSION Medical Introduction & History............................................................ 4 Overview ................................................................................................................. 6 Fields of Application ................................................................................................ 9 Methods . ................................................................................................................. 12 Parameters in Detail................................................................................................. 16 Visualization............................................................................................................. 32 PiCCO2TM Monitor, Setup and Catheters................................................................... 34 Catheters & Normal Ranges.................................................................................... 37 Recommended Literature......................................................................................... 41

PULSION Medical Systems

Manufacturer of medical equipment from Munich, Germany, established 1990 Production, development, administration, marketing and sales in Germany Subsidiaries in USA, France, Spain, UK, Benelux and Australia

PULSION headquarters in Munich, Germany

PULSION Medical Inc, Irving, Texas, USA



PiCCO-Technology
Leading specialist in less invasive hemodynamic monitoring in ICU More than 20 years experience in hemodynamic monitoring Paradigm shift in hemodynamics From pressures to volumes Integration of PiCCO into patient monitoring systems
PiCCO2 2007
TM

COLD System 1986-1997

PiCCO 1997

PiCCO plus 2002

Philips PiCCO Module 2003

Drger Infinity PiCCO SmartPod 2005

Optimization of Tissue Oxygenation

O2 uptake

O2 transport

O2 extraction

O2 utilization

PiCCO-Technology Which therapy?

Volume?

Vasopressors?

Inotropes?

Is measurement of CO enough?
Cardiac index CI Stroke volume SVI Preload GEDI, SVV, PPV Pulmonary edema ELWI Heart rate HR Afterload SVRI, MAP Contractility CFI

Volume?

Vasopressors?

Inotropes?

PiCCO2TM See more than others

Continuous cardiac output Volumetric preload Afterload Contractility Volume responsiveness Bedside pulmonary edema assessment (Lung water)

Fields of Application
Intensive Care Septic Shock Cardiogenic Shock Burns Trauma / Hypovolemic Shock ARDS Pediatrics Peri-operative Cardiac Surgery Major Surgery Neuro Surgery Pediatrics

Complete Hemodynamics via CVC and arterial line

Central venous line

(Standard CVC)

Arterial line

(PiCCO Catheter available in different sizes) Femoral, brachial or axillary artery

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PiCCO Catheters: different sizes - different sites

Axillary artery
Adults: 4F 8 cm, 3.15 in Small adults: 3F 7 cm, 2.76 in

Brachial artery
Adults: 4F 16 cm, 6.29 in Adults: 4F 22 cm, 8.66 in

Femoral artery
Adults: Adults: Small adults: Children: Children: 5F 20 cm, 7.78 in 4F 22 cm, 8.66 in 4F 16 cm, 6.29 in 3F 7 cm, 2.76 in 4F 8 cm, 3.15 in

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PiCCO - Two methods for precise parameters

Transpulmonary thermodilution Pulse contour analysis

Calibration

Thermodilution cardiac output Volumetric preload (GEDI) Contractility (CFI) Lung water (ELWI)

Continuous cardiac output Afterload (SVRI) Volume responsiveness (SVV, PPV) Stroke volume (SVI)

All parameters are explained in detail (from page 16). On the right side of the PiCCO device the parameters are identified as either continuous or discontinuous.
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PiCCO - Pulse Contour Analysis

Stroke volume is reflected by the area under the pressure curve (red area) of one heart beat Cardiac output is calculated beat-by-beat: stroke volume x heart rate

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PiCCO - Transpulmonary Thermodilution

Bolus injection

Bolus detection

The indicator is detected in a central artery The cold indicator passes through the right heart, lungs and left heart Precise cardiac output measurement based on Stewart-Hamilton algorithm Breathing or ventilator cycle independent Passage through the heart and lungs allows determination of preload volumes and lung water
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Calculation of Volumes
The shape of the thermodilution curve depends on the volume through which the indicator passes.

large volume

small volume

34 C

temperature

34 C

temperature

long passage time 36 C time in sec

short passage time

36 C

time in sec

Resulting temperature curves

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Thermodilution Cardiac Output

Cardiac Output - Volume of blood pumped by the heart in one minute Important determinant for oxygen transport

Time since TD 0 h 52 min 10:26 am

TD Results
CI GEDI ELWI T 10:18 am 10:20 am 10:22 am 10:26 am SEP 23 SEP 23 SEP 23 SEP 23

3.47 705 9 1.18

3.11 626 9 1.17

3.15 678 10 0.30

3.76 764 10 1.20

3.44 698 9

Flow

Inj. Volume
98.1

10:26 am SEP 23

15 ml CVP 5 mmHg

START READY

PCCI
SVRI 1735

5.0 3.0

4.52
l/min/m 2

98.6 0s 10s 20s 30s

Exit

CCI

dyn*s*cm-5 m 2

SVI

ml/m 2

47

CO Cardiac Output CI Cardiac Index Highly precise measurement by using thermodilution technique Calculated the same way mathematically as with the PA catheter
Volume

l/min/m 2
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Determination of Thermodilution Cardiac Output

Cardiac output is calculated by analysis of the thermodilution curve using a modified Stewart-Hamilton algorithm After central venous injection of the indicator, the thermistor at the tip of the arterial catheter measures the downstream temperature change

Cardiac output calculation: Area under the thermodilution curve

CO TDa =

(Tb - Ti) x Vi x K Tb x dt

Tb = Ti = Vi = Tb x dt = K=

Blood temperature Injectate temperature Injectate volume Area under the thermodilution curve Correction constant, made up of specific weight and specific heat of blood and injectate
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Calibrated Continuous Cardiac Output

Cardiac Output - Cardiac Output (CO) is regarded as one of the most important hemodynamic variables for the assessment of cardiac function and guidance of therapy in critically ill patients. Time since TD 0 h 52 min 10:26 am Sakka et al. BJA , 2007
Flow

PCCI
SVRI 1735

5.0 3.0

4.52
l/min/m 2

PCCI

dyn*s*cm-5 m 2

SVI

ml/m 2

47

l/min/m 2

PCCO Pulse Contour Cardiac Output Volume PCCI Pulse Contour Cardiac Index Product of stroke volume and heart rate MAP Determination beat-by-beat Maximum accuracy and safety by recalibration possibility
ml/m 2

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PiCCO Continuous Cardiac Output

Transpulmonary thermodilution Pulse contour analysis

Calibration

Discontinuous

Continuous (beat-by-beat)

The pulse contour cardiac output determination is adjusted to the patients` exact clinical situation including their aortic compliance.

Cardiac output is the product of stroke volume and heart rate CO = SV x HR

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l/min/m 2

SVRI 1735 Preload Volume instead of filling pressures PCCI

dyn*s*cm-5 m 2

SVI

ml/m 2

47

Preload - Volume of blood in the heart, available to be pumped Volumetric preload parameters are superior to filling pressures Michard, YICM 2004
Volume

l/min/m 2

MAP
ml/m 2

SVV

9
%

Organ Function GEDV Global End-Diastolic Volume GEDI Global End-Diastolic Volume Index Filling volume of all four heart chambers Adequate preload is an important prerequisite for adequate cardiac output (Frank-Starling curve) SVRI GEDI is indexed to predicted body surface area * ml/kg
* Indexing particular parameters i.g. to the predicted body weight (EVLW) or predicted body surface area (GEDV) rather than the actual body weight or body surface area is more accurate particularly in overweight patients.
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Determination of Volumetric Preload

temperature

Intra-Thoracic Thermal Volume ITTV = CO x MTt

MTt Mean transit time

time in sec

temperature

Pulmonary Thermal Volume PTV = CO x DSt

time in sec Dst Down slope time

Global End-Diastolic Volume (GEDV)

PTV = Pulmonary Thermal Volume; Volume in the biggest mixing chamber, i.e. the lungs (includes blood and water) ITTV = Intra-Thoracic Thermal Volume; The total volume in which the indicator can be distributed (chambers between point of injection and detection) CO = Cardiac output 21

Lung Water LungMAP edema assessment at the bedside

EVLW Extravascular Lung Water reflects pulmonary edema
ml/m 2

Volume

SVV

9
%

Organ Function

SVRI
ml/kg AP/CVP 1/min EVLW Extravascular Lung Water ELWI Extravascular Lung Water Index Includes intra-cellular, interstitial and intra-alveolar water (not pleural effusion) Extravascular lung water (EVLW) represents the extravascular water content of the lung tissue ELWI is indexed to Predicted Body Weight
*Predicted body weight is determined from the body height, gender and age
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Determination of Lung Water

EVLW is the difference between intra-thoracic thermal volume (ITTV) and intra-thoracic blood volume (ITBV) ITBV is the blood volume in the heart plus the pulmonary blood volume It has been found that ITBV is consistently 25% higher than GEDV

Intra-Thoracic Thermal Volume (ITTV)

Intra-Thoracic Blood-Volume (ITBV) ITBV = GEDV x 1.25

Extravascular Lung Water (EVLW)

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Lung Water Measurement vs. Chest X-ray

Pulmonary edema
Pulmonary edema is not easily detected by chest X-ray EVLW is a direct quantification of pulmonary edema ELWI 21 ml/kg BW ELWI 11 ml/kg BW ELWI 5 ml/kg BW

Lung water severely increased

Lung water moderately increased

Lung water not increased

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Source: Unpublished Data; Azriel Perel, MD, Department of Anaesthesiology and Intensive Care, Sheba Medical Center, Tel Aviv University, Tel Hashomer, Israel

Improved outcome based on fluid management

Organ function - Lung water
Ventilation days ICU days

reduced by Days

59%

reduced by

53%

Control group

Protocol group

Control group

Protocol group
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Source: Improved outcome based on fluid management in critically ill patients requiring pulmonary artery catheterization Mitchell JP, Schuller D, Calandrino FS, Schuster DP, Am Rev Respir Dis 1992; 145(5): 990-8

Time since TD 0 h 52 min 10:26 am

Flow resistance Afterload - the systemic vascular

Systemic vascular resistance - important determinant of afterload

PCCI

5.0 3.0

4.52
l/min/m 2

PCCI

SVRI 1735

dyn*s*cm-5 m 2

SVI

ml/m 2

47

l/min/m 2
Volume

SVR - Systemic Vascular Resistance SVRI - Systemic Vascular Resistance Index

MAP

ml/m 2

SVV

26

Determination of Afterload
SVR = SVRI = MAP - CVP CO SVR x BSA x 80

Vasoconstriction: Flow (CO)

Flow (CO) = Pressure Resistance

Vasodilation: Flow (CO) if pressure is constant

BSA = Body Surface Area

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ml/m 2

Contractility

% Contractility describes the performance of the cardiac muscle

Organ Function

SVV

SVRI
ml/kg AP/CVP

1/min

CFI - Cardiac Function Index Parameter of the global cardiac contractility The cardiac function index is the ratio of flow and preload CFI = CO (Cardiac Output) / GEDV (Global End-Diastolic Volume)
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Contractility

SV (ml)

80

2
40

Inotropic drugs

1 increase preload
600 800
preload GEDI (ml/m2)

Frank-Starling curve

The Frank-Starling curve reflects the interaction between preload and stroke volume 1. Increase preload volume to its optimum 2. Increased contractility shifts the curve upwards (see graphic)
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Volume Responsiveness

l/min/m 2 l/min/m 2 2 l/min/m

Volume Volume Volume

Volume Responsiveness - predicts whether volume resuscitation (preload increase) will MAP MAP result in an increase in cardiac output MAP
ml/m 2 ml/m 2 2 ml/m

SVV 9 SVV SVV 9 9% %

%
Organ Function Organ Function Organ Function

SVV Stroke Volume Variation Variation in stroke volume over the breathing cycle for a specific time frame PPV Pulse Pressure Variation AP/CVP Variation in pulse pressure over the breathing cycle for a specific time 1 /frame min AP/CVP Only applicable in mechanically ventilated patients in sinus rhythm

SVRI SVRI SVRI

ml/kg ml/kg ml/kg

AP/CVP

1/min 1/min

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Determination of Volume Responsiveness

SVmax SVmin PPmax PPmin

inspiration

expiration

inspiration

expiration

Mechanical Ventilation
Intrathoracic pressure fluctuations Changes in intrathoracic blood volume Preload changes Fluctuations in stroke volume and pulse pressure

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Basis of Success - Fast Decisions

Overview Details Trends

32

PiCCO2 Visualization of Hemodynamic Parameters

TM

Overview
Height 70 inch Weight 182 lbs Time since TD 0 h 52 min 10:26 am
Flow

PCCI

HR

86

140

AP 132/71 MAP 91 (CVP 9)

Details
AP 70

PCCI
Volume Organ Function
11 9 900 850 800 750 700

4.52

SVI

MAP

Basic
7.00 6.00 5.00 4.00 3.00

Flow

14
Volume

815

7 5 3 1 0

Trends
120

SVV

SVRI

2.86

650 600 550

AP

2.00 1.00

Organ Function

90

SpiderVision screen
TM

CI

l/min/m2

ml/m2

ELWI

60

ml/kg

9.0

PCCI/CI
x x xxx

Values at time of TD,

TD

0 h 52 min ago
5.0

Dynamic status indicator

AP/CVP

1.0 2800

Profiles screen

SVRI

Detailed insight at parameter level

2100

1400

-6h

-5h

-4h

-3h

-2h

-1h

10 : 26 am

Trends screen

Clinical trends and therapy results

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Innovative operation - via touch-screen or navigation dial

Information bar

Real-time pressure curve

Innovative data visualization

Parameter fields

Direct access buttons

34

PiCCO2 The new Hemodynamic Monitor

TM

Brilliant 13.3 colour wide screen display Touch-screen, navigation dial Slim ergonomic design Small footprint Compatible to standard mounting systems Integrated battery backup

35

PiCCO2 Setup
TM
Flush bag B

Standard CVC

E D G E Arterial connection cable

Injectate sensor cable

E F
A

Pressure connection cable

PiCCO Catheter

36

PiCCO2 Setup
TM

A B

PiCCO Catheter Injectate temperature sensor housing Injectate sensor housing Injectate sensor cable Arterial connection cable

PiCCO thermistor plug Pressure connection cable

37

PiCCO Catheters with Nitinol Guide Wire

Application Adults Adults Adults Adults Small adults Adults Children Children Small adults Artery Femoralis Brachialis cubital Femoralis Article No. PV2015L20N PV2014L22N PV2014L22N Diameter 5F / (~14G) / 1,7 mm 4F / (~16G) / 1,3 mm 4F / (~16G) / 1,3 mm 4F / (~16G) / 1,3 mm 4F / (~16G) / 1,3 mm 4F / (~16G) / 1,3 mm 4F / (~16G) / 1,3 mm 3F / (~18G) / 1,0 mm 3F / (~18G) / 1,0 mm Usable length 20 cm / 7.78 in 22 cm / 8.66 in 22 cm / 8.66 in 16 cm / 6.29 in 16 cm / 6.29 in 8 cm / 3.15 in 8 cm / 3.15 in 7 cm / 2.76 in 7 cm / 2.76 in
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Brachialis proximal PV2014L16N Femoralis Axillaris Femoralis Femoralis Axillaris PV2014L16N PV2014L08N PV2014L08N PV2013L07N PV2013L07N

Hemodynamic Measurement Guide - Normal Values

Parameter Cardiac Index Stroke Volume Index Global End-Diastolic Volume Index Intrathoracic Blood Volume Index Stroke Volume Variation Pulse Pressure Variation Systemic Vascular Resistance Index Cardiac Function Index Mean Arterial Pressure Extravascular Lung Water Index Abbreviation CI SVI GEDI ITBI SVV PPV SVRI CFI MAP ELWI Range 3.0 5.0 40 60 680 800 850 1000 < 10 < 10 1970 - 2390 4.5 6.5 70 90 < 10 Unit I/min/m2 ml/m2 ml/m2 ml/m2 % % dyn*s*cm-5 *m2 1/min mmHg ml/kg

WARNING: PULSION Medical Systems is a medical device manufacturer and does not practice medicine. PULSION does not recommend these normal values for a specific patient. The treating physician is responsible for determining and utilizing the appropriate diagnostic and therapeutic measures for each individual patient.

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Hemodynamic Measurement Guide

This decision model is not obligatory. It cannot replace the individual therapeutic decisions of the treating physician.

CI (l/min/m )
2

< 3.0 < 700 < 850 < 10 > 10 > 700 > 850 < 10 > 10 < 700 < 850 < 10

> 3.0 > 700 > 850 < 10 > 10

Measured Values

GEDI (ml/m ) or ITBI (ml/m )

2 2

ELWI (ml/kg)
Therapy Options

> 10

V+?
Targeted Values

V+? Cat?

Cat?

Cat? V-?

V+?

V+?

V-?

> 700 700-800 > 700 700-800 1. GEDI (ml/m ) > 850 850-1000 > 850 850-1000 or ITBI (ml/m ) < 10 < 10 < 10 2. Optimise SVV (%)* < 10
2 2

> 700 700-800 700-800 > 850 850-1000 850-1000 < 10 < 10 < 10 < 10 OK!

CFI (1/min) ELWI (ml/kg)

(slow response)

> 4.5

> 5.5 < 10

> 4.5

> 5.5 < 10

< 10

< 10
40

V+ = volume loading V- = volume reduction Cat = catecholamine / cardiovascular agents * SVV is only applicable in fully ventilated patients without cardiac arrhythmia

PiCCO2 - Get the complete picture ...

TM

PiCCO-Technology provides advanced hemodynamic and volumetric management for better patient care.

Evaluate PiCCO for yourself! We look forward to working with you!!

41

Advantages of PiCCO-Technology
Precise, calibrated beat-to-beat cardiac output Preload volumes instead of filling pressures Bedside pulmonary edema assessment Surpasses PA Catheter indications and offers additional fields of application

42

Recomended Literature
Cardiac Output Flow
Pulse contour cardiac output analysis in a piglet model of severe hemorrhagic shock Piehl MD, Manning JE, McCurdy SL, Rhue TS, Kocis KC, Cairns CB. Crit Care Med 2008; 36: 1189-95 Where do we go from here? Cardiac output determination in pediatrics. Hanna BD. Childrens Hospital of Philadelphia. Crit Care Med 2008; 36: 1377-8 Cardiac index measurements during rapid preload changes: a comparison of pulmonary artery thermodilution with arterial pulse contour analysis. Felbinger TW, Reuter DA, Eltzschig HK, Bayerlein J, Goetz AE. J Clin Anesth 2005; 17(4):241-8

Preload (Global Enddiastolic Volume)

Volumetric preload measurement by thermodilution: a comparison with transoesophageal echocardiography Hofer CK, Furrer L, Matter-Ensner S, Maloigne M, Klaghofer R, Genoni M, Zollinger A. ; Br J Anaesth 2005; 94(6):748-55 Global end-diastolic volume as an indicator of cardiac preload in patients with septic shock Michard F, Alaya S, Zarka V, Bahloul M, Richard C, Teboul JL. Chest 2003; 124(5):1900-8

Lung Water

Accurate characterization of extravascular lung water in acute respiratory distress syndrome Berkowitz DM, Danai PA, Eaton S, Moss M, Martin G. Crit Care Med 2008; 36: 1803-9 Extravascular lung water in sepsis-associated acute respiratory distress syndrome: indexing with predicted body weight improves correlation with severity of illness and survival. Phillips C, Chesnutt M, Smith M. Crit Care Med 2008; 36: 69-73 Extravascular lung water measurements and hemodynamic monitoring in the critically ill: bedside alternatives to the pulmonary artery catheter. Isakow W, Schuster DP. ; Am J Physiol Lung Cell Mol Physiol 2006 291: 1118 - 33 Extravascular lung water in patients with severe sepsis: a prospective cohort study Martin GS, Eaton S, Mealer M, Moss M. Crit Care 2005; 9: R74-82 Improved outcome based on fluid management in critically ill patients requiring pulmonary artery catheterization Mitchell JP, Schuller D, Calandrino FS, Schuster DP. Am Rev Respir Dis 1992; 145: 990-8

Guidelines and Standard Operating Procedures

Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008 Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, Reinhart K, Angus DC, Brun-Buisson C, Beale R, Calandra T, Dhainaut JF, Gerlach H, Harvey M, Marini JJ, Marshall J, Ranieri M, Ramsay G, Sevransky J, Thompson BT, Townsend S, Vender JS, Zimmerman JL, Vincent JL. Intensive Care Med 2008; 34: 17-60 Goal directed fluid management reduces vasopressor and catecholamine use in cardiac surgery patients Goepfert M, Reuter D, Akyol D, Lamm P, Kilger E, Goetz A. Intensive Care Medicine 2007; 33: 96-103

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Contact
For further information on: Literature for specific fields of application Case studies Product information Educational material please visit www.PULSION.com or contact us

PULSION Medical Inc. 2445 Gateway Drive Suite 110 Irving, Texas 75063 Toll free 877.655.8844 Phone 732.514.6610 Fax 732.514.6614 info@pulsion.com www.PULSION.com

MPI851105US_R01 PULSION 10/2008

See instructions for use and package insert for full prescribing information. Technical specifications are subject to change without further notice. 2008 PULSION Medical Systems AG all rights reserved.

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