Manu Malbrain - Nursing thisisit final monitoring - IFAD 2012
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Transcript of Manu Malbrain - Nursing thisisit final monitoring - IFAD 2012
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 1
Hemodynamic Monitoring Anno 2012
17th November 2012
2nd iFAD – Nursing Session
Manu Malbrain
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 2
Therapeutic Dilemma - Conflict
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 3
What I really need to know is…
When do I start giving fluids?
When do I stop giving fluids?
When do I start emptying?
When do I stop emptying?
SEE
MORE
THAN
OTHERS
benefit of fluid administration?
risk of fluid administration?
benefit of fluid removal?
risk of fluid removal?
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 4
Today’s Agenda
• Introduction
• From Invasive to Less invasive
• Results of PulsioFlex study
• Results of NexFin study
• Wrap it up
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 5
HD Monitoring Anno 2012
Introduction
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 6
Disclosure
The speaker consults for the following companies:
BMEYE
Edwards
PULSION Medical Systems
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 7
Cardiac output (CO) is the main determinant of oxygen delivery
Physical examination and vital signs alone often fail to reflect significant derangements in CO
Many of our therapeutic efforts are aimed at increasing the CO
The monitoring of CO is therefore very useful for proper decision-making in critically ill and high-risk surgical patients.
Some statements on CO measurement
Thanks to Azriel Perel
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 8
Bodies of two Air France passengers found CNN.COM June
6, 2009
The airline had failed to replace a part that monitors speed, as recommended by the
manufacturer, based on technological developments and improvements.
The fact that this statement is not
supported by EBM tells us more about the
shortcomings of EBM than those of the
measurement of CO
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 9
The two main reasons to measure CO are:
Identification of patients who have low (or high)
CO values that are not evident clinically
Measurement of the response to diagnostic and
therapeutic interventions
It is time to consider CARDIAC OUTPUT
as just another vital sign!
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 10
A Perel, M Maggiorini, M Malbrain, JL Teboul, J Belda, E Fernández-Mondéjar, M Kirov, J Wendon
The PiCClin Study
206 critically ill patients were evaluated by 166 residents and 146 specialists.
EVLWiGEDViSVRCO
124
(40.8%)
154
(49%)
107
(34.3%)
110
(34.9%)
Within±
20%
83
(27.3%)
97
(30.9%)
46
(14.7%)
170
(54%)
Under-
estimation
>20%
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 11
Because of the complexity of assessment of
clinical variables in septic patients, direct
measurement of CO by invasive hemodynamic
monitoring is advisable.
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 12
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 13
Perioperative optimization
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 14
Funk DJ, Moretti EW, Gan TJ. Anesth Analg 2009;108:887–97
With the advancing age of the surgical population and the increasing prevalence of ischemic heart disease, the need for monitoring of organ flow is likely to increase.
Clinicians (both in the OR and the critical care setting) are looking more toward the use of minimally or noninvasive monitors of CO.
Of the available monitors, the ED and the arterial pulse contour devices seem to have the greatest potential at replacing the PAC for CO measurement.
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 15
What hemodynamic monitoring do you routinely use for the management of high-risk surgery
patients?
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 16
HD Monitoring Anno 2012
Less invasive CO…
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 17
Real Time beat to beat COReal Time Preload + AfterloadAdequacy data
Minimally invasiveWidely applicable
Simple to Operate and UnderstandMeasured variables
Clear Data Display + Interpretation
Cardiac Output Monitoring
Nurse driven at the bedside
Neonates to adults
Ideal System
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 18
• Fick– Difficult, large room for
error, “Gold” standard– NiCO2
• Bioimpedance– Variable ICU accuracy– Cardiodynamics
• Doppler– Accurate, but user
dependent– HemoSonic, Deltex, WAKI
• Pulse Contour Analysis– PiCCO/EV 1000
– PulseCO
– Vigileo/ Pulsioflex
• Thermodilution– Vigilance PAC, CEDVi
– (PiCCO)
• Indicator Dilution– Invasive
– (LiDCO)
Available technologies for
continuous Cardiac Output
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 19
PA catheter
Ad
van
ced
mo
nit
ori
ng Which device for monitoring cardiac output?
PiCCO EV 1000
cardiac output cardiac output cardiac output
PAP - PAOP GEDVi GEDVi
EVLWi - PVPI EVLWi - PVPI
GEF - dpmax GEF - dpmax
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 20
• Advantages– ‘Simple’ catheter– No added fluid– No calibration– “Operator independent”– SVO2 / Volumetric measurements
• Disadvantages– Invasive– Non continuous (3-6 minutes)– Slow response to change– Poor signal to noise ratio– Non verifiable data
Vigilance - CEDVI
Gold Standard
RV end-diastolic volume (RVEDV)(pulmonary artery thermodilution)
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 21
1. Transpulmonary thermodilution 2. Arterial Pulse contour analysis
Algorithm after calibration
What is TPTD technology ?
Global end-diastolic volume (GEDV)(transpulmonary thermodilution)
Intrathoracic blood volume (ITBV)(thermo-dye transpulmonary dilution)
PiCCOorEV1000
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 22
Cardiac output measurementby transpulmonarythermodilution
RA LARV LVPBV
EVLW
Cardiacoutput
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 23
1. Transpulmonary lithiumdilution 2. Pulse power analysis algorithm combined with
indicator dilution calibration
What is LiDCO/PulseCO technology ?
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 24
•Indicator dilution technique•Lithium chloride (0.15-0.3 mmol) marker•Intravenous bolus (peripherally or centrally)•Ion selective electrode attached to arterial line•CO computed
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 25
Vigileo Eso Doppler
preloaddependance
(Δ aortic blood flow)
preload(FTc)
Pulsioflex
preloaddependance
(VVE and Δ PP)
preloaddependance
(VVE and Δ PP)
LidCOrapid
preloaddependance
(SVV and Δ PP)
continuouscardiac output
continuouscardiac output
(cardiac output)(AP curveanalysis)
continuouscardiac output
(AP curveanalysis)
continuouscardiac output
(AP curveanalysis)
Less
Inva
sive
mo
nit
ori
ng
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 26
1. CO estimation2. Pulse Contour Analysis
What is Vigileo technology ?
CO = HR * SV
•Heart Rate measurement
•Biometric and dynamic compensation for the vasculature
• Pulse pressure measurement proportional to Stroke Volume
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 27
Trending Stroke Volume
• Arterial pressure is sampled at 100 Hz(i.e., 20sec x 100Hz = 2000 data points)
• An equivalent for pulse pressure is achieved by taking the standard deviation (SD) of the 2000 sampled data points
• SD(Arterial pressure) - Pulse Pressure - Stroke Volume• Changes in stroke volume will result in corresponding changes
in the pulse pressure• SV estimates are updated over 20 seconds
20 sec.
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 28
SD is a measure of variation of the AP
↑ AP Variation ➔ ↑ SD(AP) ➔ ↑ SV
Therefore, with a constant vasculature …
↓ AP Variation ➔ ↓ SD(AP) ➔ ↓ SV
20 sec. 20 sec.20 sec.
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 29
PulsioFlex
• ProAqt sensor
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 30
Pram• Pressure• recording• analytical• method
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 31
NesCO
• Estimated
• Continuous
• CO
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 32
Cheetah - NICOM
• Bioreactance
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 33
ECOM
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 34
UsCOM
• ultrasound
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 35
Transonic
• COstatus
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 36
ImaCor
• Disposable TEE
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 37
1. Pulsed Doppler Velocity
2. M-mode aortic root diameter
What is HemoSonic technology ?
HemoSonic
Atys
Médical
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 38
Ø 7mm
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 39MM 06/2006 – 39
Probe Positioning
correct
incorrect
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 40
Doppler Principles
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 41
1. Indirect Fick Principle2. Respiratory Mechanics
What is NiCO2 technology ?
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 42
What is NiCO2 technology ?
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 43
What is NiCO2 technology ?
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 44
Arterial pressure
Esophageal Doppler
Flotrac/VigileoPulsioflex
LidCOrapid
AP catheter
CVP
PiCCOEV 1000
Basic monitoring Advanced monitoring
OR monitoring
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 45
Different panel of hemodynamic information
Arterial pressure
Esophageal Doppler
Vigileo/Pulsioflex
LidCOrapid
PAC
CVC / ScvO2
PiCCO/EV1000
vasomotortone
lungwater
cardiaccontractility
tissueoxygenation
preloadCO/SV preloaddependance
Different monitoring devices
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 46
HD Monitoring Anno 2012
How to compare 2 techniques?
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 47
1. Correlations…
Gold standard Gold standard
Inverse correlationNot equivalent
Good correlationSystematicoverestimation
Gold standard
Poor correlationSystematicunderestimation
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 48
1. Correlations…• Pearson correlation
(p<0.01)
• Line of identitycrosses “0”
• Linear relation
• R2>0.6
• R>0.75
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 49
CO
PA-
CO
A
(COPA-COA)/2Bias
Limits of Agreement = ± 2 SD
Normal HighLow
CO = 3 ± 1 l/min CO = 8 ± 1 l/min
± 12.5%
<35%
2. Bland and Altman…
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 50
3. Critchley
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 51
PRECISE
ACCURAT
E
IMPRECISE
ACCURAT
E
PRECISE
INACCURATE
IMPRECISE
INACCURATE
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 52
Are uncalibrated CO monitors
accurate enough to guide therapy?
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 53
Anesthesia Analgesia 2009, 108:707
When evaluating the role of new CO devices in clinical care, the fundamental question is whether the new device can replace thermodilution CO measurement as a guide to clinical decisions.
Despite the large number of studies evaluating new CO devices, few, if any, answer this fundamental question.
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 54
HD Monitoring Anno 2012
PulsioFlex StudyZNA Stuivenberg
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 55
PulsioFlex Escalation Study
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 56
Reference:
NEXFIN ! left ! right
Finger
Edema ! yes ! no Date
Hospital
Patient ID (anonym) Height cm Weight kg
Age Y Gender female. ! male !
Medication
Obs 6 PiCCO2 Pulsioflex Nexfin/radial NIV/Monitor Other
Time +8hrs ADsys SaO2:
ADdia Blood T°:
MAP Periph T°:
SVV Nex Hgb: CVP:
PPV dobu:
dPmax Rythm: levo:
SVRI ulti:
SVI dorm:
HR dipri:
Auto CI 1.* CCI 2. 3. 4. other:
Obs 7 ADsys SaO2:
Time + 2 hrs ADdia Blood T°:
MAP Periph T°:
SVV CVP:
PPV dobu:
dPmax Rythm: levo:
SVRI ulti:
SVI dorm:
HR dipri:
CCI other:
Obs 8 ADsys SaO2:
Time + 4 hrs ADdia Blood T°:
MAP Periph T°:
SVV CVP:
PPV dobu:
dPmax Rythm: levo:
SVRI ulti:
SVI dorm:
HR dipri:
CCI other:
Obs 9 ADsys SaO2:
Time + 6 hrs ADdia Blood T°:
MAP Periph T°:
SVV CVP:
PPV dobu:
dPmax Rythm: levo:
SVRI ulti:
SVI dorm:
HR dipri:
CCI other:Obs10+16hrs ADsys SaO2:
MV Mode ADdia Blood T°:
RR MAP Periph T°:
TV SVV Nex Hgb: CVP:
IPAP PPV dobu:
PEEP dPmax Rythm: levo:
FiO2 SVRI GEF: ulti:
pO2/pCO2 / SVI GEDVi: dorm:
pH/lact / HR EVLWi: dipri:
HCO3/BE / CCI 1. 2. 3. TPTD CI(5): other:
Auto CI 4.
! Brachial/Axillar ! Radial !Femoral
PiCCO2 ! De-escalation Arm
PiCCO placement ! left ! right
Observation: PULSIOFLEX vs. PiCCO2 8 - 16 hrs (PulsioFlex AUTOcalibration*)
PiCCO2 ! escalation Arm
Fluid Balance/8hrs! Brachial/Axillar ! Radial !Femoral
Pulsioflex placement ! left ! right
Reference:
NEXFIN ! left ! right
Finger
Edema ! yes ! no Date
Hospital
Patient ID (anonym) Height cm Weight kg
Age Y Gender female. ! male !
Medication
Time 0 PiCCO2 Pulsioflex Nexfin/radial NIV/Monitor Other
MV Mode ADsys SaO2:
RR ADdia Blood T°:
TV MAP Periph T°:
IPAP SVV Nex Hgb: CVP:
PEEP PPV dobu:
FiO2 dPmax Rythm: levo:
pO2/pCO2 / SVRI GEF: ulti:
pH/lact / SVI GEDVi: dorm:
HCO3/BE / HR EVLWi: dipri:
Auto CI 5. CCI 2. 3. 4. TPTD CI*(1): other:
Obs 2 ADsys SaO2:
Time + 2 hrs ADdia Blood T°:
MAP Periph T°:
SVV CVP:
PPV dobu:
dPmax Rythm: levo:
SVRI ulti:
SVI dorm:
HR dipri:
CCI other:
Obs 3 ADsys SaO2:
Time + 4 hrs ADdia Blood T°:
MAP Periph T°:
SVV CVP:
PPV dobu:
dPmax Rythm: levo:
SVRI ulti:
SVI dorm:
HR dipri:
CCI other:
Obs 4 ADsys SaO2:
Time + 6 hrs ADdia Blood T°:
MAP Periph T°:
SVV CVP:
PPV dobu:
dPmax Rythm: levo:
SVRI ulti:
SVI dorm:
HR dipri:
CCI other:
Obs 5 + 8hrsADsys SaO2:
MV Mode ADdia Blood T°:
RR MAP Periph T°:
TV SVV Nex Hgb: CVP:
IPAP PPV dobu:
PEEP dPmax Rythm: levo:
FiO2 SVRI GEF: ulti:
pO2/pCO2 / SVI GEDVi: dorm:
pH/lact / HR EVLWi: dipri:
HCO3/BE / CCI 1. 2. 3. TPTD CI(5): other:
Auto CI 4.
Pulsioflex placement ! left ! right
! Brachial/Axillar ! Radial !Femoral
PiCCO2 ! De-escalation Arm
Fluid Balance/8hrs
Observation: PULSIOFLEX vs. PiCCO2 0 - 8 hrs (PulsioFlex calibration with TPTD*)
PiCCO2 ! escalation Arm
PiCCO placement ! left ! right
! Brachial/Axillar ! Radial !Femoral
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 57
Patients
• So far, 37 mechanically ventilated ICU patientsincluded
• All Escalation
Age Gender height weight BMI APACHE SAPS SOFA
mean 53,2 20,0 172,8 84,1 28,3 26,0 51,1 9,8
SD 15,5 Male 9,4 22,4 7,9 6,4 11,9 2,7
8h time periods 1 2 3 4
PICCO2 Femoral
Pulsioflex Radial Femoral
Calibration TDCI AutoCI TDCI AutoCI
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 58
Regression PiCCI vs PulseCI
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 59
Correlation with TPTDCI
PulsioflexPulse contour
PiCCO2Pulse contour
ProAQTAuto Calibration
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 60
Bland and Altman
PICCI-PULSECI TDCI-PICCI TDCI-PULSECI TDCI-AUTOCIn 440 182 182 182
mean 3,7 0,00 3,7 0,04 3,7 0,04 3,7 0,03
SD 1,1 0,58 1,1 0,40 1,0 0,58 0,9 0,61
min/LLA 1,7 -1,16 1,5 -0,76 1,8 -1,13 2,0 -1,20
max/ULA 7,0 1,17 6,9 0,84 6,7 1,20 6,6 1,25
COVA 30% 29% 26% 24%
PE 8,0 31,5% 7,9 21,6% 7,7 31,4% 7,6 32,9%
PE 31.5% PE 21.6%
PE 31.4% PE 32.9%
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 61
Concordance: Changes in CI
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 62
Effect of therapeuticintervention• In total 40 interventions
• Passive leg raising (n=13)
• Fluid bolus 500ml/30 minutes (n=11)
• Increase or decrease of vasopressor (n=10)
• Increase or decrease of dobutamine (n=5)
• Increase in sedation (n=1)
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 63
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 64
HD Monitoring Anno 2012
NexFin StudyZNA Stuivenberg
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 65
The Nexfin device
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 66
The Nexfin applies 3 major steps in the
non-invasive measurement of CCO.
The Nexfin: Principles of measurement
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 67
An inflatable cuff* is wrapped around the middle phalanx of the 2nd, 3rd or 4th finger.
* 3 sizes
1. Measurement of continuous beat-by-beat finger BP
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 68
The diameter of the finger arteries is measured by a pair of LED’s.
The cuff inflates and relaxes to keep the diameter constant throughout the cardiac cycle.
The pressure that is needed to keep the diameter constant is continuously recorded generating a real-time pressure waveform.
Volume Clamp Technology
1. Measurement of continuous beat-by-beat finger BP
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 69
2. Transformation of finger BP to brachial BP by a
transfer function based on a vast clinical database
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 70
3. Calculation of the CCO from the brachial BP waveform
Nexfin CO-Trek
The Nexfin CO-Trek method is based on the hemodynamic version of Ohm's law
ΔP/Q = Zin
Thus, when the arterial input impedance (Zin) is known, a given pressure (P) allows for the calculation of the related flow (Q).
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 71
Poster @ISICEM
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 72
Patient Characteristics
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 73
CI evolution
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 74
MAP evolution
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 75
Final analysis CO (45 pats)
-5.0
-4.0
-3.0
-2.0
-1.0
0.0
1.0
2.0
3.0
4.0
5.0
0.5 2.5 4.5 6.5
Bland and Altman PiCCI vs CI NEXFIN
-5.0
-4.0
-3.0
-2.0
-1.0
0.0
1.0
2.0
3.0
4.0
5.0
0.5 2.5 4.5 6.5
Bland and Altman TDCI vs CI NEXFIN
%error = 36.9% %error = 37.1%
y = 0.8724x + 0.3928R² = 0.6781
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
0.0 5.0 10.0 15.0
Nex
CO
(l/
min
)
TDCO (l/min)
y = 0.877x + 0.5645R² = 0.7091
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0
Nex
CO
(l/
min
)
CCO (l/min)
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 76
Final Analysis MAP (45 pats)
-50.0
-40.0
-30.0
-20.0
-10.0
0.0
10.0
20.0
30.0
40.0
50.0
25.0 50.0 75.0 100.0 125.0 150.0
Bland and Altman PiCCO vs CO NEXFIN
y = 0.9417x + 3.1686R² = 0.8846
25.0
50.0
75.0
100.0
125.0
150.0
25.0 50.0 75.0 100.0 125.0 150.0
Correlation MAP Nexfin vs MAP PiCCO
%error = 14.7%
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 77
• 35 year old• suicide attempt (glucophage)• Septic shock• Metabolic (lactic) acidosis
Case studyInfusion pumps
dialysis
NEXFIN PiCCO2
Evita XL
CiMON
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 78
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 79
PiCCI
NEXCI
art rad MAP
NEXMAP
PiCCOMAP
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 80
• 35 year old man, suicide attempt, Levo 0.45y
Case studyAgitation, pain midazolam
Small drift
PiCCI
NEXCI
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 81
Case studyAgitation, pain
midazolam
MAP
NEXMAP
• 35 year old man, suicide attempt, Levo 0.45y
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 82
PiCCI
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 83
AUC (PiCCO) = 8752 vs AUC (NEXFIN) = 9847 = 88.9%
NEXCI
NEXFIN
PiCCO
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 84
Concordance Plot
y = 0.4056x - 0.0147R² = 0.3693
-4
-3
-2
-1
0
1
2
3
4
-4 -3 -2 -1 0 1 2 3 4
DN
EXC
O (
l/m
in)
DTDCO (l/min)
Exclusion zone: 35/90
Level of concordance:
50/55 (91%)
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 85
Conclusions
• TRULY non-invasive
• Reasonable results in a really critically ill patient sample (n=45)
• Performs even better than other more invasive techniques
• Correlates excellent with invasive MAP
• LA for CI acceptable although % error too big
• Better patient selection needed
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 86
The Future for NEXFIN Double Cuff for continuous CCI
Hygienic properties
Longer connectors
Physiocal optimisation
Quantification of SVV and PPV
Could be used in ER (pattern recognition) and OR setting
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 87
HD Monitoring Anno 2012
Conclusions
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 88
Evidence Based Medicine Does my new monitoring device does as
well as the gold standard?
Does my new monitoring device givenew or additional information?
Does the interpretation of the data change my treatment?
Does the new-variable-driven treatmentchange patient outcome?
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 89
The Parachute Study
Gordon C S Smith, Jill P Pell BMJ 2003; 327:1459-60
WHAT DO WE KNOW WHAT THIS STUDY ADDS
• No RCCT on parachute
• Basis for parachute use
Purely observational
• Efficacy explained by
Healthy cohort
• He who believes in EBM
Comes down
to earth
with a bump…
• Widely used
• Gravitational challenge
Prevent death
Prevent injury
• Adverse effects
Failure
Iatrogenic
• Studies free fall
no 100% mortality
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 90
No monitoring device can improve patient-centered outcomes unless it
is coupled to a treatment that improves outcome.
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 94
• Non invasive technologies offer useful additional information
• This can alter our treatment strategy• There is a learning curve with any new
technology• Each technology is different and needs to
be assessed on its own merits• By knowing the pitfalls we can obtain new
and important information• This can also alter our treatment…
Summary
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 95
HD Monitoring Anno 2012
Wrap it Up
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 96
What I really need to know
When do I start giving fluids?
When do I stop giving fluids?
When do I start emptying?
When do I stop emptying?
SEE
MORE
THAN
OTHERS
benefit of fluid administration?
risk of fluid administration?
benefit of fluid removal?
risk of fluid removal?
GEF/GEDVi↓ PPV↑ PLR+
GEF/GEDVi↑ PPV↓ PLR-
EVLW↑/PVPI↑ IAP↑/APP↓ FB+
ICG-PDR↓ APP↓ ScvO2↓ FB--
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 101
WGAP Meeting at ESICM
ACS Workshop at ISICEM
2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 102
3rd
MARK THE DATE!
FRIDAY AND SATURDAY NOV 29TH-30TH 2013 /
ANTWERP BELGIUMA CONCISE BUT COMPLETE 2 DAY SYMPOSIUM ON FLUID MANAGEMENT AND MONITORING IN THE CRITICALLY ILL
INTERACTIVE VOTING SYSTEM / POSTER SESSIONS / WORKSHOPS / ACADEMY PRIZE AWARD /
NURSING SESSION / CASE DISCUSSIONS / STATE OF THE ART LECTURES / FLUID MANAGEMENT /
HEMODYNAMIC MONITORING / ORGAN SUPPORT AND MONITORING / ROUND TABLE DISCUSSIONS /
[email protected] WWW.FLUID-ACADEMY.ORG
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