PiCCO2_Booklet_E_MPI851105_US_R01_091008_low

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Advanced Hemodynamic Monitoring

Get the complete picture ...

PiCCO 2

TM



Complete hemodynamic picture without PA catheter

Continuous cardiac output

Volumetric preload

Afterload, contractility

Volume responsiveness

Pulmonary edema / Lung water

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PiCCO 2TM



PULSION®

Medical – Introduction & History ........................................................... 4Overview ................................................................................................................. 6

Fields of Application ................................................................................................ 9

Methods .................................................................................................................. 12

Parameters in Detail ................................................................................................ 16

Visualization ............................................................................................................ 32

PiCCO 2TM Monitor, Setup and Catheters .................................................................. 34

Catheters & Normal Ranges.................................................................................... 37

Recommended Literature ........................................................................................ 41

Table of contents



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

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PULSION ® headquarters in Munich, Germany PULSION Medical Inc, Irving, Texas, USA



PiCCO ®-Technology

Leading specialist in less invasive hemodynamic monitoring in ICUMore than 20 years experience in hemodynamic monitoring

Paradigm shift in hemodynamics – From pressures to volumes

Integration of PiCCO®

into patient monitoring systems

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COLD System1986-1997

PiCCO ® 1997

PiCCO plus ® 2002 Philips PiCCO ® Module 2003

Dräger In nity®PiCCO SmartPod™

2005

PiCCO 2TM

2007



Optimization of Tissue Oxygenation

O 2 uptake O 2 transport O 2 extraction O 2 utilization

Inotropes?Vasopressors?Volume?

Which therapy?

PiCCO ®-Technology



Cardiac index CI

Stroke volumeSVI

Afterload SVRI, MAP

Contractility CFI

PreloadGEDI, SVV, PPV

Pulmonary edemaELWI

Heart rateHR

Is measurement of CO enough?

Inotropes?Vasopressors?Volume?



PiCCO 2TM – See more than others

Bedside pulmonary edema assessment(Lung water)

•Continuous cardiac output

Volumetric preload

Afterload

Contractility

Volume responsiveness

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Fields of Application

Intensive CareSeptic Shock

Cardiogenic Shock

Burns

Trauma / Hypovolemic Shock

ARDS

Pediatrics

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Peri-operative

Cardiac Surgery

Major Surgery

Neuro Surgery

Pediatrics

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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



PiCCO ® Catheters: different sizes - different sites

Femoral artery

Brachial artery

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

Adults: 4F 16 cm, 6.29 in

Adults: 4F 22 cm, 8.66 in

Adults: 5F 20 cm, 7.78 in Adults: 4F 22 cm, 8.66 inSmall adults: 4F 16 cm, 6.29 inChildren: 3F 7 cm, 2.76 inChildren: 4F 8 cm, 3.15 in



PiCCO ® - Pulse Contour Analysis

Stroke volume is re ected by the area under the pressure curve (red area) ofone heart beat

Cardiac output is calculated beat-by-beat: stroke volume x heart rate

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PiCCO ® - Transpulmonary Thermodilution

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 algorithmBreathing or ventilator cycle independent

Passage through the heart and lungs allows determination of preload volumes and lung water

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Bolusinjection

Bolusdetection



Calculation of Volumes

time in sec

temperature

36° C

34° C

Resulting temperature curves

The shape of the thermodilution curve depends on the volume through which the indicator

passes.

large volumesmall volume

time in sec

temperature

36° C

34° C

long passage timeshort passage time



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

Thermodilution Cardiac Output

TD Results

CI

GEDI

ELWI

T

READY 10s 20s0s 30s

98.1

98.6

Inj. Volume

START

15 ml

10:18 amSEP 23

3.47

705

9

1.18

10:26 amSEP 23

3.76

764

10

1.20

10:20 amSEP 23

3.11

626

9

1.17

3.44

698

9

10:26 amSEP 23

Exit

CVP

mmHg5

10:22 amSEP 23

3.15

678

10

0.30

4.52CI5.0

3.0l/min/m 2

CO – Cardiac OutputCI – Cardiac Index

Highly precise measurement by using thermodilution techniqueCalculated the same way mathematically as with the PA catheter

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Cardiac output is calculated by analysis of the thermodilution curve using a mod

Stewart-Hamilton algorithm After central venous injection of the indicator, the thermistor at the tip of the arterialcatheter measures the downstream temperature change

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Determination of Thermodilution Cardiac Output

Cardiac output calculation: Area under the thermodilution curve

CO TDa = (Tb - T i) x V i x K∫ ∆ Tb x dt

Tb = Blood temperatureTi = Injectate temperatureVi = Injectate volume∫ ∆ Tb x dt = Area under the thermodilution curveK = Correction constant, made up of speci c

weight and speci c heat of blood and injectate



Calibrated Continuous Cardiac Output

Flow

4.52PCCI 5.0

3.0l/min/m 2

Cardiac Output - Cardiac Output (CO) is regarded as one of the most important hemodynamicvariables for the assessment of cardiac function and guidance of therapy in critically ill patients.Sakka et al. BJA , 2007

PCCO – Pulse Contour Cardiac OutputPCCI – Pulse Contour Cardiac IndexProduct of stroke volume and heart rateDetermination beat-by-beatMaximum accuracy and safety by recalibration possibility

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PiCCO ® Continuous Cardiac Output

Transpulmonary thermodilution Pulse contour analysis

Calibration

Continuous (beat-by-beat)Discontinuous

Cardiac output is the product of stroke volume and heart rate

CO = SV x HR

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



Preload Volume instead of lling pressures

ml/m2

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

GEDV – Global End-Diastolic VolumeGEDI – 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)GEDI is indexed to “predicted body surface area” *

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* Indexing particular parameters i.g. to the predicted body weight (EVLW) or predicted body surface area (GEDV) ratherthan the actual body weight or body surface area is more accurate particularly in overweight patients.



Determination of Volumetric Preload

Intra-Thoracic Thermal VolumeITTV = CO x MTt

Pulmonary Thermal VolumePTV = CO x DSt-

Global End-Diastolic Volume(GEDV)

time in sec

temperature

MTtMean transit time

time in sec

temperature

DstDown slope time

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

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Lung Water – Lung edema assessment at the bedside

ml/kg

EVLW – Extravascular Lung Water re ects pulmonary edema

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 tissueELWI is indexed to “Predicted Body Weight”

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*Predicted body weight is determined from the body height, gender and age



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 volumeIt has been found that ITBV is consistently 25% higher than GEDV

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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-rayEVLW is a direct quanti cation of pulmonary edema

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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 increasedSource: Unpublished Data; Azriel Perel, MD, Department of Anaesthesiology and Intensive Care,

Sheba Medical Center, Tel Aviv University, Tel Hashomer, Israel



Improved outcome based on uid management

D a y s

Source: Improved outcome based on uid 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

Organ function - Lung water

Ventilation days ICU days

Control group Protocol group

reduced by

59%

Control group Protocol group

reduced by

53%



Afterload - the systemic vascular resistance

SVRI 1735dyn*s*cm m-5 2

Systemic vascular resistance - important determinant of afterload

SVR - Systemic Vascular ResistanceSVRI - Systemic Vascular Resistance Index



Determination of Afterload

SVR =MAP - CVP

CO x 80

SVRI = SVR x BSA

Flow (CO) =

Vasoconstriction: Flow (CO)

Vasodilation: Flow (CO)

if pressure is constant

PressureResistance

BSA = Body Surface Area



Determination of Volume Responsiveness

inspiration expiration

SV max

SV min PP min

PP max

inspiration expiration

Mechanical Ventilation Intrathoracic pressure uctuations Changes in intrathoracic blood volume

Preload changes

Fluctuations in stroke volumeand pulse pressure



Trends

Details

Overview

Basis of Success - Fast Decisions



PiCCO 2TM – Visualization of Hemodynamic Parameters

Flow Volume Organ FunctionBasic

5.00

6.00

7.00

4.00

3.00

2.00

1.00

CI l/min/m

2.86

750

700

650

600

550

850

900

800

l/m 2

815

11

9

3

1

0

5

7

ELWI ml/kg

14

Values at time of TD, 0 h 52 min ago

SVRI2800

1400

PCCI/CI

5.0

1.0

xxxxx

-6h -4h-5h -2h-3h 10 : 26 am-1h

9.0

2100

x

120

60

90

AP

PCCI

MAP

SVRISVV

SVI

’Trends’ screen Clinical trends and therapy results

’Pro les’ screen Detailed insight at parameterlevel

’SpiderVision TM’ screenDynamic status indicator

Trends

Details

Overview



Information bar

Innovative operation - via touch-screen or navigation dial

Real-timepressure curve

ParametereldsInnovativedatavisualization

Direct access buttons



PiCCO 2TM – The new Hemodynamic Monitor

Brilliant 13.3” colour wide screen display

Touch-screen, navigation dial

Slim ergonomic design

Small footprint

Compatible to standard mounting systems

Integrated battery backup

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PiCCO 2TM Setup

Flush bag

Injectate sensor

cable

PiCCO ® Catheter

Arterial connectioncable

Pressure connectioncable

StandardCVC

A

C

D

E

E

E

F

G

B

TM



PiCCO 2TM Setup

PiCCO®

Catheter

Injectate temperature sensor housing

Injectate sensor housing

Injectate sensor cable

Arterial connection cable

A

B

C

D

E

F

G

PiCCO®

thermistor plug

Pressure connection cable

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PiCCO ® Catheters with Nitinol Guide Wire

Application Artery Article No. Diameter Usable length

Adults Femoralis PV2015L20N 5F / (~14G) / 1,7 mm 20 cm / 7.78 in

Adults Brachialis cubital PV2014L22N 4F / (~16G) / 1,3 mm 22 cm / 8.66 in

Adults Femoralis PV2014L22N 4F / (~16G) / 1,3 mm 22 cm / 8.66 in

Adults Brachialis proximal PV2014L16N 4F / (~16G) / 1,3 mm 16 cm / 6.29 in

Small adults Femoralis PV2014L16N 4F / (~16G) / 1,3 mm 16 cm / 6.29 in

Adults Axillaris PV2014L08N 4F / (~16G) / 1,3 mm 8 cm / 3.15 in

Children Femoralis PV2014L08N 4F / (~16G) / 1,3 mm 8 cm / 3.15 in

Children Femoralis PV2013L07N 3F / (~18G) / 1,0 mm 7 cm / 2.76 in

Small adults Axillaris PV2013L07N 3F / (~18G) / 1,0 mm 7 cm / 2.76 in

H d i M G id N l V l



Hemodynamic Measurement Guide - Normal Values

Cardiac Index

Stroke Volume Index

Global End-Diastolic Volume Index

Intrathoracic Blood Volume Index

Stroke Volume Variation

Pulse Pressure VariationSystemic Vascular Resistance Index

Cardiac Function Index

Mean Arterial Pressure

Extravascular Lung Water Index

CI

SVI

GEDI

ITBI

SVV

PPVSVRI

CFI

MAP

ELWI

3.0 – 5.0

40 – 60

680 – 800

850 – 1000

< 10

< 101970 - 2390

4.5 – 6.5

70 – 90

< 10

I/min/m 2

ml/m 2

ml/m 2

ml/m 2

%

%dyn*s*cm -5 *m2

1/min

mmHg

ml/kg

Parameter Abbreviation Range Unit

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 respon-sible for determining and utilizing the appropriate diagnostic and therapeutic measures for each individualpatient.

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

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

< 3.0

< 700 > 700< 850 > 850

1.

2.

Targeted Values

Therapy Options

Measured Values

> 3.0

< 700 > 700< 850 > 850

CI (l/min/m 2)

GEDI (ml/m 2)or ITBI (ml/m 2)

ELWI (ml/kg)

GEDI (ml/m 2)or ITBI (ml/m 2)Optimise SVV (%)*

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

< 10

V+?

> 700> 850< 10

< 10

< 10

OK!

> 10

V-?

700-800850-1000

< 10

< – 10

< 10

V+?

> 700> 850< 10

> 4.5

> 10

V+?Cat?

700-800850-1000

< 10

> 5.5< – 10

< 10

Cat?

> 700> 850< 10

> 4.5

> 10

Cat?V-?

700-800850-1000

< 10

> 5.5< – 10

> 10

V+?

700-800850-1000

< 10

< – 10

Hemodynamic Measurement Guide

PiCCO TM G t th l t i t



PiCCO 2 - Get the complete picture ...

PiCCO ®-Technology provides advanced hemodynamic and volumetric

management for better patient care.

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

Advantages of PiCCO ® Technology



Advantages of PiCCO ®-Technology

Precise, calibrated beat-to-beat cardiac output

Preload volumes instead of lling pressures

Bedside pulmonary edema assessment

Surpasses PA Catheter indications and offersadditional elds of application

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Recomended Literature



Recomended Literature

Cardiac Output – FlowPulse contour cardiac output analysis in a piglet model of severe hemorrhagic shockPiehl MD, Manning JE, McCurdy SL, Rhue TS, Kocis KC, Cairns CB. Crit Care Med 2008; 36: 1189-95Where do we go from here? Cardiac output determination in pediatrics.Hanna BD. Childrens Hospital of Philadelphia. Crit Care Med 2008; 36: 1377-8Cardiac index measurements during rapid preload changes: a comparison of pulmonary artery thermodilution with arterial pulsecontour 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):748-55Global end-diastolic volume as an indicator of cardiac preload in patients with septic shockMichard 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 syndromeBerkowitz DM, Danai PA, Eaton S, Moss M, Martin G. Crit Care Med 2008; 36: 1803-9Extravascular lung water in sepsis-associated acute respiratory distress syndrome: indexing with predicted body weight improvescorrelation with severity of illness and survival. Phillips C, Chesnutt M, Smith M. Crit Care Med 2008; 36: 69-73Extravascular lung water measurements and hemodynamic monitoring in the critically ill: bedside alternatives to the pulmonaryartery catheter. Isakow W, Schuster DP. ; Am J Physiol Lung Cell Mol Physiol 2006 291: 1118 - 33Extravascular lung water in patients with severe sepsis: a prospective cohort study Martin GS, Eaton S, Mealer M, Moss M. Crit Care 2005; 9: R74-82Improved outcome based on uid management in critically ill patients requiring pulmonary artery catheterizationMitchell JP, Schuller D, Calandrino FS, Schuster DP. Am Rev Respir Dis 1992; 145: 990-8

Guidelines and Standard Operating ProceduresSurviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, Reinhart K, Angus DC, Brun-Buisson C, Beale R, Calandra T, DhainautJF, 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: 17-60Goal directed uid 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



Contact

PULSION Medical Inc. • 2445 Gateway • Drive Suite 110 • Irving, Texas 75063Toll free 877.655.8844 • Phone 732.514.6610 • Fax [email protected] • www.PULSION.com

For further information on:Literature for speci c elds of applicationCase studiesProduct informationEducational material

please visit www.PULSION.com or contact us

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

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