(Erasmus Room) Tuesday 24 March 2009 - PULSION · (Erasmus Room) Tuesday 24 March 2009 Manu Malbrain ... After Thoracocenthesis 1050mL EVLWi=8 Pleural effusions Atelectasis Hemorrhage

Keep an eye on costs

Keep an Eye on Costs

(Erasmus Room) Tuesday 24 March 2009

Manu Malbrain

Intensive Care UnitZiekenhuisNetwerk Antwerpen

Campus StuivenbergAntwerpen, Belgium

Pulsion SessionState of the Art Hemodynamic Monitoring I

2Keep an eye on costs

Manu Malbrain• ICU Director and manager ZNA STER• Founding President WSACS (www.wsacs.org)• Chairman WCACS 2007 (www.wcacs.org)• Educational Grant: 2003 ESICM Chris Stoutenbeek Award• Member Medical Advisory Board

– Pulsion Medical Systems– KCI Benelux– Spiegelberg– Holtech Medical– Neutec

• European Patent Holder CiMON (PMS)• Research Project: Draeger, Edwards, Bard, Wolfe Tory• Fees ‐ Honoraria: GSK, MSD

Biggest Bias = WSACSBiggest Bias = WSACS

Thanks to F. MichardThanks to F. Michard


WSACS

Jan De Waele, BCTWG

Zsolt Baogh, AUSSecretary WCACS

Michael Sugrue, AUSPresident

Manu Malbrain, BFounding President

Treasurer

Rao Ivatury, USAVice-President

Mike Cheatham, USAPresident-Elect

WSACS Executive Committee 2007-2009: Your Servants…


€3500

Costs a lotNo teaching

Self development

Costs NothingA lot of teachingSelf development

MANAGEMENT SCHOOLMANAGEMENT SCHOOL PULSION SESSIONPULSION SESSION


Who actually usesless invasive HD monitoring ?


What type of LIHD?

‐NiCO2‐LiDCO‐PiCCO‐Doppler‐Vigileo


05

101520253035404550

%

IntermittentPAC

ContinuousPAC

Doppler Pulse Contour Other

Neil 2003Neil 2003

Availability of Cardiac Output Equipment in UK ICU’s

Availability of Cardiac Output Equipment in UK ICU’s


Ideal SystemIdeal System

Real Time beat to beat COReal Time Preload + AfterloadAdequacy data

Real Time beat to beat COReal Time Preload + AfterloadAdequacy data

Minimally invasiveWidely applicableMinimally invasiveWidely applicable

Simple to Operate and UnderstandMeasured variablesSimple to Operate and UnderstandMeasured variables

Clear Data Display + InterpretationClear Data Display + Interpretation

Nurse driven at the bedsideNurse driven at the bedside

Neonates to adultsNeonates to adults

Ideal Cardiac Output MonitorIdeal Cardiac Output Monitor


LiDCOLiDCONiCO2NiCO2

CEDViCEDVi

MonitorMonitor

PiCCOPiCCO

TonometerTonometer

Evita 4Evita 4

HemoSonicHemoSonic

Ideal Situation ?Ideal Situation ?

Why $AV€ costs?Why $AV€ costs?


• Risen by 329%/ 20 years• 30% of ICU patients• Carries a high mortality• Most common cause of death in ICU• Worldwide 1400 deaths/day • In the TOP‐league of death causes

SEPSIS cost implicationsSEPSIS cost implications

Angus D et al. Crit Care Med. 2001 Jul;29(7):1303-10


HOS mortality n(%)

ICU mortality n(%)

Admissions

Severe sepsis or septic shock

Total 21,025

Total 6,534 (31.1%)

Total 8,372 (39.8%)

ICNARC 6 month Raw data, prior to adjustment for 65% submission, 70% admission

a UK perspectivea UK perspective


Lung1 Colon2 Breast3 Sepsis4

cancers1,2,3 www.statistics.gov.uk,,

4Intensive Care National Audit Research Centre (2005)

0

5

10

15

20

25

30

35

Lung Colon Breast Sepsis

a UK perspectivea UK perspective

cancers




LiDCOLiDCONiCO2NiCO2

CEDViCEDVi

MonitorMonitor

PiCCOPiCCO

TonometerTonometer

Evita 4Evita 4

HemoSonicHemoSonic

Ideal Situation ?Ideal Situation ?

How to $AV€ costs?How to $AV€ costs?


CO$T$ FOR KNOWL€DG€

0

5000

10000

15000

20000

25000

device

PiCCOLiDCONiCO2HemoSonicCEDVI

050

100150200250300350400450500

device

PiCCOLidcoNiCOHemosonicCEDVI

0

1

2

3

4

5

6

7

device


0

5

10

15

20

25

device


DEVICE SET-UP

MEASURE DAY


0

100

200

300

400

500

600

-1 1 3 5 7 9 11 13 15

Time (days)

Cos

t (€)

.

PiCCOLiDCONiCO2HemoSonicCEDVI

Cost per day Evolution


Cumulative Cost (€)

0

500

1000

1500

2000

2500

3000

3500

4000

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Time (days)

CEDVILiDCOPiCCONiCO2HemoSonic PACPAC

PiCCOPiCCOLiDCOLiDCO

Malbrain M. Yearbook ISICEM 2005: 603-31 Malbrain M. Yearbook ISICEM 2005: 603-31


SCORES

0%

10%

20%

30%

40%

50%

60%

70%

80%

Cost


Effectiveness

CO$TCO$T €FF€CT€FF€CT

0%

10%

20%

30%

40%

50%

60%

70%

Cost-Effectiveness

PiCCOLiDCONiCOHemoSonicCEDVI


LiDCO PiCCO

NiCO HEMOSONiC

CO$T €FF€CT RATiO

Malbrain M. Yearbook ISICEM 2005: 603-31 Malbrain M. Yearbook ISICEM 2005: 603-31


How to beMore

Cost Effective?

$P€ND MOR€MORE COSTS = MORE EFFECTIVE ?

$AV€ MOR€LESS COSTS = MORE EFFECTIVE ?

$€€ MOR€SAME COSTS = MORE EFFECTIVE ?


How to bemore cost effective

$€€

MOR€

THAN

OTH€RS

$€€ MOR€SAME COSTS = MORE EFFECTIVE


$€€

MOR€

THAN

OTH€RS


THE MORE YOU LOOK

THE MORE YOU SEE

THE MORE YOU LEARN

THE MORE YOU KNOW

$€€

MOR€

THAN

OTH€RS

TO SEE MORE

WHAT YOU KNOW

YOU WILL LEARN

TODAY


MAP=51

CI=2.1

LACTATE=6

CVP=5

PAOP=7

GEDVi=580

P/F=179

EVLWi=21

$€€

MOR€

THAN

OTH€RS


MAP=51

CI=2.1

LACTATE=6

CVP=22


PAOP=25

GEDVi=575

P/F=124

After Thoracocenthesis 1050mLEVLWi=8

Pleural effusionsAtelectasisHemorrhageHerniationDiaphragm

Pleural pressure ?PEEP ? - IAP ?

Cardiac compliance?Lung compliance?

$€€

MOR€

THAN

OTH€R$


• 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– PulseCO– Vigileo

• Thermodilution– Vigilance PAC, CEDVi– (PiCCO)

• Indicator Dilution– Invasive– (LiDCO)

Available technologies forcontinuous Cardiac Output Available technologies forcontinuous Cardiac Output


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?

SV

GEDVi

EVLWi

DO2

$€€

MOR€

THAN

OTH€RS


The Parachute Study

Gordon C S Smith, Jill P Pell BMJ 2003; 327:1459-60

• Widely used• Gravitational challenge

Prevent deathPrevent injury

• Adverse effectsFailureIatrogenic

• Studies free fallno 100% mortality

• Widely used• Gravitational challenge

Prevent deathPrevent injury

• Adverse effectsFailureIatrogenic

• Studies free fallno 100% mortality

WHAT DO WE KNOWWHAT DO WE KNOW WHAT THIS STUDY ADDSWHAT 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 earthwith a bump…

• No RCCT on parachute• Basis for parachute use

Purely observational• Efficacy explained by

Healthy cohort• He who believes in EBM

Comes down to earthwith a bump…


$€€ MOR€ THAN OTH€R$

SV

GEDVi EVLWi

DO2


Improve Outcome

Use the right parameters

FLOW

PRELOAD

ORGAN

O2XYGEN


Improve Outcome

Use the right parameters

FLOW

PRELOAD

ORGAN

O2XYGEN

SV/CO

GEDVi/SVVPPV/SVRidPmax

GEF/EVLWiScvVO2

VO2/DO2


ARE YOU GETTING

ENOUGH FOR YOUR MONEY


WiTHLeSS

WiTHLeSS

DoMoREDo

MoREWiTHMoREWiTHMoRE



SV

SV/COSV/CO


Landmark PAPERLandmark PAPER

Optimisation PROTOCOLOptimisation PROTOCOL• Using a PAC does not alter outcome• Protocolised care affects outcome

– Postop complications ↓– ICU and HOS stay↓– Total cost ↓– Mortality ↓


SV/COSV/CO

Controlgroup

Protocolgroup

Controlgroup

Protocolgroup

Controlgroup

Protocolgroup

Controlgroup

Protocolgroup

SinclairSinclair WakelingWakeling McKendryMcKendry

McKendry M, McGloin H, Saberi D, Caudwell L, Brady AR, Singer M.Randomised controlled trial assessing the impact of a nurse delivered, flow monitored protocol for optimisation of circulatory status after cardiac surgery.

British Medical Journal 2004; 329(7460): 258.

McKendry M, McGloin H, Saberi D, Caudwell L, Brady AR, Singer M.McKendry M, McGloin H, Saberi D, Caudwell L, Brady AR, Singer M.Randomised controlled trial assessing the impact of a nurse deliRandomised controlled trial assessing the impact of a nurse delivered, flow monitored protocol for optimisation of circulatory svered, flow monitored protocol for optimisation of circulatory status after cardiac surgery.tatus after cardiac surgery.

British Medical Journal 2004; 329(7460): 258.British Medical Journal 2004; 329(7460): 258.


SV/COSV/COMcKendry BMJ 2004; 329: 258McKendryMcKendry BMJ 2004; 329: 258BMJ 2004; 329: 258


SV/COSV/CO• 174 CABG pts analysed• Protocol: SVI > 35 ml/m2

• Postop complications: 26 (2 deaths) vs. 17 (4 deaths)

• HOS stay reducedfrom 13.9 to 11.4 days

• HOS bed days reduced: 18%• ICU bed usage reduced: 23%

McKendry BMJ 2004; 329: 258McKendryMcKendry BMJ 2004; 329: 258BMJ 2004; 329: 258

DeLTEX


Sinclair S et al. British Medical Journal 1997; 315(7113): 909-12Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fractureSinclair S et al. Sinclair S et al. British Medical Journal 1997; 315(7113): 909British Medical Journal 1997; 315(7113): 909--1212IntraoperativeIntraoperative intravascular volume optimisation and length of hospital stay aintravascular volume optimisation and length of hospital stay after repair of proximal femoral fracturefter repair of proximal femoral fracture

SVSV FlowFlow COCO

40 patientsHip replacement



Sinclair S, James S, Singer MBritish Medical Journal 1997; 315(7113): 909-12Sinclair S, James S, Singer MSinclair S, James S, Singer MBritish Medical Journal 1997; 315(7113): 909British Medical Journal 1997; 315(7113): 909--1212

HOSacHOSac

Discharge time

Discharge time HOStot

HOStot




Wakeling HG et al. Br J Anaesth 2005: 95(5): 634-42Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery

WakelingWakeling HG et al. Br J HG et al. Br J AnaesthAnaesth 2005: 95(5): 6342005: 95(5): 634--4242IntraoperativeIntraoperative oesophageal Doppler guided fluid management shortens postoperatoesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgeryive hospital stay after major bowel surgery

DeLTEX



SV

GEDVi


Controlgroup

Protocolgroup

Controlgroup

Protocolgroup

Controlgroup

Protocolgroup

Controlgroup

Protocolgroup

PRELOADPRELOAD

Lopes/AngusLopes/Angus GöpfertGöpfert CsontosCsontos

PPV ITBViGEDVi


Göpfert MS, Reuter DA, Akyol D, Lamm P, Kilger E, Goetz AE.Goal-directed fluid management reduces vasopressor and catecholamine use in cardiac surgery patients.

Intensive Care Med 2007; 33: 96-103

GöpfertGöpfert MS, Reuter DA, MS, Reuter DA, AkyolAkyol D, D, LammLamm P, P, KilgerKilger E, Goetz AE.E, Goetz AE.GoalGoal--directed fluid management reduces directed fluid management reduces vasopressorvasopressor and catecholamine use in cardiac surgery patientsand catecholamine use in cardiac surgery patients..

Intensive Care Med 2007; 33: 96Intensive Care Med 2007; 33: 96--103103

GEDViGEDVi

Less pressorsLess pressors

80 CABG patients

80 CABG patients


Lopes MR, Oliveira MA, Pereira VO, Lemos IP, Auler JO Jr, Michard F.Goal-directed fluid management based on pulse pressure variation monitoring during high risk surgery

Crit Care 2007;11(5): R100

Lopes MR, Oliveira MA, Pereira VO, Lopes MR, Oliveira MA, Pereira VO, LemosLemos IP, IP, AulerAuler JO JO JrJr, , MichardMichard F.F.GoalGoal--directed fluid management based on pulse pressure variation monidirected fluid management based on pulse pressure variation monitoring during high risk surgerytoring during high risk surgery

CritCrit Care 2007;11(5):Care 2007;11(5): R100R100

Less complicationsLess complications

33 patientsHigh risk surgery

33 patientsHigh risk surgery

Shorter stayShorter stay

PPVPPV


Csontos C, Foldi V, Fischer T, Bogar L.Arterial thermodilution in burn patients suggests a more rapid fluid administration during early resuscitation.

Acta Anaesthesiol Scand 2008; 52:742-9

CsontosCsontos C, C, FoldiFoldi V, Fischer T, V, Fischer T, BogarBogar L.L.Arterial Arterial thermodilutionthermodilution in burn patients suggests a more rapid fluid administration durin burn patients suggests a more rapid fluid administration during early resuscitation.ing early resuscitation.

ActaActa AnaesthesiolAnaesthesiol Scand 2008; 52:742Scand 2008; 52:742--99

Less MOFLess MOF

24 patients>15% TBSA burns

24 patients>15% TBSA burns

Higher ScvO2Higher ScvO2

ITBViITBVi



SV

GEDVi EVLWi


Controlgroup

Protocolgroup

Controlgroup

Protocolgroup

ORGAN FUNCTIONORGAN FUNCTION

Mitchell JP et al. Am Rev Respir Dis 1992; 145(5): 990-8Improved outcome based on fluid management in critically ill patients requiring pulmonary artery catheterization.

Mitchell JP et al. Am Rev Mitchell JP et al. Am Rev RespirRespir DisDis 1992; 145(5): 9901992; 145(5): 990--88Improved outcome based on fluid management in critically ill patImproved outcome based on fluid management in critically ill patients requiring pulmonary artery catheterizationients requiring pulmonary artery catheterization..

PROTOCOL52 patients

EVLWiFluid resitriction

PROTOCOL52 patients

EVLWiFluid resitriction

CONTROL49 patients

PAOP

CONTROL49 patients

PAOP

MitchellMitchell

EVLWi



SV

GEDVi EVLWi

DO2


DO2 DETERMINANTS

DO2DO2


DO2DO2

Direct COSTSDirect COSTS

“…a very small investment for a much greater return…”“…a very small investment for a much greater return…”


SvO2 DETERMINANTS

SvO2SvO2

SvO2SvO2


ScvO2ScvO2

RiversRivers


Controlgroup

Protocolgroup

Controlgroup

Protocolgroup

OXYGENATIONOXYGENATION

Rivers E. et al. N Engl J Med 2001; 345(19): 1368-77Early goal-directed therapy in the treatment of severe sepsis and septic shock

Rivers E. et al. N Rivers E. et al. N EnglEngl J Med 2001; 345(19): 1368J Med 2001; 345(19): 1368--7777Early goalEarly goal--directed therapy in the treatment of severe sepsis and septic shdirected therapy in the treatment of severe sepsis and septic shockock

PROTOCOL130 patients

EGDT

PROTOCOL130 patients

EGDT

CONTROL133 patients

standard

CONTROL133 patients

standard

ScvO2ScvO2RiversRivers


RCCT’s showing benefit RCCT’s showing benefit

EBM = 17 RCCT’sEBM = 17 RCCT’s



SV

GEDVi EVLWi

DO2


YOU NEED TO $P€ND TO…

SAVE LIVES

SAVE TIME

$AV€ MONEY

SEE MORE



SAVE LIVES



SAVE TIME



$AV€ MONEY



Hospital LOS reduction Hospital LOS reduction Savings per patient (€) Savings per patient (€)

1740

2400

1200

1500

1260

200

200

200

200

200

1540

2200

1000

1300

1060

Net Savings/patient (€) Net Savings/patient (€)



WiTH PiCCO2 YOU$€€ MOR€ THAN OTH€R$

SV

GEDVi EVLWi

DO2



SAVE LIVES

SAVE TIME

$AV€ MONEY

SEE MORE


The bottom line is…

Join the WSACS clinical trials working groupLeave your e-mail at WSACS Booth!

Think different and produce great results…

It is time to pay attention

www.wsacs.org

June 25-27, 2009

ACS Update‐workshop ISICEM – Brussels

23 march 2009www.intensive.org

Visit the WSACS Booth 11.002!Visit the WSACS Booth 11.002!


Join WSACS ‐ Information

www.wsacs.org

Visit the WSACS Booth: 11.002Visit the WSACS Booth: 11.002

www.wsacs.org

Main Entrance HALL 11Main Entrance HALL 11

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(Erasmus Room) Tuesday 24 March 2009 - PULSION · (Erasmus Room) Tuesday 24 March 2009 Manu Malbrain ... After Thoracocenthesis 1050mL EVLWi=8 Pleural effusions Atelectasis Hemorrhage