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


Therapeutic Dilemma - Conflict


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?


Today’s Agenda

• Introduction

• From Invasive to Less invasive

• Results of PulsioFlex study

• Results of NexFin study

• Wrap it up


HD Monitoring Anno 2012

Introduction


Disclosure

The speaker consults for the following companies:

BMEYE

Edwards

PULSION Medical Systems

[email protected]


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


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


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!


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%


Because of the complexity of assessment of

clinical variables in septic patients, direct

measurement of CO by invasive hemodynamic

monitoring is advisable.



Perioperative optimization


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.


What hemodynamic monitoring do you routinely use for the management of high-risk surgery

patients?



Less invasive CO…


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


• 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


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


• 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)


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


Cardiac output measurementby transpulmonarythermodilution

RA LARV LVPBV

EVLW

Cardiacoutput


1. Transpulmonary lithiumdilution 2. Pulse power analysis algorithm combined with

indicator dilution calibration

What is LiDCO/PulseCO technology ?


•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


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


(cardiac output)(AP curveanalysis)


(AP curveanalysis)


(AP curveanalysis)

Less

Inva

sive

mo

nit

ori

ng


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


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.


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.


PulsioFlex

• ProAqt sensor


Pram• Pressure• recording• analytical• method


NesCO

• Estimated

• Continuous

• CO


Cheetah - NICOM

• Bioreactance


ECOM


UsCOM

• ultrasound


Transonic

• COstatus


ImaCor

• Disposable TEE


1. Pulsed Doppler Velocity

2. M-mode aortic root diameter

What is HemoSonic technology ?

HemoSonic

Atys

Médical


Ø 7mm

2nd iFAD 17/11/2012 Hemodynamic Moitoring Anno 2012 39MM 06/2006 – 39

Probe Positioning

correct

incorrect


Doppler Principles


1. Indirect Fick Principle2. Respiratory Mechanics

What is NiCO2 technology ?



http://www.novametrix.com/nico/technology/techreview/index.asp

http://www.novametrix.com/nico/technology/techreview/index.asp




Arterial pressure

Esophageal Doppler

Flotrac/VigileoPulsioflex

LidCOrapid

AP catheter

CVP

PiCCOEV 1000

Basic monitoring Advanced monitoring

OR monitoring


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



How to compare 2 techniques?


1. Correlations…

Gold standard Gold standard

Inverse correlationNot equivalent

Good correlationSystematicoverestimation

Gold standard

Poor correlationSystematicunderestimation


1. Correlations…• Pearson correlation

(p<0.01)

• Line of identitycrosses “0”

• Linear relation

• R2>0.6

• R>0.75


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…


3. Critchley


PRECISE

ACCURAT

E

IMPRECISE

ACCURAT

E

PRECISE

INACCURATE

IMPRECISE

INACCURATE


Are uncalibrated CO monitors

accurate enough to guide therapy?


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.



PulsioFlex StudyZNA Stuivenberg


PulsioFlex Escalation Study


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:


MAP Periph T°:

SVV CVP:

PPV dobu:

dPmax Rythm: levo:

SVRI ulti:

SVI dorm:

HR dipri:

CCI other:

Obs 9 ADsys SaO2:


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:


MAP Periph T°:

SVV CVP:

PPV dobu:

dPmax Rythm: levo:

SVRI ulti:

SVI dorm:

HR dipri:

CCI other:

Obs 3 ADsys SaO2:


MAP Periph T°:

SVV CVP:

PPV dobu:

dPmax Rythm: levo:

SVRI ulti:

SVI dorm:

HR dipri:

CCI other:

Obs 4 ADsys SaO2:


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


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



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


Regression PiCCI vs PulseCI


Correlation with TPTDCI

PulsioflexPulse contour

PiCCO2Pulse contour

ProAQTAuto Calibration


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%


Concordance: Changes in CI


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)




NexFin StudyZNA Stuivenberg


The Nexfin device


The Nexfin applies 3 major steps in the

non-invasive measurement of CCO.

The Nexfin: Principles of measurement


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


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


2. Transformation of finger BP to brachial BP by a

transfer function based on a vast clinical database


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).


Poster @ISICEM


Patient Characteristics


CI evolution


MAP evolution


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)


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%


• 35 year old• suicide attempt (glucophage)• Septic shock• Metabolic (lactic) acidosis

Case studyInfusion pumps

dialysis

NEXFIN PiCCO2

Evita XL

CiMON



PiCCI

NEXCI

art rad MAP

NEXMAP

PiCCOMAP


• 35 year old man, suicide attempt, Levo 0.45y

Case studyAgitation, pain midazolam

Small drift

PiCCI

NEXCI


Case studyAgitation, pain

midazolam

MAP

NEXMAP

• 35 year old man, suicide attempt, Levo 0.45y


PiCCI


AUC (PiCCO) = 8752 vs AUC (NEXFIN) = 9847 = 88.9%

NEXCI

NEXFIN

PiCCO


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%)


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


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



Conclusions


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?


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


No monitoring device can improve patient-centered outcomes unless it

is coupled to a treatment that improves outcome.


• 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

[email protected]



Wrap it Up


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--


WGAP Meeting at ESICM

ACS Workshop at ISICEM


3rd

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Manu Malbrain - Nursing thisisit final monitoring - IFAD 2012