hemodynamic monitoring

in critically ill patients, intensive care,echo, usg, mechanical vent, oesophageal doppler

1. HEMODYNAMIC MONITORING Part 2 Dr. Gagan Brar MD,IDCCM EDIC

2. 3 Standard Monitoring Monitoring Respiration Rate NIBP ECG Temperature Urine Production Oxygen Saturation Blood Circulation (clinical assessment)

3. will fluid increase perfusion to end organs, or will it worsen pulmonary or systemic edema ?

4. CVP = 8 – 12 mm Hg CONTINUE AS LONG AS THERE IS HAEMODYNAMIC IMPROVEMENT

5. Does it improve organ perfusion? By how much? For how long?

6. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med. 2006 Jun 15;354(24):2564-75. FACTT trial – fluid conservative (-136) Vs liberal (6992 ml) in the first 7 days

7. FACTT – VENTILATOR FREE DAYS Comparison of two fluid-management strategies in acute lung injury. N Engl J Med. 2006 Jun 15;354(24):2564-75.

8. Sepsis in European intensive care units : results of the SOAP study . Crit Care Med. 2006 Feb;34(2):344-53. In a multicentre European observational study, a CUMULATIVE FLUID balance at 72 hours was among the strongest predictors of death. 24 European countries, 198 ICUs, 3147 adult patients. Cumulative fluid balance in the first 72 hrs

9. Fluid overload is associated with an increased risk for 90-day mortality in critically ill patients with renal replacement therapy: data from the prospective FINNAKI study. Critical Care 2012, 16:R197 Prospective observational study of 296 RRT treated patients. Fluid overload – gain in more than 10% body weight at time of RRT. Fluid overload led to increased 90 day mortality; odds ratio: 2.6

10. Fluid overload is associated with an increased risk for 90-day mortality in critically ill patients with renal replacement therapy: data from the prospective FINNAKI study. Critical Care 2012, 16:R197

11. Pressure that dilates the ventricle = intraventricular – pleural pressure (what we can measure at best is intra-cavity pressure)

12. Static measurements have failed as a meaningful endpoint for fluid resuscitation Rapid fluid bolus is a reasonable diagnostic and potentially therapeutic option Has the potential to cause harm May delay institution of appropriate therapy . GOALS SHOULD BE BASED IN SCIENCE AND SUPPORTED BY EVIDENCE.

13. CARDIAC OUTPUT

14. cardiac output first measured by the German physician and physiologist Adolf Fick 1870 using an oxygen uptake method.

15. The Fick method was later modified in 1897 by Stewart to use a continuous saline infusion and then in 1928 by Hamilton to use a bolus injection of dye technique .

16. Monitoring Invasive pulmonary artery catheter Non-invasive Bio impedence cardiac output monitoring Partial carbon dioxide re breathing cardiac output monitoring

17. Minimally invasive oesophageal Doppler Transpulmonary thermodilution and pulse contour analysis PiCCO LiDCO Pulse contour analysis, FlowTrac , PRAM Ultrasound dilution , COstatus

18. Pulse Index Continuous Cardiac Output( PiCCO )

19. PiCCO Technology is a combination of transpulmonary thermodilution and pulse contour analysis Principles of Measurement Left Heart Right Heart Pulmonary Circulation Lungs Body Circulation PULSIOCATH PULSIOCATH CVC PULSIOCATH arterial thermodilution catheter central venous bolus injection Introduction to the PiCCO-Technology – Function central venous injection of a cold bolus and detection of the temperature course in a peripheral large artery (femoral, axillary, brachial) through a special thermodilution catheter. calibrated from the results of the thermodilution measurement and delivers continuous haemodynamic parameters in contrast to intermittent thermodilution.

20. Bolus injection concentration changes over time (Thermodilution curve) After central venous injection the cold bolus sequentially passes through the various intrathoracic compartments The temperature change over time is registered by a sensor at the tip of the arterial catheter Introduction to the PiCCO-Technology – Function Left heart Right heart Lungs RA RV LA LV PBV EVLW EVLW Principles of Measurement The individual cardiac chambers and the lung with the extravascular lung water are mixing chambers in which the cold bolus is distributed

21. T b x dt (T b - T i ) x V i x K T b Injection t ∫ D = CO TD a T b = Blood temperature T i = Injectate temperature V i = Injectate volume ∫ ∆ T b . dt = Area under the thermodilution curve K = Correction constant, made up of specific weight and specific heat of blood and injectate The CO is calculated by analysis of the thermodilution curve using the modified Stewart-Hamilton algorithm Calculation of the Cardiac Output Various volume parameters can be calculated from the thermodilution curve, which is recorded via the thermodilution catheter (PiCCO catheter).

22. The area under the thermodilution curve is inversely proportional to the CO. 36,5 37 5 10 Thermodilution curves Normal CO: 5.5l/min Introduction to the PiCCO-Technology – Thermodilution 36,5 37 36,5 37 Time low CO: 1.9l/min High CO: 19l/min Time Time Temperature Temperature Temperature

23. MTt: Mean Transit time the mean time required for the indicator to reach the detection point DSt : Down Slope time the exponential downslope time of the thermodilution curve Recirculation t e -1 Tb From the characteristics of the thermodilution curve it is possible to determine certain time parameters Extended analysis of the thermodilution curve Introduction to the PiCCO-Technology – Thermodilution Injection In Tb MTt DSt T b = blood temperature; lnTb = logarithmic blood temperature; t = time time from injection to the point at which the thermodilution curve has fallen to 75% of its maximum . Downslope time in which TD curve falls from 75% of its max to 25% of its maximum.mixing behaviour of the indicator in the largest mixing chamber

24. Pulmonary Thermal Volume PTV = Dst x CO By using the time parameters from the thermodilution curve and the CO ITTV and PTV can be calculated Calculation of ITTV and PTV Introduction to the PiCCO-Technology – Thermodilution Recirculation t e -1 Tb Injection In Tb Intrathoracic Thermal Volume ITTV = MTt x CO MTt DSt

25. Intrathoracic Compartments (mixing chambers) Introduction to the PiCCO-Technology – Function Pulmonary Thermal Volume (PTV) Intrathoracic Thermal Volume (ITTV) Total of mixing chambers RA RV LA LV PBV EVLW EVLW Largest single mixing chamber ITTV : all four cardiac chambers, the pulmonary circulation and the extravascular lung water forms the total intrathoracic thermal volume. The largest single mixing chamber in this system is the pulmonary thermal volume, which consists of the blood volume of the pulmonary circulation and the extravascular lung water.

26. Pulmonary Thermal Volume (PTV) Intrathoracic Thermal Volume (ITTV) Calculation of ITTV and PTV Einführung in die PiCCO-Technologie – Thermodilution ITTV = MTt x CO PTV = Dst x CO RA RV LA LV PBV EVLW EVLW PTV represents the largest single mixing chamber in the thorax, the pulmonary thermal volume, which consists of the blood volume of the pulmonary circulation (pulmonary blood volume, PBV) and the extravascular lung water (EVLW).

27. GEDV is the difference between intrathoracic and pulmonary thermal volumes Global End-diastolic Volume (GEDV) Volumetric preload parameters – GEDV RA RV LA LV PBV EVLW EVLW ITTV GEDV PTV Introduction to the PiCCO –Technology – Thermodilution the total blood volume in all 4 cardiac chambers that gives information about the filling condition of the heart and thus about cardiac preload.

28. Volumetric preload parameters – ITBV Intrathoracic Blood Volume (ITBV) GEDV ITBV PBV RA RV LA LV PBV EVLW EVLW Introduction to the PiCCO –Technology – Thermodilution ITBV is the total of the Global End-Diastolic Volume and the blood volume in the pulmonary vessels (PBV) the total blood volume present in the heart and pulmonary circulation

29. Transpulmonary Thermodilution The pulse contour analysis is calibrated through the transpulmonary thermodilution and is a beat to beat real time analysis of the arterial pressure curve Calibration of the Pulse Contour Analysis Introduction to the PiCCO-Technology – Pulse contour analysis Injection Pulse Contour Analysis T = blood temperature t = time P = blood pressure CO TPD = SV TD HR

30. PCCO = cal • HR •   P(t) SVR + C(p) • dP dt ( ) dt Cardiac Output Patient- specific calibration factor (determined by thermodilution) Heart rate Area under the pressure curve Shape of the pressure curve Aortic compliance Systole Introduction to the PiCCO-Technology – Pulse contour analysis Parameters of Pulse Contour Analysis Besides the area under the pressure curve and other factors, calculation of the continuous PiCCO pulse contour cardiac output also involves the aortic compliance measured by thermodilution , which represents an important advantage compared to systems that cannot be calibrated .

31. SV max – SV min SVV = SV mean SV max SV min SV mean The Stroke Volume Variation is the variation in stroke volume over the ventilatory cycle, measured over the previous 30 second period. Parameters of Pulse Contour Analysis Introduction to the PiCCO-Technology – Pulse Contour Analysis Dynamic parameters of volume responsiveness – Stroke Volume Variation

32. PP max – PP min PPV = PP mean The pulse pressure variation is the variation in pulse pressure over the ventilatory cycle, measured over the previous 30 second period. Parameters of Pulse Contour Analysis Introduction to the PiCCO-Technology – Pulse Contour Analysis Dynamic parameters of volume responsiveness – Pulse Pressure Variation PP max PP mean PP min

33. Contractility is a measure for the performance of the heart muscle Contractility parameters of PiCCO technology: dPmx (maximum rate of the increase in pressure) GEF (Global Ejection Fraction) CFI (Cardiac Function Index) Contractility Introduction to the PiCCO-Technology – Contractility parameters kg

34. ITTV – ITBV = EVLW The Extravascular Lung Water is the difference between the intrathoracic thermal volume and the intrathoracic blood volume. It represents the amount of water in the lungs outside the blood vessels. Calculation of Extravascular Lung Water (EVLW) Introduction to the PiCCO –Technology – Extravascular Lung Water

35. Differentiating Lung Oedema PVPI = Pulmonary Vascular Permeability Index is the ratio of Extravascular Lung Water to Pulmonary Blood Volume is a measure of the permeability of the lung vessels and as such can classify the type of lung oedema (hydrostatic vs. permeability caused) EVLW PVPI = PBV PBV EVLW Introduction to PiCCO Technology – Pulmonary Permeability

36. permeability PVPI normal (1-3) PVPI raised (>3) Classification of Lung Oedema with the PVPI Difference between the PVPI with hydrostatic and permeability lung oedema: Lung oedema hydrostatic PBV EVLW PBV EVLW PBV EVLW PBV EVLW Introduction to PiCCO Technology – Pulmonary Permeability

37. EVLWI answers the question: Clinical Relevance of the Pulmonary Vascular Permeability Index PVPI answers the question: and can therefore give valuable aid for therapy guidance! How much water is in the lungs? Why is it there? Introduction to PiCCO Technology – Pulmonary Permeability

38. Relevance of EVLW- Management 101 patients with pulmonary edema were randomized to a pulmonary artery catheter (PAC) management group in whom fluid management decisions were guided by PCWP measurements and to an Extravascular Lung Water (EVLW*) management group using a protocol based on the bedside measurement of EVLW *. ICU days and ventilator-days were significantly shorter in patients of the EVLW* group. Mitchell et al, Am Rev Resp Dis 145: 990-998, 1992 22 days 15 days 9 days 7 days * * Ventilation days ICU days n=101 EVLW* group PAC group EVLW* group PAC group

39. Normal ranges Parameter Range Unit CI 3.0 – 5.0 l/min/m 2 SVI 40 – 60 ml/m2 GEDI 680 – 800 ml/m 2 ITBI 850 – 1000 ml/m 2 ELWI* 3.0 – 7.0 ml/kg PVPI* 1.0 – 3.0 SVV  10 % PPV  10 % GEF 25 – 35 % CFI 4.5 – 6.5 1/min MAP 70 – 90 mmHg SVRI 1700 – 2400 dyn*s*cm-5*m

40. Thermodilution Parameters Cardiac Output CO Global End-Diastolic Volume GEDV Intrathoracic Blood Volume ITBV Extravascular Lung Water EVLW Pulmonary Vascular Permeability Index PVPI Cardiac Function Index CFI Global Ejection Fraction GEF Pulse Contour Parameters Pulse Contour Cardiac Output PCCO Arterial Blood Pressure AP Heart Rate HR Stroke Volume SV Stroke Volume Variation SVV Pulse Pressure Variation PPV Systemic Vascular Resistance SVR Index of Left Ventricular Contractility dPmx Parameters measured with the PiCCO -Technology

41. Lithium Dilution Monitoring

42. Uses the arterial pressure waveform to Measure COO The difference over other monitors ( such as the LiDCO ®) is that it does not need to be calibrated with an indicator Application of advanced statistical principles to the arterial pressure tracing Result in the creation of a proprietary algorithm Recalibrates itself constantly By measuring the arterial pressure over a 20 s period at 100 Hz, the system obtains 2000 data points for analysis The standard deviation of these points is then compared with empirical data stored in the proprietary algorithm of the software correlating the standard deviation of the arterial pressure measurements with the appropriate SV . The FloTrac ® is also able to account for changes in arterial compliance which allows for the device to remain accurate and reliable during periods when CO, vasomotor tone or both are changing.

43. Partial Co2 rebreathing fick monitoring ( NICO) The NICO monitor uses a rearrangement of the fick equation for CO2 elimination. Can only be used for patients who are intubated The partial rebreathing technique gives a better approximation of cardiac output in patients who are less critically ill and have normal alveolar gas exchange Best suited for monitoring trends in critically ill patients with stable lung function rather than diagnostic interpretation Gama de Abreu M, Quintel M, Ragaller M, et al : Partial carbon dioxide rebreathing: A reliable technique for noninvasive measurement of nonshunted pulmonary capillary bloodflow.Crit Care Med1997; 25:675–683 Jopling MW: Noninvasive cardiac output determination utilizing the method of partial CO2rebreathing. A comparison with continuous and bolus thermodilution cardiac output.Anesthesiology1998; 89:A544

44. Thoracic bioimpendance The technique depends on the change in bioimpedance of the thoracic cavity during systole A series of ECG type electrodes are placed on the thorax and neck. A small, non-painful current is passed and measurements made

45. Oesophageal doppler Was first described in 1971 and later refined in 1989

46. PRINCIPLE Flow in a cylinder is equal to the area of the cross-section of the cylinder times the velocity of fluid in cylinder Movement of blood is pulsatile and the velocity changes with time The velocity can be characterized by the area under the velocity-time curve between two points in time area under the curve computed mathematically as the integral of the derivative of volume over time (dv/ dt ) from T1 to T2, Time integrated velocity. Stroke volume ( sv ) is calculated by multiplying the cross sectional area by the time-integrated velocity.

47. important consideration is the importance of positioning To have a good approximation of velocity , the Doppler beam should be within 20°of axial flow cross-sectional area of the aorta is actually dynamic and is dependent on the pulse pressure and aortic compliance flow in the aorta is not always laminar

48. Oesophageal Doppler

49. Normal ranges   FTc : Flow Time corrected measure of cardiac preload 330 -360 milliseconds   PV : Peak Velocity-an index of contractility 20 yrs : 90 - 120 cm/sec  50 yrs : 70 - 100 cm/sec 70 yrs : 50 -80 cm/sec Concurrent shifts in FTc and PV indicates changes in after load   MA : Mean Acceleration depends on the patient   SD : Stroke Distance depends on the patient

50. Narrow waveform base, decreased FTc characteristic of hypovolaemia

51. Same patient after fluid resuscitation

52. Minimally invasive Real time measurement Rapid insertion. Results available within few minutes. Minimal technical skill required Short training period Good trend monitor Advantages

53. Interference by nasogastric tube Dislodgement by movement. This may result in loss of signal or may result in changes in monitored values Some patients contraindicated ( eg post- oesophagectomy , oesophageal injuries) Absolute values of cardiac output not very accurate Disadvantages

54. Ballard C, Cohen Y, Fosse JP, et al: Haemodynamic measurements (continuous cardiac output and systemic vascular resistance) in critically ill patients: Transoesophageal Doppler versus continuous thermodilution.Anaesth Intensive Care1999; 27:33–37 Valtier B, Cholley BP, Belot JP, et al: Noninvasive monitoring of cardiac output in critically ill patients using transesophageal Doppler. Am J Respir Crit Care Med1998; 158: 77–83 Madan AK, UyBarreta VV, Shaghayegh AW, et al : Esophageal Doppler ultrasound monitor versus pulmonary artery catheter in the hemodynamic management of critically ill surgical patients.J Trauma1999; 46:607–611

55. Why do we need dynamic indices???

56. PHYSIOLOGIC RATIONALE OF DYNAMIC INDICES

57. PRELOAD

58. Frank-Starling curve

59. Assessment of PRELOAD is not assessment of PRELOAD DEPENDENCE Stroke volume Ventricular preload normal heart failing heart preload-dependence preload-independence

60. Dynamic indices apply a controlled and reversible preload variation and measure the hemodynamic response.

61. Effects of mechanical ventilation on left and right ventricular stroke volume

62. CLASSIFICATION OF DYNAMIC INDICES OF FLUID RESPONSIVENESS Functional hemodynamic monitoring and dynamic indices of fluid responsiveness F . CAVALLARO, C. SANDRONI, M. ANTONELLI MINERVA ANESTESIOL 2008;74:123-35

63. Stroke volume variation (SVV)

64. Pulse pressure variation (PPV)

65. PLETHYSMOGRAPHY

66. Evidence for pulse oximetric variation? – not validated

67. Respiratory variability of the inferior vena cava

68. Distensibility index of the IVC ( divc ) defined as ( Dmax-Dmin )/ Dmin and expressed as a percentage predictive of fluid responsiveness with a sensitivity of 90% and a specificity of 90 % DDivc as maximal – minimum IVC diameter divided by the mean of the two values and expressed as a percentage . DDivc of 12% predicted fluid responsiveness with a positive predictive value of 93% and negative predictive value of 92%

69. Cyclical swing in intra-thoracic pressure Swing in IVC size means preload is along the steep part of the Starling Curve

70. IVC size variation = Max Diam – Min Diam / Mean x 100

71. Cautions Regarding Cavallaro Group A And B Indices

72. Passive Leg Raising

73. Venous return = Mean Systemic Pressure – RAP PLR Increased MSP venous return RV output LV filling Acts as a brief, totally reversible fluid challenge

74. PLR induced increase of SV by 12.5%, resulted in an increase of stroke volume by 15% after fluid challenge with 500 mls .

75. Limits of Preload-Responsiveness Preload  Preload-responsiveness Preload-responsiveness  Need for fluids The means of altering preload matters Size of Vt , passive leg raising, spontaneous breaths Different measures of pressure or flow variation will have different calibrations Pinsky Intensive Care Med 30: 1008-10, 2004

76. Where does echocardiography stand? Tool for “functional” haemodynamic monitoring Help predict fluid responsiveness LV, RV, valve function Acute PE, pericardial effusion Clots

77. LVOT AREA = ∏ (3.14) X (D/2) 2 Velocity – Time Integral Distance travelled by the blood is a function of the velocity and time = velocity – time integral. Otherwise called stroke distance. VTI x area of the LVOT

78. To calculate SV : velocity across the aorta or LVOT & CSA of aorta As velocity/flow is not constant : measured as VTI View the heart on the 5CV Switch on the PWD Place the cursor or sampling volume at the level of LVOT Ensure that line of the cursor should be in line with LVOT Once u switch on P WD u get waveform / envelope formed by flow across LVOT Trace out the Evelope which will give VTI from the inbuilt software

79. Stroke Vol = VTI x CSA Measure LVOT diameter Plax view Freeze the frame in systole Aortic leaflets will be fully open and apposed to the aortic valve

80. LV systolic function To measure EF by teicholz method, Parasternal long axis view Place the M mode cursor at right angles to the septum and the free wall of the LV. On the m mode, measure the systolic diameter and the diastolic diameter. Use the calculation menu on the echo machine to measure ef by teicholz method.

81. LV dysfunction LV dysfunction common in the ICU Ventricular performance may be markedly impaired in sepsis EF may be unreliable because of the low SVR Important for haemodynamic optimisation - fluid or inotrope ?

82. DCM WITH POOR FUNCTION

83. POOR LV FUNCTION

84. PSAX OF LV FAILURE

85. RV dilatation/dysfunction Massive PE, ARDS Excessive PEEP, RV afterload increase due to other causes RV infarction Air, fat embolism Sickle cell crisis Myocardial contusion, sepsis RVEDA/LVEDA 0.6 TO 1.0 = moderate >1 = severe, >2 = extreme Eye balling – as large or larger than LV on A4C

86. Pulmonary embolism

87. Pulmonary Artery

88. Pulmonary Embolism

89. PA pressure Tricuspid jet Measure tricuspid gradient = 4V 2 Tricuspid gradient (TG) = RV psys – RA psys RV psys = TG + RA psys RA psys = CVP RV psys = PA sys = TG +CVP Place CWD on regurgitent Jet Measure the depth of the waveform from baseline

90. Pericardial Effusion Echo free space around the heart Distinguish between pericardial and pleural effusions Cardiac tamponade

91. RA CLOT

92. Mitral stenosis

93. THANK YOU