PiCCO Monitor

PiCCO monitor indication, contraindications, how does it work and how to interpret

1. OSAMA ELAZZOUNY PGY 3 ANESTHESIA RESIDENT HMC, April 2019

2. I have no conflict of interest in relation to this lecture

3. Objectives Introduction Indications and contraindications for PiCCO How does PiCCO work? Parameters measured by PiCCO : definitions & normal values Decision tree for hemodynamic monitoring using PiCCO

4. Objectives Introduction Indications and contraindications for PiCCO How does PiCCO work? Parameters measured by PiCCO : definitions & normal values Decision tree for hemodynamic monitoring using PiCCO

5. INTRODUCTION PiCCO is an acronym for Pulse Contour Cardiac Output. It enables assessment of the patient’s haemodynamic status to guide fluid or vasoactive drug therapy Requires the insertion of a central venous pressure (CVP) catheter and a thermodilution arterial line.

6. Objectives Introduction Indications and contraindications for PiCCO How does PiCCO work? Parameters measured by PiCCO : definitions & normal values Decision tree for hemodynamic monitoring using PiCCO

7. INDICATIONS FOR PiCCO Shock: cardiogenic, hypovolaemic , septic Sepsis Trauma Pulmonary oedema Acute lung injury Burns Any condition that requires assessment of haemodynamic and/ or volumetric function

8. Contraindications for use of PiCCO : Conditions that distort the arterial wave form: Atrial or ventricular arrhythmia IABP ECMO Conditions that affect pulmonary vasculature: Pneumonectomy Massive pulmonary embolism Intracardiac shunt

9. Objectives Introduction Indications and contraindications for PiCCO How does PiCCO work? Parameters measured by PiCCO : definitions & normal values Decision tree for hemodynamic monitoring using PiCCO

10. HOW DOES PiCCO WORK? The PiCCO technology is based on two physical principles Transpulmonary thermodilution : calculates volumetric measurements of preload and cardiac output Pulse contour analysis: continuous cardiac output and stroke volume variation.

11. TRANSPULMONARY THERMODILUTION Injection of cold saline through a CVC. Mixes with the blood volume & passes through the Rt heart, through the pulmonary vessels & back through the Lt heart Just after the Lt heart the arterial line measures the drop in blood temperature & from this we obtain a Thermodilution Curve. Transpulmonary Thermodilution

12. Transpulmonary thermodilution: Volumetric parameters All volumetric parameters are obtained by advanced analysis of the thermodilution curve Below shows the graph of change in temp (inverted) against time

13. Firstly cardiac output is calculated from the Stewart Hamilton equation The product of volume/unit time x time= volume. The product of CO X MTt represents the total volume traversed by the indicator i.e . total volume between site of injection and detection. The greater the volume the bolus has to travel through the longer it will take. The product of CO x DSt represents the largest individual mixing volume( Lungs) in a series of indicator mixing chambers.

14. The pulse contour analysis provides continuous information while transpulmonary thermodilution provides static measurements. Transpulmonary thermodilution is used to calibrate the continuous pulse contour parameters . Arterial pulse contour analysis

15. PULSE CONTOUR ANALYSIS: The PiCCO system continually estimates the SV from the arterial waveform, using an arterial catheter. CO is then estimated from the SV & HR Beat by beat parameters are obtained from the shape of the arterial pressure wave The initial transpulmonary thermodilution calibrates the parameters & the algorithm is then capable of computing each single stroke volume

16. PULSE CONTOUR ANALYSIS:

17. Objectives Introduction Indications and contraindications for PiCCO How does PiCCO work? Parameters measured by PiCCO : definitions & normal values Decision tree for hemodynamic monitoring using PiCCO

18. PARAMETERS MEASURED: DEFINITIONS & NORMAL VALUES Preload: Global End Diastolic Volume (GEDV) The volume of blood contained in the 4 chambers of the heart 680- 800ml/m₂ Intrathoracic Blood Volume (ITBV) : The volume of the 4 chambers of the heart plus the blood volume in the pulmonary vessels 850-1000ml/m₂ Stroke Volume Variation (SVV) : Reflects the sensitivity of the heart to the cyclic changes in cardiac preload induced by respiration 3.0 L/min/m2 or less than 10%

19. Contractility: Cardiac Function Index : The ratio of the index of cardiac output to the index of the GEDV. A measure of how well the CO is doing in relation to its preload. 4.5- 6.5% Global ejection fraction (GEF) : A % of total blood expelled from the heart every beat to the total amount of blood estimated to be present just prior to ventricular systole. 25- 35% Lung function/?Pulmonary Edema: Pulmonary Vascular Permeability Index(PVPI) : Indication of pulmonary oedema in relation to preload 1.0- 3.0 Extravascular Lung Water (EVLW) : Measures the fluid in the interstitial space outside of the pulmonary blood volume 3-7mls/kg Afterload: Systemic vascular resistance : SVR : MAP - CVP/CO

20. Objectives Introduction Indications and contraindications for PiCCO How does PiCCO work? Parameters measured by PiCCO : definitions & normal values Decision tree for hemodynamic monitoring using PiCCO