PiCCO Monitor
- 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
- 6. 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.
- 8. 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
- 9. 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
- 10. 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
- 11. 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
- 12. 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.
- 13. 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
- 15. 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
- 16. • 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.
- 18. • 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
- 19. 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
- 21. 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
- 22. 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%
- 25. • 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
- 26. 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