PiCCO -...
Transcript of PiCCO -...
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PULSION PiCCO plus
PiCCO ...
...Simple – Safe – Speedy - Specific
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COMPONENTI
LINEA VENOSA CENTRALE
LINEA ARTERIOSA
Introduttore
Dilatatore
Seldinger
Cavo di collegamento
Catetere da : 3F (pediatrico da 6 cm)
4F (radiale da 50 cm)
5F (femorale da 20 cm)
PiCCO (Pulse Continuos Cardiac Output)
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Central venous line (CV)
Thermodilution catheter with lumen for
arterial pressure measurement
• Axillary (A)
• Brachial (B)
• Femoral (F)
• Radial (R), long catheter
Arterial pressure transducer
Configuration
CV
A
B
F
R
www.slidetube.it
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PiCCO (Pulse Continuos Cardiac Output)
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PiCCO (Pulse Continuos Cardiac Output)
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PiCCO (Pulse Continuos Cardiac Output)
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PiCCO (Pulse Continuos Cardiac Output) www.slidetube.it
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The PiCCO-Technology is also available as a module for
Philips IntelliVue / CMS patient monitoring systems.
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Sistema di monitoraggio
Monitoraggio in continuo*:
• pressione arteriosa
• frequenza cardiaca
• stroke volume
• gittata cardiaca
• stroke volume variation
• resistenze vascolari sistemiche
Monitoraggio volumetrico:
• volume di sangue intratoracico (precarico)
• acqua polmonare
PiCCO (Pulse Continuos Cardiac Output)
*= dopo calibrazione iniziale.
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Calibrazione del sistema principio della termodiluizione
Si inietta il più velocemente possibile il volume noto (15-
20 ml) di soluzione salina o glucosata fredda o a
temperatura ambiente nella vena centrale.
PiCCO (Pulse Continuos Cardiac Output)
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PiCCO plus setup
Central venous catheter
Injectate temperature
sensor housing
PV4046
Arterial thermodilution catheter
Injectate temperature sensor cable
PC80109
PULSION disposable pressure transducer PV8115
PCCI
AP 13.03 16.28 TB37.0
AP 140
117 92
(CVP) 5
SVRI 2762
PC
CI 3.24
HR 78
SVI 42
SVV 5%
dPmx 1140
(GEDI) 625
DPT Monitor cable
PMK-206
Interface cable
PC80150
Connection cable
to bedside monitor
PMK - XXX
AUX adapter
cable
PC81200
www.slidetube.it
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a. Transpulmonary Thermodilution Per misurare la termodiluizione transpolmonare si
richiede semplicemente l'iniezione venosa centrale di un
liquido freddo(< 8°C) o Tiepido(< 24°C) di Soluzione fisiologica…
CV Bolo
Cuore
Destro
Polmoni
Cuore
sinistro
PiCCO Catetere In arteria femorale
www.slidetube.it
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PiCCO Thermodilution Cardiac Output
Dopo l'iniezione venosa centrale nell'indicatore, il termostato nella
punta del catetere arterioso misura le variazioni di temperatura a valle.
La gittata cardiaca è calcolata con l'analisi della curva
di termodiluizione utilizzando una versione modificata dell’algoritmo
Stewart-Hamilton :
Injection
t
-Tb
www.slidetube.it
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Tb injection
t
dtT
KV)T(TCO
b
iibTDa
Transpulmonary thermodilution: Cardiac Output
Metodo Stewart-Hamilton
Tb = Blood temperature
Ti = Injectate temperature
Vi = Injectate volume
∫ ∆ Tb . dt = Area under the thermodilution curve
K = Correction constant, made up of specific weight and
specific heat of blood and injectate
www.slidetube.it
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Monitoraggio Continuo
Gittata cardiaca (C.O):
Sull’analisi dell’onda
pressoria è possibile il
monitoraggio continuo
della C.O. ovvero si
osservano battito per
battito le variazioni
istantanee della C.O.
PiCCO (Pulse Continuos Cardiac Output)
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L’analisi del contorno del polso arterioso fornisce un continuo battito
per battito, parametri ottenuti dalla forma dell'onda di pressione arteriosa.
L'algoritmo è in grado di calcolare ogni singolo volume corsa (SV), dopo
essere stato calibrato da un iniziale termodiluizione transpolmonare.
b. Arterial Pulse Contour Analysis
t
-∆T
t
-∆P
Calibration
t [s]
P [mm Hg] SV
www.slidetube.it
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Arterial Pulse Contour Analysis
t [s]
P [mm Hg]
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Monitoraggio Continuo
Stroke volume (S.V.):
E’ direttamente proporzionale all’area sottesa alla curva
della pressione arteriosa.
Gittata cardiaca in continuo (CCO)= SVxFC
PiCCO (Pulse Continuos Cardiac Output)
Sec.
P.A.[mm Hg]
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Monitoraggio Continuo
Resistenze vascolari sistemiche (S.V.R.):
A B •Il flusso ematico in un condotto (vaso sanguigno) e’ garantito da un ΔP (pressione A > pressione B)
•Il condotto, con le sue pareti, offre resistenza al flusso ematico
• Pertanto F= ΔP/R
Da cui R= ΔP/F SVR = PAm-PVC · 80 (cost.)
C.O.
PiCCO (Pulse Continuos Cardiac Output)
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CO is calculated as stroke volume x heart rate (SVxHR)
Cardiac Output and Systemic Vascular Resistances
SVR is calculated as (mean arterial pressure - central venous pressure) / CO
Come analisi del contorno del polso si misura continuamente la gittata sistolica e
la pressione arteriosa, la gittata cardiaca (CO) e le resistenze vascolari
sistemiche (SVR) è calcolato come segue:
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Monitoraggio Continuo
PiCCO (Pulse Continuos Cardiac Output)
Frequenza
cardiaca
Stroke volume
Gittata
cardiaca
Pressione
arteriosa
Resistenze
vascolari
sistemiche
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Global Enddiastolic Volume GEDV
Intrathoracic Blood Volume ITBV
Extravascular Lung Water EVLW*
ln Tb
injection
At
recirculation
MTt t
e -1
DSt
Tb
* not available in USA
PiCCO Volumetric Parameters
Advanced Thermodilution Curve Analysis
Monitoraggio Volumetrico
Questi parametri volumetrici sono ottenuti per l'analisi avanzata
della curva di termodiluizione.
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Methodology of volumetric monitoring (I)
ln c (I)
injection
At
recirculation
MTt t
e -1
DSt
c (I)
MTt: tempo medio di transito
≈ half of the indicator passed
the point of detection
DSt: Tempo discendente
≈ exponential downslope time of TD curve
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COa X tTD Volumi termici (ITTV-PTV)
Volumi intravascolari
Indicatori di precarico (GEDV-ITBV)
Volume extravascolare
Indicatore di edema polmonare (EVLW)
Monitoraggio Volumetrico
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Methodology of volumetric monitoring (II)
Vall = V1 + V2 + V3 + V4 = MTt x Flow
V3 = largest volume = DSt x Flow
flow
V3 V4 V2 V1
injection detection
La MTT determina il
volume intero dell'indicatore attraversato
dal punto di iniezione fino al punto
di rilevazione.
Il DST determina il più grande singolo
volume (min. 20% più grande!) In una serie di
camere di miscelazione
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Methodology of volumetric monitoring (III)
RAEDV LAEDV LVEDV RVEDV
PTV
ITTV
PTV = Volume polmonare termico
largest thermal volume in the series of mixing chambers (DSt – Volume)
ITTV = Volume termico intratoracico
volume from the point of injection to the point of detection (MTt – Volume)
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GEDV = Volume globale di fine diastole
End-diastolic volume of the 4 heart chambers
PTV RAEDV LAEDV LVEDV RVEDV
GEDV
GEDV = ITTV - PTV
Methodology of volumetric monitoring (IV)
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ITTV = CO * MTtTDa
PTV = CO * DStTDa
ITBV = 1.25 * GEDV
EVLW = ITTV - ITBV
GEDV = ITTV - PTV RAEDV RVEDV LAEDV LVEDV
RAEDV RVEDV LAEDV LVEDV PBV
RAEDV RVEDV LAEDV LVEDV PTV
PTV
EVLW
EVLW
Calculation of volumes
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Global Enddiastolic Volume
Global Enddiastolic Volume (GEDV) = Volume globale nelle 4 camere del cuore.
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Intrathoracic Blood Volume
Intrathoracic Blood Volume (ITBV) : è il volume delle 4 camere del cuore + il
volume di sangue nei vasi polmonari.
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Extravascular Lung Water*
Extravascular Lung Water (EVLW)*.
* not available in USA
è la quantità di contenuto di acqua nei polmoni.
Esso consente la quantificazione capezzale del
grado di edema polmonare
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Cardiac Preload is
Volume, NOT Pressure
Volume management requires
volume measurement
Intrathoracic Blood Volume (ITBV)
RAEDV PBV LAEDV LVEDV RVEDV
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Liquido extra-vascolare polmonare
EVLW
EVLW
Clinical validation
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EVLW Extravascular Lung Water
Direct quantification in ml
Water content of the lungs
High accuracy and reproducibility
Fast bedside determination
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ITBV= corretta quantificazione del precarico cardiaco, permette di
valutare in modo opportuno la funzione cardiaca sia in
termini di riempimento che di funzionalità. Ciò consente di
impiegare inotropi o la somministrazione di volume nel
modo più efficace.
EVLW= corretta quantificazione dell’acqua extravascolare
polmonare, permette di valutare in modo opportuno l’edema
polmonare. Ciò consente di guidare la somministrazione di
liquidi o diuretici.
PiCCO (Pulse Continuos Cardiac Output)
I.T.B.V.I.= v.n. 850 – 1000 ml/m² E.V.L.W.I.= v.n. 3.0 – 10 ml/Kg
Monitoraggio Volumetrico
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Indicazioni: nei pazienti in cui si rende necessario un monitoraggio cardiovascolare volumetrico. Es. pazienti degenti in reparti di terapia intensiva, ustionati,grossa chirurgia.
Controindicazioni:
nei pazienti con by-pass aorto-bifemorale;
nei pazienti con arteriopatie degli arti;
nei pazienti con contropulsatore aortico.
PiCCO (Pulse Continuos Cardiac Output)
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Clinical
Application
Drugs
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PiCCO (Pulse Continuos Cardiac Output)
V+ = carico volemico (! = con cautela ) V- = restrizione volemica Ino. = inotropi
>10
V+!
Ino.
>10
Ino.
V-
<10
V+
>10
V+!
<10
Ino.
<10
V+
>3.0 <3.0
>1000 <1000 >1000
<10
OK!
<1000
>10
V-
CI l/min/m2)
EVLWI (ml/kg)
ITBVI (ml/m2)
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Interazione cuore-polmoni in IPPV
In inspirazione:
Ptransmurale (Pintracardiaca-Pintratoracica) ↓
Precarico Vsx ↑, Postcarico Vsx ↓
Precarico Vdx ↓, Postcarico Vdx ↑
Interdipendenza ventricolare
Variazione ciclica di VSsx (max in inspirazione, min in espirazione)
Fluttuazione dell’onda di PA, maggiore con il ridursi del volume intravascolare, durante IPPV
INDICI DINAMICI DI PRECARICO IN IPPV
I sistemi di monitoraggio beat-to-beat misurano questa fluttuazione
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SVmax
SVmin
SVmean
SVmax – SVmin SVV =
SVmean
SVmax and SVmin are determined over last 30 s window
Determination of the Stroke Volume Variation (SVV)
Only applicable in controlled mechanically ventilated patients
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SVV riflette la sensibilità del cuore ai cambiamenti ciclici nel precarico cardiaco indotto
da ventilazione meccanica.1,14,17,18,19
SVV può prevedere se la gittata sistolica aumenta con l'espansione del volume.
Stroke Volume Variation (SVV)
Nei pazienti ventilati meccanicamente senza aritmia,
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SVV – clinical application
SVV
Applicabile solo nei pazienti in ventilazione meccanica controllata
SVV la prognosi per la reazione del cuore in volume e di carico
corrisponde direttamente alla pendenza della curva di Frank - Starling.
Berkenstadt et al, Eur J Anaesthesiol 17 (19): 49, 2000
Reuter et al, Eur J. Anaesthesiol 17 (Suppl 19): 163, 2000
Reuter et al, Britisch Journal of Anaesthesia 88 (1) 124-6, 2002
è un parametro dinamico, misurato in continuo
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How to manage my patient with the PiCCO-Technology?
Parametri emodinamici normali
Cardiac Index CI 3.0 – 5.0 l/min/m2
Global Enddiastolic Blood Volume Index GEDVI 680 – 800 ml/m2
Intrathoracic Blood Volume Index ITBVI 850 – 1000 ml/m2
Stroke Volume Variation SVV 10 %
Extravascular Lung Water Index ELWI* 3.0 – 7.0 ml/kg
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Complicanze
• Ematoma
• Lesione arteria femorale
• Infezioni
• Embolia gassosa
PiCCO (Pulse Continuos Cardiac Output)
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2. What are the advantages of the PiCCO-Technology?
Less Invasiveness - Only central venous and arterial access required
- No pulmonary artery catheter required
- Applicable also in small children
Short Set-up Time - Can be installed within minutes
Dynamic, Continuous Measurement - Cardiac Output, Afterload and Volume Responsiveness
are measured beat-by-beat
No Chest X-ray - To confirm correct catheter position no x-ray is necessary
Cost Effective - Less expensive than pulmonary artery catheter technique
- Arterial PiCCO catheter can be in place for >10 days
- Potential to reduce ICU stay and costs
More Specific Parameters - PiCCO parameters are easy to use and interpret even
for less experienced clinical staff
Extravascular Lung Water* - Lung edema can be excluded or quantified at the bed-side
* not available in USA
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PiCCO - Advantages
TD-Catheter: Less time required for placement; can be in place up to 10 days;
Quick and simple handling; Short response time
Dynamic and less invasive „beat by beat“ measurement;
No right heart catheter (RHC),
Reduces ICU stay and costs
Direct clinically applicable parameters, no interpretation necessary
Quantification of extravascular lung water
Measurement of flow, preload, afterload and contractility
Easy to apply in paediatric patients