COMBINED USE OF TRANSPULMONARY
THERMODILUTION (TPTD) TECHNIQUE
IN FLUID MANAGEMENT FOR SEPSIS PATIENTS
K. Morisawa1,
M. Yanai1, Y. Takamatsu1, M. Takita1, S. Fujiwara1
B. Lohman1, J. Matsumoto1, S. Fujitani2, Y. Taira1
1 St.
Marianna University School of Medicine, Kanagawa, Japan
Department of Emergency and Critical Care Medicine
2 Tokyobay
UrayasuIchikawa Medical Center, Chiba, Japan
INTRODUCTION
 Treatment for sepsis requires proper fluid transfusion and
monitoring of hemodynamic changes.
 The mainstay guidelines recommend CVP for fluid management.
 Fluid management with CVP monitoring may lead to excessive
transfusion resulting in the following adverse reactions.
 TPTD is a technique that can estimate the global end-diastolic
volume (GEDV) from the thermodilution curve.
TPTD monitoring
GEDV
= Blood volume in the
4 chambers of the heart
CV catheter
Pulmonary
circulation
Blood
temperature
Thermodilution curve
Bolus cold
saline
Bolus
cold saline
TPTD catheter measures
the downstream temperature changes.
TPTD catheter
Systemic
circulation
at
femoral artery
Time
CVP, central vein pressure; MV, mechanical ventilation; TPTD, transpulmonary thermodilution; GEDV, global end-diastolic volume
PROTOCOL
We assessed and compared the
clinical outcome and total fluid balance
between 2 groups of sepsis patients
that were managed with TPTD and
CVP respectively within 72 hours of
admission to the ICU.
TPTD group
: using GEDI and SVV
GEDI, global end-diastolic volume index
calculated by the body surface area (mL/㎡)
CVP group
: based on the original EGDT
Primary outcome
: 28-day mortality
Secondary outcome
: ICU stay days
: Mechanical ventilation days
: Total volume balance
YES
NO
Intubation and oxygenation
for SpO2 ≥ 92 %
Adequate volume resuscitation ?
TPTD group
CVP group
GEDI 650 – 850 ?
SVV < 15 % ?
CVP
12 – 15 mmHg ?
MAP 65 - 90 mmHg ?
Volume
infusion
or
reduction
Norepinephrine
or
Nitroglycerin
Hct > 30 % ?
RBC transfusion
ScvO2 ≥ 70 % ?
Dobutamine
Goal ?
 Adequate volume resuscitation
 Hct > 30 %
 ScvO2 ≥ 70 %
 Lactate < 4 mmol/L
 SpO2 ≥ 92 %
 MAP 65 - 90 mmHg
Further
treatment
TPTD, transpulmonary thermodilution; CVP, central vein pressure; EGDT, early-goal directed therapy; GEDV, global end-diastolic volume; SVV, stroke volume variation
PARTICIPANTS
 23 severe sepsis and septic shock patients in the ICU
 Vasopressors and Mechanical ventilation
 September 2012 to August 2013
TPTD group
(n = 11)
CVP group
(n = 12)
P value
Age
73 (10)
74 (9)
ns
Male [n(%)]
8 (73%)
6 (50%)
ns
SAPS II
53 (13)
56 (16)
ns
SOFA
11 (3)
10 (4)
ns
Pneumonia
4
5
Peritonitis
3
2
UTI
2
2
Others
2
3
Lactate
3.5 (2.9)
2.5 (1.8)
Flow diagram
43 sepsis patients in study
20 patients excluded
No vasopressors (n=3)
Protocol deviation (n=9)
No infection (n=4)
Data deficiency (n=3)
DNAR order (n=1)
TPTD group
(n = 11)
CVP group
(n = 12)
[mmol/L]
ns
(Mean ± SD)
TPTD, transpulmonary thermodilution; CVP, central vein pressure; SAPS II, simplified acute physiology score II
SOFA, sequential organ assessment score; UTI, urinary tract infection
RESULTS
TPTD group
(n = 11)
CVP group
(n = 12)
P value
28-day mortality [n(%)]
2 (18)
4 (33)
ns
ICU stay days
6.3 (5.3)
8.8 (3.4)
0.01
MV days
4.2 (2.3)
5.6 (2.3)
ns
0-24hr
2666 (1798)
5014 (3351)
0.02
24-48hr
69 (1095)
1889 (2120)
0.01
48-72hr
59 (648)
171 (1446)
ns
Total in 3 days
2885 (2678)
7074 (5248)
0.01
Volume balance[ml]
TPTD, transpulmonary thermodilution; CVP, central vein pressure; MV, mechanical ventilation
(Mean ± SD)
CONCLUSIONS
 TPTD monitoring may help reduce any excess
fluid transfusion.
 TPTD monitoring method may help shorten ICU
hospitalization in patients with severe sepsis and
septic shock.
 RCT is needing to validate our result.
 Multicenter RCT for this question is in process.
(UMIN000011493)