PiCCO, CeVOX & LiMON Technology
Training in methodology, operation, application and safety
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2
Overview
A. Introduction
B. Disposables
C. Start-Up
D. Measurement
E. Parameters
F. PiCCO Strategies
3
User orientated presentation
Basic nurse training
Basic medical training
Intensive care nurse training
Intensive care medical training
4
A. Introduction
5
History of the PiCCO-Technology
• Intelligent hemodynamic monitoring
• Paradigm shift in hemodynamic monitoring
• Integration into patient monitoring monitors
• Most widely used less-invasive method
PulsioFlex™
2010
PiCCO2
2007
Dräger Smart
Pod 2005
PiCCO 1997
PiCCO plus 2002
COLD System 1990
6
Philips PiCCO
Module 2003
PULSION – Made in Germany
PULSION Head Office
• Medical device manufacturer based in
Munich, founded in 1990
• Production, development, management,
marketing and distribution in Munich
Clean Room
• Subsidiaries in USA, France, Spain,
United Kingdom, Benelux, Poland, Austria
and Switzerland
• Distribution and licensing worldwide
Production
7
Why Monitor Hemodynamics?
• What are hemodynamics?
• When is hemodynamic
monitoring indicated?
• What types of hemodynamic
monitoring are there?
• Why do you need the
PiCCO-Technology?
Illustrative case
8
Key questions
Is the O2 supply sufficient?
Volume or catecholamine's ?
Is there Pulmonary edema?
9
What are Hemodynamics?
O2 uptake
Gas exchange
O2 transport
O2 delivery
O2 consumption
Macro-circulation
(Cardiac Output, Hb)
Micro-circulation
Cellular O2 consumption
(ScVO2, PDRICG*)
Maintenance of oxygen extraction!
* Parameter is not available in the USA
10
Intervention Options
-
+
Respiration
-
-
+
+
Volume
Catecholamines
Volume loading?
Volume withdrawal?
Diuretics?
Vasopressors?
Vasodilators?
Inotropes?
The correct decision, early!
11
-
+
Hemoglobin
Anatomy and physiology of the circulatory system
Determinants of cardiac output:
Preload:
- Blood volume, blood available for pumping
Afterload:
- Resistance, against which the heart must pump
Contractility:
- Performance of the heart muscle
Heart rate

Circulatory model
Flow is the result of: preload, afterload, contractility & heart rate
12
Hemodynamic Parameters
O2 Delivery
DO2
Gas exchange?
SaO2
O2 Transport?
Hb
Flow?
CI
Stroke Volume
SVI
Preload
GEDI
SVV
Lung
ELWI
PVPI*


!
O2 Consumption
Mixed- / CentralVenous
O2-Saturation
VO2
ScVO2
DO2
VO2
Frequency
HR
x
Afterload
MAP
SVRI
Contractility
dPmx, CPI*
CFI*, GEF*
* Parameters are not available in the USA
13
Treatment strategies
Sepsis
Cardiac surgery
Cardiology
Neurosurgery/ Neurology /Stroke
Burns
Trauma
14
Monitoring and Diagnostic systems
Diagnostics
CO - Monitoring
Doppler
TTE/TEE
CT/ MRI
LiDCO rapid
Diagnostics & Advanced Monitoring
Vigileo
Bioimpendance
PulsioFlex
Vigilance / PAC
15
PiCCO2
B. Disposables
16
PiCCO Catheter
• For advanced hemodynamic monitoring with
the PiCCO-Technology
• Temperature sensor at the catheter tip for
transpulmonary thermodilution
• Pressure lumen for arterial pressure
measurement
• For use with
• PiCCO2
• PiCCO plus
• Philips PiCCO technology module and
• Draeger Infinity® PiCCO SmartPod®.
17
PiCCO Catheter Placement Options
A. Axilla
Adult
A. Brachial
Proximal
4F - 16cm
Adult distal (cubital) 4F - 22cm
A. Femoral
Adult
5F - 20cm
Children/peds
3F - 07cm
Adult
4F - 50cm*
A. Radial
4F - 08cm
* Product is not available in the USA
18
PiCCO Catheter Safety Tips
•
Catheter handling according to hospital hygiene policy
•
Latex and DEHP free
•
Remove catheter if there are any signs of
inflammation/infection
19
CeVOX Probe*
•
Continuous monitoring of ScvO2
•
Convenient application
•
Access via already placed standard CVC
•
Easy application
•
Continuous ScvO2 within minutes
* Product is not available in the USA
20
CeVOX Probe Selection and Placement
Remove slide clamp
from CeVOX lumen
Insert probe through
the distal lumen of your
CVC
Secure CeVOX probe
Luer lock to CVC
distal Luer lock
Tip of CeVOX probe is
positioned 2.5 ± 0.5 cm
past the tip of the CVC
No stopcock / 3 way tap in-between probe and CVC!
Remove slide clamp from CeVOX lumen!
* Product is not available in the USA
21
Connect the CeVOX
probe to the optical
module and perform
an in-vivo calibration
CeVOX-probe
indicator
CeVOX* CVC-lumen
•
Blood samples for in-vivo calibration are withdrawn from the Y-connector
at the end of the CeVOX probe.
(if not possible then from the next (medial) lumen from the same CVC)
•
In-vitro calibration (pre-calibration) is not validated and raises hygiene
issues
•
Keep the CeVOX lumen open by continuous flow
•
•
Online CVP via pressure transducer
•
3ml/h flush solution via syringe pump
Infusions and medication can be administered via the CeVOX-CVC lumen
•
No catecholamines!
* Product is not available in the USA
22
CeVOX* probe safety tips
• CeVOX probe and CVC handling according to
hospital policy
• Latex and DEHP- free
• Remove CeVOX probe together with CVC if there
are signs of inflammation at the injection site or
signs of catheter related infection
• Remove slide clamp from CeVOX lumen!
• Do not place a stopcock (3 way tap) between
probe and CVC
* Product is not available in the USA
23
PiCCO Pressure Transducer
24
PiCCO Pressure Transducer
• PV8215
PiCCO transducer
incl. PV 4046
• PV8215-2
2in1 PiCCO transducer
with continuous AP and CVP
incl. PV4046
• PV8215CVP
PiCCO transducer
with discontinuous CVP
incl. PV4046
• PV8615
CVP online transducer
• DPT-100
In-Line transducer
• PV4046
Injectate sensor housing
PV82xx transducers are not available in all markets. Alternative products are available on request.
25
Movie
Transducer Safety Tips
• Change transducer according to hospital policy
(usually around every 96 hours)
• PV82XX is Latex and DEHP free
• Use only PULSION approved transducers for PiCCO monitoring
(CE-Conformity).
26
Injectate Sensor Housing PV4046
•
Measures the temperature of injectate at time of injection
•
Included in PiCCO transducer kits
•
Also available separately
27
C. Start-UP
28
Connectivity
PiCCO2
PiCCO plus
Philips IntelliVue Model
Dräger Infinity PiCCO SmartPod
29
Connectivity PiCCO2
Flush bag
LiMON
Sensor
1 CeVOX Module
(Art. No. PC3015)
1a
1a LiMON Module*
CeVOX probe
via standard CVC
(Art. No. PC5100)
2 Injectate-Sensor cable
(Art. No. PC80109)
1
3 Temperature cable
(Art. No. PC80150)
2
4 Pressure cable
3
(Art. No. PMK-206)
4
PiCCO monitoring kit
PiCCO catheter
* Product is not available in the USA
30
Connectivity Philips IntelliVue Module
Flush bag
1 Injectate -Sensor cable
(Art. No. PC80109)
2 Temperature cable
(Art. No. PC80150)
3 Pressure transducer
cable
(Art. No. PMK-206)
1
2
3
PiCCO catheter
PiCCO monitoring Kit
31
Connectivity Dräger Infinity PiCCO SmartPod®
1 Injectate Sensor cable
Flush bag
(Art. No. PC80109)
2 Temperature cable
(Art. No. PC80150)
1
3 Pressure transducer
cable
2
(Art. No. PMK-206)
To bedside
monitor
3
Connected to the
back
PiCCO catheter
PiCCO monitoring kit
32
Connectivity PiCCO plus
PV8215
PV2015L20N
33
PiCCO2 Connectivity
Input
Output
CeVOX ScvO2 Module
PiCCO –
Thermodilution
PiCCO –
arterial pressure
AUX port for
connection to
bedside monitoring
Online - CVP
CVP
AP
35
PiCCO2 Connectivity
Interface
Mains Lead
2x USB
LAN
RS 232
Mains
connection
PotentialEquilization
36
Start-Up
1. Power Switch
2. On/Off button
3. Alarm indicator
4. Charge warning light
PiCCO2
1
2 4
3
Blinking = charging
Permanently on = Fully charged
38
Screen layout
Information bar
Real-time
arterial waveform
Innovative
visualizations
Touch screen
Direct access buttons & dial knob
39
Parameter
fields
Direct Access Buttons and Navigation Dial
1. On / Off
2. Help
3. Print
4. Suspend alarm
5. Back (to previous level)
6. Back (to main screen)
1
2
3
4
40
5
6
Help Function
- Press
Help button to
open the help
screen
Setup scheme
41
Help Function
Parameter information
42
Help Function
Therapy
algorithm
43
Help Function
Help funktion
Physiological
parameter model
with intervention
options
44
Help Function
How to contact
PULSION
and the PiCCO2
serial number
45
Help Function
Press „Exit“ or “Next” to proceed to next screen
46
Zeroing of AP and CVP
47
•
Zero pressures once
per shift and as
required
•
Manually enter CVP in
mmHg
•
Continuous CVP can
be monitored via a
second transducer
System Check
1
2
1 AP plausible?
(PiCCO and patient monitor)
2 Systole identified?
3
3.. Blood temp (TB) plausible?
3
48
PiCCO2 Supports Your Decisions
Spider Vision
View the patient status
at a glance
Profile
Detailed insight at a
parameter level
Trends
Clinical course &
treatment success
50
Configuration of Parameters
Press on the parameter field on the right side of the screen to go to parameter configuration
51
Configuration of Alarms
80
65
52
Configuration of Normal and Target Values
•
Switch to target mode via
Selection “Target Values”
•
Enter your target values
•
It is possible to adjust target
ranges for each individual patient
Normal values
53
Target values
Configuration SpiderVision
• Select the number of
required arms
• Place the parameters onto
the arms by:
1. Selecting a
SpiderVision parameter
2. Touching the parameter
label onto the Spider
arm
54
Configuration Trend Screen
• Customizable trend screen
with up to 8 parameters
• Select:
55
-
Trend period
-
Trend graphic or
-
Trend table
D. Thermodilution
56
Principles of the PiCCO-Technology
T
P
Injection
t
Thermodilution
t
Pulse contour analysis
Calibration
The PiCCO-Technology is a unique combination of two methods;
•
Firstly the hemodynamic and volumetric status is determined by
transpulmonary thermodilution (TD).
•
Secondly arterial pulse contour is calibrated.
57
Thermodilution
Detection
Injection
•
•
The indicator passes through heart and lungs.
CO, Preload and Lung water are measured.
58
PiCCO2
Booklet
Pulse Contour Analysis
The second step is that arterial pulse contour is calibrated by TD - CO
T
•The systolic part of the curve, representing
stroke volume, is calibrated.
Injection
t
• Each new TD automatically recalibrates the
pulse contour
Calibration
• PiCCO-PCCI is “beat to beat”
P
•Calibration also integrates the patients
aortic compliance
t
59
Workflow - Thermodilution
PiCCO2
PiCCO plus
Philips IntelliVue Model
Dräger Infinity PiCCO SmartPod
60
Start thermodilution
•1 Select the injectate
volume
• For an adult 15mls
saline is
recommended
• In the „Measurement“
menu you will find the
recommended volume
1
•2 Press „Start“
2
Auto –
Thermodilution
mode (x in a row)
61
Thermodilution
When „Wait“ is displayed in the TD window the blood temperature profile is being
calculated.
1 Once the message ‘Inject xx ml’ appears, inject the saline bolus rapidly past the
injectate sensor housing.
2 The word ‘Injection’ indicates that the monitor has recognized the bolus injection.
3 The thermodilution curve appears in the TD window.
4 The results are highlighted in green in the table above the thermodilution curve.
4
2
1
62
3
Selection of results
•
The TD results are averaged
from the set of TD
measurements.
•
CI, GEDI and ELWI should
be within 10% of each other
•
Results that are outside this
range should be excluded from
the set of measurements.
•
Measurements can be excluded
by double clicking on the results.
•
Excluded results are crossed out
63
Quality of the thermodilution
36,7°
36,8°
Quality of thermodilution:
∆T =0.3°C
Optimized when ∆T >0.3°C
Good when
∆T >0.2°C
Weak when
∆T <0.15°C
∆T = change in temperature
-
36,9°
37°
Optimize the
thermodilution by:
36,7°
-
36,8°
36,9°
∆T =0.14°C
37°
64
More injection volume
Colder injection
Faster injection
Raising blood temperature if
hypothermic (after surgery)
ScvO2 Calibration
• Press
ScVO2 CAL
to start calibration
• The quality indicator should show a medium
to high signal
• Withdraw blood from the Y- connector of the
CeVOX probe. Ensure that you get only
blood and no infusion fluid.
• Do a venous blood gas sample and flush
the lumen with saline afterwards.
• Press “Sample drawn” after withdrawing
blood.
• Enter the results of the BGA .
• Press „Confirm“
• If DO2 and VO2 are enabled you need to
enter the SaO2 (SpO2) value
DO2 & VO2
Measurement
66
LiMON – PDRICG*
• Press
to go to LiMON calibration.
• Attach the LiMON sensor to a well perfused finger.
• Wait 3 minutes until the finger perfusion becomes
adapted to the sensor.
• Ensure that the sensor is not subjected to strong
direct light. If necessary cover the sensor during
the measurement of the PDRICG
• SpO2 and perfusion level will be displayed. The
signal should be stable.
• Press
Calc
to calculate the ICG dose.
• Select target concentration:
0.25mg/Kg or 0.5mg/Kg
• Select the number and size of vials
• Use XX mls ‘water for injection’
• ICG quantity: dose in mgs to inject
• Volume: Volume in mls to inject
* Parameter is not available in the USA
67
LiMON – PDRICG*
4
2
3
5
1.
Prepare the calculated ICG bolus
2.
Press ‘START’
3.
“Wait” will be displayed until the signal is stable.
4.
Inject calculated volume of ICG.
5.
Curve detected will be displayed
6.
PDRICG reading will be displayed after 5 – 8 mins
7.
Time of next possible measurement will be
displayed.
6
7
* Parameter is not available in the USA
68
E. - Parameters
69
Therapy control
Maintenance of oxygen extraction
O2 uptake
Gas exchange
O2 transport
Macro-hemodynamics
O2 delivery
O2 consumption
Micro-circulation
Cellular O2 consumption
Options for Intervention
-
+
Respiration
-
-
+
+
Catecholamine
Volume
70
-
+
Hemoglobin
Main Parameters
• ScvO2:
Adequate global tissue oxygenation?
• CI:
Adequate flow?
• GEDI:
Adequate cardiac preload?
• SVV/PPV:
Volume responsiveness?
• SVRI:
Vasopressor therapy necessary?
• ELWI:
Lung edema?
71
Monitoring Strategy
1.
Identification
of the
problem
3.
Coordination
of suitable
interventions
5. Quality
check
2.
Identification
of the cause
4.
Goal directed
therapy
72
Hemodynamic parameters
O2 Delivery
DO2
Gas exchange?
SaO2
O2 Transport?
Hb
Flow?
CI
Stroke Volume
SVI
Preload
GEDI
SVV/PPV
Lung
ELWI
PVPI*


!
O2 Consumption
Mixed- / CentralVenous
O2-Saturation
DO2
VO2
ScVO2
VO2
Organ function?
Frequency
HR
x
Afterload
MAP
SVRI
Contractility
dPmx, CPI*
CFI*, GEF*
* Parameters are not available in the USA
73
If ScVO2 >75%
PDRICG* - Liver
ScvO2 - Indicates insufficient tissue oxygenation
ScvO2 – Central venous oxygen saturation
• Imbalance between O2 delivery and O2 consumption?
• Measurement via standard CVC
• ScvO2 (via CVC) correlates with SvO2 (via Pulmonary Artery
Catheter)
O2 Delivery
O2 Consumption
• CO
• Hemoglobin
• Arterial O2 saturation
• Fever
• Stress
• Muscle work
(shivering)
ScvO2
74

ScvO2
SvO2
70-80%
65-75%
Cardiac Output – Blood volume, amount of blood pumped by the heart per minute
CI – Cardiac Index (Thermodilution)
PCCI – Pulse Contour Cardiac Index (Cont. Pulse Contour)
SVI – Stroke Volume Index
•
•
•
•
Cardiac Index indicates the global blood flow
Cardiac Index is Heart Rate x Stroke Volume Index
Stroke Volume depends on preload, afterload and contractility
Cardiac Index is indexed to the Body Surface Area (BSA)
CO
Stroke volume
Preload
Heart rate
Afterload

Contractility
75
PCCI
SVI
3-5 l/min/m2
40-60 ml/m2
Preload Volume – Blood volume which fills the heart just prior to beating
GEDI – Global End-diastolic Volume Index
• Filling volume of all 4 heart chambers
• Adequate preload volume is necessary for an adequate CO
• GEDI is indexed to the PBSA*
• Volumetric preload assessment
* Predicted Body Surface Area
(normalized body surface area)

76
GEDI 680-800 ml/m2
Direct correlation between GEDI and CO
CI (l/min/m2)
7.5
Frank-Starling-Curve
5.0
Inotropes
2.5
Preload increase
200
400
600
800
1000
1200
1400
GEDI (ml/m2)
• Preload optimization (GEDI) will increase Cardiac Index (CI) to a
defined maximum (top of the Frank-Starling-Curve)
• After preload optimization CI can be increased further by inotropes
77
Volume responsiveness – predicts the response of cardiac output to volume loading
SVV – Stroke Volume Variation
PPV – Pulse Pressure Variation
Stroke volume (SV)
Respiratory fluctuations in the arterial pressure curve in fully
controlled ventilated patients.
• High SVV/PPV (>10%) indicates the stroke volume will
increase following preload volume loading
• At values >10% volume replacement can be useful
SVV > 10%
PPV > 10%
SVV 0-10%
PPV 0-10%
Preload (GEDI)
78

SVV
PPV
< 10%
< 10%
SVV / PPV – Safety Tips
SVV / PPV – can only be used as a volume responsive parameter
under controlled conditions.
 Is the patient on fully controlled ventilation?
Spontaneous breathing or assisted breathing may cause incorrect measurements.
 Is the patient in sinus rhythm?
The arterial pressure curve cannot be used in arrhythmic patients.
 Is the arterial pressure curve free from artifacts?
Artifacts such as coughing or dys-synchronisation with the ventilator.
 Sufficiently high tidal volume?
In cases of low tidal volume, the effect of ventilation on the arterial pressure curve is inadequate.
(usable with a tidal volume >= 8ml/KG* PBW).
* Muller et al. The influence of the airway driving pressure on pulsed pressure variation as a predictor of fluid responsiveness . ICM 2010; 36: 496-503
De Backer et al. Pulse pressure variations to predict fluid responsiveness: influence of tidal volume. ICM 2005; 31:517–523
79
Lung water– water content of the lungs
ELWI – Extravascular Lung Water Index
• Measurement of the intracellular, interstitial
and intra-alveolar water content of the lungs
(not pleural effusion)
• Direct and easy bedside quantification and tracking of
pulmonary edema
ELWI = 19 ml/kg
ELWI = 7 ml/kg

ELWI = 14 ml/kg
ELWI = 8 ml/kg
80
ELWI 3-7 ml/kgPBW
Predicted Body Weight (PBW)
• Absolute values (cardiac output, GEDV, EVLW)
are indexed to the body surface area (BSA)
and body weight (BW indexed) to make values
comparable between patients.
• The size of the heart and lungs are proportional to
‘ideal’ BSA and ‘ideal’ weight, but not to actual
BSA and weight KG
• GEDV and EVLW are indexed to ‘ideal’
BSA (PBSA) and ‘ideal’ weight (PBW).
In order to avoid an underestimation of
values in obese patients
• Cardiac output is indexed to the
current BSA in order to ensure
comparability to other systems.
81
5
CI
Hydrostatic volume shift
3
1.
If preload is low, volume is given.
2.
Preload loading can increase CI
to its maximum.
3.
Excessive preload loading will
also increase the hydrostatic
pressure in the vascular system.
This can lead to an increase in
lung water.
ELWI
GEDI
7
3
680
800
GEDI
82
Hydrostatic vs. osmotic edema
Infusion
Hydrostatic Edema
Osmotic Edema
Intravascular
Extravascular
Normal tissue permeability
Disturbed tissue permeability
Osmotically active particle (protein & salt)
H2O
83
Differentiate between types of pulmonary edema
PVPI* – Pulmonary Vascular Permeability Index
• Provides a differentiated view of pulmonary edema:
• cardiac
• osmotic
• Corresponds to the ratio between lung water (EVLW)
and pulmonary blood volume (PBV)
* Parameter is not available in the USA
Normal situation PVPI 1-3
EVLW
PBV
1
1
PVPI =1
3
3
PVPI =1
Cardiac lung edema PVPI 1-3
EVLW
PBV

Osmotic lung edema PVPI 3-5
Extravascular fluid / EVLW
Intravascular fluid / PBV
EVLW
PBV
4
1
84
PVPI =4
PVPI*
1-3
Afterload – Resistance against which the heart must overcome to eject blood
SVRI - Systemic Vascular Resistance Index
• Measurement of the resistance against which the heart
must pump
• Depends on the degree of vasoconstriction
• Increased:
Centralization, Vasopressor therapy, Cardiogenic shock
• Decreased:
Septic shock, Anaphylactic shock
.
Resistance =
Vasoconstriction: Flow (CO)
Pressure (RR)
Pressure
Flow (CO)
Vasodilation: Flow (CO)
Pressure (RR)
85

SVRI 1700-2400
dyn/sec/m2
Contractility
- Performance of the heart muscle
GEF* – Global Ejection Fraction
• Ratio of ejection to ventricular filling
• Measures global cardiac contractility
• GEF correlates well with LVEF (Echocardiography)
* Parameter is not available in the USA
GEF* =

86
4 x SV
GEDV
GEF*
25 - 35 %
LVEF
50 – 70 %
Contractility
- Performance of the heart muscle
CFI* – Cardiac Function Index
• Index of the relationship between flow and cardiac
preload
• Measures global cardiac performance
* Parameter is not available in the USA
CI
5
4,9
7
4
3,5
1,5
High contractility
9
Normal contractility
5
6
CFI* =
2
2
Low contractility
CO
GEDV
3

400ml
700ml
900ml
GEDI
87
CFI*
4,5 – 6,5
Contractility
- Performance of the heart muscle
dPmx – Left Ventricular (LV) contractility
• Measures the contractility of the left ventricle to afterload
• Maximum pressure increase over time in the aorta
(∆Pmax / ∆t)
• Trending parameter, no normal range
• NB: Preload and afterload both influence dPmx
Steep pressure increase
High LV Contractility
Flatter pressure increase
Low LV Contractility
 dPmx
900-1200
for a healthy heart
88
Contractility
- Performance of the heart muscle
CPI* – Cardiac Power Index
• CPI is the left ventricular cardiac output (W) as a product
of flow and pressure
• The strongest independent predictor of hospital mortality
in cardiogenic shock
* Parameter is not available in the USA
Power = Watt
1 Watt = 1 Joule/Second
Power (Watt) = Current (V) x Amps (A) (x conversion factor)
CPI*
=
MAP
x
CI
(x 0.0022)

89
CPI* 0.5 – 0.7
W/m²
The relationship between DO2 and VO2
Delivery: DO2I = CI x Hb x 1.34 x SaO2
SaO2
CO, Hb
Oxygen uptake
Oxygen transport
Oxygen release
Oxygen consumption
S(c)vO2
Consumption: VO2I = CIxHbx1.34x(SaO2 – S(c)vO2)
O2 supply VO2 ml/min/m²
Enough
- DO2 and VO2 indicate the
relationship between O2 supply and
O2 consumption
- If DO2 falls below a critical point,
tissue hypoxia will occur

O2 transport capacity DO2 ml/min/m²
90
DO2I 400-650 ml/min/m2
VO2I 125-175 ml/min/m2
Liver perfusion / Splanchnic perfusion
PDRICG*– Plasma Disappearance Rate of
Indocyanine Green (ICG)
• Shows the excretion of ICG dye from the blood by the liver
• Is a marker of global liver function and perfusion
• The value is decreased if:
• the liver cell function is impaired.
• the liver has insufficient perfusion.
• Highly prognostic regarding mortality
* Parameter is not available in the USA
Hepatocyte
Distribution
in blood
Transport to the liver

Liver
ICG Injection
Gall bladder
Colon
Excretion by the
liver
91
PDRICG*18 - 25 %/min
Therapy control
93
Doctor & Nurse Communication
Planning Phase
Doctor: Examination and
diagnosis
Doctor: Treatment Decisions
Implementation Phase
Do
Plan
Evaluation Phase
Doctor: Follow up or
redefinition of treatment
Nurse: Execution of the
treatment plan
Control Phase
Act
Check
Nurse: Monitoring
ongoing situation
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94
I. Summary
Thank you for your attention!
Contact:
PULSION Medical Systems AG
Joseph-Wild-Str. 20
81829 Munich
Germany
Tel: +49 (0) 89 45 99 14 – 0
Fax: +49 (0) 89 45 99 14 – 18
info@pulsion.com
www.PULSION.com
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96
Auto Thermodilution mode
In the configuration screen
the Auto thermodilution
function can be activated
Option to select 3 – 5
measurements in a row,
without having to press the
start button each time

97
Selection of oxygen parameters
• Visualization of DO2 and VO2 in real-time to monitor oxygen delivery and
oxygen consumption
(CI and ScvO2 must be monitored continuously)
*Physically dissolved oxygen is ignored.
Oxygenation
98
Patient admission
Admission from a general ward:
5 days post-operative after a colon resection, no CVC, no A-line
Vital signs
• GCS:
• Respiration:
• Pulse:
• NIBP
• Temperature
somnolent
tachypnea
120
90/50
39.8°C
99
Patient admission
ECG
• Monitor heart rhythm
SR
• Monitor heart rate
120/min
SpO2 > O2 mask with 5l/min
• Awareness of respiratory failure
95%
• Monitor O2-supply and respiration
> Intubation
100
Basic Monitoring
Electrocardiogram (ECG)
NIBP (RR)
Pulse oximetry
(SpO2)
• Can we identify the source of the shock?
• Can we control the patients circulation with this level of monitoring?
101
Standard Monitoring
Invasive blood pressure monitoring
•
•
•
•
A. Axilla
A. Brachial
A. Radial
A. Femoral
Differentiation
• Central perfusion (Femoral, Brachial and Axilla)
• Peripheral perfusion (Radial)
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Compensation mechanism
10:30 RR is decreasing!
AP
CI
MAP 65mmHg
MAP 55mmHg
CI 3L/min
CI 2L/min
10:00
10:30
10:22 Flow decreasing!
• The blood pressure gives only a delayed picture when a circulatory problem is occurring.
• Continuous CI responds to problems much earlier.
• Conventional parameters for monitoring circulation (RR + HR) may be meaningless or even
misleading
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Physiological model of the circulatory system
Pump
104