Haemodynamic Monitoring
Theory and Practice
Haemodynamic Monitoring
2
A.
Physiological Background
B.
Monitoring
C.
Optimising the Cardiac Output
D.
Measuring Preload
E.
Introduction to PiCCO Technology
F.
Practical Approach
G.
Fields of Application
H.
Limitations
Measuring Preload
Volumetric Preload Parameters, Volume Responsiveness and Filling Pressures
Preload
Filling Pressures
CVP / PCWP
3
Volumetric
Preload parameters
GEDV / ITBV
Volume
Responsiveness
SVV / PPV
Measuring Preload
Role of the filling pressures CVP / PCWP
Correlation between Central Venous Pressure CVP and Stroke Volume
Kumar et al., Crit Care Med 2004;32: 691-699
4
Measuring Preload
Role of the filling pressures CVP / PCWP
Correlation between Pulmonary Capillary Wedge Pressure PCWP and
Stroke Volume
Kumar et al., Crit Care Med 2004;32: 691-699
5
Measuring Preload
Role of the filling pressures CVP / PCWP
The filling pressures CVP and PCWP do not give an adequate
assessment of cardiac preload.
The PCWP is, in this regard, not superior to CVP
(ARDS Network, N Engl J Med 2006;354:2564-75).
Pressure is not volume!
Influencing Factors:
-Ventricular compliance
-Position of catheter (PAC)
-Mechanical ventilation
-Intra-abdominal hypertension
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Measuring Preload
Role of the volumetric preload parameters GEDV / ITBV
Preload
Filling Pressures
CVP / PCWP
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Volumetric
Preload parameters
Volume
Responsiveness
GEDV / ITBV
SVV / PPV
Measuring Preload
Role of the volumetric preload parameters GEDV / ITBV
GEDV = Global Enddiastolic Volume
Lungs
Pulmonary
Circulation
Right Heart
Left heart
Body Circulation
Total volume of blood in all 4 heart chambers
8
Measuring Preload
Role of the volumetric preload parameters GEDV / ITBV
GEDV shows good correlation with the stroke volume
Michard et al., Chest 2003;124(5):1900-1908
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Measuring Preload
Role of the volumetric preload parameters GEDV / ITBV
ITBV = Intrathoracic Blood Volume
Lungs
Pulmonary
Circulation
Right heart
Left heart
Body Circulation
ITBV =GEDV + PBV
Total volume of blood in all 4 heart chambers plus the pulmonary blood volume
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Measuring Preload
Role of the volumetric preload parameters GEDV / ITBV
ITBV is normally 1.25 times the GEDV
ITBVTD (ml)
3000
2000
1000
0
ITBV = 1.25 * GEDV – 28.4 [ml]
0
1000
GEDV vs. ITBV in 57 Intensive Care Patients
Sakka et al, Intensive Care Med 2000; 26: 180-187
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2000
3000 GEDV (ml)
Measuring Preload
Role of the volumetric preload parameters GEDV / ITBV
The static volumetric preload parameters GEDV and ITBV
• Are superior to filling pressures for assessing cardiac preload
(German Sepsis Guidelines)
• Are, in contrast to cardiac filling pressures, not falsified by other pressure
influences (ventilation, intra-abdominal pressure)
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Measuring Preload
Role of the dynamic volume responsiveness parameters SVV / PPV
Preload
Filling Pressures
CVP / PCWP
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Volumetric
Preload
parameters
GEDV / ITBV
Volume Responsiveness
SVV / PPV
Measuring Preload
Physiology of the dynamic parameters of volume responsiveness
Fluctuations in blood pressure during the respiration cycle
Early Inspiration
Intrathoracic pressure
„Squeezing “ of the pulmonary blood
Left ventricular preload
Left ventricular stoke volume
Late Inspiration
Intrathoracic pressure
Venous return to left and right ventricle
Left ventricular preload
Left ventricular stroke volume
Systolic arterial blood pressure
Inspiration
PPmax
14 Reuter
Expiration
PPmin
et al., Anästhesist 2003;52: 1005-1013
Systolic arterial blood pressure
Inspiration
PPmax
Expiration
PPmin
Measuring Preload
Physiology of the dynamic parameters of volume responsiveness
Fluctuations in stroke volume throughout the respiratory cycle
SV
SV
SV
V
V
Preload
Mechanical Ventilation
Intrathoracic pressure fluctuations
Changes in intrathoracic blood volume
Preload changes
Fluctuations in stroke volume
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Measuring Preload
Role of the dynamic volume responsiveness parameters SVV / PPV
SVV = Stroke Volume Variation
SVmax
SVmin
SVmean
• The variation in stroke volume over the respiratory cycle
• Correlates directly with the response of the cardiac ejection to
preload increase (volume responsiveness)
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mean
Measuring Preload
Role of the dynamic volume responsiveness parameters SVV / PPV
SVV is more accurate for predicting volume responsiveness than CVP
Sensitivity 1
0,8
0,6
0,4
- - - CVP
___ SVV
0,2
0
0
Berkenstadt et al, Anesth Analg 92: 984-989, 2001
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0,5
Specificity 1
Measuring Preload
Role of the dynamic volume responsiveness parameters SVV / PPV
PPV = Pulse Pressure Variation
PPmean
PPmax
PPmin
• The variation in pulse pressure amplitude over the respiration cycle
• Correlates equally well as SVV for volume responsiveness
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Measuring Preload
Role of the dynamic volume responsiveness parameters SVV / PPV
A PPV threshold of 13% differentiates between responders
and non-responders to volume administration
respiratory
changes in arterial
pulse pressure (%)
Non – Responders
n = 24
Responders
n = 16
Michard et al, Am J Respir Crit Care Med 162, 2000
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Measuring Preload
Role of the dynamic volume responsiveness parameters SVV / PPV
The dynamic volume responsiveness parameters SVV and PPV
- are good predictors of a potential increase in CO due to volume administration
- are only valid with patients who are fully ventilated and who have no cardiac
arrhythmias
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Extra
Role of extravascular lung water EVLW
EVLW = Extravascular Lung Water
Lungs
Pulmonary
circulation
Left Heart
Right Heart
Body circulation
Extravascular water content of the lung
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Extra
Role of extravascular lung water EVLW
The Extravascular Lung Water EVLW
- is useful for differentiating and quantifying lung oedema
- is, for this purpose, the only parameter available at the bedside
- functions as a warning parameter for fluid overload
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Measuring Preload
Summary and Key Points
• The volumetric parameters GEDV / ITBV are superior to the filling pressures
CVP / PCWP for measuring cardiac preload.
• The dynamic parameters of volume responsiveness (SVV and PPV) can predict
whether CO will respond to volume administration.
• GEDV and ITBV show what the actual volume status is, whilst SVV and PPV reflect
the volume responsiveness of the heart.
• For optimal control of volume therapy simultaneous monitoring of both the static
preload parameters and the dynamic parameters of volume responsiveness is
sensible (F. Michard, Intensive Care Med 2003;29: 1396).
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