1. Hemodynamic monitoring Prof. Jean-Louis TEBOUL University Paris-South
in septic patients
Prof. Jean-Louis TEBOUL
Medical ICU
Bicetre hospital
University Paris-South
France

2. Conflicts of interest
Member of the Medical Advisory Board of Pulsion

3. hypovolemia vascular tone myocardial depression depression
Hemodynamic failure in septic patients: 3 components
vascular tone
depression
myocardial
depression
hypovolemia
Importance of assessing
the degree of each component
to select and apply the best therapeutic option
fluids
vasopressors
inotropes
presence of associated lung injury

4. Methods currently available to assess hemodynamics in ICU pts
Echocardiography
non invasive 
Esophageal Doppler
less invasive 
Central Venous Catheter
Systemic Artery Catheter
FloTrac/Vigileo
LidCO
PiCCO / VolumeView
 invasive 
Pulmonary Artery Catheter 4

5. non invasive Echocardiography Esophageal Doppler
Methods currently available to assess hemodynamics in ICU pts
Echocardiography
intermittent measurements of several cardiac
function variables
non invasive 
Esophageal Doppler 5

6. Esophageal Doppler
Advantages
non-invasive
real-time monitoring of descending aorta blood flow
prediction of fluid responsiveness (variability or PLR)

7. real-time monitoring of descending aorta blood flow
Esophageal Doppler
Advantages
non-invasive
real-time monitoring of descending aorta blood flow
prediction of fluid responsiveness (variability or PLR)
assessment of LV systolic function
Br. J. Anaesth. (2013) 111 (5): 

8. Esophageal Doppler
Advantages
non-invasive
real-time monitoring of descending aorta blood flow
prediction of fluid responsiveness (variability or PLR)
assessment of LV systolic function
Inconveniences
aortic diameter is not fixed and changes with MAP

9. utility in case of circulatory failure with associated lung injury?
Esophageal Doppler
Advantages
non-invasive
real-time monitoring of descending aorta blood flow
utility in case of circulatory failure
with associated lung injury?
prediction of fluid responsiveness (variability or PLR)
assessment of LV systolic function
Inconveniences
aortic diameter is not fixed
blood flow partition upper/lower part of the body may vary

10. Hemodynamic failure in septic patients: 3 components
Echocardiography
non invasive 
Esophageal Doppler
less invasive 
Central Venous Catheter 10

11. CVP and SvcO2 Central venous catheter
(with or without fiberoptic probe)
Configuration
What is needed to accomplish art. thermodilution cardiac output & pulse contour cardiac output?
Any central venous line.
Injectate temperature sensor for detection of the cold bolus. The injectate temperature sensor (PV4045) is included in the monitoring kit (e.g. PV8015)
22G - 5F Thermodilution catheter with lumen for arterial pressure, placed in the Femoral artery or the Axillary artery. The reason that a large artery needs to be accessed is that the catheter needs to have blood flow around it to detect a temperature change. Are you aware that a traditional radial arterial line does not have blood flow? Only 30% of the patients with a radial artery line have blood flow around catheter. 70 % do not have flow.
Arterial pressure transducer

12. (mostly through elevation of CO)
SvO2 = SaO2 -
VO2
CO x Hb x 13.4
SvO2 indicator of VO2 / DO2 balance
a low SvO2 may incite
to elevate DO2
(mostly through elevation of CO) 12

13. Methods currently available to assess hemodynamics in ICU pts
Echocardiography
non invasive 
Esophageal Doppler
less invasive 
Central Venous Catheter
Systemic Artery Catheter 13

14. radial arterial catheter
AP monitoring
radial arterial catheter
Configuration
What is needed to accomplish art. thermodilution cardiac output & pulse contour cardiac output?
Any central venous line.
Injectate temperature sensor for detection of the cold bolus. The injectate temperature sensor (PV4045) is included in the monitoring kit (e.g. PV8015)
22G - 5F Thermodilution catheter with lumen for arterial pressure, placed in the Femoral artery or the Axillary artery. The reason that a large artery needs to be accessed is that the catheter needs to have blood flow around it to detect a temperature change. Are you aware that a traditional radial arterial line does not have blood flow? Only 30% of the patients with a radial artery line have blood flow around catheter. 70 % do not have flow.
Arterial pressure transducer
femoral arterial catheter

15. Monitoring blood pressure…. … is not only monitoring
Arterial Pressure (mmHg)
SAP
140 PP
Monitoring blood pressure….
… is not only monitoring
systolic blood presssure
120
100
MAP 80
DAP 60 40
A lot of useful pieces of information can be drawn
from MAP, DAP, PP
and from analysis of the AP waveform 20
Time

16. MAP: driving pressure for perfusion
Arterial Pressure (mmHg)
140
120
100
MAP 80 60
MAP: driving pressure for perfusion
of important organs (e.g. brain, kidney) 40 20
Time

17. MAP: important hemodynamic target of resuscitation of shock states
Arterial Pressure (mmHg)
140
120
100
MAP 80 60
MAP: important hemodynamic target
of resuscitation of shock states 40 20
Time

18. DAP: reflection of vasomotor tone
Arterial Pressure (mmHg)
140
120
100 80
DAP 60
DAP: reflection of vasomotor tone 40 20
Time

19. DAP: reflection of vasomotor tone
Arterial Pressure (mmHg)
140
120
100 80
DAP 60
DAP: reflection of vasomotor tone 40
DAP: driving pressure
for left coronary circulation 20
Time

20. Arterial Pressure (mmHg)
140 PP
120
100 80 60 40 20
Time

21. suggests that the stroke volume is low
Pulse pressure
Aortic PP = k. SV . aortic stiffness
Chemla et al AJP 1998
If aorta is stiff (elederly, ateriosclerosis, hypertension, diabetes, etc)
A low PP (30-40 mmHg)
suggests that the stroke volume is low 21

22. Methods currently available to assess hemodynamics in ICU pts
Echocardiography
non invasive 
Esophageal Doppler
less invasive 
Central Venous Catheter
Systemic Artery Catheter
PPV
Pulse Pressure Variation
dynamic index of fluid responsiveness 22

23. Methods currently available to assess hemodynamics in ICU pts
Echocardiography
non invasive 
Esophageal Doppler
less invasive 
Central Venous Catheter
Systemic Artery Catheter
FloTrac/Vigileo 23

24. radial arterial catheter
Configuration
What is needed to accomplish art. thermodilution cardiac output & pulse contour cardiac output?
Any central venous line.
Injectate temperature sensor for detection of the cold bolus. The injectate temperature sensor (PV4045) is included in the monitoring kit (e.g. PV8015)
22G - 5F Thermodilution catheter with lumen for arterial pressure, placed in the Femoral artery or the Axillary artery. The reason that a large artery needs to be accessed is that the catheter needs to have blood flow around it to detect a temperature change. Are you aware that a traditional radial arterial line does not have blood flow? Only 30% of the patients with a radial artery line have blood flow around catheter. 70 % do not have flow.
Arterial pressure transducer
radial arterial catheter

25. FloTrac/VigileoTM Technology
Real-time CO monitoring from AP waveform
Complex algorithm based on statistical analysis of the AP signal
No need of calibration
Any type of arterial catheter and any site including the radial site
Validation studies?

26. surgical pts 26

27. 3rd generation
Percentage Error = 54%

28. induced by fluid infusion induced by norepinephrine
septic pts
3rd generation
Concordance: 73%
Concordance: 60%
Changes in CI (%)
induced by fluid infusion
Changes in CI (%)
induced by norepinephrine

29. FloTrac/VigileoTM Technology
Real-time CO monitoring from AP waveform
Complex algorithm based on statistical analysis of the AP signal
No need of calibration
Any type of arterial catheter and any site including the radial site
Validation studies?
seems valid in the absence of changes in vascular tone
serious doubts on its validity in cases of changes in vascular tone
(sepsis, vasopressor use)

30. Methods currently available to assess hemodynamics in ICU pts
Echocardiography
non invasive 
Esophageal Doppler
less invasive 
Central Venous Catheter
Systemic Artery Catheter
FloTrac/Vigileo
LidCO 30

31. Central Venous Catheter (Lithium bolus injection)
Configuration
What is needed to accomplish art. thermodilution cardiac output & pulse contour cardiac output?
Any central venous line.
Injectate temperature sensor for detection of the cold bolus. The injectate temperature sensor (PV4045) is included in the monitoring kit (e.g. PV8015)
22G - 5F Thermodilution catheter with lumen for arterial pressure, placed in the Femoral artery or the Axillary artery. The reason that a large artery needs to be accessed is that the catheter needs to have blood flow around it to detect a temperature change. Are you aware that a traditional radial arterial line does not have blood flow? Only 30% of the patients with a radial artery line have blood flow around catheter. 70 % do not have flow.
Arterial pressure transducer
Radial arterial catheter

32. LidCOplus continuous CO
Two proprietary algorithms
a continuous arterial waveform analysis system
coupled to a single point lithium indicator dilution calibration system
continuous CO
dynamic preload responsiveness parameters (PPV/SVV) 32

33. Methods currently available to assess hemodynamics in ICU pts
Echocardiography
non invasive 
Esophageal Doppler
less invasive 
Central Venous Catheter
Systemic Artery Catheter
FloTrac/Vigileo
LidCO
LidCOrapid
Trends in CO
PPV, SVV 33

34. Methods currently available to assess hemodynamics in ICU pts
Echocardiography
non invasive 
Esophageal Doppler
less invasive 
Central Venous Catheter
Systemic Artery Catheter
FloTrac/Vigileo
LidCO
PiCCO / VolumeView 34

35. Central Venous Catheter (cold bolus injection)
Thermodilution femoral arterial catheter
Configuration
What is needed to accomplish art. thermodilution cardiac output & pulse contour cardiac output?
Any central venous line.
Injectate temperature sensor for detection of the cold bolus. The injectate temperature sensor (PV4045) is included in the monitoring kit (e.g. PV8015)
22G - 5F Thermodilution catheter with lumen for arterial pressure, placed in the Femoral artery or the Axillary artery. The reason that a large artery needs to be accessed is that the catheter needs to have blood flow around it to detect a temperature change. Are you aware that a traditional radial arterial line does not have blood flow? Only 30% of the patients with a radial artery line have blood flow around catheter. 70 % do not have flow.
Arterial pressure transducer

36. Transpulmonary thermodilution monitors allow measurements
of cardiac output

37. Transpulmonary thermodilution
monitors are not only
CO monitoring devices

38. GEDV marker of cardiac preload Transpulmonary thermodilution
1- Cardiac output
2- Global end-diastolic volume (GEDV)

39. cardiac systolic function
CFI
Index of
cardiac systolic function
Transpulmonary thermodilution
1- Cardiac output
2- Global end-diastolic volume (GEDV)
3- Cardiac function index (CFI) = CO/GEDV

40. EVLW quantitative measure
of pulmonary edema
Transpulmonary thermodilution
1- Cardiac output
2- Global end-diastolic volume (GEDV)
3- Cardiac function index
4- Extravascular lung water (EVLW)

41. 200 pts
D28 mortality: 54%
Odds Ratio ( CI 95%)
p value
Maximal blood lactate
1.29
( )
0.0001
Mean PEEP
0.78
(0.67 – 0.91)
0.002
Minimal PaO2 / FiO2
0.98
( )
0.006
SAPS II
1.03
( )
0.02
EVLWmax
1.07
( )
0.007
Mean fluid balance
1.0004
( – )
0.02

42. EVLW:
safety parameter
during
fluid management

43. * * * * Time (hours) Cumulative fluid balance (L) 7 WP group 5 5 3 1
EVLW group -1 -3
* p < vs temps 0 -5
Time (hours)

44. 25 20 15 *
WP group * 10
EVLW group 5
MV days
ICU days 44

45. pulmonary vascular permeability
PVPI
marker of
pulmonary vascular permeability
Transpulmonary thermodilution
1- Cardiac output
2- Global end-diastolic volume (GEDV)
3- Cardiac function index
4- Extravascular lung water (EVLW)
5- Pulmonary vascular permeability index

46. 200 pts
D28 mortality: 54%
Odds Ratio ( CI 95%)
p value
Maximal blood lactate
1.27
( )
0.0002
Mean PEEP
0.78
(0.67 – 0.91)
0.002
Minimal PaO2 / FiO2
0.98
( )
0.0009
SAPS II
1.03
( )
0.008
PVPImax
1.07
( )
0.03
Mean fluid balance
1.0004
( – )
0.03

47. predictors of volume responsiveness
SVV and PPV
predictors of volume responsiveness
Transpulmonary thermodilution
1- Cardiac output
2- Global end-diastolic volume (GEDV)
3- Cardiac function index
4- Extravascular lung water (EVLW)
5- Pulmonary vascular permeability index
Pulse contour analysis
1- Continuous cardiac output (CCO)
2- Stroke volume variation (SVV)
3- Pulse pressure variation (PPV)

48. Complete picture of the patient’s hemodynamic status
Transpulmonary thermodilution
1- Cardiac output
2- Global end-diastolic volume (GEDV)
3- Cardiac function index (CFI)
4- Extravascular lung water (EVLW)
5- Pulmonary vascular permeability index
Pulse contour analysis
1- Continuous cardiac output (CCO)
2- Stroke volume variation (SVV)
3- Pulse pressure variation (PPV)
ScvO2

49. PiCCO or VolumeView monitoring
useful tools to deal with fluid loading and/or depletion
… especially if associated respiratory and circulatory failures
SVV and PPV to predict fluid responsiveness
What to do if PPV or SVV are not interpretable?
GEDV to check that preload actually increases with fluid loading
CO to assess the real hemodynamic response to fluid infusion
EVLW and PVPI to assess lung tolerance to fluid infusion
SVV/PPV
GEDV CO
EVLW
to help to decide
To start fluid infusion
To continue fluid infusion
To stop fluid infusion

50. PiCCO or VolumeView monitoring
useful tools to deal with fluid loading and/or depletion
… especially if associated respiratory and circulatory failures
PLR and EOT to predict fluid responsiveness
SVV and PPV to predict fluid responsiveness
GEDV to check that preload actually increases with fluid loading
CO to assess the real hemodynamic response to fluid infusion
EVLW and PVPI to assess lung tolerance to fluid infusion
SVV/PPV
GEDV CO
EVLW
PLR/EOT
GEDV CO
EVLW
to help to decide
To start fluid infusion
To continue fluid infusion
To stop fluid infusion

51. non invasive less invasive invasive Echocardiography
Methods currently available to assess hemodynamics in ICU pts
Echocardiography
non invasive 
Esophageal Doppler
less invasive 
Central Venous Catheter
Systemic Artery Catheter
FloTrac/Vigileo
LidCO
PiCCO / VolumeView
Continuous CO and SvO2
monitoring +
Intermittent measurements
RAP, PAOP and PAP
 invasive 
PAC 51

52. non invasive Echocardiography
Methods currently available to assess hemodynamics in ICU pts
intermittent but
repeatable measurements
of cardiac function variables
Echocardiography
non invasive 
availability of a device?
availability of a skilled operator?
not a continuous method 52

53. non invasive Esophageal Doppler
Methods currently available to assess hemodynamics in ICU pts
Real-time monitoring of
aortic blood velocity,
Vpeak and Acc
non invasive 
Esophageal Doppler
aortic diameter changes with arterial pressure
blood flow partition between upper and lower body
can change with therapy 53

54. Methods currently available to assess hemodynamics in ICU pts
less invasive 
Central Venous Catheter
CVP and ScvO2
Systemic Artery Catheter
AP and PPV
No access to CO
or to any other important variables 54

55. Methods currently available to assess hemodynamics in ICU pts
reliability in cases of changes in vasomotor tone?
no access to other hemodynamic variables
less invasive 
FloTrac/Vigileo
Real-time CO, SVV
and ScvO2 monitoring
Poor reliability of other uncalibrated CO monitors in ICU pts
ProAqt-Pulsioflex
Mostcare
Nexfin 55

56. less invasive PiCCO / VolumeView
Methods currently available to assess hemodynamics in ICU pts
Real-time CO, PPV, SVV
and ScvO2 monitoring +
Intermittent measurements
GEDV, CFI, EVLW, PVPI
less invasive 
PiCCO / VolumeView
femoral artery access 56

57. Methods currently available to assess hemodynamics in ICU pts
invasiveness
need of experience for correct data interpretation
Continuous CO and SvO2
monitoring +
Intermittent measurements
RAP, PAOP and PAP
 invasive 
PAC 57

58. Which monitoring technique is suitable in the ICU?
Echocardiography
non invasive 
Esophageal Doppler
less invasive 
Central Venous Catheter
Systemic Artery Catheter
FloTrac/Vigileo
LidCO
PICCO/ VolumeView
 invasive 
PAC 58

59. Which monitoring technique is suitable in the ICU?
current clinical situation (lung injury?)
history of cardiovascular disease
- clinical questions you want to answer
- your experience with either technique
The ideal monitoring device is not yet
your choice will depend on:
Try to early perform echocardiography, chest X-ray and blood gases,
which should help selecting the best monitoring strategy

60. hypovolemia vascular tone myocardial depression depression fluids
Hemodynamic failure in septic patients: 3 components
vascular tone
depression
myocardial
depression
hypovolemia
fluids
vasopressors
inotropes
presence of associated lung injury

61. myocardial depression inotropes
Hemodynamic failure in septic patients: 3 components
myocardial
depression
Echocardiography
+ CFI (PiCCO)
inotropes

62. vascular tone depression vasopressors
Hemodynamic failure in septic patients: 3 components
vascular tone
depression
Arterial catheter (DAP ++)
vasopressors

63. hypovolemia fluids presence of associated lung injury
Hemodynamic failure in septic patients: 3 components
hypovolemia
Prediction of fluid responsiveness
PPV, SVV
PLR or end-expiratory occlusion test
if SB, arrhythmias, low TV or low lung compliance
Evaluation: real-time CO
fluids
Lung tolerance
PAOP
EVLW
presence of associated lung injury

64. Patient with circulatory failure
First, try to perform echocardiography to assess cardiac function
Normal
cardiac fonction
Abnormal
cardiac function
Lung injury ?
ABG, Chest X-ray
If no response
to initial therapy
yes no
Basic
monitoring
advanced
monitoring
yes no
PiCCO
only
PAC
VolumeView
CVC +
Art cath CO
PAOP
RAP, PAP
SvO2 CO
GEDV, EVLW, CFI
PPV, SVV
ScvO2
CVP
SvcO2 AP
PPV
considered valid? 64

65. 65

66. Thank you 66