1. Haemodynamic Monitoring Theory and Practice

2. 2 Haemodynamic Monitoring A.Physiological Background B.Monitoring C.Optimizing the Cardiac Output D.Measuring Preload E.Introduction to PiCCO Technology F.Practical Approach G.Fields of Application H.Limitations

3. 3 Monitoring the Vital Parameters Monitoring Respiration Rate Temperature

4. 4 Monitoring the Vital Parameters Monitoring ECG Heart Rate Rhythm Respiration Rate Temperature

5. 5 Monitoring the Vital Parameters Monitoring Blood Pressure (NiBP) no correlation with CO no correlation with oxygen delivery ECG Respiration Rate Temperature

6. 6 DO 2 ml*m -2 *min -1 100300500700 30 60 90 120 150 MAP mmHg n= 1232 Monitoring the Vital Parameters Monitoring MAP: Mean Arterial Pressure, DO 2: Oxygen Delivery The Mean Arterial Pressure does not correlate with Oxygen Delivery! Reinhart K in: Lewis, Pfeiffer (eds): Practical Applications of Fiberoptics in Critical Care Monitoring, Springer Verlag Berlin - Heidelberg - NewYork 1990, pp 11-23

7. 7 Monitoring the Vital Parameters Monitoring Blood Pressure (NiBP) No correlation with CO No correlation with oxygen delivery No correlation with volume status ECG Respiration Rate Temperature

8. 8 Monitoring the Vital Parameters 80% of blood volume is found in the venous blood vessels, only 20% in the arterial blood vessels! Monitoring

9. 9 Monitoring the Vital Parameters Monitoring Blood Pressure (NiBP) ECG Respiration Rate Temperature No correlation with CO No correlation with oxygen delivery No correlation with volume status No evidence of what is the ‘ right ’ perfusion pressure

10. 10 Standard Monitoring Monitoring Oxygen Saturation NIBP ECG Respiration Rate Temperature No information re the O 2 transport capacity No information re the O 2 utilisation in the tissues

11. 11 Standard Monitoring Monitoring Respiration Rate NIBP ECG Temperature Urine Production Oxygen Saturation Blood Circulation (clinical assessment)

12. 12 What other parameters do I need? Advanced Monitoring Monitoring The standard parameters do not give enough information in unstable patients.

13. 13 Advanced Monitoring Monitoring Invasive Blood Pressure (IBP) Continuous blood pressure recording Arterial blood extraction possible Limitations as with NiBP

14. 14 Advanced Monitoring Monitoring IBP Arterial BGA Information re: Pulmonary Gas exchange Acid Base Balance No information re oxygen supply at the cellular level

15. 15 Advanced Monitoring Monitoring IBP Lactate Marker for global metabolic situation Significant limitations due to: Liver metabolism Reperfusion effects Arterial BGA

16. 16 Advanced Monitoring Monitoring IBP CVP Arterial BGA Lactate central venous blood gas analysis possible When low: hypovolaemia probable When high: hypovolaemia not excluded Not a reliable parameter for volume status

17. 17 Advanced Monitoring Monitoring IBP ScvO 2 Good correlation with SvO 2 (oxygen consumption) Surrogate parameter for oxygen extraction Information on the oxygen consumption situation When compared to SvO 2 less invasive (no pulmonary artery catheter required) Arterial BGA Lactate CVP

18. Reinhart K et al: Intensive Care Med 60, 1572-1578, 2004; Ladakis C et al: Respiration 68, 279-285, 2000 Monitoring n = 29 r = 0.866 ScvO 2 = 0.616 x SvO 2 + 35.35 ScvO 2 SvO 2 r = 0.945 30 50 70 90 709050 SvO 2 (%) 65 70 85 7090 30604080 ScvO 2 (%) 40 60 80 6040 75 60 50 Monitoring of the central venous oxygen saturation The ScvO 2 correlates well with the SvO 2 !

19. 19 avDO 2 ml/dl Monitoring Monitoring of the central venous oxygen saturation 30405060708090100 7.0 6.0 7.0 4.0 3.0 2.0 1.0 0 r= -0.664 n= 1191 avDO 2 = 12.7 -0.12*ScvO 2 ScvO 2 % A low ScvO 2 is a marker for increased global oxygen extraction! avDO 2 : arterial-venous oxygen content difference, ScvO 2 : central venous oxygen saturation Reinhart K in: Lewis, Pfeiffer (eds): Practical Applications of Fiberoptics in Critical Care Monitoring, Springer Verlag Berlin - Heidelberg - NewYork 1990, pp 11-23

20. 20 Monitoring Monitoring of the central venous oxygen saturation avDO 2 ml/dl 7.0 6.0 7.0 4.0 3.0 2.0 1.0 r= -0.664 n= 1191 avDO 2 = 12,7 -0.12*ScvO 2 Consumption VO 2 :VO 2 = CO x Hb x 1.34 x (SaO 2 - S(c)vO 2 ) Delivery DO 2 : DO 2 = CO x Hb x 1.34 x SaO 2 CO Hb Mixed / Central Venous Saturation S(c)vO 2 SaO 2 avDO 2 : arterial-venous oxygen content difference, ScvO 2 : central venous oxygen saturation 30405060708090100 0 ScvO 2 % Reinhart K in: Lewis, Pfeiffer (eds): Practical Applications of Fiberoptics in Critical Care Monitoring, Springer Verlag Berlin - Heidelberg - NewYork 1990, pp 11-23

21. 21 Early goal-directed therapy Rivers E et al. New Engl J Med 2001;345:1368-77 O 2 - Therapy and Sedation Intubation + Ventilation Central Venous Catheter Invasive Blood Pressure Monitoring CVP MAP ScVO 2 Cardiovascular Stabilisation Volume therapy 8-12 mmHg < 8 mmHg 65 mmHg Inotropes >70%  70% < 70% no Therapy maintenance, regular reviews < 65 mmHg Vasopressors Blood transfusion to Haematocrit 30% Monitoring Monitoring of the central venous oxygen saturation < 70% Goal achieved? yes ScVO 2 Hospital 60 days Mortality

22. Monitoring Monitoring of the ScvO 2 – Clinical Relevance Significance of the ScvO 2 for therapy guidance 22

23. Monitoring of the ScvO 2 – Clinical Relevance Monitoring Early monitoring of ScvO 2 is crucial for fast and effective hemodynamic management! 23

24. Monitoring ScvO 2 – therapeutic consequences in the example of sepsis Pt unstable ScvO 2 < 70% Volume bolus (when absence of contraindications) ScvO 2 > 70% or < 80% Re - evaluation Continuous ScvO 2 monitoring – CeVOX Advanced Monitoring - PiCCO Volume / Catecholamine Erythrocytes Monitoring ScvO 2 < 70% 24

25. Tissue hypoxia despite ”normal“ or high ScvO 2 ? ? Microcirculation disturbances in SIRS / Sepsis Monitoring ScvO 2 – Limitations Monitoring 25 SxO 2 in % modified from: Reinhart K in: Lewis, Pfeiffer (eds): Practical Applications of Fiberoptics in Critical Care Monitoring, Springer Verlag Berlin - Heidelberg - NewYork 1990, pp 11-23

26. Monitoring ScvO 2 – therapeutic consequences in the example of sepsis ScvO 2 Pt unstable ScvO 2 < 70% Re- evaluation Monitoring ScvO 2 > 80% Tissue hypoxia despite „normal“ or high ScvO 2 ? ? Volume administration (when absence of contraindications) ScvO 2 > 70% but < 80%ScvO 2 < 70% Advanced Monitoring cont. ScvO 2 monitoring Volume / Catecholamine / Erythrocytes

27. Pt unstable ScvO 2 > 80% ScvO 2 70% Re-evaluation Monitoring ScvO 2 > 80% Tissue hypoxia despite ”normal“ or high ScvO 2 ? Microcirculation? Organ perfusion? Further information needed Macro-haemodynamics (PiCCO) Liver function (PDR – ICG) Renal function Neurological assessment Volume bolus (when absence of contraindications) 27 Monitoring ScvO 2 – therapeutic consequences in the example of sepsis

28. Monitoring Summary and Key Points Standard monitoring does not give information re the volume status or the adequacy of oxygen delivery and consumption. The CVP is not a valid parameter to measure volume status The measurement of central venous oxygen saturation gives important information re global oxygenation balance and oxygen extraction Measuring the central venous oxygenation can reveal when more advanced monitoring is indicated 28