continuous cardiac output: a necessity - pulsion filecontinuous cardiac output: a necessity •in...
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Prof. JeanProf. Jean--Louis TEBOULLouis TEBOUL
Medical ICUCHU Bicetre
Université Paris Sud 11France
Continuous cardiac output: Continuous cardiac output:
a necessitya necessity
MemberMember of the Medical of the Medical AdvisoryAdvisory BoardBoard of of Pulsion Pulsion
Conflicts of interestConflicts of interest
Yes, of course
Continuous cardiac output: a necessityContinuous cardiac output: a necessity
• In the OR as an early warning system
nonsurvivorsnonsurvivors
survivorssurvivors
Changes in cardiaccardiac indexindex are not reflected by
changes in heartheart raterate and MAPMAP during surgery
Yes, of course
Continuous cardiac output: a necessityContinuous cardiac output: a necessity
• In the OR as an early warning system
• In the ICU for following short-term changeswith therapy and during diagnostic or therapeutic tests
…. however, three important conditions should be met
…. however, three important conditions should be met
• real-time rather than continuous CO measurements
…. however, three important conditions should be met
• real-time rather than continuous CO measurements
Central venous catheter
Thermodilution femoral arterial catheter
TranspulmonaryTranspulmonary thermodilutionthermodilution
Pulse contour Pulse contour analysisanalysis
Cal Cal = calibration factor = calibration factor obtainedobtained fromfrom transpulmonarytranspulmonary thermodilutionthermodilution(cold (cold bolusbolus injection)injection)
Stroke volumeStroke volume = Cal. x SurfaceSurface
PCCO = cal PCCO = cal .. HRHR .. ∫∫ (P(t)/SVR + C(p) (P(t)/SVR + C(p) .. dPdP//dtdt) ) dtdtsystolesystole
PatientPatient--specificspecificcalibration factorcalibration factor((determineddetermined withwiththermodilutionthermodilution))
compliancecompliance shapeshape of of pressure pressure
curvecurve
area of area of pressure pressure
curvecurve
P (mmHg)
t (s)
…. however, three important conditions should be met
• real-time rather than continuous CO measurements
• accurate CO measurements
(COpc oldold + COtd) / 2 (COpc newnew + COtd) / 2
Crit Care Med 2002, 30:52-58
CO
pcol
dol
d-C
Otd
CO
pcne
wne
w-C
Otd
PCCO = cal x FC x Surface PCCO = cal . FC . ∫ (P(t)/SVR + C(p) . dP/dt) dt
Percentage error = 2 SD/mean ≈ 28 % Percentage error = 2 SD/mean ≈ 46 %
Validation of Validation of continuouscontinuous cardiaccardiac outputoutput measurementmeasurement byby thethepulse pulse contourcontour analysisanalysis ((PiCCOPiCCO system)system)
• Roedig G et al. Br J Anaesth 1999; 82: 525-530
• Goedje O et al. Ann Thorac Surg 1999; 68: 1532-1536
• Buhre W et al. J Cardiothorac Vasc Anesth 1999; 13: 437-440
• Goedje O et al. Crit Care Med 1999; 27: 2407-2412
• Zollner C et al. J Cardiothorac Vasc Anesth 2000;14: 125-129
• Goedje O et al. Med Sci Monit 2001; 7: 1344-1350
• Felbinger TW et al. J Clin Anaesth 2002; 14: 296-301
• Goedje O et al. Crit Care Med 2002; 30:52-58
• Rauch H et al. Acta Anaesthesiol Scand 2002; 46: 426-429
• Felbinger et al. J Clin Anaesth 2005; 17: 241-248
• Ostergaard et al. Acta Anaesthesiol Scand 2006; 50: 1044-1049
…. however, three important conditions should be met
• real-time rather than continuous CO measurements
• accurate CO measurements
• changes in CO must be tracked reliably
PiCCO Vigileo
r = r = -- 0.010.01
-15 0 15 30 45 60 75 90 105 120
-15
0
15
30
45
60
75
90
ΔC
O p
c (%
)
ΔCO td (%)
r = 0.74r = 0.74
-15 0 15 30 45 60 75
-15
0
15
30
45
60
75
ΔC
O p
c (%
)
ΔCOtd (%)
Monnet X, Monnet X, AnguelAnguel N, Naudin B, Jabot J, Richard C, Teboul JL (N, Naudin B, Jabot J, Richard C, Teboul JL (revisedrevised))
HemodynamicHemodynamic changes changes inducedinduced by by norepinephrinenorepinephrine
TransientTransient increase in preload and in CO in preload-responsive patientsThe Pulse Contour CO responseresponse to PLR PLR
should predict the hemodynamic responseresponse to volumevolume infusioninfusion
ContinuousContinuous and and realreal--timetime CO CO usefuluseful
for for followingfollowing shortshort--termterm and and transienttransient CO changes CO changes
duringduring diagnostic diagnostic teststests
0
20
40
60
80
100
0 20 40 60 80 100
100 - s pec if ic ity
sens
itivity
E ffec ts of pas s i ve leg rais ing on p uls e pres s ure
A UC 0.675 [0.497-0.829]
0
20
40
60
80
100
0 20 40 60 80 100
100 - s pec if ic ity
sens
itivity
E ffec ts of pas s i ve leg rais ing on p uls e pres s ure
0
20
40
60
80
100
0 20 40 60 80 100
100 - s pec if ic ity
sens
itivity
E ffec ts of pas s i ve leg rais ing on p uls e pres s ure
A UC 0.675 [0.497-0.829]AUC: 0.675AUC: 0.675 [0.497-0.829]
PredictionPrediction of volume of volume responsivenessresponsivenessby the by the responseresponse of of Pulse PressurePulse Pressure
to PLRto PLR
100 - specificityRR-10
0
10
20
30
40
50
60
70
80
90
NR
%
-10
0
10
20
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40
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60
70
80
90
-10
0
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NR
%
Effects of passive leg raising on Pulse Contour CO
End-expiratory occlusion test
EndEnd--expiratory occlusionexpiratory occlusion
15 sec
The Pulse Contour CO responseresponse to endend--expiratoryexpiratory occlusion occlusion
should predict the hemodynamic responseresponse to volumevolume infusioninfusion
ContinuousContinuous and and realreal--timetime CO CO usefuluseful
for for followingfollowing shortshort--termterm and and transienttransient CO changes CO changes
duringduring diagnostic diagnostic teststests
Effects of end-expiratory occlusionon Pulse Contour CO
-10
0
10
20
30
40
50
NR
%
-10
0
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20
30
40
50
-10
0
10
20
30
40
50
NR
%
RR
Continuous cardiac output: a necessityContinuous cardiac output: a necessity
• In the OR as an early warning system
• In the ICU for following short-term changeswith therapy and during diagnostic or therapeutic tests
…. however, three important conditions should be met
• real-time rather than continuous CO measurements
• accurate CO measurements
• changes in CO must be tracked reliablyThankThank youyou