Invasive hemodynamic Invasive hemodynamic monitoring: new trends monitoring: new trends and possibilitiesand possibilities

Mikhail Kirov

Department of Anesthesiology and Intensive Care Medicine, Northern State Medical University, Arkhangelsk, Russia

HRMAP

EVLW

CI

Cannesson M et al. Crit Care 2011;15:R197

The key properties of an The key properties of an ‘‘idealideal’’

hemodynamic monitoring systemhemodynamic monitoring system

Vincent Vincent JL JL et al. et al. Crit Care Crit Care 2011, 15:2292011, 15:229

�� Provides measurement of relevant Provides measurement of relevant

variablesvariables

�� Provides accurate and reproducible Provides accurate and reproducible

measurementsmeasurements

�� Provides interpretable dataProvides interpretable data

�� Is easy to useIs easy to use

�� Is readily availableIs readily available

The key properties of an The key properties of an ‘‘idealideal’’

hemodynamic monitoring systemhemodynamic monitoring systemVincent Vincent JL JL et al. et al. Crit Care Crit Care 2011, 15:2292011, 15:229

�� Is operatorIs operator--independentindependent

�� Has a rapid responseHas a rapid response--timetime

�� Causes no harmCauses no harm

�� Is costIs cost--effectiveeffective

�� Should provide information that is able to Should provide information that is able to

guide therapyguide therapy

Indications for invasive arterial Indications for invasive arterial pressure monitoring pressure monitoring

1) 1) Critically ill patients (Critically ill patients (hypoperfusionhypoperfusion, , shock, ARDS, cardiac arrest, etc.shock, ARDS, cardiac arrest, etc.))

2) 2) Infusion of Infusion of inotropesinotropes and and vasoactivevasoactivedrugsdrugs

3) 3) Major surgery (cardiothoracic, Major surgery (cardiothoracic, abdominal, abdominal, neuroneuro, etc.), etc.)

4) 4) Blood analyses (arterial blood gases, Blood analyses (arterial blood gases, etc.)etc.)

SITES OF SITES OF ARTERIALARTERIALPUNCTUREPUNCTURE

ARTERIAL PRESSUREARTERIAL PRESSURE

Vasospasm Vasodilation

Low contractility High contractility

PRELOADPRELOAD

Static parametersStatic parameters

�� PressuresPressures ((CVPCVP,, PAOPPAOP))

�� Volumes Volumes ((endend--diastolic volumesdiastolic volumes, , intrathoracicintrathoracicblood volume etc.blood volume etc.))

Dynamic parametersDynamic parameters

�� Variations of blood pressure and stroke Variations of blood pressure and stroke volumevolume

CVP AS A MARKER OF PRELOADCVP AS A MARKER OF PRELOADIncreased CVPIncreased CVP

�� Right heart failure Right heart failure �� HypervolemiaHypervolemia�� ThromboembolismThromboembolism�� Pulmonary hypertension Pulmonary hypertension �� TamponadeTamponade�� Increased Increased intrathoracicintrathoracic pressure (mechanical pressure (mechanical

ventilation, COPD, ventilation, COPD, pneumothoraxpneumothorax, etc.), etc.)�� Increased Increased intraabdominalintraabdominal pressure (pressure (ascitisascitis, ,

pregnancy) pregnancy) �� Increased vascular tone (Increased vascular tone (vasopressorsvasopressors))

CVP AS A MARKER OF PRELOADCVP AS A MARKER OF PRELOADDecreased CVPDecreased CVP

�� HypovolemiaHypovolemia (dehydration, bleeding, etc.)(dehydration, bleeding, etc.)

�� Systemic Systemic vasodilationvasodilation (septic shock, (septic shock, vasodilators, spinal trauma, regional vasodilators, spinal trauma, regional anesthesia etc.)anesthesia etc.)

�� CVP<5 mm Hg predicts fluid responsiveness CVP<5 mm Hg predicts fluid responsiveness

only in 47% of casesonly in 47% of cases

TbInjection

t

∫ ⋅∆⋅⋅−=

dtT

KV)T(TCO

b

iibTDa

StewartStewart--Hamilton Hamilton methodmethod

Tb = Blood temperature

Ti = Injectate temperature

Vi = Volume of injectate

d Tb. dt = Area under thermodilution curve

K = Specific constant

SwanSwan--GanzGanz catheter and cardiac outputcatheter and cardiac output

•• Position of catheterPosition of catheter

•• Ventricular complianceVentricular compliance

•• PAOP<12 mm Hg predicts PAOP<12 mm Hg predicts

fluid responsiveness only in fluid responsiveness only in

54% of cases54% of cases

•• PAOP is not always a good PAOP is not always a good

predictor of the volume predictor of the volume

statusstatusLeft atrium

Zone IPA > Pa > PV

Zone IIIPa > PV > PA

Zone IIPa > PA > PV

West zones

Pressure is not a volume!Pressure is not a volume!

Pulmonary artery occlusion pressure (PAOP)Pulmonary artery occlusion pressure (PAOP)DurairajDurairaj L et al. L et al. ChestChest 2008;133:2522008;133:252--263263

Pressures and preloadPressures and preload

Lichtwarck-Aschoff et al, Intensive Care Med 18: 142-147, 1992

�� SwanSwan--GanzGanz catheter catheter –– no improvement no improvement

in clinical outcome compared with CVPin clinical outcome compared with CVP

�� Rate of use decreased significantly over Rate of use decreased significantly over

last years: in Canada from 16.4% to last years: in Canada from 16.4% to

6.5% of ICU patients6.5% of ICU patientsKoo KKY et al. Koo KKY et al. CritCrit Care Med 2011; 39:1613Care Med 2011; 39:1613--16181618

Single transpulmonary thermodilution

c(l)

Bolus

Recirculation

In c(l)

e-¹

At

MTt DSt

t

Stewart-Hamilton method

(Tb-Ti)×Vi×K

∫∆ Tb×dtCOTDa=

Body T

Bolus

t

ITTV = CO × MTt

PTV = CO × DSt

GEDV = ITTV – PTV

ITBV = 1.25 × GEDV

EVLW = ITTV – ITBV

Single transpulmonary thermodilution

RAEDV RVEDV PTV LAEDV LVEDV

RAEDV RVEDV PTV LAEDV LVEDV

RAEDV RVEDV

EVLW

LAEDV LVEDV

EVLW

RAEDV RVEDV PTV LAEDV LVEDV

RAEDV RVEDV PBV LAEDV LVEDV

Intrathoracic blood volume/Intrathoracic blood volume/

global endglobal end--diastolic volume and preloaddiastolic volume and preload

Lichtwarck-Aschoff et al. Intensive Care Med 1992; 18: 142-147 Durairaj L et al. Chest 2008;133:252-263

Global end-diastolic volume < 680 ml/m2 – predicts fluid responsiveness in 77% cases

Extravascular lung water = (CO x DSt) – (0.25 x GEDV)

Global end-diastolic volume (GEDV) = CO x MTt x f(S2/S1),

where S1 and S2 – rise and decay of thermodilution curve, f - constant

Methodology of VolumeViewBendjelid K et al. Crit Care 2010, 14:R209

• Heat exchange of thermoindicator with myocardium and

vessels – overestimation of lung water

• Recirculation of indicator when CO is low - flattening of

thermodilution curve and increase of volumes

• Shunting of indicator in ASD and VSD – two-peak

(“camel”) curve: modification of PiCCO algorithm

• Severe changes in pulmonary blood flow (pulmonary

embolism) limit the distribution of indicator and decrease

the measured volumes

Factors which can influence the results of transpulmonary thermodilution

EVLWI and LIS: r2=0.18,

EVLWI and radiograph score: r2=0.28, p<0.0001

EVLWI, CVP, and lung injury Kirov MY et al. Anesteziol Reanimatol 2003;4:41-45Kirov MY et al. Yearbook of Intensive Care and Emergency Medicine 2005; p. 449-461Martin GS et al. Crit Care 2005;9:R74-R82Kuzkov VV et al. Crit Care Med 2006;34:1647-1653

EVLW and prognosis in ALI and sepsisKirov MY et al. Anesteziol Reanimatol 2003;4:41-45 Martin GS et al. Crit Care 2005;9:R74-R82 Kuzkov VV et al. Crit Care Med 2006;34:1647-1653

SmetkinSmetkin AA et alAA et al. . Intensive Care Med 2009;35 (suppl. 1): 0953; S246.Intensive Care Med 2009;35 (suppl. 1): 0953; S246.

Patients with a decrease in EVLWI

during the first 12 hrs had higher

survival rate as compared to those

with unchanged or increased EVLWI.

Clinical value of EVLWEisenberg PR et al. Am Rev Resp Dis 1987;136:662-668Mitchell et al. Am Rev Resp Dis 1992;145:990-998Pino-Sanchez F et al. J Trauma 2009;67:1220-1224

Monitoring of EVLW changes the strategy for fluid and vasoactive therapyWhen EVLW is increased, fluid restriction can improve the clinical outcome

Global ejection fraction (GEF)

GEF =GEDV

4 x SV N = 20-30%

Cardiac function index

CFI = CI / GEDVI

Correlates with Echo EF and predicts the response on inotropes

Julien J et al. Crit Care Med 2009;37

Area under

pressure

curve

Pressure

curve

shape

CCO = cal • HR •⌠⌠⌠⌠⌡⌡⌡⌡

Systole

P(t)SVR

+ C(p) •dPdt

( ) dt

Aortic

complianceHRCalibration

factor

t [s]

P [mm Hg]

Continuous monitoring of cardiac output: Continuous monitoring of cardiac output:

pulse contour analysispulse contour analysis

PiCCOplus, PiCCO2, VolumeView: volumetrics and CI, TD calibration Vigileo and

PulsioFlex: CI,no TD calibration

Continuous monitoring of cardiac outputContinuous monitoring of cardiac output

LiDCO (lithium dilution)Calibration by lithium indicator

Edwards Vigilance IICalibration, Swan-Ganz catheter

Modules Philips, Draeger, Schiller, GE, MindrayBasing on PiCCO technology

Continuous monitoring of cardiac outputContinuous monitoring of cardiac output

Possible problems of pulse contour analysisPossible problems of pulse contour analysisBottgerBottger SS--F et al. F et al. Med Sci Monit 2010; 16: PR1Med Sci Monit 2010; 16: PR1--77

Camporota L, Beale R. Crit Care 2010;14:124Camporota L, Beale R. Crit Care 2010;14:124

�� Quality of blood pressure signal and position of Quality of blood pressure signal and position of

cathetercatheter

�� Accuracy is decreasing during rapid changes of Accuracy is decreasing during rapid changes of

vascular tone (vasodilators, vascular tone (vasodilators, vasopressorsvasopressors, ,

sepsis, shock, cardiac surgerysepsis, shock, cardiac surgery))

�� Calibration by dilution techniquesCalibration by dilution techniques

Functional hemodynamic parameters (pressure and stroke volume variations) are

the most sensitive parameters for the assessment of fluid responsiveness in mechanically ventilated patients with

prediction value of 95-98%

Responsive: can increase CI Non-responsive

Durairaj L et al. Chest 2008;133:252-263

Variations of stroke volume (SVV) and pulse pressure (PPV) Variations of stroke volume (SVV) and pulse pressure (PPV) Michard F et al. Crit Care 2007, 11:131De Waal EEC et al. Crit Care Med 2009, 37Marik PE et al. Crit Care Med 2009, 37: 2642-7Marik PE et al. Ann Intensive Care 2011, 1

SVmeanSVmean

SVmaxSVmax –– SVminSVminSVV =SVV =

SVmeanSVmean

�Fluid responsiveness if SVV>10% and PPV>13%�Therapy based on PPV and SVV decreases duration of mechanical ventilation, complications, and ICU stay

� Valid only in sinus rhythm, closed chest, and mechanical ventilation

Cannesson M et al. Crit Care 2011;15:R197

Belda FJ et al. BJA 2011;106:482-486

• Major and high-risk surgery

• ALI of any etiology

• Severe sepsis and septic shock

• Acute cardiac failure, cardiogenic shock, and

pulmonary edema

• Multiple trauma

• Severe burns (>40%)

• MODS

Monitoring of cardiac output and its’ determinants: indicationsSeeling M et al. Euroanesthesia 2008, Refresher Course of Lectures, 17-22.

Pearse R et al, Critical Care 2004, 8(Suppl 1):P51

Venous saturation – SvO2 and ScvO2Venous saturation Venous saturation –– SvOSvO22 and ScvOand ScvO22

Venous saturation

OXYGEN DELIVERY

OXYGEN CONSUMPTION

SaO2Hb Сardiacoutput

Functional cell activity

Low ScvOLow ScvO22 appears to indicate patients at high risk of appears to indicate patients at high risk of complications after surgery. complications after surgery.

ScvOScvO22 may indicate may indicate hypovolemiahypovolemia at an earlier stage than at an earlier stage than traditional parameters. traditional parameters.

ScvOScvO22 may be a suitable hemodynamic goal.may be a suitable hemodynamic goal.

Monitoring of venous saturation

METHODS

Monitoring of venous saturation

METHODS

Discrete Continuous

Pearse RM, Rhodes A. Mixed and central venous oxygen saturation. In: Vincent JL, ed. Yearbook of Intensive Care and Emergency Medicine. Berlin: Springer; 2005. 592–602.

Surviving Sepsis Campaign Guidelines (based on Rivers et al, NEJM 2001)

Central venous saturation in septic shockCentral venous saturation in septic shockPerner A et al. Acta Anaesth Scand 2010;54:98-102

�� ScvOScvO22>64% >64% -- CICI >2,5 >2,5

l/min/ml/min/m2 2 (sensitivity(sensitivity 98%, 98%,

specificityspecificity 77%)77%)

�� Monitoring of cardiac Monitoring of cardiac

output whenoutput when ScvOScvO22<64% <64%

despite fluid therapy?despite fluid therapy?

Monitoring of ScvO2 and O2 transport in high-risk surgeryPolonen P. et al. Anesth Analg 2000;90:1052-1059.Smetkin A et al. Acta Anaesth Scand 2009; 53: 505-514 Ospina-Tacson G.A. et al. Intensive Care Med 2008

�� Facilitates early detection and correction of Facilitates early detection and correction of

hemodynamic changeshemodynamic changes

�� Influences the strategy for fluid and Influences the strategy for fluid and inotropeinotrope therapytherapy

�� In a combination with the monitoring of lactate can In a combination with the monitoring of lactate can

improve the course of postoperative period and improve the course of postoperative period and

decrease mortalitydecrease mortality

Monitoring of oxygen transport in critically illMonitoring of oxygen transport in critically ill

Maintaining DO2I within 400-600 ml/min/m2 (?)

Hofer CK et al. Hofer CK et al. EurEur J J AnaesthAnaesth 2009;26:9962009;26:996--10021002

Perioperative hemodynamic monitoring basing on the surgical and the patient riskKirov MY et al. Curr Opin Сrit Care 2010;16:384–392.

Hemodynamic monitoring and optimizationMayer J. et al. Crit Care 2010; 14:R18.Gurgel S.T. et al. Anesth Analg 2011;112:1384-1391. Hamilton M.A. et al. Anesth Analg 2011;112:1392-1402. Cecconi M. et al. Crit Care 2011; 15:R132. Takala J. et al. Crit Care 2011; 15:R148. Dalfino L. et al. Crit Care 2011; 15:R154.

�� Helps to guide therapy and maintain tissue perfusionHelps to guide therapy and maintain tissue perfusion

�� Protects surgical patients against postoperative Protects surgical patients against postoperative

hospitalhospital--acquired infections acquired infections

�� Associates with a reduced length of hospital stay and Associates with a reduced length of hospital stay and

a lower incidence of complications in different a lower incidence of complications in different

categories of patientscategories of patients

Hemodynamic monitoring and optimizationMayer J. et al. Crit Care 2010; 14:R18.Gurgel S.T. et al. Anesth Analg 2011;112:1384-1391. Hamilton M.A. et al. Anesth Analg 2011;112:1392-1402. Cecconi M. et al. Crit Care 2011; 15:R132. Takala J. et al. Crit Care 2011; 15:R148. Dalfino L. et al. Crit Care 2011; 15:R154.

�� Reduces surgical mortality and morbidityReduces surgical mortality and morbidity

�� Must be strongly encouraged, Must be strongly encouraged, particularilyparticularily in the in the

setting of the highsetting of the high--risk surgical population risk surgical population

�� Some monitoring technologies and treatment Some monitoring technologies and treatment

protocols do not facilitate early hemodynamic protocols do not facilitate early hemodynamic

stabilization stabilization

Preload &Preload &Fluid responsivenessFluid responsiveness

Cardiac Output

EVLW

Oxygen transport

Clinical examination, vital signs, urine output, Hb, lactate...

• Perioperative period and many critical states are often accompanied by severe changes in hemodynamics requiring invasive monitoring

• The level of hemodynamic monitoring should be individualized according to the status of the patient

Invasive hemodynamic monitoring: conclusions

• Novel monitoring techniques should be validated in clinical trials

• Monitoring of hemodynamics followed by goal-oriented therapy is able to improve the clinical outcome

Invasive hemodynamic monitoring: conclusions

CI 2,7

MAP 60

SVV 12%

EVLWI 7

CVP 13

????