LiMON in Intensive Care Medicine

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LiMON in Intensive Care Medicine
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Basics

• The Plasma Disappearance Rate of ICG-PULSION
  (PDR) is influenced by liver function and liver
  perfusion.
• Changes of ICG-PDR within a short period of time
  are reflecting liver respectively splanchnic
  perfusion, as the function of liver cells does
  not change rapidly.
• LiMON provides an easy, fast and non-invasive
  monitoring of liver and splanchnic perfusion.

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Scientific facts I

• PDR as parameter of prognosis of survival
• ICG-PDR is perfectly suited as parameter for
  prognosis of survival of surgical intensive care
  patients compared to the complex scores SAPS II
  and APACHE II.

Sakka S, Reinart K, Meier-Hellmann A Chest 122
(5), 1715-1720, 2002
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Scientific facts II

• PDR and mortality
• 2/3 of surgical intensive care patients qualified
  for advanced hemodynamic monitoring exhibit
  reduced ICG-PDR values, accompanied with a
  significantly increased mortality.

• PDR threshold value
• An ICG-PDR ? 16 /min requires intervention.

Sakka S, Reinart K, Meier-Hellmann A Chest 122
(5), 1715-1720, 2002
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Scientific facts III

• PDR in septic shock
• Patients in septic shock will not survive if a
  reduced ICG elimination can not be increased
  within the first 120 hours.

According to Kimura S, Yoshioka T, Shibuya M,
Sakano T, Tanaka R, Matsuyama S Crit Care Med 29
(6), 1159-1163, 2001
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Scientific facts IV

• Multi-Organ-Management
• The combination of PiCCO and LiMON enables
  optimized volume therapy. In case of volume
  withdrawal due to increased lung water,
  splanchnic perfusion can be monitored and a
  cut-off point for volume withdrawal can be
  defined.

Sakka S, Meier-Hellmann A Int J Intensive Care 9
(2), 66-72, 2002
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Recommendations for application in intensive care

• ICG-PDR monitoring
• In all critically ill patients at least once per
  day
• In patients undergoing volume withdrawal or
  inotropic/vasoactive therapy a more frequent
  monitoring is recommended
• Therapeutic recommendations (please refer to
  check list)
• Reduction of hepatotoxic substances
• Optimization of hemodynamics
• Liver support therapy
• ICG-PDR target value
• ICG-PDR gt 16/min
• Measurement site
• Disposable sensor at the ear lobe
• ICG dosage
• 0.25 mg/kg body weight per measurement

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LiMON Therapeutic check list
ICG-PDR ? 16 /min
RESULT
Optimize global hemodynamic situation
Reduce/stop hepatotoxic drugs
Liver support therapy
? Advanced hemodynamic monitoring (PiCCO
Technology) ? Optimize splanchnic inflow by -
Optimizing cardiac preload - Positive
inotropic or vasoactive drugs1
? Contact liver specialist
T H E R A P Y
? Treatment of alcoholic hepatitis3
? Optimize venous return by - Reduction of
intrathoracic pressure - Reduction of intra
abdominal pressure - Improvement of (right)
heart function2
? Install extracorporal support system (MARS)
ICG-PDR gt 16 /min
TARGET
1 dobutamine, phosphodiesterase III inhibitor,
prostaglandin 2 dobutamine, phosphodiesterase
III inhibitor, adrenaline, prostaglandin, NO
inhalation 3 steroids, pentoxyfylline
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Conclusion

• Routine monitoring of ICG-PDR (minimum once
  daily) may contribute to an early detection or
  prevention of reduced liver/splanchnic perfusion.
• Previous studies demonstrated that ICG-PDR values
  ? 16/min are requiring intervention. Thus, a
  goal-directed therapy to achieve an ICG-PDR gt
  16/min is recommended.
• An early detection and, if necessary, a
  goal-directed therapy of a reduced splanchnic
  perfusion contributes to a prevention of
  complications and therewith to cost reduction.

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Appendix

• ICG dosage
• ICG-PDR can be measured accurately with a reduced
  ICG dosage of 0.25 mg/kg body weight.

Sakka S, Koeck H, Meier-Hellmann A Intensive
Care Med 30 (3) 506-509, 2004