Folie 1

1
Haemodynamic Monitoring
Theory and Practice
2
Introduction to the PiCCO-Technology Function
Principles of Measurement
PiCCO Technology is a combination of
transpulmonary thermodilution and pulse contour
analysis
CVC
Lungs
Pulmonary Circulation
central venous bolus injection
PULSIOCATH arterial thermodilution catheter
Left Heart
Right Heart
PULSIOCATH
PULSIOCATH
Body Circulation
3
Introduction to the PiCCO-Technology Function
Principles of Measurement
After central venous injection the cold bolus
sequentially passes through the various
intrathoracic compartments
Bolus injection
concentration changes over time (Thermodilution
curve)
Lungs
Left heart
Right heart
The temperature change over time is registered by
a sensor at the tip of the arterial catheter
4
Introduction to the PiCCO-Technology Function
Intrathoracic Compartments (mixing chambers)
Intrathoracic Thermal Volume (ITTV)
Pulmonary Thermal Volume (PTV)
Largest single mixing chamber
Total of mixing chambers
5
Haemodynamic Monitoring
E. Introduction to PiCCO Technology

1. Principles of function
2. Thermodilution
3. Pulse contour analysis
4. Contractility parameters
5. Afterload parameters
6. Extravascular Lung Water
7. Pulmonary Permeability

6
Introduction to the PiCCO-Technology
Thermodilution
Calculation of the Cardiac Output
The CO is calculated by analysis of the
thermodilution curve using the modified
Stewart-Hamilton algorithm
Tb
Injection
t
(Tb - Ti) x Vi x K
COTD a

Tb x dt
D
?
Tb Blood temperature Ti Injectate
temperature Vi Injectate volume ? ? Tb . dt
Area under the thermodilution curve K
Correction constant, made up of specific weight
and specific heat of blood and injectate
7
Introduction to the PiCCO-Technology
Thermodilution
Thermodilution curves
The area under the thermodilution curve is
inversely proportional to the CO.
Temperature
36,5
Normal CO 5.5l/min

37
Temperature
Time
36,5
low CO 1.9l/min
37
Temperature
Time
36,5
High CO 19l/min
37
10
5
Time
8
Introduction to the PiCCO Technology
Thermodilution
Transpulmonary vs. Pulmonary Artery Thermodilution
Transpulmonary TD (PiCCO)
Pulmonary Artery TD (PAC)
Aorta
PA
Pulmonary Circulation
Lungs
LA
central venous bolus injection
RA
LV
RV
PULSIOCATH arterial thermo-dilution catheter
Right Heart
Left heart
Body Circulation
In both procedures only part of the injected
indicator passes the thermistor. Nonetheless the
determination of CO is correct, as it is not the
amount of the detected indicator but the
difference in temperature over time that is
relevant!
9
Introduction to the PiCCO-Technology
Thermodilution
Extended analysis of the thermodilution curve
From the characteristics of the thermodilution
curve it is possible to determine certain time
parameters
Tb
Injection
Recirculation
In Tb
e-1
MTt
DSt
t
MTt Mean Transit time the mean time required
for the indicator to reach the detection point
DSt Down Slope time the exponential downslope
time of the thermodilution curve
Tb blood temperature lnTb logarithmic blood
temperature t time
10
Introduction to the PiCCO-Technology
Thermodilution
Calculation of ITTV and PTV
By using the time parameters from the
thermodilution curve and the CO ITTV and PTV can
be calculated
Tb
Injection
Recirculation
In Tb
e-1
MTt
DSt
t
Pulmonary Thermal Volume PTV Dst x CO
Intrathoracic Thermal Volume ITTV MTt x CO
11
Einführung in die PiCCO-Technologie
Thermodilution
Calculation of ITTV and PTV
Intrathoracic Thermal Volume (ITTV)
Pulmonary Thermal Volume (PTV)
PTV Dst x CO
ITTV MTt x CO
12
Introduction to the PiCCO Technology
Thermodilution
Volumetric preload parameters GEDV
Global End-diastolic Volume (GEDV)
ITTV
PTV
GEDV
GEDV is the difference between intrathoracic and
pulmonary thermal volumes
13
Introduction to the PiCCO Technology
Thermodilution
Volumetric preload parameters ITBV
Intrathoracic Blood Volume (ITBV)
GEDV
PBV
ITBV
ITBV is the total of the Global End-Diastolic
Volume and the blood volume in the pulmonary
vessels (PBV)
14
Introduction to the PiCCO-Technology
Thermodilution
Volumetric preload parameters ITBV
ITBV is calculated from the GEDV by the PiCCO
Technology
Intrathoracic Blood Volume (ITBV)
ITBVTD (ml)
ITBV 1.25 GEDV 28.4 ml
GEDV (ml)
GEDV vs. ITBV in 57 Intensive Care Patients
Sakka et al, Intensive Care Med 26 180-187, 2000
15
Introduction to the PiCCO-Technology Function
Intrathoracic Compartments (mixing chambers)
Intrathoracic Thermal Volume (ITTV)
Pulmonary Thermal Volume (PTV)
Largest single mixing chamber
Total of mixing chambers
16
Introduction to the PiCCO Technology
Extravascular Lung Water
Calculation of Extravascular Lung Water (EVLW)
ITTV ITBV EVLW
The Extravascular Lung Water is the difference
between the intrathoracic thermal volume and the
intrathoracic blood volume. It represents the
amount of water in the lungs outside the blood
vessels.
17
Introduction to the PiCCO Technology
Extravascular Lung Water
Validation of Extravascular Lung Water
EVLW from the PiCCO technology has been shown to
have a good correlation with the measurement of
extravascular lung water via the gravimetry and
dye dilution reference methods
Gravimetry
Dye dilution
ELWI by PiCCO
ELWIST (ml/kg)
Y 1.03x 2.49
40
25
20
30
n 209 r 0.96
15
20
10
10
5
R 0,97 P lt 0,001
0
0
20
30
10
15
25
5
0
10
0
20
ELWI by gravimetry
ELWITD (ml/kg)
Sakka et al, Intensive Care Med 26 180-187, 2000
Katzenelson et al,Crit Care Med 32 (7), 2004
18
Haemodynamic Monitoring
E. Introduction to PiCCO Technology

1. Principles of function
2. Thermodilution
3. Pulse contour analysis
4. Contractility parameters
5. Afterload parameters
6. Extravascular Lung Water
7. Pulmonary Permeability

19
Introduction to the PiCCO-Technology Pulse
contour analysis
Calibration of the Pulse Contour Analysis
The pulse contour analysis is calibrated through
the transpulmonary thermodilution and is a beat
to beat real time analysis of the arterial
pressure curve
Transpulmonary Thermodilution
Pulse Contour Analysis
Injection
COTPD
SVTD
HR
T blood temperature t time P blood pressure
20
Introduction to the PiCCO-Technology Pulse
contour analysis
Parameters of Pulse Contour Analysis
Cardiac Output
P(t)
dP
(
PCCO cal HR
C(p)
)
dt
SVR
dt
Systole
Heart rate
21
Introduction to the PiCCO-Technology Pulse
Contour Analysis
Parameters of Pulse Contour Analysis
Dynamic parameters of volume responsiveness
Stroke Volume Variation
SVmax SVmin
SVV
SVmean
The Stroke Volume Variation is the variation in
stroke volume over the ventilatory cycle,
measured over the previous 30 second period.
22
Introduction to the PiCCO-Technology Pulse
Contour Analysis
Parameters of Pulse Contour Analysis
Dynamic parameters of volume responsiveness
Pulse Pressure Variation
PPmax
PPmin
PPmean
PPmax PPmin
PPV
PPmean
The pulse pressure variation is the variation in
pulse pressure over the ventilatory cycle,
measured over the previous 30 second period.
23
Introduction to the PiCCO-Technology Pulse
contour analysis
Summary pulse contour analysis - CO and volume
responsiveness

• The PiCCO technology pulse contour analysis is
  calibrated by transpulmonary thermodilution
• PiCCO technology analyses the arterial pressure
  curve beat by beat thereby providing real time
  parameters
• Besides cardiac output, the dynamic parameters
  of volume responsiveness SVV (stroke volume
  variation) and PPV (pulse pressure variation) are
  determined continuously