PowerPoint-Pr

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PiCCO plus Standalone Monitor
PiCCO-Technology
PiCCO ... ...Simple Safe Speedy - Specific
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Contents

• What is the PiCCO-Technology?.....................
  ..................................................
  .............
• What are the advantages of the PiCCO-Technology?..
  ..................................................
  
• How does the PiCCO-Technology work?...............
  ..................................................
  ......
• How to use the PiCCO-Technology?..................
  ..................................................
  .........
• Which disposables do I need for the
  PiCCO-Technology?.................................
  ...........
• References..
• 7. Where can I get what I need?...................
  ..................................................
  .....................

3 4 6 19 22 24 25
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1. What is the PiCCO-Technology?

• The PiCCO Technology is a combination of 2
  techniques for advanced hemodynamic and
  volumetric management without the necessity of a
  pulmonary artery catheter in most patients

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2. What are the advantages of the
PiCCO-Technology?
The PiCCO measures the following main parameters

• Thermodilution Parameters
• Cardiac Output CO
• Global Enddiastolic Volume GEDV
• Intrathoracic Blood Volume ITBV
• Extravascular Lung Water EVLW
• Pulse Contour Parameters
• Pulse Continuous Cardiac Output PCCO
• Systemic Vascular Resistance SVR
• Stroke Volume Variation SVV

not available in USA
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2. What are the advantages of the
PiCCO-Technology?

• Less Invasiveness - Only central venous and
  arterial access required - No pulmonary artery
  catheter required - Applicable also in small
  children
• Short Set-up Time - Can be installed within
  minutes
• Dynamic, Continuous Measurement - Cardiac Output,
  Afterload and Volume Responsiveness are
  measured beat-by-beat
• No Chest X-ray - To confirm correct catheter
  position no x-ray is necessary
• Cost Effective - Less expensive than pulmonary
  artery catheter technique - Arterial PiCCO
  catheter can be in place for 10 days or more
  - Potential to reduce ICU stay and costs
• More Specific Parameters - PiCCO parameters are
  easy to use and interpret even for less
  experienced clinical staff
• Extravascular Lung Water - Lung edema can be
  excluded or quantified at the bed-side

not available in USA
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3. How does the PiCCO-Technology work?

• Most of hemodynamic unstable and/or severely
  hypoxemic patients are instrumented with

• The PiCCO-Technology uses any standard CV-line
  and a thermistor-tipped arterial PiCCO-catheter
  instead of the standard arterial line.

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Configuration
CV

• Central venous line (CV)
• Thermodilution catheter with lumen for arterial
  pressure measurement
• Axillary (A)
• Brachial (B)
• Femoral (F)
• Radial (R), long catheter
• Arterial pressure transducer

A
B
R
F
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a. Transpulmonary Thermodilution

• Transpulmonary thermodilution measurement simply
  requires the central venous injection of a cold
  (lt 8C) or room-tempered (lt 24C) saline bolus

CV Bolus Injection
Lungs
Right Heart
Left Heart
PiCCO Catheter e.g. in femoral artery
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PiCCO Thermodilution Cardiac Output

• After central venous injection of the indicator,
  the thermistor in the tip of the arterial
  catheter measures the downstream temperature
  changes
• The cardiac output is calculated by analysis of
  the thermodilution curve using a modified
  Stewart-Hamilton algorithm

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PiCCO Volumetric Parameters

• Global Enddiastolic Volume GEDV
• Intrathoracic Blood Volume ITBV
• Extravascular Lung Water EVLW

These volumetric parameters are obtained by
advanced analysis of the thermodilution curve.
(Detailed information and formulas available on
request.)
Advanced Thermodilution Curve Analysis
not available in USA
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Global Enddiastolic Volume

• Global Enddiastolic Volume (GEDV) is the volume
  of blood contained in the 4 chambers of the heart.

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Intrathoracic Blood Volume

• Intrathoracic Blood Volume (ITBV) is the volume
  of the 4 chambers of the heart the blood volume
  in the pulmonary vessels.

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Extravascular Lung Water

• Extravascular Lung Water (EVLW) is the amount of
  water content in the lungs. It allows bedside
  quantification of the degree of pulmonary edema.

not available in USA
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PiCCO Preload Indicators

• Intrathoracic Blood Volume, ITBV and Global
  Enddiastolic Volume, GEDV have shown to be far
  more sensitive and specific to cardiac preload
  than the standard cardiac filling pressures CVP
  PCWP but also than right ventricular enddiastolic
  volume. 2,3,5,6,8,9,12,13,22
• The striking advantage of ITBV and GEDV is that
  they are not wrongly influenced by mechanical
  ventilation and give correct information on the
  preload status under any condition.
  2,3,6,7,8,9,12,13, 22

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Extravascular Lung Water

• Extravascular Lung Water, EVLW assessment by
  transpulmonary thermodilution has been validated
  against dye dilution and the reference
  gravimetric method.11,16,21,23

• Extravascular Lung Water, EVLW has shown to have
  a clear correlation to severity of ARDS, length
  of ventilation days, ICU-Stay and Mortality and
  to be superior toassessment of lung edema by
  chest x-ray.7,8,15,20,23,24

not available in USA
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b. Arterial Pulse Contour Analysis

• Arterial pulse contour analysis provides
  continuous beat-by-beat parameters obtained from
  the shape of the arterial pressure wave.
• The algorithm is capable of computing each single
  stroke volume (SV) after being calibrated by an
  initial transpulmonary thermodilution.

Calibration
SV
P mm Hg
t s
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Cardiac Output and Systemic Vascular Resistances
As pulse contour analysis continuously measures
stroke volume and arterial pressure, cardiac
output (CO) and systemic vascular resistance
(SVR) are computed as follows

• CO is calculated as stroke volume x heart rate

• SVR is calculated as (mean arterial pressure -
  central venous pressure) / CO

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Stroke Volume Variation (SVV)
In mechanically ventilated patients without
arrhythmia,

• SVV reflects the sensitivity of the heart to the
  cyclic changes in cardiac preload induced by
  mechanical ventilation.1,14,17,18,19
• SVV can predict whether stroke volume will
  increase with volume expansion.1,14,17,18,19

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4. How to use the PiCCO-Technology?

1. Connect the injectate-temperature sensor housing
   to the CV line already in place.
2. Insert a PiCCO arterial thermistor catheter into
   a large artery, preferable femoral artery, but
   also brachial / axillary artery and radial artery
   (with long catheter).
3. Connect the injectate sensor, the arterial
   catheters thermistor and pressure line to your
   PiCCO monitor.
4. For blood pressure transfer to any bedside
   monitoring system, connect the cable at the back
   side of the PiCCO monitor.
5. Now the system is ready to work.
6. For information how to handle your PiCCO monitor,
   please refer to your accompanying PiCCO
   Operators Manual.

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How to manage my patient with the
PiCCO-Technology?

• Management of a patients hemodynamic situation
  is easily possible by following the
  therapeutic guideline shown below.
• It was developed out of daily clinical practice,
  has shown to be successful in over a hundred
  thousand patients and refers to below listed
  normal values of indices

Cardiac Index CI 3.0 5.0 l/min/m2 Global
Enddiastolic Blood Volume Index GEDI 680
800 ml/m2 Intrathoracic Blood Volume
Index ITBI 850 1000 ml/m2 Stroke Volume
Variation SVV ? 10 Extravascular Lung Water
Index ELWI 3.0 7.0 ml/kg
not available in USA
without guarantee
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Decision tree for hemodynamic / volumetric
monitoring
CI (l/min/m
2
)
gt3.0
lt3.0
R
GEDI (ml/m
2
)
gt700
lt700
gt700
lt700
E
S
ITBI (
ml/m
2
)
gt850
lt850
gt850
lt850
or
U
L
T
ELWI (ml/kg)
lt10
gt10
lt10
lt10
lt10
gt10
gt10
gt10
S
V
V!
V!
V
Cat
Cat
V
-
Cat
V
-
T
2
700
-
800
700
-
800
700
-
800
GEDI (ml/m
)
gt700
700
-
800
gt700
gt700
1.
H
ITBI (ml/m
2
)
gt850
850
-
1000
850
-
1000
850
-
1000
850
-
1000
gt850
gt850
or
E

T
R
lt10
Optimise to
SVV ()
lt10
lt10
lt10
2.
lt10
lt10
lt10
lt10
A
A
R
P
G
Y
CFI (1/min)
gt4.5
gt5.5
gt4.5
gt5.5
E
GEF ()
OK!
gt25
gt30
gt25
gt30
or
T

ELWI (ml/kg)



10

10
10
10
(slowly responding)
V

volume loading (! cautiously)
V
-
volume contraction
Cat catecholamine / cardiovascular agents

SVV only applicable in ventilated patients
without cardiac arrh
ythmia
without guarantee
not available in USA
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5. Which disposables do I need with the
PiCCO-Technology?

• PULSIOCATH arterial thermodilution catheter
• Injectate temperature sensor housing
• Any standard central venous catheter

• Specifically designed for less invasive
  volumetric, hemodynamic monitoring
• To be placed with Seldinger Technique
• Several sizes available for pediatric and adult
  patients
• Can remain within the patient up to 10 days or
  longer

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PULSIOCATH arterial thermodilution catheters
product range
PULSIOCATH arterial thermodilution catheters are
specifically designed for less invasive
volumetric hemodynamic monitoring with the PiCCO
Technology. The catheters are placed with
Seldinger Technique. Several versions and sizes
are available. They can remain within the patient
up to 10 days or even longer.
Article number PV2013L07 PV2014L08 PV2014L16 PV2015L20 PV2014L50LGWA
Outer diameter 3F (20G) / 0,9mm 4F (18G) / 1,4mm 4F (18G) / 1,4mm 5F (16G) / 1,7mm 4F (18G) / 1,4mm
Usable length 7cm 8cm 16cm 20cm 50cm
Common feature Latex free Latex free Latex free Latex free Latex free
Technical specifications are subject to change
without further notice
The catheters are also available as complete kits
(e.g. PVPK2015L20-46), including a disposable
pressure transducer and the injectate temperature
sensor housing. These kits can optionally be
ordered with an additional pressure line for
intermittent central venous pressure
monitoring. Catheters have to be selected
depending on patient size, weight and insertion
site.
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6. References
1. Berkenstadt H et al., Anesth Analg,
2001 2. Bindels A et al., Crit Care 4,
2000 3. Boussat S et al., Int Care Med
2002 4. Brock H et al., Eur J Anaesth 19 (4),
2002 5. Della Rocca G et al., Eur J Anaesth 19,
2002 6. Della Rocca G et al., Anesth Analg 95,
2002 7. Eisenberg PR et al., Am Rev Respir Dis
136 (3), 1987 8. Gödje O et al., Chest 118,
2000 9. Gödje O et al., Eur J of Cardio-thoracic
Surgery 13, 1998 10. Haperlin et al., Chest,
1985 11. Katzenelson et al., SCCM 2001, San
Diego 12. Lichtwarck-Aschoff M et al., Journal of
Critical Care 11 (4), 1996 13. Lichtwarck-Aschoff
M et al., Intensive Care Med 18, 1992 14. Michard
F et al., Yearbook of Intensive Care Med,
2002 15. Mitchell JP et al., Am Rev Respir Dis
145 (5), 1992 16. Neumann et al., Intensive Care
Med 1999 17. Reuter DA et al., Crit Care Med,
2003 18. Reuter DA et al., Intensive Care Med,
2002 19. Reuter DA et al., Brit J Anaesth,
2002 20. Sakka SG et al., Chest 122,
2002 21. Sakka S et al., Intensive Care Med
2000 22. Sakka S et al., Journal of Critical Care
14 (2), 1999 23. Sturm JA, Practical Applications
of Fiberoptics in Critical Care Monitoring,
1990 24. Takeda A et al., J Vet Med Sci 57, 1995
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7. Where can I get what I need?
For further information or ordering, please
contact your local PULSION Office
PULSION Medical Systems AG Stahlgruberring 28 D-
81829 München Germany Tel. [phone] PULSION
49 (0)89 4599140 Fax 49 (0)89
45991418 info_at_pulsion.com
PULSION Medical U.K., Ltd. P.O. Box 315 Arundel
Road Uxbridge, Middlesex GB- UB8 2US,
England Great Britain Tel. [phone]
455255 Fax [phone] info_at_pulsionmedica
l.co.uk
PULSION France sarl 6, Place Jeanne dArc F-
13100 Aix en Provence France Tél.  33 (0)4 42
27 67 19 Fax  [phone]
90 info_at_pulsion.fr
PULSION Medical Systems Ibérica S.L. Pol. Ind.
Las Nieves, C/ Puerto Canencia 21 E- 28935
Móstoles, Madrid Spain Tel. [phone]
12 Fax [phone] info_at_pulsioniberica.com
Seda S.p.A. Via Tolstoi, 7/B I- 20090 Trezzano
sul Naviglio (MI) Italy Tel. 39 02
48424219 Fax [phone] sd_at_sedaitaly.it
PULSION Benelux nv/sa Maaltecenter, Blok
G Derbystraat 341 B- 9051 Gent (SDW) Belgium Tel. 
32 (0)9 242 99 10 Fax  [phone]
11 info_at_pulsion.be
If your country is not listed above, please
contact PULSION Germany
PULSION Pacific Pty. Ltd. P.O. Box 823 AUS-
Randwick, NSW Australia, 2031 Australia Tel. 61
(0) 2 9340 5525 Fax [phone]
5515 info_at_pulsionpacific.com.au
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• The PiCCO-Technology is also available as a
  module for Philips IntelliVue / CMS patient
  monitoring systems.

For more information please refer to your local
PULSION representative (page 25) or visit
www.pulsion.com
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• For further information, please visit
• www.pulsion.com
• There you will find also information on other
  revolutionary PULSION products
• LiMON - noninvasive bedside liver function
  monitor
• ICG-PULSION - indocyanine green dye for
  diagnostics
• VoLEF - PiCCO plus add-on monitor for cardiac
  sub-volumes and RVEF
• IC-VIEW - laser fluorescence makes tissue
  perfusion visible

_at_ PULSION 07/2003 MPI812205