PowerPoint-Pr

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PULSION Medical Systems AG
PiCCO plus
PiCCOplus_highLevel_R10_EN_020205
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Contents
Page

1. What is the PiCCO-Technology? 3
2. What are the advantages of the PiCCO-Technology?
   5
3. How does the PiCCO-Technology work? 6
4. How to use the PiCCO-Technology? 57
5. Which disposables do I need for the
   PiCCO-Technology? 58
6. References 60
7. Where can I get what I need? 61
8. Philips PiCCO Module 62
9. Other PULSION Products 63
10. PiCCO-Technology in USA 64

3
1.What is the PiCCO-Technology?

• The PiCCO-Technology is a unique combination of
  2 techniques
• for advanced hemodynamic and volumetric
  management without
• the necessity of a right heart catheter in
  most patients

• Transpulmonary Thermodilution

CV Bolus injection
CALIBRATION
PULSIOCATH

• Pulse Contour Analysis

4
Parameters measured with the PiCCO-Technology
The PiCCO measures the following parameters

• Thermodilution Parameters
• Cardiac Output CO
• Global End-Diastolic Volume GEDV
• Intrathoracic Blood Volume ITBV
• Extravascular Lung Water EVLW
• Pulmonary Vascular Permeability Index PVPI
• Cardiac Function Index CFI
• Global Ejection Fraction GEF

• Pulse Contour Parameters
• Pulse Contour Cardiac Output PCCO
• Arterial Blood Pressure AP
• Heart Rate HR
• Stroke Volume SV
• Stroke Volume Variation SVV
• Pulse Pressure Variation PPV
• Systemic Vascular Resistance SVR
• Index of Left Ventricular Contractility dPmx

not available in the USA (p 63)
5
2.What are the advantages of the PiCCO-Technology?

• Less Invasiveness - Only central venous and
  arterial access required - No pulmonary
  artery catheter required - Also applicable
  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
• Cost Effective - Less expensive than
  continuous pulmonary artery catheter -
  Arterial PiCCO catheter can be in place for 10
  days - Potential to reduce ICU stay
  and costs
• More Specific Parameters - PiCCO parameters
  are easy to use and interpret even
  for less experienced
  caregivers
• Extravascular Lung Water - Lung edema can be
  excluded or quantified at the bed-side

not available in the USA (p 63)
6
3.How does the PiCCO-Technology work?

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

Central venous line (e.g. for vasoactive agents
administration)
Arterial line (accurate monitoring
of arterial pressure, blood samples)

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

7
PiCCO Catheter

• Central venous line (CV)
• PULSIOCATH thermodilution catheter with
  lumen for arterial pressure measurement
• Axillary 4F (1,4mm) 8cm
• Brachial 4F (1,4mm) 22cm
• Femoral 3-5F (0,9-1,7mm) 7-20cm
• Radial 4F (1,4mm) 50cm

CV
A
B
R
F
No Right Heart Catheter !
8
PiCCO plus setup
Central Venous Catheter
Injectate temperature sensor housing
13.03 16.28 TB37.0
AP
AP 140 117 92 (CVP) 5 SVRI 2762 PC CI
3.24 HR 78 SVI 42 SVV 5 dPmx
1140 (GEDI) 625
PCCI
Pressure cable
Injectate temperature sensor cable
Temperature interface cable
PULSION disposable pressure transducer
PULSIOCATH thermodilution catheter
9
A. Thermodilution parameters
PiCCO Catheter e.g. in femoral artery
Bolus Injection

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

Lungs
not available in the USA (p 63)
10
Transpulmonary thermodilution Cardiac Output

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

injection
Tb
CO Calculation ? Area under the Thermodilution
Curve
t
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

• For correct calculation of CO, only a fraction
  of the total injected indicator needs to pass
• the detection site. Simplified, only the
  change of temperature over time is relevant.

11
Transpulmonary thermodilution Volumetric
parameters 1

• All volumetric parameters are obtained by
  advanced analysis of the thermodilution curve

For the calculations of volumes
Advanced Thermodilution Curve Analysis
Tb
Mtt Mean Transit time time when half of the
indicator has passed the point of detection in
the artery
injection
recirculation
ln Tb
and
-1
e
DSt Down Slope time exponential downslope
time of the thermodilution curve
t
MTt
DSt
are important.
12
Transpulmonary thermodilution Volumetric
parameters 2
After injection, the indicator passes the
following intrathoracic compartments
ITTV
PTV
Thermodilution curve measured with arterial
catheter
CV Bolus Injection
RVEDV
LVEDV
RAEDV
Lungs
Left Heart
Right Heart

• The intrathoracic compartments can be
  considered as a series of mixing chambers
• for the distribution of the injected
  indicator (intrathoracic thermal volume).

• The largest mixing chamber in this series are
  the lungs, here the indicator (cold) has its
• largest distribution volume (largest thermal
  volume).

13
Transpulmonary thermodilution Newman Model
ITTV
PTV
injection
detection
RVEDV
LVEDV
RAEDV
Lungs
Left Heart
Right Heart
flow

• Multiplication of MTt (Mean Transit time) with
  CO results in the complete
• Inttrathoracic Thermal Volume (ITTV) which is
  the whole needle to needle volume.

ITTV RAEDV RVEDV Lungs LAEDV LVEDV
MTt x Flow (CO)

• Multiplication of DSt (Downslope time) with CO
  yields the largest mixing volume
• which is the lungs.

PTV Thermal Volume of the Lungs DSt x
Flow (CO)
Newman et al, Circulation 1951
14
Global End-Diastolic Volume GEDV

• Global End-Diastolic Volume (GEDV)
• is the volume of blood contained in
• the 4 chambers of the heart, in the
• end-diastoly, each.

GEDV

• GEDV is calculated by subtraction of
• PTV from ITTV.

PTV
RVEDV
LVEDV
RAEDV
LAEDV
GEDV ITTV - PTV
ITTV
15
Intrathoracic Blood Volume

• Intrathoracic Blood Volume (ITBV)
• is Global End-Diastolic Volume (GEDV)
• the blood volume in the pulmonary
• vessels (PBV).

ITBV PBV GEDV
RAEDV
ITBV can be directly measured with thermal dye
dilution technique (COLD System) and has shown
to be consistently 25 greater than GEDV
measured by single thermodilution technique
(PiCCO).
Therefore it is possible to compute ITBV based on
measurement of GEDV ITBV 1,25 x GEDV
ITBVTD (ml)
r 0.96
ITBV 1.25 GEDV 28.4 ml
GEDV vs. ITBV in 57 intensive care patients Sakka
et al, Intensive Care Med 26 180-187, 2000
16
Extravascular Lung Water

• Extravascular Lung Water (EVLW) represents the
  amount of water content of the
• lungs and is calculated by subtraction of
  ITBV from ITTV.

ITTV
ITBV
EVLW

not available in the USA (p 63)
17
Calculation of volumes - Summary
ITTV CO MTtTDa
RAEDV
RVEDV
LAEDV
LVEDV
PTV
PTV CO DStTDa
PTV
GEDV ITTV - PTV
RAEDV
RVEDV
LAEDV
LVEDV
ITBV 1.25 GEDV
EVLW ITTV - ITBV
not available in the USA (p 63)
18
Pulmonary Vascular Permeability Index

• Pulmonary Vascular Permeability Index (PVPI)
  is the ratio of Extravascular
• Lung Water (EVLW) to pulmonary blood volume
  (PBV). It allows to identify the
• type of pulmonary oedema.

normal
EVLW
EVLW
?
PBV
PVPI
Normal Lungs
PBV
normal
Extra Vascular Lung Water
Pulmonarv Blood Volume
normal
elevated
EVLW
EVLW
Hydrostatic pulmonary edema
?
PBV
PVPI
PBV
normal
elevated
elevated
Permeability pulmonary edema
EVLW
EVLW
PVPI
?
PBV
PBV
elevated
normal
not available in the USA (p 63)
19
Global Ejection Fraction

• Ejection Fraction Stroke Volume related to
  End-Diastolic Volume

Lungs
Left Heart
Right Heart
EVLW
PBV
RAEDV
RVEDV
EVLW
LAEDV
LVEDV
Stroke Volume SV
2
3
1

?
4 x SV
GEF
GEDV
Global Ejection Fraction (GEF) (transpulmonary
thermodilution)
RV ejection fraction (RVEF) (pulmonary artery
thermodilution)
LV ejection fraction (LVEF) (echocardiography)
not available in the USA (p 63)
20
b. Arterial Pulse Contour Analysis
P mm Hg
t s
21
Pulse Contour Analysis - Principle

• 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.

Reference CO value from thermodilution
Measured blood pressure(P(t), MAP, CVP)
Calibration
22
Calculation of Beat by Beat Pulse Contour Cardiac
Output

• Rise and fall of the blood pressure curve is
• also dependent on the patients individual
• aortic compliance.

P(t), Diastole
P(t), Systole

• After calibration, the pulse contour Algorithm
  is able to follow the cardiac output
• Beat by Beat.

P mm Hg
t s
Shape of pressure curve
Heart rate
Aortic compliance
Area under pressure curve
Patient-specific calibration factor (determined
by thermodilution)
23
Index of Left Ventricular Contractility

• dPmx dP/dtmax of arterial pressure curve

• dPmx represents left ventricular pressure
  velocity increase and thus is a
• parameter of myocardial contractility

not available in the USA (p 63)
24
Stroke Volume Variation Calculation

• Stroke Volume Variation (SVV) represents the
  variation of stroke volume (SV) over the
• ventilatory cycle.

SVmax
SVmin
SVmean

• SVV is...
• ... measured over last 30s window
• only applicable in controlled mechanically
  ventilated patients with regular heart rhythm

25
Pulse Pressure Variation Calculation

• Pulse pressure variation (PPV) represents the
  variation of the pulse pressure
• over the ventilatory cycle.

PPmean
PPmax
PPmin
PPmax PPmin
PPV
PPmean

• PPV is...
• measured over last 30s window
• only applicable in controlled mechanically
  ventilated patients with regular beat rhythm

26
Validation of PiCCO - Parameters
a. Cardiac Output
27
Validation of Transpulmonary Thermodilution
Comparison to PA thermodilution COTDa vs. COTDpa n (pat. / measurements) bias SD(l/min) bias SD(l/min) bias SD(l/min) r
Friedman Z et al., Eur J Anaest, 2002 17/102 -0,04 0,41 0,95
Della Rocca G et al., Eur J Anaest 14, 2002 60/180 0,13 0,52 0,93
Holm C et al., Burns 27, 2001 23/218 0,32 0,29 0.98
Bindels AJGH et al., Crit Care 4, 2000 45/283 0,49 0,45 0,95
Sakka SG et al., Intensive Care Med 25, 1999 37/449 0,68 0,62 0,97
Gödje O et al., Chest 113 (4), 1998 30/150 0,16 0,31 0,96
McLuckie A. et a., Acta Paediatr 85, 1996 9/27 0,19 0,21 - / -
Comparison to Fick Method
COTDa vs. COFick
Pauli C. et al., Intensive Care Med 28, 2002 18/54 0,03 0,17 0,98
Tibby S. et al., Intensive Care Med 23, 1997 24/120 0,03 0,24 0,99
28
Validation of Pulse Contour Analysis
Comparison to PA thermodilution PCCO COTDpa n (pat. / measurements) n (pat. / measurements) bias SD (l/min) bias SD (l/min) r
Mielck et al., J Cardiothorac Vasc Anesth 17 (2), 2003 Mielck et al., J Cardiothorac Vasc Anesth 17 (2), 2003 22 / 96 -0,40 1,3 - / -
Rauch H et al. Acta Anaesth Scand 46, 2002 Rauch H et al. Acta Anaesth Scand 46, 2002 25 / 380 0,14 0,58 - / -
Felbinger TW et al. J Clin Anesth 46, 2002 Felbinger TW et al. J Clin Anesth 46, 2002 20 / 360 -0,14 0,33 0,93
Della Rocca G et al. Br J Anaesth 88 (3), 2002 Della Rocca G et al. Br J Anaesth 88 (3), 2002 62 / 186 -0,02 0,74 0,94
Gödje O et al. Crit Care Med 30 (1), 2002 Gödje O et al. Crit Care Med 30 (1), 2002 24 / 517 -0,2 1,15 0,88
Zöllner C et al. J Cardiothorac Vasc Anesth 14 (2), 2000 Zöllner C et al. J Cardiothorac Vasc Anesth 14 (2), 2000 19 / 76 0,31 1,25 0,88
Buhre W et al., J Cardiothorac Vasc Anesth 13 (4), 1999 Buhre W et al., J Cardiothorac Vasc Anesth 13 (4), 1999 12 / 36 0,03 0,63 0,94

• These tables are only an excerpt of
  publications, in total there are more than 200
  articles on the PiCCO-Technology.

29
Validation of PiCCO - Parameters
b. Volumetric Parameters
30
Thermodilution ITBVIST vs. double indicator
dilution ITBVITD

• ITBV (thermodilution) is calculated by GEDV x
  1,25 (see also page 15).
• ITBV significantly correlates to ITBV
  (dye dilution), which is the Gold-Standard.

ST
ST
TD
n 209 r 0.97
Bias -7.6 ml/m2SD 57.4 ml/m2
ITBVIST vs. ITBVITD in 209 critically ill
patients Sakka et al, Intensive Care Med 26
180-187, 2000
31
Validation of Extravascular Lung Water 1

• Extavascular Lung Water (EVLW) by double
  indicator dilution (COLD-SystemTM)
• compared to gravimetric EVLW measurement in
  brain-dead humans.

Sturm, In Practical Applications of Fiberoptics
in Critical Care Monitoring Springer Verlag
Berlin - Heidelberg - NewYork 1990, pp 129-139
not available in the USA (p 63)
32
Validation of EVLW 2

• PiCCO EVLW vs. gravimetric EVLW
• in animals with
  cardiogenic noncardiogenic Pulmonary Edema

Katzenelson et al,Crit Care Med 32 (7), 2004 in
15 dogs
R 0,85 P lt 0,0001
Kirov et al, Crit Care 8 (6), 2004 in 18 sheep
not available in the USA (p 63)
33
EVLW measurement with thermodilution technique
TM

• Validation of Extravascular Lung Water
  measurement with the COLD System
• Dye dilution (EVLW ) vs. single
  thermodilution technique (EVLW )

ST
TD
n 209 r 0.96
Bias -0.2 ml/kgSD 1.4 ml/kg
EVLWIST vs. EVLWITD in 209 intensive care
patients Sakka et al, Intensive Care Med 26
180-187, 2000
not available in the USA (p 63)
34
Clinical Application
Volume
Drugs
35
PiCCO answers all relevant questions
CO GEDV SVV
SVR EVLW
What is the current situation?......Cardi
ac Output! What is the preload?......Globa
l End-Diastolic Volume! Will volume increase
CO?........Stroke Volume Variation! What is
the afterload?....Systemic Vascular
Resistance! Are the lungs still
dry?..........Extravascular Lung Water!

not available in the USA (p 63)
36
PiCCO preload indicators

• Global End-Diastolic Volume, GEDV and
  Intrathoracic Blood Volume, ITBV have shown to
  be far more sensitive and specific to cardiac
  preload compared to
• the standard cardiac filling pressures
  CVP PCWP as well as right ventricular
  enddiastolic volume. 2,3,6,7,9,10,12,15,16,25
• The striking advantage of GEDV and ITBV is that
  they are not adversely influenced
• by mechanical ventilation and give correct
  information of the preload status under any
  condition. 2,3,7,8,9,10,15,16, 25
• Following charts 12,16 show a highly
  significant correlation of PiCCO preload volume
  to cardiac index or stroke volume index, whereas
  filling pressure show lack of correlation.

37
Pressure or volume as indicator of Cardiac
Preload? 1
Relationship between changes in cardiac index
(?CI) and changes in central venouse pressure
(?CVP), pulmonary capillary wedge pressure
(?PCWP), or intrathotracic blood volume index
(?ITBI) in patients with acute respitarory
failure and mechanical ventilation.
16 Lichtwarck-Aschoff et al, Intensive Care Med
18 142-147, 1992
38
Pressure or volume as indicator of Cardiac
Preload? 2
GEDV is a more reliable preload parameter than
PCWP and CVP Goedje et al, Chest 2000
39
Extravascular Lung Water

• Extravascular Lung Water, EVLW assessment by
  transpulmonary thermodilution
• has been validated against dye dilution and
  the reference gravimetric method.13,14, 19,24,26

• Extravascular Lung Water, EVLW has shown to
  have a clear correlation to
• severity of ARDS, length of ventilation days,
  ICU-Stay and Mortality and is
• superior to assessment of lung edema by chest
  x-ray and clearly indicates fluid overload.
  8,9,18,23,26,27

not available in the USA (p 63)
40
Comparison of EVLW to Chest X-ray
Source Comparison Correlation Baudendistel et
al, 1982, J Trauma 22 983 X-ray score
vs.EVLW 77 Sibbald et al, 1983, Chest 83 725
comparison cardiac edema r 0,66 comparison
non cardiac edema r 0,7 Sivak et al, 1983,
Crit Care Med. 11 498 X-ray score vs EVLW 64
? X-ray score vs. ? EVLW 42 Laggner et al,
1984, Intensive Care Med. 10 309 X-ray score
vs. EVLW r 0,84 no / low / high PE, estimated
by radiologists Halperin et al, 1985, Chest 88
649 ? X-ray score vs. ? EVLW r
0,51 Haller et al, 1985, Fortschr. Röntgenstr.
142 68 X-ray score vs. EVLW 66 Eisenberg et
al, 1987, Am Rev Resp Dis 136 662 X-ray score
vs. EVLW 76 Takeda et al, 1995, J Vet Med Sci
57 (3) 481 X-ray score vs. EVLW X-ray
insensitive

• Chest X-ray is often influenced by pleural
  effusion and technical problems of
• radiography at the bedside.

not available in the USA (p 63)
41
EVLW and oxygenation
Capillary
Alveola
Erythrocyte
1

2
Alveola
Interstitial space
Moderate to high lungwater values are not
necessarily related to a decrease in oxygenation.
Lung water accumulates first in the free
interstitial space (1). If lung water increases
further, it penetrates into the restricted
interstitial space (2) and the gas exchange is
affected 26. Böck, Lewis, In Practical
Applications of Fiberoptics in Critical Care
Monitoring, Springer Verlag Berlin -
Heidelberg - NewYork 1990, pp 129-139
not available in the USA (p 63)
42
EVLW and mortality 1

• There is a direct relationship between the
  amount of lung edema and patient prognosis.
• An increase of mortality to more than 70 can
  be observed with increasing EVLW.

gt
Mortality as function of EVLW in 81 critically
ill ICU patients. Sturm, In Practical
Applications of Fiberoptics in Critical Care
Monitoring, Springer Verlag Berlin - Heidelberg
- NewYork 1990, pp 129-139
not available in the USA (p 63)
43
EVLW and mortality 2
ELWI ml/ kg
Mortality as function of ELWI in 373 critically
ill ICU patients 193 sepsis, 49 ARDS, 48 head
trauma, 83 hemorrage and hemorrhagic shock.
Patients were classified into four groups
according to their highest EVLW value. Sakka et
al , Chest 2002
not available in the USA (p 63)
44
Relevance of EVLW - Management
Ventilation days
ICU days
n101


EVLW group
PAC group
EVLW group
PAC group
22 days
15 days
9 days
7 days
101 patients with pulmonary edema were randomized
to a pulmonary artery catheter (PAC) management
group in whom fluid management decisions were
guided by PCWP measurements and to an
Extravascular Lung Water (EVLW) management group
using a protocol based on the bedside measurement
of EVLW . ICU days and ventilator-days were
significantly shorter in patients of the EVLW
group. Mitchell et al, Am Rev Resp Dis 145
990-998, 1992
not available in the USA (p 63)
45
ELWI and GEDI in septic patients
ELWI ml/kg
ELWI , ml/kg
ELWI ml/kg
500 1000 1500 2000
CVP mmHg
PCWP mmHg
GEDI ml/m2
Intravascular volume monitoring and ELWI in
septic patients with pulmonary oedema. No
significant correlation between ELWI and CVP or
PCWP was found. There was a significant
correlation between ELWI and GEDI. Boussat et
al, Intensive Care Med, 2002
not available in the USA (p 63)
46
Pulmonary Vascular Permeability Index 1
Normal GEDI
PVP increased
ELWI ml/kg
PVP normal
GEDI ml/m2
960
800
680
560
Relationship of ELWI to volume status in a
patient with increased pulmonary vascular
permeability (PVP) and in a patient with normal
permeability High PVP leads to increased ELWI
even with moderate volume loading and increases
dramatically if the patient is volume
overloaded. Unpublished data
not available in the USA (p 63)
47
Pulmonary Vascular Permeability Index 2
4
PVPI
3
CAP
CHF
2
Pulmonary vascular permeability Index (PVPI) in
16 patients with congestive heart failure (CHF)
and community acquired pneumonia (CAP). ELWI was
16 ml/kg in both groups, PVPI allowed to
identify patients suffering from capillary
leakage. from Benedikz et al ESICM 2002
not available in the USA (p 63)
48
Global Ejection Fraction and Cardiac Function
Index
GEF and CFI provide a reliable evaluation of LV
systolic function. Low CFI and GEF can be
considered as an indicator to perform an
echocardiography to discriminate between right
and left ventricular dysfunction.5
Combes et al, Intensive Care Med 30, 2004
49
PiCCO - Cardiac Output during Off-Pump Coronary
Surgery

• PCCO is fast responding, Beat by Beat!

Cardiac output monitoring during off-pump CABG.
PiCCO derived continuous cardiac output (PCCO)
closely follows the flow measured with an aortic
Doppler flow probe.
data from Dr. S. Thierry Henri Mondor Hospital,
Créteil, France, 2003
50
Stroke Volume Variation - SVV
In controlled mechanically ventilated patients
without arrhythmia,

• SVV reflects the sensitivity of the heart to the
  cyclic changes in cardiac
• preload induced by mechanical
  ventilation.1,17,20,21,22
• SVV can predict whether stroke volume will
  increase with volume
• expansion and by this avoid time consuming
  volume challenge.1,17,20,21,22
• SVV ON-LINE CARDIAC VOLUME RESPONSIVENSS

51
SVV as predictor of volume responsiveness
Preload shifts (? EDV) induced by mechanically
ventilation lead to different stroke volumes (?
SV), depending on the patient's individual
starling curve. A volume respondent patient is on
the linear part of the starling curve which leads
to a high variation in stroke volume (SVV).
SV
SVV small
? SV2
SVV large
? SV1
? EDV1
? EDV2
EDV
The increase of preload volume is equal ? EDV1
? EDV2 but ? SV1 gt
? SV2
52
SVV and PPV Clinical Studies 1

• SVV and PPV are excellent predictors of volume
  responsiveness.

1
Sensitivity
0,8
Central Venous Pressure (CVP) can not predict
whether volume load leads to an increase in
stroke volume or not.
0,6
0,4
- - - CVP __ SVV
0,2
Berkenstadt et al, Anesth Analg 92 984-989, 2001
0
0,5
1
0
Specificity
53
SVV and PPV Clinical Studies 2

• Respiration dependent changes of arterial pulse
  pressure accurately predict
• fluid responsiveness.

PPV was measured in 40 septic patients with acute
circulatory failure. After a volume loading with
500ml of colloids, patients with high PPV
(threshold value 13) were responding, whereas
patients with low PPV were not responding with an
increase of cardiac output. Thus PPV can predict
if a controlled mechanically ventilated patient
will react on volume loading.
Michard et al, Am J Respir Crit Care Med 162,
2000
54
How to manage my patient with the
PiCCO-Technology?

• Management of a patients hemodynamic situation
  is readily possible by
• following the therapeutic guideline displayed
  in the PiCCO decision tree.
• The ranges of normal values and the decision
  tree were developed from
• daily clinical practice and have shown to be
  successful in more than 400.000
• patients. (as of May 2005)

without guarantee
55
Decision tree for hemodynamic / volumetric
monitoring
CI (l/min/m2)
gt3.0
lt3.0
R E S U L T S
lt700 lt850
gt700 gt850
lt700 lt850
GEDI (ml/m2) or ITBI (ml/m2)
gt700 gt850
ELWI (ml/kg)
lt10
gt10
lt10
lt10
lt10
gt10
gt10
gt10
V
V-
V
V!
V!
Cat
Cat
Cat
V-
T H E R A P Y
700-800 850-1000
700-800 850-1000
700-800 850-1000
gt700 gt850
700-800 850-1000
gt700 gt850
GEDI (ml/m2) or ITBI (ml/m2)
gt700 gt850
1.
T A R G E T
lt10
2.
lt10
lt10
Optimise to SVV ()
lt10
lt10
lt10
lt10
lt10
CFI (1/min) or GEF ()
gt4.5 gt25
gt5.5 gt30
gt4.5 gt25
gt5.5 gt30
OK!
?10
?10
?10
?10
ELWI (ml/kg) (slowly responding)
V volume loading (! cautiously)
V- volume contraction
Cat catecholamine / cardiovascular agents
SVV only applicable in ventilated patients
without cardiac arrhythmia
not available in the USA (p 63)
Without guarantee
56
Normal ranges

• Parameter Range Unit
• CI 3.0 5.0 l/min/m2
• SVI 40 60 ml/m2
• GEDI 680 800 ml/m2
• ITBI 850 1000 ml/m2
• ELWI 3.0 7.0 ml/kg
• PVPI 1.0 3.0
• SVV ? 10
• PPV ? 10
• GEF 25 35
• CFI 4.5 6.5 1/min
• MAP 70 90 mmHg
• SVRI 1700 2400 dynscm-5m

not available in the USA (p 63)
57
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 operate your PiCCO monitor, please refer
to your accompanying PiCCO Operators
Manual and Setup guide.
58
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
• Is placed with Seldinger Technique
• Several sizes available for pediatric and adult
  patients
• Can remain within the patient up to 10 days or
  longer

59
PULSIOCATH thermodilution catheter 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 PV2014L22 PV2015L20 PV2014L50LGW
Outer diameter 3F (20G) / 0,9mm 4F (18G) / 1,4mm 4F (18G) / 1,4mm 4F (18G) / 1,4mm 5F (16G) / 1,7mm 4F (18G) / 1,4mm
Usable length 7cm 8cm 16cm 22cm 20cm 50cm
Common feature Latex free / DEHP free Latex free / DEHP free Latex free / DEHP free Latex free / DEHP free Latex free / DEHP free Latex free / DEHP 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. Optionally, these kits can be
ordered with an additional pressure line for
intermittent central venous pressure
monitoring. Catheters should be selected
depending on patient size, weight and insertion
site.
not available in the USA (p 63)
60
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. Combes et al, Intensive Care Med 30, 2004
6. Della Rocca G et al., Eur J Anaesth 19, 2002
7. Della Rocca G et al., Anesth Analg 95, 2002
8. Eisenberg PR et al., Am Rev Respir Dis 136 (3),
   1987
9. Gödje O et al., Chest 118, 2000
10. Gödje O et al., Eur J of Cardio-thoracic Surgery
    13, 1998
11. Haperlin et al., Chest, 1985
12. Hoeft A, Yearbook of Intensive Care and Emergency
    Medicine, 1995
13. Katzenelson et al,Crit Care Med 32 (7), 2004
14. Kirov et al, Crit Care 8 (6), 2004
15. Lichtwarck-Aschoff M et al., Journal of Critical
    Care 11 (4), 1996
16. Lichtwarck-Aschoff M et al., Intensive Care Med
    18, 1992
17. Michard F et al., Yearbook of Intensive Care Med,
    2002
18. Mitchell JP et al., Am Rev Respir Dis 145 (5),
    1992
19. Neumann et al., Intensive Care Med 1999

61
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] 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. 44 (1895)
270951 Fax [phone] info_at_pulsionmedical.
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 Pacific Pty. Ltd. P.O. Box 823 AUS-
Randwick, NSW Australia, 2031 Australia Tel. 61
(7) 3266-8448 Fax [phone] info_at_pulsionp
acific.com.au
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
PULSION Medical Inc., USA 125 Poinsetta
Suite Vista, CA, 92083 USA Tel. [phone]
1370 toll free (USA) 1-877-655-8844 Fax
1-(0)760-295 1373 info_at_pulsionmedical.com
If your country is not listed above, please
contact PULSION Germany
62
8.Philips PiCCO Module

• 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 or visit
www.PULSION.com
63
9.Other PULSION Products

• For more detailed information and information on
  other revolutionary monitoring technology, please
  visit
• www.PULSION.com
• LiMON - non-invasive bedside liver function
  monitor
• CeVOX - central venous oxygen saturation
  monitor
• CiMON - continuous Monitoring of
  Intra-Abdominal Pressure (IAP)
• IC-VIEW - laser fluorescence makes tissue
  perfusion visible
• ICG-PULSION - indocyanine green dye for
  diagnostics

These products are not available in the USA.
64
10. PiCCO-Technology in USA
PiCCO-Technology with its full functionality is
also available (FDA approved) in the USA.

• EVLW is not yet FDA approved and therefore not
  displayed.
• However, ETVI (Extravascular Thermal Volume
  Index) which correlates to the amount of
• Extravascular Lung Water Index is displayed
  on the screen to be used as a quality indicator.
• It enables determination of the appropriate
  temperature of the indicator bolus used for
  transpulmonary thermodilution measurement. If
  ETVI is higher than 10, only iced injectate
  should be used.
• PVPI, dPmx and PV2014L50 are not yet available.

65
PiCCO... ...Simple Speedy Specific