5/9/2015 Disclosures NONE I Want That New Monitoring - - PDF document

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5/9/2015 Disclosures NONE I Want That New Monitoring - - PDF document

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5/9/2015 Disclosures NONE I Want That New Monitoring Technologies Lee-lynn Chen May 9, 2015 Objectives Hemodynamic Monitoring Outline existing hemodynamic monitoring Prevent Tissue Hypoperfusion technologies Ensure

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I Want That … New Monitoring Technologies

Lee-lynn Chen May 9, 2015

Disclosures

  • NONE

Objectives

  • Outline existing hemodynamic monitoring

technologies

  • Review evidence behind its use
  • List strategies to improve care in the ICU setting

Hemodynamic Monitoring

  • Prevent Tissue Hypoperfusion
  • Ensure Adequate Oxygen Delivery
  • Responsiveness to fluid bolus

– 500 cc bolus with increase of CO by 13%

  • Traditional monitors
  • Newer monitoring technology
  • Adaptation of traditional monitors

4

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Case

  • 58 yo alcoholic male presenting with acute

pancreatitis transferred from an outside hospital after receiving 10 liters of crystalloid for

  • resuscitation. Currently, intubated and sedated.
  • How do you decide whether to give more fluids

versus initiating vasoactive medications?

  • BP 80/50, HR 100

5

Non-Invasive Blood Pressure Cuff

6

Arterial Blood Pressure Monitoring

7

The Pulmonary Artery Catheter

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Other helpful measures

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BP = CO X SVR

Frank-Starling Curve

11

Why not give fluid to everyone?

12

Michard & Teboul. Chest 121:2000-8, 2002

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Goldilocks for Fluids

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Passive Leg Raise

14

Teboul and Monnet. Intensive Care Medicine 2008

Passive Leg Raise

15

Esophageal Doppler

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How does the Esophageal Doppler work?

17

Descending Aorta Flow Profile

18

Anatomy of the waveform

19 20

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Hypovolemia

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Left Ventricular Failure

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High Afterload

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Waveform Changes

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Limitations

  • Intra-aortic balloon
  • Thoracic aortic aneurysm, stents, aortic coarctation
  • Fast atrial fibrillation (irregular systoles)
  • Aortic regurgitation (poorly defined end of systole)
  • Aortic valve disease (poorly defined start of systole)
  • Access to head

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Protocol Driven Patient Care

26

BMJ 2004, 329:258-261

Protocol Driven Patient Care

27

Nurse delivered flow monitor protocol

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Results

29

Bioreactance

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Pulse Contour Analysis

  • Relationship between BP, SV, arterial

compliance and SVR

  • Pressure-volume conversion algorithms

– Indicator Dilution CO measurement (LiDCO, PiCCO) – Arterial impendence and demographic (FloTrac) – No calibration or preloaded data needed (MostCare)

31

Effects of Mechanical Ventilation

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33

Pulse Pressure Variation

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Predictive Value of Techniques

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Stroke Volume Variation

  • PPV/SPV/SVV – surrogate measure of relative

preload responsiveness

  • High sensitivity and specificity compared to

traditional indicators of fluid responsiveness

  • Limitations

– Mechanically Ventilated (PEEP) – No arrhythmias – Vascular Tone

36

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37

PVI

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Brain/Tissue Oxygen Monitor

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Assessing volume responsiveness

  • Passive Leg Raising
  • Pulse Pressure Variations
  • Systolic Pressure Variations
  • Stroke Volume Variations

40

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Take Home Messages

  • Audit your practice
  • Standardize Care
  • Identify Barriers at your institutions
  • Improve your Knowledge

QUESTIONS?