critical care monitoring nuts and bolts mike mcevoy, phd, remt-p, rn, ccrn albany medical center,...
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Critical Care Critical Care Monitoring Monitoring
Nuts and BoltsNuts and Bolts
Mike McEvoy, PhD, REMT-P, RN, CCRNAlbany Medical Center, Albany, New York, USA
Cardiothoracic Surgical ICU
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Mike McEvoy, PhD, RN, CCRN, REMT-P
www.mikemcevoy.com
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DisclosuresDisclosures• I serve on the speakers bureaus for
Masimo Corp. and Medtronic Corp.• I have no other financial
relationships to disclose.• I am the EMS editor for Fire
Engineering magazine.• I do not intend to discuss any
unlabeled or unapproved uses of drugs or products.
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Jones & Bartlett, 2010Jones & Bartlett, 2010
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Goals for this talk:Goals for this talk:• Objectives of hemodynamic
monitoring• Blood pressure measurement• Art lines in practice• Preventing complications• Troubleshooting• Treatment parameters/goals• Non-invasive monitoring• New technologies
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Goal of hemodynamic Goal of hemodynamic monitoringmonitoring
• Assess tissue perfusion– Oxygenation and distribution (flow)
• Others?– Respirations
– Hydration
– Labs:» Chemistries
» Hematology
» Toxicology
» Microbiology
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3 types of shock:3 types of shock:
1. Distributive (septic)
2. Volume (hypovolemic)
3. Pump (cardiogenic)
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Are physical findings Are physical findings enough?enough?
• HR
• LOC
• BP
• UO
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Apparently not…Apparently not…
• 50% of physical assessments wrong • Therapeutic interventions altered with
invasive assessment 34 - 56% of the time:– 1980 Del Guercio - 1984 Connors – 1984 Eisenberg - 1990 Bailey – 1991 Steinberg - 1993 Coles – 1994 Minoz - 1998 Staudinger – 2002 Jacka
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Lung Sounds in HFLung Sounds in HF
• If rales were present, all had a wedge pressure >18, very specific
• Only 9 of 37 with a wedge pressure >18 had rales, very insensitive
• So…clear lung fields tell you very little about fluid status in heart failure
Butman et al. J Amer Coll Cardiol. 10/93
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So we dove right in…So we dove right in…
Swan Ganz Catheterization
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Connors et al 1996 Connors et al 1996 JAMAJAMA
5734 adult ICU patients 1989-1994, 5 ICUs at 15 tertiary med centers
PA cath = 30 day mortality, ICU LOS, costs of care
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Harvey et al: PAC-Man Harvey et al: PAC-Man 2005 Lancet 2005 Lancet - - Game Game Over?Over?
1014 patients at 65 UK institutions:NO DIFFERENCE between PA cath versus no PA cath
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Cochrane R & R: 2006 Cochrane R & R: 2006 (Review and Reappraisal)(Review and Reappraisal)
“The PAC is a monitoring tool; if it is used to direct therapy
and there is noimprovement in outcome, then the therapy does not
help.”
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Two Problems:Two Problems:
1. Define “normal”
2. Who’s behind the wheel?
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Blood Pressure
BP = CO x SVR
Indirect Pressure Measurement Direct Pressure Measurement
** A diastolic pressure of 60 is necessary to maintain coronary artery perfusion.
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Why do we measure Why do we measure BP?BP?• Because we can.
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Purpose of blood Purpose of blood pressurepressure
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Biventricular CV Biventricular CV SystemSystemL (systemic) R (pulmonic)
LV 110/10 RV 25/ 0-5
AO 120/80 PA 25/10
capillary 30-50 capillary 12-17
RA 0-5 LA 8-12
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Arterial Pressure Arterial Pressure MonitoringMonitoring
Direct
Pressure
Indirect
Flow
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Flow Measurements Flow Measurements Not Accurate:Not Accurate:
• Low blood flow states
• High SVR states– Avg 33.1 mmHg difference
cuff vs. a-line
– Cuff consistently underestimates pressure
- Cohn, JM (JAMA 199:972, 1967)
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Flow measurements Flow measurements • Pulses• Cuff• NIBP• Doppler
All sense pulsatile flow
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What We What We KnowKnow about about FlowFlow
(Indirect Measurement)(Indirect Measurement)• Pulses: – Carotid = SBP > 60– Femoral = SBP > 70– Radial = SBP > 80
• Cuff– Errors in measurement r/t size and heart level
• NIBP– Calculates systolic and diastolic based on MAP and HR
• Doppler– PEA
• Flow based measurements are NOT accurate in low flow states or with high SVR, e.g. shock
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Avoid assumptions !Avoid assumptions !
1. BP ≠ blood flow
levophed…
2. Blood flow ≠ perfusion
O2 or nutrient deficiency…
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Arterial Pressure Monitoring Indications
Patient in shock not rapidly responsive to therapy
Insertion SitesRadialBrachialAxillaryFemoralDorsalis Pedis
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Arterial Pressure Monitoring
Radial artery has the benefit of collateral circulation from the ulnar artery
Allen Test used to evaluate the collateral flow prior to radial artery cannulation
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A-line Monitoring Set-up
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Invasive Monitoring Equipment
Flush solution -- usually heparinized Continuous flush system (usually a
pressure bag or pump) Pressure transducer and pressure tubing Invasive catheter Monitor
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Transducers
Convert one form of energy to another
Sense pressure Convert it to an
electrical signal Electrical signal
causes monitor reading
+
-
Dom e
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Leveling, Referencing, Balancing…
Placing the air-fluid interface of the catheter system at the phlebostatic axis
This negates the weight effect of the fluid in the catheter tubing (hydrostatic pressure)
“Setting the correct reference point is the single most important step in setting up a pressure monitoring system.” … Gardner, 1993
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Leveling: the # 1 Cause of Error in Pressure Monitoring
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Phlebostatic Axis Located at the
intersection of the 4th ICS and midway between the anterior and posterior surfaces of the chest
Midaxillary line is NOT interchangeable with mid anteroposterior level in all persons … Bartz, et al, 1988
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Phlebostatic Axis
As the patient moves from flat to upright, the phlebostatic level rotates on the axis and remains horizontal. This position confirmed by CT by Paolella, et al, 1988.
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Phlebostatic Axis
The phlebostatic axis moves to midchest at the 4th ICS when patient is in the lateral position.
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Leveling
Air fluid interface is the point in the system that is opened to air during zeroing
Inaccuracies are produced if the air-fluid interface is above or below the phlebostatic axis – 1.86 mmHg/inch
Phlebostatic axis determined by Windsor and Burch (1945) as correct reference for measurement of venous pressures
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Give 500 ml of LR for CVP < 5 Transducer leveled 2 inches too
high 1.86 mmHg/inch x 2 =
underestimation of actual CVP by 3.72 mmHg (Ooops!)
Recorded CVP = 3 500 cc bolus of LR given Actual CVP = 7 (before LR
bolus)
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Zeroing
Opening the system to air to establish atmospheric pressure as zero (0)
This negates all pressure contributions from the atmosphere
Allows only pressure values that exist within the heart or vessel to be measured
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When to Zero Before insertion After disconnecting transducer from
pressure cable When values are in question
Ahrens, T. et al. Frequency requirements for zeroing transducers in hemodynamic monitoring, Am J Crit Care, 1995;4:466-471
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Arterial Pressure Waveform
1. Systole
2. Dicrotic notch
3. Diastole
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Placement of Arterial Placement of Arterial LineLine
150
90
60
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MAPMAP
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Art Line Placement:Art Line Placement:• The farther out, the higher the SBP• Cuff has no correlation
– Pressure vs. Flow
• Mean Pressure always consistent
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If BP increases, does If BP increases, does flow increase?flow increase?
• Think of levophed…
NOPE
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Preventing Complications with Arterial Lines
Complication Preventive Measure
Confusion with venous line Clearly label tubing as “Arterial”
Hemorrhage ALARMS, routinely check connectors
Infection Label dressing, careful sampling
Loss of waveform, catheter movement Immobilize extremity, secure catheter to skin
Blood back-up into tubing, loss of waveform
Pressurize system > patient blood pressure
Loss of circulation distal to site ?spasm vs thrombus? - may need to d/c
Clotted Use continuous flush system
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Troubleshooting Common Arterial Line Problems
Damping of waveformCauses:
Flush bag empty or pressure < patient pressure Catheter tip against vessel wall Clot at catheter tip Air bubbles in system Kinked catheter or tubing
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Troubleshooting Common Arterial Line Problems
Damping of waveform Interventions:
Keep flush bag at 300 mmHg Reposition extremity, use splint if necessary Gently aspirate clot, then flush line Clear system of air bubbles (limit to 1
stopcock) Remove kinks in tubing, check site, consider
suturing catheter to skin
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Troubleshooting Common Arterial Line Problems
Abnormally high/low readingsCauses:
Transducer not level Hypertension/hypotension System error
Interventions: Re-level system Assess pressure with alternate means Determine and optimize system dynamic
response
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Two Problems:Two Problems:
1. Define “normal”
2. Who’s behind the wheel?
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What is “normal”?What is “normal”?
Blood Pressure:
• Bland, ShoemakerJ Surg Obst 1978 -– 74 % of survivors
achieved normal values– 76% of NON-
SURVIVORS achieved normal vital signs
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Is it the car or the Is it the car or the driver?driver?• If you don’t know how to drive, a car can be a dangerous weapon.
• If you don’t know how to interpret the data, a monitoring catheter can be a dangerous weapon.
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What we really treat:What we really treat:NL Treat
HR 60 – 100 < 40 or > 120
MAP 70 – 105 < 60 – 70
CVP 2 – 6 < 5, Panic > 20
Sa02 95 – 100% < 90
ScvO2 > 70% (sepsis) <70% if hct >30
CI 2.5 – 4.0 < 2.2 – 2.5
SI 25 - 45 < 25 concerns you
Lactate 1 – 2 > 4 mmol/L and pH < 7.30 suggests tissue hypoxia
pH 7.35 – 7.45 Hmmm… 6.888, BE + 5…
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Critical Information
• Oxygenation
• Perfusion
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Evaluating PerfusionEvaluating Perfusion• Tools we have
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Lactate (Lactic Acid)Lactate (Lactic Acid)
Hypoperfusion severity index
NL < 2, concerned when > 4
> 15 often fatal
More helpful as trend
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POC Lactate TestingPOC Lactate Testing
• Developed for athletes & climbers
• Not FDA approved
• Currently underinvestigation in EMSand Fire service
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SvOSvO22
• Reflects O2 reserve & extraction
• < 60% requires investigation:– Hct, CO, SaO2
– VO2
• The lower the level, the worse…
• < 40% typically fatal
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ScvOScvO22
• O2 reserve & extraction upper body
• Typically 5 – 13% > SvO2 (avg 7.5)
• NL > 70%
• Sampled from CVC (oximetric CVL available)
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Gastric Mucosal COGastric Mucosal CO22
• Recent data suggest PgCO2 may reflect perfusion
• CO2 clearance reflects perfusion
• A-g CO2 gap < 10 is normal
• Pa CO2 - PgCO2 gap > 10 is bad
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Sublingual COSublingual CO22 – PslCO – PslCO22 Very proximal gut
NL = 44 – 64 mmHg
levels correlate with perfusion
Studies halted August 2004
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Nellcor Capnoprobe™ Nellcor Capnoprobe™ US approval Jan 2003.
Research study: Children's Medical Center – Dallas TX.
11 kids infected Burkholderia cepacia, 2 died.
Traced to saline solution packaging of probes.
5,600 units @ 30 centers recalled
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CapnographyCapnography
• CO2 clearance reflects perfusion!
• Available for intubated and non-intubated patients
• Developmentscoming: IPI
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Decision to Call the Decision to Call the CodeCode• 120 prehospital patients in
nontraumatic cardiac arrest
• EtCO2 had 90% sensitivity in predicting ROSC
• Maximal level of <10mmHg during the first 20 minutes after intubation was never associated with ROSC
Source: Canitneau J. P. 1996. End-tidal carbon dioxide during cardiopulmonary resuscitation in humans presenting mostly with asystole, Critical Care Medicine 24: 791-796
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End-tidal COEnd-tidal CO22 (EtCO (EtCO22))
Normal a-A gradient– 2-5mmHg difference between the EtCO2
and PaCO2 in a patient with healthy lungs
– Wider differences found » In abnormal perfusion and ventilation » Incomplete alveolar emptying» Poor sampling
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Future DevelopmentsFuture Developments
• Perfusion assessment derived from exhaled CO coupled with bioimpedance data.
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Integrated Pulmonary Integrated Pulmonary IndexIndex™™
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IPI Values – fuzzy logicIPI Values – fuzzy logic
IPI Patient Status10 Normal
8-9 Within normal range
7 Close to normal range; requires attention
5-6 Requires attention
3-4 Requires attention or intervention
1-2 Requires intervention
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Acoustic Resp Acoustic Resp MonitoringMonitoring• Likely release 2010
• Electrical sensor based• Initially will report RR
• Future versions VT
• Telemetry based• May replace capnography?
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Esophageal doppler Esophageal doppler (TED)(TED) Transducer probe inserted into distal esophagus
Blood flow measured by doppler principle
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TTE (Trans Thoracic TTE (Trans Thoracic Echo)Echo)• Also nurse or medic driven
• Chest wall instead of esophageal
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TED/TTE:TED/TTE:
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Bioimpedance (TEB)Bioimpedance (TEB)
• Thoracic electrical bioimpedance
• 4 electrodes sent current through thorax, analyze flow resistance
• With age, gender, height, weight calculate SV, ejection time, CO, thoracic fluid content, acceleration index, velocity index, etc.
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TEB (CardioDynamics TEB (CardioDynamics BioZBioZ®®))
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RELIANT RELIANT Non Invasive Hemodynamic MonitorNon Invasive Hemodynamic Monitor
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SVR MAP-CVP / CO
CO Cardiac Output
CI Cardiac Index
SV Stoke Volume
SVV Stroke Volume Variance
SVI Stroke Volume Index
HR Heart Rate
TPR Total Peripheral Resistance
VET Ventricular Ejection Time
MAP Mean Arterial Pressure
NIBP Non Invasive Blood Pressure
TFC Thoracic Fluid Content
TFCd % Directional Change in TFC/Time
CP Cardiac Power
CPI Cardiac Power Index
CAPTURES (14 ) PARAMETERSCAPTURES (14 ) PARAMETERS“In Real Time”“In Real Time”
TPR : Dynes – (MAP / CO)*80 TPR : mmHg * min./liters – (MAP / CO)
TFCd : % Change in TFC over 15 mins. Vs. baseline TFC CP: MAP*CO/451
CPI: CP/BSA
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Current of a known amplitude & frequency is applied on outer electrodes
Voltage signal captured on inner electrodes
100% Noninvasive100% NoninvasiveMonitors Any Patient, AnywhereMonitors Any Patient, Anywhere
Change in phase of the frequency is recorded and the signal translated to flow (similar to Doppler in concept)
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0 I
II
II
I
Volts
Io
Vo
Io
Vo
0 I
II
II
I
Amp.
Bioimpedance
Bioreactance
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PASSIVE LEG RAISE TEST (PLRT)PASSIVE LEG RAISE TEST (PLRT)
12%12%
FLUIDFLUIDRESPONSIVERESPONSIVE
12%12%
NOT FLUIDNOT FLUIDRESPONSIVERESPONSIVE
3 MINS. BASE LINE CO/CI
11
VENOUS BLOOD SHIFT
BEFORE PLRBEFORE PLR DURING PLRDURING PLR3 MINS. CO/CI POST SHIFT
22
CO & CI IMPACTCO & CI IMPACT
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• Volume expansion 1st line of therapy.
• Only ½ of patients respond to fluids with increased CO.
• Need a reliable means to determine ability to respond to fluid.
Problem: Enough Volume? Problem: Enough Volume?
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Chest 2002;121;1245-1252
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PLR?? PLR?? Passive
Leg Raising45 °
Semi-Fowler’s Passive
Leg Raising45 °
Semi-Fowler’s
• 150 – 300 ml volume• Effects < 30 sec.. Not more than 4 minutes• Self-volume challenge• Reversible
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Ocular ScannerOcular Scanner
EyeMarker Systems™
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Retinal imagingRetinal imaging• Pattern
recognition:– Botulism,
neurotoxins– Nerve Agents– Carbon Monoxide– Cyanide
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Hydration StatusHydration Status
• Saliva osmolality
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Perfusion IndexPerfusion Index• Perfusion Index is an objective method for
measuring a patient’s peripheral perfusion• Perfusion Index is an early indicator of
deterioration
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Perfusion IndexPerfusion Index
Infrared
Saturation
Red
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• 108 healthy, 37 critically ill adults (finger sensors)
• PI range: 0.3% to 10%, median 1.4%
• ROC used to determine the “cutoff” value
• 1.4% PI best discriminated normal from abnormal
What is a “Normal” PI ?What is a “Normal” PI ?
Lima, et al. CCM 2002
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Clinical Uses for PI Normals have been suggested to be:
>1.4% adults, >1.27% neonates1.Site selection (varies between patients and sites)2.Chorioamnionitis (placental membrane/amniotic
fluid infection)3.Effectiveness of Servoflorane anesthesia4.Monitor onset/effectiveness of epidural anesthesia5.Predict illness severity scores (good correlation)6.Monitor/quantify peripheral perfusion7.Detect shock states
8.PI trend may best reflect changes in condition
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PhotoplethysmographyPhotoplethysmography
Abs
orpt
ion
TimeTime
R IR
Photodetector
Pleth Waveform
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Pleth WaveformPleth Waveform
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A-line versus Pulse Ox Pleth
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Definition of PVIDefinition of PVI• Pleth Variability Index (PVI) is a
measure of dynamic changes in PI that occur during the respiratory cycle
• PVI is a percentage from 1 to 100%: 1 = no variability and 100 = maximum variability
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Fluid Status/Volume Responsiveness
• High variability (high PVI) = volume depletion
• 15 – 50% of patients are fluid non-responders – low variability (low PI) suggests the patient is a non-responder– The ventricle more sensitive to respiratory
changes is more responsive to preload
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Pulse CO-Oximetry
Oxygenated Hb and reduced Hb absorb different amounts of Red (RD) and Infrared (IR) Light
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Pulse CO-Oximetry
Oxygenated Hb and reduced Hb absorb different amounts of Red (RD) and Infrared (IR) Light
1. Carboxyhemoglobin
2. Methemoglobin
3. Hemoglobin
4. ? Glucose
5. ? Cyanide
6. ?
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SummarySummary
• Perfusion is the goal
• Perfusion = oxygenation + flow
• You cannot do it alone
• Less invasive is better
• Technology should make you a better clinician (only as good as u)
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Thanks for your Thanks for your attention!attention!