PiCCO based algorithms - PULSION Medical Systems SE

11.06.2010 / 1
European Society of Anaesthesiologists Annual Meeting
12.-15. June 2010, Helsinki, Finland
PiCCO
based
algorithms
Berthold Bein, MD, PhD, DEAA
Department of Anaesthesiology and Intensive
Care Medicine
University Hospital Schleswig-Holstein
Campus Kiel

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Conflict
of interest
� Medical advisory board Pulsion Medical Systems

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Prospective Trial of Supranormal Values of Survivors as
Therapeutic Goals in High-Risk Surgical Patients*
William C. Shoemaker, M.D.; Paul L. Appel, M.PA; Harrq B. Kram, M.D.; Kenneth
Waxman, M.D; and Tai-Shion Lee, M.D., F.C.G.P
� High risk patients (n=340)
� Study 1: n=252 patients (n=151 controls,
n=101 GDT), dependend on on call rota
�GDT: DO2 >600 ml·min-1 ·m-2 , CI >4.5
L·min-1 ·m-2 �Controls: DO2 400-550 ml·min-1 ·m-2 , CI
2.8-3.5 L·min-1 ·m-2 � Study 2: n=88 patients, randomised
� Primary endpoint: in-hospital mortality
Mortality Patients (%)
40
30
20
10
0
Control1
*
Protocol 1
Control 2
Protocol 2
*

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Improved
CO/SvO2, no effect
on mortality
n = 762
Controls (252)
→ CI 2,5 –
CI-Group
SAPS > 11
3,5 l/min/m 2
(253)
→ CI > 4,5 l/min/m 2
SvO2-Group (257)
→ >70%
Gattinoni et al. N Engl J Med 333, 1995: 1025

„In view of the accumulation of evidence showing that increasing DO2 in high-risk surgical patients may reduce morbidity and save lives, it
may be considered unethical not to use goal-directed perioperative
therapy once patient identification and the methods to be used in
treating them are refined.”
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n = 1994
Age > 60 years
ASA-Klasse III or IV
Major abdominal surgery
Discharged to ICU
DO2 550-600 ml·min-1 ·m-2 CI 3.5-4.5 L·min-1 ·m-2 PAOP≥18 mmHg
PAC: Mortality 7,7%
Controls: Mortality 7,8%
Sandham et al. NEJM 348, 2003: 5-14

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� Patients with severe sepsis and septic shock (n=263)
� Group 1: Early goal directed therapy for at least 6 h (n=130)
� Group 2: Standard of care (n=133)
� ScvO 2 key therapeutic target
� Endpoint: in-hospital mortality, after 28 and 60 days
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Rivers et al.: NEJM 345, 2001 :1368-1377

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Goal directed
therapy
in septic
sepsis

In-hospital
Mortality (%)
75
50
25
0
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Goal directed
therapy
Standard Goal directed
*
in septic
60 Tage
Mortality (%)
75
50
25
0
patients
*
Standard Goal directed
Rivers et al.: NEJM 345, 2001:1368

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Statement
Timing is the most important issue for effective goal
directed therapy. The anaesthesiologist in the emergency
room/OR is in this respect more important than the
intensivist

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Components
of GDT-Algorithms
� Preload variables: CVP, PCWP, GEDV
� Fluid responsiveness: SPV, PPV, SVV, GEDV
� Perfusion: CO, CI, SV
� O 2 delivery: DO 2
� Mixed-venous (SvO 2) or central venous (ScvO 2) oxygen saturation
� Lactate
� pHi

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A simple algorithm…
Hours/days
40
30
20
10
0
*
Protocol A
Protocol B
*
Fit for discharge Hospital stay

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Blood
pressure
and CO
Blood pressure (mm Hg)
MAP = HZV X TPR
Cardiac index (l/min/m2 )
Linton et al.: J Cardiothorac Vasc
Anesth 2002 (16):4

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Hypovolemia
Hypervolemia

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Statement
Cardiac filling pressures (CVP, PCWP) and MAP are not
suitable components of a goal directed algorithm

� n=174 patients, elective CABG
� Group 1: SV > 35 ml·m -2 (n=89)
� Group 2: Controls (n=85)
� Nurse driven algorithm
� Endpoint: ICU-, hospital length of stay
11.06.2010 / 17 Sinclair, S. et al. BMJ 1997;315:909-912

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SV-based
algorithm
Sinclair, S. et al. BMJ 1997;315:909-912

Volume (ml)
2500
2000
1500
1000
500
0
More
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colloids, increased
Cristalloids Colloids
CO
∆SV (ml)
5
0
-5
-10
-15
SV CO
Controls
Protocol
1
0
-1
-2
-3
∆ CO (L)
Sinclair, S. et al. BMJ 1997;315:909-912

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Shorter
hospital
length
of stay
Sinclair, S. et al. BMJ 1997;315:909-912

11.06.2010 / 21 Abbas et al. Anaesthesia 2008;63:44

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Major impact
before
Bias: 1,2 l/min
2SD: 3,2 l/min
of training
training after
training
Bias: 0,1 l/min
2SD: 2,2 l/min
Lefrant et al: Intensive Care Med (1998)
24: 347

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Statement
Measurement tools for a GDT algorithm will most probably
not become widely accepted when they are largely
observer dependent or only available discontinously.

� n=33 patients, high risk surgery
� Randomisation:
� Group 1: „Standard of care“
� Group 2: PPV based volume administration (PPV

Volume (ml)
3000
2000
1000
0
Significant differences
…and to outcome
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Colloids Cristalloids
Protocol
Controls
with
respect
to volume
infused…
Lopes et al., Crit Care 2007; 11:R 100

If
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Statement
you treat the patients in the control group significantly
below standard of care, you will find impressive
differences applying any protocol and enrolling any
number of patients

� n=40 patients prospectively GDT
� n=40 historic controls (matched pairs)
� Elective CABG
� GEDVI ≥ 640 ml, CI ≥ 2.5L·min-1 ·m-2 ,
MAP ≥
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70 mmHg
� Vasopressors, volume administration
� Time on ventilator, ICU length of stay
Goepfert et al., Intensive Care Med 2007;
33:96-103

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Complex
algorithm
Goepfert et al., Intensive Care Med 2007;
33:96-103

Less
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vasopressors, earlier
Norepinephrine-dose
fit for
Hours/days
80
60
40
20
0
discharge
ICU-Fit
*
*
Ventilator
Controls
Protocol
ICU-Stay
Goepfert et al., Intensive Care Med 2007;
33:96-103

� n=40 patients, elective CABG
� Group 1: Conventional Monitoring (CM)
� CVP, MAP, HR
� Group 2: Advanced Monitoring (AM)
� PiCCO preload variables (ITBVI),
cardiac index (CI), central venous
oxygen saturation (ScvO2, CeVOX),
MAP and HR.
� Hospital LOS, ICU-LOS
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Control
group
vs. Advanced
monitoring group

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Results: more
fluids
and dobutamine, less
Hours/days
25
20
15
10
5
0
*
ephedrine
*
LOS ICU LOS Hospital
Control
EGDT

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Statement
Complex algorithms are not necessarily more effective
compared with simple ones. It is, however, significantly
less probable that they get implemented into daily clinical
routine

„We recommend a fluid challenge to predict fluid responsiveness…with
a goal of obtaining a rise in CVP of at least 2 mmHg.”
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Statement
Even experts
are
prone
to error….

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A recommended
EGDT algorithm
Better GEDV!

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GEDVI and PPV: the
Prelaod/GEDV = ΔSV
Prelaod/GEDV = ΔSV
Responder
%
100
80
60
40
20
0
Low
*
GEDV intermediate
GEDV
High GEDV
Kiel concept
Michard et al., CHEST 2003; 124:
1900 –1908

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EGDT algorithm
Modified according to
Smetkin et al.
13%
GEDVI
GEDVI 680-800ml·m -2
PPV
Consider furosemide
Colloids (HAES 130) OK
PPV800 ml·m -2

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Fluid responsiveness indicated by GEDV
� n=92 patients before CABG after induction of anesthesia and during
passive leg raising (PLR).
� CVP, GEDVI, SVITPTD and PPV were measured using the PiCCO
monitoring system. ∆VTILVOT was obtained by TOE. Responders were
defined to increase their SVITPTD >15% during PLR.
� Correlation ∆SVI/variables studied
� ROC analysis
Broch et al.: submitted for publication

ΔSVI TPTD (%)
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Results: GEDVI, ∆VTI
80
r=-0.54
60
p

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ROC analysis
Sensitivity (%)
1.0
0.8
0.6
0.4
ΔVTI
AUC: 0.74
p=

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Summary
� Several diiferent EGDT agorithms have been reported
� The majority of them is based on supranormal DO 2-values and goals
with respect to SvO 2 or ScvO 2
� From a physiological standpoint, SvO 2 or ScvO 2 as well as variables
indicating fluid responsiveness (PPV/SVV) or prelaod (GEDV) are
reasonable components
� Filling pressures should not be essential parts of a EGDT algorithm.
� Implementation into daily clinical routine is more probable with a
simple algorithm
� As of to date, EGDT algorithms have only gained limited impact on
our daily clinical practice

The
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expert
physician
Outcome
P

11.06.2010 07.05.2009 / 45
Many
thanks
for
your
attention!