PiCCO2 Nurse Booklet - PULSION Medical Systems SE

Get the complete picture ... 

TM 

PiCCO2 

Advanced Hemodynamic Monitoring 

Information for Nurses

TM 

PiCCO2 - A complete hemodynamic picture 

• Continuous cardiac output 

• Volumetric preload 

• Afterload 

• Contractility 

• Volume responsiveness 

• Pulmonary edema / Lung water 

TM 

PiCCO2 2

Table of contents 

Overview.................................................................................................................. 

Fields of Application ................................................................................................ 

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PiCCO Disposables and Set up 2 

.......................................................................... 

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Principles of PiCCO Technology 2 

.......................................................................... 

Parameter Overview ................................................................................................ 

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PiCCO2 Monitor ..................................................................................................... 

Normal Ranges........................................................................................................ 

Decision Tree Model ................................................................................................ 

Summary of Benefits ............................................................................................... 

Recommended Literature ........................................................................................ 

Contact Information ................................................................................................. 32 

4 - 6 

7 

8 - 11 

12 - 14 

15 - 25 

26 

27 

28 

29 

30 

3

Cardiac Output - Optimizing Oxygen delivery 

O 2 uptake O 2 transport O 2 extraction O 2 utilization 

Which therapy? 

Volume? 

PiCCO-Technology 

Vasopressors? 

Inotropes? 

4

Is measuring just the CO enough? 

Stroke volume 

SV 

Preload 

GEDV, SVV, PPV 

Pulmonary edema 

EVLW 

Volume? 

Cardiac output 

CO 

Heart rate 

HR 

Afterload 

SVR, MAP 

Vasopressors? 

Contractility 

CFI 

Inotropes? 

5

TM 

PiCCO2 – See more than others 

Optimize CO 

• Continuous cardiac output 

• Volumetric preload 

• Afterload 

• Contractility 

• Volume responsiveness 

Protect the lungs 

• Monitor Pulmonary Edema 

(lung water) at the bedside. 

• Respond quickly 

• More reliable than Chest X Ray 

6

Fields of Application 

Intensive Care 

• Septic Shock 

• Cardiogenic Shock 

• Burns 

• Trauma / Hypovolemic Shock 

• ARDS / Acute Lung Injury 

• Pediatrics 

OR/Post surgery 

• Cardiac Surgery 

• Major Surgery 

• Neuro Surgery 

• Pediatrics 

7

Use your existing CVC and the PiCCO arterial line 

Central venous line 

(Standard CVC) 

Internal jugular, subclavian, femoral 

Arterial line 

(PiCCO Catheter available in different sizes) 

Brachial, axillary or femoral artery 

8

PiCCO arterial catheters - The choice is yours 

Axillary artery 

Adults: 4F 8 cm / 3.15 in 

Small adults: 3F 7 cm / 2.76 in 

Brachial artery 



Femoral artery 



Small adults: 4F 16 cm / 6.29 in 

Children: 3F 7 cm / 2.76 in and 4F 8 cm / 3.15 in 

9

TM 

PiCCO2 Setup 

Thermodilution 

D 

F 

C 

B 

CVP line 

A G 

E 

Flush bag 

A 

B 

C 

D 

E 

F 

G 

Pressure output adapter 

PiCCO Catheter 

Distal lumen of CVC 

Injectate sensor housing 

Injectate sensor cable 

Arterial connection cable 

PiCCO thermistor plug 

Pressure connection 

cable 

10

PiCCO - Two principles for reliable information 

Transpulmonary thermodilution Pulse contour analysis 

Intermittent parameters from 

thermodilution technique 

• Thermodilution cardiac output (CO) / 

cardiac index (CI) 

• Volumetric preload (GEDV/GEDI) 

• Contractility (CFI) 

• Lung water (EVLW/ELWI) 

Calibration 

Continuous parameters from analysis of 

the arterial waveform (pulse contour) 

• Pulse contour cardiac output (PCCO) / 

cardiac index (PCCI) 

• Afterload (SVR/SVRI) 

• Volume responsiveness (SVV, PPV) 

• Stroke volume (SV/SVI) 

11

PiCCO - Transpulmonary Thermodilution (TD) 

Bolus 

injection 

Bolus 

detection 

• The bolus injection of cold saline is detected by the temperature sensor attached to the CVC 

• The saline bolus passes through the heart and lungs and is detected downstream by the 

thermistor on the tip of the PiCCO arterial line 

• The change in temperature between the two thermistors provides a TD curve 

• Mathematical analysis of the TD curve gives the cardiac output CO 

• Further analysis of the TD curve allows determination of preload volumes and lung water 

12

PiCCO - Pulse Contour Analysis 

• Stroke volume is the area under the systolic part of the pressure curve (red area) 

of one heart beat 

• Cardiac output is calculated and updated beat-by-beat: stroke volume x heart rate 

• In severely “shocked” patients organ perfusion pressure and pulse contour CO is 

more reliably represented by central arterial pressure (femoral / brachial / axillary) 

than by radial arterial pressure 

13

CI 

Thermodilution (TD) Cardiac Output / Index 

Cardiac Output - Volume of blood pumped by the heart in one minute 

- Important determinant for oxygen delivery to the body 

TD Results 

CI 

GEDI 

ELWI 

T 

10:18 am 10:20 am 10:22 am 10:26 am 

SEP 23 SEP 23 SEP 23 SEP 23 

3.47 3.11 3.15 3.76 3.44 

705 626 678 764 698 

9 9 10 10 9 

1.18 1.17 0.30 1.20 

Inj. Volume 

98.1 

10:26 am 15 ml 

SEP 23 

CVP 

5 mmHg 

START 

98.6 

READY 0s 10s 20s 

30s Exit 

Time since TD 0 h 52 min 10:26 am 

Flow 

PCCI 

SVRI 1735 

-5 2 

5.0 

3.0 

4.52 

l/min/m2 SVI 47 

ml/m 

Volume 

2 

l/min/m2 dyn*s*cm m 

CO – Cardiac Output 

CI – Cardiac Index 

The Thermodilution CO is used to “calibrate“ the continuous CO obtained from the arterial waveform 

(pulse contour) analysis. 

14

Pulse Contour Cardiac Output / Index 

Cardiac Output - Following thermodilution a “calibrated” continuous CO can be obtained 


PCCI 

Flow 

PCCI 

SVRI 1735 

PCCO – Pulse Contour Cardiac Output 

PCCI – Pulse Contour Cardiac Index 

Volume 

• Product of stroke volume and heart rate 

• Determination beat-by-beat MAP 

• Reliability and patient safety possible due to calibration technique 

-5 2 

dyn*s*cm m 

5.0 

3.0 

4.52 

l/min/m2 SVI 47 

ml/m 2 

l/min/m 2 

ml/m 2 

15

Preload Volume instead of filling SVRI pressures 1735 

PCCI 

MAP 

Volume 

SVV 9 

-5 2 

dyn*s*cm m 

Preload - Volume of blood in the heart, available to be pumped 

l/min/m 2 

SVI 47 

ml/m 2 

l/min/m2 Volumetric preload parameters are superior to filling pressures (CVP / PCWP) Michard, YICM 2004 

ml/m 2 

GEDV – Global End-Diastolic Volume / GEDI – Global Organ End-Diastolic Function Volume Index 

• Combined diastolic volume of all four heart chambers 

• Adequate preload is an important prerequisite for adequate cardiac output (Frank-Starling curve) 

• GEDI is indexed to “predicted body surface area” * 

* Indexing particular SVRI parameters i.g. to the predicted body weight (EVLW) or predicted body surface area (GEDV) rather 

than the actual body weight or body surface area is more accurate particularly in overweight patients. 

ml/kg 

% 

16

Lung Water – Pulmonary MAP edema assessment at the bedside 

SVRI 

Volume 

EVLW – Extravascular Lung Water reflects pulmonary edema 

SVV 9 

Organ Function 

ml/m 2 

ml/kg 

AP/CVP 

EVLW – Extravascular Lung Water / ELWI – Extravascular Lung Water 1/min Index 

• Extravascular lung water (EVLW) represents the extravascular water content of the lung tissue 

• Includes intra-cellular, interstitial and intra-alveolar water (not pleural effusion) 

• ELWI is indexed to “Predicted Body Weight” 

*Predicted body weight is determined from the body height, gender and age 

% 

17

Fluid management using lung water (ELWI) 

Improved patient outcomes 

Organ function - Lung water 

Days 

Control group 

PCWP 

Ventilation days 

reduced by 

59% 

Protocol group 

EVLW 

Comparison of fluid therapy targeting lung water (protocol 

group) or wedge pressure (standard group) 

Control group 

PCWP 

ICU days 

reduced by 

53% 

Protocol group 

EVLW 

Source: Improved outcome based on fluid management in critically ill patients requiring pulmonary artery catheterization 

Mitchell JP, Schuller D, Calandrino FS, Schuster DP, Am Rev Respir Dis 1992; 145(5): 990-8 

18

Afterload - the systemic vascular Flow resistance 

PCCI 

MAP 

Volume 


PCCI 4.52 

l/min/m2 Systemic vascular resistance - Represents the vascular “tone” of the blood vessels. 

SVR - Systemic Vascular Resistance 

SVRI - Systemic Vascular Resistance Index 

• Helps to determine levels of vasodilation or vasoconstriction 

• Useful for guiding vasopressor management. 

SVRI 1735 

-5 2 

dyn*s*cm m 

5.0 

3.0 

SVI 47 

ml/m 2 

l/min/m 2 

ml/m 2 

19

Heart Contractility 

SVRI 

AP/CVP 

SVV 9 

Contractility – describes the performance of the cardiac muscle 


CFI - Cardiac Function Index 

• Parameter of the global cardiac contractility 

• The cardiac function index is the ratio of flow and preload 

• CFI = CO (Cardiac Output) / GEDV (Global End-Diastolic Volume) 

% 

1/min 

ml/m 2 

ml/kg 

20

Balance fluid and inotrope therapy correctly 

SV (ml) 

80 

40 

600 800 

Inotropic drugs 

preload 

GEDI (ml/m 2 ) 

The Frank-Starling curve reflects the interaction between preload and stroke volume 

1. Increase preload volume to its optimum 

2. Increased contractility shifts the curve upwards (see graphic) 

2 

1 increase preload 

Frank-Starling 

curve 

21

Volume Responsiveness 

Volume 

Volume 

Volume 

Volume Responsiveness - predicts MAPwhether 

cardiac output will improve with volume resuscitation 

SVRI SVRI 

SVRI 

MAP MAP 

SVV SVV 9 

SVV 9 9 % 

% 

% 




l/min/m2 l/min/m2 l/min/m2 ml/m 2 

ml/m 2 

ml/m 2 

SVV – Stroke Volume Variation 

ml/kg 

• Variation in stroke volume over the breathing cycle during positive pressure ventilation ml/kg 

ml/kg 

PPV – Pulse Pressure Variation 

• Variation in pulse pressure over the breathing cycle during positive pressure ventilation 

AP/CVP 

1/min 

Limitations: Only applicable in fully 

AP/CVP 

AP/CVP mechanically ventilated 1/min patients 

1/min 

in sinus rhythm 

22

Determination of Volume Responsiveness 

SVmax 

inspiration 

Mechanical Ventilation 

SVmin 

expiration 

PPmax 

inspiration 

PPmin 

expiration 

Intrathoracic pressure fluctuations 

Changes in intrathoracic blood volume 

Preload changes 

Fluctuations in stroke volume 

and pulse pressure 

23

Different views - Early warning, details, response to treatment 

Overview 

SVI 

SVV 

PCCI 

SVRI 

MAP 

’SpiderVision TM ’ screen 

Dynamic status indicator 

Height 70 inch Weight 182 lbs Time since TD 0 h 52 min 10:26 am 

HR 86 

Basic 

140 

AP 132/71 

AP 

MAP 91 

(CVP 9) Details 

70 

7.00 

6.00 

5.00 

4.00 

3.00 

2.00 

1.00 

CI l/min/m2 2.86 

Flow Volume Organ Function 

900 

850 

800 

750 

700 

650 

600 

550 

815 

ml/m 2 

Values at time of TD, 0 h 52 min ago 

11 

TD AP/CVP 

9 

7 

5 

3 

1 

0 

14 

ELWI ml/kg 

’Profiles’ screen 

Detailed insight at parameter 

level 

Flow 

PCCI 4.52 

Volume 

Organ Function 90 

Trends 

120 

AP 

60 

9.0 

PCCI/CI 

5.0 

1.0 

2800 

SVRI 

2100 

1400 

x 

xxx 

-6h -5h -4h 

-3h -2h 

-1h 10:26 am 

’Trends’ screen 

Clinical trends and therapy results 

24

Innovative operation - via touch-screen or navigation dial 

Real-time 

pressure curve 

Innovative 

data 

visualization 

Information bar 

Direct access buttons 

Parameter 

fields 

25

PiCCO Catheter codes and descriptions 

Application Artery Article No. Diameter Usable length 

Adults Femoral PV2015L20N 5F / (~14G) / 1,7 mm 20 cm / 7.78 in 

Adults Brachial Cubital PV2014L22N 4F / (~16G) / 1,3 mm 22 cm / 8.66 in 

Adults Femoral PV2014L22N 4F / (~16G) / 1,3 mm 22 cm / 8.66 in 

Adults Brachial Proximal PV2014L16N 4F / (~16G) / 1,3 mm 16 cm / 6.29 in 

Small adults Femoral PV2014L16N 4F / (~16G) / 1,3 mm 16 cm / 6.29 in 

Adults Axillary PV2014L08N 4F / (~16G) / 1,3 mm 8 cm / 3.15 in 

Children Femoral PV2014L08N 4F / (~16G) / 1,3 mm 8 cm / 3.15 in 

Children Femoral PV2013L07N 3F / (~18G) / 1,0 mm 7 cm / 2.76 in 

Small adults Axillary PV2013L07N 3F / (~18G) / 1,0 mm 7 cm / 2.76 in 

26

Hemodynamic Measurement Guide - Normal Values 

Cardiac Index 

CI 

3.0 – 5.0 

I/min/m 

Stroke Volume Index 

SVI 

40 – 60 

Global End-Diastolic Volume Index GEDI 

680 – 800 

Stroke Volume Variation 

SVV 

< 10 

Pulse Pressure Variation 

PPV 

< 10 

Systemic Vascular Resistance Index SVRI 

1970 - 2390 

Cardiac Function Index 

CFI 

4.5 – 6.5 

Mean Arterial Pressure 

MAP 

70 – 90 

Extravascular Lung Water Index ELWI 

< 10 

2 

ml/m2 ml/m2 % 

% 

dyn*s*cm-5 *m2 Parameter Abbreviation Range Unit 

1/min 

mmHg 

ml/kg 

WARNING: PULSION Medical Systems is a medical device manufacturer and does not practice medicine. 

PULSION does not recommend these normal values for a specific patient. The treating physician is responsible 

for determining and utilizing the appropriate diagnostic and therapeutic measures for each individual patient. 

27

Hemodynamic Measurement Guide 

This decision model is not obligatory. It cannot replace the individual therapeutic decisions of the treating physician. 

CI (l/min/m 

Measured Values 

2) 

GEDI (ml/m2) ELWI (ml/kg) 

Therapy Options 

Targeted Values 

1. GEDI (ml/m2) 2. Optimise SVV (%)* 

CFI (1/min) 

ELWI (ml/kg) 

(slow response) 

< 10 

V+? 

> 700 

< 10 

> 4.5 

< 3.0 

< 700 > 700 

> 10 

V+? 

Cat? 

700-800 

< 10 

> 5.5 

< – 10 

< 10 

Cat? 

> 700 

< 10 

> 4.5 

> 10 

Cat? 

V-? 

700-800 

< 10 

> 5.5 

< – 10 

< 10 

V+? 

> 700 

< 10 

> 3.0 

< 700 > 700 

> 10 

V+? 

700-800 

< 10 

< 10 

OK! 

> 10 

V-? 

700-800 

V+ = volume loading V- = volume reduction Cat = catecholamine / cardiovascular agents *SVV is only applicable in fully ventilated patients without cardiac arrhythmia 

< 10 

< – 10 

< 10 

< – 10 

28

The benefits of PiCCO-Technology 

• Reliable information from a calibrated system 

• A Cardiac Ouput/Index that is more reliable for organ perfusion 

• Protect the lungs with lung water assessment at the bedside 

• Patient volume status using volumes not filling pressures 

• Accurate information means increased patient safety 

• Gain a better understanding of your patients’ condition 

TM • Simple step by step set up of the PiCCO2 system 

29

Recommended Literature 

Outcome Papers 

• Performance of Bedside Transpulmonary Thermodilution Monitoring for Goal-Directed HemodynamicManagement After Subarachnoid 

Hemorrhage; Mutoh T, Kazumata K, Ishikawa T, Terasaka S Stroke 2009; 40(7): 2368 – 74 

• Single transpulmonary thermodilution and continuous monitoring of central venous oxygen saturation during off-pump coronary 

surgery; Smetkin AA, Kirov M, Kuzkov VV, Lenkin AI, Eremeev AV, Slastilin VY, Borodin VV, Bjertnaes LJ. Acta Anaesthesiol 

Scand 2009; 53: 505-14 

• Arterial thermodilution in burn patients suggests a more rapid fluid administration during early resuscitation; Csontos C, Foldi V, 

Fischer T, Bogar L. Acta Anaesthesiol Scand 2008; 52(6): 742-9 

• Goal directed fluid management reduces vasopressor and catecholamine use in cardiac surgery patients; Goepfert M, Reuter D, 

Akyol D, Lamm P, Kilger E, Goetz A. Intensive Care Medicine 2007; 33: 96-103 

• Improved outcome based on fluid management in critically ill patients requiring pulmonary artery catheterization; Mitchell JP, 

Schuller D, Calandrino FS, Schuster DP. Am Rev Respir Dis 1992; 145(5): 990-8 

30


Guidelines and Standard Operating Procedures 

• Goal directed fluid management reduces vasopressor and catecholamine use in cardiac surgery patients; Goepfert M, Reuter D, 

Akyol D, Lamm P, Kilger E, Goetz A. Intensive Care Medicine 2007; 33: 96-103 

• Influence of extravascular lung water determination in fluid and vasoactive therapy; Pino-Sanchez F, Lara-Rosales R, Guerrero- 

Lopez F, Chamorro-Marin V, Navarrete-Navarro P, Carazo-de la Fuente E, Fernandez-Mondejar E. J Trauma 2009; 67(6): 1220-4 

• 2007 American College of Critical Care Medicine clinical practice parameters for hemodynamic support of pediatric and neonatal 

septic shock; Brierley J, Choong K, Cornell T, Decaen A,Deymann A, Doctor A, Davis A, Duff J, Dugas MA et al. Crit Care Med 2009; 

37(2): 666 – 688 

• Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008; Dellinger RP, Levy 

MM, Carlet JM, Bion J, Parker MM, Jaeschke R, Reinhart K, Angus DC, Brun-Buisson C, Beale R, Calandra T, Dhainaut JF, Gerlach 

H, Harvey M, Marini JJ, Marshall J, Ranieri M, Ramsay G, Sevransky J, Thompson BT, Townsend S, Vender JS, Zimmerman JL, 

Vincent JL. Intensive Care Med 2008; 34(1): 17-60 

• Implementation of an evidence-based „standard operating procedure“ and outcome in septic shock; kortgen A, Niederprün P, Bauer 

M. Crit Care Med 2006; 34(4): 939-9 

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Cardiac Output – Flow 

• Where do we go from here? Cardiac output determination in pediatrics; Hanna BD. Childrens Hospital of Philadelphia Crit Care Med 

2008; 36: 1377-8 

• Cardiac index measurements during rapid preload changes: a comparison of pulmonary artery thermodilution with arterial pulse 

contour, analysis; Felbinger TW, Reuter DA, Eltzschig HK, Bayerlein J, Goetz AE. J Clin Anesth 2005; 17(4):241-8 

Preload (Global Enddiastolic Volume) 

• Volumetric preload measurement by thermodilution: a comparison with transoesophageal echocardiography; Hofer CK, Furrer L, 

Matter-Ensner S, Maloigne M, Klaghofer R, Genoni M, Zollinger A. Br J Anaesth 2005; 94(6):748-55 

• Global end-diastolic volume as an indicator of cardiac preload in patients with septic shock; Michard F, Alaya S, Zarka V, Bahloul M, 

Richard C, Teboul JL.; Chest 2003 124(5):1900-8 

Lung Water 

• Extravascular lung water in sepsis-associated acute respiratory distress syndrome: indexing with predicted body weight improves 

correlation with severity of illness and survival. Phillips C, Chesnutt M, Smith M. Crit Care Med 2008; 36: 69-73 

• Extravascular lung water measurements and hemodynamic monitoring in the critically ill: bedside alternatives to the pulmonary artery 

catheter. Isakow W, Schuster DP. ; Am J Physiol Lung Cell Mol Physiol 2006 291: 1118 – 33 

• Extravascular lung water in patients with severe sepsis: a prospective cohort study; Martin GS, Eaton S, Mealer M, Moss M. Crit 

Care 2005; 9: R74-82 

• Improved outcome based on fluid management in critically ill patients requiring pulmonary artery catheterization; Mitchell JP, Schuller 

D, Calandrino FS, Schuster DP. Am Rev Respir Dis 1992; 145: 990-8 

32

Contact 

For further information on: 

• Literature for specific fields of application 

• Case studies 

• Product information 

• Educational material 

visit www.PULSION.com or contact us toll free 877.655.8844 

See instructions for use and package insert for full prescribing information. Technical specifications are subject to change without further notice. 

© 2010 PULSION Medical Systems AG all rights reserved. 

PULSION Medical Inc. • 2445 Gateway • Drive Suite 110 • Irving, Texas 75063 

Toll free 877.655.8844 • Phone 214.446.8500 • Fax 214.446.6702 

info@pulsion.com • www.PULSION.com 

MPI851805US_R00 © PULSION ® 05/2010 

33

PiCCO2 Nurse Booklet - PULSION Medical Systems SE

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