Original article
Haemodynamic monitoring with pulse-induced contour cardiac output (PiCCO) in critical care

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Abstract

Haemodynamic monitoring is essential for the management of the critically ill. Effective monitoring can give data that permit analysis of key circulatory functions and the anticipation of deterioration so that pro-active treatments can be initiated.

There are many methods of monitoring the haemodynamic status of patients. The authors have compared three of the most commonly used methods in the general Critical Care Unit. These are the pulmonary artery catheter (PAC), oesophageal Doppler, and pulse-induced contour cardiac output (PiCCO) studies.

The focus is upon PiCCO, which is a comparatively less invasive method than the traditionally used PAC. This has been chosen due to the authors’ particular interest in the additional parameters which can be monitored using PiCCO. With the PiCCO system it is possible to measure intrathoracic blood volume (ITBV), extravascular lung water (EVLW) and cardiac function index (CFI). These parameters are of interest as they are considered to be the most specific measures of cardiac preload, pulmonary oedema and contractility and a global indicator of cardiac performance.

Introduction

Management of critically ill patients is based on knowledge of fundamental physiological variables. Monitoring techniques of the haemodynamic status of these patients have developed from the non-invasive monitoring of single parameter to more invasive monitoring of multiple parameters. This leads to a far more comprehensive analysis allowing clinicians to anticipate events and provide more effective treatment.

Jacobsen (1995) states that in the critically ill and haemodynamically unstable patients the nearest measurable parameters to tissue oxygenation are cardiac output, arterial blood pressure, central venous pressure, arterial and central venous oxygenation and haemoglobin. Therefore, the measurement of these parameters is seen as essential in the management of these patients. Burchell et al. (1997) considered that the measurement of cardiac output is now accepted as a routine part of bedside monitoring. In the authors’ unit, three main methods of monitoring the patient’s haemodynamic status have evolved. The pulmonary artery catheter (PAC) was the initial method, this was superseded by non-invasive oesophageal Doppler and most recently the unstable patients have been monitored using the pulse-induced continuous cardiac output (PiCCO). These three techniques are compared in Table 1.

Section snippets

Pulse-induced continuous cardiac output

PiCCO is a device that quantifies several parameters, including continuous (pulse contour) cardiac output, cardiac preload, systemic vascular resistance and extravascular lung water (EVLW). The patient requires a central venous line ideally sited in the internal jugular or subclavian vein, and an arterial catheter with a thermister is placed in one of the larger systemic arteries, e.g. the femoral or brachial artery. As Salukhe and Wyncoll (2002) explain the PiCCO system works on the principle

Intrathoracic blood volume

The PiCCO offers the possibility to assess ITBV derived from global end diastolic volume (GEDV) determined by thermodilution measurement. GEDV correlates well with ITBV in both experimental and clinical studies. Bindels et al. (2000) found that ITBV is more reliable and therefore a superior indicator of cardiac preload in the clinical situation than pulmonary artery wedge pressure (WP). Buhre et al. (2000) support this by concluding that the measurement of ITBV by indicator dilution enables

Extravascular lung water

EVLW correlates to extravascular thermal volume in the lungs and is evaluated by the PiCCO through the mean transit time method.EVLW=IntrathoracicthermalvolumeIntrathoracicbloodvolumeThe quantification of EVLW correlating to pulmonary oedema is not possible with routine clinical studies and examinations. The early accumulation of interstitial oedema and small changes in water content of the lungs are not reliably detected or quantified with chest X-ray or arterial blood gases. The chest X-ray

Cardiac function index

Evaluation of the contractile state of the heart is a crucial task in critical care. This can be measured via a left ventricular catheter, and by using the reference standard dP/dt max. dP/dt is a direct measurement of contractility. It calculates how fast the pressure is rising during systole. If pressure close to the aortic valve is measured, the rise in blood pressure during ventricular systole is proportional to the force of contraction.

It is not possible within the general Critical Care

Calibration of the PiCCO

As already stated, the PiCCO requires calibration by thermodilution determination. If the patient is stable, it is recommended this is repeated every 8 hours. However, this is very patient dependant and the manufacturers suggest that it may be necessary to recalibrate every hour in the initial stages of resuscitation. Recalibration is also recommended if the continuous cardiac output has changed consistently in the same direction for 15 minutes or if there are large or sudden changes in the

Advantages and disadvantages of the PiCCO

The PiCCO is now the monitoring system which is being used more frequently in the authors’ unit, but its advantages and disadvantages need to be examined. The main advantages over the PAC is that it is considered to be far less invasive, requiring only a central line and arterial line which the majority of critical care patients have as a matter of course. This in turn leads to far less risk of complications. Sakka et al. (2000) state that in comparison to the PAC the PiCCO system is considered

The role of the nurse

As the scope of nursing evolves the profession must be self-determining, influencing the boundaries of practice, and the development of new skills, roles and knowledge. Wright et al. (1996) state that nurses play a pivotal role in individualising patient care and Taylor (1996) explains that doctors and nurses working together in a non-hierarchical manner can contribute to decision making regarding patient treatment. The relationship is characterised by trust and mutual respect.

As already

Conclusion

Accurate monitoring of the haemodynamic status of the critically ill patient is essential to effective management. The PiCCO offers a method of obtaining detailed information with relatively few additional risks to the patients. The PiCCO allows the clinician to measure three parameters, which are relatively new, ITBV, EVLW and CFI. These allow for a far more holistic view of the haemodynamic status of the patient and allows for the applied treatment to be evaluated continuously. This should

Ros Cottis Senior Sister Critical Care, BSc (Hons) Specialist Nursing Practice ENB 100, Critical Care Unit, Southend Hospital, Prittlewell Chase, Southend on Sea, Essex SS0 ORY, UK. Tel: +44 1702 221351; E-mail: [email protected]

(Requests for offprints to RC)

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Ros Cottis Senior Sister Critical Care, BSc (Hons) Specialist Nursing Practice ENB 100, Critical Care Unit, Southend Hospital, Prittlewell Chase, Southend on Sea, Essex SS0 ORY, UK. Tel: +44 1702 221351; E-mail: [email protected]

(Requests for offprints to RC)

Neil Magee Staff Nurse Critical Care, Southend Hospital, ENB 100 Southend Hospital, Prittlewell Chase, Southend on Sea, Essex SS0 ORY, UK. Tel: +44 1702 221351; E-mail: [email protected]

David J. Higgins FRCA, Director of Critical Care, Southend Hospital, Prittlewell Chase, Southend on Sea, Essex SS0 ORY, UK. Tel: +44 1702 221351; E-mail: [email protected]

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