The-Nexfin-HD---Potential-Applications.ppt

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,The Nexfin HD-,Potential Applications,A,zriel Perel,Professor and Chairman,Department of Anesthesiology and Intensive CareSheba Medical Center,Tel Aviv University,Israel,ESCTAIC Amsterdam 2010,Disclosure,The speaker cooperates with the following companies,BMEYE,PULSION,What Is the Best Way To Measure Cardiac Output,?,Who Cares,Anyway,?,Caruso LJ et al.,Chest.,2002;122:771-774,Monitor wizards can be dangerous,Robin ED,McCauley RF.,Chest,1998;114:1511,I have a suspicion that even the medical device manufacturers realize that CO is not an important variable in the critical care arena.,PPV alone is the best way to predict volume responsiveness.Therefore,it is less clear why we want to know the CO in the first place.,This explains why all of the recently marketed devices purport a slew of other data(e.g.,stroke volume variance,EVLW,blood velocity),although many of these measurements are derived from CO determination to begin with.,The Nexfin HD device(BMEYE,Amsterdam)uses a non-invasive,continuous blood pressure(BP)measurement(based on the Finapres method)to measure cardiac output continuously.,The Nexfin HD device,Stover JF,et al.BMC Anesthesiology 2009:9:6,Comparison of Nexfin HD CO to PiCCO intermittent TTD CO,Why do we need real-time CCO?,Intermittent TD CO measurements have a well known intrinsic limited reproducibility.This limitation makes them inferior to continuously measured real-time CO in assessing the response to therapeutic or diagnostic events with,short time constants,.,Fluid loading(e.g.,periop.optimization),Passive leg raising,end-exp.occlusion.,Immediate response to inotropes,Nexfin HD Applications,Syncope diagnostics-tilt table testing,Will my patient respond to fluids?,Yes.Give 1735 ml over 30 minutes.,“Will my patient respond to fluids?”,Passive leg raising-induced changes in CO can reliably predict fluid responsiveness regardless of ventilation mode and cardiac rhythm.,Passive leg raising-induced changes in CO have a significantly higher predictive value than passive leg raising-induced changes in arterial pulse pressure.,The hemodynamic response to a 15-second end-expiratory occlusion can predict volume responsiveness in mechanically ventilated patients.,The accumulation of evidence showing that increasing DO,2,in high-risk surgical patients may reduce morbidity and save lives has led Boyd and Bennett to claim that,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.,A bolus of 200 ml colloid(e.g.,6%HES 130/0.4)is administered over 2 min,and 5 min later the SV is assessed.,The procedure is repeated if there was an increase in SV of 10%.When the fluid bolus does not result in a SV increment 10%,optimization is regarded as achieved and surgery commenced.,Intermittent TD CO measurements have a well known intrinsic limited reproducibility which makes them inferior to continuously measured real-time CO in the process of perioperative optimization.,Optimization when and how?,Transesophageal,Doppler ultrasound,Patient needs to be anesthetized,The Vigileo system,Patient needs to have an arterial line,The Nexfin HD,Totally non-invasive,Optimization when and how?,NEXFIN,It is essential that the present,individualized,GDT approach includes optimization of flow-related parameters,such as cardiac stroke volume,within the limit of the individual patients cardiac capacity,.,The concept is therefore different from the original Shoemaker concept for optimization,which used predetermined supra-physiologic values of cardiac index and DO,2,as therapeutic goals.,The perioperative fluid management strategy determines the monitoring modality!,Blood volume after fasting is normal,and a fluid-consuming third space has never been reliably shown.,The endothelial,glycocalyx,plays a key role and is destroyed not only by ischemia and surgery,but also by acute,hypervolemia,.,Undifferentiated fluid handling may increase the shift toward the interstitial space,the consequence being a positive fluid balance and weight gain of up to 10 kg,which may be related to severe complications.,Optimization Maximization,National Confidential Enquiry into Patient Outcome and Death.,1999 Report:Extremes of Age.,National Confidential Enquiry into Perioperative Death have highlighted over-hydration as a contributory cause in the genesis of postoperative problems leading to death.,Carefully considered case histories have led to specific recommendations regarding careful fluid management(the implication being restriction)in vulnerable patients and those most at risk,such as the elderly.,A variety of metabolic endpoints are surrogate flow measurements,such as lactate,SvO,2,ScvO,2,which may be useful during resuscitation,but CO(,CI,4.5 L/min/m,2,)and oxygen transport goals(,DO,2,I 600 ml/min/m,2,)are important so direct flow monitoring should be implemented.,Fluids should be given to increase CO,and inodilators such as dopexamine and dobutamine added once the patient is no longer fluid(preload)responsive or not achieving the goals.,A variety of metabolic endpoints are surrogate flow measurements,such as lactate,SvO,2,ScvO,2,which may be useful during resuscitation,but CO(,CI,4.5 L/min/m,2,)and oxygen transport goals(,DO,2,I 600 ml/min/m,2,)are important so direct flow monitoring should be implemented.,Fluids should be given to increase CO,and inodilators such as dopexamine and dobutamine added once the patient is no longer fluid(preload)responsive or not achieving the goals.,This systematic review demonstrated a very poor relationship between CVP and blood volume as well as the inability of CVP/,CVP to predict the hemodynamic response to a fluid challenge.,CVP should not be used to make clinical decisions regarding fluid management.,Overall,only 56 16%of 803 patients that were included in the 24 studies responded to a fluid challenge.,Perioperative fluid optimization necessitates real-time CCO,Intermittent TD CO measurements have a well known intrinsic limited reproducibility.This limitation makes them inferior to,continuously,measured,real-time,CO in assessing the response to therapeutic or diagnostic events with short time constants.,Fluid loading(e.g.,periop.optimization),Passive leg raising,end-exp.occlusion.,Immediate response to inotropes,Transesophageal,Doppler ultrasound,Patient needs to be anesthetized,The Vigileo system,Patient needs to have an arterial line,The Nexfin HD,Totally non-invasive,Limitations,Duration of measurement is restricted to 8 hours,Peripheral vasoconstriction(age,cold,vasopressors),Edematous fingers,Currently no PPV/SVV,GUI more suitable for a cardiology clinic,Limitations,Duration of measurement is restricted to 8 hours,Peripheral vasoconstriction(age,cold,vasopressors),Edematous fingers,Currently no PPV/SVV,GUI more suitable for a cardiology clinic,Additional benefits,Semi-disposable finger cuff,Touch screen,Instant data retrieval with DOK,Boulain T,et al.,Chest 2002;121:124552,Monnet X,et al.,Crit Care Med 2006;34:1402-7,Lafanechere A,et al.,Crit Care 2006;10:R132,Lamia B,et al.,Intensive Care Med 2007;33:112532,Maizel J,et al.,Intensive Care Med 2007;33:11338,Caille V,et al.,Intensive Care Med 2008;34:123945,Thiel SW,et al.,Crit Care 2009;13:R111,Biais M,et al.,Crit Care 2009,13:R195,Prediction of volume,responsiveness,by using passive leg raising,Changes in stroke volume,radial pulse pressure,and peak velocity of femoral artery flow induced by passive leg raising are accurate and interchangeable indices for predicting fluid responsiveness in non-intubated patients with severe sepsis or acute pancreatitis.,13 patients were studied within 2 h of arrival in the ICU following CABG or mitral valve reconstruction.,Cardiac output(CO)was evaluated using the FloTrac(COed),the modified Modelflow(COmf),and the ultra-sound HemoSonic system(COhs),and compared with thermodilution(COtd)as the reference(triplicate,automated system under computer control,equally spread measurements over the ventilatory cycle).,104 paired CO values were assessed before,during and after four interventions:(i)an increase of tidal volume by 50%;(ii)a 10 cm H,2,O increase in PEEP;(iii)passive leg raising;(iv)head up position.,COmf has best precision(0.69 l/min)and smallest range of the limits of agreement(-1.081.68 l/min),26%,compared with the COed and COhs (-1.472.13),34%,and(-2.621.80 l/min),44%,respectively.,FloTracVigileo(COed),Modified,Modelflow method,(COmf),HemoSonic 100,ultrasound system,(COhs),Our main finding is that only he modified Modelflow yields limits of agreement(26%)that are below the 30%criteria for a theoretically acceptable alternative to thermodilution cardiac output.,Monitoring changes or trends in cardiac output can be performed reasonably well with the Modelflow and the HemoSonic,while the FloTrac performs less well in this regard.,Encouraged by the simplicity of setup procedure and advantage for the patient,we suggest future work focuses on the Modelflow system.,