Experience with LiDCO, PiCCO or FloTrac/Vigileo

[PMPMD]

I've looked up the evidence for these CO monitors, it was somewhat underwhelming (percent errors in 40s % vs PAC thermodilution). I would like to know what other institutions are using for hemodynamic monitoring in septic shock, postop patients, or other forms of hemodynamic instability. I'm at a PAC heavy institution, so I would like to get more perspective. I know echo is the future, but what do you use as a trend monitor?

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[Hernandez]

What specifically are you monitoring? CO, CI, SVV? Looking for predictors k fluid responsiveness.

 

[jdh71]

Does knowing the information even improve outcomes? That's a better question.

 

[PMPMD]

Does knowing the information even improve outcomes? That's a better question.

Good point, I doubt there's good outcome data for the new devices.

 

[PMPMD]

What specifically are you monitoring? CO, CI, SVV? Looking for predictors k fluid responsiveness.

I would like to have some predictor of fluid responsiveness. Do you use SVV for this?

 

[Hernandez]

I would like to have some predictor of fluid responsiveness. Do you use SVV for this?

As long as they're intubated, not in a-fib,, not on hfov/aprv/psv, and have an artline, I use SVV off the vigeleo. I Also combine it with leg raising.

Otherwise, I'm trying to get comfortable with a cavel index,

As far as CO, im biased in that i dont think there are many pts that I can't get a decent idea what's going on, if there is any question, echo or PAC if the answers might change my management.

 

[Hernandez]

Does knowing the information even improve outcomes? That's a better question.

I think this is a very good question, but not a reason to dismiss these tests out of hand. Boyd et al has a study that shows elevated CvP and a positive fluid balance in sepsis lead to higher mortality, so if a test like SVV can give me info to minimize ivf instead of just loading everyone with 40mL/kg, then I say if Boyd is right, we can minimize mortality.

 

[proman]

As long as they're intubated, not in a-fib,, not on hfov/aprv/psv, and have an artline, I use SVV off the vigeleo. I Also combine it with leg raising.

Otherwise, I'm trying to get comfortable with a cavel index,

As far as CO, im biased in that i dont think there are many pts that I can't get a decent idea what's going on, if there is any question, echo or PAC if the answers might change my management.

I did a liver transplant recently where the CCO PA-C wasn't working and they hooked up the Vigeleo (had never seen it before). I compared the measured stroke volume by TEE to the Vigeleo and they correlated very well. There was some lag in the Vigeleo, and a lot of lag in the TEE (depended on me manually obtaining the measurement). Since stroke volume is simply the AUC of a arterial pulse, it should be fairly accurate.

That being said, I'd much rather have a real CCO PA-C than any of these other gimmicks, and I'd really really rather have a TEE.

 

[jdh71]

I think this is a very good question, but not a reason to dismiss these tests out of hand. Boyd et al has a study that shows elevated CvP and a positive fluid balance in sepsis lead to higher mortality, so if a test like SVV can give me info to minimize ivf instead of just loading everyone with 40mL/kg, then I say if Boyd is right, we can minimize mortality.

Don't get me wrong, I'd love to play around with one, but so often is the case we think all our fancy stuff is causing improved patient outcomes when far too often it doesn't really matter.

 

[Hernandez]

I did a liver transplant recently where the CCO PA-C wasn't working and they hooked up the Vigeleo (had never seen it before). I compared the measured stroke volume by TEE to the Vigeleo and they correlated very well. There was some lag in the Vigeleo, and a lot of lag in the TEE (depended on me manually obtaining the measurement). Since stroke volume is simply the AUC of a arterial pulse, it should be fairly accurate.

That being said, I'd much rather have a real CCO PA-C than any of these other gimmicks, and I'd really really rather have a TEE.

I'm your world is where these devices have been better studied, ive also used the Nico2 end tidal system to calculate CO, but haven't been able to compare it to PAC

 

[Hernandez]

Don't get me wrong, I'd love to play around with one, but so often is the case we think all our fancy stuff is causing improved patient outcomes when far too often it doesn't really matter.

well then perhaps you should go into geriatrics since you're going to be a ICU nihilist

 

[jdh71]

I'm your world is where these devices have been better studied, ive also used the Nico2 end tidal system to calculate CO, but haven't been able to compare it to PAC

I agree that the OR is a different beast and it simply makes intuitive sense to me that these kinds of monitors could/would make a difference to the guy at the head of the bead.

 

[jdh71]

well then perhaps you should go into geriatrics since you're going to be a ICU nihilist

You say, "nihilist" and I say, "realist" the septic 86 y/o guy with CAD, COPD, Afib, DM2, stage III CKD . . . if he survives, I usually put that on luck, god, or the universe. It would make for a pretty easy observation study in an MICU, someone should do it, if it's not already done.

 

[Hernandez]

You say, "nihilist" and I say, "realist" the septic 86 y/o guy with CAD, COPD, Afib, DM2, stage III CKD . . . if he survives, I usually put that on luck, god, or the universe. It would make for a pretty easy observation study in an MICU, someone should do it, if it's not already done.

Easy? That study wouldn't be printed outside of an obscure east Cuban journal. Unless you control for the variables and have a matched pt poPulation to be remotely useful. And at least at my place there would be enormous selection bias wince the people I bust these toys out are when I'm going full tits out.

 

[jdh71]

Easy? That study wouldn't be printed outside of an obscure east Cuban journal. Unless you control for the variables and have a matched pt poPulation to be remotely useful. And at least at my place there would be enormous selection bias wince the people I bust these toys out are when I'm going full tits out.

With some of the garbage I've seen published in the last year? There was that one study in resp and crit care a few months ago that essentially said patients with delirium are sicker . . . ummm . . . duh (?)

But that's besides the point here. It may be problematic to run some sort of randomized trial, but to either look retrospectively back or observationally forward, you could still crunch some numbers and see if it appeared these devices did anything for us in patients in the ICU as it relates to mortality and length of stay.

 

[SLUser11]

I've looked up the evidence for these CO monitors, it was somewhat underwhelming (percent errors in 40s % vs PAC thermodilution). I would like to know what other institutions are using for hemodynamic monitoring in septic shock, postop patients, or other forms of hemodynamic instability. I'm at a PAC heavy institution, so I would like to get more perspective. I know echo is the future, but what do you use as a trend monitor?

I use the Flotrac/Vigileo and I like it overall. I will often use SVV to guide resuscitation, but I'm still kind of old school, and tend to just look up at the variations in arterial waveform to determine fluid status.

For a while, we were using the central lines that measure SvO2, with a sepsis protocol/flowsheet, but I've fallen out of love with them since the catheter itself isn't that great, and if it's an IJ, you can't really curve it in the neck without messing up the readings.

It's interesting how medicine has changed. Although the evidence about Swans not being good has been around for a while, I was still routinely floating swans through my PGY-2 year. In the last 3 years, however, I've only floated maybe 5 or 10 swans.

 

[Hernandez]

For a while, we were using the central lines that measure SvO2, with a sepsis protocol/flowsheet, but I've fallen out of love with them since the catheter itself isn't that great, and if it's an IJ, you can't really curve it in the neck without messing up the readings.

I agree, I don't use the flowtrac catheter as it's more difficult to maintain sterile technique, the equipment in the box isn't the treatise and doesn't have full sheet (and my hospital doesn't have full size sterile drapes either), the wire is just too short to do the in vivo calibration, and IJ can be a little finicky.

 

[proman]

Any idea on the cost of these devices? The ones I know:

PA catheter:
CCO, $350, VIP, $50 (mixed venous gas is ~$150 charge)
+ Introducer, ~$50
TEE:
Machine, ~$200,000, Probe, ~$40,000, annual upkeep ~$5-10,000
reimbursement for an exam: ~$120

How about the others?

 

[LukeWhite]

I've used the FloTrac from time to time, mainly in septic patients with cardiomyopathy or those needing multiple pressors but bouncing in and out of difficult-to-manage arrhythmias. It's been helpful for titrating optimal pressor combos.

I haven't found SVV especially useful, mainly because the level of sedation required to maintain perfect vent compliance is usually problematic. If they meet the above criteria and are so neurologically gone as to be compliant they seem poor candidates for FloTrac, and if they have some neurological function I think the deep sedation needed to accurately measure SVV over time has been pretty convincingly shown to be counterproductive. Bedside TTE/IVC echo and fluid challenges seem to get the answer nearly as well.

 

[Stellar Clouds]

As long as they're intubated, not in a-fib,, not on hfov/aprv/psv, and have an artline, I use SVV off the vigeleo. I Also combine it with leg raising.

Otherwise, I'm trying to get comfortable with a cavel index,

As far as CO, im biased in that i dont think there are many pts that I can't get a decent idea what's going on, if there is any question, echo or PAC if the answers might change my management.

necro bump.

Is svv not accurate on a vigileo if they are not intubated? what about on a lidco?

 

[Hernandez]

necro bump.

Is svv not accurate on a vigileo if they are not intubated? what about on a lidco?

PPV/SVV has not been studied outside of intubated pts. (Last time I checked). In theory it can work, but if you read the original studies, you'll see the way they get such a high positive predictive value is to optimize the pleural pressure swings by using VACV and not allow spontaneous breathing,

When I use it in an extubate pt, I run the maneuver by asking the pt to take a big breath and hold it for as long s they can, and then calculate the SVV and if I can print the ART Line and mark where they inhale/exhale, i calc a PPV as week

 

[nephrondoc]

I am trying to understand why should anyone use Flotrac/Vigileo at all ? From what i understand, it calculates stroke volume based on arterial pressure wave contour analysis. All other variables including CO/CI/SVR are derived from stroke volume, HR, CVP and MAP. The basic assumption is that pulse pressure is a poor man's stroke volume. Is pulse pressure or PPV already not enough to guess about hypovolemic/vasodilatory/cardiogenic shock, if we are going to believe in the CO/CI based on these assumptions. We can argue that it also provides SVV and global EF. I can get global EF in a much more reliable way from a bedside ECHO.

Also, most of the patients come to the unit having gotten already 3-4 liters of iv fluids. How does fluid responsiveness matter at that time ? How can we say fluid responsiveness means fluid tolerant and that we shouldn't be starting vasopressors early, in which case the flotrac is not reliable anyways. Even if SVV is more than 13%, How can we say that we shouldn't be using vasopressors/inotropes to improve cardiac output, if the absolute CO/CI numbers matter at all. Its frustrating to see people using these monitors to give more fluids based on SVV, even when they are in 30-40 liters positive fluids balance. The most frequent argument that i hear is that those patients are intravascularly depleted, which makes me laugh, mad and depressed about the standard of care that these patients are getting. Of course, not everybody is the same though.

Whats your experience with other monitors ? Any other thoughts would be highly appreciated.

 

[Hernandez]

They wouldn’t sell machines if they said were giving you ppv which you can calculate by hand with nothing but an aline

Personally bias. I like ppv in bleeders or pre-Cms bull****, to decide if I want to give that bills to get to 20 or 30mL/kg ivf in septic pts.

 

[smartparts]

the single biggest problem with all these non-invasive devices is confirmation bias. people only believe the numbers when they agree with them.

 

[Dr.CCM]

The problem with echo/Ivc is you have to actually do the exam. When you have 20-30 sick patients, no one has time for that.

I like to look at the a line (see if it’s “swinging”) or the New Phillips Monitors will actually give you the PPV every minute. Can give a small bolus/PLR and see if it changes.

How are you guys using a PLR or mini fluid bolus to see if the patient needs fluids typically?

The lit shows both PPV and PLR to be our best predictors in spontaneously breathing patients.

 

[psychbender]

The problem with echo/Ivc is you have to actually do the exam. When you have 20-30 sick patients, no one has time for that.

I like to look at the a line (see if it’s “swinging”) or the New Phillips Monitors will actually give you the PPV every minute. Can give a small bolus/PLR and see if it changes.

How are you guys using a PLR or mini fluid bolus to see if the patient needs fluids typically?

The lit shows both PPV and PLR to be our best predictors in spontaneously breathing patients.

Still just a fellow, but I often use echo in my assessment of volume responsiveness, and appear to be one of the few in my hospital to do passive leg raise regularly. Some of the nurses think I'm nuts running around the unit lifting legs before ordering another fluid bolus.

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[Dr.CCM]

Still just a fellow, but I often use echo in my assessment of volume responsiveness, and appear to be one of the few in my hospital to do passive leg raise regularly. Some of the nurses think I'm nuts running around the unit lifting legs before ordering another fluid bolus.

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Yeah. I’m thinking about when I’m 20 patients deep in a mixed med surg community icu. Just not gonna do that anymore.

 

[Hamhock]

Still just a fellow, but I often use echo in my assessment of volume responsiveness, and appear to be one of the few in my hospital to do passive leg raise regularly. Some of the nurses think I'm nuts running around the unit lifting legs before ordering another fluid bolus.

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How are you measuring cardiac output with all these PLRs?

Or are you looking for an increased MAP after PLR? If using MAP, what study are you basing this on?

All PLR I know about is to see if IVF will increase CO. (same thing for PPV studies)

HH

 

[psychbender]

How are you measuring cardiac output with all these PLRs?

Or are you looking for an increased MAP after PLR? If using MAP, what study are you basing this on?

All PLR I know about is to see if IVF will increase CO. (same thing for PPV studies)

HH

I'm generally not directly measuring CO during PLRs. If I have a med student or intern to lift the legs while I doppler down the LVOT, then I will, but this is less common. Usually, I am just looking at the pulse pressure before, during, and after the leg is raised. Yes, I realize that this leads to less accuracy than when directly compared to measured CO, but accuracy is still fair, and it's very quick and simple to perform. Sometimes, if I actually have a neuromuscularly relaxed patients, I'll also see if the ETCO2 changes along with the MAP during SLR. As for reference, there was a meta-analysis in Crit Care Medicine back in 2016 regarding PLR and PPV. I think I got the ETCO2 change from an anesthesiology journal, and will have to look for a link later.

 

[Hamhock]

I think there's some confusion regarding PPV.

This number predicts increased cardiac output with IVF bolus. Fluids (i.e. PLR) is not used to see if PPV goes down.

The PLR is also has been studied to see if IVF will increase cardiac output.

Perhaps there are new studies out, but I am unaware of evidence regarding measuring changes in PPV with intervention. PPV is itself a dynamic hemodynamic measure.

HH