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any one using vigileo in OR . If yes what specific scenarios do you feel that it is useful in guiding management.
 

DreamLover

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any one using vigileo in OR . If yes what specific scenarios do you feel that it is useful in guiding management.
I used a Flotrac during residency but have been using a Lidco regularly out in practice. Both are good noninvasive measures.

I use a Lidco regularly on all of my large fluid shift cases where I use goal directed therapy and even more specifically, when using enhanced recovery after surgery protocols where an A-line is an appropriate choice for the patient (doing a lot of colorectal and surgonc now-hoping to expand). Bringing my surgeons around to the ERAS protocols has actually been going pretty well.

The Lidco has been good for following fluid trends and being able to significantly decrease total IVF as well as helping me give fluid at the right time. Outcomes have shown definite benefit in GDT, so I think it does have a solid use there.
 

ryanjmy

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I think they require the pt to be paralysed and mechanically ventilated. That limits their usefulness vs a swan especially as a post op monitor. Also the cost makes them hard to justify for every case that requires an aline.
 
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DreamLover

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I think they require the pt to be paralysed and mechanically ventilated. That limits their usefulness vs a swan especially as a post op monitor. Also the cost makes them hard to justify for every case that requires an aline.
Yes it is true that Interpretation of the Stroke Volume Variation (SVV) requires paralysis and positive pressure ventilation, but the CO/CI and SVR are accurate awake or asleep.
 

Hawaiian Bruin

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For patients on pressors, the Flotrac is a random number generator. Completely worthless.

For changes in CO from volume administration in patients not on pressors, it's maybe OK, but IMO doesn't tell you much you don't already know.

I used to use the Flotrac, but have pretty much stopped completely.
 
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DreamLover

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For patients on pressors, the Flotrac is a random number generator. Completely worthless.

For changes in CO from volume administration in patients not on pressors, it's maybe OK, but IMO doesn't tell you much you don't already know.

I used to use the Flotrac, but have pretty much stopped completely.
I too feel that if you use any non invasive CO monitoring system, that the volume status is best predicted by the trend in changes of the SVV Vs the CO/CI and to use the SVV the patient must be intubated on positive pressure ventilation, so that is definitely limiting in the non-or setting.
 

BLADEMDA

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For patients on pressors, the Flotrac is a random number generator. Completely worthless.

For changes in CO from volume administration in patients not on pressors, it's maybe OK, but IMO doesn't tell you much you don't already know.

I used to use the Flotrac, but have pretty much stopped completely.
Agree about the use of FLotrac for Volume status/SVV and CO for those NOT on pressors. I don't use the Flotrac in A.Fib either. I found the Flotrac quite helpful at times to the CRNA in the room doing the case. The flotrac allows me to quickly assess the volume status of patients while I cover FOUR rooms.
In addition, I like to track the ABG, serial ABGs, as another source of volume status (look at the base deficit and acidosis which can develop).
 

fakin' the funk

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It requires PPV, but doesn't require paralysis. It DOES require the patient to be not participating in ventilation. Not the same thing as neuromuscular blockade.
 

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SPV/PPV just installed on our monitors and I love it. no flow-trac needed, just put in the aline, and put the PPV on the screen. Most of these cases the patient is paralyzed (or at least not breathing) and on the vent anyways. Not too often do you really care that much about fluid status in a patient who is spontaneously breathing during a case. Who cares about outside of the operating room? not my problem, I use PPV to document hydration pre-op intra-op and and drop off. More evident that I am doing my job appropriately. I love to document PPVS of 30+ pre-op and document less than 13 post op. Your welcome primary service ;) Also stops the blame game of "anesthesia is under-resuscitating" really? not according to the PPVs documented, looks like they came in dry, were tanked up, and again became dry at the 100ml/hr for 3 days after in the sicu. i dont do cardiac but i can understand how it would be less useful than a swann or tee peri-operatively.
 
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nephrondoc

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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.
 
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dchz

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So when we do TAVRs and other cath lab procedures, the cardiologists asks us for a cardiac output. the number does not factor anything into their management, they just have to document it durin ghe TAVR.

The above is a perfect scenario for the flotrac or vigileo 's CO function. If we spend $200 on the transducer and buy the machine, the numbers must mean something!!

Also, as i understand it, the calculation involves some calculus involving dp/dt, which factors into the contractility. But no one can confirm or deny this as it's all proprietary
 
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Mman

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I am trying to understand why should anyone use Flotrac/Vigileo at all ?
We use it because there is reasonable data that using it or something similar to help guide fluid administration in certain cases can improve patient outcome compared to not using it. Pulse Pressure Variation is what I care about from the Lidco since it's actually a measured variable. The Stroke Volume Variation is calculated from those measurements which I think can introduce more error.

Pt needs to be in sinus rhythm and mechanically ventilated for it to work.
 

Robotic Wis-Hipple

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The scenarios where this thing may have some validity are far outnumbered by those where it is clearly inaccurate. They keep updating their algorithm, they’re up to v4.x at this point last I checked, but it’s still based on an “X factor” constant estimating vascular compliance based on biometric data. So imo garbage in garbage out.

There’s OK data for GDT/ERAS protocols but it’s unclear if the vigileo is the cause or simply a correlation as practitioners clearly pay more attention to volume status and multimodal techniques with these protocols.
 
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Mman

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There’s OK data for GDT/ERAS protocols but it’s unclear if the vigileo is the cause or simply a correlation as practitioners clearly pay more attention to volume status and multimodal techniques with these protocols.
Considering the control arms are people who know what is being monitored (fluid administration) you can kinda assume they are paying just as much attention.
 

shepardsun

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Pt needs to be in sinus rhythm and mechanically ventilated for it to work.
And most of the early studies suggesting usefulness were done with tidal volumes of 8 cc/kg and no PEEP, which is not really similar to the respiratory parameters most of the patients in the OR are on, particularly if they are sick...

Equally hand wavey and black box-y are the newer non-invasive monitors- anybody using Cheetahs or Nexfins?
 

Hawaiian Bruin

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The only one of these things I find at all useful is the Lidco, which allows me to calibrate it to a TEE-derived CO (3D planimetry of LVOT area x LVOT VTI x HR).

Without the calibration, it's just as useless as everything else. With the calibration, it actually spits out meaningful numbers.

Even then, I hardly ever use it.
 
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T-burglar

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It’s a piece of sh!t
and should not be used for important decisions or diagnoses
 
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Robotic Wis-Hipple

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The only one of these things I find at all useful is the Lidco, which allows me to calibrate it to a TEE-derived CO (3D planimetry of LVOT area x LVOT VTI x HR).

Without the calibration, it's just as useless as everything else. With the calibration, it actually spits out meaningful numbers.

Even then, I hardly ever use it.
Question for you;

What view are you using to acquire your 3D LVOT for planimetry? I’m assuming a full volume acquisition. But in that case how do you verify the location you’re measuring is where you placed your PW gate? Using a 3D zoom from TG views makes more sense to me from a location of PW standpoint but I’d expect the 3D acquisition to be poor.

Obviously, for CO calculation we don’t need perfectly accurate measurements, but if that’s the caveat, why not just use LVOT diameter at your PW gate and accept that you’re calculating a circular area for a non-circular outflow tract?

Not important for this posts/threads subject but I’m just curious.
 

GA8314

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any one using vigileo in OR . If yes what specific scenarios do you feel that it is useful in guiding management.
Used to use it for Whipple's. If surgeon was struggling with anastomoses, and feeling the need to blame our "fluids" (causing edema) on his difficulties, then I could always say I was using "goal directed fluid therapy" and indeed monitoring SVV and SV.

Similarly, for large paraesophageal hernias, with similar logic. Occasionally for long VATS/Thors.

There is also some ERAS data suggesting it's use in colectomies. And we use ClearSight (formerly NexFin)for this as we have a pretty good ERAS protocol for such caes. Sometimes will use that for patients in which an A-line really is not warranted for hemodynamics.
 

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I pulse wave the LVOT from a TG long axis and just eyeball or caliper the distance from the annulus where I pulsed. Pull back to ME AV long and acquire full volume, then trace LVOT CSA in qlab at a point approximately the same distance from the annulus where I acquired the VTI. The accuracy you gain from the 3D LVOT trace more than makes up for the small error in not measuring LVOT exactly at the point you pulsed.
 

Hawaiian Bruin

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I pulse wave the LVOT from a TG long axis and just eyeball or caliper the distance from the annulus where I pulsed. Pull back to ME AV long and acquire full volume, then trace LVOT CSA in qlab at a point approximately the same distance from the annulus where I acquired the VTI. The accuracy you gain from the 3D LVOT trace more than makes up for the small error in not measuring LVOT exactly at the point you pulsed.
Yeah, this exactly.
 
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T-burglar

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You guys are monitoring noncardiac cases with TEE in your private practices?
 

Hawaiian Bruin

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You guys are monitoring noncardiac cases with TEE in your private practices?
Especially cataracts.

Snow them for the retro/peri/whateverbulbar block, throw down the echo real fast, take a quick look, rack up the units, baby.

At that age they've all got some pathology too, so you can kick some referrals to your cardiology friends and then get paid again when they go for their TAVR or Mitraclip.
 
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