Non invasive co monitoring

[bkell101]

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We had a grand rounds today that touched on this topic.


Just started reading about these devices on my own so i don't know much. (Besides the basics on how they work)

Does anybody use the nicom monitor? What has been your experience? Any solid data on this device?

any good papers I should read regarding use of ppv, flotrac, esophageal Doppler, ect?

 

[IlDestriero]

I like TEE.
1. Is heart empty?
Y= fluid bolus
N= good, see question 2.
2. Is heart contracting well?
Y= good, see question 1.
N= inotropes

It's often that easy. We really should use TEE more in our complex patients having major surgery. If we had good a good TTE system, we'd use it every day.

 

[Oggg]

Our Cath lab bought a Sonosite with a linear probe and a p21 probe (the cardiac one). They never used it, so I have it on indefinite loan. I plug it into the main OR Sonosite and we have instant Self service TTE.

 

[bkell101]

I like TEE.
1. Is heart empty?
Y= fluid bolus
N= good, see question 2.
2. Is heart contracting well?
Y= good, see question 1.
N= inotropes

It's often that easy. We really should use TEE more in our complex patients having major surgery. If we had good a good TTE system, we'd use it every day.

I totally agree. I think tee Is under utilized. With my very small and limited experience, I think the obstacles are ....1. Not all people know how to use it. 2.it's large and cumbersome to bring into the room 3. The department only has a few of them and the cardiac rooms need them.....Over the last two months ive been sticking in quite a few og tubes and temp probes down there....why not stick the tee probe down there and have some really useful information? What are your thoughts?

Instead of putting all the effort into designing flotrac and nicom, why can't they make a tee probe that attaches to an ipad and is super portable. Maybe they already have this? I've heard of a pocket echo tte.

 

[urge]

We had a grand rounds today that touched on this topic.


Just started reading about these devices on my own so i don't know much. (Besides the basics on how they work)

Does anybody use the nicom monitor? What has been your experience? Any solid data on this device?

any good papers I should read regarding use of ppv, flotrac, esophageal Doppler, ect?

I don't find any of this gimmicks useful.

Next question.

 

[KLPM]

I like TEE.
1. Is heart empty?
Y= fluid bolus
N= good, see question 2.
2. Is heart contracting well?
Y= good, see question 1.
N= inotropes

It's often that easy. We really should use TEE more in our complex patients having major surgery. If we had good a good TTE system, we'd use it every day.

The God Algorithm.

 

[periopdoc]

I like it. Pretty close to my algorithm...

Look at heart. Give fluid bolus.

Does heart contract better?

Yes - continue with fluid admin
No - start inotropes.

-pod

 

[Ventil8]

I use both Masimo and Edwards' arterial waveform analysis devices to do goal directed therapy protocols.

If used appropriately they are quite useful. TEE is obviously better, but there are obvious limitations to its availability. In our 30ish ORs I'd say we use these monitors on 5ish patients per day.


Of interest, I'm half way through a prospective study in head and neck flaps (12-18h cases historically requiring no pressors). We use a GDT algorithm with Edwards' EV1000 and assess volume status, CO, and then SVR and treat each component discretely.

38pts so far, and treatment pts getting out of ICU 2/3 day earlier and direct cost of care decreased by 3k per patient. This matter if you're doing 200 a year like we do...

Don't avoid progress just because you're unfamiliar!

 

[bkell101]

That's really interesting.

One thing you mentioned was volume status.....

I'm only familiar with ppv and limited exposure to flotrac....my understanding is that the ppv and flotrac can give you an idea of volume Responsiveness....

Lets say my ppv is 16 ...is it possible that my pt's volume status is adequate, but his cardiac output would improve with more volume?

 

[bkell101]

Two other questions about ppv....

I understand that they have to have a tv of 8-10 cc/kg to induce enough pressure inside the chest to squeeze the right side and reduce preload.

What if you have an obese lady getting laparoscopic surgery and her airway pressures are 28-30 (or even higher) with only 6-7cc/kg tv.....will the ppv reading of 16 indicate fluid responsiveness even though I haven't given 10cc/kg tv.?

What about ppv on an Aline when doing a thoracotomy .....I would assume even if you gave a big breath to the dependent lung with the chest open, the ppv wouldn't be reliable because its not a closed system anymore?