Impedance Cardiography (ICG) Application of ICG in Intensive Care and Emergency
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1 Impedance Cardiography (ICG) Application of ICG in Intensive Care and Emergency
2 Aim of haemodynamic monitoring in ICU and ED Detection and therapy of insufficient organ perfusion Answers to common cardiovascular questions: Hydration or Dehydration therapy? Which catecholamine should be used? Indication of further medication (vasopressin, vasodillators)? Parameters required for sufficient haemodynamic monitoring: Haemodynamics - SV Stroke Volume - CO Cardiac Output - CI Cardiac Index Afterload - SVRI Systemic Vascular Resistance Index - MAP Mean Arterial Pressure Contractility - ACI Acceleration Index
3 Fluid Management Preload Responsiveness Question: Will SV increase after application of additional fluid? Current situation: Available parameters like CVP (central venous pressure) and PWP (pulmonary wedge pressure) are a poor predictor of preload responsiveness Parameters have to be measured invasively and are not available in every situation Solution with Niccomo: Measurement of SVV (stroke volume variation) in ventilated patients as a highly sensitive indicator of preload responsiveness Standardized passive leg raising (PLR) test for patients who are spontaneously breathing
4 Fluid Management Stroke Volume Variation (SVV) Respiration affects: Heart Rate Blood Pressure Stroke Volume (SV) SVV describes the variation of SV during expiration to inspiration and is a predictor of preload responsiveness Restrictions: Only possible in ventilated patients with tidal volumes of 8cc/kg Arrhythmias adversely reduce accuracy of SVV Example: ICG amplitude modulation (red wave) by respiration (blue wave): Inspiration Expiration ICG ECG Respiration SVV over 15 % Fluid responsive
5 Fluid Management Passive Leg Raising Test (PLR) Preload change caused by PLR Record of SV change during PLR Standardized test procedure with software support Clear reproducible results due to beat-by-beat measurement SV change over 15 % Fluid responsive
6 Cardiogenic Shock cardiac cause Causes: Heart attack Heart insufficiency Diagnosis: Decreased CI Increased SVRI due to vasoconstriction Decreased blood pressure Decreased contractility Therapy: Nitroglycerin Catecholamine Ramirez, et al. Journal of the American College of Cardiology, 2004;43
7 Cardiogenic Shock non-cardiac cause Causes: Pulmonary embolism Pneumothorax Diagnosis: Decreased CI Increased SVRI due to vasoconstriction Decreased blood pressure Normal contractility Therapy: Anticoagulation Chest tube
8 Septic Shock Causes: Systemic infection Diagnosis: Increased CI Decreased SVRI Decreased blood pressure Normal contractility Therapy: Antibiotics Summers R, et al. EJEM. 1999;6:1-7.
9 Hypovolemic Shock Causes: Internal bleeding Traumatic bleeding Diagnosis: Decreased CI Increased SVRI Decreased blood pressure Normal contractility Therapy: Infusions Blood transfusions
10 Pulmonary Oedema Question Congestive Heart Failure or Volume Overload? ICG diagnosis: Increased TFC Decreased ACI ICG diagnosis: Increased TFC Normal ACI SVV < 10% during passive leg rising test Congestive Heart Failure Volume Overload Therapy: Catecholamine Positive inotropic agents Therapy: Diuretics
11 Dyspnea Case study Patient: History: Current therapy: 81 year old female Hypertension, left ventricular hypertrophy, mitral regurgitation, atrial fibrillation, normal ejection fraction, chronic obstructive pulmonary disease. Digoxin mg qd, ACE inhibitor (Enalapril 5 mg bid). Visit Symptoms / Exam CI SI SVRI TFC #1 Rales, rhonchi, shortness of breath HR 76, BP 160/ ICG Interpretation: Normal CI, SVRI, and TFC do not indicate decompensated HF or pulmonary edema. Likely cause of symptoms is pulmonary disease. Decision: Initiate antibiotics, bronchodilator. From John Strobeck, M.D., The Heart Lung Center, Hawthorne, NJ
12 Conclusion Benefit of Impedance Cardiography in ICU and ED: Quick, easy haemodynamic assessment in addition to standard parameters Fast evaluation of preload responsiveness Early detection of changes in the haemodynamic status Optimization of medications Ideal for long term patient monitoring No additional physiological stress for the patient
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