Common pitfalls and tips and tricks to get the most out of your transpulmonary thermodilution device: results of a survey and state-of-the-art review

Abstract

Background: Haemodynamic monitoring with transpulmonary thermodilution (TPTD) is less invasive than a pulmonary artery catheter, and is increasingly used in the Intensive Care Unit and the Operating Room. Optimal treatment of the critically ill patient demands adequate, precise and continuous monitoring of clinical parameters. Little is known about staff knowledge of the basic principles and practical implementation of TPTD measurements at the bedside. The aims of this review are to: 1) present the results of a survey on the knowledge of TPTD measurement among 252 nurses and doctors; and 2) to focus on specific situations and common pitfalls in order to improve patient management in daily practice. Methods: Web-based survey on knowledge of PiCCO technology (Pulsion Medical Systems, Feldkirchen, Germany), followed by PubMed and Medline search with review of the relevant literature regarding the use of TPTD in specific situations. Results: In total, 252 persons participated in the survey: 196 nurses (78%) and 56 medical doctors (22%) of whom 17 were residents in training. Knowledge on the use of TPTD appears to be suboptimal, with an average score of 58.3%. Doctors performed better than nurses (62.7% vs 57.0%, P = 0.012). About 190 out of 252 (75.4%) scored at least 50% but only 45 respondents (17.9%) obtained a score of 70% or more. Having five years of PiCCO experience was present in 15.8% of the participants and this was correlated to passing the test, defined as obtaining a test result of ≥ 50% (P = 0.07) or obtaining a test result of ≥ 70% (P = 0.05). There were no other parameters significantly predictive for obtaining a result above 50% or above 70% such as gender or doctor versus nurse or Belgian versus Dutch residency, or years of ICU experience. High quality education of nursing and medical staff is necessary to perform the technique correctly and to analyse and interpret the information that can be obtained. Visual inspection of thermodilution curves is important as this can point towards specific pathology. Interpretation of the parameters that can be obtained with TPTD in specific conditions is discussed. Finally, a practical approach is given in ten easy steps for nurses and doctors. Conclusion: TPTD has gained its place in the haemodynamic monitoring field, but, as with any technique, its virtue is only fully appreciated with correct use and interpretation.

An overview on fluid resuscitation and resuscitation endpoints in burns: Past, present and future. Part 2 — avoiding complications by using the right endpoints with a new personalized protocolized approach

“…If both a central venous catheter and an arterial PiCCO catheter are placed in an ipsilateral femoral site, a crosstalk phenomenon can occur as the cold bolus injected through the central venous catheter passes the thermistor of the arterial catheter, leading to errors in measurement. This may be avoided by withdrawing the arterial PiCCO catheter a few centimetres [52].…”

“…Classically, fluid responsiveness is defined as an increase in cardiac index of 15% or more after a fluid bolus. It should be emphasized that PPV and SVV are unreliable in patients with spontaneous breathing activity, cardiac arrhythmias, pericarditis, cardiac tamponade, right ventricular failure (high CVP), high PEEP or high IAP and low tidal volumes (< 6 mL kg -1 ) [52].…”

“…During the taking of measurements, a known volume of cold normal saline is injected through the central venous line. The arterial catheter detects temperature differences and generates a thermodilution curve to which the Stewart Hamilton equation is applied to calculate cardiac output (CO) and volumetric preload indices, indexed according to body surface area [52]. Some pathologies may create inaccurate measurements such as intracardiac shunts, aortic aneurysms, aortic valvular stenosis, severe mitral or tricuspid regurgitation, pneumonectomy, pulmonary embolism, the presence of a balloon pump and unstable arrhythmias.…”

Initial resuscitation from severe sepsis: one size does not fit all

“…However, there are certain limitations to the use of functional hemodynamic monitoring, such as stroke volume variation (SVV) or pulse pressure variation (PPV). The patient needs to be in regular sinus rhythm, while the presence of atrial fibrillation, along with ventricular or supraventricular extra systoles, limit their use [76]. The patient also needs to be fully mechanically ventilated without spontaneous breathing, while tidal volumes must be above 6 mL kg -1 [77,78].…”

Incidence and prognosis of intra-abdominal hypertension and abdominal compartment syndrome in severely burned patients: Pilot study and review of the literature

“…Transpulmonary thermodilution measurements were obtained by injection of three 20 mL boluses of cooled saline (< 8°C) into the central venous catheter. For each set of thermodilution determinants, the mean value was used for statistical analysis [20]. Cardiac output (CO), global end diastolic volume (GEDV), extravascular lung water (EVLW), global ejection fraction (GEF), pulmonary vascular permeability index (PVPI), stroke volume variation (SVV) and pulse pressure variation (PPV) were calculated.…”