Manage septic shock patients with PiCCO

 

PiCCO is the gold standard in haemodynamic monitoring

 

 

  • Challenges
  • Patient case
  • Common Pitfalls
  • Features
  • Benefits
  • Study
  • Literature

When each of your decisions has critical consequences...

Patient case*: Head injury, severe ARDS & septic shock

 

This patient seems to be hypovolemic based on the given standard clinical parameters like MAP and CVP. Haemodynamic monitoring with PiCCO reveals that this patient is severely hypervolaemic. Giving him fluids would be a critical mistake! PiCCO parameters show that this patient needs noradrenaline and aggressive diuresis. This case demonstrates the value of advances haemodynamic monitoring with PiCCO and illustrates how an incomplete picture can lead to incorrect therapy.

*This real patient case was kindly provided by Dr. Eran Segal and Prof. Azriel Perel, Department of Anesthesiology and Critical Care, Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel.

Common pitfalls in the management of septic shock

  • Physical examination alone often fails to reflect the haemodynamic status 5,12
  • CVP & PAOP do not reflect fluid status 2,4
  • Fluid overload 50% of ICU patients do not respond to fluid administration 2,3 

Benefits of managing septic shock with PiCCO

PiCCO Features

 

**The high accuracy of the cardiac output value given by the PiCCO-Technology is based on calibration via transpulmonary thermodilution.

Study

PiCCO provides a number of important parameters including continuous CO at the bedside which can have a significant impact on clinical decisions

A recent study by Perel et al. demonstrated the limited ability of clinicians to accurately estimate important physiological parameters from clinical assessment and routine haemodynamic monitoring. In 75% of clinical cases in this study, the physicians underestimated the patient’s CO and 54% underestimated it by more than 20%.
Once the PiCCO was inserted, and information given about the CO, preload status, and amount of lung water, a significant number of the physicians changed major therapeutic decisions, made originally on the basis of existing clinical information.12

Literature

1. Dellinger et al., Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012. Crit Care 2013, 41(2): 580-637.

2. Marik et al., Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Crit Care Med 2013, 41(7): 1774-1781.

3. Marik & Bellomo, A rational approach to fluid therapy in sepsis. Br J Anaesth 2016, 116 (3): 339-349.

4. Cecconi et al., Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine. Intensive Care Med 2014, 40(12): 1795-1815.

5. Beale et al., Vasopressor and inotropic support in septic shock: an evidence-based review. Crit Care Med 2004, 32(11): 455-465.

6. Sakka et al., Assessment of cardiac preload and extravascular lung water by single transpulmonary thermodilution. Intensive Care Med 2000, 26(2): 180-187.

7. Marik et al., Hemodynamic parameters to guide fluid therapy. Annals of Intensive Care 2011, 1(1): 1-9.

8. Michard et al., Global end-diastolic volume as an indicator of cardiac preload in patients with septic shock. Chest 2003, 124(5): 1900-1908.

9. Malbrain et al., The debate on fluid management and haemodynamic monitoring continues: between Scylla and Charybdis, or faith and evidence... . Anaesthesiol Intensive Ther 2014, 46(5): 313-318.

10. Jozwiak et al., Extravascular lung water in critical care: recent advances and clinical applications. Ann. Intensive Care 2015, 5(38): 1-13.

11. Monnet at al., Assessing pulmonary permeability by transpulmonary thermodilution allows differentiation of hydrostatic pulmonary edema from ALI/ARDS. Intensive Care Med 2007, 33(3): 448-453.

12. Perel et al., The effects of advanced monitoring on hemodynamic management in critically ill patients: a pre and post questionnaire study. J Clin Monit Comput 2015, epub.

Webinar: Manage septic shock patients with PiCCO®

Charles Phillips MD, Associate Professor

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PULSION is part of Maquet Getinge Group