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Doppler Haemodynamics

Individualized haemodynamic
Management
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Circulation the big picture

Circulation; complex, dynamic


relationship between preload,
contractility and afterload
Function to deliver Oxygen
and to maintain perfusion
pressure
SV is the sum of preload,
contractility and afterload

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Circulation Management

Preload CO Afterload

Systemic
Fluid volume Vascular
Resistance

Vasodilators
Inotrope
Increase +ve or -ve contractility, SV + CO
Decrease afterload, increase CO
Volume expansion- packed red cells, Nitrpprusside and nitrates
Dobutamine and dopamine
crystalloid, colloid Vasopressors
Decrease Chronotrope Increase afterload, decrease CO
Rate control Epinephrine and norepinephrine
diuretic

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DOES NOT TELL US
ABOUT CIRCULATING
BLOOD VOLUME

AND

DOES NOT TELL US


ABOUT HEARTS ABILITY
DO DELIVER OXYGEN

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Haemodynamics & Shock
Adequate pressure does not always mean adequate perfusion
Vascular
Resistance
% of Control

100 BP = CO x SVR

Blood Pressure
Compensated Decompensated
Shock Shock Cardiac Output

Time SV x HR

The tissues control blood flow locally by vasodilation


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Blood Pressure?
Her BP and HR are normal.

BP CO and BP DO2
Anybody NOT (Courtesy
www.uscom.com.au wantof Drto know her CI,The
Joe Brierley, GOSH, London.)
SVRI, DO2?!!
Measure of Life
a very poor relationship between CVP and blood
volume
inability of the CVP/CVP to predict haemodynamic
response to a fluid challenge

Chest 2008; 134: 172-8


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CVP should NOT be used to make clinical decision
regarding fluid management
CVP should NO longer be routinely measured in the
ICU, operating theatre or Emergency Department

Chest 2008; 134: 172-8


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Imaging the IVC?
Echo shows that;

A normal collapsing IVC during respiration: CVP is 5-10mmHg.


Dilated IVC with normal respiratory collapse: CVP is 10-15mmHg.
Dilated IVC with collapse only on sniffing: CVP is 15-20mmHg.
Dilated IVC without collapse on sniffing: CVP is 20+mmHg.

Echo can reliably estimate CVP from the IVC.but


Shippey et al., Marik et. Al., and others have proven that CVP
isnt useful for predicting fluid status and responsiveness.

Therefore echo estimation of IVC is as limited as CVP in


estimating preload status.

See also chapter by Anthony Dean, Philadelphia, who did all


www.uscom.com.au the original work on IVC distensibility.
The Measure of Life
Circulation Management

BP = CO x SVR; SVR = BP / CO; CO = BP / SVR


SV = blood flow across AV (and PV) in one beat
SV the pressure wave in the finger
SV pressure wave in radial artery
SV pressure wave in the femoral artery
SV Temperature change across the heart
SV Impedance between electrodes on the chest
(BioImpedance/BioReactance/CardiacImpedance)
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Oxygen Delivery DO2 X
Blood Pressure
X
Hb SpO2 Cardiac Output SVR

Stroke Volume Heart Rate

Preload Inotropy Afterload


?
Traditional
We need themeasures, BP, HRof&the
missing pieces SpO2 don't tell us
haemodynamic
anything
jigsaw
www.uscom.com.auabout
to befluid
ablestatus and oxygen
to manage delivery
circulation
The Measure of Life
USCOM Introduction

USCOM 1A

Unique non-invasive, beat to beat,


real time cardiac output monitor
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CW Doppler Ultrasound

Quantitative
Safe
Sensitive
Accurate
Reproducible
Economical

Measures blood velocity and volume


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Calculating Flow
Cardiac Output = Stroke Volume x HR

Stroke Volume = Stroke Distance x Flow Area

x
Vti (stroke distance) CSA
(directly measured by USCOM)
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Flow Area
Flow area (OTD) determined by Algorithm
Linear relationship with Height
Neonates (<50cm/20ins) Weight

Height Area

Nidorf SM, Picard MH, Triulzi MO, Thomas JD, Newell J, King ME, Weyman AE. New perspectives in the
assessment of cardiac chamber dimensions during development and adulthood. J Am Coll Cardiol 1992;19:983-8

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Right and Left CO

AORTIC ACCESS PULMONARY ACCESS


Left sided CO Right sided CO

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Right and Left CO

Aortic Access - LV CO Pulmonary Access - RV CO


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USCOM

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USCOM, Trending Display

Beat-by-beat Stroke Volume Monitoring multiple


(SV) derived automatically by haemodynamic parameters
FlowTracer and trends simultaneously

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22 Haemodynamic Parameters
Vpk: Peak Velocity of flow
vti: Velocity Time Integral
HR: Heart Rate
MD: Minute Distance
ET%: Ejection Time Percent
SV: Stroke Volume
SVI: Stroke Volume Index
SVV: Stroke Volume Variation
CO: Cardiac Output
CI: Cardiac Index
SVR: Systemic Vascular Resistance
SVRI: Systemic Vascular Res. Index
Pmn: Mean Pressure Gradient
FT: Flow Time
FTc: Flow Time Corrected
SW: Stroke Work
Measures of Cardiovascular Function including: CPO: Cardiac Power
Preload SpO2:
SVS:
Oxygen Saturation
Stroke Volume Saturation
Contractility DO2: Oxygen Delivery
SMII: Inotropic Index
Afterload PKR: Ratio Potential : Kinetic Energy
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VALIDATION

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SV, CO is the amount of blood flow across
the aortic/pulmonic valve, yes, we all agree?

Why not measure


www.uscom.com.au it where it actually
The happens?
Measure of Life
Stroke Volume & Cardiac Output

SV & CO is not blood pressure


SV & CO is simply the amount of blood flow (ml/min)
across Aortic (AV) and Pulmonic Valve (PV).
Blood flow across AV & PV is
what USCOM directly
measures! This is why USCOM
is more accurate than a
pressure based monitor

USCOM measures SV & CO whereThe


www.uscom.com.au it happens!
Measure of Life
USCOM Validations
MECABIO Institute, France
Computer controlled haemodynamics model
Exact agreement from 1.0 to 1.6 metres per second

2.2MHz velocity measurements (-1 to 2m/s)


Flow model

USCOM 1.6
probe 1.4
1.2

Velocity (m/s)
Tank
1
FlowProbe
0.8
Flow USCOM
0.6
probe
Pump 0.4
0.2
0
-1 -0.8 -0.6 -0.4 -0.2 0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6

USCOM measures vs Flow Probe measures Measured velocities (m/s)

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USCOM vs. FP
FLOW PROBE

Prince of Wales Hospital, Chinese University of Hong Kong


Flow probes in dogs.
Mean difference: 1.1% (n=335)
Presented: World Congress of Anaesthesiology,Paris, May 2004
Published: Anaesthesia & Analgesia, February 2005

CO Flow probe vs USCOM in 6 conscious dogs

4
3.5
3
2.5
FlowProbe
2
USCOM
1.5
1
0.5
0
Dog1 Dog2 Dog3 Dog6 Dog7 Dog8
Professor Lester Critchley
CUHK, Prince of Wales Hospital
Hong Kong

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USCOM vs. PAC
Swan HJ, Ganz W, Forrester J, Marcus H, Diamond G, Chonette D.
Catheterization of the heart in man with use of a flow-directed, balloon-
tipped catheter. N Engl J Med 1970;283:477

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USCOM
Validationsvs. PAC

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UK NHS Guidelines include
USCOM for improving surgical
care.
Friday 11th of May 2012: Uscom (ASX
code: UCM).

http://www.ntac.nhs.uk/
Thiel SW, Kollef MH, Isakow W. Non-invasive stroke volume measurement
and passive leg raising predict volume responsiveness in medical ICU
patients: an observational cohort study. Critical Care 2009;39:666-688.

29
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The new standard of care

Uscom Validated: 400+ puplications (vs. FP, Fick, PAC etc.)


0.12 liters per min to 18.5 liters per minute
26 weeks gestational age (390 grams)
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The Measure
USCOM Learning Curve

Asc Ao

AV AV AV AV

Ascending
Aorta

Aortic
Valve

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USCOM Learning Curve

Asc Ao

AV AV AV AV

Ascending
Aorta

Aortic
Valve

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USCOM Learning Curve

Pulmonary
Valve

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USCOM Learning Curve

Pulmonary
Valve

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USCOM Learning Curve
Vanderbilt University ( Heerman WJ, Churchwell KB, Taylor MB, Monroe C Jr. Clinical Utility of CW Doppler Ultrasound for Measuring Cardiac
Output (USCOM). Pediatric Cardiac Intensive Care Society ASM, Dec 12th 2005, Miami Florida) "With low intra-user variability and an
average measurement time of less than 2 minutes, the USCOM device proves to be a practical method of assessing
cardiac status in a pediatric critical care setting."

Measuring CO non-invasively with


Loma Linda University Hospital study covering 44 operators. (Losey T, Nguyen HB, Corbett SW, Wittake WA. Inter-Rater Agreement of a
Non-Invasive Ultrasound Cardiac Output Monitor (USCOM) Device in Emergency Department Patients. Annals Emerg Med 2005; 46(3):518) "The

the USCOM method is simple,


USCOM is a feasible non-invasive hemodynamic monitoring device in the ED with acceptable inter-rater agreement
when utilized by ED personnel involved in patient care.

rapid, safe, well-tolerated and cost-


Gelderse Vallei Hospital, The Netherlands (L.E.M. Haas, D.H.T. Tjan, J. van Wees, A.R.H. van Zanten) Validation of the USCOM-1A cardiac
output monitor in hemodynamic unstable intensive care patients. Presented Netherlands Intensive Care Society Congress, February 2006.
Measuring CO non-invasively with the USCOM method is simple, rapid, safe, well-tolerated and cost-effective.
effective. USCOM is a reliable
USCOM is a reliable method of measuring CO in critically ill patients

method of measuring CO in
Fremantle (Dey I, Sprivulis P. Emergency Physicians can reliably assess Emergency Department patient cardiac output using the USCOM
continuous wave Doppler cardiac output monitor. Emerg Med Aus 2005;17,193-199) "With the aid of an appropriate training package,
clinical staff with no prior ultrasonographic experience can be trained to reliably obtain cardiac output estimations."

critically ill patients


Chinese University, Hong Kong (Lam JM, Tang CO, Graham CA, Rainer TH. Emergency Physicians Can Reliably Assess Patient Cardiac
Output Using Non-invasive Ultrasonic Cardiac Output (USCOM). Hong Kong J Emerg Med 2005; 12(4):270) "Emergency physicians can be
trained to obtain reliable cardiac output estimations upon emergency department patients with the USCOM over the
course of 15 patient assessments."
Gelderse Vallei Hospital, The Netherlands, February 2006

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USCOM Learning Curve
USCOM Success with Experience

100
90
80
70
60
% 50 Success
40
30
20
10
0
0 5 10 15 20 25 30 35 40 45 50
Cases

The more you do, the better you get!!!!


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The study of 1197 children aged 0 to 12yrs with repeated by observations by a
blinded and independent operator has found:
Interobserver reliability for USCOM was superior to that
for standard blood pressure and heart rate measurement.
This study addresses this comprehensively by confirming the reproducibility of the
method and establishing normal reference values for children in a large well
published study.
Conclusions: This large study presents normal values for cardiovascular
indices in children using the Ultrasonic Cardiac Output Monitor with good
interobserver reliability.

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IN CLINICAL
PRACTICE

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39
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Oxygen Delivery DO2
Blood Pressure

Hb SpO2 Cardiac Output SVR

Stroke Volume Heart Rate

Preload Inotropy Afterload

USCOM provides us with the missing pieces


in the haemodynamic puzzle
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Oxygen Delivery DO2
DO2 = Oxygen Delivery

SpO2
hb

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Oxygen Delivery DO2
Blood Pressure

Hb SpO2 Cardiac Output SVR

Stroke Volume Heart Rate

Preload Inotropy Afterload

USCOM provides us with the missing pieces


in the haemodynamic puzzle
www.uscom.com.au The Measure of Life
Oxygen Delivery DO2
Blood Pressure

Hb SpO2 Cardiac Output SVR

Stroke Volume Heart Rate

Preload Inotropy Afterload

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Afterload
SVR = Systemic Vascular Resistance

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Oxygen Delivery DO2
Blood Pressure

Hb SpO2 Cardiac Output SVR

Stroke Volume Heart Rate

Preload Inotropy Afterload

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Preload (SVV)

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Preload (FTc)
Twice as effective for fluid management in sepsis!
SV defined Fluid Responsiveness
0.81
0.9
0.8
0.7
0.6 0.4
0.5 0.3
r

0.4
0.3
0.2
0.1
0 FTc=Flow Time
BNP CVP FTc corrected for HR
USCOM
* Sturgess DJ, Pascoe RLS, Scalia G, Venkatesh B. A comparison of transcutaneous Doppler corrected flow time, b-type natriuretic peptide and central venous pressure as
predictors of fluid responsiveness in septic shock: a preliminary study. Anesth Int Care 2009;38(2):336-341

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Preload (SV )
Fluid responsiveness identified by USCOM SV and PLR only

Subjects included
- AF
- On and off ventilation
- On vasoactive therapies

Follows Frank-Starling
Theory

Fluid responsiveness not predicted by any other parameter. Thiel Critical Care 2009;13:R111
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Rational Circulatory Management
Rational and Personalised optimisation to Frank-Starling Curve

Fluid Diuretic Inotrope Vaso

+ve
Dilator
Stroke
Volume
(mls) Constrictor
-ve

Preload (mls)

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Preload: To Add or not to add?
F 90yo, post Infarct in ICU

Prior to Passive Leg Raise Test Immediate to Passive Leg Raised


SV = 48 ml SV = 58 ml

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Preload: To Add or not to add?
M 12yo, sepsis, in ICU

Real-time stroke volume (SV)


Slight compression on the liver => increase venous return
Response with marked increase in SV
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Oxygen Delivery DO2
Blood Pressure

Hb SpO2 Cardiac Output SVR

Stroke Volume Heart Rate

Preload Inotropy Afterload

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Inotropy How to Assess?

We use (dubious) surrogates of global cardiac


function
BP, HR, urine output, skin perfusion, capillary
refill, skin temperature, bowel sounds
Ejection Fraction (EF).(Mark I Human Eyeball)

All of these are notoriously unreliable


indicators of cardiac function even in the
hands of senior clinicians!
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Ejection Fraction?
Assume a normal heart, EF 65. Now give sodium nitroprusside
=> Vaso Dilation => SV Increases, but vaso-dilation also results
in a Pre-Load Decrease, i.e. lower LVEDV. As EF = SV / LVEDV
=> Increased EF! So sodium nitroprusside is therefore a positive
inotrope??? (nope, obviously not).

Assume a normal heart, EF 65. Now give Norepinephrine /


Noradrenaline => Vaso Constriction => SV Decrease, but vaso
constriction also results in Pre-Load Increase, i.e. higher LVEDV.
As EF = SV / LVEDV => Decreased EF! So Norepinephrine is
therefore a negative inotrope??? (nope, wrong again).

EF is affected by pre-load and even more so by afterload! It is


even affected by heart rate. EF may be ok in normal pre-load and
normal afterload (Cardiology Outpatients), but really
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Why is this so important?

In the past 20 years, 250,000

the mortality of

Deaths/Year
200,000

severe sepsis & 150,000

septic shock has 100,000

remained dismal at 50,000

40 to 50% 0

AIDS Breast Ca AMI Sepsis


Prof. Joe Carcillo, Pittsburg, PA.
All About Sepsis World Congress 2010
Chiang Mai, Thailand.

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Stop Sepsis Save Lives!

what are we
missing?...

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FLUID RESPONSIVE

1.0ml/kg

1.2ml/kg

1.1ml/kg II = 1.68
II = 1.74
II = 1.65

Courtesy of:
Associate Professor Brendan Smith
School of Biomedical Science, Charles Sturt University,
Bathurst,
Courtesy Newof:South Wales, Australia.

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Specialist in Anaesthesia and Intensive Care,
Professor Brendan
Bathurst Base Hospital, E. Smith
New South Wales, Australia. The Measure of Life
FLUID NON RESPONSIVE
(Negative response)
II = 0.94
II = 0.86
0.8ml/kg
II = 0.79
0.66ml/kg

0.75ml/kg

Courtesy of:
Associate Professor Brendan Smith
School of Biomedical Science, Charles Sturt University,
Bathurst,
Courtesy Newof:South Wales, Australia.

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Specialist in Anaesthesia and Intensive Care,
Professor Brendan
Bathurst Base Hospital, E. Smith
New South Wales, Australia. The Measure of Life
~90% of severe sepsis and septic
shock patients have significant
myocardial depression with low
Inotropy!

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Measurement of Inotropy

Determinants are:
SV*, Flow Time*, Velocity*, Pressure.
www.uscom.com.au *) Measured by USCOM The Measure of Life
Measurement of Inotropy
Normal adults (1,467) = 1.6 2.2 W/m2
Normal INO pediatric = 1.4 to 2.0 W/m2

LVF patients (83) = 0.43 0.97 W/m2

Septic Shock (124) = 0.52 1.23 W/m2

~ 90% of septic shock patients have significant


myocardial depression with low Inotropy

- Annals of Emergency Medicine 2008; 51, No 4: 480.


Courtesy of:
www.uscom.com.au
Professor Brendan E. Smith The Measure of Life
- British Journal of Anaesthesia; 2013; doi:10.1093/bja/aet118
Hallmarks of Septicaemia
BP = 74/38
Hyperdynamic

High FTc (no fluid!)

High Stroke Volume

High CO, CI

Low SVR

High DO2

Low INO (give inotrope!)

Low PKR

Severe sepsis with High Output Failure!


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Fluid Management made easy!

SVI < 45
FLUID HEART
PROBLEM >1.4 W/m2 <1.1 W/m2 PROBLEM
INO

Give Give Which inotrope?


Check SVR
Fluid Inotrope

If INO is between 1.1 and 1.3, try a small test dose of fluid. If SVI increases, carefully
add more fluid to achieve adequate SVI. If SVI does not increase give inotrope
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USCOM-Limitations
Advanced haemodynamics
* Haemodynamic understanding is Learning curve
limited USCOM Success with Experience
* Requires education to apply 100
90

Success
Ultrasound limitations 80
70
* Air, Bone, patient position 60
%
50
Operator learning curve 40
30
* 30-50 patients 20
* The more you do the better you get 10
0
Patient conditions
0 5 10 15 20 25 30 35 40 45 50

* COPD and pneumothorax Cases

* Congenital heart problems


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USCOM Advantages
Individualized Hemodynamic Management
Noninvasive and Reliable
Accurate and strongly Validated
Adults, Children & Neonates
Critically ill and Well Patient
Hospital wide Applications
Fast, Portable & Safe
Highly Economical
Doctors, Nurses, Paramedics
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