Femoral indicator injection for transpulmonary thermodilution using the EV1000/VolumeView®: do the same criteria apply as for the PiCCO®?

Journal of Zhejiang University-SCIENCE B, Jul 2016

Wolfgang Huber, Veit Phillip, Josef Höllthaler, Caroline Schultheiss, Bernd Saugel, Roland M. Schmid

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Femoral indicator injection for transpulmonary thermodilution using the EV1000/VolumeView®: do the same criteria apply as for the PiCCO®?

J Zhejiang Univ-Sci B (Biomed & Biotechnol) 1673-1581 Femoral indicator injection for transpulmonary thermodilution Wolfgang HUBER 0 Veit PHILLIP 0 Josef HÖLLTHALER 0 Caroline SCHULTHEISS 0 Bernd SAUGEL 0 Roland M. SCHMID 0 Case Report: 0 (Second Medical Department, Klinikum rechts der Isar, Technical University of Munich , 81675 Munich , Germany) Objective: Comparison of global end-diastolic volume index (GEDVI) obtained by femoral and jugular transpulmonary thermodilution (TPTD) indicator injections using the EV1000/VolumnView® device (Edwards Lifesciences, Irvine, USA). Methods: In an 87-year-old woman with hypovolemic shock and equipped with both jugular and femoral vein access and monitored with the EV1000/VolumeView® device, we recorded 10 datasets, each comprising duplicate TPTD via femoral access and duplicate TPTD (20 ml cold saline) via jugular access. Results: Mean femoral GEDVI ((674.6±52.3) ml/m2) was significantly higher than jugular GEDVI ((552.3±69.7) ml/m2), with P=0.003. Bland-Altman analysis demonstrated a bias of (+122±61) ml/m2, limits of agreement of −16 and +260 ml/m2, and a percentage error of 22%. Use of the correction-formula recently suggested for the PiCCO® device significantly reduced bias and percentage error. Similarly, mean values of parameters derived from GEDVI such as pulmonary vascular permeability index (PVPI; 1.244±0.101 vs. 1.522±0.139; P<0.001) and global ejection fraction (GEF; (24.7±1.6)% vs. (28.1±1.8)%; P<0.001) were significantly different in the case of femoral compared to jugular indicator injection. Furthermore, the mean cardiac index derived from femoral indicator injection ((4.50±0.36) L/(min·m²)) was significantly higher (P=0.02) than that derived from jugular indicator injection ((4.12±0.44) L/(min·m²)), resulting in a bias of (+0.38±0.37) L/(min·m²) and a percentage error of 19.4%. Conclusions: Femoral access for indicator injection results in markedly altered values provided by the EV1000/VolumeView®, particularly for GEDVI, PVPI, and GEF. Hemodynamic monitoring; Transpulmonary thermodilution; Central venous catheter; Femoral vein; Jugular vein; Global end-diastolic volume; EV1000/VolumeView®; PiCCO® http; //dx; doi; org/10; 1631/jzus; B1500244 CLC number; R472 1 Introduction The usefulness of transpulmonary thermodilution (TPTD) for the measurement of cardiac index (CI), global end-diastolic volume index (GEDVI), extra vascular lung water index (EVLWI), pulmonary vascular permeability index (PVPI), and global ejection fraction (GEF) has been demonstrated in a number of studies (Michard et al., 2003; Kuzkov et al., 2006; Goepfert et al., 2007; Renner et al., 2007; Malbrain et al., 2010; Jozwiak et al., 2013; Sun et al., 2015) . Usually TPTD is performed by indicator injection via the jugular or subclavian vein. However, under certain circumstances, superior vena cava access is not feasible due to thrombosis of the jugular or subclavian vein, polytrauma, burns, infection, or use of the superior vena cava access for dialysis catheters. In these cases, femoral access can be used for TPTD. Femoral access accounts for up to 20%–35% of all catheter insertions (Deshpande et al., 2005; Gowardman et al., 2008) . However, two studies (Schmidt et al., 2007; Saugel et al., 2010) comparing jugular and femoral TPTD indicator bolus injections using PiCCO® device (Pulsion Medical Systems AG, Munich, Germany) have demonstrated significant overestimation particularly of GEDVI due to the additional volume of the inferior vena cava participating in the indicator dilution in the case of femoral injection. Both studies suggested correction for this volume. One of these studies provided correction formulae for femoral GEDVI (GEDVIfem), femoral EVLWI (EVLWIfem), and femoral CI (CIfem) based on data from 48 TPTDs in 24 patients (Saugel et al., 2010) . This study was able to demonstrate the usefulness particularly of the correction of GEDVIfem in another 6 subsequent patients. Recently, in addition to the PiCCO® device, another commercially available device for TPTD has been introduced, EV1000/VolumeView® (Edwards Lifesciences, Irvine, USA) (Bendjelid et al., 2010; 2013; Kiefer et al., 2012; Cho et al., 2015) . Based on TPTD, the EV1000/VolumeView® uses similar methodologies and algorithms as the PiCCO® device, which resulted in a good agreement of the data obtained simultaneously by the PiCCO system and the EV1000/VolumeView® in one animal and one clinical evaluation study (Bendjelid et al., 2010; Kiefer et al., 2012) . Nevertheless, regarding calculation of GEDVI and EVLWI there is a certain difference between these devices: calculations based on the “downslope time” used by the PiCCO® system have been replaced by a “proprietary function” of the maximum ascending and descending slopes of the thermodilution curve in the EV1000/VolumeView®. To the best of our knowledge, there are no reports on the bias induced by femoral indicator injection using the EV1000/Vo (...truncated)


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Wolfgang Huber, Veit Phillip, Josef Höllthaler, Caroline Schultheiss, Bernd Saugel, Roland M. Schmid. Femoral indicator injection for transpulmonary thermodilution using the EV1000/VolumeView®: do the same criteria apply as for the PiCCO®?, Journal of Zhejiang University-SCIENCE B, 2016, pp. 561-567, Volume 17, Issue 7, DOI: 10.1631/jzus.B1500244