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)