COVID-19 / Coronavirus Outbreak: Hemodynamic monitoring with PiCCO artery

Coronavirus / COVID-19 Procedures
JoVE Journal
Coronavirus / COVID-19 Procedures
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Wunderlich, R., Spiros Nikomanis, P., Ring, C., Häberle, H., Münch, A. COVID-19 / Coronavirus Outbreak: Hemodynamic monitoring with PiCCO artery. J. Vis. Exp. (159), e6433, (2020).

Abstract

During pandemics, medical staff become a key resource in treating and managing patients with these infectious diseases. To achieve the best medical care, relevant techniques and procedures must be taught to medical staff which minimize the risk of work-related transmission of infection. When carrying out hemodynamic monitoring in cardiovascularly unstable patients, it is possible to utilize a Pulse Contour Cardiac Output (PiCCO) catheter. This system utilizes a thermodilution method to analyze a patient’s cardiovascular status. This video highlights the placement and setup of a PiCCO catheter and system, including both the practical component and analysis of the thermodilution method, whilst taking into account important personal protection measures.

Protocol

  1. A central venous catheter is necessary for the injection of cold 0.9% sodium chloride.
  2. All required equipment should be prepared outside of the patient's room.
    NOTE: The choice of PiCCO catheter size is dependent upon the puncture site. The preferred puncture site is the femoral artery. In this instance a 5 French and 20 cm long catheter will be used. A 4 French 22 cm catheter would be used if the Brachial artery was to be punctured.
  3. When entering the patient's room, always use suitable personal protective equipment. In this case a FFP2 mask is sufficient.
  4. Explain the procedure to the patient in order to gain verbal consent, if at all possible.
  5. Cover the intimate areas and place an absorbent and waterproof protective sheet under the patient's pelvis. If required, the puncture site can be shaved and cleaned to remove visible dirt.
  6. Disinfect the area with a spray disinfectant.
  7. Firmly stick the protective film to the ultrasound probe, and if necessary, disinfect the area once more.
  8. Identify the local anatomy and target area sonographically. Position the probe in a mediolateral direction: Identifiable is the femoral vein, femoral artery and femoral nerve. The mnemonic NAVY can be helpful (Nerve-artery-vein-Y fronts (or Midline)).
  9. Consider sedation of the patient as needed.
  10. Following a further spray disinfection, the local area may be infiltrated with Mepivacain 1%. The eventual puncture and suture sites should be infiltrated.
  11. Arrange all further equipment, allowing time for the effect of the local anesthetic.
  12. Disinfect your hands. Sterile gloves and a sterile gown should be worn with help from an assistant.
  13. Repeatedly disinfect the puncture site with a color-tinted disinfectant. Allow the disinfectant time to dry. The disinfected area can now be covered.
  14. Pull a sterile protective film over the ultrasound probe and cable. Have an assistant hold the ultrasound probe cable, and assist in the pulling of the protective film over this cable. The protective film may be fixed to the ultrasound probe with the white adhesive tape provided. The cable will in turn be fixed to the patient's bed.
  15. Flush the PiCCO catheter with 0.9% sodium chloride. Check the guidewire.
  16. Now, puncture the artery. This should be carried out under sonographic control and constant aspiration. Visualize and check the position of the hollow needle tip using sonography.
  17. Assume successful puncture of the artery if bright red blood is seen oozing from the hollow needle in a pulsating manner.
  18. Advance the guidewire, without resistance, approximately 20 cm.
  19. Control the guidewire's position sonographically.
  20. Now, dilate the tissues.
  21. Following dilation, pass the catheter over the guidewire and insert it into the artery lumen until it can not be further advanced.
    NOTE: The guidewire must at all times be held by the healthcare worker.
  22. Remove the guidewire, and aspirate and flush the catheter.
  23. A three-way valve may be attached to the lumen.
  24. Finally, anchor the PiCCO catheter with sutures to the skin.
  25. If required, blood cultures may now be taken. These should be prepared by an assistant.
  26. Fix the PiCCO catheter into place with a plaster, and remove the sterile drapes.
  27. The sterile gown and gloves may now be removed.
  28. Cardiac Output and other hemodynamic parameters can now be measured.
  29. First, attach the PiCCO monitor adapter to the telemetry monitor, and then attach the PiCCO cable to this adapter. The PiCCO cable will be connected to the red attachment point.
  30. Connect the arterial blood pressure transducer to the PiCCO arterial line.
  31. Connect the flush adapter with the blue connector to the central venous catheter at the proximal attachment site. Close the central venous pressure valve.
    NOTE: To ensure accurate calculation of the various hemodynamic parameters, it is important to correctly input the patient's details into the vital signs monitor. Of particular importance are the patient's size, weight, birthday and case number.
  32. IMPORTANT: Select the 20 mL test volume dose on the vital signs monitor.
    NOTE: In order to save any following results, it is important to add a PiCCO category in your computer program (if supported).
  33. The measurements are based on a thermodilution method. Administer a 20 mL bolus of 0.9% odium chloride, which has been cooled in the fridge.  Start the measurement by either pressing the blue hand trigger or by pressing start on the monitor.
  34. Administer the fluid bolus as soon as the measurement allows for, which will be stated on the patient monitor.
  35. Carry out at least 3 separate and valid measurements, in order to attain more reliable results.
  36. Measure the difference in temperature over a period of time following injection of the fluid bolus through the central venous catheter using the temperature probe in the PiCCO catheter.
  37. If there is greater than 10% variation between the results, these should be repeated and respectively removed from the overall calculation.
  38. Once all measurements are completed, the central venous pressure valve can be opened. Now all the measurements may be saved. The hemodynamic status of the patient may be calculated. The results will subsequently be printed out and also transferred to the central computer network.
  39. The continuous cardiac output function should be calibrated once during each work shift.

Disclosures

No conflicts of interest declared.