COVID-19 / התפרצות נגיף הקורונה: ניטור המודינמי עם עורק PiCCO

Dearest colleagues, when carrying out hemodynamic monitoring in cardiovascularly unstable patients, it’s possible to utilize a PiCCO or Pulse Contour Cardiac Output catheter. A thermodilution method is used for analysis. A central venous catheter is necessary. All required equipment will be prepared outside of the patient’s room.

The choice of PiCCO catheter is dependent upon the puncture site. The preferred puncture site is the femoral artery. In this instance, a 5 French and 20 centimeter-long catheter will be used. A 4 French 22  would be used if the brachial artery was to be punctured.

When entering the patient’s room, always use suitable personal protective equipment. In this case, an FFP2 mask is sufficient. Explain the procedure to the patient in order to gain verbal consent if at all possible. The intimate areas will be covered,and an absorbent and waterproof protective sheet is placed under the patient’s pelvis. If required, the puncture site can be razored and cleaned to remove visible dirt.

Disinfect the area with a spray disinfectant. Firmly stick the protective film to the ultrasound probe, and if necessary, disinfect the area once more. The local anatomy and target area is now sonographically identified. 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. Sedation of the patient may also be considered. Following a further spray disinfection, the local area may be infiltrated with mepivicaine 1%. The eventual puncture and suture sites should be infiltrated. All further equipment can now be arranged allowing time for the effect of the local anesthetic.

Firstly, the hands should be disinfected. Sterile gloves and a sterile gown should be worn with help from an assistant. The puncture site is now repeatedly disinfected with a color-tinted disinfectant.

Allow the disinfectant time to dry. The disinfected area can now be covered as sterile protective film is pulled over the ultrasound probe and cable. The assistant holds the ultrasound probe cable and assists in the pulling over 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 is in turn, fixed to the patient’s bed. The PiCCO catheter is flushed with sodium chloride 0.9%. The guidewire is checked. The artery is now punctured. This is carried out under sonographic control and constant aspiration. Visualize and check the position of the hollow needle tip using sonography. If bright red blood is oozing from the hollow needle in a pulsating manner, we can assume successful puncture of the artery. The guidewire should, without resistance, be advanced approximately 20 centimeters. The guidewire’s position is sonographically controlled.

The tissues are now dilated. Following dilation, the catheter is passed over the guidewire and inserted into the artery till it cannot be further advanced. The guidewire is at all times held by the health care worker. Following the removal of the guidewire, the catheter is aspirated and flushed. A three-way valve may be attached to the lumen. Finally, the PiCCO catheter is anchored with sutures to the skin.

If required, blood cultures can now be taken. These are prepared by an assistant. The PiCCO catheter is now fixed into place with a plaster and the sterile drapes removed. The sterile gown and gloves may now be removed. We now measure the cardiac output and other hemodynamic parameters.

First, attach the PiCCO monitor adapter to the telemetry monitor, and then attach the PiCCO cable to this adapter. The PiCCO cable is connected to the red attachment point. The arterial blood pressure transducer is, in turn, connected to the PiCCO arterial line.

The flash adapter with the blue connector is connected to the central venous catheter at proximal to the attachment site. The central venous pressure valve is now closed. To ensure accurate calculation of the various hemodynamic parameters, it’s 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.

Important– the 20-milliliter test volume dose should be selected on the vital signs monitor. In order to save any following results, it’s important to add a PiCCO category in your computer program. The measurements are based on a thermal dilution method. A 20-milliliter bolus of sodium chloride 0.9%, which has been cooled in the fridge, is administered.

The measurements can now be started by either pressing the blue hand trigger or by pressing Start on the monitor. The fluid bolus is administered as soon as the measurement allows for, which will be stated on the patient monitor.

At least three separate and valid measurements should be carried out in order to obtain more reliable results. A temperature probe in the PiCCO catheter measures the difference in temperature over a period of time following injection of the fluid bolus through the central venous catheter. In this case, four measurements are carried out.

If there is a greater than 10% variation between the results, these should be repeated and respectively removed from the overall calculation. In this case, the first measurement varies greatly to the others. Once all measurements are complete, the central venous pressure valve can be opened. Now, all the measurements may be saved. Now, the hemodynamic status of the patient is calculated. The results are subsequently printed out and also transferred to the central computer network. The continuous cardiac output functions should be calibrated once during each work shift. Thank you very much.