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Title: The Nexfin HD -


1
The Nexfin HD - Potential Applications Azriel
Perel Professor and Chairman Department of
Anesthesiology and Intensive CareSheba Medical
Center, Tel Aviv University, Israel
ESCTAIC Amsterdam 2010
2
Disclosure The speaker cooperates with the
following companies
BMEYE PULSION
3
Monitor wizards can be dangerous Robin ED,
McCauley RF. Chest 1998 114 1511
What Is the Best Way To Measure Cardiac Output?
Who Cares, Anyway? Caruso LJ et al. Chest.
2002122771-774
4
I have a suspicion that even the medical device
manufacturers realize that CO is not an important
variable in the critical care arena. PPV alone
is the best way to predict volume responsiveness.
Therefore, it is less clear why we want to know
the CO in the first place. This explains why
all of the recently marketed devices purport a
slew of other data (e.g., stroke volume variance,
EVLW, blood velocity), although many of these
measurements are derived from CO determination to
begin with.
5
The monitoring of CO is considered to be very
useful for proper decision-making in critically
ill and high-risk surgical patients.
Bodies of two Air France passengers found
CNN.COM June 6, 2009 The airline had failed to
replace a part that monitors speed, as
recommended by the manufacturer, based on
technological developments and improvements.
The fact that this statement is not supported by
EBM tells us more about the shortcomings of EBM
than those of the measurement of CO.
6
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7
The Nexfin HD device
The Nexfin HD device (BMEYE, Amsterdam) uses a
non-invasive, continuous blood pressure (BP)
measurement (based on the Finapres method) to
measure cardiac output continuously.
8
Stover JF, et al. BMC Anesthesiology 2009 9 6
9
Stover JF, et al. BMC Anesthesiology 2009 9 6
Importantly, there were no clinical signs of
disturbed microcirculation of the fingers in
these patients during application of the finger
cuff, indicating a safe use of the Nexfin HD
system. The noninvasiveness of this technique
allows to avoid complications related to more
invasive techniques. This new system is very
easy to use and quickly to install within
minutescould offer a quick initial hemodynamic
overview.on trend of MAP and CO. This would
allow to bridge the time until a longer lasting
invasive monitoring can be installed in the case
of a deteriorating patient.
10
Comparison of Nexfin HD CO to PiCCO
intermittent TTD CO
11
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12
Pre CPB
13
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14
Post CPB
15
Why do we need real-time CCO?
  • Intermittent TD CO measurements have a well known
    intrinsic limited reproducibility. This
    limitation makes them inferior to continuously
    measured real-time CO in assessing the response
    to therapeutic or diagnostic events with short
    time constants.
  • Fluid loading (e.g., periop. optimization)
  • Passive leg raising, end-exp. occlusion.
  • Immediate response to inotropes

16
Nexfin HD Applications
Syncope diagnostics - tilt table testing
17
Upon standing postoperatively, CO (Modelflow)
declined by a mean of 1.4 L/min. Conclusions
The early postoperative postural cardio-vascular
response is impaired after radical prostatectomy
with a risk of orthostatic intolerance, limiting
early post-operative mobilization.
18
Will my patient respond to fluids?
Will my patient respond to fluids?
Yes. Give 1735 ml over 30 minutes.
19
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20
Passive leg raising-induced changes in CO can
reliably predict fluid responsiveness regardless
of ventilation mode and cardiac rhythm. Passive
leg raising-induced changes in CO have a
significantly higher predictive value than
passive leg raising-induced changes in arterial
pulse pressure.
21
The hemodynamic response to a 15-second
end-expiratory occlusion can predict volume
responsiveness in mechanically ventilated
patients.
22
The accumulation of evidence showing that
increasing DO2 in high-risk surgical patients may
reduce morbidity and save lives has led Boyd and
Bennett to claim that it may be considered
unethical not to use goal-directed perioperative
therapy once patient identification and the
methods to be used in treating them are refined.
23
Unlike approaches that adopt a specific clinical
practice, like liberal or restrictive fluid
regimen, goal-directed approaches employ various
monitoring techniques and interventions in order
to achieve specific end-points for selected
parameters.
  • Cardiac index (CI)
  • Stroke volume (SV)
  • Oxygen delivery (DO2)
  • Mixed venous (SvO2) or central venous
    (ScvO2) oxygen saturation
  • Lactate concentration
  • pHi

24
Optimization when and how?
  • A bolus of 200 ml colloid (e.g., 6 HES 130/0.4)
    is administered over 2 min, and 5 min later the
    SV is assessed.
  • The procedure is repeated if there was an
    increase in SV of gt10. When the fluid bolus does
    not result in a SV increment gt10, optimization
    is regarded as achieved and surgery commenced.

Intermittent TD CO measurements have a well known
intrinsic limited reproducibility which makes
them inferior to continuously measured real-time
CO in the process of perioperative optimization.
25
Optimization when and how?
  • Transesophageal Doppler ultrasound
  • Patient needs to be anesthetized
  • The Vigileo system
  • Patient needs to have an arterial line
  • The Nexfin HD
  • Totally non-invasive

26
NEXFIN
27
  • CO (CI gt 4.5 L/min/m2) and oxygen transport
    goals (DO2I 600 ml/min/m2) are important so
    direct flow monitoring should be implemented.
  • Fluids should be given to increase CO, and
    inodilators, such as dopexamine and dobutamine,
    added once the patient is no longer fluid
    (preload) responsive or not achieving the goals.

28
It is essential that the present individualized
GDT approach includes optimization of
flow-related parameters, such as cardiac stroke
volume, within the limit of the individual
patients cardiac capacity. The concept is
therefore different from the original Shoemaker
concept for optimization, which used
predetermined supra-physiologic values of cardiac
index and DO2 as therapeutic goals.
29
The perioperative fluid management strategy
determines the monitoring
modality!
30
The Nexfin HD- A truly non-invasive CCO
monitor THANK YOU!
31
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32
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33
  • Blood volume after fasting is normal, and a
    fluid-consuming third space has never been
    reliably shown.
  • The endothelial glycocalyx plays a key role and
    is destroyed not only by ischemia and surgery,
    but also by acute hypervolemia.
  • Undifferentiated fluid handling may increase the
    shift toward the interstitial space, the
    consequence being a positive fluid balance and
    weight gain of up to 10 kg, which may be related
    to severe complications.

Optimization ? Maximization
34
National Confidential Enquiry into
Patient Outcome and Death. 1999
Report Extremes of Age. http//www.ncepod.org.uk
National Confidential Enquiry into Perioperative
Death have highlighted over-hydration as a
contributory cause in the genesis of
postoperative problems leading to death.
Carefully considered case histories have led to
specific recommendations regarding careful fluid
management (the implication being restriction) in
vulnerable patients and those most at risk, such
as the elderly.
35
A variety of metabolic endpoints are surrogate
flow measurements, such as lactate, SvO2, ScvO2,
which may be useful during resuscitation, but CO
(CI gt 4.5 L/min/m2) and oxygen transport goals
(DO2I 600 ml/min/m2) are important so direct
flow monitoring should be implemented. Fluids
should be given to increase CO, and inodilators
such as dopexamine and dobutamine added once the
patient is no longer fluid (preload) responsive
or not achieving the goals.
36
A variety of metabolic endpoints are surrogate
flow measurements, such as lactate, SvO2, ScvO2,
which may be useful during resuscitation, but CO
(CI gt 4.5 L/min/m2) and oxygen transport goals
(DO2I 600 ml/min/m2) are important so direct
flow monitoring should be implemented. Fluids
should be given to increase CO, and inodilators
such as dopexamine and dobutamine added once the
patient is no longer fluid (preload) responsive
or not achieving the goals.
37
This systematic review demonstrated a very poor
relationship between CVP and blood volume as well
as the inability of CVP / ?CVP to predict the
hemodynamic response to a fluid challenge. CVP
should not be used to make clinical decisions
regarding fluid management.
38
Overall, only 56 16 of 803 patients that were
included in the 24 studies responded to a fluid
challenge.
39
Perioperative fluid optimization necessitates
real-time CCO
  • Intermittent TD CO measurements have a well known
    intrinsic limited reproducibility. This
    limitation makes them inferior to continuously
    measured real-time CO in assessing the response
    to therapeutic or diagnostic events with short
    time constants.
  • Fluid loading (e.g., periop. optimization)
  • Passive leg raising, end-exp. occlusion.
  • Immediate response to inotropes

40
  • Transesophageal Doppler ultrasound
  • Patient needs to be anesthetized
  • The Vigileo system
  • Patient needs to have an arterial line
  • The Nexfin HD
  • Totally non-invasive

41
  • Limitations
  • Duration of measurement is restricted to 8 hours
  • Peripheral vasoconstriction (age, cold,
    vasopressors)
  • Edematous fingers
  • Currently no PPV / SVV
  • GUI more suitable for a cardiology clinic

42
  • Limitations
  • Duration of measurement is restricted to 8 hours
  • Peripheral vasoconstriction (age, cold,
    vasopressors)
  • Edematous fingers
  • Currently no PPV / SVV
  • GUI more suitable for a cardiology clinic
  • Additional benefits
  • Semi-disposable finger cuff
  • Touch screen
  • Instant data retrieval with DOK

43
Prediction of volume responsiveness by using
passive leg raising
Boulain T, et al. Chest 2002 121124552 Monnet
X, et al. Crit Care Med 2006 341402-7 Lafaneche
re A, et al. Crit Care 2006 10R132 Lamia B, et
al. Intensive Care Med 2007 33112532 Maizel
J, et al. Intensive Care Med 2007
3311338 Caille V, et al. Intensive Care Med
2008 34123945 Thiel SW, et al. Crit Care
200913R111 Biais M, et al. Crit Care 2009,
13R195
44
Changes in stroke volume, radial pulse pressure,
and peak velocity of femoral artery flow induced
by passive leg raising are accurate and
interchangeable indices for predicting fluid
responsiveness in non-intubated patients with
severe sepsis or acute pancreatitis.
45
13 patients were studied within 2 h of arrival in
the ICU following CABG or mitral valve
reconstruction. Cardiac output (CO) was
evaluated using the FloTrac (COed), the modified
Modelflow (COmf ), and the ultra-sound HemoSonic
system (COhs), and compared with thermodilution
(COtd) as the reference (triplicate, automated
system under computer control, equally spread
measurements over the ventilatory cycle). 104
paired CO values were assessed before, during and
after four interventions (i) an increase of
tidal volume by 50 (ii) a 10 cm H2O increase in
PEEP (iii) passive leg raising (iv) head up
position.
46
COmf has best precision (0.69 l/min) and smallest
range of the limits of agreement (-1.081.68
l/min), 26, compared with the COed and COhs
(-1.472.13), 34, and (-2.621.80 l/min), 44,
respectively.
FloTracVigileo (COed)
Modified Modelflow method (COmf)
HemoSonic 100 ultrasound system (COhs)
47
Our main finding is that only he modified
Modelflow yields limits of agreement (26) that
are below the 30 criteria for a theoretically
acceptable alternative to thermodilution cardiac
output. Monitoring changes or trends in cardiac
output can be performed reasonably well with the
Modelflow and the HemoSonic, while the FloTrac
performs less well in this regard. Encouraged by
the simplicity of setup procedure and advantage
for the patient, we suggest future work focuses
on the Modelflow system.
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