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Unformatted text preview: LiDCOplus Hemodynamic Monitoring Monitoring Instructions for Set-Up and Instructions Calibration Calibration 1 LiDCOplus Hemodynamic Monitor Contents – Introduction and background – Set-up of LiDCOplus – Calibration – Monitoring parameters – Troubleshooting – Discontinuing – Contraindications – References – Appendix 1: Glossary – Appendix 2: Summary of steps ( 1 – 10) (11 – 23) (24 – 42) (43 – 45) (46 – 50) (51 – 53) ( 54 ) ( 55 ) (56 – 61) (62 – 70) 2 LiDCOplus Hemodynamic Monitor LiDCO Group – founded in 1991 – CEO Terry O’Brien Research, development, and Research, manufacturing of advanced cardiovascular monitoring devices cardiovascular 3 LiDCOplus Hemodynamic Monitor Two complementary software programs – LiDCO Lithium Dilution Cardiac Output – PulseCO Pulse Cardiac Output 4 LiDCOplus Hemodynamic Monitor LiDCO program – calibration process – Lithium chloride bolus – marker – Injected into a venous line – Recovered in art-line – CO determined based on rate of dilution – Calibration factor is calculated Cardiac output (CO) – volume of blood ejected Cardiac from the heart at each beat multiplied by the heart rate 5 LiDCOplus Hemodynamic Monitor PulseCO program – continuous assessment PulseCO of CO of Analyzing beat-to-beat arterial pressure Analyzing waveform waveform ‘Pulse Power Analysis’ 6 LiDCOplus Hemodynamic Monitor Provides real-time observation of: – Cardiac function – Fluid status – Oxygen delivery to tissues Timely changes in therapy Optimize patient care 7 LiDCOplus Hemodynamic Monitor Reduces morbidity and mortality Shorter length of ICU hospitalization Useful for: Cardiac and high risk surgery Severe hypovolemia Acute heart failure Fluid shifts Sepsis Complex circulatory conditions Drug intoxication Organ transplantation Acute renal failure Medical emergencies 8 LiDCOplus Hemodynamic Monitor Advantages over thermodilution methods – Requires only art-line and venous line – Provides continuous, real-time monitoring – Easily set up by staff nurses and doctors – Not restricted to use in ICU’s – At least as accurate as thermodilution At methods methods 9 LiDCOplus Hemodynamic Monitor Accurate calibration is essential Instruction for staff nurses Set-up Calibration Monitoring Shut down and storage Troubleshooting 10 LiDCOplus Set-Up Gather equipment – LiDCO monitor – LiDCO disposable injectate kit – Foil envelope containing lithium Foil sensor sensor – HP module with analog output HP jack jack – 500 cc bag normal saline – 20 cc syringe – 3 cc syringe 11 LiDCOplus Set-Up Place LiDCO monitor in patient room – Screen readily visible – Monitor cable within Monitor reach of patient monitor reach 12 LiDCOplus Set-Up Plug monitor into Plug electrical outlet electrical Turn on – Rocker switch under Rocker right corner right Allow a few minutes Allow to warm up to Rocker switch 13 LiDCOplus Set-Up Insert jack plug into ICU monitor module or Insert analog output opposite the pressure cable analog – Either 1/8 inch or 1/4 inch adapter 14 LiDCOplus Set-Up First section of injectate kit – Luer lock spike for saline bag – Park and Ride tubing – Patient identification label For saline bag 15 LiDCOplus Set-Up Spike saline bag Hang saline on LiDCO stand 16 LiDCOplus Set-Up Flush Park and Ride with saline Withdraw 20 cc saline Set aside 17 LiDCOplus Set-Up Check expiration date Remove lithium sensor Remove from foil pack from Flush sensor with about Flush 20 cc saline to wet wick Remove air bubbles Remove 18 LiDCOplus Set-Up Second section of injectate kit – – – – 10 cc syringe Disposable filter straw Lithium chloride vial Patient identification Patient label label Attach filter straw Attach to syringe to 19 LiDCOplus Set-Up Snap top off lithium chloride vial Draw up lithium chloride 20 LiDCOplus Set-Up Label syringe Attach needle free valve Place syringe in platform bracket 21 LiDCOplus Set-Up Open third section of Open injectate kit injectate Attach tubing to lithium Attach sensor sensor Thread tubing through Thread regulator pump regulator Change 9-volt battery in pump monthly, or as needed 22 LiDCOplus Set-Up Connect sensor interface pod (blue box) to Connect lithium sensor via sensor cable lithium LiDCOplus is ready for calibration 23 LiDCOplus Calibration Determining the calibration factor for PulseCO program Obtain patient information – Height – Dry weight – Recent hemoglobin value Recent hemoglobin – Recent sodium value Recent sodium 24 LiDCOplus Calibration Should be done during stable Should hemodynamic period hemodynamic Do not calibrate while blood is infusing Accurate calibration is essential Incorrect calibration = erroneous data 25 LiDCOplus Calibration Touch yellow start icon Patient information screen – – – – Identification (number) Height Dry weight Target values if desired 26 LiDCOplus Calibration Press PulseCO icon – Make sure data is Make coming across monitor cable and module cable Touch the arterial Touch – Match blood pressure – Match heart rate 27 LiDCOplus Calibration Press LiDCO icon to Press access patient details access Fill in yellowed fields Fill – Saturation value for DO2 – CVP if available for CVP accurate SVR calculation accurate Sensor constant 10.5 Concentration 0.300 mmol mmol Concentration – Value changes for pediatric Value patients (< 40 kg) patients 28 LiDCOplus Calibration Change metric and standard measurements 29 LiDCOplus Calibration Draw 2 cc lithium chloride Draw cc – Inject into Park and Ride Inject Park tubing tubing Attach Park and Ride Attach Park tubing to venous port tubing – Shut off fluids and clamp Shut tubing tubing 30 LiDCOplus Calibration Refill 20 cc syringe with Refill 20 cc saline 20 Lithium may bleed back Lithium into 20 cc syringe if attached too early attached 31 LiDCOplus Calibration Check art-line for patency Attach lithium sensor to Attach stop-cock stop-cock – Within 12 inches of cannula Turn stop-cock off to Turn patient patient – Flush sensor with the Flush arterial flush and squeeze red ears on regulator-red remove air bubbles 32 LiDCOplus Calibration Turn stop-cock off to Turn flush flush – Allow arterial blood to Allow flow past sensor by squeezing red ears on pump pump Attach 20 cc saline Attach syringe to Park and Ride tubing Ride 33 LiDCOplus Calibration Touch LiDCO icon – calibration screen Check sensor and battery voltage Check indicators they should both be green they If sensor voltage is red If red – Check all cable connections – Check for air bubbles – Check for blood clots – Flush wick Flush – Possibly change sensor If battery voltage is red If red – Check or replace blue pod – Check USB connection to pod Calibration screen 34 LiDCOplus Calibration Turn on regulator pump – Blood flows at 4 cc / minute 35 LiDCOplus Calibration Press Reset Baseline Press Reset icon repeatedly icon – Bring the baseline Bring to 0.0 to – System icon should turn green turn Unclamp venous Unclamp tubing to receive lithium bolus lithium System Icon 0.0 Reset Icon 36 LiDCOplus Calibration Check all indicator fields – – – – Green ‘Ready to use’ icon Baseline at 0.0 Sensor and battery fields green Regulator pump running Press green Inject icon Press icon Count to 5 Infuse 20 cc saline steadily Infuse for 5 seconds for 37 LiDCOplus Calibration Dilution curve appears in 10 to 20 seconds 38 LiDCOplus Calibration Turn off regulator pump when Turn the prompt appears the Flush art line Flush sensor Touch ‘Done’ icon Check output curve for three Check components components Touch ‘Calibrate PulseCO’ Touch icon Allow arterial waveform to be transduced transduced 39 LiDCOplus Calibration Press done icon Press blinking ‘=‘ icon Press when dark blue when 40 LiDCOplus Calibration LiDCO monitor is now LiDCO calibrated calibrated Press PulseCO icon to Press return to hemodynamic screen Hemodynamic screen 41 LiDCOplus Calibration Document calibration Document factor factor – Changes with each Changes calibration calibration Repeat calibration Repeat every 8 to 12 hours every Replace disposable Replace equipment according to hospital IV protocol to 42 LiDCOplus Monitoring Parameters recorded Parameters ordered by physician ordered – – – Oxygen perfusion (DO2) Cardiac output (CO) Systemic vascular Systemic resistance (SVR) resistance Normal values provided Normal in handouts in Record on Nursing Flow Record Sheet at requested intervals intervals 43 LiDCOplus Monitoring Preload indicators – Help determine patient fluid Help status status – SPV – systolic pressure SPV variation > 5 preload responsive responsive – PPV – pulse pressure PPV variation > 10 preload responsive responsive – SVV – stroke volume SVV variation > 10 preload responsive responsive 44 LiDCOplus Monitoring History Screen – Retrieve data for Retrieve the last 24 hours – Touch the time on Touch the top bar – Touch the graph to Touch get parameters get 45 LiDCOplus Monitoring Troubleshooting If no CO is displayed: – Pump turned off too soon – Saline flushed in too quickly (Count to 5, inject for 5) 46 LiDCOplus Monitoring Troubleshooting If CO appears to double – Possibly high dicrotic notch Compare Heart Rate on patient monitor and Compare LiDCO monitor LiDCO Move Beat Detector up to 60%, or until heart Move Beat rates match on monitors rates CO does not match clinical picture – Check art-line for dampening – Recalibrate 47 LiDCOplus Monitoring Troubleshooting If dilution curve appears flat not peaked – All of the lithium may not have infused at one time Check to see that the IV tubing was occluded toward the IV bag – Saline may have been flushed too slowly Re-park lithium and pinch or clamp tubing above injection site Re-park before flushing with 20 cc of saline before If LiDCO icon is missing – Check cables to and from blue pod – Check USB cable to back of monitor 48 LiDCOplus Monitoring Troubleshooting SVR appears to be SVR inaccurate inaccurate – CVP may not have CVP been entered been – If default CVP (7) is If used, do not document document It will only be a It trended number trended 49 Problems With Calibration Troubleshoot with other staff Contact one of the ‘Super-Users’ on Contact your unit your Call your LiDCO Regional Manager or the Call LiDCO answering service LiDCO – (877) 543-2658 50 Ask for someone with LiDCO to return your call Discontinuing the LiDCOplus Touch door icon lower right Touch door corner corner Wait for screen to turn black Turn off monitor when ‘safe to Turn turn off’ indicator appears turn Turn off at rocker switch Unplug computer and Unplug disconnect monitor cable disconnect 51 Discontinuing the LiDCOplus Place equipment in Place basket basket – Blue sensor interface box – Cables and cords – Regulator pump Waste bag and sensor in Waste biohazard bag biohazard Dispose of saline bag and Dispose syringes syringes 52 Discontinuing the LiDCOplus Wipe down monitor Return to storage area Try to keep equipment clean, Try organized and together organized 53 Contraindications for LiDCO Use Highly dampened arterial lines Oral lithium therapy or lithium Oral allergy allergy First trimester of pregnancy Some muscle relaxants – – – – Pancuronium Vecuronium Atracurium Rocuronium Methamphetamine 54 References AIM company profile – LiDCO Group plc. London Stock Exchange. 5 July, 2001. AIM http://www.londonstockexchange.com/en-gb/products/companyservices/joiningbeingonma… 1/10/2006. http://www.londonstockexchange.com Continuous, Real-Time Cardiovascular Monitoring. LiDCO Cardiac Sensor Systems. www.lidco.com 1/10/06 Continuous, www.lidco.com LiDCOplus Set-up Procedure. Video made available by www.lidco.com. LiDCOplus www.lidco.com Mosby’s Medical Nursing & Allied Health Dictionary, fifth edition. Mosby, Inc. St. Louis. 1998. Parlry-Jones, Pittman. Arterial pressure and stroke volume variability as measurements for cardiovascular Parlry-Jones, optimisation. International Journal of Intensive Care. Volume 10, Number 2. Summer 2003. optimisation. Pittman, James, Bar-Yosef, Shahar, SumPing, Johns, Sherwood, Matthew, Mark, Jonathan. Continuous cardiac Pittman, output monitoring with pulse contour analysis: A comparison with lithium indicator dilution cardiac output measurement. Critical Care Medicine, 2005, Vol. 33, No. 9. PP. 2015 – 2021. measurement. 55 Appendix 1 Glossary of Terms Associated with LiDCO Operation CI (cardiac index)—a measure of the cardiac output of a patient per square CI meter of body surface area. It is obtained by dividing the cardiac output in liters per minute by the body surface area. Normal values for an adult are 2.5 – 4.0 L/min/m2 Normal CO (cardiac output)—the volume of blood pumped by the heart per minute. CO Normal range is 4.0 – 8.0 L/min Normal CVP (central venous pressure)—the pressure of blood in the superior vena CVP cava. It is approximately equal to the right atrial pressure. Normal values are 2 – 14 mm H2O Normal DO2—amount of oxygen delivered to the tissues. DO2—amount Normal values are 950 – 1150 mls/min Normal 56 Appendix 1: Appendix Glossary (cont’d) Glossary Hemodynamics—the study of the physical aspects of blood circulation, including cardiac function and peripheral vascular physiologic function characteristics. characteristics. Hemoglobin—a protein-iron compound in the blood that carries oxygen to Hemoglobin—a the cells from the lungs and carbon dioxide away from the cells to the lungs. In LiDCO calibration the hemoglobin value is converted to packed red blood cell volume, which is important because the lithium is found only in the plasma. The additional volume of the blood due to the packed cell volume then becomes important in the cardiac output determination. determination. Lithium chloride—a natural salt (found in drinking water) that is used as a Lithium chemical marker in LiDCO calibration, has no pharmacological impact on the body, which is injected into a vein. It passes through the heart and lungs, and is picked by the lithium sensor in an arterial line. The characteristics of dilution as it travels through the circulatory system are used to calculate the cardiac output. Lithium’s positive electrical charge is what allows it to be measured electrically by the lithium sensitive sensor. sensitive 57 Appendix 1: Appendix Glossary (cont’d) Glossary MAP (mean arterial pressure)—the arithmetic mean of the blood pressure in MAP the arterial part of the circulation. It is calculated by adding the systolic pressure reading plus two times the diastolic reading, divided by 3. Normal values are 70 – 105 mmHg Normal PPV (pulse pressure variation)—pulse pressure is the difference between PPV the systolic pressure and the diastolic pressure. During mechanical respiration, the increase and decrease in intrathoracic pressure cause changes in the pulse pressure. The difference between the high and low pulse pressures represent the pulse pressure variation, and are calculated as a percentage. PPV is one of several sensitive indicators of preload. Normal values are < 10%. Values > 10% indicate the patient would benefit from a fluid bolus benefit Preload—the maximum stretch on the heart’s muscle fibers at the end of Preload—the diastolic filling. The degree of stretch is determined by the volume of blood contained in the ventricle at that time. The heart performs most efficiently when it is appropriately filled with blood. Pre-load indicators include SVP, SVV, PPV. include 58 Appendix 1: Appendix Glossary (cont’d) Glossary Sodium—one of the most important elements in the body, sodium is an Sodium—one alkaline metal found as a positive ion. It is involved in acid-base balance, water balance, transmission of nerve impulses, and contraction of muscles. The sodium value is used in the CO determination in LiDCO calibration as a baseline voltage before the lithium is injected, since it has a positive electrical charge like the lithium. lithium. SPV (systolic pressure variation)—the difference between the maximal and SPV minimal values of the systolic blood pressure (SBP) during a mechanical (ventilator) breathing. It is one of several sensitive indicators of preload. Normal values are less than 5 mm Hg. Values greater than 5 mm Hg (considered to be 10 mm Hg by some, Ken) indicate the patient is ‘dry’ (considered SV (stroke volume)—the amount of blood ejected by the ventricle during SV contraction. Normal values are 60 – 100 mls/beat Normal 59 Appendix 1: Appendix Glossary (cont’d) Glossary SVR (systemic vascular resistance)—refers to the resistance to blood flow SVR by all of the systemic vasculature, excluding the pulmonary vasculature. It is affected by changes in blood vessel diameters and changes in blood viscosity. SVR also represents the resistance against which the left ventricle must eject to force out its stroke volume with each beat. Normal values are 800 – 1200 dynes.sec/cm5 Normal SVRI (systemic vascular resistance index)—the systemic vascular SVRI resistance per body area (m2). resistance ). Normal values are 1970 to 2390 dynes.sec/cm5/m2. Normal SVV (stroke volume variation)—the reduction in stroke volume associated SVV with reduced venous return during positive pressure ventilation. Normal values are < 10%. Values > 10% indicate the patient would benefit from a fluid bolus benefit 60 Appendix 1: Appendix Glossary (cont’d) Glossary Swan-Ganz Catheter—a long thin catheter with a tiny balloon at the tip. It Swan-Ganz is used to determine left ventricular function by measuring pulmonary capillary wedge pressure. capillary 61 Appendix 2 Summary of Set-Up and Calibration Gather equipment Place LiDCO monitor in pt. room – Plug in, turn on, warm up Attach cable to overhead monitor 62 Appendix 2: Set-Up Set-Up First injectate envelope – Spike saline bag (and label) – Hang on LiDCO stand Withdraw 20 cc saline Flush Park and Ride tubing Flush Park Check expiration date on sensor packet Flush sensor with saline 63 Appendix 2: Set-Up Set-Up Second injectate envelope – – Open lithium ampule Draw the 10 cc of lithium into the 10cc syringe with Draw the filter straw the – Place multiuse port and label on the 10 cc syringe Third injectate envelope – Attach tubing to sensor – Thread tubing into regulator pump Connect sensor cable to sensor 64 Appendix 2: Calibration Calibration Obtain patient information – Height, weight, Hgb, Na Touch yellow Start icon Touch Start Enter patient information Touch PulseCo icon—make sure data is being displayed Touch LIDCO icon – – – Enter data in yellowed fields CVP if available; O2 saturation is important Sensor constant 10.5; concentration 0.300 mmol 65 Appendix 2: Calibration Calibration Inject 2 cc lithium (if pt. > 40 kg) into Park and Inject Ride tubing Ride Refill 20 cc syringe with saline Attach sensor to art-line – – – – – Turn stopcock off to arterial line Flush to remove bubbles Turn stopcock off to arterial flush open to arterial line Flush with arterial blood Attach 20 cc syringe of saline to Park and Ride tubing Attach Park 66 Appendix 2: Calibration Calibration Touch LIDCO icon to bring up Touch Calibration Screen Calibration – Voltage indicators green Turn on regulator pump to pump arterial blood Reset to bring baseline to 0.0 Unclamp venous tubing to receive lithium bolus 67 Appendix 2: Calibration Calibration Check: – – – – System ‘Ready to Use’ icon green Sensor and battery fields green Baseline at 0.0 Regulator pump running Press green inject icon Count to 5, then inject for 5 68 Appendix 2: Calibration Calibration Dilution curve appears If curve is good, follow instructions and touch If blinking icons blinking – – – – – – – Turn off regulator Flush lines Press done icon Check dilution curve Press Calibrate PulseCO icon Press ‘Done’ icon Pressing blinking ‘=‘ icon when numbers appear 69 Appendix 2: Calibration Calibration Press PulseCO icon to return to Press hemodynamic screen hemodynamic Document calibration factor Repeat every 8 to 12 hours 70 LiDCO, Limited gratefully LiDCO, acknowledges Clark Willoughby at the University of Iowa for the development of this program development 71 ...
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