esCCO Information vol.

Optimizing Diagnosis,
Treatment and Clinical Outcomes
Hemodynamics Graphfor GDTGoal directed therapy (GDT), a hemodynamic optimization protocol, has been shown
to be effective for improving outcomes of patients with septic shock and related shockconditions, including reductions in mortality and shorter length of stay.

Dr. Suraphong Lorsomradee, MD., PhD.
Associate Professor, Director of TIVA Training Center,Division fo Cardiothoracicand Vascular Anesthesia Divisionof Liver Transplantation Anesthesia, and Department ofAnesthesiology Faculty of Medicine at the Chiang Mai
University, Chiang Mai, Thailand

Dr. Suraphong Lorsomradee, a strong

Hemodynamics Graph as a monitoring tool

advocate of GDT, has shared his clinicalfor patients’ hemodynamics. He believes

experience using a Hemodynamic Graphicthat the Graph may be useful in GDT.

display. We present it here to summarize
the benefits of this important graphic
breakthrough that visually captures
therapeutic progress and efficacy by giving

Hemodynamics Graphthe clinician exactly what is needed to best

There has been growing global demand

treat the patient. Dr. Lorsomradee has had

for advanced monitoring tools withgood experience with Nihon Kohden’s

intuitive graphic displays and more noninvasive and continuous measurements
and parameters. The Hemodynamics
Graph is a monitoring tool that displays
comprehensive hemodynamic information
on data collected from Nihon Kohden
bedside monitors. The Hemodynamics
Graph is designed to provide an intuitive
approach to diagnostic and therapeutic
decision-making during the managementof hemodynamics. The unique Graphic
display actually consists of 2 graphs thatare interrelated: the Target Graph and theTrend Graph (Figure 1).

4Hemodynamics Graphis available
on the following
NIHON KOHDEN
patient monitors

Early Decision
Making in
Goal Directed Fluid
ManagementTarget Graph

Target Zone

Trend Graph

Figure 1 : Hemodynamics Graph
The Target and the Trend Graphs as displayed on the Nihon Kohden CSM-1900 Patient Monitor. The Target
Graph shows the progress of the patients’ hemodynamic condition towards the predetermined goal.
* Data provided by NATIONAL DEFENSE MEDICAL COLLEGE, Japan.

If the Hemodynamics Graph can ‘catch’therapies are time-consuming and overly

the transition at the early stages of thecomplicated. Alternatively, goal-directed

deterioration of a patient’s condition,therapy is a direct and straight-forward

serious conditions such as sepsis may

approach to improving the outcome of

be avoided by appropriate and timely

critically ill patients.

interventions, reducing healthcare costs

What is goal-directed therapy
and why is it effective?

Clinical usefulness ofthe Hemodynamics Graphin the ER, OR, ICU
and other care areas.

GDT is an optimization protocol to manage

The Hemodynamics Graph is useful

the hemodynamic condition of patients

throughout the course of treatment,with shock, including septic shock. Also,

following the patient from the emergency

GDT can be a critical part of perioperativeroom (ER), to the operating room (OR), andhemodynamic management in patientsto the intensive care unit (ICU). Since theundergoing moderate to high risk

Hemodynamics Graph can monitor bothsurgery. Goal-directed therapy represents

invasive and non-invasive parameters,a predetermined treatment objective

the graphic display can be used as adesigned to lead to a specific goal. The

quick identifier of severe hemodynamicmost common goal of the treatment is toimpairment in the ER, supporting quick

restore adequate microcirculation in shock

treatment decisions specific for the patient.

patients. It is very important to monitor

In the OR, depending on the severity

and improve the microcirculation of eachof surgery, invasive monitoring is oftenorgan, especially the brain, heart, lung,required. If the surgery is of only moderatekidney and liver. To treat for the sameor low risk, continuous monitoring using

desired outcome, patients can also be

the Hemodynamics Graph to monitor non-managed in various ways other than goal-invasive parameters can improve patient

directed therapy. Many of these othermanagement before, during, and afterand saving patient lives.

esCCO Information vol.4
anesthesia. If the patient is moved to the ICU, and after
weaning from invasive monitoring, the Hemodynamics
Graph can be used to continue monitoring with other,innovative non-invasive parameters, such as with esCCO,
a non-invasive and continuous measurement of Cardiac
Output.

Can the Hemodynamics Graphbe used for diagnosis?
The Hemodynamics Graph is useful for identifying thecharacteristics of shock. For example, in the case ofhypovolemic shock, using the Target Graph to display
dynamic parameters such as cardiac output and staticparameters such as blood pressure, PCWP and CVP,
can provide the ability to distinguish compensated vs.
uncompensated shock, allowing for quicker therapeutic

Figure 2 : Target Graph with CCI and PPV
Patient’s responsiveness to fluid therapy can be assessed using theTarget Graph with CCI and PPV. The area bounded by the pink lines
is the “Target Zone”, the goal of a treatment. These dots depict thecourse of patient’s condition, with a green dot showing the latest
condition. With its simplicity and ease of use, the Hemodynamics
Graph captures the clinician’s vision for successful treatment.

decisions. Patients with compensated shock tend tomaintain normal blood pressure and cardiac output

such as PPV and CI, together to manage volume status(by increasing heart rate), myocardial contractility andbased on the Frank-Starling mechanism (Figure 2). If

systemic vascular resistance. The Hemodynamics Graph

the Hemodynamics Graph indicates that the patient

provides rapid identification of the immediate condition ofis not transitioning toward to the Target Zone, or isthe patient, and of equal importance, how the therapeutic

moving in the wrong direction, the main problem mayinterventions are progressing towards the desired goal. By

be hypovolemia complicated by another condition,

looking at combined parameters in the Trend Graph andpotentially requiring inotropic support or systemic

Target Graph, the Hemodynamic Graph reveals “where thevascular resistance manipulation.

patient is”, and “where they are going.” The Graphic canhelp identify early stages of shock and rapidly recognize
the uncompensated condition, which leads to earlier
decisions as to the best treatment for the patient.

Other benefits ofthe Hemodynamics Graph?
The Hemodynamics Graph can provide a visualization of

How can the Hemodynamics Graphbe used after diagnosis?

what the physician already ’sees’ within his own mind,

With the Hemodynamics Graph, clinicians can takethe physician training, experience, and wisdom is anearlier action for treatment even before laboratory tests

invaluable tool for patient care. It removes language

confirm the diagnosis. Also, the display enables thebarriers and communicates, graphically, what is needed

confirmation of the effect and progress of treatment.

for each patient.

potentially improving team-approached medicine.
A simple graphic that captures the full benefit of

For diagnosis, clinicians would like to know if the patient
has cardiogenic shock, septic shock, neurogenic shock,

In today’s healthcare environment, simple graphs are faror hypovolemic shock as soon as possible to provide

superior to complicated displays, tables, and plots that

optimum treatment. Note that on occasion cardiogenicencumber treatment decisions by limiting the clinicalshock may occur coincident with hypovolemic shock or

input to a select individual or a small group of specialists.

septic shock. Monitoring more than 2 parameters using

For example, by managing a patient using PPV in thethe Hemodynamics Graph can be a very effective way

ICU, based on setting Target Zones aimed at the patientsto determine the best treatment path and monitor its

specific condition, the clinical team (Doctors, Nurses,effectiveness toward the specific, targeted goals. For

Respiratory Therapists) can work together as an integrated

example, assessing the patient’s responsiveness to fluid

team with the same goal - to best treat the patient.

administration can be improved by focusing on theThe Hemodynamics Graph can be useful for sharing

combined display of PPV and esCCI (continuous andtherapeutic strategy with all team members involved innoninvasive cardiac index) and determining if care isdesigning the best treatment for the patient.

adequate towards the predefined goal, or if adjustments
are required. It’s more efficient to look at 2 parameters,

8755 SP64-058A ’16. 7. CLB. A.