Copyright HEMO SAPIENS^®

This 24-minute case study documents the hemodynamic and oxygen transport management capability of the HOTMAN^® BAS System in the intensive care setting. The patient was a 65-year old female who underwent a mitral valve replacement surgery. She was transported from the operating room into the intensive care unit at about 10:00 on October 31, 1996. Prior to attachment of the HOTMAN^® BAS System at 12:45, the patient was managed by conventional methods from information obtained from the patient monitor (HR, MAP) and from the thermodilution (TD) catheter. The TD catheter was used to measure the invasive CI values, CVP and PAOP pressures, and to periodically draw a sample of the mixed venous blood. The SvO (saturation of oxygen in mixed venous blood) value was determined in the Blood Laboratory from this blood sample. As a result of thoracic and open heart surgery, at 12:56 the patient is dysrhythmic, hemodiluted (Hgb = 9.6 g/dl vs. normal value of 14 g/dl) and has an elevated level of thoracic fluids (TFC). The CI values measured by the thermodilution catheter and CI values measured by the HOTMAN^® System were in good clinical agreement. Since the SvO value was available, the HOTMAN^® System was switched to operate in the Invasive Data Available mode, processing and displaying complete oxygen transport data (including oxygen consumption). The measured values of CVP = 18 Torr, PAOP = 17 Torr, Hgb = 9.6 g/dl and SvO = 74% were entered via the HOTMAN^® BAS System's keyboard.

Above is the left half of the patient's Digital Data Page (stored on the hard disk automatically every minute), starting at 12:56 and ending at 13:19. The ECG (please note the disrhythmia), dZ/dt (an image of aortic blood flow), Z and rate of respiration signals are displayed in the four blue-green windows on the left. Please return to this page after reaching the end of the study to further analyze the information discussed below.

Below is the Monitoring Page at 12:56. Patient's blood flow, oxygen transport data and the parameters of left heart are compromised. However, since the patient underwent a major surgery and is approximately three hours after the surgery, she should be viewed and managed through the POSTOPERATIVE Therapeutic Goal, requiring a supranormal level of oxygen delivery. The HOTMAN^® System was, therefore, switched into the POSTOPERATIVE Goal. Her oxygen consumption is profoundly compromised, expressed by the position of the VOI diamond, which, due to exceeding the bargraph linear range, changed the color to green.

Below is the corresponding Hemodynamic Management Page.

The hemodynamic causes are: Reduced inotropic and chronotropic state and vasoconstriction.

Her Hemodynamic Management Page was analyzed at this time by the special hemodynamic modeling capability of the HOTMAN^® BAS System. With a touch of the key, the system was switched to Hemodynamic Modeling Page (below):

The original hemodynamic point of the patient is documented by the small yellow hexagon, corresponding to the Hemodynamic Management Page above. Using a mouse, the operator can move the sliders to increase or decrease the level of each hemodynamic modulator. The center position of the sliders corresponds to the current level of hemodynamic modulators for the hemodynamic state at 12:56. Since the patient is normovolemic, the VOLUME slider is left in the center position. Profound (124%) hypoinotropy is rectified by moving the INOTROPES slider toward POSITIVE inotrope side till normoinotropy is reached. Similarly, the 59% vasoconstriction is rectified by moving the VASOACTIVE DRUGS slider till NORMOVASOACTIVITY is displayed in the HEMODYNAMIC MODULATORS column.

Based upon this hemodynamic management information from HOTMAN^® BAS System, the rate of volume expansion was maintained unchanged, the positive inotropic support (dopamine) was increased and a vasodilator (sodium nitropruside) in a higher titration was used for further afterload reduction. No chronotropic therapy was used, since the increase of SI provided an increase in CI, thus gradually decreasing and, eventually, eliminating the hypochronotropy. (Please study the changes of all parameters recorded in increments of every minute in the digital data page on top of this page).

The effects of normohemodynamic management are astounding: The Hemodynamic Management Page (POSTOPERATIVE) 24 minutes later is displayed below. Please note that due to a rapid intravenous drug infusion, the patient is in a normal hemodynamic and perfusion flow (CI) state in only 24 minutes. Also note an increase in peak aortic blood flow (an increased magnitude of the dZ/dt signal). Please note the results of the therapy closely correspond to its modeling prior to its institution.

The corresponding Monitoring Page (POSTOPERATIVE) at 13:19 is below. Please note a profound improvement of all hemodynamic and perfusion flow parameters. The oxygen transport (consumption and delivery) are still at infranormal levels due to hemodilution. A subsequent transfusion of packed red blood cells (not shown here) increased Hgb level and corrected this last oxygen delivery abnormality.

The patient was therapeutically managed to remain in this hemodynamic state and, as a result, underwent a normal and uneventful recovery.