PiCCO Trouble Shooting Guide | For PulsioFlex with PiCCO module

Patient situation

Interference of certain clinical situations with the PiCCO measurement 

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Intra-cardiac shunt
(Left-to-right heart)

A correct PiCCO thermodilution measurement requires the physiologic pathway of the blood in the central circulation through the right atrium, right ventricle, the lungs, left atrium and left ventricle. In case of left-to-right heart shunt a certain amount of the injected saline bolus is transferred back from the left to the right heart and is recirculated. This will cause an extended downslope of the thermodilution curve. 

  1. Cardiac index (CI) is most likely correct, possibly slightly underestimated
  2. Volumetric parameters (GEDI, ELWI) likely to be overestimated

Atrial septum defect (ASD)

Ventricle septum defect (VSD)

Atrioventricular septum defect

Intra-cardiac shunt
(Right-to-left heart)

A correct PiCCO thermodilution measurement requires the physiologic pathway of the blood in the central circulation through the right atrium, right ventricle, the lungs, left atrium and left ventricle. In case of right-to-left heart shunt a certain amount of the injected saline bolus is directly transferred from the right to the left heart without passing through the lungs. This will cause a double humped thermodilution curve, a so-called ‘Camel curve’.

  1. All thermodilution results are doubtful and should be evaluated very carefully

Cardiac valve insufficiencies

Cardiac valve insufficiencies will cause regurgitation of the saline bolus and result in prolonged thermodilution curves and indicator transit times.

  1. Validity of thermodilution results are dependent on the severity of valve insufficiencies
  2. In case, thermodilution results are available, cardiac index (CI) and extravascular lung water (ELWI) should be correct, but preload (GEDI) is likely to be overestimated

Normal Valve

Degenerative mitral valve prolapse

Degenerative mitral valve flail

Cardiac arrhythmia

The effect of cardiac arrhythmia on the PiCCO pulse contour analysis depends on the severity of arrhythmia. Mild or moderate arrhythmia like occasional extra systoles do not have any impact on availability and accuracy of PiCCO parameters and values.

Severe arrhythmia like atrial or ventricular fibrillation will have a major influence on pulse contour analysis and thus continuous parameters might be inaccurate, if displayed at all.

However, thermodilution measurements are still possible and accurate, even pulse contour values are not available.

Severe cardiac arrhythmia

Pulmonary perfusion disturbances

For correct results concerning pulmonary edema the saline bolus for thermodilution measurement needs to have access to the complete lung area. In case of severe pulmonary perfusion disturbances (e.g. pulmonary embolism) the accessible lung area is reduced.

  1. Pulmonary edema (ELWI) might be underestimated
  2. Cardiac index (CI) and preload volume (GEDI) are valid

Pulmonary Embolism

Abdominal aortic aneurysm

The saline bolus for thermodilution measurement needs to pass the extended intravascular volume by the aortic aneurysm and will prolong the indicator passage time.

  1. Cardiac index (CI) and Pulmonary edema (by ELWI) are valid
  2. Preload volume (GEDI) might be overestimated

Femoral venous thermodilution bolus injection

The use of the femoral artery for the PiCCO catheter and the femoral vein for the thermodilution bolus injection can cause signal interference, when the arterial and venous catheter are placed at the same patient side. This is the so-called ‘cross-talk phenomenon’.


Interference can be avoided by:

  1. Use of different patient sides for the arterial and venous catheter
  2. Ensure, that the venous catheter tip is positioned more proximal than the PiCCO catheter tip

The problem was not solved?

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