Edwards Lifesciences
Vigileo Monitor Simulation Instructors Guide for v2.0 Oct 2011
Instructors Guide
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e cec Edwards Critical Care Education
Vigileo Monitor Simulation Instructors Guide for v2.0 October 2011
Welcome to the Edwards Lifesciences Vigileo Monitor Simulation The Vigileo monitor simulation integrates the Vigileo monitor with the Laerdal SimMan platform for simulation training. The program includes three preprogrammed patient scenarios. This toolkit includes all the direction an instructor needs to proctor the Vigileo monitor simulator program to healthcare providers. Contents Overview of the Vigileo Monitor Simulation... 2 Installation... 3 System Requirements... 3 Recommended Software... 3 Installation Steps... 4 Displays and Equations... 6 Instructors Guide for Operating the Vigileo Monitor Simulation... 7 Simulation Scenario... 7 Starting the Scenario... 7 Patient History... 7 Instructions... 7 Instructors Guide for Operating Laerdal SimMan with the Vigileo Monitor Simulation... 8 Medications... 8 Selecting Medications During a Scenario... 8 Drug Interactions... 9 Miscellaneous... 10 Selecting Decompensation ON/OFF... 10 Selecting Labs or X-ray During a Scenario... 11 ABC... 12 Heart Rhythm... 12 Selecting Atrial Fibrillation . ... 12 Selecting Passive Leg Raise During a Scenario... 13 Selecting PEEP During a Scenario ... 13 Instructors Guide for Operating the Vigileo Monitor Façade... 14 Turn Monitor On or Off... 14 Switching Between Numerical and Trend Values... 14 Changing Display Options... 15 End Points of Simulation Scenario... 16 Scenario Debriefing... 16 Other Important Features... 17 Instructor Monitor Configuration... 18 Simulation Scenarios... 21
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Overview of the Vigileo Monitor Simulator Program The Vigileo monitor allows for monitoring the balance of oxygen delivery and consumption by displaying continuous central venous oxygen saturation (ScvO2) when used with the PreSep catheter. Additionally, the Vigileo monitor also displays key flow parameters such as continuous cardiac output (CCO/CCI), stroke volume (SV), stroke volume variation (SVV), and systemic vascular resistance (SVR) when used with the FloTrac sensor. Vigileo Monitor - Expandsthe options for monitoring high-risk patients: • Guiding fluid optimization • Assessing real-time changes in vascular tone • Guiding inotropic therapy in real time • Optimizing the effects of HR and SV • Managing precise titration of cardiovascular medications FloTrac Sensor - Provides continuous cardiac output (CCO), stroke volume (SV), stroke volume variation (SVV), and systemic vascular resistance (SVR) through an existing arterial line. The FloTrac sensor connects to an existing arterial catheter: • Performs continuous self-calibration through its automatic vascular tone adjustment • Calculates key flow parameters every 20 seconds • Continuously monitors changes in patient’s vascular tone (compliance and resistance) • Validated against the clinical gold-standard Swan-Ganz pulmonary artery catheter PreSep Oximetry Catheter (ScvO2) - Central venous oximetry as measure in the superior vena cava by a central venous catheter with integrated fiberopitc strands which is connected to an Edwards oximetry computer (EV1000, Vigileo, Vigilance II).
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Installation System Requirements • Processor: Minimum Pentium M 1.8 GHz or better • Hard drive: 60 GB minimum • RAM: 512 MB minimum • System: Windows XP and Windows 7 • CD-ROM drive Recommended Software • Laerdal SimMan with software version 3.5
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Installation Steps 1. Remove all previously loaded Vigileo, Vigilance II, and EV1000 programs as well as the previously loaded SimSuite monitor interface. 2. Close all open applications. 3. Insert the installation disk in the CD drive. The installation will begin automatically after the disk is inserted. 4. Follow the steps on the installer using the ‘Next’ and ‘Back’ buttons.
5. Click the ‘Close’ button when the setup wizard has completed the installation.
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6. Multiple installers will launch automatically. Continue to use the ‘Next’ and ‘Back’ buttons to complete the installation process. 7. Restart the computer. 8. Open the ‘Edwards Lifesciences Scenarios’ shortcut on your desktop.
9. Right click on the ‘Edwards Lifesciences’ folder and select ‘Copy’. 10. Start SimMan. 11. Select ‘File’ from the list of menus as the top of the SimMan window. 12. Select ‘Start Scenario’. 13. Right click in the new window and select ‘Paste’. If asked if you want to merge and/or copy any files, select ‘Yes’.
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Displays and Equations In order for each of the parameters to change in synch with each other from a physiologic perspective values are based upon well established equations. The following are parameters, the equations that affect the values, and how they are displayed on the Vigileo monitor simulation. Cardiac Output or Cardiac Index (CO/CI) Cardiac output or cardiac index values displayed on the Vigileo monitor simulation are double the value on the instructors screen of the SimMan program. This was to allow the simulation of high output or hypderdynamic states. Cardiac index is calculated by CO/BSA, with BSA calculated using the Dubios scale. Stroke Volume or Stroke Volume Index (SV/SVI) Stroke volume or stroke volume index on the Vigileo monitor simulation are calculated by dividing the CO or CI displayed on the Vigileo monitor by the heart rate displayed next to the ECG (CO/HR or CI/HR). Systemic Vascular Resistance (SVR/SVRI) Systemic vascular resistance or systemic vascular resistance index is calculated and displayed on the Vigileo monitor simulation based upon the standard equation SVR = MAP-CVP/CO x80 or SVRI = MAPCVP/CI x 80.
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Instructors Guide for Operating the Vigileo Monitor Simulation Simulation Scenarios 1. Vigileo Cardiogenic Shock (Cardiogenic Shock due to NSTEMI). 2. Vigileo Hypovolemic Shock (Hypovolemic Shock due to Lower GI Bleed). 3. Vigileo Septic Shock (Septic Shock due to Pneumonia). 4. Vigileo On The Fly. Starting the Scenario 1. Click ‘Start Scenario’. 2. Select ‘Edwards Lifesciences’. 3. Select ‘Vigileo’. 4. Select desired scenario. Patient History • Review the patient history handout prior to starting the scenario to add context to the case • A participant copy of the patient histories can be found in the “Participant Materials” section Instructions The objective of the simulation scenario is to evaluate hemodynamic data from the Vigileo monitor and the patient bedside monitor to most appropriately treat a patient in a shock state. Therapeutic options include fluid resuscitation, blood products, vasopressors, inotropes, and diuretic administration. Continue to manage your patient until end points of resuscitation are met.
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Instructors Guide for Operating Laerdal SimMan with the Vigileo Monitor Simulation Medications Selecting Medications During a Scenario
• Select the desired medication from the list of interventions in the medication event menu - Selecting the same medication more than once simulates giving multiple doses of fluid or upward titration of a medication • Interventions listed under ‘Decrease or Discontinue Medications’ on the medication event menu allow the instructor to discontinue a previous intervention - If an intervention is selected more than once, interventions listed under “Decrease or Discontinue Medications” allow the instructor to downward titration of the medication • Intervention peak effect occurs in 1 minute after being selected • Avoid selecting multiple interventions in rapid succession. Rapid selection of interventions may not trigger the intended effect in the simulation scenario although it may appear as if it was selected
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Drug Interactions HR
SBP
DBP
CVP
SVV
ScvO2
CO
Hgb
HR
SBP
DBP
CVP
etN2O
ICP
CO
etAGT SimMan Parameter
85
110
70
6
23
57
3.2
10
Crystalloid 500 ml
Independent
-5
4
2
1
-3
2
0.3
0
Crystalloid 1000 ml
Independent
-10
8
4
2
-6
4
0.6
-1
Colloid
Independent
-5
4
2
1
-3
2
0.3
0
PRBC
Independent
-5
4
2
1
-3
2
0.3
0
FFP
Independent
-5
4
2
1
-3
2
0.3
0
Norepinephrine
SVV > 15
2
10
7
1
0
2
-0.3
0
SVV < 15
2
10
7
2
0
2
0.3
0
Vasopressin
SVV > 15
2
10
7
1
0
2
-0.3
0
SVV < 15
2
10
7
2
0
2
0.3
0
Phenylephrine
SVV > 15
-5
10
7
1
0
2
-0.3
0
SVV < 15
-5
10
7
2
0
2
0.3
0
Dopamine
SVV > 15
10
10
7
1
0
4
0.2
0
SVV < 15
5
10
7
1
0
4
0.4
0
Epinephrine
SVV > 15
12
10
7
1
0
5
0.3
0
SVV < 15
7
10
7
2
0
5
0.6
0
Dobutamine
SVV > 15
10
-5
-3
-1
3
2
0.3
0
SVV < 15
5
0
0
0
0
4
0.6
0
Nitroglycerine
SVV > 15
10
-10
-7
-2
2
-3
-0.2
0
SVV < 15
5
-10
-7
-2
0
-2
0.2
0
Nitroprusside
SVV > 15
7
-10
-7
-2
3
-3
-0.2
0
SVV < 15
3
-10
-7
-2
1
2
0.2
0
Hydralazine
SVV > 15
7
-10
-7
-2
3
-3
-0.2
0
SVV < 15
3
-10
-7
-2
1
2
0.2
0
SVV > 15
6
-8
-4
-2
5
-5
-0.4
2
Furosemide
SVV<15,SBP>140
2
-4
-2
-1
1
2
0.3
1
SVV<15,SBP<140
2
-4
-2
-1
2
0
-0.2
1
PLR/Fluid Challenge
Positive Response
-10
8
4
2
-6
4
0.8
0
Negative Response
-5
4
2
1
-3
2
0.2
0
Parameter
Initial Vital Signs
(Drug Interactions: A list of interventions and there affect on each parameter based upon the SVV at that time)
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Miscellaneous
Selecting Decompensation ON/OFF ‘Decompensation ON’ sets the simulators parameters to decompensate 2 minutes after an intervention has had its full affect. ‘Decompensation OFF’ sets the simulators parameters to maintain at the level achieved after an intervention has had its full affect.
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Selecting Labs or X-ray During a Scenario • Labs can be displayed on the patient monitor by selecting ‘Labs’ under the ‘Diagnostics’ folder from the ‘Miscellaneous’ event menu • A chest x-ray can be displayed on the patient monitor by selecting ‘CXR’ under the ‘Diagnostics’ folder from the ‘Miscellaneous’ event menu
Chemistry Sodium Potassium Chloride CO2 Glucose BUN Creatinine
Patient Values 136 4.1 100 20 187 25 1.4
Ref. Values 135 – 145 mmol/L 3.5 – 5.0 mmol/L 98 – 108 mmol/L 21– 30 mmol/L 70 – 140 mmol/L 7 – 20 mg/dL 0.5 – 1.1 mg/dL
CBC HBG HCT PLT WBC
Patient Values 10 31.4 215 11.8
Ref. Values 12.0 – 17.3 g/dL 35 – 40% 150 – 450 thousand/mm 3.2 – 12 thousand/mm
Coagulation Patient Values INR 1 PTT 35
Ref. Values 0.9 – 1.1 26.4 – 35.5 sec
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ABC
Heart Rhythm The rhythm of the ECG can be changed to include sinus, sinus with occasionally arrhythmias, sinus with frequent arrhythmias and atrial fibrillation. The “Yellow Heart” icon will appear when atrial fibrillation is selected indicating that SVV should not be used to evaluate fluid responsiveness. Selecting Artial Fibrillation Demonstrates the display of the yellow heart icon and the inability to use SVV as an indication of preload responsiveness.
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Selecting Passive Leg Raise (PLR)/Fluid Challenge During a Scenario Select the desired result from the list of interventions under the “Passive Leg Raise” folder from the miscellaneous event menu. Options for passive leg raise include: • Positive response • Negative response
Positive
P assive Leg Response Raise / Fluid Negative Challenge Presponse
HR
SBP
DBP
CVP
SVV
ScvO2
CO
Hgb
SpO2
Parameter
HR
SBP
DBP
CVP
etN2O
0
-5
-5
1
2
ICP
CO
etAGT
SpO2
SimMan Parameter
-3
-0.3
0
5
0
0
0
1
1
0
0
0
5
Selecting PEEP During a Scenario Effects of PEEP on hemodynamics can be simulated by selecting “Increase PEEP 2.5 cm” or “Decrease PEEP 2.5 cm” found in the “PEEP” folder under the ABC event menu.
EEP P 2.5 cm H20
HR
SBP
DBP
CVP
SVV
ScvO2
CO
Hgb
SpO2
Parameter
HR
SBP
DBP
CVP
etN2O
ICP
CO
etAGT
SpO2
SimMan Parameter
SVV >15
0
-5
-5
1
2
-3
-0.3
0
5
SVV <15
0
0
0
1
1
0
0
0
5
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Instructors Guide for Operating the Vigileo Monitor Façade The Vigileo monitor façade simulates the actual Vigileo monitor and is integrated with Laedal SimMan scenario programming. The façade replicates what the participant might commonly see displayed while using the Vigileo monitor in actual patient care. The façade does not contain all of the customization functionality of the actual Vigileo monitor. Turn Monitor On or Off • Press the ‘On/Off’ button to turn the façade monitor on or off. A chime will sound when the monitor is turned on. The monitor can be turned on and off during a simulation scenario without losing data
Switching Between Numerical and Trend Views • Press the ‘Multipurpose Frame Switch’ button to switch between the numerical and trend views
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Changing Display Options • The façade display can be customized by pressing anywhere on the display screen
• ‘Return’ will close the option menu and restore the display • ‘Swap CI and CO’ swaps cardiac index and cardiac output. The variables will be swapped on the numerical view. The trend view will also switch between CI and CO • ‘Hide CO’ hides the cardiac output in addition to all the derived parameters on the numerical view. CO (or CI) will be hidden on the trend view • ‘Hide ScvO2’ hides the ScvO2 on the numerical view. ScvO2 will be hidden on the trend view • ‘Refresh every 20 seconds’ will update the numerical parameters every 20 seconds rather than the default 2 seconds
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End Points of Simulation Scenario • The objective of the scenario is to resuscitate the simulated patient with a combination of multiple interventions. A predefined end point for the scenarios has not been stipulated. Participants may continue to treat the patient until satisfied with the results • General resuscitation goals: - ScvO2 ≥ 70% - Cardiac Index ≥ 2.5 L/min/m2 - SVV ≤ 10% Scenario Debriefing • Scenario debriefing allows the instructor and participants to review what occurred during the simulation scenario. Debriefing details can be saved for later review 1. Click ‘Debrief’. 2. Select ‘Yes’ on Do you really want to go to debriefing? 3. Adjust ‘Level of Detail’ to display the amount of detail desired for your debriefing session.
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Other Important Features • Additional features are available to the instructor by right clicking on the ‘Edwards E’ icon in the icon tray
• ‘Patient Info’ displays the patient’s information in a separate window in real time. The patient Information window can be used in situations where the instructor or controller does not have visibility to the Vigileo monitor facade. The information includes some additional calculated values (DO2 and VO2) as well as the current hemoglobin
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Instructor Monitor Configuration In order to configure the default screens for your instructors: Click on ‘Edit’ on the top menu. Select ‘Edit Monitor Setup’. a. Select ‘5 Waveform Layout’, and then setup the monitor according to these instructions. 1. Click on the ‘Waveform 2’ box: select ‘Secondary ECG Lead’ on the available parameters box to the right. Then click ‘Select Parameter.’ 2. Click on the ‘Waveform 3’ box: select ‘Arterial BP’ on the available parameters box to the right. Then click ‘Select Parameter.’ 3. Click on the ‘Waveform 4’ box: select ‘CVP’ on the available parameters box to the right. Then click ‘Select Parameter.’ 4. Click on the ‘Waveform 5’ box: select ‘Pleth (SpO2)’ on the available parameters box on the right. Then click ‘Select Parameter.’ 5. Click on the ‘Numeric 6’ box: select ‘AGT’ on the available parameters box on the right. Then click ‘Select Parameter.’ 6. Click on the ‘Numeric 7’ box: select ‘N20’ on the available parameters box on the right. Then click ‘Select Parameter.’ 7. Click on the ‘Numeric 8’ box: select ‘ICP’ on the available parameters box on the right. Then click ‘Select Parameter.’ 8. Click on the ‘Numeric 5’ box: select ‘NONE’ on the available parameters box on the right. Then click ‘Select Parameter.’ 9. Click on the ‘Numeric 4’ box: select ‘NONE’ on the available parameters box on the right. Then click ‘Select Parameter.’ 10. Click on the ‘Numeric 3’ box: select ‘C.O.’ on the available parameters box on the right. Then click ‘Select Parameter.’ 11. Click on the ‘Numeric 2’ box: select ‘Tblood’ on the available parameters box on the right. Then click ‘Select Parameter.’ 12. Click on the ‘Numeric 1’ box: select ‘Pulse’ on the available parameters box on the right. Then click ‘Select Parameter.’ 13. Rename layout name at the top to whatever you want. 14. Click on the ‘Save Setup’ box. The image below will pop-up.
Click on ‘Save’. Vigileo Monitor Simulation Instructors Guide
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To make this the default monitor: 15. Go to edit on your top menu bar. 16. Select ‘Configuration’. 17. Select ‘Patient Monitor’.
Click on instructor’s monitor setup click on drop down arrow select desired setup click ‘OK’.
18. A message will appear, select ‘Yes’.
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