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Within a hospital setting in Northeast Ohio, to promote positive patient outcomes, yearly analysis
of intensive care unit (ICU) policies and procedures must be conducted. The clinical nurse
educators are in charge of coordinating this process. The policy and procedure for the noninvasive cardiac output monitor (NICOM) had not been reviewed since June 2014. Using
evidence-based sources, a thorough analysis and subsequent updates were executed.
Appendix A
Original NICOM Policy and Procedure
PURPOSE:
To provide non-invasive assessment of the patients hemodynamic status for purposes of fluid
optimization, differential diagnosis, and drug titration.
POLICY:
The primary goal of patient fluid and/or other forms of resuscitation is to restore adequate tissue
perfusion. Cardiac output (CO), which drives tissue perfusion, is equal to the product of stroke
volume (SV) and heart rate (HR). SV is dependent upon complex interactions between preload,
afterload, and cardiac contractility. Various measurements (hemodynamic parameters) and
technologies (advanced hemodynamic monitoring) have been developed to assess preload and
afterload. Advanced hemodynamic monitoring is an important part of treatment in clinical
situations where aggressive, yet guided hemodynamic interventions are required in order to
stabilize the patient and optimize outcomes. Clinical situations in which hemodynamic
monitoring may be indicated, include shock (hypovolemic, cardiogenic, septic, anaphylactic, and
neurogenic), trauma, acute myocardial infarction with shock, and increased metabolic demands
(burns, infection and peri-operative states). The NICOM is a non-invasive advanced
hemodynamic monitoring technology. A discussion of the merits of alternative means of
hemodynamic monitoring is beyond the scope of this policy
Page 2 of 6
PROCEDURE:
Equipment:
NICOM
NICOM Electrodes/Sensors
NICOM Non-Invasive Blood Pressure (NIBP) cuff (attached to NICOM)
Passive leg raise (PLR) wedge, if available
The NICOM is not defibrillator protected: disconnect the lead wires from the electrodes
prior to defibrillation! Keep NICOM plugged in to retain full battery power.
STEPS:
KEY POINTS:
1. Obtain ordering provider order for NICOM
monitoring.
2. Explain procedure to patient/family.
3. Follow standard precautions during procedure
by washing/degerming hands before and after
patient contact.
4. Assemble equipment/obtain NICOM
NICOM electrodes are a charge item.
electrodes/sensors.
5. Apply NICOM BP cuff.
To apply electrodes:
1. If necessary, clip hair. If skin is oily, wipe
with alcohol prep pad.
2. Gently rub skin with sand paper included
in electrode packet.
3. Place upper set of electrodes length-wise
on patients chest, shoulders, or back (midclavicular line). Place lower set of
electrodes length-wise on abdomen (midclavicular line), flanks, or back. Avoid
placement into skin folds. Ensure electrode
cable connector points downward toward
patients feet. (Refer to pictures on
electrodes and packaging for guidance).
4. Attach leads to NICOM cables: red to red,
transparent to black).
5. Secure lead cables to patients skin
approximately 2 inches below electrode
with adhesive tape.
Page 3 of 6
KEYPOINTS:
STEPS:
6. Write date/time of electrode
application on adhesive tape.
To begin monitoring:
1. Turn on monitor by pressing and
holding the green ON switch for
approximately 30 seconds. Wait
for beep.
2. For existing patient, select
existing patient and highlight
patients medical record number
{MRN}. If details are correct,
highlight RUN and press OK. If
details are incorrect, highlight
Update
3. details and press OK. Correct
details as needed. Skip to step #
5.
4. For new patient, select new
patient. Enter patient
information. Navigate
numbers/letters using arrow keys.
Press OK to enter selection. After
each data set is entered, click
NEXT to move to the next data
field.
MRN
Age
Weight
Height
Gender
5. After gender is entered, press
FINISH.
6. Review screen appears. Review
patient data for accuracy.
7. When completed, click RUN to
move to RUN screen. Click OK to
initiate calibration/monitoring.
6
NICOM electrodes are for single use only and
may last up to 48 hours, depending on signal quality.
7
KEYPOINTS:
choose to utilize maneuvers such as the PLR or Bolus
Protocols to immediately determine fluid
responsiveness.
Page 4 of 6
STEPS:
KEYPOINTS:
Equation
HR x SV/1000
CO/BSA
CO/HR x 1000
SV/BSA
Directly from oscillometric profile
80 x (MAP)/CO
80 x MAP/CI
(SVmax-SVmin)/{(SVmaxSVmin)/2} x 100
Normal Range
4.0 8.0 l/min
2.5 4.0 l/min
60 100 ml/beat
33 47 ml/m2/beat
70 105 mmHg
800 1200 dynes sec/cm5
1970 2390 dynes sec/cm5/m2
<10% unlikely to be preload responsive
>15% likely to be preload responsive
10
Ranges_poster-Feb21_2012-70x100.pdf.
3. Cheetah Medical. (2014, June 4). Cheetah NICOM Online Training. Retrieved from Cheetah
Medical - Non-invasive Hemodynamic Monitoring:
http://www.cheetahmedical.com/resources/training.
4. Cheetah Medical. (2014, June 4). Passive Leg Raise (PLR) Protocol with the Cheetah
NICOM System. Retrieved from Cheetah Medical : http://files.cheetahmedical.netdnacdn.com/cdn/ farfuture/JADXGHEm_jezvAwdq2- xuNWCvnJCk6jZ0dE3flB6kbI/mtime:
1398868310/sites/default/files/PLR_Challenge_F.pdf.
APPROVAL:
SICU Operations Committee
Infection Prevention and Control Services, Manager
Professional Practice Council
Appendix B
Updated NICOM Policy and Procedure
PURPOSE:
To provide non-invasive assessment of the patients hemodynamic status for purposes of fluid
optimization, differential diagnosis, and drug titration.
POLICY:
The primary goal of hemodynamic monitoring is to assess the ability of the cardiovascular
system to respond to the tissue oxygen demands within the body. Cardiac output (CO), a key
indicator of tissue perfusion, represents the volume of blood pumped by the ventricles every
minute. CO is the product of stroke volume (SV) and heart rate (HR). SV, the amount of blood
pumped by each ventricle with each cardiac cycle, is dependent upon complex interactions
between preload, afterload, and cardiac contractility. Various measurements (hemodynamic
parameters) and technologies (advanced hemodynamic monitoring) have been developed to
assess preload and afterload. With this information appropriate interventions to obtain
hemodynamic stability may be executed. Clinical situations in which hemodynamic monitoring
may be indicated include shock (cardiogenic, hypovolemic, and distributive), trauma, and times
of increased metabolic demands (peri-operative) The NICOM is a non-invasive advanced
hemodynamic monitor. A discussion of the merits of alternative means of hemodynamic
monitoring is beyond the scope of this policy.
11
Page 2 of 6
PROCEDURE:
Equipment:
NICOM
NICOM Electrodes (Sensors)
NICOM Non-Invasive Blood Pressure (NIBP) cuff (attached to NICOM)
Passive leg raise (PLR) wedge, if available
The NICOM is not defibrillator protected: disconnect the lead wires from the electrodes
prior to defibrillation! Keep NICOM plugged in to retain full battery power.
STEPS:
KEY POINTS:
6. Obtain order from ordering provider.
7. Explain procedure to patient/family.
8. Follow standard precautions during procedure
by performing hand hygiene before and after
patient contact.
9. Gather and assemble NICOM equipment.
10. Apply NICOM BP cuff.
NICOM electrodes are a charge item.
To apply electrodes:
7. If necessary, clip hair.
8. Gently rub skin with sand paper included
in electrode packet.
9. Place upper set of electrodes on patients
upper chest, shoulders, upper back, or
axillary region. Place lower set of
electrodes on patients lower ribs, flanks,
or back. Place in a lengthwise direction.
Ensure electrode cable connector points
downward toward patients feet. (Refer to
12
Page 3 of 6
STEPS:
To begin monitoring:
8. Turn on monitor by pressing and
holding the green ON switch. Wait
for beep.
9. For existing patient, select
existing patient and highlight
patients medical record number
[MRN]. If details are correct, press
RUN. If details are incorrect, press
Update
Details and correct details as
needed. When finished updating
details, press FINISH, then press
RUN. From this point, skip to step
#7.
10.
For new patient, select new
patient. Enter patient information using
touch screen technology. After each data
set is entered, select NEXT to move to the
next data field.
MRN
Age
Weight
Height
Gender
11.
After gender is entered,
KEYPOINTS:
NICOM electrodes are for single use only and
may last up to 48 hours, depending on signal quality.
13
patient. Screen displays a message that indicates
calibration is in process. Ensure patient remains still
during calibration. Parameters available include CO,
Cardiac Index (CI), SV, Stroke Volume Index (SVI),
Mean Arterial Pressure (MAP), Total Peripheral
Resistance (TPR), Total Peripheral Resistance Index
(TPRI), and Stroke Volume Variation (SVV). SVV
should not be utilized for diagnostic purposes unless
patient is in sinus rhythm and receiving positive
pressure mechanical ventilation. Ordering providers
may use these parameters to select interventions or may
choose to utilize maneuvers such as the PLR or Bolus
Protocols to immediately determine fluid
responsiveness.
KEYPOINTS:
Page 4 of 6
STEPS:
To obtain NIBP reading:
6. Press MENU key.
7. Press NIBP.
8. Press MANUAL NIBP.
9. If you want NIBP readings at timed
intervals, press MENU key.
10.
Press NIBP.
11.
Press NIBP Time Interval.
12.
Press the desired timed
interval to activate.
To assess fluid responsiveness using
either PLR or bolus protocol:
To perform PLR Test:
(Not recommended for traumatic brain injury,
leg amputees, uncontrolled atrial fibrillation,
deep vein thrombosis, pregnancy, or patients
with portal hypertension. Intermittent
pneumatic compression devices (IPCDs) on
14
Follow the monitor prompts in order to obtain the series
of readings to determine baseline and PLR readings.
KEYPOINTS:
Test is positive if SVI rises 10% or more, indicating
patient is fluid responsive. Test is negative if SVI rises
less than 10%, indicating patient is not fluid responsive.
Page 5 of 6
STEPS:
18. When monitor prompts, lower the patients
HOB to flat. Elevate the patients legs to a 45
degree angle. May hold patients legs up or use
PLR wedge pillow, if available.
19. Press NEXT on monitor to continue the
test.
20. The monitor counts down 3
minutes.
21. After 3 minutes is up, lower the
patients legs back down and raise
the HOB to a comfortable position.
Turn IPCDs back on, if applicable.
Resume IV fluids.
To perform BOLUS Test:
5. Press MENU, PROTOCOL, and BOLUS
TEST.
6. To obtain baseline data, press NO.
15
Equation
HR x SV/1000
CO/BSA
CO/HR x 1000
SV/BSA
Directly from oscillometric profile
80 x (MAP)/CO
80 x MAP/CI
SVmax-SVmin/[(SVmax +
SVmin)/2] x 100
Normal Range
4.0 8.0 l/min
2.5 4.0 l/min/m2
60 100 ml/beat
33 47 ml/m2/beat
70 105 mmHg
800 1200 dynes sec/cm5
1970 2390 dynes sec/cm5/m2
<10% unlikely to be preload responsive
>12% likely to be preload responsive
16