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See all Premium member Presentation Transcript Hemodynamic Monitoring : 1 Hemodynamic Monitoring Dr S Kumar Consultant cardiac anesthesiologist, Meenakshi Mission Hospital, Madurai Why is it important? : 2 Why is it important? Allows the assessment of physiological reserve Judge the effectiveness of applied treatment Most expensive monitoring for the most critically ill Misdirected therapy Information obtained : Cardiovascular perfomance Changes in hemodynamic status and organ perfusion Prognosis What is available? : 3 What is available? Non-invasive Vital signs → HR, BP, and RR Arterial oxygen saturation Transthoracic echocardiography Invasive Eliminates potential for error due to measurement technique Assessment is not inhibited in low-flow states Recommended for all ICU patients with cardiovascular instability In 50% of shock patients non-invasive methods underestimate BP by > 30 mmhg Invasive Hemodynamic Monitoring : 4 Invasive Hemodynamic Monitoring Arterial catheter Central venous catheter Pulmonary artery catheter The Physiologic Signal : 5 The Physiologic Signal Slide 6: 6 I. SETTING UP PRESSURE MONITORING SYSTEM II. PREVENTION OF INFECTION III. PREVENTION OF THROMBOSIS I. SETTING UP PRESSURE MONITORING SYSTEM : 7 I. SETTING UP PRESSURE MONITORING SYSTEM Equipment Transducer components Priming Zeroing Waveforms Troubleshooting Equipment Needed : 8 Equipment Needed 1. Barrier Kit, extra IV pole, transducer holder and cables. 2. Consent. 3. Set up pressure lines and transducers. 4. Level to the phlebostatic axis. 5. Zero the transducers. 6. Connect tubings to patient. Flush all ports. 7. Document findings on the ICU flowsheet Leveling and Zeroing : 9 Leveling and Zeroing Key step in obtaining accurate pressures Phlebostatic Axis : 10 Phlebostatic Axis 4th intercostal space, mid-axillary line Level of the atria Troubleshooting : 11 Troubleshooting Dampened waveform No waveform Overshooting Troubleshooting… : 12 Troubleshooting… Damp tracings / inaccurate readings Is the monitor in the proper mode and scale settings? Is the transducer level with the phlebostatic axis ? Are all the connection tight and all the stopcocks pointing in the correct direction? Is there blood in the line? Are there air bubbles in the system that may cause wave form distortions Are there occlusions or kinking in the line Troubleshooting… : 13 Troubleshooting… Inability to obtain/zero waveform Connections between cable & monitor Position of stopcocks Retry zeroing after above adjustments Slide 14: 14 Overshooting Patients with High vascular resistance Abnormally low body temperatures Complications : 15 Complications Infections. Thrombosis and emboli. Catheter wedges. Ventricular irritation. II. PREVENTION OF INFECTION : 16 II. PREVENTION OF INFECTION Use aseptic technique during insertion Remove Catheter as soon as possible Use non-vented caps on all stopcocks Change line components per policies Minimize system entry -use closed blood sampling system -use continuous cardiac output system III. PREVENTION OF THROMBOSIS : 17 III. PREVENTION OF THROMBOSIS Use continuous flush device Remove Catheter as soon as possible Use of heparin in flush solution, -supportive data unclear -contraindicated with any coagulopathy Use of catheters with heparin coating Direct Arterial Monitoring : 18 Direct Arterial Monitoring Arterial cannulation w/ continuous pressure waveform display remains the accepted standard for BP monitoring Indications : 19 Indications Arterial blood sampling Continuous real time monitoring Interventional, pharmacologic or mechanical cardiovascular manipulation Failure of indirect blood pressure measurement Timing of intra –aortic balloon Deliberate induced hypotension Cardiac surgery and Major vascular surgery. Administration of vasoactive drug infusions Arterial Pressure Monitoring : 20 Arterial Pressure Monitoring Radial Ulnar Femoral Dorsalis pedis Brachial and axillary Prerequisite : 21 Prerequisite Adequacy of collateral flow to the hands must be assessed by performing a modified Allen test Slide 22: 22 The Arterial Waveform in relation to the EKG : 23 The Arterial Waveform in relation to the EKG Systolic Upstroke Systolic Peak Pressure Systolic Decline Dicrotic Notch Diastolic Runoff End-diastolic Pressure Arterial Pressure Monitoring – Information Obtained : 24 Arterial Pressure Monitoring – Information Obtained Systolic, mean and diastolic arterial pressures Myocardial contractility Systemic vascular resistance (a low dicrotic notch suggests rapid aortic run-off) Stroke volume (area under ejection phase, upstroke to dicrotic notch is proportional to SV) Heart rate and hemodynamic effects of alterations in rhythm Contd….. Arterial Pressure Monitoring – Information Obtained : 25 Arterial Pressure Monitoring – Information Obtained Adequacy of intravascular volume,exaggerated respiratory swing suggests intravascular volume depletion Systolic pressure x time is a measure of myocardial oxygen demand Diastolic pressure x time is a measure of myocardial oxygen supply Complications : 26 Complications Ischemia Hemorrhage Thrombosis/ Embolism Cerebral air embolism (retrograde flow assoc. w/ flushing) Aneurysm / Arteriovenous Fistula formation Skin necrosis Infection (Stopcocks are an important source) Slide 27: 27 CVP PAP Introduction : 28 Introduction Venous pressure is a term that represents the average blood pressure within the venous compartment. The term "central venous pressure" (CVP) is often used to describe the pressure in the thoracic vena cava near the right atrium. Purpose : 29 Purpose To assess the left ventricular end-diastolic pressure indirectly. To evaluate the hemodynamic response to fluid therapy, medication and other treatments. To obtain accurate central vascular pressures in the presence of low cardiac output. To obtain mixed venous blood samples. To measure cardiac output. Slide 30: 30 Blood volume Cardiac function Intrathoracic (PEEP) & intraperitoneal pressure Capacitance vessel tone Indications for CVP : 31 Indications for CVP Major operative procedures involving large fluid shifts and / or blood loss Intravascular volume assessment Major trauma Surgical procedures with a high risk of air embolism For vasoactive drug administration Inadequate peripheral venous access For insertion of PAC/transvenous pacing/ hemodialysis/ plamapheresis Contraindications for CVP : 32 Contraindications for CVP Absolute Infection at the insertion site SVC syndrome Relative Coagulopathies Newly inserted pacemaker wires Complications of CVP : 33 Complications of CVP Arterial puncture Pneumothorax Nerve injury (brachial plexus) Air embolism Catheter or sheath shearing Arrythmias CVP insertion – video : 34 CVP insertion – video 34 CVP - Interpretation : 35 CVP - Interpretation Interpretation from waveforms Interpretation from numbers CVP Waveform Components : 36 CVP Waveform Components Right Atrial Pressure MonitoringWaveform Analysis : 37 Right Atrial Pressure MonitoringWaveform Analysis Elevated RAP RV failure Tricuspid regurgitation Tricuspid stenosis Pulmonary hypertension Hypervolemia Cardiac tamponade Chronic LV failure Constrictive pericarditis Decreased RAP Hypovolemia Increased contractility Camel ? : 38 Camel ? Why do you look at the shadow? : 39 Why do you look at the shadow? Pulmonary Artery Catheter : 40 Pulmonary Artery Catheter Hemodynamic data Volume status Ventricular function Oxygen delivery / consumption Fluid / medication administration Components of a PA Catheter : 41 Components of a PA Catheter PA catheter : 42 PA catheter 1.5-cc balloon 4 cm prox to balloon - thermistor 20 cm 30 cm port 110 cm long 10 cm Indications : 43 Indications Diagnostic Diagnosis of shock states Differentiation of high- versus low-pressure pulmonary edema Diagnosis of primary pulmonary hypertension (PPH) Diagnosis of valvular disease, intracardiac shunts, cardiac tamponade, and pulmonary embolus (PE) Monitoring and management of complicated AMI Indications ….. : 44 Indications ….. Assessing hemodynamic response to therapies Management of multiorgan system failure and/or severe burns Management of hemodynamic instability after cardiac surgery Assessment of response to treatment in patients with PPH Contraindications : 45 Contraindications Tricuspid or pulmonary valve mechanical prosthesis Right heart mass (thrombus and/or tumor) Tricuspid or pulmonary valve endocarditis Complications : 46 Complications Central venous cannulation : Arterial puncture Pneumothorax Nerve injury (brachial plexus) Air embolism Catheter or sheath shearing Arrythmias Complications …. : 47 Complications …. Insertion of the PAC Arrhythmias Right bundle-branch block (RBBB Knotting Maintenance of the catheter in the PA PA rupture Pulmonary infarction Unintentional distal migration Endocardial lesions (eg, thrombi, hemorrhage, vegetations) PA Catheter Hemodynamic Parameters : 48 PA Catheter Hemodynamic Parameters Pulmonary capillary wedge pressure (6 – 12 mmHg) Pulmonary artery pressure (20 – 30 mmHg) Cardiac output (CO) → 4-7 L/min, Cardiac index (CI) → 2.4-4 L/min/m2 Systemic vascular resistance (SVR) → 800 – 1400 dyne/sec/min-5 Central venous pressure (CVP) → 1 - 6 mmHg Slide 49: 49 Pulmonary Capillary Wedge Pressure (PCWP) : 50 Pulmonary Capillary Wedge Pressure (PCWP) Zero the transducer to the patient’s phlebostatic axis. Measure the PCWP at end expiration PCWP should not be higher than PA diastolic PCWP is an indirect measurement of left ventricular end diastolic pressure. Cardiac Output : 51 Cardiac Output It is the amount of blood pumped by the heart in one minute. Calculated by multiplying heart rate times stroke volume. Cardiac Index is the cardiac output adjusted for body surface area. Reasons for elevated PA pressure : 52 Reasons for elevated PA pressure Mechanical obstruction of pul. Circulation /airways Pul. arteriolar smooth muscle hypertrophy Inflammatory response to CPB Acidosis and hypoxia Elevated LA pressure Unrestrictive VSD or large PDA Slide 53: 53 Nursing HOURLY assessment: Air in line or stopcocks Precipitates Leaking at site Increasing resistance Condition of entrance sites Noninvasive Hemodynamic Monitoring : 54 Noninvasive Hemodynamic Monitoring Noninvasive BP Heart Rate, pulses Mental Status Skin Temperature Capillary Refill Urine Output Blood Pressure : 55 Blood Pressure Manual Oscillotonometry Manual Blood Pressure : 56 Manual Blood Pressure Profile of Korotkoff sound Manual Blood Pressure : 57 Manual Blood Pressure Korotkoff IV vs V sound Korotkoff IV is a better indication of diastolic pressure according to theory However Korotkoff V is the commonly recommended measuring point except in pregnant patients because It is associated with less inter-observer variations It is easier to detect by most observer Manual Blood Pressure : 58 Manual Blood Pressure Korotkoff sounds vs invasive blood pressure Korotkoff IV is on average 8mm Hg above the invasively measured diastolic blood pressure Korotkoff V is on average 2mm Hg above the invasively measured diastolic blood pressure Blood Pressure - Oscillotonometry : 59 Blood Pressure - Oscillotonometry Limitations Inaccurate / unreliable in shock patients Inaccurate / unreliable in patients with arrhythmias The algorithm of measurement assumes a regular pulse, so the reading is un-reliable in patients with irregular pulse Blood Pressure - Oscillotonometry : 60 Blood Pressure - Oscillotonometry Interpretation It was shown that the mean pressure obtained by oscillotonometry correlates best with other means of blood pressure monitoring It is also the parameter that is most reproducible. Slide 61: 61 Slide 62: 62 ‘To be conscious that you are ignorant is a great step towards knowledge.’ - Benjamin Disraeli Slide 63: 63 You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.