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
Information obtained :
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
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
Troubleshooting Equipment Needed : 8 Equipment Needed 1. Barrier Kit, extra IV pole, transducer holder and cables.
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
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
High vascular resistance
Abnormally low body temperatures Complications : 15 Complications Infections.
Thrombosis and emboli.
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
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
End-diastolic Pressure Arterial Pressure Monitoring – Information Obtained : 24 Arterial Pressure Monitoring – Information Obtained Systolic, mean and diastolic arterial pressures
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
Cerebral air embolism (retrograde flow assoc. w/ flushing)
Aneurysm / Arteriovenous Fistula formation
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
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
Newly inserted pacemaker wires Complications of CVP : 33 Complications of CVP Arterial puncture
Nerve injury (brachial plexus)
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
Chronic LV failure
Constrictive pericarditis Decreased RAP
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
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 :
Nerve injury (brachial plexus)
Catheter or sheath shearing
Arrythmias Complications …. : 47 Complications …. Insertion of the PAC
Right bundle-branch block (RBBB
Maintenance of the catheter in the PA
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
Leaking at site
Condition of entrance sites Noninvasive Hemodynamic Monitoring : 54 Noninvasive Hemodynamic Monitoring Noninvasive BP
Heart Rate, pulses
Mental Status Skin Temperature
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