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Haemodynamic monitoring-Minati

This document discusses hemodynamic monitoring in the operating room and intensive care unit. It begins by explaining why monitoring is important to assess oxygen delivery and detect any inadequacies in perfusion. It then discusses what parameters can be monitored, such as cardiac output, oxygen delivery and consumption, and pressures. Finally, it covers how these parameters are monitored, through the use of arterial lines, central venous lines, and pulmonary artery catheters which can measure values like cardiac output, pressures, and derived measurements like systemic vascular resistance. Complications of these monitoring methods are also reviewed.

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Hemodynamic Monitoring in operating Room and Intensive care unit Dr Minati Choudhury Professor Cardiothoracic Sciences Centre AIIMS New Delhi
What I intend to discuss • Why to monitor? • What to monitor? • How to monitor • What is the evidence that what we are doing actually makes a difference
3 Can’t I look at my patient and tell if they are OK? NO! Physical Assessment is often inaccurate, slow to change and difficult to interpret
Why to monitor? • Respiration and circulation ..Essential for sustaining life • Oxygen ,,,,,, the real necessity for organ function • To gather information that will indicate whether the conditions that are required to maintain tissue perfusion are adequately maintained.
To assure the adequacy of perfusion Early detection of inadequacy of perfusion To titrate therapy to specific hemodynamic end point To differentiate among various organ system dysfunctions
Why hemodynamic monitoring? • Preoptimization for high-risk surgery patients treated in the operating room • EGDT (< 12 h) resuscitation in septic patients treated in the emergency department reduce morbidity, mortality, and resource use. • The closer the resuscitation is to the insult, the greater the benefit. • Focus of these monitoring protocols .......... to establish a mean arterial pressure > 65 mm Hg and then to increase DO2 to 600 mL/min/m2 within the first few minutes to hours of presentation.
Adequate Oxygen Delivery? ConsumptionDemand
Oxygen Delivery Arterial Blood Gas Hemoglobin PaO2 Oxygen Content Oxygen Delivery Cardiac Output Oxygen Content= X Hemodynamic Monitors
Oxygen Consumption Oxygen Delivery Oxygen Consumed Remaining Oxygen to Heart = + Oxygen Uptake by Organs & Tissues Oxygen Content in CVP & PA
Hemodynamic Monitoring Truth •No monitoring device, no matter how simple or complex, invasive or non-invasive, inaccurate or precise will improve outcome •Unless coupled to a treatment, which itself improves outcome Pinsky & Payen. Functional Hemodynamic Monitoring, Springer, 2004
Different Environments Demand Different Rules Emergency Department Trauma ICU Operation Room ICU & RR Rapid, invasive, high specificity Somewhere in between ER and OR Accurate, invasive, high specificity Close titration, zero tolerance for complications Rapid, minimally invasive, high sensitivity
Traditional Monitoring  Electrocardiography • HR, dysrhythmnias, HR variability  Pulse oxymetry  NIBP  Arterial blood pressure  Central venous pressure
Pulse Oxymetry • ABSORBTION SPECTRO PHOTOMETRY • BEER LAMBERT LAW • LAMBERT’S LAW states that when a light falls on a homogenous substance,intensity of transmitted light decreases as the distance through the substance increase • BEER’S LAW states that when a light is transmitted through a clear substance with a dissolved solute ,the intensity of transmitted light decreases as the concentration of the solute increases Uses two lights of wavelengths • 660nm –deoxy Hb absorbs ten times as oxy hb • 940 nm – absorption of oxyHb is greater • Lab oximeters use 4 wavelengths to measure 4 species of haemoglobin • It =I o e –Ecd [Ecd –absorbance]
Oxygen desaturation • Saturation is defined as is a relative measure of the amount of oxygen that is dissolved or carried in a given medium(percentage). • Desaturation leads to Hypoxemia – a relative deficiency of O2 in arterial blood. PaO2 < 80mmHg – hypoxemia • Oxygen saturation will not decrease until PaO2 is below 85mmHg. • Rough guide for PaO2 between saturation of 90%-75% is,, PaO2 = SaO2 - 30. • SaO2< than 76% is life threatening.
• PaO2 [mmHg] SaO2 [%] • Normal 97 to ≥80 97 to ≥95 • Hypoxia < 80 < 95 • Mild 60-79 90-94 • Moderate 40 – 59 75 – 89 • Severe <40 < 75
Cardiovascular response to hypoxemia SPO2% HR BP Stroke volume SVR Response >80    No change Reflex 60-80   No change  Direct <60     Direct
Limitations  Shivering patient -motion artefacts  High intensity ambient light  Perfusion of the patient ear probe may be more reliable  Abnormal pulses –erratic perfomance  Carboxy Hb – Produces SpO2 > than true O2 saturation (10- 20% in heavy smokers)  Methaemoglobinemia – absorbs equal amount of red &infra red light (SpO2 to move towards 85%) Endo / exogenous dyes interfere  Blue ,Black ,Green nail polishes Diathermy leads to disturbance in monitor
Problems • False positives and negatives • Burn injury • Pressure injuries
Invasive Arterial pressure
Normal arterial wave form
Dampened trace Arterial catheter Fling Air bubble/blood in line Clot Disconnect/loose tubing Underinflated pressure bag Catheter tip against wall Compliant tubing
ARTERIAL LINE MONITORING SITES • Radial – Low complications – Allen’s test – Poss median n damage b/o dorsiflexion • Ulnar – Primary source hand flow – Low complications – Poss median n. damage
ARTERIAL LINE MONITORING SITES • Brachial – Medial to biceps tendon – Potential median n damage • Axillary – At junction pectoralis major & deltoid – Safer than brachial – Low thromboembolic issues
ARTERIAL LINE MONITORING SITES • Femoral Easy access in shock states Potential hemorrhage (local/retroperitoneal) Requires longer catheter • Doralis Pedis Post tibial collateral circ Estimates systolic higher Contraind in DM & PVD
ALLEN’S TEST • OCCLUDE ulnar and radial arteries • Have pt clench fist until hand blanches • Release ulnar a with hand open • Color return within 5 sec = adequate collateral circ
MODIFIED ALLEN’S TEST • Elevate arm above heart • Have pt open and close fist several times • Tightly clench fist • Occlude radial and ulnar a • Lower hand, open fist, release ulnar a • Color return within 7 sec = OK
RELATIVE CONTRAINDICATIONS • Inadequate circulation • Infection at the site • Recent cannulation same artery • Peripheral vascular disease
COMPLICATIONS ARTERIAL LINE • Thrombosis/embolus • Hematoma • Infection • Nerve damage/palsy • Disconnect=blood loss • Fistula • Aneurysm • Digital ischemia
mlr/2007 LOSS OF WAVEFORM • Stopcock in wrong position • Monitor not on correct scale • Nonfunctioning monitor • Nonfunctioning transducer • Kinked/clotted catheter • Asystole
Patient effect on arterial pressure Tachycardia Hypotension Atrial fibrillation Wave form quality Crisp: sharp, clear lines, flowing ◦ideal Dampened: blunted, smooth ◦Low flow states, air in line Hyperdynamic: spikes ◦Pinched, compliant tubing
Patient effect on arterial pressure Upstroke of wave • Related to velocity of blood ejected • Slowed upstroke  AS  LV failure • Inc sharp vertical in hyperdynamic states  Anemia  Hyperthermia  Hyperthyroidism  SNS  Aortic regurg
CENTRAL VENOUS PRESSURE MONITORING  Usually put in coditions where…….  Rapid administration of fluids and blood products in patients with any form of shock  Administration of vasoactive and caustic drugs  Administration of parenteral nutrition, electrolytes or hypertonic solutions  Venous access for monitoring CVP and assessing the response to fluid or vasoactive drug therapy  Insertion of transvenous pacemaker  Lack of accessible peripheral veins  Hemodynamic instability
CVP ACCESS RIJ (OR) EJ Subclavian(ICU) Antecubital Femoral
mlr/2007 CVP ACCESS
Central venous pressure monitoring kit
Typical CVP wave form
Elevations in Central venous pressure • Hypervolemia • Right ventricular infarction • Impaired RV contraction • Pulmonary hypertension • Pulmonic stenosis • Left to right shunts • Tricuspid valve disease • Cardiac tamponade
Low Central venous pressure • Hypovolemia • Dehydration • Poor vascular tone • Peripheral vasodilation • Hemorrhage • Addisonian crisis • Sepsis • Regional anesthesia • Polyuria • Sympathetic dysfunct
Contraindication • Coagulopathies or bleeding disorders (monitor platelet count, PT, PTT) • Current or recent use of fibrinolytics or anticoagulants • Insertion sites that are infected or burned, or where previous vascular surgery has been performed, or involve catheter placement through vascular grafts • Patients with suspected or confirmed vena cava injury
Central venous pressure • Limitations..... • Evaluate as a trend • Systemic vasoconstriction can present a CVP elevated despite hypovolemia • Mechanical ventilation  Positive pressure ventilation ↑ thoracic and central venous pressures  Measure at end-expiration Complication……… • Arterial puncture – Hematoma – False aneurysm – Fistula • Catheter position during placement  Wall perf/tamponade  Dysrhythmias • Catheter shear • Brachial plexus injury • Thoracic duct injury
Direct monitoring of Cardiac output Invasive PA catheter  Fick’s method  Dye dilution  Thermo dilution Non-invasive and semi invasive Echocardiography  Oesophageal doppler Aortovelography Transthoracic impedance Arterial pulse contour analysis (PiCCO) Arterial pulse power analysis (LiDCO)  Flotrac-vigileo
PA Catheter Swan-Ganz Catheter Swan
Use in… MI with complications  CHF  Pulmonary HTN  Respiratory failure  Shock  Sepsis  Trauma  Hemodynamic instability  High risk cardiac surgery  Peripheral vascular surgery  Aortic surgery  Neuro surgery DO NOT USE INCASE OF Tricuspid or pulmonary valve mechanical prosthesis Right heart mass (thrombus and/or tumor) Tricuspid or pulmonary valve endocarditis
PA Catheter on float
Waveforms during PAC insertion and distance from skin insertion
Proximal port in Right atrium
Right ventricular port (orange)
Distal port (yellow) Normal values PA systolic pressure = 20- 30 mm Hg PA diastolic pressure = 8- 12 mm Hg Mean PAP=12-15 mmHg
Measurements that can be done from PA catheter CVP Rt ventricular pressure PAP PCWP CO CI = CO/BSA, L/min/m2 Stroke volume= CO/HR 1,000, mL/min Stroke index = stroke volume/BSA, mL/m2 LV stroke work= stroke volume (MAP- Ppao), mL mm Hg LV stroke work index= LV stroke work/BSA, mL mm Hg/m2
Derived Hemodynamic Parameters From Hemodynamic Monitoring* Systemic vascular resistance= (MAP- Pra)/CO× 80,dyne s/cm5 RV stroke work = stroke volume × (MPAP- Pra), mL mm Hg RV stroke work index= RV stroke work/BSA, mL mm Hg/m2 Pulmonary vascular resistance= [(MPAP – Ppao)/CO] × 80,dyne s/cm5
Derived Hemodynamic Parameters From Hemodynamic Monitoring* Global Do2† = CO× (Sao2 - Svo2) × Hb × 1.36 × 1,000, mL oxygen/min Global Do2 index†= CI × (Sao2- Svo2) × Hb × 1.36, mL oxygen/min Global V˙ o2† = CO × Sao2 × Hb × 1.36 1,000, mL oxygen/min Global V˙ o2 index† = CI × Sao2 × Hb × 1.36 × 1,000, mL oxygen/min
Normal values Directly measured • CVP 2-4 mm Hg • PA 25/10 • PAOP 8-12 • SvO2 60-75% • Cardiac output 4-8 L/m • Cardiac index 2.5-4.0 L/min/M2 Calculated • SVR 900-1200 dynes sec/cm5 • PVR 50-140 • SV 50-100mL • SV index 25-45
Mean PAP ↑MPAP •Volume infusions •Low CO states(LV failure ,RV failure) •Peripheral vasoconstriction •Hypothermia •Vasopressors •Alpha adrenergic agents •Increased blood viscosity ↓MPAP •Diuretics •Vasodilators •Peripheral vasodilation •Inotropic therapy(PDIII inhibitor) •Hyperdynamic phase of sepsis •Loss of vasomotor tone
PVR ↑PVR •Hypoxia •Hypercarbia •PEEP •Pulmonary edema •Pulmonary hypertension •ARDS •Sepsis •Pulmonary emboli •Valvular heart disease •Congenital heart defects ↓ PVR •Vasodilator therapy •Prostaglandins •Correction of hypoxia •Prostacyclin
Systemic vascular resistance ↑SVR •Volume infusion •Decreased LV contractility •Hypervolemia •Hypoxia •Pulmonary vasoconstriction •Pulmonary hypertension •COPD ↓ SVR •Hypovolemia •Diuretics •Inotropic therapy •Pulmonary vasodilation •Pulmonary vasodilators
Pulmonary capillary wedge pressure  Normal mean value: 8-12 mm Hg  Low (< 8 mm Hg):Hypovolemia  High (>12 mm Hg):Hypervolemia Low Sepsis Cirrhosis anemia High LV failure Overload Mitral v. issues Tamponade Pericardial effusion Stiff LV PPV
Complications due to PA catheter • Dysrhythmias • RBBB/CHB in pt with LBBB • PA/RA/RV rupture • Knot/kink/coil catheter • Infection • Balloon rupture • Thrombus • Air embolus • Pneumothorax • Phrenic n. block • Horner’s – R/T stellate ganglion damage – Eyelid ptosis
Transesophageal echocardiography • Measurement of LVOT diameter • Measurement of LVOT area=(∏×LVOT dia2 )/4 • Measurement of LVOT VTI from signal’s envelope
Transesophageal echocardiography Cardiac output (l/min) = Stroke volume x Heart Rate Pit falls….. Irregular rhythm→false measurement
Esophageal doppler CO A small probe is inserted into the esophagus of mechanically-ventilated patients, usually during anesthesia The probe is introduced orally and advanced gently until its tip is located approximately at the mid-thoracic level, and then rotated so that it faces the descending aorta.
Esophageal doppler CO • The tip of the probe contains a Doppler transducer which transmits an ultrasound beam (4 MHz continuous-wave or 5 MHz pulsed-wave). • The change in frequency of this beam as it reflects off a moving object allows measurement of blood flow velocity in the descending aorta. This measurement, when combined with an estimate of the cross-sectional area of the aorta, allows calculation of hemodynamic variables including stroke volume and cardiac output.
Esophageal doppler CO,potential complications • Operator dependency, occasional difficulties in probe placement • Difficulty interpreting the signal during periods of arrhythmia
CO measurement from expired gas...Indirect Fick’s principle
CO measurement from expired gas...Indirect Fick’s principle • Continuous cardiac output • • Principle: Differential CO2 Fick’s partial rebreathing method • CO= VCO2/ CvCO2-CaCO2 • To estimate CvCO2 , 150 ml of dead space is added to the ventilator circuit by opening a rebreathing valve
CO measurement from expired gas...Indirect Fick’s principle • Cardiac output is computed on breath-by-breath measurements of CO2 elimination. • Rebreathing measurements are made every three minutes for 35 seconds. • Cardiac output is proportional to the change in CO2 elimination divided by the change in end tidal CO2 resulting from a brief rebreathing period. • These measurements are accomplished and measured by the proprietary NICO Sensor, which periodically adds a rebreathing volume into the breathing circuit.
CO measurement from expired gas...Indirect Fick’s principle ADVANTAGES  Noninvasive  No infection risks  Automated and continuous  Not technique dependent  Extremely simple to set up and use  Can be used in AF. LIMITATIONS Assumption about CvCO2 Accurate only if PaCO2 > 30mmHg Any change in ventilation parameters will change the CO Requires an intubated patient No parameter to monitor intravascular volume status
THORACIC ELECTRICAL BIOIMPEDANCE • Bioimpedance monitoring (1965) , NASA...... to estimate cardiac output non-invasively in astronauts • Impedance ....... the resistance to alternating current • Theory of technique • The technique depends on the change in bio impedance of the thoracic cavity during systole • The bioimpedance monitors apply a small (3 mA) high- frequency current to the thorax and use an array of thoracic electrodes to measure the resulting potential changes to give an impedance-time or dZ/dt trace • Cardiac output is estimated from the 0.5% variation in impedance that occurs with the cardiac cycle,
THORACIC ELECTRICAL BIOIMPEDANCE Stroke Volume / Index (SV / SI) Cardiac Output / Index (CO / CI) Systemic Vascular Resistance / Index (SVR / SVRI) Systolic Time Ratio (STR) Pre-ejection Period (PEP) LV Ejection Time (LVET) Velocity Index (VI) Acceleration Index (ACI) Thoracic Fluid Content (TFC)
THORACIC ELECTRICAL BIOIMPEDANCE LIMITATIONS Physical Height: Between 4 feet and 7 feet, 8 inches Weight: Between 67 lbs. and 341 lbs.  Warning  Pacemakers,  thoracotomy,  emphysema  PE  ARDS Precautions HR > 250 bpm Septic Shock (End stage sepsis) Severe Aortic Valve Regurgitation Extremely High Blood Pressure (MAP > 130) Intra-Aortic Balloon Pump
THORACIC ELECTRICAL BIOIMPEDANCE INTRAOPERATIVE LIMITATIONS Electrocautery Mechanical ventilation Changes in volume in chest Surgical manipulation Assumption of hemodynamic stability Loose electrodes during rewarming Acute change in tissue water, pulm edema, chest wall edema VET from QRS: Arrythmias
LiDCO • Principle: Indicator dilution • A small dose of lithium chloride (0.15 -0.30 mmol) is injected via a central or peripheral venous line; the resulting arterial lithium concentration-time curve is recorded by withdrawing blood past a lithium sensor attached to the patient’s existing arterial line.
1) A bolus of Lithium is flushed through a central or venous line 2) A Lithium sensitive sensor, attached to a peripheral arterial line, detects the concentration of Lithium ions in the arterial blood 4) This value is then used to calibrate the LiDCOplus to give continuous cardiac output and derived variables from arterial waveform analysis. L i D C O ™ The LiDCOplus - Lithium Indicator Dilution 16 3) The Lithium indicator dilution ‘wash-out’ curve on the LiDCOplus provides an accurate absolute cardiac output value
LiDCO Cardiac Output = (Lithium Dose x 60)/(Area x (1-PCV))
LiDCO  ADVANTAGES  Provides an absolute cardiac output value  Requires no additional invasive catheters to insert into the patient  Is safe – using non-toxic bolus dosages  Is simple and quick to set up  Is not temperature dependent
Pulse Contour analysis FloTrac • PRINCIPLE – PCA • Flow is determined by a pressure gradient along a vessel and the resistance to that flow (F=P/R). • The FloTrac algorithm uses a similar principle to measure pulsatile flow by incorporating the effects of both vascular resistance and compliance through a conversion factor known as Khi
Pulse Contour analysis (Flo Trac) • The FloTrac algorithm analyzes the pressure waveform at one hundred times per second over 20 seconds, capturing 2,000 data points for analysis. • These data points are used along with patient demographic information to calculate the standard deviation of the arterial pressure(σAP).
Pulse Contour analysis FloTrac The vigileo (c) and Flotrac Sensor (B) for measurement of cardiac output from area under the curve (A)
Pulse Contour analysis FloTrac LIMITATIONS Paed. Patients Cardiac shunts AR Artherosclerosis Atrial fibrillation Elderly patients with altered compliance of artery  The FloTrac sensor level is continually maintained.  Intra aortic balloon pump creates artificially high diastolic pressure  Non-Invasive Blood Pressure cuff on same arm as FloTrac™ sensor may cut arterial pressure signal off intermittently when cuff is inflated.  Long, flexible femoral catheters may be more predisposed to arterial pressure artifact
Pulse Contour analysis FloTrac ADVANTAGES PCA method which does not require calibration Accounts for changes in compliance Accuracy in changing hemodynamics Parameters of fluid responsiveness (SVV)
FloTrac set up Accurate Height, Weight, Sex and Age of the Patient If patient’s BSA changes by more than 0.1 m2---------------- ------check and re-enter the patient’s weight. (esp… for patients with rapid changes in weight eg.renal failure/dialysis, acute severe burns, etc. When taking sample data, ensure. . . Patient is not agitated or coughing Radial line or femoral line waveform artifact maybe introduced through constant movement. Ensure stable waveforms prior to taking the data samples. Other procedures deferred during sample taking (turning patients, bathing, suctioning, etc) Patient preferably in supine position
FloTrac: Waveform fidelity The accuracy and fidelity of the FloTrac sensor is of importance as the cardiac output is calculated from pressures measured and waveform assessment  No “T”ing of arterial lines with other devices  System is free of bubbles  Pressure bag for flush is pressurized to and maintained at 300 mmHg  Accurate zero referencing and calibration  Accurate leveling of FloTrac™ sensor relevant to patient’s Phlebostatic Axis must be maintained at all times
Case scenarios, case I • 55 yr old, post op whipples procedure • Post op 5th hr SpO2 100%,HR 130/min,BP 110/46mmHg,CVP 2 mmHG,Hb 8.5 • ABG N Management????????
Case scenarios, case I • Analgesic • Blood transfusion 1U • 6%HES 1U • HR 82/min,BP 113/58mmHg,CVP 5 mmHg
Case scenarios, case II • 65 yr old,FUC bronchial asthma admitted to ICU with severe respiratory distress • Irritable,SpO2??,HR 120/min,BP 140/90,ECG sinus tachy • ABG with mask O2 ...... PH 7.2,PO2 40,PCO2 105, BE -4.5, HCO3 20 , Na 130, K 4.2, Hb 14.5 • Intubated........ Bronchial hyegine........ Improved.... Gradual weaning.....Extubated D3 .... Calm, cooperative
Case scenarios, case II • ABG in room air....... ...... PH 7.39,PO2 65,PCO2 43,BE -2.3, HCO3 22 , Na 132, K 3.8, Hb 12.8 • HR 110,BP 105/50,RA13,SVV 15%, CO 4.6L/min Is any Therapy needed???
Case scenarios, case II • Transfusion of 1U RL....... Improve hemodynamic • HR 78, BP 130/63, RA 14 CO 4.5 L/min, SVV 8%
Case scenarios, case III • 35 year old,TVD, CABG following ACS....... • Normal intraopertive course • Exubation 5th hr, normal ABG and hemodynamics • D1 ...... ABG (N) HR 80/min,BP 75/50,RA 14, SVV 6, CO 2.5 L/min Management??????
Case scenarios, case III • Fluid challenge 100 ml RL.... No response • Adr 0.5µkg/hr,Douta 5µ kg/hr,NTG 0.5µkg/hr • 5th hr................ ABG (N) HR 90/min,BP 105/58,RA 8, SVV 7, CO 3.9 L/min
• Tachycardia is never a good thing. • Hypotension is always pathological. • There is no normal cardiac output. • CVP is only elevated in disease. • A higher mortality was shown in patients with right ventricular dysfunction and an increase of pulmonary vascular resistance. The Truths in Hemodynamics
The Truths in Hemodynamic Monitoring • Monitors associate with inaccuracies, misconceptions and poorly documented benefits. • A good understanding of the pathophysiological underpinnings for its effective application across patient groups is required. • Functional hemodynamic monitors are superior to conventional filling pressure. • The goal of treatments based on monitoring is to restore the physiological homeostasis.
ANY IDEAL SYSTEM? Ideal • Non invasive • Accurate • Reliable • Continuous • Compatible in paed. Pts. • Reproducible • Fast response • Operator independent
Questions? ??????????? ??

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Haemodynamic monitoring-Minati

  • 1.
    Hemodynamic Monitoring in operatingRoom and Intensive care unit Dr Minati Choudhury Professor Cardiothoracic Sciences Centre AIIMS New Delhi
  • 2.
    What I intendto discuss • Why to monitor? • What to monitor? • How to monitor • What is the evidence that what we are doing actually makes a difference
  • 3.
    3 Can’t I lookat my patient and tell if they are OK? NO! Physical Assessment is often inaccurate, slow to change and difficult to interpret
  • 4.
    Why to monitor? •Respiration and circulation ..Essential for sustaining life • Oxygen ,,,,,, the real necessity for organ function • To gather information that will indicate whether the conditions that are required to maintain tissue perfusion are adequately maintained.
  • 5.
    To assure theadequacy of perfusion Early detection of inadequacy of perfusion To titrate therapy to specific hemodynamic end point To differentiate among various organ system dysfunctions
  • 6.
    Why hemodynamic monitoring? •Preoptimization for high-risk surgery patients treated in the operating room • EGDT (< 12 h) resuscitation in septic patients treated in the emergency department reduce morbidity, mortality, and resource use. • The closer the resuscitation is to the insult, the greater the benefit. • Focus of these monitoring protocols .......... to establish a mean arterial pressure > 65 mm Hg and then to increase DO2 to 600 mL/min/m2 within the first few minutes to hours of presentation.
  • 7.
  • 8.
  • 9.
    Oxygen Consumption Oxygen Delivery Oxygen Consumed Remaining Oxygen to Heart =+ Oxygen Uptake by Organs & Tissues Oxygen Content in CVP & PA
  • 10.
    Hemodynamic Monitoring Truth •No monitoringdevice, no matter how simple or complex, invasive or non-invasive, inaccurate or precise will improve outcome •Unless coupled to a treatment, which itself improves outcome Pinsky & Payen. Functional Hemodynamic Monitoring, Springer, 2004
  • 11.
    Different Environments Demand DifferentRules Emergency Department Trauma ICU Operation Room ICU & RR Rapid, invasive, high specificity Somewhere in between ER and OR Accurate, invasive, high specificity Close titration, zero tolerance for complications Rapid, minimally invasive, high sensitivity
  • 12.
    Traditional Monitoring  Electrocardiography •HR, dysrhythmnias, HR variability  Pulse oxymetry  NIBP  Arterial blood pressure  Central venous pressure
  • 13.
    Pulse Oxymetry • ABSORBTIONSPECTRO PHOTOMETRY • BEER LAMBERT LAW • LAMBERT’S LAW states that when a light falls on a homogenous substance,intensity of transmitted light decreases as the distance through the substance increase • BEER’S LAW states that when a light is transmitted through a clear substance with a dissolved solute ,the intensity of transmitted light decreases as the concentration of the solute increases Uses two lights of wavelengths • 660nm –deoxy Hb absorbs ten times as oxy hb • 940 nm – absorption of oxyHb is greater • Lab oximeters use 4 wavelengths to measure 4 species of haemoglobin • It =I o e –Ecd [Ecd –absorbance]
  • 15.
    Oxygen desaturation • Saturationis defined as is a relative measure of the amount of oxygen that is dissolved or carried in a given medium(percentage). • Desaturation leads to Hypoxemia – a relative deficiency of O2 in arterial blood. PaO2 < 80mmHg – hypoxemia • Oxygen saturation will not decrease until PaO2 is below 85mmHg. • Rough guide for PaO2 between saturation of 90%-75% is,, PaO2 = SaO2 - 30. • SaO2< than 76% is life threatening.
  • 16.
    • PaO2 [mmHg]SaO2 [%] • Normal 97 to ≥80 97 to ≥95 • Hypoxia < 80 < 95 • Mild 60-79 90-94 • Moderate 40 – 59 75 – 89 • Severe <40 < 75
  • 17.
    Cardiovascular response to hypoxemia SPO2%HR BP Stroke volume SVR Response >80    No change Reflex 60-80   No change  Direct <60     Direct
  • 18.
    Limitations  Shivering patient-motion artefacts  High intensity ambient light  Perfusion of the patient ear probe may be more reliable  Abnormal pulses –erratic perfomance  Carboxy Hb – Produces SpO2 > than true O2 saturation (10- 20% in heavy smokers)  Methaemoglobinemia – absorbs equal amount of red &infra red light (SpO2 to move towards 85%) Endo / exogenous dyes interfere  Blue ,Black ,Green nail polishes Diathermy leads to disturbance in monitor
  • 19.
    Problems • False positivesand negatives • Burn injury • Pressure injuries
  • 20.
  • 21.
  • 22.
    Dampened trace Arterial catheterFling Air bubble/blood in line Clot Disconnect/loose tubing Underinflated pressure bag Catheter tip against wall Compliant tubing
  • 25.
    ARTERIAL LINE MONITORINGSITES • Radial – Low complications – Allen’s test – Poss median n damage b/o dorsiflexion • Ulnar – Primary source hand flow – Low complications – Poss median n. damage
  • 26.
    ARTERIAL LINE MONITORINGSITES • Brachial – Medial to biceps tendon – Potential median n damage • Axillary – At junction pectoralis major & deltoid – Safer than brachial – Low thromboembolic issues
  • 27.
    ARTERIAL LINE MONITORINGSITES • Femoral Easy access in shock states Potential hemorrhage (local/retroperitoneal) Requires longer catheter • Doralis Pedis Post tibial collateral circ Estimates systolic higher Contraind in DM & PVD
  • 28.
    ALLEN’S TEST • OCCLUDEulnar and radial arteries • Have pt clench fist until hand blanches • Release ulnar a with hand open • Color return within 5 sec = adequate collateral circ
  • 29.
    MODIFIED ALLEN’S TEST •Elevate arm above heart • Have pt open and close fist several times • Tightly clench fist • Occlude radial and ulnar a • Lower hand, open fist, release ulnar a • Color return within 7 sec = OK
  • 30.
    RELATIVE CONTRAINDICATIONS • Inadequatecirculation • Infection at the site • Recent cannulation same artery • Peripheral vascular disease
  • 31.
    COMPLICATIONS ARTERIAL LINE •Thrombosis/embolus • Hematoma • Infection • Nerve damage/palsy • Disconnect=blood loss • Fistula • Aneurysm • Digital ischemia
  • 32.
    mlr/2007 LOSS OF WAVEFORM •Stopcock in wrong position • Monitor not on correct scale • Nonfunctioning monitor • Nonfunctioning transducer • Kinked/clotted catheter • Asystole
  • 33.
    Patient effect onarterial pressure Tachycardia Hypotension Atrial fibrillation Wave form quality Crisp: sharp, clear lines, flowing ◦ideal Dampened: blunted, smooth ◦Low flow states, air in line Hyperdynamic: spikes ◦Pinched, compliant tubing
  • 34.
    Patient effect onarterial pressure Upstroke of wave • Related to velocity of blood ejected • Slowed upstroke  AS  LV failure • Inc sharp vertical in hyperdynamic states  Anemia  Hyperthermia  Hyperthyroidism  SNS  Aortic regurg
  • 35.
    CENTRAL VENOUS PRESSURE MONITORING Usually put in coditions where…….  Rapid administration of fluids and blood products in patients with any form of shock  Administration of vasoactive and caustic drugs  Administration of parenteral nutrition, electrolytes or hypertonic solutions  Venous access for monitoring CVP and assessing the response to fluid or vasoactive drug therapy  Insertion of transvenous pacemaker  Lack of accessible peripheral veins  Hemodynamic instability
  • 36.
  • 37.
  • 38.
  • 39.
  • 40.
    Elevations in Centralvenous pressure • Hypervolemia • Right ventricular infarction • Impaired RV contraction • Pulmonary hypertension • Pulmonic stenosis • Left to right shunts • Tricuspid valve disease • Cardiac tamponade
  • 41.
    Low Central venouspressure • Hypovolemia • Dehydration • Poor vascular tone • Peripheral vasodilation • Hemorrhage • Addisonian crisis • Sepsis • Regional anesthesia • Polyuria • Sympathetic dysfunct
  • 42.
    Contraindication • Coagulopathies orbleeding disorders (monitor platelet count, PT, PTT) • Current or recent use of fibrinolytics or anticoagulants • Insertion sites that are infected or burned, or where previous vascular surgery has been performed, or involve catheter placement through vascular grafts • Patients with suspected or confirmed vena cava injury
  • 43.
    Central venous pressure • Limitations..... •Evaluate as a trend • Systemic vasoconstriction can present a CVP elevated despite hypovolemia • Mechanical ventilation  Positive pressure ventilation ↑ thoracic and central venous pressures  Measure at end-expiration Complication……… • Arterial puncture – Hematoma – False aneurysm – Fistula • Catheter position during placement  Wall perf/tamponade  Dysrhythmias • Catheter shear • Brachial plexus injury • Thoracic duct injury
  • 44.
    Direct monitoring ofCardiac output Invasive PA catheter  Fick’s method  Dye dilution  Thermo dilution Non-invasive and semi invasive Echocardiography  Oesophageal doppler Aortovelography Transthoracic impedance Arterial pulse contour analysis (PiCCO) Arterial pulse power analysis (LiDCO)  Flotrac-vigileo
  • 45.
  • 46.
    Use in… MI withcomplications  CHF  Pulmonary HTN  Respiratory failure  Shock  Sepsis  Trauma  Hemodynamic instability  High risk cardiac surgery  Peripheral vascular surgery  Aortic surgery  Neuro surgery DO NOT USE INCASE OF Tricuspid or pulmonary valve mechanical prosthesis Right heart mass (thrombus and/or tumor) Tricuspid or pulmonary valve endocarditis
  • 47.
  • 48.
    Waveforms during PACinsertion and distance from skin insertion
  • 49.
    Proximal port inRight atrium
  • 50.
  • 51.
    Distal port (yellow) Normalvalues PA systolic pressure = 20- 30 mm Hg PA diastolic pressure = 8- 12 mm Hg Mean PAP=12-15 mmHg
  • 52.
    Measurements that canbe done from PA catheter CVP Rt ventricular pressure PAP PCWP CO CI = CO/BSA, L/min/m2 Stroke volume= CO/HR 1,000, mL/min Stroke index = stroke volume/BSA, mL/m2 LV stroke work= stroke volume (MAP- Ppao), mL mm Hg LV stroke work index= LV stroke work/BSA, mL mm Hg/m2
  • 53.
    Derived Hemodynamic ParametersFrom Hemodynamic Monitoring* Systemic vascular resistance= (MAP- Pra)/CO× 80,dyne s/cm5 RV stroke work = stroke volume × (MPAP- Pra), mL mm Hg RV stroke work index= RV stroke work/BSA, mL mm Hg/m2 Pulmonary vascular resistance= [(MPAP – Ppao)/CO] × 80,dyne s/cm5
  • 54.
    Derived Hemodynamic ParametersFrom Hemodynamic Monitoring* Global Do2† = CO× (Sao2 - Svo2) × Hb × 1.36 × 1,000, mL oxygen/min Global Do2 index†= CI × (Sao2- Svo2) × Hb × 1.36, mL oxygen/min Global V˙ o2† = CO × Sao2 × Hb × 1.36 1,000, mL oxygen/min Global V˙ o2 index† = CI × Sao2 × Hb × 1.36 × 1,000, mL oxygen/min
  • 55.
    Normal values Directly measured •CVP 2-4 mm Hg • PA 25/10 • PAOP 8-12 • SvO2 60-75% • Cardiac output 4-8 L/m • Cardiac index 2.5-4.0 L/min/M2 Calculated • SVR 900-1200 dynes sec/cm5 • PVR 50-140 • SV 50-100mL • SV index 25-45
  • 56.
    Mean PAP ↑MPAP •Volume infusions •LowCO states(LV failure ,RV failure) •Peripheral vasoconstriction •Hypothermia •Vasopressors •Alpha adrenergic agents •Increased blood viscosity ↓MPAP •Diuretics •Vasodilators •Peripheral vasodilation •Inotropic therapy(PDIII inhibitor) •Hyperdynamic phase of sepsis •Loss of vasomotor tone
  • 57.
    PVR ↑PVR •Hypoxia •Hypercarbia •PEEP •Pulmonary edema •Pulmonary hypertension •ARDS •Sepsis •Pulmonaryemboli •Valvular heart disease •Congenital heart defects ↓ PVR •Vasodilator therapy •Prostaglandins •Correction of hypoxia •Prostacyclin
  • 58.
    Systemic vascular resistance ↑SVR •Volumeinfusion •Decreased LV contractility •Hypervolemia •Hypoxia •Pulmonary vasoconstriction •Pulmonary hypertension •COPD ↓ SVR •Hypovolemia •Diuretics •Inotropic therapy •Pulmonary vasodilation •Pulmonary vasodilators
  • 59.
    Pulmonary capillary wedgepressure  Normal mean value: 8-12 mm Hg  Low (< 8 mm Hg):Hypovolemia  High (>12 mm Hg):Hypervolemia Low Sepsis Cirrhosis anemia High LV failure Overload Mitral v. issues Tamponade Pericardial effusion Stiff LV PPV
  • 60.
    Complications due toPA catheter • Dysrhythmias • RBBB/CHB in pt with LBBB • PA/RA/RV rupture • Knot/kink/coil catheter • Infection • Balloon rupture • Thrombus • Air embolus • Pneumothorax • Phrenic n. block • Horner’s – R/T stellate ganglion damage – Eyelid ptosis
  • 61.
    Transesophageal echocardiography • Measurementof LVOT diameter • Measurement of LVOT area=(∏×LVOT dia2 )/4 • Measurement of LVOT VTI from signal’s envelope
  • 62.
    Transesophageal echocardiography Cardiac output (l/min)= Stroke volume x Heart Rate Pit falls….. Irregular rhythm→false measurement
  • 63.
    Esophageal doppler CO Asmall probe is inserted into the esophagus of mechanically-ventilated patients, usually during anesthesia The probe is introduced orally and advanced gently until its tip is located approximately at the mid-thoracic level, and then rotated so that it faces the descending aorta.
  • 64.
    Esophageal doppler CO •The tip of the probe contains a Doppler transducer which transmits an ultrasound beam (4 MHz continuous-wave or 5 MHz pulsed-wave). • The change in frequency of this beam as it reflects off a moving object allows measurement of blood flow velocity in the descending aorta. This measurement, when combined with an estimate of the cross-sectional area of the aorta, allows calculation of hemodynamic variables including stroke volume and cardiac output.
  • 65.
    Esophageal doppler CO,potential complications •Operator dependency, occasional difficulties in probe placement • Difficulty interpreting the signal during periods of arrhythmia
  • 66.
    CO measurement fromexpired gas...Indirect Fick’s principle
  • 67.
    CO measurement fromexpired gas...Indirect Fick’s principle • Continuous cardiac output • • Principle: Differential CO2 Fick’s partial rebreathing method • CO= VCO2/ CvCO2-CaCO2 • To estimate CvCO2 , 150 ml of dead space is added to the ventilator circuit by opening a rebreathing valve
  • 68.
    CO measurement fromexpired gas...Indirect Fick’s principle • Cardiac output is computed on breath-by-breath measurements of CO2 elimination. • Rebreathing measurements are made every three minutes for 35 seconds. • Cardiac output is proportional to the change in CO2 elimination divided by the change in end tidal CO2 resulting from a brief rebreathing period. • These measurements are accomplished and measured by the proprietary NICO Sensor, which periodically adds a rebreathing volume into the breathing circuit.
  • 69.
    CO measurement from expiredgas...Indirect Fick’s principle ADVANTAGES  Noninvasive  No infection risks  Automated and continuous  Not technique dependent  Extremely simple to set up and use  Can be used in AF. LIMITATIONS Assumption about CvCO2 Accurate only if PaCO2 > 30mmHg Any change in ventilation parameters will change the CO Requires an intubated patient No parameter to monitor intravascular volume status
  • 70.
    THORACIC ELECTRICAL BIOIMPEDANCE • Bioimpedancemonitoring (1965) , NASA...... to estimate cardiac output non-invasively in astronauts • Impedance ....... the resistance to alternating current • Theory of technique • The technique depends on the change in bio impedance of the thoracic cavity during systole • The bioimpedance monitors apply a small (3 mA) high- frequency current to the thorax and use an array of thoracic electrodes to measure the resulting potential changes to give an impedance-time or dZ/dt trace • Cardiac output is estimated from the 0.5% variation in impedance that occurs with the cardiac cycle,
  • 71.
    THORACIC ELECTRICAL BIOIMPEDANCE StrokeVolume / Index (SV / SI) Cardiac Output / Index (CO / CI) Systemic Vascular Resistance / Index (SVR / SVRI) Systolic Time Ratio (STR) Pre-ejection Period (PEP) LV Ejection Time (LVET) Velocity Index (VI) Acceleration Index (ACI) Thoracic Fluid Content (TFC)
  • 72.
    THORACIC ELECTRICAL BIOIMPEDANCE LIMITATIONS Physical Height:Between 4 feet and 7 feet, 8 inches Weight: Between 67 lbs. and 341 lbs.  Warning  Pacemakers,  thoracotomy,  emphysema  PE  ARDS Precautions HR > 250 bpm Septic Shock (End stage sepsis) Severe Aortic Valve Regurgitation Extremely High Blood Pressure (MAP > 130) Intra-Aortic Balloon Pump
  • 73.
    THORACIC ELECTRICAL BIOIMPEDANCE INTRAOPERATIVELIMITATIONS Electrocautery Mechanical ventilation Changes in volume in chest Surgical manipulation Assumption of hemodynamic stability Loose electrodes during rewarming Acute change in tissue water, pulm edema, chest wall edema VET from QRS: Arrythmias
  • 74.
    LiDCO • Principle: Indicatordilution • A small dose of lithium chloride (0.15 -0.30 mmol) is injected via a central or peripheral venous line; the resulting arterial lithium concentration-time curve is recorded by withdrawing blood past a lithium sensor attached to the patient’s existing arterial line.
  • 75.
    1) A bolusof Lithium is flushed through a central or venous line 2) A Lithium sensitive sensor, attached to a peripheral arterial line, detects the concentration of Lithium ions in the arterial blood 4) This value is then used to calibrate the LiDCOplus to give continuous cardiac output and derived variables from arterial waveform analysis. L i D C O ™ The LiDCOplus - Lithium Indicator Dilution 16 3) The Lithium indicator dilution ‘wash-out’ curve on the LiDCOplus provides an accurate absolute cardiac output value
  • 76.
    LiDCO Cardiac Output =(Lithium Dose x 60)/(Area x (1-PCV))
  • 77.
    LiDCO  ADVANTAGES  Providesan absolute cardiac output value  Requires no additional invasive catheters to insert into the patient  Is safe – using non-toxic bolus dosages  Is simple and quick to set up  Is not temperature dependent
  • 78.
    Pulse Contour analysis FloTrac •PRINCIPLE – PCA • Flow is determined by a pressure gradient along a vessel and the resistance to that flow (F=P/R). • The FloTrac algorithm uses a similar principle to measure pulsatile flow by incorporating the effects of both vascular resistance and compliance through a conversion factor known as Khi
  • 79.
    Pulse Contour analysis(Flo Trac) • The FloTrac algorithm analyzes the pressure waveform at one hundred times per second over 20 seconds, capturing 2,000 data points for analysis. • These data points are used along with patient demographic information to calculate the standard deviation of the arterial pressure(σAP).
  • 80.
    Pulse Contour analysis FloTrac Thevigileo (c) and Flotrac Sensor (B) for measurement of cardiac output from area under the curve (A)
  • 81.
    Pulse Contour analysis FloTrac LIMITATIONS Paed.Patients Cardiac shunts AR Artherosclerosis Atrial fibrillation Elderly patients with altered compliance of artery  The FloTrac sensor level is continually maintained.  Intra aortic balloon pump creates artificially high diastolic pressure  Non-Invasive Blood Pressure cuff on same arm as FloTrac™ sensor may cut arterial pressure signal off intermittently when cuff is inflated.  Long, flexible femoral catheters may be more predisposed to arterial pressure artifact
  • 82.
    Pulse Contour analysis FloTrac ADVANTAGES PCAmethod which does not require calibration Accounts for changes in compliance Accuracy in changing hemodynamics Parameters of fluid responsiveness (SVV)
  • 83.
    FloTrac set up AccurateHeight, Weight, Sex and Age of the Patient If patient’s BSA changes by more than 0.1 m2---------------- ------check and re-enter the patient’s weight. (esp… for patients with rapid changes in weight eg.renal failure/dialysis, acute severe burns, etc. When taking sample data, ensure. . . Patient is not agitated or coughing Radial line or femoral line waveform artifact maybe introduced through constant movement. Ensure stable waveforms prior to taking the data samples. Other procedures deferred during sample taking (turning patients, bathing, suctioning, etc) Patient preferably in supine position
  • 84.
    FloTrac: Waveform fidelity Theaccuracy and fidelity of the FloTrac sensor is of importance as the cardiac output is calculated from pressures measured and waveform assessment  No “T”ing of arterial lines with other devices  System is free of bubbles  Pressure bag for flush is pressurized to and maintained at 300 mmHg  Accurate zero referencing and calibration  Accurate leveling of FloTrac™ sensor relevant to patient’s Phlebostatic Axis must be maintained at all times
  • 85.
    Case scenarios, caseI • 55 yr old, post op whipples procedure • Post op 5th hr SpO2 100%,HR 130/min,BP 110/46mmHg,CVP 2 mmHG,Hb 8.5 • ABG N Management????????
  • 86.
    Case scenarios, caseI • Analgesic • Blood transfusion 1U • 6%HES 1U • HR 82/min,BP 113/58mmHg,CVP 5 mmHg
  • 87.
    Case scenarios, caseII • 65 yr old,FUC bronchial asthma admitted to ICU with severe respiratory distress • Irritable,SpO2??,HR 120/min,BP 140/90,ECG sinus tachy • ABG with mask O2 ...... PH 7.2,PO2 40,PCO2 105, BE -4.5, HCO3 20 , Na 130, K 4.2, Hb 14.5 • Intubated........ Bronchial hyegine........ Improved.... Gradual weaning.....Extubated D3 .... Calm, cooperative
  • 88.
    Case scenarios, caseII • ABG in room air....... ...... PH 7.39,PO2 65,PCO2 43,BE -2.3, HCO3 22 , Na 132, K 3.8, Hb 12.8 • HR 110,BP 105/50,RA13,SVV 15%, CO 4.6L/min Is any Therapy needed???
  • 89.
    Case scenarios, caseII • Transfusion of 1U RL....... Improve hemodynamic • HR 78, BP 130/63, RA 14 CO 4.5 L/min, SVV 8%
  • 90.
    Case scenarios, caseIII • 35 year old,TVD, CABG following ACS....... • Normal intraopertive course • Exubation 5th hr, normal ABG and hemodynamics • D1 ...... ABG (N) HR 80/min,BP 75/50,RA 14, SVV 6, CO 2.5 L/min Management??????
  • 91.
    Case scenarios, caseIII • Fluid challenge 100 ml RL.... No response • Adr 0.5µkg/hr,Douta 5µ kg/hr,NTG 0.5µkg/hr • 5th hr................ ABG (N) HR 90/min,BP 105/58,RA 8, SVV 7, CO 3.9 L/min
  • 92.
    • Tachycardia isnever a good thing. • Hypotension is always pathological. • There is no normal cardiac output. • CVP is only elevated in disease. • A higher mortality was shown in patients with right ventricular dysfunction and an increase of pulmonary vascular resistance. The Truths in Hemodynamics
  • 93.
    The Truths inHemodynamic Monitoring • Monitors associate with inaccuracies, misconceptions and poorly documented benefits. • A good understanding of the pathophysiological underpinnings for its effective application across patient groups is required. • Functional hemodynamic monitors are superior to conventional filling pressure. • The goal of treatments based on monitoring is to restore the physiological homeostasis.
  • 94.
    ANY IDEAL SYSTEM? Ideal •Non invasive • Accurate • Reliable • Continuous • Compatible in paed. Pts. • Reproducible • Fast response • Operator independent
  • 95.