Hemodynamic monitoring

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Hemodynamic monitoring

  1. 1. BEDSIDE HEMODYNAMIC MONITORING
  2. 2. Bedside Hemodynamic MonitoringOutline• Indications and evidence for effectiveness – Sepsis – CHF – Peri-op• Insertion• Complications• Measurement
  3. 3. Bedside Hemodynamic MonitoringDefinition• The use of an indwelling catheter to measure – pulmonary artery pressure – pulmonary capillary wedge pressure – right atrial pressure – pulmonary artery oxygen saturation – thermodilution cardiac output in the intensive care unit.
  4. 4. IndicationsSummary of ACP/AHA/ACC Expert Panel• “To help direct management in medical patients in whom hemodynamics will alter treatment and clinical estimates are unreliable”• “To assist management of surgical patients”• “To establish or assist in establishing specific diagnoses” – Cardiac vs. non-cardiac pulmonary edema – VSD vs. MR in acute MI – Pericardial tamponade – RV MI Friesinger et al. JAMA 1990; 15: 1460
  5. 5. Evidence for EffectivenessDecompensated Heart Failure: ESCAPE trial• Randomized trial of PAC vs. no PAC – 433 pts hospitalized with CHF and volume overload – In PAC group: goal PCW 15 and RA 8 – PAC group had greater wt loss (4.0 vs 3.2 kg) but similar final BUN/creat – 9 serious adverse events in PAC group (infection, bleed, catheter knot, VT, pulmonary infarction) ESCAPE Investigators. JAMA 2005; 294: 1625
  6. 6. Evidence for EffectivenessDecompensated Heart Failure: ESCAPE trial• For the primary endpoint, there was no difference between intervention and control groups: ESCAPE Investigators. JAMA 2005; 294: 1625
  7. 7. Evidence for EffectivenessDecompensated Heart Failure: ESCAPE trial• For the secondary endpoints: – No change in exercise capacity – Change in QoL at 1 month only – Improved patient assessment of health state (TTO) at 1 & 6 months ESCAPE Investigators. JAMA 2005; 294: 1625
  8. 8. Evidence for EffectivenessMedical ICU: PAC-Man trial• Randomized trial of PAC vs. no PAC – 1041 pts admitted to ICU who attending thought needed a PAC. 66% medical. 65% multi-organ dysfunction. – Therapy at the discretion of the clinician – Serious complications occurred in 10% of pts in the PAC group Harvey et al. Lancet 2005; 366: 472
  9. 9. Evidence for Effectiveness Medical ICU: PAC-Man trial• For the primary endpoint, there was P = 0.381 no difference between intervention and control groups: Harvey et al. Lancet 2005; 366: 472
  10. 10. Evidence for EffectivenessPeri-operative management Study N Result Schultz. 1985 70 ↓ mortality in PAC group Shoemaker. 1988 88 ↓ mortality in PAC group Isaacson. 1990 102 No differences Berlauk. 1991 89 No differences Bender. 1997 104 No differences Valentine. 1998 120 Borderline ↓ mort in PAC group Bonazzi. 1992 100 No differences Sandham. 2003 1994 No differences
  11. 11. Evidence for Effectiveness Meta-analysis • Quantitative review of 13 RCTs of PAC vs. no PAC in – medical – surgical – cardiac patients demonstrated no mortality benefit: Combined OR 1.04 (0.90 – 1.20) PAC better No PAC betterShah et al. JAMA 2005; 294: 1664
  12. 12. Bedside Hemodynamic MonitoringIndications and Evidence for Effectiveness• Despite assertions by experts, there is no demonstrated benefit on mortality or length of stay associated with bedside hemodynamic monitoring• Its use should be limited to “rescue” situations where all other options have failed, and diagnostic situations where non-invasive options have been inconclusive
  13. 13. … So if you really feel like youabsolutely have to use it …
  14. 14. Bedside Hemodynamic MonitoringInsertion Complication rates• Choose insertion site to minimize complications – Subclavian vs femoral: 19.8% 17.3% 18.8% subclavian preferred – Subclavian vs IJ: not tested; likely IJ has > 4.5% infection rate and < severe Infectious Mechanical mechanical complications Femoral Subclavian (except arterial puncture) – Consider brachial in patients with coagulopathy Merrer et al. JAMA 2001; 286: 700. Taupenot et al. NEJM 2002; 348: 12.
  15. 15. Bedside Hemodynamic MonitoringInsertion- complications• Other potential complications: – Infection – Thrombosis and thromboembolism – Hemorrhage – Pneumothorax and hemothorax – Nerve injury – Pneumomediastinum – Air embolus – Foreign body embolus – RBBB – Ventricular arrhythmias – Pulmonary infarction – Pulmonary artery rupture – Heparin-induced thrombocytopenia (heparin-bonded catheter)
  16. 16. Bedside Hemodynamic MonitoringInsertion- complications• Risk factors for complications: – Insertion site – Time taken for insertion – Duration of insertion – Operator experience (>50 vs <50) – Site preparation• Scheduled insertion changes don’t decrease rates of complications
  17. 17. Bedside Hemodynamic MonitoringWaveform analysis- normal valuesRight atrium 0-7 mmHgRight ventricle 40 (sys) / 9 (end diastolic)Pulmonary artery 25-40 / 10-20Pulmonary wedge 2-14Cardiac index 2.2 – 3.6Mixed venous O2 saturation 68 – 76%
  18. 18. Bedside Hemodynamic MonitoringWaveform analysis Right Atrium Pulmonary Artery Right Ventricle Wedge
  19. 19. Bedside Hemodynamic MonitoringWaveform analysis: Respiratory variation End-expiratory
  20. 20. Bedside Hemodynamic MonitoringWaveform analysis- diagnosing pathology “dip & plateau”
  21. 21. Bedside Hemodynamic MonitoringCardiac Output• Measured by thermodilution: – Inject cool saline or warm the blood in the RA – Measure change in temperature with time in the PA – Integral of T vs. t curve is used to compute CO• There are many pitfalls in bedside CO measurement; be skeptical when the “number” doesn’t match the clinical data• Cardiac output is an imperfect indicator of circulatory function
  22. 22. Bedside Hemodynamic MonitoringOxygen saturation• Useful check on accuracy of cardiac output• Can be used to confirm “wedged” position• Can be used to diagnose (relatively large) intracardiac shunts

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