Hemodynamic Pressure Monitoring

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Hemodynamic Pressure Monitoring

  1. 1. HEMODYNAMIC PRESSURE MONITORING Dr. Mueen Ullah Khan Assitant professor Department of Anaesthesia KKUH December 2 2009 Lecture series resident 1 and 2 Anaesthesia
  2. 2. A. STANDARD <ul><li>Qualified anesthesia personnel shall be present in the room throughout the conduct of all general anesthetics, regional anesthetics and monitored anesthesia care. </li></ul>
  3. 3. CIRCULATION <ul><li>OBJECTIVE : To ensure the adequacy of the patient's circulatory function during all anesthetics. </li></ul><ul><li>METHODS: </li></ul><ul><li>(a) Every patient receiving anesthesia shall have the electrocardiogram continuously displayed from the beginning of anesthesia until preparing to leave the anesthetizing location. </li></ul><ul><li>(b) Every patient receiving anesthesia shall have arterial blood pressure and heart rate determined and evaluated at least every five minutes. </li></ul><ul><li>(c) Every patient receiving general anesthesia shall have, in addition to the above, circulatory function continually evaluated by at least one of the following: palpation of a pulse, auscultation of heart sounds, monitoring of a tracing of intraarterial pressure, ultrasound peripheral pulse monitoring, or pulse plethysmography or oximetry. </li></ul>
  4. 4. DEFINATIONS <ul><li>The arterial pulse is a wave of vascular distention resulting from the impact of the stroke volume of each beat being ejected into a closed system. </li></ul><ul><li>Arterial pressure is the lateral pressure exerted by the contained blood on the walls of the </li></ul><ul><li>vessels. </li></ul><ul><li>Mean arterial pressure is the product of the cardiac output and the systemic vascular resistance. </li></ul><ul><li>Mean pressure is about one-third the difference between the systolic and diastolic pressures. </li></ul>
  5. 5. Arterial pressure <ul><li>Arterial pressure varies with the respiratory cycle. </li></ul><ul><li>It normally decreases 6 mm Hg or less </li></ul><ul><li>REASON: </li></ul><ul><li>Increase in venous capacitance during inspiration </li></ul><ul><li>Increase in right-sided heart venous return and output, thus causing a decrease in left ventricular stroke output and pressure. </li></ul>
  6. 6. BLOOD PRESSURE MONITORING <ul><li>PERIOPERATIVE SYSTEMIC BLOOD PRESSURE MONITORING </li></ul><ul><li>INDIRECTLY using extremity-encircling cuffs </li></ul><ul><li>DIRECTLY By inserting a catheter into an artery and transducing the arterial pressure trace. </li></ul>
  7. 7. Indirect Measurement of Arterial Blood Pressure
  8. 8. Indirect Measurement of Arterial Blood Pressure <ul><li>PREREQUISITES </li></ul><ul><li>The bladder width for indirect blood pressure monitoring should approximate 40% of the circumference of the extremity. </li></ul><ul><li>Bladder length should be sufficient to encircle at least 60% of the extremity . </li></ul><ul><li>AUSCULTATION OF THE KOROTKOFF SOUNDS </li></ul>
  9. 9. Indirect Measurement of Arterial Blood Pressure <ul><li>LIMITATIONS </li></ul><ul><li>Quick deflations underestimate blood pressure. </li></ul><ul><li>Unreliable during conditions of low flow. </li></ul>
  10. 10. NIBP <ul><li>Most current instruments use oscillometric techniques to measure systolic, diastolic, and mean blood pressures. </li></ul><ul><li>Automated oscillometry underestimate </li></ul><ul><li>Systolic blood pressure, with mean errors reported from -6.9 to -8.6 mm Hg compared with direct radial artery pressure measurements. </li></ul>
  11. 11. Invasive Measurement of Vascular (Arterial Blood) Pressure
  12. 12. Invasive Measurement of Vascular (Arterial Blood) Pressure <ul><li>Indwelling arterial cannulation permits the opportunity to monitor arterial blood pressure continuously and to have vascular access for arterial blood sampling. </li></ul>
  13. 13. INTRAVASCULAR PRESSURE MONITORING Physiology Monitor Mechanical energy Transducer system Electronic signal Transducer system
  14. 14. COMPONENTS 1. Transducer Change mechanical energy to electronic signal. 2. Continuos washing system Saline solution in a pressure bag (300mmHg) or infusion pump ( less fluid volume!!! ) 3. Proximal stopcock Useful to set “Zero”. 4. Connection to catheter Transfer pressure pulse from caterer to transducer 5. Distal stopcock Useful to take out blood sample. 2 4 5 INTRAVASCULAR PRESSURE MONITORING 1 3
  15. 15. Transducer system CONNECTION LINE: SHORTER , LONG and STIFFER! INTRAVASCULAR PRESSURE MONITORING Resonance Damping
  16. 16. Calibration - “ZERO” WHY R emove atmospheric pressure interference (~760mmHg) WHEN connection from transducer to monitor Not when you change transducer position!!! TEST Open Proximal Stopcock to connect transducer to air , monitor must show a Straight line and measure “zero”. SET: RANGE Measured pressure is always relative to a reference point. It’s a difference! INTRAVASCULAR PRESSURE MONITORING
  17. 17. Level: Reference point RIGHT ATRIUM = “ Mean Axillary Line” Supine position WHEN: SET LEVEL Every time patient moves (Otherwise measurement is not right!!!) INTRAVASCULAR PRESSURE MONITORING
  18. 18. RAPID FLUSH TEST To determinate the dynamic response of catheter and transducer system Overdamped INTRAVASCULAR PRESSURE MONITORING
  19. 19. Invasive arterial pressure WHEN: <ul><li>Beat to beat chance in BP </li></ul><ul><li>Expecting large fluid shifts </li></ul><ul><li>Cardiac arrest </li></ul><ul><li>Shock syndrome </li></ul><ul><li>Hypertensive crisis </li></ul><ul><li>Use of vasoactive drugs </li></ul><ul><li>Use on IABP </li></ul><ul><li>MULTIPLE BLOOD GAS ANALYSIS </li></ul><ul><li>Mechanical Ventilation </li></ul><ul><li>Respiratory failure </li></ul><ul><li>Sepsis </li></ul>INTRAVASCULAR PRESSURE MONITORING
  20. 20. WHERE: <ul><li>Radial Artery </li></ul><ul><li>Femoral Artery </li></ul><ul><li>Brachial Artery </li></ul><ul><li>Axillary Artery </li></ul><ul><li>Dorsalis pedis artery </li></ul>90% TECHNIQUE OF CANNULATION : <ul><li>Use always </li></ul><ul><li>Seldinger Technique </li></ul>Invasive arterial pressure - 2 INTRAVASCULAR PRESSURE MONITORING
  21. 21. MAP = PAd + (PAs-PAd) / 3 Pulse Pressure : PAs-PAd Invasive arterial pressure - 3 INTRAVASCULAR PRESSURE MONITORING
  22. 22. Invasive arterial pressure - 4 INTRAVASCULAR PRESSURE MONITORING NORMAL RANGE SYSTOLIC BLOOD PRESSURE Age Wt mmHg Term 3.4kg 40-60 3 mo 6kg 45-75 6 mo 7.5kg 50-90 1 yr 10kg 50-100 3yr 14kg 50-100 7yr 22kg 60-90 10yr 30kg 60-90 12yr 38kg 65-95 14yr 50kg 65-95
  23. 23. Invasive arterial pressure INTRAVASCULAR PRESSURE MONITORING RESPIRATORY CHANGES IN ARTERIAL WAVE FORM IN MECHANICALLY VENTILATED PATIENTS  SYSTOLIC PRESSURE VARIATION - SPV  PULSE PRESSURE VARIATION - PPV
  24. 24. <ul><li>SYSTOLIC PRESSURE VARIATION - SPV </li></ul>
  25. 25. Invasive arterial pressure INTRAVASCULAR PRESSURE MONITORING SYSTOLIC PRESSURE VARIATION - SPV The difference between the maximal and minimal value of systolic blood pressure during one mechanical breath. SPV can be divided into two components by interposing a brief (5sec) apnea, and using the systolic blood pressure during apnea as a reference value: down  up The difference between the maximal systolic value and the systolic blood pressure during apnea. The difference between the apneic systolic blood pressure and the minimal systolic value.
  26. 26. Invasive arterial pressure SYSTOLIC PRESSURE VARIATION - SPV
  27. 27. Invasive arterial pressure INTRAVASCULAR PRESSURE MONITORING SYSTOLIC PRESSURE VARIATION - SPV  Down reflects the expiratory decrease in LV preload and SV related to the inspiration decrease in RVSV
  28. 28. Invasive arterial pressure INTRAVASCULAR PRESSURE MONITORING SYSTOLIC PRESSURE VARIATION - SPV Perel A. et al.-Anesthesiology 1987:67;498-502 Pizov R. et al.-Anesth Analg 1988:67;170-174 Preisman S. et al.-Int Care Med1997:23;651-657 <ul><li>During hypovolemia, as during hemorrage </li></ul><ul><li>  SPV by   Down </li></ul><ul><ul><li>The amount of blood loss was closely correlated </li></ul></ul><ul><ul><li>with SPV and  Down </li></ul></ul><ul><ul><li>Volume expansion   SPV and  Down </li></ul></ul>
  29. 29. PULSE PRESSURE VARIATION - PPV
  30. 30. Invasive arterial pressure INTRAVASCULAR PRESSURE MONITORING PULSE PRESSURE VARIATION - PPV PULSE PRESSURE The difference between systolic and diastolic arterial pressure <ul><li>In mechanically ventilated patients: </li></ul><ul><li>PP is maximum at the end of inspiratory period </li></ul><ul><li>PP is minimum during the expiratory period </li></ul>Respiratory changes in LVSV are reflected by respiratory changes in PP.
  31. 31. Invasive arterial pressure INTRAVASCULAR PRESSURE MONITORING PULSE PRESSURE VARIATION - PPV  PP (%) = (PPmax- PPmin) / ((Ppmax+Ppmin)/2)*100
  32. 32. Invasive arterial pressure INTRAVASCULAR PRESSURE MONITORING PULSE PRESSURE VARIATION - PPV Michard et al.: Am J Resp Crit Care Med 2000; 162:134-138 <ul><li>PPV before volume expansion can accurately predict the effect of </li></ul><ul><li>volume expansion on CO </li></ul><ul><li>PPV is a more reliable indicator of fluid responsiveness than  PS </li></ul><ul><li>A patients with a baseline PPV value of more than 13% was very likely to respond to volume expansion by increasing CO by  15% (positive predicted value 94%). </li></ul><ul><li>By contrast, if PPV  13%, the patients was unlikely to respond to fluid challenge (negative predictive value 96%). </li></ul>
  33. 33. Central Venous Pressure
  34. 34. Central Venous Pressure - 1 WHEN: <ul><li>Pre-operative preparation </li></ul><ul><li>Total parenteral nutrition </li></ul><ul><li>Pulmonary artery catheter </li></ul><ul><li>Emergency management </li></ul><ul><li>Use of vasoactive and irritant drugs </li></ul><ul><li>Cardiac arrest </li></ul><ul><li>Neurosurgery </li></ul>INTRAVASCULAR PRESSURE MONITORING
  35. 35. CVP monitoring <ul><li>Proponents of CVP monitoring believe that CVP pressures are essentially equivalent to right atrial pressures and serve as a reflection of right ventricular preload </li></ul><ul><li>CVP monitoring is less invasive and less costly than pulmonary artery monitoring and offers unique understanding of right-sided hemodynamic events and the status of vascular volume. </li></ul>
  36. 36. WHERE: <ul><li>Depend on surgery plan!! </li></ul><ul><li>I nternal Jugular vein </li></ul><ul><li>Subclavian vein </li></ul><ul><li>Basalic/cephalic veins- long line </li></ul><ul><li>2. Femoral vein- long line </li></ul>TECHNIQUE OF CANNULATION: - Use always Seldinger Technique INTRAVASCULAR PRESSURE MONITORING 1. 5Kg ⇒ 4 Fr- 5cm bi-lumen 5,5Fr 5cm triple-lumen 2. 5-10 Kg ⇒ 4 Fr 8cm triple-lumen 5,5Fr 5cm triple-lumen 3. 10-20 Kg ⇒ 5,5 Fr 8 cm triple-lumen 4. 20 Kg ⇒ 5.5 Fr 8 - 13cm triple-lumen 5. Adults 6 Fr 16-18 cm Central Venous Pressure - 2
  37. 37. CVP – Central Venous Pressure / Right Atrium waveform <ul><li>A wave  Atrium Systole </li></ul><ul><li>C wave  Tricuspid valve closure </li></ul><ul><li>X wave  Atrial relaxation </li></ul><ul><li>V wave  Atrial filling with tricuspid valve closed </li></ul><ul><li>Y wave  Ventricular filling after ticuspid valve opening </li></ul>INTRAVASCULAR PRESSURE MONITORING
  38. 38. Central Venous Pressure / Ventilation Spontaneous Breathing Mechanical Ventilation (  = Inspiration) INTRAVASCULAR PRESSURE MONITORING
  39. 39. CVP – Central Venous Pressure / Right Atrium waveform • TRICUSPID REGURGITATION: Elevated CVP Evident positive V wave • CARDIAC TAMPONADE: Elevated CVP Damping or absence of Y wave Equalization of CVP, diastolic PAP and PAWP INTRAVASCULAR PRESSURE MONITORING
  40. 40. Complications
  41. 41. Superior Vena Cava >Tricuspid Valve > Right Ventricle > Pulmonary Artery PULMUNARY ARTERY CATHETER - SWAN-GANZ
  42. 42. SWAN-GANZ CATHETER 1. Distal lumen 2. Proximal lumen 3. Balloon inflation lumen 1 2 3
  43. 43. <ul><li>WHEN: </li></ul><ul><li>Complicated MI </li></ul><ul><li>Shock (cardiogenic-hypovolemic-Septic) </li></ul><ul><li>Respiratory distress (cardiogenic – noncardiogenic) </li></ul><ul><li>Management post-cardiac surgery patient </li></ul><ul><li>Others </li></ul>INTRAVASCULAR PRESSURE MONITORING Pulmunary Artery Catheter - 1
  44. 44. <ul><li>CONTROINDICATIONS: </li></ul><ul><li>Stenosis tricuspid, </li></ul><ul><li>LBBB </li></ul>Inserction: Arrhythmias (TV, FV) 0.3-63 % Right bundle branch (0.1-4.3 %), Total AVB (0-8.5 %) Intracardiac and valve damage Tromboembolic complication “ Knotting” (loop) After inserction: Infection (0-22%) Septicemia Endocarditis (2.2 -100%) Pulmonary infarction (0.1 -7 %) Pulmonary artery perforation (0.06-0.2 %) Balloon rupture COMPLICATION: INTRAVASCULAR PRESSURE MONITORING Pulmunary Artery Catheter - 2
  45. 45. INTRAVASCULAR PRESSURE MONITORING Pulmunary Artery Catheter - 3 Insertion technique
  46. 46. INTRAVASCULAR PRESSURE MONITORING Pulmunary Artery Catheter - 4 Insertion technique
  47. 47. INTRAVASCULAR PRESSURE MONITORING Pulmunary Artery Catheter - 5
  48. 48. MEASUREMENTS: Cardiac Output Thermodilution (Fegler G., 1954/Ganz W, 1971) Cold solution in injected into right atrium. The thermistor records blood temperature change on the top of pulmonary artery catheter. Stewart-Hamilton formula CO = Vol injected x (TB-TF)1.08K/ ? ? TB(t)dt • TB, TF = Blood and cold fliud temperature • ?? TB(t)dt = under-curve area • K = computational constants INTRAVASCULAR PRESSURE MONITORING Pulmunary Artery Catheter - 6
  49. 49. MEASUREMENTS: Pulmonary Artery Occlusion Pressure (PAOP) INTRAVASCULAR PRESSURE MONITORING Pulmunary Artery Catheter - 7
  50. 50. MEASUREMENTS: Pulmonary Artery Occlusion Pressure (PAOP) INTRAVASCULAR PRESSURE MONITORING Pulmunary Artery Catheter - 7 In Pediatric Cardiac Surgery you can put a catheter direct In Left Atrium LVEDP LAP
  51. 51. MEASUREMENTS: Pulmonary Artery Occlusion Pressure (PAOP) INTRAVASCULAR PRESSURE MONITORING Pulmunary Artery Catheter - 8 Error in interpretation – Damped PAP
  52. 52. MEASUREMENTS: Pulmonary Artery Occlusion Pressure (PAOP) INTRAVASCULAR PRESSURE MONITORING Pulmunary Artery Catheter - 9 Error in interpretation – Overwedging
  53. 53. MEASUREMENTS: Pulmonary Artery Occlusion Pressure (PAOP) INTRAVASCULAR PRESSURE MONITORING Pulmunary Artery Catheter - 10 Error in interpretation – Mitral regurgitation
  54. 54. • Central Venous Line – CVP – Blood gas (ScvO2) • Arterial line – Continuous Blood Pressure – SPV / PPV • Pulmonary Artery Catheter (PAC) – Occlusion pressure, PAP – C.O. / SVR / PVR – SvO2 – DO2 / VO2 <ul><li>CONTRACTION </li></ul><ul><li>PRELOAD </li></ul><ul><li>AFTERLOAD </li></ul>CONCLUSIONS DRUGS? VOLUME? ECHO!!!
  55. 55. <ul><li>THANK YOU </li></ul><ul><li>QUESTIONS ? </li></ul>

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