Hemodynamic Pressure Monitoring

HEMODYNAMIC PRESSURE MONITORING Dr. Mueen Ullah Khan Assitant professor Department of Anaesthesia KKUH December 2 2009 Lecture series resident 1 and 2 Anaesthesia

A. STANDARD
Qualified anesthesia personnel shall be present in the room throughout the conduct of all general anesthetics, regional anesthetics and monitored anesthesia care.

CIRCULATION
OBJECTIVE : To ensure the adequacy of the patient's circulatory function during all anesthetics.
METHODS:
(a) Every patient receiving anesthesia shall have the electrocardiogram continuously displayed from the beginning of anesthesia until preparing to leave the anesthetizing location.
(b) Every patient receiving anesthesia shall have arterial blood pressure and heart rate determined and evaluated at least every five minutes.
(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.

DEFINATIONS
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.
Arterial pressure is the lateral pressure exerted by the contained blood on the walls of the
vessels.
Mean arterial pressure is the product of the cardiac output and the systemic vascular resistance.
Mean pressure is about one-third the difference between the systolic and diastolic pressures.

Arterial pressure
Arterial pressure varies with the respiratory cycle.
It normally decreases 6 mm Hg or less
REASON:
Increase in venous capacitance during inspiration
Increase in right-sided heart venous return and output, thus causing a decrease in left ventricular stroke output and pressure.

BLOOD PRESSURE MONITORING
PERIOPERATIVE SYSTEMIC BLOOD PRESSURE MONITORING
INDIRECTLY using extremity-encircling cuffs
DIRECTLY By inserting a catheter into an artery and transducing the arterial pressure trace.

Indirect Measurement of Arterial Blood Pressure

PREREQUISITES
The bladder width for indirect blood pressure monitoring should approximate 40% of the circumference of the extremity.
Bladder length should be sufficient to encircle at least 60% of the extremity .
AUSCULTATION OF THE KOROTKOFF SOUNDS

LIMITATIONS
Quick deflations underestimate blood pressure.
Unreliable during conditions of low flow.

NIBP
Most current instruments use oscillometric techniques to measure systolic, diastolic, and mean blood pressures.
Automated oscillometry underestimate
Systolic blood pressure, with mean errors reported from -6.9 to -8.6 mm Hg compared with direct radial artery pressure measurements.

Invasive Measurement of Vascular (Arterial Blood) Pressure

Invasive Measurement of Vascular (Arterial Blood) Pressure
Indwelling arterial cannulation permits the opportunity to monitor arterial blood pressure continuously and to have vascular access for arterial blood sampling.

INTRAVASCULAR PRESSURE MONITORING Physiology Monitor Mechanical energy Transducer system Electronic signal Transducer system

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

Transducer system CONNECTION LINE: SHORTER , LONG and STIFFER! INTRAVASCULAR PRESSURE MONITORING Resonance Damping

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

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

RAPID FLUSH TEST To determinate the dynamic response of catheter and transducer system Overdamped INTRAVASCULAR PRESSURE MONITORING

Invasive arterial pressure WHEN:
Beat to beat chance in BP
Expecting large fluid shifts
Cardiac arrest
Shock syndrome
Hypertensive crisis
Use of vasoactive drugs
Use on IABP
MULTIPLE BLOOD GAS ANALYSIS
Mechanical Ventilation
Respiratory failure
Sepsis
INTRAVASCULAR PRESSURE MONITORING

WHERE:
Radial Artery
Femoral Artery
Brachial Artery
Axillary Artery
Dorsalis pedis artery
90% TECHNIQUE OF CANNULATION :
Use always
Seldinger Technique
Invasive arterial pressure - 2 INTRAVASCULAR PRESSURE MONITORING

MAP = PAd + (PAs-PAd) / 3 Pulse Pressure : PAs-PAd Invasive arterial pressure - 3 INTRAVASCULAR PRESSURE MONITORING

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

Invasive arterial pressure INTRAVASCULAR PRESSURE MONITORING RESPIRATORY CHANGES IN ARTERIAL WAVE FORM IN MECHANICALLY VENTILATED PATIENTS  SYSTOLIC PRESSURE VARIATION - SPV  PULSE PRESSURE VARIATION - PPV

SYSTOLIC PRESSURE VARIATION - SPV

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.

Invasive arterial pressure SYSTOLIC PRESSURE VARIATION - SPV

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

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
During hypovolemia, as during hemorrage
  SPV by   Down
The amount of blood loss was closely correlated
with SPV and  Down
Volume expansion   SPV and  Down

PULSE PRESSURE VARIATION - PPV

Invasive arterial pressure INTRAVASCULAR PRESSURE MONITORING PULSE PRESSURE VARIATION - PPV PULSE PRESSURE The difference between systolic and diastolic arterial pressure
In mechanically ventilated patients:
PP is maximum at the end of inspiratory period
PP is minimum during the expiratory period
Respiratory changes in LVSV are reflected by respiratory changes in PP.

Invasive arterial pressure INTRAVASCULAR PRESSURE MONITORING PULSE PRESSURE VARIATION - PPV  PP (%) = (PPmax- PPmin) / ((Ppmax+Ppmin)/2)*100

Invasive arterial pressure INTRAVASCULAR PRESSURE MONITORING PULSE PRESSURE VARIATION - PPV Michard et al.: Am J Resp Crit Care Med 2000; 162:134-138
PPV before volume expansion can accurately predict the effect of
volume expansion on CO
PPV is a more reliable indicator of fluid responsiveness than  PS
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%).
By contrast, if PPV  13%, the patients was unlikely to respond to fluid challenge (negative predictive value 96%).

Central Venous Pressure

Central Venous Pressure - 1 WHEN:
Pre-operative preparation
Total parenteral nutrition
Pulmonary artery catheter
Emergency management
Use of vasoactive and irritant drugs
Cardiac arrest
Neurosurgery

CVP monitoring
Proponents of CVP monitoring believe that CVP pressures are essentially equivalent to right atrial pressures and serve as a reflection of right ventricular preload
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.

WHERE:
Depend on surgery plan!!
I nternal Jugular vein
Subclavian vein
Basalic/cephalic veins- long line
2. Femoral vein- long line
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

CVP – Central Venous Pressure / Right Atrium waveform
A wave  Atrium Systole
C wave  Tricuspid valve closure
X wave  Atrial relaxation
V wave  Atrial filling with tricuspid valve closed
Y wave  Ventricular filling after ticuspid valve opening

Central Venous Pressure / Ventilation Spontaneous Breathing Mechanical Ventilation (  = Inspiration) INTRAVASCULAR PRESSURE MONITORING

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

Complications

Superior Vena Cava >Tricuspid Valve > Right Ventricle > Pulmonary Artery PULMUNARY ARTERY CATHETER - SWAN-GANZ

SWAN-GANZ CATHETER 1. Distal lumen 2. Proximal lumen 3. Balloon inflation lumen 1 2 3

WHEN:
Complicated MI
Shock (cardiogenic-hypovolemic-Septic)
Respiratory distress (cardiogenic – noncardiogenic)
Management post-cardiac surgery patient
Others
INTRAVASCULAR PRESSURE MONITORING Pulmunary Artery Catheter - 1

CONTROINDICATIONS:
Stenosis tricuspid,
LBBB
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

INTRAVASCULAR PRESSURE MONITORING Pulmunary Artery Catheter - 3 Insertion technique

INTRAVASCULAR PRESSURE MONITORING Pulmunary Artery Catheter - 4 Insertion technique

INTRAVASCULAR PRESSURE MONITORING Pulmunary Artery Catheter - 5

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

MEASUREMENTS: Pulmonary Artery Occlusion Pressure (PAOP) INTRAVASCULAR PRESSURE MONITORING Pulmunary Artery Catheter - 7

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

MEASUREMENTS: Pulmonary Artery Occlusion Pressure (PAOP) INTRAVASCULAR PRESSURE MONITORING Pulmunary Artery Catheter - 8 Error in interpretation – Damped PAP

MEASUREMENTS: Pulmonary Artery Occlusion Pressure (PAOP) INTRAVASCULAR PRESSURE MONITORING Pulmunary Artery Catheter - 9 Error in interpretation – Overwedging

MEASUREMENTS: Pulmonary Artery Occlusion Pressure (PAOP) INTRAVASCULAR PRESSURE MONITORING Pulmunary Artery Catheter - 10 Error in interpretation – Mitral regurgitation

• 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
CONTRACTION
PRELOAD
AFTERLOAD
CONCLUSIONS DRUGS? VOLUME? ECHO!!!

THANK YOU
QUESTIONS ?

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Hemodynamic Pressure Monitoring

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Hemodynamic Pressure Monitoring — Presentation Transcript