Pulmonary Artery Catheters

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Pulmonary Artery Catheters

  1. 1. DIVISION OF CRITICAL CARE MEDICINE GWUMC Pulmonary Artery Catheters or perhaps not
  2. 2. DIVISION OF CRITICAL CARE MEDICINE GWUMC Housestaff perception of PA catheters: MAP=SBP+2DBP/3 CO=HRxSV/1000 CI=CO/BSA SVR=80x(MAP-RAP)/CO PVR=80x(MAP-PAWP)/CO RVEF=SV/EDV CaO2=(.0138xHgbxSaO2)+.0031xPaO2 VO2=(C(a-v)O2) x CO x 10
  3. 3. DIVISION OF CRITICAL CARE MEDICINE GWUMC Some Equations... • MAP = 1/3 SBP + 2/3DBP • CO = SV x HR • CI = CO/BSA • SVR = (MAP-CVP)/CO x 80 • PVR = (MPAP - PAOP)/CO x 80 • LVSWI = SVI x (MPAP-PAOP)/BSA x 0.0136
  4. 4. DIVISION OF CRITICAL CARE MEDICINE GWUMC Normal Values • Cardiac Output (CO) : 4 -8 L/min • Cardiac Index (CI) : 2.4 - 4.0 L/min/m2 • MAP : 70-105 mm Hg • Systemic Vascular Resistance (SVR): 800 - 1200 dynes/sec/cm5 • Pulmonary Vascular Resistance (PVR): <250 dynes/sec/cm5 • Stroke Volume (SV): 60-100 ml/beat
  5. 5. DIVISION OF CRITICAL CARE MEDICINE GWUMC 1. Why is this patient hypotensive? 2. Why is this patient in shock? 3. Why is this patient in pulmonary edema? 4. How can I minimize fluid infusion while maintaining perfusion in my hypoxic patient? 4. Will this patient tolerate empiric resuscitation and diagnosis through therapeutic challenge?
  6. 6. DIVISION OF CRITICAL CARE MEDICINE GWUMC “The patient’s dead, he just doesn’t know it yet” Dennis Quinlan, MD 1995
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  9. 9. DIVISION OF CRITICAL CARE MEDICINE GWUMC Volume 345:1368-1377 November 8, 2001 Number 19 Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock Emanuel Rivers, M.D., M.P.H., Bryant Nguyen, M.D., Suzanne Havstad, M.A., Julie Ressler, B.S., Alexandria Muzzin, B.S., Bernhard Knoblich, M.D., Edward Peterson, Ph.D., Michael Tomlanovich, M.D., for the Early Goal-Directed Therapy Collaborative Group
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  13. 13. DIVISION OF CRITICAL CARE MEDICINE GWUMC Central venous O2 saturation (SCVO2) ? Mixed venous O2 saturation (SMVO2) SMVO2 is approximately 5% lower than SCVO2 -10.0 -5.0 0.0 5.0 10.0 15.0 20.0 40 50 60 70 80 90 100 (Sv cO2 + SvO2)/2 % (SvcO2-SvO2)% Zia et al Crit.Care Medicine 2003;30:A71 Bland-Altman Plot
  14. 14. DIVISION OF CRITICAL CARE MEDICINE GWUMC
  15. 15. DIVISION OF CRITICAL CARE MEDICINE GWUMC BP = CO x SVR
  16. 16. DIVISION OF CRITICAL CARE MEDICINE GWUMC BP = CO x SVR HR SV
  17. 17. DIVISION OF CRITICAL CARE MEDICINE GWUMC BP = CO x SVR HR SV LVEDV Contractility
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  24. 24. DIVISION OF CRITICAL CARE MEDICINE GWUMC The four (five) causes of hypotension Hypovolemia Pump failure Hemorrhage Myocardial ischemia GI losses Cardiomyopathy Dehydration Valvular disease Insensible Arrhythmias Distribution Obstruction Sepsis Pulmonary Embolism Anaphylaxis Tension pneumothorax Neurogenic Cardiac tamponade Adrenal insufficiency Constrictive pericarditis
  25. 25. DIVISION OF CRITICAL CARE MEDICINE GWUMC The four (five) causes of hypotension Hypovolemia Pump failure Hemorrhage Myocardial ischemia GI losses Cardiomyopathy Dehydration Valvular disease Insensible Arrhythmias Distribution Obstruction Sepsis Pulmonary Embolism Anaphylaxis Tension pneumothorax Neurogenic Cardiac tamponade Adrenal insufficiency Constrictive pericarditis DRUGS & DOCTORS
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  31. 31. DIVISION OF CRITICAL CARE MEDICINE GWUMC HR/RHYTHM CVP/PCWP SVR CO DX RX ⇑ ⇓ ⇓ ⇑ ⇓ Hypovolemia Volume ⇓ or ? ⇑ ⇑ ⇓ Pump Pacer, antiarrhythmic ⇑ ⇑ ⇑ ⇑ ⇓ Pump Inotrope nl, ⇑ ⇑ ⇑ ⇑⇑ ⇓ Pump Valve, rate control ⇑ ⇓ ⇓ ⇓ ⇑ Distribution Pressors, volume ⇑ ⇑ ⇓ ⇑ ⇓ Obstruction Chest tube TPA
  32. 32. DIVISION OF CRITICAL CARE MEDICINE GWUMC The data obtained from pulmonary artery catheters should aid, not replace, clinical judgement. Treat the patient, not the numbers. Remember
  33. 33. DIVISION OF CRITICAL CARE MEDICINE GWUMC And of course…

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