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Monitoria cardiovascular

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marcelino murillo

marcelino murillo

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  • 1. ¿QUÉ AYUDASTENEMOS PARA ELMONITOREOCARDIOVASCULAR DENUESTROS PACIENTES?
  • 2. MONITORIACARDIOVASCULAR Marcelino Murillo Deluquez Residente Anestesia y Reanimación Universidad de Cartagena
  • 3. MONITOREO CIRCULATORIO
  • 4. USO DEL FONENDOSCOPIO LAENNEC 1.818 Harvey Cushing 1908
  • 5. MONITOREO DE LA FRECUENCIACARDIACA
  • 6. DIFERENCIAS ENTRE FC Y PULSO Disociación electromecánica. Actividad eléctrica sin pulso. Fibrilación auricular. Taponamiento cardiaco. Hipovolemia marcada.
  • 7. TÉCNICA MANUAL DE TOMA DE TENSIÓNARTERIAL  Riva-Rocci  Korotkoff 1.905
  • 8. PSEUDO HIPERTENSIÓN TEMBLOR CALCIFICACIONES “signo de Osler” TAMAÑO INAPROPIADO
  • 9. PSEUDO HIPOTENSIÓN Shock cardiogénico Vasopresores a altas dosis.
  • 10. TOMA DE LA TA AUTOMATIZADA
  • 11. COMPLICACIONES EN LA MEDICIÓN DE LA T.A.NO INVASIVACOMPLICACIONESDOLORPETEQUIAS Y EQUIMOSISEDEMA DE LA EXTREMIDADESTASIS VENOSO Y TROMBOFLEBITISNEUROPATÍA PERIFERICASINDROME COMPARTIMENTAL
  • 12. MONITORÍA ARTERIALINDICACIONES PARA LINEA ARTERIAL INVASIVAMonitoría de TA en tiempo real, continua.Manipulación cardiovascular mecánica, farmacológica.Toma de muestras continuas.Falla en la toma de TA indirecta.Información diagnostica suplementaria de onda arterial.Determinación de la respuesta volumétrica de la presión sistólica y variación en lapresión de pulso.
  • 13. MONITORIA ARTERIAL DIRECTA Arteria Radial. Slogoff et al. Test Allen Mod. Procedimiento.
  • 14. COMPLICACIONES DE LA CANALIZACIÓN DE LAARTERIA RADIAL < 0.1 %  Vasoespasmo Arterial.  Lesion Arterial.  Trombocitosis  Shock POCO COMUN  Altas dosis de vasopresores.  Canulación prolongada.  Infección.
  • 15. COMPLICACIONES DEL MONITOREO DE TADIRECTA.COMPLICACIONESIsquemia distal, pseudoaneurisma, fistula AVHematoma, Hemorragia.Embolización Arterial.Infección local y sepsisNeuropatía periférica.Mala interpretación de datosMal uso de los equipos.
  • 16. PRESION ARTERIAL INVASIVA
  • 17. ONDA DE PRESIÓN ARTERIAL NORMAL
  • 18. ONDAS DE PRESIÓN ARTERIAL Y DE PULSO A NIVEL PERIFERICO
  • 19. ONDAS DE PRESIÓN ARTERIAL JOVEN Y ADULTO
  • 20. VARIABILIDAD SISTÓLICA DE LA PRESIÓN ARTERIAL
  • 21. VARIABILIDAD DE PRESIÓN DE PULSO
  • 22. MONITORIZACIÓN DE LA PRESIÓN VENOSA CENTRAL
  • 23. TECNICA DE CANALIZACIÓN VENOSA CENTRAL DERECHA
  • 24. CATETERIZACIÓN YUGULAR INTERNA IZQUIERDA Riesgo de Pneumotórax. Lesión del conducto toráxico. Lesión de la pared lateral derecha de la cava superior. La vena Yugular interna izquierda es más pequeña. Requiere confirmación radiográfica.
  • 25. CANALIZACIÓN DE LA SUBCLAVIA Menor riesgo de infección. Terapia IV por largo tiempo. Hiperalimentación. Quimioterapia. En Trauma cervical. Máximo 2 – 3 intentos. VIDEO
  • 26. CANALIZACIÓN YUGULAR EXTERNA Menos riesgo de pneumotórax. Se pueden realizar más intentos. Venas más tortuosas. Abducción del hombro 90 grados. No hacer fuerza al pasarlo por la subclavia.
  • 27. CANALIZACIÓN DE LA VENA FEMORAL ALTERNATIVA EN LESIONES DE CUELLO, TÓRAX, CRANEO. LESION ARTERIA O NERVIO FEMORAL. RIESGO DE TROMBOEMBOLISMO RIESGO DE INFECCIÓN
  • 28. IMAGEN ULTRASONOGRAFICA EN LA CANALIZACIÓN DE LA YUGULAR INTERNA
  • 29. CANALIZACIÓN VENOSA CENTRAL BAJO ULTRASONIDO Beneficio comprobado en UCI y QX. Solo es usa en un 15 % Se puede usar con Doppler Bidimensional 10 Hz Operador dependiente. Confirmar posición realizada sin ultrasonido. Accesos Yugular, Subclavio, Femoral.
  • 30. PRESIÓN VENOSA CENTRAL PRESIÓN CAVA-AURICULA FUERZA DE LLENADO AURICULAR DEPENDE DEL VOLUMEN SANGUINEO INTRAVASCULAR. REFLEJA LA CAPACIDAD FUNCIONAL V.D, VALORA: FUNCIÓN V.D Y VOLUMEN SANGUINEO
  • 31. ONDAS NORMALES DE PRESIÓN VENOSA CENTRAL
  • 32. ONDAS DE PRESIÓN VENOSA CENTRAL
  • 33. ONDAS DE PRESIÓN VENOSA CENTRAL
  • 34. ANORMALIDADES EN LA ONDA DE PVC
  • 35. CAMBIOS EN LA PVC
  • 36. INFLUENCIA DEL CICLO RESPIRATORIO EN L,A PVC
  • 37. PRESSURE WAVEFORM AND DISPLAYS A, C, AND V WAVES. RIGHT VENTRICULAR PRESSURESHOWS HIGHER SYSTOLIC PRESSURE THAN SEEN IN THE RIGHT ATRIUM, ALTHOUGH THE END-DIASTOLIC PRESSURES ARE EQUAL IN THESE TWO CHAMBERS. PULMONARY ARTERY PRESSURESHOWS A DIASTOLIC STEP-UP WHEN COMPARED WITH VENTRICULAR PRESSURE. NOTE ALSOTHAT RIGHT VENTRICULAR PRESSURE INCREASES DURING DIASTOLE WHEREAS PULMONARYARTERY PRESSURE DECREASES DURING DIASTOLE (SHADED BOXES). PULMONARY ARTERYWEDGE PRESSURE HAS A SIMILAR MORPHOLOGY TO RIGHT ATRIAL PRESSURE, ALTHOUGH THEA-C AND V WAVES APPEAR LATER IN THE CARDIAC CYCLE RELATIVE TO THEELECTROCARDIOGRAM
  • 38. FIGURE 40-28 THE TIP OF THE PULMONARY ARTERY CATHETER MUST BE WEDGED IN LUNGZONE 3 TO PROVIDE AN ACCURATE MEASURE OF PULMONARY VENOUS (PV) OR LEFT ATRIAL (LA)PRESSURE. WHEN ALVEOLAR PRESSURE (PA) RISES ABOVE PV IN LUNG ZONE 2 OR ABOVEPULMONARY ARTERIAL PRESSURE (PA) IN LUNG ZONE 1, WEDGE PRESSURE WILL REFLECTALVEOLAR PRESSURE RATHER THAN INTRAVASCULAR PRESSURE. LV, LEFT VENTRICLE; PA,PULMONARY ARTERY; RA, RIGHT ATRIUM; RV, RIGHT VENTRICLE
  • 39. FIGURE 40-29 TEMPORAL RELATIONSHIPS BETWEEN NORMAL SYSTEMIC ARTERIALPRESSURE (ART), PULMONARY ARTERY PRESSURE (PAP), CENTRAL VENOUSPRESSURE (CVP), AND PULMONARY ARTERY WEDGE PRESSURE (PAWP). NOTE THATTHE PAWP A-C AND V WAVES APPEAR TO OCCUR LATER IN THE CARDIAC CYCLE THANTHEIR COUNTERPARTS ON THE RIGHT SIDE OF THE HEART SEEN IN THE CVP TRACE.THE ART SCALE IS ON THE LEFT; THE PAP, CVP, AND PAWP PRESSURE SCALES ARE ONTHE RIGHT.
  • 40. FIGURE 40-30 TALL LEFT ATRIAL PRESSURE (LAP) A AND V WAVES TRANSMITTED INA RETROGRADE DIRECTION THROUGH THE PULMONARY VASCULATURE DISTORT THEANTEGRADE PULMONARY ARTERY PRESSURE (PAP) WAVEFORM. THE LAP A WAVEDISTORTS THE SYSTOLIC UPSTROKE, AND THE V WAVE DISTORTS THE DICROTICNOTCH
  • 41. FIGURE 40-31 NORMAL TEMPORAL RELATIONSHIPS BETWEEN THEELECTROCARDIOGRAPHIC, CENTRAL VENOUS PRESSURE (CVP), AND LEFT ATRIALPRESSURE (LAP) TRACES. THE LAP AND CVP WAVEFORMS HAVE NEARLY IDENTICALMORPHOLOGIES, ALTHOUGH THE CVP A WAVE SLIGHTLY PRECEDES THE LAP A WAVE
  • 42. FIGURE 40-32 ARTIFACTUAL PRESSURE PEAKS AND TROUGHS IN THE PULMONARY ARTERY PRESSURE (PAP)WAVEFORM CAUSED BY CATHETER MOTION. THE CORRECT VALUE FOR PULMONARY ARTERY END-DIASTOLICPRESSURE IS 8 MM HG (A), ALTHOUGH THE MONITOR DIGITAL DISPLAY ERRONEOUSLY REPORTS THE PAP AS28/0 MM HG (B).
  • 43. ARTIFACTUAL WAVEFORM RECORDINGS. THE FIRST TWO ATTEMPTS TO INFLATE THEPA CATHETER BALLOON (FIRST TWO ARROWS) PRODUCE A NONPULSATILEINCREASING PRESSURE CAUSED BY AN OCCLUDED CATHETER TIP. AFTER THECATHETER IS WITHDRAWN SLIGHTLY, BALLOON INFLATION ALLOWS PROPER WEDGEPRESSURE MEASUREMENT (THIRD ARROW). BEFORE THE THIRD ATTEMPT ATBALLOON INFLATION, THE PA PRESSURE LUMEN IS FLUSHED, WHICH RESTORES THEAPPROPRIATE PULSATILE PRESSURE DETAILED TO THE PA AND WEDGE PRESSUREWAVEFORMS ON THE RIGHT SIDE OF THE TRACE.
  • 44. FIGURE 40-34 SEVERE MITRAL REGURGITATION. A TALL SYSTOLIC V WAVE ISINSCRIBED IN THE PULMONARY ARTERY WEDGE PRESSURE (PAWP) TRACE AND ALSODISTORTS THE PULMONARY ARTERY PRESSURE (PAP) TRACE, THEREBY GIVING IT ABIFID APPEARANCE. THE ELECTROCARDIOGRAM (ECG) IS ABNORMAL BECAUSE OFVENTRICULAR PACING. LEFT VENTRICULAR END-DIASTOLIC PRESSURE IS ESTIMATEDBEST BY MEASURING PAWP AT THE TIME OF THE ELECTROCARDIOGRAPHIC R WAVE,BEFORE ONSET OF THE REGURGITANT V WAVE. NOTE THAT MEAN PAWP EXCEEDSLEFT VENTRICULAR END-DIASTOLIC PRESSURE IN THIS CONDITION
  • 45. LEFT ATRIAL PRESSURE-VOLUME CURVES DESCRIBE THE THREE FACTORS THAT DETERMINE VWAVE HEIGHT. A, INFLUENCE OF LEFT ATRIAL VOLUME. FOR THE SAME REGURGITANT VOLUME(X), THE LEFT ATRIAL V WAVE WILL BE TALLER IF BASELINE ATRIAL VOLUME IS GREATER (POINT BVERSUS POINT A). B, INFLUENCE OF LEFT ATRIAL COMPLIANCE. FOR THE SAME REGURGITANTVOLUME (X), THE LEFT ATRIAL V WAVE WILL BE TALLER IF BASELINE ATRIAL COMPLIANCE ISREDUCED (POINT B VERSUS POINT A). C, INFLUENCE OF REGURGITANT VOLUME. BEGINNING ATTHE SAME BASELINE LEFT ATRIAL VOLUME (POINTS A AND B), IF REGURGITANT VOLUMEINCREASES (X VERSUS X), THE LEFT ATRIAL PRESSURE V WAVE WILL INCREASE (V VERSUS V).
  • 46. Figure 40-36 Mitral stenosis.Mean pulmonary artery wedgepressure (PAWP) is increased(35 mm Hg) and the diastolic ydescent is markedly attenuated.Compare the slope of the ydescent in the PAWP trace withthe y descent in the centralvenous pressure (CVP) trace. Inaddition, compare this PAWP ydescent with the PAWP y descentin mitral regurgitation (see Fig40-34 ). A waves are not seen inthe PAWP or CVP traces becauseof atrial fibrillation. ART, arterialblood pressure
  • 47. FIGURE 40-37 MYOCARDIAL ISCHEMIA. PULMONARY ARTERY PRESSURE (PAP) ISRELATIVELY NORMAL AND MEAN PULMONARY ARTERY WEDGE PRESSURE (PAWP) ISONLY SLIGHTLY ELEVATED (15 MM HG). HOWEVER, PAWP MORPHOLOGY IS MARKEDLYABNORMAL, WITH TALL A WAVES (21 MM HG) RESULTING FROM THE DIASTOLICDYSFUNCTION SEEN IN THIS CONDITION.
  • 48. Figure 40-38 Pericardialconstriction. This conditioncauses elevation andequalization of diastolic fillingpressure in the pulmonary arterypressure (PAP), pulmonary arterywedge pressure (PAWP), andcentral venous pressure (CVP)traces. The CVP waveformreveals tall a and v waves withsteep x and y descents and amid-diastolic plateau wave (*) orh wave
  • 49. FIGURE 40-39 CARDIAC TAMPONADE. THE CENTRAL VENOUS PRESSURE WAVEFORM SHOWSINCREASED MEAN PRESSURE (16 MM HG) AND ATTENUATION OF THE Y DESCENT. COMPAREWITH FIGURE 40-38 .
  • 50. FIGURE 40-40 INFLUENCE OF POSITIVE-PRESSURE MECHANICAL VENTILATION ONPULMONARY ARTERY PRESSURE. PULMONARY ARTERY PRESSURE SHOULD BEMEASURED AT END-EXPIRATION #1, 15 MM HG) TO OBVIATE THE ARTIFACT CAUSEDBY POSITIVE PRESSURE INSPIRATION (#2, 22 MM HG). COMPARE WITH FIGURE 40-26
  • 51. LEFT VENTRICULAR (LV) PRELOAD. THERE ARE THREE INTERPRETATIONS OF INCREASEDTRANSDUCED PULMONARY ARTERY WEDGE PRESSURE (PAWP, 20 MM HG). A, JUXTACARDIACPRESSURE (-5 MM HG) AND LV COMPLIANCE ARE NORMAL, TRANSMURAL PAWP IS INCREASED(25 MM HG), AND LV VOLUME IS INCREASED. B, JUXTACARDIAC PRESSURE IS INCREASED(+10 MM HG), LV COMPLIANCE IS NORMAL, TRANSMURAL PAWP IS DECREASED (10 MM HG),AND LV VOLUME IS NORMAL OR DECREASED. C, JUXTACARDIAC PRESSURE IS NORMAL, LVCOMPLIANCE IS DECREASED, TRANSMURAL PAWP IS INCREASED (25 MM HG), AND LV VOLUMEIS NORMAL OR DECREASED.
  • 52. FIGURE 40-42 ANATOMIC AND PHYSIOLOGIC FACTORS THAT INFLUENCE THE RELATIONSHIPSBETWEEN VARIOUS MEASURES OF LEFT VENTRICULAR (LV) FILLING AND TRUE LV PRELOAD. THEFURTHER UPSTREAM FILLING PRESSURE IS MEASURED, THE MORE CONFOUNDING FACTORSMAY INFLUENCE THE RELATIONSHIP BETWEEN THIS MEASUREMENT AND LV PRELOAD. CVP,CENTRAL VENOUS PRESSURE; LA, LEFT ATRIUM; LAP, LEFT ATRIAL PRESSURE; LVEDP, LEFTVENTRICULAR END-DIASTOLIC PRESSURE; PA, PULMONARY ARTERY; PADP, PULMONARY ARTERYDIASTOLIC PRESSURE; PAWP, PULMONARY ARTERY WEDGE PRESSURE; P-V, PRESSURE-VOLUME;RA, RIGHT ATRIUM, RV, RIGHT VENTRICLE
  • 53. Figure 40-43 Relationshipbetween left atrial pressure (LAP)and left ventricular end-diastolicpressure (LVEDP). LVEDP ismeasured at the Z-point on theleft ventricular pressure (LVP)trace at the time of theelectrocardiographic R wave.Mean LAP (9 mm Hg)underestimates LVEDP (15 mmHg), but the LAP a wave pressurepeak closely estimates LVEDP.
  • 54. MODIFIED FROM MARK JB: PREDICTING LEFT VENTRICULAR END-DIASTOLICPRESSURE. IN MARK JB (ED): ATLAS OF CARDIOVASCULAR MONITORING. NEW YORK,CHURCHILL LIVINGSTONE, 1998, P 59.LAP, LEFT ATRIAL PRESSURE; LVEDP, LEFT VENTRICULAR END-DIASTOLIC PRESSURE;PADP, PULMONARY ARTERY DIASTOLIC PRESSURE; PAWP, PULMONARY ARTERYWEDGE PRESSURE
  • 55. MODIFIED FROM MARK JB: PREDICTING LEFT VENTRICULAR END-DIASTOLICPRESSURE. IN MARK JB (ED): ATLAS OF CARDIOVASCULAR MONITORING. NEW YORK,CHURCHILL LIVINGSTONE, 1998, P 59.LAP, LEFT ATRIAL PRESSURE; LVEDP, LEFT VENTRICULAR END-DIASTOLIC PRESSURE;PADP, PULMONARY ARTERY DIASTOLIC PRESSURE; PAWP, PULMONARY ARTERYWEDGE PRESSURE
  • 56. FORMULAS DE LA LAMINA ANTERIOR
  • 57. PULMONARY ARTERY CATHETER–DERIVED HEMODYNAMIC VARIABLESTHE CARDIOVASCULAR SYSTEM IS OFTEN MODELED AS AN ELECTRICAL CIRCUIT, WITHTHE RELATIONSHIP BETWEEN CARDIAC OUTPUT, BLOOD PRESSURE, AND RESISTANCETO FLOW RELATED IN A
  • 58. FIGURE 40-44 PULMONARY HYPERTENSION. THE INCREASED GRADIENT ACROSS THEPULMONARY VASCULATURE CAUSES PULMONARY ARTERY DIASTOLIC PRESSURE TOEXCEED PULMONARY ARTERY WEDGE PRESSURE (PAWP). PAP, PULMONARY ARTERYPRESSURE.
  • 59. FIGURE 40-45 SPECTRAL DOPPLER TRACINGS OF AORTIC BLOOD FLOW RECORDED WITHESOPHAGEAL DOPPLER CARDIAC OUTPUT MONITORING. THE VELOCITY-TIME WAVEFORM SHAPEREFLECTS ALTERATIONS IN CONTRACTILITY (MAINLY AFFECTING PEAK VELOCITY AND MEANACCELERATION), PRELOAD (MAINLY AFFECTING SYSTOLIC FLOW TIME CORRECTED FOR HEARTRATE [FTC]), AND AFTERLOAD (WHICH AFFECTS FTC, MEAN ACCELERATION, AND PEAK FLOWVELOCITY).
  • 60. FUE MONITORIZADO ?