Hemodynamic monitoring has advanced with new equipment allowing continuous, non-invasive monitoring of key parameters. Pulse contour analysis uses an arterial catheter to provide beat-to-beat measurements used to calculate stroke volume, cardiac output, and contractility. Thermodilution techniques inject cold saline to measure parameters like intrathoracic blood volume, extravascular lung water, and ejection fraction. Echocardiography non-invasively assesses cardiac structure and function. These advances allow early detection and guided therapy for shock.
1. AdvAnces in HemodynAmicAdvAnces in HemodynAmic
monitoringmonitoring
ByBy
moHAmed A. AlimoHAmed A. Ali
security Forces HospitAl mAKKAHsecurity Forces HospitAl mAKKAH
2. introduction
• Hemodynamics is concerned with the forces
generated by the heart and the resulting motion of
blood through the cardiovascular system.
• Hemodynamic monitoring is the intermittent or
continuous observation of physiological
parameters related to the circulatory system that
lead to early detection of the need for therapeutic
interventions.
4. old equipments
1. ArteriAl line
1. Real time SBP, DBP, MAP
2. Pulse pressure variation (∆PP)
• ΔPP (%) = Respiratory-induced pulse pressure variations obtained
with an arterial line which indicate fluid responsiveness in
mechanically ventilated patients
5. • AdvAntAgeAdvAntAge
– Easy setup
– Real time BP monitoring
– Beat to beat waveform display
– Allow regular sampling of blood for lab tests
• disAdvAntAgesdisAdvAntAges
– Invasive
– Risk of haematoma, distal ischemia, pseudoaneurysm
formation and infection
6. 2. centrAl venous cAtHeter2. centrAl venous cAtHeter
– Measurement of CVP, medications infusion and
modified form allow for dialysis
•AdvAntAgesAdvAntAges
– Easy setup
– Good for medications infusion
•disAdvAntAgesdisAdvAntAges
– Cannot reflect actual RAP in most situations
– Multiple complications
•Infections, thrombosis, complications on insertion,
vascular erosion and bleeding
7. limitAtion oF cvp
Systemic venoconstriction
Decrease
right
ventricular
compliance
Obstruction of
the great veins
Tricuspid regurgitation
Mechanical
ventilation
9. indicAtions For pApindicAtions For pAp
monitoringmonitoring
1. Shock of all types
2. Assessment of cardiovascular
function and response to therapy
3. Assessment of pulmonary status
4. Assessment of fluid requirement
5. Perioperative monitoring
10. clinicAl ApplicAtions oFclinicAl ApplicAtions oF
pAcpAc
PAC can generate large numbers of
haemodynamic variables
BAsic pArAmeters
• Central venous pressure (CVP)
• Pulmonary artery pressure (PAP)
• Pulmonary arterial occlusion pressure (PAOP)
• Cardiac output (CO)
derived pArAmeters
• cardiac index (CI)
• Stroke volume (SV)
• Rt ventricle ejection fraction/ end diastolic volume (RVEF / RVEDV)
• Systemic vascular resistance index (SVRI)
• Pulmonary vascular resistance index (PVRI)
• Oxygen delivery / uptake (DO2 / VO2)
11. cArdiogenic
• High CVP
• Low CI
• High SVRI
[[
⇒ Consider
inotropes / IABP
vAsogenic
• Low CVP
• High CI
• Low SVRI
⇒ Consider
vasopressor
pAtient witHpAtient witH
HypotensionHypotension
Hypovolemic
•Low CVP
•Low CI
•High SVRI
⇒ Consider fluid
challenge
12. mixed venousmixed venous
sAturAtion (svo2)sAturAtion (svo2)
• Measured in pulmonary artery blood
• Marker of the balance between whole body O2
delivery (DO2) and O2 consumption (VO2)
• VO2 = DO2 * (SaO2 – SvO2)
• In fact, DO2 is determined by CO, Hb and SaO2.
Therefore, SvO2 affected by
– CO
– Hb
– Arterial oxygen saturation
– Tissue oxygen consumption
14. • AdvAntAgesAdvAntAges
– Provide lot of important haemodynamic parameters
– Sampling site for SvO2
• disAdvAntAgesdisAdvAntAges
– Costly
– Invasive
– Multiple complications (eg. arrhythmia, catheter looping,
balloon rupture, PA injury, pulmonary infarction)
15. AdvAnce in hAemodynAmicAdvAnce in hAemodynAmic
AssessmentAssessment
1. Modification of old equipment
2. Echocardiogram and esophageal doppler
3. Pulse contour analysis and transpulmonary
thermodilution
4. Partial carbon dioxide rebreathing with
application of Fick principle
5. Electrical bioimpedance
17. • As CO increase, blood
flow over the heat
transfer device increase
and the device require
more power to keep the
temp. difference
Therefore provide
continuous CO data
18. • AdvAntAgeAdvAntAge
– Continuous CO monitoring
– Provision of important haemodynamic parameter
as PAC
• disAdvAntAgedisAdvAntAge
– Invasive
– Costly
– Complications associated with PAC use
19. echo
• Assessment of cardiac structure, ejection
fraction and cardiac output
• Based on 2D and doppler flow technique
EF (%) =
[(EDV - ESV) / EDV] x 100
20. echo dopplerecho doppler
ultrAsoundultrAsound• Measure blood flow velocity in heart and great vessels
• Based on Doppler effect ⇒ “ Sound freq. increases as
sound source moves toward the observer and decreases
as the sound moves away”
21. trAnsthorAcic echotrAnsthorAcic echo
• AdvAntAges
– Fast to perform
– Non invasive
– Can assess valvular structure and myocardial function
– No added equipment needed
• disAdvAntAges
– Difficult to get good view (esp. whose on ventilator /
obese)
– Cannot provide continuous monitoring
22. esophAgeAl Aortic doppleresophAgeAl Aortic doppler
usus
• Doppler assessment of decending
aortic flow
• CO is determined by measuring
aortic blood flow assuming a
constant partition between caudal
and cephalic blood supply areas
• Probe is smaller than that of TEE
• Correlate well with CO measured
by thermodilution
Decending
aorta
23. • AdvAntAgesAdvAntAges
– Easy placement, minimal training needed (~ 12 cases)
– Provide continuous,real-time monitoring
– Low incidence of iatrogenic complications
– Minimal infective risk
• disAdvAntAgesdisAdvAntAges
– High cost
– Poor tolerance at awake patient, so it’s used for those
intubated
– Probedisplacement can occur during prolonged monitoring
and patient’s turning
– High inter-observer variability when measuring changes in SV
in response to fluid challenges
25. pulse contourpulse contour
AnAlysisAnAlysis
• PiCCOPiCCO and LiDCOLiDCO are the two commonly used
model on basis of PCA
• PCA involves the use of an arterially placed catheter
with a pressure transducer, which can measure
pressure tracings on a beat-to-beat basis
26. TheThe PiCCOPiCCO Technology uses any standard CV-lineTechnology uses any standard CV-line
without the need for Rt. Heart catheter (PAC) and awithout the need for Rt. Heart catheter (PAC) and a
thermistor-tipped arterialthermistor-tipped arterial PiCCOPiCCO catheter instead of thecatheter instead of the
standard arterial line.standard arterial line.
how does the phow does the piicco-technology work?cco-technology work?
pArAmeters meAsured with the picco-technologypArAmeters meAsured with the picco-technology
thermodilution pArAmetersthermodilution pArAmeters
• Cardiac Output CO
• Global End-Diastolic Volume GEDV
• Intrathoracic Blood Volume ITBV
• Extravascular Lung Water EVLW
•Cardiac Function Index CFI
• Global Ejection Fraction GEF
• Pulmonary Vascular Permeability Index
PVPI*
pulse contour pArAmeterspulse contour pArAmeters
• Pulse Contour Cardiac Output
PCCO
• Arterial Blood Pressure AP
• Heart Rate HR
• Stroke Volume SV
• Stroke Volume Variation SVV
• Pulse Pressure Variation PPV
• Systemic Vascular Resistance SVR
• Index of Left Ventricular Contractility
dPmx*
27. CV
A
B
F
R
picco cAtheterpicco cAtheter
1. centrAl venous line (cv)
2. pulsiocAth thermodilution
cAtheter
with lumen for arterial pressure
measurement
Axillary: 4F (1,4mm) 8cm
Brachial: 4F (1,4mm) 22cm
Femoral: 3-5F (0,9-1,7mm) 7-20cm
Radial: 4F (1,4mm) 50cm
No Right Heart Catheter !
30. Tb
Injection
Time
∫ ⋅∆
⋅⋅−
=
dtT
KV)T(T
CO
b
iib
TDa
CardiaC ouTpuTCardiaC ouTpuT
Tb = Blood temperature
Ti = Injectate temperature
Vi = Injectate volume
∫ ∆ Tb
.
dt = Area under the thermodilution curve
K = Correction constant, made up of specific weight and
specific heat of blood and injectate
CO Calculation:
Area under the
Thermodilution
Curve
•After central venous injection of the indicator, the thermistor at
the tip of the arterial catheter measures the downstream
temperature changes.
•Cardiac output is calculated by analysis of the thermodilution
curve using a modifiedmodified Stewart-Hamilton algorithm:Stewart-Hamilton algorithm:
31. Advanced Thermodilution CurveAdvanced Thermodilution Curve
AnalysisAnalysis
VolumeTriC parameTersVolumeTriC parameTers
1.1. MTt: Mean TransitMTt: Mean Transit
time :time :
• Time when half of the
indicator has passed the
point of detection in the
artery
2.2. DSt: Down SlopeDSt: Down Slope
time :time :
• Exponential downslope time
of the thermodilution curve
For the calculations of
volumes
injection
recirculation
MTt
t
DSt
All volumetric parameters are obtained by advanced analysis of the
Thermodilution Curve:Thermodilution Curve:
32. RAEDV
Thermodilution
curve measured
with arterial
catheter
CV Bolus
Injection
LAEDV LVEDVRVEDV Lungs
afTer injeCTion, The indiCaTor passes The followingafTer injeCTion, The indiCaTor passes The following
inTraThoraCiC ComparTmenTs:inTraThoraCiC ComparTmenTs:
• The intrathoracic compartments can be considered as a series of
“mixing chambers” for the distribution of the injected indicator
(intrathoracic thermal volume).
• The largest mixing chamber in this series are the lungs, here the
indicator (cold) has its largest distribution volume (largest thermal
volume).
Intra thoracic Thermal VolumeIntra thoracic Thermal Volume
(ITTV)(ITTV)PulmonaryPulmonary
Thermal VolumeThermal Volume
(PTV)(PTV)
PBV
EVLW
EVLW
34. pulmonary VasCular permeabiliTy indexpulmonary VasCular permeabiliTy index
Pulmonary Vascular Permeability Index (PVPI*) is the ratio of
Extravascular Lung Water (EVLW*) to pulmonary blood volume (PBV).
It allows to identify the type of pulmonary oedema.
Pulmonarv Blood
Volume
Hydrostatic
Pulmonary
Odema
Permeability
pulmonary edema
PVPI =
PBV
EVL
W
Norma
l
Elevat
e
d
Elevate
d
PVPI =
PBV
EVL
WElevat
e
d
Elevated
Norma
l
PVPI =
PBV
EVL
WNorma
l
Norma
l
Norma
l
PBV
PBV
PBV Norma
Lun
g
Extra Vascular
Lung Water
35. Global Ejection Fraction
(GEF)
(Transpulmonary Thermodilution)
GEF =
GED
V
4 x SV
RVEF =
RVEDV
SV
LVEF =
LVEDV
SV
RV ejection fraction
(RVEF)
(Pulm. Artery Thermodilution)
LV ejection fraction
(LVEF)
(Echocardiography)
1 2& 3
global ejeCTion fraCTion
Right
Heart
Left
Heart
Lungs
RAED
V
RVED
V
LVED
V
Stroke Volume
SV
LAED
V
• Ejection Fraction: Stroke Volume related to End-Diastolic Volume
PBV
EVL
W
EVL
W
36. index of lefT VenTriCular ConTraCTiliTy
t [s]
P [mm Hg]
• dPmx* -- It represents left ventricular pressure velocity increasedPmx* -- It represents left ventricular pressure velocity increase
and thus is a parameter ofand thus is a parameter of myocardial contractilitymyocardial contractility
dtmax of arterial pressuredtmax of arterial pressure
ccurveurve
dPdP
dPmx*dPmx* ==
37. SVSVmaxmax
SVSVminmin
SVSVmeanmean
SVSVmaxmax – SV– SVminmin
SVV =SVV =
SVSVmeanmean
sTroke Volume VariaTionsTroke Volume VariaTion
• Stroke Volume Variation (SVV) represents the variation of stroke
volume (SV) over the ventilatory cycle.
• SVV is...
1- measured over last 30s window
2- only applicable in controlled mechanically ventilated patients with
regular heart
rhythm
38. pulse pressure VariaTionpulse pressure VariaTion
PPPPmaxmax – PP– PPminmin
PPV =PPV =
PPPPmeanmean
PPPPmaxmax
PPPPmeanmean
PPPPminmin
• Pulse pressure variation (PPV) represents the variation of the pulse
pressure
over the ventilatory cycle.
• PPV is...
1- measured over last 30s window
2- only applicable in controlled mechanically ventilated patients with
regular heart
rhythm
39. sVV and ppV – CliniCal sTudiessVV and ppV – CliniCal sTudies
Sensitivity
Specificity
• Central Venous Pressure
(CVP) can not predict
whether volume load leads
to an increase in stroke
volume or not.
- - - CVP
__
SVV
1
0,2
0,4
0,6
0,8
1
0,50
0
•SVV and PPV are excellent predictors of volume responsiveness.
40. Drugs
Volume
What is the current situation?.………..…....…..………….Cardiac
Output!
What is the preload?.……………….....….Global End-Diastolic
Volume!
Will volume increase CO?....………...….…….Stroke Volume
Variation!
CliniCal appliCaTion
41. • Global End-Diastolic Volume, GEDV and Intrathoracic Blood
Volume (ITBV): have shown to be far more sensitive and specific to cardiac
preload compared to the standard cardiac filling pressures CVP + PCWP as well as
right ventricular enddiastolic volume.
• The striking advantage of GEDV and ITBV is that they are not adversely
influenced by mechanical ventilation
• Extravascular Lung Water, EVLW* has shown to have a clear correlation
to severity of ARDS, length of ventilation days, ICU-Stay and Mortality and is
superior to assessment of lung odema by chest x-ray and clearly indicates fluid
overload
signifiCanCesignifiCanCe
43. Decision tree for hemoDynamic / volumetric monitoring
CI (l/min/m2
)
GEDI
(ml/m2
)
or ITBI
(ml/m2
)
ELWI* (ml/kg)
(slowly responding)
>3.0<3.0
>700
>850
<700
<850
>700
>850
<700
<850
ELWI* (ml/kg)
GEDI
(ml/m2
)
or ITBI
(ml/m2
)
CFI (1/min)
or GEF (%)
<10 >10 <10 <10 <10>10 >10 >10
V+ V+! V+!V+Cat Cat
OK!
V-
>700
>850
700-800
850-1000
>4.5
>25
>5.5
>30
>4.5
>25
700-800
850-1000
Cat
>5.5
>30
>700
>850
700-800
850-1000
700-800
850-1000
≤10 ≤10 ≤10 ≤10
V-
V+ = volume loading (! = cautiously)V- = volume contractionCat = catecholamine / cardiovascular agen
** SVV only applicable in ventilated patients without cardiac arrhythmia
>700
>850
<10Optimise to SVV** (%)<10 <10 <10
R
E
S
U
L
T
S
T
A
R
G
E
T
T
H
E
R
A
P
Y
1.
2. <10 <10 <10 <10
44. • The LiDCO™ System provides a bolus indicator
dilution method of measuring cardiac output.
• A small dose of LITHIUM CHLORIDE is injected via a
central or peripheral venous line ; the resulting
arterial lithium concentration-time curve is recorded
by withdrawing blood past a lithium sensor attached
to the patient’s existing arterial line.
• The dose of lithium needed (0.15 - 0.3 mmol for an
average adult) is very small and has no known
pharmacological effects
lliiDco systemDco system
45. liDco™plus monitor
The LiDCOplus System combines the LiDCO & PulseCO Systems
software and provides a real-time and continuous assessment of a
patient’s hemodynamic status.
PulseCO System
It’s a software (incorporated in the LiDCO™plus Monitor) that
calculates continuous beat-to-beat cardiac output by analysis of the
arterial blood pressure trace following calibration with an absolute
LiDCO cardiac output value.
This method has been shown to be accurate and reliable in various
clinical settings.
It has also been shown that recalibration is unnecessary for at least
eight hours and more recently for 24 hours.
46. PULSEco system autocorrelation
algorithm
The analogue arterial blood pressure trace is
slaved from the conventional blood pressure
monitor and undergoes a three step
transformation
•Step 1: Arterial pressure transformation into a volume-
time waveform.
•Step 2: Deriving nominal stroke volume and heartbeat
duration.
•Step 3: Actual stroke volume via calibration with an
absolute cardiac output value
47. liDco™plus Parameters
•Body Surface Area
•Systolic Pressure Variation & Pulse Pressure Variation
•Cardiac Index
•Oxygen Delivery & Oxygen Delivery Index
•Heart Rate & Heart Rate Variation
•Stroke Volume & Stroke Volume Index
•Stroke Volume Variation
•Intra Thoracic Blood Volume
•Systemic Vascular Resistance
•Systemic Vascular Resistance Index
48. aDvantages of liDco plus system
•Provides an absolute cardiac output value via a novel and proven
indicator dilution technique
•Provides ITBV
•Requires no additional invasive catheters
•Safe – using non-toxic bolus dosages
•Simple and quick to set up and can be used by nursing staff
•Accurate
•Temperature non-dependent
•Less invasive monitoring
•Utilises existing peripheral or central venous and arterial lines
52. electrical bioimPeDance
• Make use of constant electrical current stimulation for identification
of thoracic or body impedance variations induced by vascular blood
flow.
• Electrodes are placed in specific areas on the neck and thorax.
• A low-grade electrical current, from 2 - 4 mA is emitted, and
received by the adjacent electrodes.
• Impedance to the current flow produces a waveform.
• Through electronic evaluation of these waveforms, the timing of
aortic opening and closing can be used to calculate the left
ventricular ejection time and stroke volume.
53.
54. electrical bioimPeDance
aDvantage:
•Non invasive
•Some report same clinical accuracy as thermodilution technique.
•New generation of EB device using upgraded computer technology
and refined algorithms to calculate CO and get better results.
DisaDvantage:
•Reliability in critically ill patients still not very clear.
•Other report poor agreement in those haemodynamically unstable
and post cardiac surgery.
55. conclusionconclusion
• Haemodynamic monitoring enable early
detection of change in patient’s conditions.
• New techniques provide reasonably good
results and less invasive
• Always correlate the readings and findings
with clinical pictures in order to provide the
best treatment options
Editor's Notes
Intravascular volume: the amount of fluid circulating in the vasculature. This can be affected by dehydration, diuresis, and volume overload due to heart or kidney failure
myocardial contraction and HR affected by exercise, stress and pharmaceutical agents or cardiac disease
Vasoactivity affected by hormone eg angiotenson II, epinephrine, norepinephrine, and vasopressin
PAOP affected by patient body position, presence of mitral valve disease (eg MS/ MR) and L ventricular dysfx
