Hemodynamic monitoring

Dr.Krishna Kumar. R
DNB trainee
KMCH
DR KRISHNA KUMAR 112/5/2018

CENTRAL VENOUS PRESSURE
MONITORING

• CVP ~ Right Atrial Pressure ~Right ventricular end diastolic
volume (preload)
• Reflects a patient’s
• Cardiac function →venous return to the heart
• Right ventricular function
• Intravascular fluid volume status
• Normal CVP values range 2- 6mmHg or 4-12cmH20
INTRODUCTION

INDICATIONS FOR CENTRAL VENOUS
CANNULATION
• Central venous pressure monitoring
• Pulmonary artery catheterization and monitoring
• Temporary hemodialysis
• Drug administration
• Concentrated vasoactive drugs
• Hyperalimentation
• Chemotherapy
• Agents irritating to peripheral veins
• Prolonged antibiotic therapy

• Rapid infusion of fluids (via large cannulas)
• Trauma
• Major surgery
• Aspiration of air emboli
• Inadequate peripheral intravenous access
• Sampling site for repeated blood testing

NORMAL
CARDIOVASCULAR
PRESSURES

CVP WAVEFORM COMPONENTS

CARDIAC CYCLE

CVP VALUES
• Increased in
 Fluid overload
 Right heart failure
 Cardiac tamponade
 Pleural effusion
 Tension pneumothorax
 Mechanical ventilation
• Decreased in
 Hypovolemia
 Shock

Tricuspid regurgitation
increases mean CVP, and
the waveform displays a tall
systolic c-v wave that obliterates
the x
descent.

Tricuspid stenosis increases
mean CVP, the diastolic y
descent is attenuated, and
the end-diastolic a wave is
prominent.

Atrial fibrillation
Note absence of the a
wave,
a prominent c wave,
and a preserved v
wave and y descent

COMPLICATIONS OF CENTRAL VENOUS
PRESSURE MONITORING
• Mechanical
• Vascular injury
• Arterial
• Venous
• Cardiac tamponade
• Respiratory compromise
• Airway compression from
hematoma
• Pneumothorax
• Nerve injury
• Arrhythmias
• Thromboembolic
• Venous thrombosis
• Pulmonary embolism
• Arterial thrombosis and
embolism
• Catheter or guidewire embolism
• Infectious
• Insertion site infection
• Catheter infection
• Bloodstream infection
• Endocarditis

PULMONARY ARTERY PRESSURE
MONITORING

• Lewis Daxter (1945): first pulmonary artery catherization
• In 1970, Swan, Ganz, and colleagues introduced pulmonary
artery catheterization into clinical practice for the hemodynamic
assessment of patients with acute myocardial infarction

INDICATIONS
• Surgical patients associated with high risk of complications from
hemodynamic changes
• Advance cardiopulmonary diseases
• Goal directed fluid therapy

PULMONARY ARTERY CATHETERIZATION
• The standard PAC
 7.0- to 9.0-fr circumference,
 110 cm in length marked at 10-cm intervals,
 Four internal lumina.
 Distal port at the catheter tip - pulmonary artery pressure monitoring,
 Second port more proximal - for CVP monitoring.
 Third lumen leads to a balloon near the tip, and
 Fourth lumen houses wires for a temperature thermistor, the end of which
lies just proximal to the balloon.

ADDITIONAL GUIDELINES FOR PULMONARY
ARTERY CATHETER INSERTION
• From a right IJV puncture site, the right atrium should be
reached when the PAC is inserted 20 to 25 cm, the right
ventricle at 30 to 35 cm, the pulmonary artery at 40 to 45 cm,
and the wedge position at 45 to 55 cm.
• For other sites extra distance required
• Lt IJV/ Rt & Lt EJV : 5-10 cm
• Femoral veins : 15cm
• Antecubital veins : 30-35 cms

a wave follows “P” wave on ECG
v wave follows the QRS complex on ECG
RAP = mean (average) of a wave
• Right atrial pressure (RAP) is measured by the distal tip of the PAC
on insertion or by the proximal port post insertion.
a = atrial systole
v = ventricular systole
Right Atrium
Tricuspid valve
Pulmonic valve
P
QRS

MEASUREMENT OF RIGHT ATRIAL PRESSURE (RA)
FROM PULMONARY ARTERY CATHETER
a wave follows “P”
wave on ECG
v wave follows the
QRS complex on ECG
• Right atrial pressure (RAP) is measured by the distal tip of the PAC
on insertion or by the proximal port post insertion.
a = atrial systole
Right Atrium
Tricuspid valve
Pulmonic valveP

RA WAVEFORM
“c” wave = closure of the tricuspid valve
“x” decent = follows closure of the tricuspid valve,
“y” decent = follows closure of the pulmonic valve

ALTERATIONS IN RA PRESSURE
• Reflects filling volume of the right atrium
• Low pressure consistent with hypovolemia:
• Trauma-> blood loss
• Dehydration
• Loss of fluid from drains
• Vomiting, diarrhea
• Burns
• 3rd spacing of fluid
• Consistent with tachycardia, ↓ urine output, dry skin & mucous
membranes

CLINICAL SITUATIONS CONSISTENT WITH
ELEVATIONS IN RA PRESSURES
• Tricuspid stenosis, regurgitation
• RV ischemia or failure
• Pulmonary hypertension
• Pulmonic stenosis
• Atrial ventricular dissociation with loss of synchrony
• Atrial arrythmias, A-V conduction blocks)

RV Waveform
Systole
Diastole

Onset of systole follows QRS complex on ECG
End diastole occurs at the onset of systole.

ALTERATIONS IN RVP
Reflects filling volume of right ventricle
• Low pressure consistent with low volume
• Usually accompanies low RAP
• Elevation associated with:
• Hypervolemia
• Outflow obstruction
• RV infarct/failure
• Pericarditis/tamponade
• LV failure
• Primary and secondary pulmonary
hypertension (PHTN)
• Pulmonic stenosis
• COPD

PA
systolic
PA
diastolic
Dicrotic notch
Represents closure of the pulmonic valve
• Pulmonary artery pressure (PAP) is measured from the distal tip of PAC on insertion and
distal tip post insertion.
• It has a systolic and diastolic component.
• Systolic pressure follows QRS on ECG.
• Diastole begins at the closure of the pulmonic valve and continues to next onset of systole.
Pulmonic valve
QRS

ALTERATIONS IN PAP
Represents filling volume in the pulmonary artery and resistance to
flow within the pulmonary circuit
• Low pressure consistent with hypovolemia
• Consistent with ↓ RAP and ↓ RVP
• High pressure consistent with
• PHTN
• COPD
• ARDS
• Pulmonary embolism (PE)
• Mitral stenosis
• Left ventricular heart failure

PAP Waveform

PULMONARY ARTERY WEDGE PRESSURE
• PAOP or PAWP is pressure within the pulmonary arterial
system when catheter tip ‘wedged’ in the tapering branch of one
of the pulmonary arteries in most patients this estimates LVEDP
thus is an indicator of LVEDV (preload of the left ventricle)
• Normally 6-12mmhg (1-5mmhg less than the pulmonary artery
diastolic pressure)
• PCWP >18 mmhg in the context of normal oncotic pressure
suggests left heart failure

• Pulmonary capillary wedge pressure (PCWP) or pulmonary artery wedge
pressure (PAWP) is measured from the distal port of PAC with balloon
inflated.
a = atrial systole

Catheter tip looks “through” the pulmonary circulation to “see” the left atrial
pressure.
PCWP indirectly measures left atrial pressure

ALTERATIONS OF PCWP
• Low pressure consistent with hypovolemia
• Elevations consistent with:
• Mitral stenosis/regurgitation
• Aortic stenosis/regurgitation
• Acute LV ischemia/infarct
• LV failure
• Atrial ventricular dissociation with loss of synchrony
• Both RA and PCWP elevated in cardiac tamponade, constrictive
pericarditis, and hypervolemia

PA CATHETER MEASUREMENTS

COMPLICATIONS OF PULMONARY ARTERY
CATHETER MONITORING
• Catheterization
 Arrhythmias, ventricular fibrillation
 Right bundle branch block, complete heart block
• Catheter residence
 Mechanical, catheter knots
 Thromboembolism
 Pulmonary infarction
 Infection, endocarditis
 Endocardial damage, cardiac valve injury
 Pulmonary artery rupture, pseudoaneurysm

INVASIVE ARTERIAL PRESSURE
MONITORING

INTRODUCTION
• Intra-arterial blood pressure (IBP) measurement is often
considered to be the gold standard of blood pressure
measurement.
• Despite its increased risk, cost, and need for technical expertise
for placement and management, its utility in providing crucial
and timely information outweighs its risks in many cases

INDICATIONS FOR ARTERIAL CANNULATION
 Continuous, real-time blood pressure monitoring
 Planned pharmacologic or mechanical cardiovascular manipulation
 Repeated blood sampling
 Failure of indirect arterial blood pressure measurement, e.g. burns
or obesity
 Supplementary diagnostic information from the arterial waveform

BASIC PRICIPLES
• The pressure waveform of the arterial pulse is transmitted via
the column of fluid, to a pressure transducer where it is
converted into an electrical signal.
• This electrical signal is then processed, amplified and converted
into a visual display by a microprocessor.

PERCUTANEOUS RADIAL ARTERY
CANNULATION
• The radial artery is the most common site for invasive blood
pressure monitoring because it is technically easy to cannulate
and complications are uncommon
• Modified Allen’s test

ULTRASOUND IMAGING

ALTERNATIVE ARTERIAL PRESSURE
MONITORING SITES
• Ulnar
• Brachial
• Axillary
• Femoral
• Dorsalis pedis

COMPLICATIONS OF DIRECT ARTERIAL PRESSURE
MONITORING
• Hemorrhage
• Misinterpretation of data
• Distal ischemia
• Pseudoaneurysm
• Arteriovenous fistula
• Arterial embolization
• Infection

PHYSICAL PRINCIPLES
• A wave is a disturbance that travels through a medium,
transferring energy but not matter.
• One of the simplest waveforms is the sine wave

• Fourier Analysis
 The arterial waveform is clearly not a simple sine wave, but
it can be broken down into a series of many component sine
waves
 The process of analysing a complex waveform in terms of its
constituent sine waves is called Fourier Analysis.

PROPERTIES
• Natural frequency
• Damping coefficient

• The natural frequency of a system determines how rapidly the
system oscillates after a stimulus
• The damping coefficient reflects frictional forces acting on the
system and determines how rapidly it returns to rest after a
stimulus

NATURAL FREQUENCY
• It is important that the IBP system has a very high natural
frequency – at least eight times the fundamental frequency of
the arterial waveform (the pulse rate).

NATURAL FREQUENCY
• The natural frequency of a system may be increased by:
 Reducing the length of the cannula or tubing
 Reducing the compliance of the cannula
 Reducing the density of the fluid used in the tubing
 Increasing the diameter of the cannula or tubing

DAMPING
• Anything that reduces energy in an oscillating system will reduce the
amplitude of the oscillations. This is termed damping.
• Some degree of damping is required in all systems (critical damping),
but if excessive (overdamping) or insufficient (underdamping) the
output will be adversely effected.

Underdamped arterial
pressure waveform
Overdamped arterial
pressure waveform

Factors that cause overdamping include:
 Friction in the fluid pathway
 Three way taps
 Bubbles and clots
 Vasospasm
 Narrow, long or compliant tubing
 Kinks in the cannula or tubing

FAST-FLUSH TEST / SQUARE WAVE TEST
• Provides a convenient bedside method for determining dynamic
response of the system
• Natural frequency is inversely proportional to the time between
adjacent oscillation peaks
• The damping coefficient can be calculated mathematically, but
it is usually determined graphically from the amplitude ratio

COMPONENTS OF AN IBP MEASURING SYSTEM

COMPONENTS OF AN IABP MEASURING
SYSTEM
• Intra-arterial cannula

SYSTEM
• Fluid filled tubing

SYSTEM
• Transducer

WHEATSTONE BRIDGE
• The Wheatstone bridge is a network of four resistors connected, with
a battery or DC voltage source (electromotive force) connected
between A and C and a voltmeter (V) connected between B and D.
• The bridge is said to be “balanced” when the voltmeter reads zero
potential difference between points B and D.
• From Ohm’s law (V = IR), it is easy to show that balance occurs when
Rx = Rs × (R2/R1)
• If Rs is an adjustable standard resistor and R1 and R2 are fixed
known resistors, then the balanced bridge provides a very precise
means of determining Rx, the unknown resistance.
• In this case, the transducer, itself, is the unknown resistance Rx.

• The transducer is usually a soft silicone diaphragm attached to
a Wheatstone bridge.
• It converts the pressure change into a change in electrical
resistance of the circuit. This can be viewed as waveform.

COMPONENTS OF AN IBP MEASURING
SYSTEM
• Transducer
• Infusion/flushing system
• Signal processor, amplifier and display

LEVELLING AND ZEROING
• Zeroing :
 For a pressure transducer to read accurately, atmospheric
pressure must be discounted from the pressure
measurement.
 This is done by exposing the transducer to atmospheric
pressure and calibrating the pressure reading to zero.

• Levelling :
 The pressure transducer must be set at the appropriate level in
relation to the patient in order to measure blood pressure
correctly.
 Defined as "the selection of a position of interest at which the
reference standard (zero ) is set".
 This is usually taken to be level with the patient’s heart, at the
4th intercostal space, in the mid-axillary line.

 A transducer too low over reads, a transducer too high under
reads.
 The phlebostatic axis corresponds roughly with the position
of the RA, and this level has generally been accepted as the
ideal reference level.
 It was therefore adopted as the reference level for CVP
measurement.
 For arterial pressure measurements, at least since 2001 or
so we have been also leveling the arterial lines at the
phlebostatic axis.
 For every 10cm below the phlebostatic axis, the art line will
add 7.4mmHg of pressure.

NORMAL ARTERIAL PRESSURE WAVEFORMS
• The systolic waveform components consist of a steep pressure
upstroke, peak, and ensuing decline, and immediately follow the
ECG R wave.
• The downslope of the arterial pressure waveform is interrupted
by the dicrotic notch, continues its decline during diastole after
the ECG T wave, and reaches its nadir at end-diastole

• Systolic upstroke:
 This is the ventricular ejection.
 The slope of this segment has some vague relationship with
the rate of flow through the aortic valve (probably more so
when measured in the actual aorta). When its slope is
slurred, there may be aortic stenosis.

• Peak systolic pressure:
 This is the maximum pressure generated during the
systolic ejection.
• Systolic decline
 This is the rapid decline in arterial pressure as the
ventricular contraction comes to an end.
 This decline is even more rapid when there is a left
ventricular outflow tract obstruction (and systole comes to an
abrupt halt before the left ventricle is finished with the
ejection).

• Dicrotic notch:
 In perfect circumstances, when measured in the aorta, this
notch is very sharp and it actually does represent the closing
of the aortic valve. As you move further out
 As mentioned below, the dicrotic notch position varies with
the position of the arterial line.
 A suspiciously low dicrotic notch could mean very poor
vascular resistance, eg. in a situation like severe septic
shock.
• Diastolic runoff:
 This is the rapid decline in arterial pressure as the
ventricular contraction comes to an end.

• As the pressure wave travels from the central aorta to the
periphery, the arterial upstroke becomes steeper, the systolic
peak increases, the dicrotic notch appears later, the diastolic
wave becomes more prominent, and end-diastolic pressure
decreases.

AIR BUBBLES IN LINE
• Air bubbles can result in a lower frequency response and
greater resonance response.
• Small amount may augment systolic pressure reading; while
large amount cause an over-damped system.

ABNORMAL ARTERIAL PRESSURE WAVEFORMS
• Morphologic features of individual arterial pressure waveforms
can provide important diagnostic information

SYSTOLIC PRESSURE VARIATION - SPV
• The difference between the maximal and minimal value of
systolic blood pressure during one mechanical breath
• This cyclic variation in systemic arterial pressure is known as
the systolic pressure variation
• In a mechanically ventilated patient, normal SPV is 7 to 10 mm
Hg, with Δ Up being 2 to 4 mm Hg and Δ Down being 5 to 6 mm
Hg.

SYSTOLIC PRESSURE VARIATION - SPV
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.

• SPV
• > 10 mmHg - fluid responsive
• < 5 mmHg - not fluid responsive

PULSE PRESSURE VARIATION - PPV

• Pulse pressure is 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

• PPV % = 100 x (PPmax – PPmin) / ((PPmax + PPmin) / 2)
• PPV
• > 15% - fluid responsive
• < 7% - not fluid responsive

CARDIAC OUTPUT MONITORING

THERMODILUTION CARDIAC OUTPUT
MONITORING
• The thermodilution technique has become the de facto clinical
standard for measuring cardiac output because of its ease of
implementation
• For thermodilution, a known volume of iced or room-temperature
fluid is injected as a bolus into the proximal (right atrium) lumen
of the PAC, and the resulting change in the pulmonary artery
blood temperature is recorded by the thermistor at the catheter
tip.
• In adults, an injectate volume of 10 mL should be used, whereas
in children, an injectate volume of 0.15 mL/kg is recommended.

• The thermodilution technique measures right ventricularoutput.
• Usually, three cardiac output measurements performed in rapid
succession are averaged to provide a more reliable result.
• When only a single injection was used to determine cardiac
output, a difference between sequential cardiac output
measurements of 22% was required to suggest a clinically
significant change.
• In contrast, when three injections are averaged to determine the
thermodilution measurement, a change greater than 13%
indicates a clinically significant change in cardiac output

Sources of error in thermodilution
cardiac output monitoring
• Intracardiac shunts
• Tricuspid or pulmonic valve regurgitation
• Inadequate delivery of thermal indicator
 Central venous injection site within catheter introducer sheath
 Warming of iced injectate
• Thermistor malfunction from fibrin or clot
• Pulmonary artery blood temperature fluctuations
 Following cardiopulmonary bypass
 Rapid intravenous fluid administration

CONTINUOUS THERMODILUTION CARDIAC
OUTPUT MONITORING
• In brief, small quantities of heat are released from a 10-cm
thermal filament incorporated into the right ventricular portion of
a PAC, approximately 15 to 25 cm from the catheter tip, and the
resulting thermal signal is measured by the thermistor at the tip
of the catheter in the pulmonary artery.
• Reproducibility and precision appear to be better with the CCO
method compared with the standard bolus thermodilution
technique.

• Although these catheters are more expensive than standard
PACs, obviating the need for bolus injections reduces nursing
workload and the potential risk of fluid overload or infection.
• As a result, a cardiac output measured by the CCO method may
provide a more accurate measurement of global cardiac output
for patients

TRANSPULMONARY THERMODILUTION
CARDIAC OUTPUT
• Icecold saline is injected into a central venous line while the change
in temperature is measured in a large peripheral artery (femoral,
axillary, or brachial artery) via a special arterial catheter equipped
with a thermistor.

• Mathematic derivation from the transpulmonary thermodilution
curve
• Extravascular lung water
• Measure of pulmonary edema
• Guide fluid therapy in patients with acute lung injury or
sepsis.
• Other derived indices
• Global end-diastolic volume and
• Intrathoracic blood volume.

• These indices are a better measure of cardiac preload than
traditional measurements such as CVP or pulmonary artery
wedge pressure.
• The last parameter derived from the transpulmonary
thermodilution curve is called the cardiac function index,
calculated using cardiac output and the intrathoracic blood
volume.
• It correlates closely with echocardiography-derived left
ventricular ejection fraction.

THERMODILUTION MEASUREMENT OF CARDIAC
OUTPUT WITH THE PULMONARY ARTERY CATHETER

THE STEWART-HAMILTON EQUATION FOR
MEASURING CARDIAC OUTPUT
• The basic physics
 If you inject a known amount of a substance upstream, the
change in its concentration downstream is related to the rate
of the flow.

FICK'S PRINCIPLE OF CARDIAC OUTPUT
MEASUREMENT
• The principle:
" the total uptake of (or release of) a substance by the peripheral
tissues is equal to the product of the blood flow to the peripheral
tissues and the arterial-venous concentration difference (gradient)
of the substance."

• VO2 ( oxygen consumption)
 Can also be estimated. Conventionally, resting metabolic
consumption of oxygen is
 3.5 ml of O2 per kg per minute, or
 125ml O2 per square meter of body surface area per minute.

• So, in a normal person, with a body surface area of 2m2 and
thus with a VO2 of 250ml per minute,
CO = 250ml / (200ml – 150ml)
= 250 / 50
= 5 L/min

PULSE CONTOUR CARDIAC OUTPUT (PICCO)
• PiCCO uses a combination of two techniques for advanced
haemodynamic and volumetric monitoring
• Transpulmonary thermodilution
• Pulse contour analysis
• The thermodilution technique calculates volumetric measurements
of preload and cardiac output.
• Pulse contour analysis provides continuous cardiac output and
stroke volume variation.
• PiCCO requires the insertion of a CVP catheter and a
thermodilution arterial line.

• Indications for PiCCO
 Shock: cardiogenic, hypovolaemic, septic
 Sepsis
 Trauma
 Pulmonary oedema
 Acute lung injury
 Burns
 Any condition that requires assessment of haemodynamic
and/ or volumetric function

• PULSE CONTOUR ANALYSIS: Continuous analysis
 The PiCCO system continually estimates the stroke volume from
the arterial waveform, using an arterial catheter.
 Cardiac output is then estimated from the stroke volume and heart
rate.
 Provides continuous beat by beat parameters which are obtained
from the shape of the arterial pressure wave
 The area under the arterial curve during systole, minus the
background diastolic area, is assumed to be proportional to the
stroke volume. This means that the stroke volume and thus the
cardiac output can be measured beat to beat.

 The initial transpulmonary thermodilution calibrates the
parameters & the algorithm is then capable of computing each
single stroke volume
 Continuous CO readings are achieved using the area under the
systolic part of the curve, a calibration factor (cal) derived from
the thermodilution run, the heart rate (HR) and the individual’s
aortic compliance (which is termed C (p) and characterised by
the thermodilution CO and the measured BP).

PARAMETERS MEASURED & NORMAL VALUES
• Thermodilution Parameters
 CO – Cardiac Output: 4 - 8litres/min
 CI – Cardiac Index : 3- 5litres/min/m₂
 Preload
 GEDI – Global end diastolic index: 680- 800ml/m₂
 ITBVI – Intra thoracic blood volume index: 850-1000ml/m₂
 Pulmonary oedema
 ELWI –Extravascular lung water index: 3-7mls/kg
 PVPI - Pulmonary vascular permeability index: 1.0- 3.0
 Contractility
 CFI - Cardiac function index: 4.5- 6.5%
 GEF - Global ejection fraction: 25- 35%

• Pulse contour Parameters
 Flow
 PCC -Pulse contour cardiac output
 ABP - Arterial blood pressure
 HR - Heart rate
 SV - Stroke volume: 50-110mls
 Volume responsiveness
 SVV - Stroke volume variation: <10%
 PPV - Pulse pressure variation
 Afterload
 SVRI - Systemic vascular resistance index: 1700-2400 dyn*s*cm-5*m2
 Contractility
 Index of left ventricular contractility

LITHIUM DILUTION CARDIAC
OUTPUT MONITORING
• Derives its fundamental basis from indicator dilution principles
• In brief, following an intravenous bolus injection of a small dose
of lithium chloride, an ion-selective electrode attached to a
peripheral arterial catheter measures the lithium dilution curve,
from which the cardiac output is derived.
• The lithium indicator can be injected through a peripheral
intravenous catheter with similar measurement accuracy, thus
eliminating the need for a central venous line.

• Advantages over Thermodilution PiCCO
 The concentration stays the same throughout the arterial circulation, and
thus
You don’t need a big central artery to sample the lithium.
You don’t need to inject the lithium through a central vein
 The technique shows good agreement with PA catheter thermodilution
measurement.

• Limitations
 Same as all dilution methods, you get inaccurate results if there are
shunts in the heart.
 If you are already on lithium, this background lithium concentration will
cause the machine to overestimate your cardiac output.
 “electrode drift” can occur if there are high doses of muscle relaxants
present
 You do end up disposing of some blood each time you sample.

OTHER METHODS FOR MONITORING
CARDIAC OUTPUT AND PERFUSION
• PARTIAL CO2 REBREATHING CARDIAC OUTPUT
MONITORING
 based on a restatement of the Fick equation for carbon
dioxide elimination rather than oxygen uptake.
Q˙ =V˙ CO2/(CvCO2 −CaCO2)
where Q˙ = cardiac output
V˙ co2 = rate of carbon dioxide elimination
Cvco2 = carbon dioxide content of mixed venous blood
Caco2 = carbon dioxide content of arterial blood

• GASTRIC TONOMETRY
 Gastric tonometry aims at monitoring gastric circulation as
an early indication of splanchnic hypoperfusion
• ESOPHAGEAL DOPPLER CARDIAC OUTPUT MONITORING
• BIOIMPEDANCE CARDIAC OUTPUT MONITORING

THANK YOU

Hemodynamic monitoring

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