This document discusses hemodynamic monitoring in pediatrics. It begins with definitions of hemodynamics and hemodynamic monitoring. Both invasive and noninvasive monitoring methods are described, including arterial blood pressure monitoring, central venous pressure monitoring, and pulmonary artery catheterization. Complications of invasive methods are outlined. Normal hemodynamic parameters for children are provided. The document emphasizes the importance of hemodynamic monitoring in critically ill children to guide treatment and optimize tissue perfusion and oxygen delivery.

1. DR.D.RASIKAPRIYA
FIRST YEAR
MD PEADIATRICS

2. PRETEST
 1. Name some invasive measures and noninvasive ways
of hemodynamic monitoring
 2.Name some advanced hemodynamic monitoring
parameters
 3.What test you do before arterial line insertion
 4.Name a site contraindicated for arterial line
 5.Normal mixed venous oxygen saturation
 6. What is oxygen delivery and oxygen consumption
 7.what is passive leg raising test

3. OBJECTIVES
 HEMODYNAMICS
 What is it?
 Why is it important to monitor?
 Whom to include?
 How to measure?
 Its merits and demerits.

4. HEMODYNAMICS- DEFINITION
 the forces which circulate blood through the
body.
 used to describe the intravascular pressure and
flow that occurs when the heart muscle contracts
and pumps blood throughout the body.

5. Hemodynamic Monitoring
 measurement of pressure, flow and oxygenation of blood
within the cardiovascular system.
OR
 Using invasive technology to provide quantitative
information about vascular capacity, blood volume, pump
effectiveness and tissue perfusion.
OR
 measurement and interpretation of biological systems that
describes the performance of cardiovascular system

6. QUESTION???????
 HOW MANY TIMES DOES OUR HEART
BEATS/DAY?

7. PURPOSE OF MONITORING
 Circulatory shock is an important cause of pediatric
morbidity and mortality.
 Early recognition of inadequate tissue perfusion &
oxygenation followed by prompt treatment most important.
 In pediatric circulatory shock, cardiac output (CO) & BP can
be low, normal, or high.
 Physical examination, poorly reflects CO, preload status, or need
for fluid or other hemodynamic interventions.
 BP & HR often do not reflect blood flow

8.  Potential clinical value of 4 advanced hemodynamic
monitoring technologies
 CO monitoring
 Venous oximetry
 Fluid responsiveness
 Lung water

9. DO2 = SaO2 × Hb × CO
After load
Preload SV × HR
Contractility
Blood pressure = SVR × CO
HEMODYNAMIC PHYSIOLOGY

10. Physical Examination
Level of consciousness, activity, or agitation
State of hydration
Peripheral edema
Respiratory pattern
Peripheral perfusion/capillary refill time
Toe-to-core temperature gap
Heart rate and rhythm
Pulse characteristics
Urine output
Hepatomegaly
Jugular venous pressure
Pulmonary and cardiac auscultation

11. METHODS
NON INVASIVE INVASIVE
 NIBP
 ECG
 Chest X ray
 ECHO
 Blood pressure monitoring-ABP
 Central venous pressure monitoring
 Pulmonary artery pressure
monitoring
 Mixed venous oxygen monitoring
 Cardiac output

12. QUESTION???
 EACH VENTRICLE EJECTS - ? ml of blood/beat.

13. NON INVASIVE METHODS
 BLOOD PRESSURE:
INDIRECT ARTERIAL BP MEASUREMENT :
 palpation method (Riva-Rocci)
 auscultatory method
 oscillometric method
 rheographic method
 the phase-shift method
 ultrasonic arterial wall motion detector

15. CONTD..
Flow required across an occlusive cuff
Methods
 Auscultatory
 Oscillometric
Width of the inflatable bladder be 40% of the mid-
circumference of the limb, length should be twice the
width

16. Auscultatory NIBP
Pneumatic cuff inflated to occlude arterial blood flow
As cuff is deflated, audible frequencies (Korotkoff
sounds) are created
First sound = SBP
Last sound (or when muffled) = DBP

17. Auscultatory NIBP
 Errors in measurement:
 Long stethoscope tubing
 Poor hearing in observer
 Calibration errors of sphygmomanometer
 Decreased blood flow in the extremity
 Severe atherosclerosis (unable to occlude)
 Inappropriate cuff size
 Too rapid deflation
 accuracy reduced : low cardiac output, significant
hypotension, hypoperfusion, vasoconstriction, dysrhythmias,
edema.

18. Oscillometric NIBP
 Pneumatic cuff inflated to
occlude arterial blood flow
 Cuff deflated, arterial
pressure pulsations detected
and analyzed
 SBP = rapidly increasing
oscillations
 MAP = maximal point of
oscillations
 DBP = rapidly decreasing
oscillations
 Dina map (device for
indirect noninvasive mean
arterial pressure)

19. Variations in BP by Age
Age Mean BP (mm Hg)
Newborn 73/55(30-60)
1 year 90/55
6 years 95/57(60-100)
10 years 102/62
14 years 120/80
Adult 120/80
Elderly (over 70 years) Diastolic pressure may increase

20. NIBP - Complications
Too frequent inflations
 extremity edema
 nerve paresthesias
 compartment syndrome
Skin irritation

21. ELECTROCARDIOGRAM
 Evaluation of heart rate and rhythm,
ischemia, and conduction defects
 Trend monitor
 Sources of errors:
 Waveform artefact
 Electrocautery (diathermy) is the
main source of electrical
interference
 Muscle activity
 Movement artefact

23. INVASIVE MONITORING
 INVASIVE BLOOD PRESSURE:
 Continuous monitoring of systemic arterial blood
pressure,
 Frequent blood sampling, and
 Withdrawal of blood during exchange transfusions

24. Arterial Blood Pressure
Monitoring Components
 Arterial cannula with a
heparinized saline column
and flushing device
 Transducer
 Amplifier
 Oscilloscope.

25.  Advantages
Providing continuous monitoring,
Providing access for blood sampling
Display of the waveform in addition to the BP value
True heart rate in the presence of dysrhythmias
Allows specific management strategies to be directed
by changes in systolic, diastolic, or pulse pressure,
rather than mean pressure alone.

26. Complications
Bleeding
Thrombosis
Hematoma
Infection
Vascular compromise
Nerve damage
Accidental injection of air
or thrombus
Digital necrosis
Arteriovenous fistulae
Carpal tunnel syndrome

27.  Factors that increase the risk of arterial catheter
thrombosis:
 Larger catheter-to-vessel ratio
 Prolonged cannulation
 Multiple cannulation attempts
 Presence of peripheral vascular disease
 Venous and arterial femoral Catheterization in single
extremity
 Younger age
 Thrombogenic conditions

28.  Sources of error
 Inaccurate transducer level.
 Recordings should be made with the child in the supine
position and the transducer at the level of the mid-chest
or mid-axillary line. ( 7.5 mm Hg for each 10 cm change
in position)
 Zeroing
 Careful flushing of the catheter and pressure tubing to
remove blood and air bubbles and choosing the
shortest, stiffest, and largest catheter.

29. SVO2 60-75%
Stroke volume 50-100 mL
Stroke index 25-45 mL/M2
Cardiac output 4-8 L/min
Cardiac index 2.5-4.0 L/min/M2
MAP 60-100 mm Hg
CVP 2-6 mm Hg
PAP systolic 20-30 mm Hg
PAP diastolic 5-15 mm Hg
PAOP (wedge) 8-12 mm Hg
SVR 900-1300 dynes.sec.cm-5

30. Central Venous Pressure Monitoring
Indications:
 assessment of right heart filling pressure
 monitoring of large fluid shifts from the intravascular to
the extravascular space and vice versa
 Infusion of vasoactive substances
 infusion of hyperosmolar fluids and/or irritants

31. Central Venous Pressure Monitoring
Secure IV access in critically ill children who may
require large-volume fluid infusions or parenteral
nutrition
Monitoring cvp-indirect measurement of cardiac
preload
Provides access for blood sampling for measurement
of mixed venous saturation.
CVP- 0 – 6 mmHg

34. Information Obtained from CVP
Waveforms
Loss of A wave and irregular rhythm = suggests atrial
fibrillation or flutter
Cannon A waves = junctional rhythm, complete heart
block, ventricular arrhythmias, TS, RVH, PS, Pulm
HTN

35. Complications
Central line insertion Indwelling catheters
 Arterial (carotid, subclavian, femoral)
puncture
 Local hematoma
 Air embolism
 Catheter malposition (to neck tissue,
mediastinal, pericardial, or pleural
cavities)
 Pneumothorax
 Hemothorax
 Brachial plexus injury
 Dysrhythmias
 Infection
 Local hematoma
 Extravasation
 Vascular thrombosis
 Embolus (clot or air)
 Intracardiac thrombus
 Superior vena cava syndrome
 Chylothorax
 Local nerve damage

36. PULMONARY ARTERY CATHETERS
Septic shock unresponsive to fluid resuscitation and
low-dose vasopressor support,
Refractory shock following severe burn injuries,
Children with CHD, multiple organ failure, and
respiratory failure requiring high mean airway
pressures

39. CAPABILITIES OF PAC
 determination of CVP,
 pulmonary artery pressure (PAP), and
 pulmonary artery occlusion pressure (PAOP), also
referred to as pulmonary capillary wedge pressure (Pw)

40. PULMONARY ARTERY PRESSURE
MONITORING
Assess fluid status
CO
tissue oxygenation (Svo2),
oxygen delivery (Do2) and consumption (Vo2),
pulmonary vascular resistance (PVR) and systemic
vascular resistance (SVR)

41. Complications of PAC Placement
 Arrhythmias, complete heart block
 Endobronchial hemorrhage
 Pulmonary infarction
 Catheter knotting and entrapment
 Valvular damage
 Thrombocytopenia, thrombus formation
 Incorrect placement, balloon rupture

42. Cardiac Output Monitoring
 CO = HR x SV
 3.5 – 5 L/min/m2
 Preload, afterload, HR, contractility
 determinant of systemic oxygen delivery
 shock, multiple organ failure, unexplained
hypotension, severe cardiac disease, significant
cardiopulmonary interactions.

43. Measures of adequate o2 supply
Mixed venous o2 saturation
blood lactate
Tissue CO2 tonometry
NIRS (Near Infrared Spectroscopy)

44. BLOOD LACTATE
 Tissue dysoxia in states of mitochondrial dysfunction associated
with sepsis, poisoning, and various inborn errors of metabolism
 Accelerated anerobic glycolysis
 Lactate-containing replacement fluids during high-volume
hemofiltration
 Acute hyperventilation can elevate blood lactate levels, perhaps
secondary to increased splanchnic release of lactate during
hyperventilation

45. Tissue PCO2 Monitoring Using Tonometry
 Designed to measure tissue hypoperfusion
 Involves placement of a CO2-permeable balloon
adjacent to a mucosal surface
 Tissue hypoperfusion- increased intracellular CO2
 Gastric tonometry: inconsistent results
 Sublingual tonometry, suggested during early phases
of resuscitation

47. Near Infrared Spectroscopy
 Monitoring device for patients with potential
hemodynamic instability or deficits in regional
(primarily cerebral) perfusion
 Deoxy Hb absorbs light in the range of 760 nm or
lower, whereas both deoxy and oxy Hb absorb light at
~800 nm

49. TAKE HOME MESSAGE
 Multiple different methods of hemodynamic
monitoring
Keys to success
 Know when to use which method
 Technical skills for device placement
 Know how to interpret the data
 Remember the limitations of the technology

50. THANK U