1. Clinical examination alone is not sufficient to assess hemodynamic status in critically ill patients as individual vital signs do not reflect overall status. 2. Arterial lines can be used to monitor blood pressure, heart rate, and derive parameters like cardiac output but waveforms require interpretation and may be affected by various artifacts. 3. Pulmonary artery catheters can measure central venous and pulmonary artery pressures as well as cardiac output but have potential complications and their use remains controversial with no proven benefits shown in large trials.

1. REVIEW OF HD MONITORING
DR GHALEB ALMEKHLAFI
MD,SFCCM,EDIC

2. HEMODYNAMICS
• DEFENITION-MOVEMENT
• COMPONENTS-CIRCULATION
• TARGETS-PERFUSION
• PHYSIOLOGY/PATHOPHYSIOLOGY
• METHODS OF MONITORING
PARAMETERS AND VALIDITY
DIAGNOSIS OR TREATMENT
WHICH METHOD AND WHEN?

3. 1-Myocardial
contraction
&heart rate
2-Vasoactivity
4factors that affecting the hemodynamic conditions
3-volume
C.O.= HR x Stroke
Volume (60-130 Ml/beat)
Stroke Volume has
three components
1. Preload
2. Afterload
3.Contractility
4-MICROCIRCULATION/PERFUSION

4. hypovolemia vascular tone
depression
myocardial
depression
Importance of assessing
the degree of each component
to select and apply the best therapeutic option
vasopressors inotropes
Hemodynamic failure in critically ill patients: 3 components
fluids
presence of associated lung injury

5. methods
Clinical methods
• Physical examination:
systemic clinical
examination
• V/S:NI-BP, Heart rate
• Skin, extremities
• Urine output
• Mental status
Classic methods
• A-LINE
• Pulse waveform analysis
• Invasive BP
• CVP
• PAC
Advanced methods
Non invasive
invasiveLAB:
SCVO2,LA

6. • Clinical examination remains an important initial step in the
diagnosis and risk stratification of critically ill patients.
• Individual vital signs often do not reflect hemodynamic
status.
• High or low pulse rate is neither sensitive nor specific for
the diagnosis of hemodynamic instability.
• Respiratory rate lacks adequate specificity or sensitivity to
serve as a test for hemodynamic instability.
• Skin or toe temperature is not a sensitive indicator of
hemodynamic instability.
• Oliguria may have causes other than renal Hypoperfusion.
• TRENDS

8. Mottling score

10. mlr/2007
ARTERIAL LINE

12. Arterial waveform components

13. 20
40
60
80
100
120
140
0
Arterial Pressure (mmHg)
DAP: reflection of vasomotor tone
DAP

14. 20
40
60
80
100
120
140
0
Arterial Pressure (mmHg)
DAP: reflection of vasomotor tone
DAP: driving pressure
for left coronary circulation
DAP

15. 20
40
60
80
100
120
140
0
PP
Arterial Pressure (mmHg)

16. 20
40
60
80
100
120
140
0
MAP
Arterial Pressure (mmHg)
MAP: driving pressure for perfusion
of important organs (e.g. brain, kidney)

17. 20
40
60
80
100
120
140
0
Arterial Pressure (mmHg)
MAP: important hemodynamic target
of resuscitation of shock states
MAP

18. MAP is a goal of resuscitation
• Correction of hypotension with a vasopressor
allows improving organ perfusion and
microcirculation
Which MAP value to target?

19. Target MAP
• increasing MAP above 65 mmHg results in
little benefit
• Probably higher target value if:
1. History of chronic hypertension
2. Elevated CVP
3. Elevated abdominal pressure

20. Target blood pressure in circulatory shock
• We recommend individualizing the target blood pressure during shock resuscitation.
Recommendation Level 1: QoE moderate (B)
• We recommend to initially target a MAP of ≥ 65 mmHg.
Recommendation: Level 1; QoE low (C)
• We suggest a higher MAP in septic patients with a history of hypertension.
Recommendation: Level 2; QoE low (B)

21. arterial line waveform
Slowed upstroke
– AS
– LV failure
• sharp vertical in
hyperdynamic states
– Anemia
– Hyperthermia
– Hyperthyroidism
– SNS
– Aortic regurg
Age effect

22. arterial waveforms –differential iagnosis
.
Pulsus alternance Seen
in:LVD/cardiomyopathies, HTN,AS,Normal
hearts with SVT
pulsus bisfrenus is a sign of combined aortic
valve lesion, also seen in hypertrophic
obstructive cardiomyopathy (HOCM), patent
ductus arteriosus, arteriovenous fistulas and
normal hearts in a hyperdynamic state
hyperdynamic states
AR
AS
LV failure

23. COMPLICATIONS ARTERIAL LINE
• Thrombosis/embolus
• Hematoma
• Infection
• Nerve damage/palsy
• Disconnect=blood loss
• Fistula
• Aneurysm
• Digital ischemia
mlr/2007

24. mlr/2007
LOSS OF WAVEFORM
•asystole
• Stopcock
• Monitor not on correct scale
• Nonfunctioning monitor
• Nonfunctioning transducer
• Kinked/clotted catheter

25. Technical issues/resonance artifacts

26. resonance artifacts
DAMPENED WAVEFORM
• Air bubble/blood in line
• Clot
• Disconnect/loose tubing
• Underinflated pressure bag
• Catheter tip against wall
• Compliant tubing
UNDERDAMPED WAVEFORM
• Too many stopcocks
• Long tubing
• Air bubbles
• Defective transducer

27. Arterial line dynamic response testing

28. Other functions of A-line
• Blood extraction
• pulse rate and rhythm
• effects of dysrhythmia
on perfusion
• ECG lead disconnection
• continuous cardiac
output using pulse
contour analysis
• pulse pressure variation
(suggests fluid
responsiveness)
• steeper upstroke of pulse
pressure = increased
contractility
• area under upstroke = SV
• steep down stroke = low
SVR

29. classification of cardiac output
monitoring systems.
 INVASIVE-PAC
 LESS INVASIVE
- PCM: pulse contour method
- TPD :transpulmonary dilution
- TED :trans esophageal Doppler
 NONINVASIVE
- PCM
- TTE/US
- BIOEMPEDANCE,BIOREACTANCE
- NICO

30. PULMONARY ARTERY CATHETER
Markings on catheter.
1. Each thin line= 10 cm.
2. Each thick line= 50
cm.
CVP Proximal (pressure line - injectate port for
CO)-BLUE
PA Distal (Pressure line hook up)- Yellow
Extra port - usually- Clear
Thermistor – Red Cap

31. PA Catheter Timeline
Swan HJ,
Ganz W,
Forrester J.
NEJM.Aug,
1970
Iberti TJ, Fischer EP,
Leibowitz AB, et al.
Pulmonary Artery Catheter
Study Group.
JAMA. Dec, 1990
1970 19901980 2000 2005
Connors AF, et al.
JAMA. Sept, 1996
1995
PA Catheters
Are Good
PA Catheters
Might be Bad
PA Catheters
Are Bad
MDs Are
Ignorant
Rhodes A.
Int Care Med.
Feb, 2002
French PAC Study Group
JAMA. Nov, 2003
Founding of the
Society of Critical
Care Medicine
PACMAN,
Escape, ARDSnet
2004 -2006

32. EBM
Overall Conclusion:
1. No difference in LOS in the ICU
2. No difference in Mortality
3. No benefit, no harm
• “There is no guided therapy tailored towards
PAC use.”
• “PAC is a diagnostic tool, not a therapeutic
one

33. Advances-PCM
• beat-to beat stroke volume analysis is based on the
Windkessel model, which was described by Otto Frank
in1899
• In 1993 Wesseling et al described a method of using the
finger cuff arterial pressure wave to derive cardiac
output“ Model Flow ” Currently the Nexfin
• In 1997 the first commercial system, the PiCCO (Pulsion,
Munich, Germany) was released
• in 2002 the LiDCO-plus (and later rapid), (LiDCO Ltd.,
Cambridge, England)
• In 2004 the FloTrac-Vigileo, (Edwards Lifesciences,
Irvine, CA, USA). Then volume view in 2010

35. Pulmonary Artery Catheter
indications
Diagnostic
Diagnosis of shock states
high- versus low-pressure pulmonary edema
primary pulmonary hypertension valvular disease,
intracardiac shunts, cardiac tamponade, and
pulmonary embolus (PE)
Monitoring complicated AMI
hemodynamic instability after cardiac surgery
Therapeutic
- Aspiration of air emboli
- local thromplytics
Contra-indications:
• Tricuspid or pulmonary valve
mechanical prosthesis
• Right heart mass (thrombus and/or
tumor)
• Tricuspid or pulmonary valve
endocarditis

36. PAC parameters and NL values
Measured values
• CVP: 2-6mmHg
• PAWP: 8-12mmHg
• PAP: 25/10mmHg
• SvO2: 0.65-0.70
• Temperature
• Q: 4-8L/min
• CI: 2.5-4L/min
Derived values – use of
formula: Q = MAP-CVP/SVR
• SV: 50-100mL/beat
• SVI: 25-45mL/beat/m2
• SVR: 900-1300 dynes-
sec/cm5
• SVRI: 1900-2400 dyne-
sec/cm5
• PVR: 40-150 dyne-
sec/cm5
• PVRI: 120-200 dynes-
sec/c

37. EQUATIONS
• Cardiac Output=Fick equation [VO2 = QT x
(CaO2-CvO2)]

38. Change in pressure / total blood flow
Systemic Vascular Resistance
Index =SVRI
= (MAP ) = (MAP-CVP)(80)/CI
Pulmonary Vascular Resistance
Index = PVRI
= (MPAP-PAOP)(80)/CI
80 converts mm Hg 80 converts mm Hg-
min-m2/liters to dynes*sec/*cm-5
SVR: 900-1300 dynes-sec/cm5
SVRI: 1900-2400 dyne-sec/cm5
PVR: 40-150 dyne-sec/cm5
PVRI: 120-200 dynes-sec/c

39. PAC WAVES

40. PAWP

42. How to measure the PAOP?

43. HOW TO LOCALIZE DURING SPONTANEOUS VENT.?

44. ALL PA measurements are calculated at end expiration
because the lungs are at their most equal -
(negative vs. positive pressures)

45. HOW TO LOCALIZE DURING MECH. VENT.?

46. PAW WAVEFORM WITH MECHANICAL
VENTILATION

51. What is the abnormality?

52. What is the abnormality?

53. What is the abnormality?

55. Pericardial tamponade: high PCWP, high SVR, CVP = PCWP
Right heart failure: high CVP, low CI, high PVR

56. Complications of PAC
• Venous access
complications
- include arterial
puncture
- hemothorax
- Pneumothorax
• Arrhythmias
- PVCs or nonsustained
VT
- Significant VT or
ventricular fibrillation
• Right bundle-branch
block (RBBB)
• PA rupture
• PAC related infection
• Pulmonary infarction

57. SUGGESTED APPROACH TO PAC USE
• potentially useful in undifferentiated, multi-factorial
shock states (for Q and ScVO2)
• useful in right heart pathology and pulmonary
hypertension
• requires careful patient selection (including a
contraindication assessment)
• don’t wedge (PADP can usually be used to estimate
PAOP)
• monitor for complications (predominantly on insertion)
• remove after 72 hours

59. ARTERIAL WAVEFORM ANALYSIS
TECNIQUES
other devices
PRAM: Pressure Recording
Analytical Method
SD of 2000 arterial
waveform points
Statistical analysis of
Arterial Pressure

60. Pulse Contour Parameters
Pulse Contour Cardiac Output PCCO
• Arterial Blood Pressure AP
• Heart Rate HR
• Stroke Volume ,CO SV
• Stroke Volume Variation SVV
• Pulse Pressure Variation PPV
• Systemic Vascular Resistance SVR
• Index of Left Ventricular Contractility dPmx*
MANY OTHER PARAMETERS AWAITING VALIDATION

61. Non invasive PCM

62. CALIBRATION FOR PCM
 Cardiac output is measured by another more accurate modality to
initially calibrate the PCA system and then for recalibration as needed
1-Transpulmonary Thermodilution Methods:
• PiCCO (Pulsion Medical Systems&GE technology)
• Volume View (Edwards Life Sciences)
2-Lithium Dilution Technique:
• LiDCO /LiDCOplus/LiDCOrapid ( LiDCO limited)
3-Ultrasound Indicator Dilution :COstatus (Transonic Systems, Inc.)
Device that do not need calibration:
-FLOTRAC/VIGILEO: estimate CO by the standard deviation of pulse pressure sampled during a time
window of 20 seconds
-PRAM :estimate cardiac output using frequency of 1000 HZ
62

63. Transpulmonary thermodilution-PICCO
and Edward / Volume View TM
• .
63

64. Advanced Thermodilution Curve Analysis
Transpulmonary thermodilution: Volumetric curve
Mtt: Mean Transit time
time when half of the indicator
has passed the point of detection in
the artery
DSt: Down Slope time
exponential downslope time of the
thermodilution curve
For the calculations of volumes…
ln Tb
injection
recirculation
MTt
t
e-1
DSt
Tb
…and…
All volumetric parameters are obtained by advanced analysis of the
thermodilution curve:
ITTV = CO * MTt
PTV = CO * DSt

65. ITTV = CO * MTt
PTV = CO * DSt
ITBV = 1.25 * GEDV
EVLW* = ITTV - ITBV
GEDV = ITTV - PTV RAEDV RVEDV LAEDV LVEDV
RAEDV RVEDV LAEDV LVEDVPBV
RAEDV RVEDV LAEDV LVEDVPTV
PTV
EVLW*
EVLW*
Calculation of volumes

66. Transpulmonary thermodilution
monitors are not only
CO monitoring devices

67. Transpulmonary thermodilution
2- Global end-diastolic volume (GEDV)
1- Cardiac outputGEDV
marker of
cardiac preload

68. Extravascular lung water (EVLW)
• Normal – 3-7 mL/kg
• Increased > 7 mL/kg
• Pulmonary edema > 10
mL/kg

69. .
Pulmonarv Blood
Volume
Hydrostatic
pulmonary edema
Permeability
pulmonary edema
PVPI =
PBV
EVLW*
normal
elevated
elevated

PVPI* =
PBV
EVLW*
elevated
elevated
normal
PVPI=
PBV
EVLW*
normal
normal
normal

PBV
PBV
PBV Normal Lung
Extra Vascular
Lung Water
Pulmonary Vascular Permeability Index-PVPI
• It allows to identify the type of pulmonary oedema

70. PARAMETERS Definitions
• LVSWI = SVI × (MAP – PAOP) × 0.0136
• CP = MAP × CO/451
• ITTV = CO × MTt
• PTV = CO × DSt
• GEDV = ITTV - PTV = CO × (MTt - DSt)
• ITBV = 1.25 × GEDV
• CFI = (CO/GEDV) × 103
• GEF = SV/(GEDV/4)
• EVLW = ITTV - ITBV
• PVPI = EVLW/PBV

71. Normal ranges
PARAMETER RANGE UNIT
 CI 3.0 – 5.0 l/min/m2
 SVI 40 – 60 ml/m2
 GEDI 680 – 800 ml/m2
 ITBI 850 – 1000 ml/m2
 ELWI* 3.0 – 7.0 ml/kg
 PVPI* 1.0 – 3.0
 SVV  10 %
 PPV  10 %
 GEF 25 – 35 %
 CFI 4.5 – 6.5 1/min
 MAP 70 – 90 mmHg
 SVRI 1700 – 2400 dyn*s*cm-5*m
71

72. Transpulmonary thermodilution
2- Global end-diastolic volume (GEDV)
4- Extravascular lung water (EVLW)
1- Cardiac output
3- Cardiac function index (CFI)
5- Pulmonary vascular permeability index
Pulse contour analysis
1- Continuous cardiac output (CCO)
2- Stroke volume variation (SVV)
3- Pulse pressure variation (PPV)
ScvO2
Complete picture
of the patient’s
hemodynamic status

73. Clinical application
What is the current situation?.………..……..………….Cardiac Output!
What is the preload?.……………….....…Global End-Diastolic Volume!
What is the afterload?……………..…..Systemic Vascular Resistance!
What about the contractility?........................ dPmx* LV pressure velocity
What about the Perfusion ?............................central venous saturation
Will volume increase CO?...fluid response….Stroke Volume Variation!
Are the lungs still dry?...…….……...…..….Extravascular Lung Water!*
pulmonary vascular permeability index… Dx of p.edema

74. hypovolemia vascular tone
depression
myocardial
depression
vasopressors inotropesfluids
presence of associated lung injury
Hemodynamic failure in critically ill patients: 3 components

75. Myocardial
depression
inotropes
+ CFI (PiCCO)
Echocardiography
Hemodynamic failure in critically ill patients: 3 components

76. vascular tone
depression
vasopressors
Arterial catheter (DAP ++)
Hemodynamic failure in critically ill patients: 3 components

77. hypovolemia
fluids
Prediction of fluid responsiveness
• PPV, SVV
• PLR or end-expiratory occlusion test
if SB, arrhythmias, low TV or low lung compliance
Evaluation: real-time CO
Lung tolerance
PAOP EVLW
presence of associated lung injury
Hemodynamic failure in critically ill patients: 3 components

78. First, try to perform echocardiography to assess cardiac function
Normal
cardiac fonction
Lung injury ?
ABG, Chest X-ray
Abnormal
cardiac function
no yes
CVC
CVP
SvcO2
Art cath
AP
PPV
PiCCO
CO
GEDV, EVLW, CFI
PPV, SVV
ScvO2
Basic
monitoring
+
advanced
monitoring
yes
considered valid?
no
only
Patient with circulatory failure
VolumeViewPAC
CO
PAOP
RAP, PAP
SvO2

82. Which measurement is most reliable for
predicting fluid responsiveness in a patient with
septic shock requiring mechanical ventilation?
Pick one best answer
• A. Central venous pressure (CVP)
• B. Pulmonary artery occlusion pressure (PAOP)
• C. Pulse pressure variation (ΔPP)
• D. Mixed venous oxygen saturation (SvO2)

84. vpw
• measured by 1,
dropping a
perpendicular line from
the point at which the
left subclavian artery
exists the aortic arch
and 2, measuring
across to the point at
which the superior
vena cava crosses the
right mainstem
bronchus.

85. 71 mm and 62 mm for supine and erect CRs, respectively.