Using Arterial Pressure Based Cardiac Output to Guide Therapy - Chris Saraceno
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Using Arterial Pressure Based Cardiac Output to Guide Therapy NCANA District 3 & 4 Meeting Chris Saraceno
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Hemodynamic parameters & fluid therapy Asim
Assessment of haemodynamics a critically ill patient and its management has always been a matter if debate. Over time a lot of studies and therapeutic interventions have been carried out. This presentation is a review of such interventions and their impact on the outcome.
Static and dynamic indices of hemodynamic monitoring
This document discusses static and dynamic indices used in hemodynamic monitoring. It provides a brief history of evidence-based medicine and emphasizes the importance of asking well-formulated clinical questions. Both static (e.g. CVP, PAOP) and dynamic (e.g. SVV, PPV, PLR) indices are covered. While static indices are poorly predictive of fluid responsiveness, dynamic indices can reliably assess volume responsiveness, even in spontaneously breathing patients or those with arrhythmias. The passive leg raise test is highlighted as a non-invasive alternative to fluid challenges for predicting fluid responsiveness. Overall, the document stresses the need for dynamic assessment to optimize fluid management and avoid potential harms of under- or
Which cardiac output monitoring?
1) The document discusses choosing cardiac output monitoring devices for peri-operative and ICU settings. It considers devices' reliability with changing vascular resistance and ability to provide useful clinical information.
2) For peri-operative monitoring of high-risk surgical patients, less invasive devices using uncalibrated pulse contour analysis like Vigileo and Clearsight may be suitable when vascular resistance does not change significantly.
3) For ICU patients receiving vasopressors where resistance changes greatly, more reliable thermodilution methods like PiCCO, EV1000 and pulmonary artery catheter are recommended to measure cardiac output and assess ventricular function.
Flotrac
The document discusses the FloTrac system, which uses an existing arterial line to continuously monitor cardiac output (CO) and other hemodynamic values through advanced arterial waveform analysis. While the trends provided by FloTrac can be useful for estimating hemodynamic status, its specific CO and cardiac index values may not correlate exactly with pulmonary artery catheter measurements. FloTrac requires good arterial signal quality and its values could be affected by factors like arrhythmias, hemodynamic instability, or ventilator settings like PEEP. Clinical judgment is still needed to interpret the data from FloTrac.
Newer modes of ventilation
HERE IS A SEMINAR BASED ON ALL THE NEWER MODES OF MECHANICAL VENTILATION .
MY SINCERE APOLOGIES , BECAUSE I HAD TO TAKE INFORMATION FROM OTHERS SLIDES TOO , SINCE THERE IS VERY LESS INFORMATION AVAILABLE ABOUT THIS TOPIC
Coagulation Monitoring in Critical Care
This document discusses monitoring coagulation in the intensive care unit (ICU). It begins by outlining reasons for monitoring coagulation in the ICU, such as sepsis, liver disease, and anticoagulant/antiplatelet therapy. It then describes various laboratory tests for coagulation including standard tests like PT, PTT, fibrinogen and newer point-of-care whole blood tests like thromboelastography and ROTEM. The advantages and limitations of different tests are provided. The document concludes by discussing areas where point-of-care coagulation monitoring has potential benefits in the ICU but also needs further standardization and research.
Advanced modes of Mechanical Ventilation-Do we need them?
The document discusses advanced modes of mechanical ventilation. It begins by outlining newer modes such as VAPS, APRV/BIPAP, PAV+, Smartcare, and their benefits over basic modes. These advanced modes aim to improve synchrony between the patient and ventilator, reduce asynchrony issues, and make ventilation proportional to patient effort through feedback loops. The document argues that automated closed-loop ventilation is the future as it reduces workload and errors while allowing for quicker weaning and lower costs through greater ease of use and patient safety.
Fluid responsiveness in critically ill patients
This document discusses fluid responsiveness in critically ill patients. It begins by defining fluid responsiveness as an increase in cardiac index after fluid infusion. It then describes three scenarios involving fluid resuscitation: patients with acute blood or fluid loss requiring immediate resuscitation, patients with suspected septic shock where early goal-directed therapy with fluids is important, and ICU patients who have already received fluids and their fluid responsiveness needs to be assessed. The document discusses various methods of assessing preload and preload dependence, including filling pressures, volumes, respiratory variations in inferior vena cava diameter, inspiratory drops in right atrial pressure, and predicting responsiveness through respiratory variations in parameters related to cardiac index. It emphasizes that preload alone
Recommended
Hemodynamic parameters & fluid therapy Asim
Assessment of haemodynamics a critically ill patient and its management has always been a matter if debate. Over time a lot of studies and therapeutic interventions have been carried out. This presentation is a review of such interventions and their impact on the outcome.
Static and dynamic indices of hemodynamic monitoring
This document discusses static and dynamic indices used in hemodynamic monitoring. It provides a brief history of evidence-based medicine and emphasizes the importance of asking well-formulated clinical questions. Both static (e.g. CVP, PAOP) and dynamic (e.g. SVV, PPV, PLR) indices are covered. While static indices are poorly predictive of fluid responsiveness, dynamic indices can reliably assess volume responsiveness, even in spontaneously breathing patients or those with arrhythmias. The passive leg raise test is highlighted as a non-invasive alternative to fluid challenges for predicting fluid responsiveness. Overall, the document stresses the need for dynamic assessment to optimize fluid management and avoid potential harms of under- or
Which cardiac output monitoring?
1) The document discusses choosing cardiac output monitoring devices for peri-operative and ICU settings. It considers devices' reliability with changing vascular resistance and ability to provide useful clinical information.
2) For peri-operative monitoring of high-risk surgical patients, less invasive devices using uncalibrated pulse contour analysis like Vigileo and Clearsight may be suitable when vascular resistance does not change significantly.
3) For ICU patients receiving vasopressors where resistance changes greatly, more reliable thermodilution methods like PiCCO, EV1000 and pulmonary artery catheter are recommended to measure cardiac output and assess ventricular function.
Flotrac
The document discusses the FloTrac system, which uses an existing arterial line to continuously monitor cardiac output (CO) and other hemodynamic values through advanced arterial waveform analysis. While the trends provided by FloTrac can be useful for estimating hemodynamic status, its specific CO and cardiac index values may not correlate exactly with pulmonary artery catheter measurements. FloTrac requires good arterial signal quality and its values could be affected by factors like arrhythmias, hemodynamic instability, or ventilator settings like PEEP. Clinical judgment is still needed to interpret the data from FloTrac.
Newer modes of ventilation
HERE IS A SEMINAR BASED ON ALL THE NEWER MODES OF MECHANICAL VENTILATION .
MY SINCERE APOLOGIES , BECAUSE I HAD TO TAKE INFORMATION FROM OTHERS SLIDES TOO , SINCE THERE IS VERY LESS INFORMATION AVAILABLE ABOUT THIS TOPIC
Coagulation Monitoring in Critical Care
This document discusses monitoring coagulation in the intensive care unit (ICU). It begins by outlining reasons for monitoring coagulation in the ICU, such as sepsis, liver disease, and anticoagulant/antiplatelet therapy. It then describes various laboratory tests for coagulation including standard tests like PT, PTT, fibrinogen and newer point-of-care whole blood tests like thromboelastography and ROTEM. The advantages and limitations of different tests are provided. The document concludes by discussing areas where point-of-care coagulation monitoring has potential benefits in the ICU but also needs further standardization and research.
Advanced modes of Mechanical Ventilation-Do we need them?
The document discusses advanced modes of mechanical ventilation. It begins by outlining newer modes such as VAPS, APRV/BIPAP, PAV+, Smartcare, and their benefits over basic modes. These advanced modes aim to improve synchrony between the patient and ventilator, reduce asynchrony issues, and make ventilation proportional to patient effort through feedback loops. The document argues that automated closed-loop ventilation is the future as it reduces workload and errors while allowing for quicker weaning and lower costs through greater ease of use and patient safety.
Fluid responsiveness in critically ill patients
This document discusses fluid responsiveness in critically ill patients. It begins by defining fluid responsiveness as an increase in cardiac index after fluid infusion. It then describes three scenarios involving fluid resuscitation: patients with acute blood or fluid loss requiring immediate resuscitation, patients with suspected septic shock where early goal-directed therapy with fluids is important, and ICU patients who have already received fluids and their fluid responsiveness needs to be assessed. The document discusses various methods of assessing preload and preload dependence, including filling pressures, volumes, respiratory variations in inferior vena cava diameter, inspiratory drops in right atrial pressure, and predicting responsiveness through respiratory variations in parameters related to cardiac index. It emphasizes that preload alone
Cardiac output monitoring
Cardiac output can be measured through various invasive and non-invasive methods. The pulmonary artery catheter using thermodilution is still considered the gold standard but is invasive. Minimally invasive methods include lithium dilution, pulse contour analysis devices, esophageal Doppler, and transesophageal echocardiography. Non-invasive methods include partial gas rebreathing, thoracic bioimpedance, and Doppler ultrasound. The ideal monitor is accurate, continuous, non-invasive and provides reliable measurements during different physiological states.
Fluid responsiveness - an ICU phoenix
Fluid administration is commonly used to resuscitate ICU patients, but determining which patients will respond to fluids, known as fluid responsiveness, remains challenging. Static parameters like CVP are poor predictors of fluid responsiveness. Dynamic parameters that measure beat-to-beat variations related to mechanical ventilation, such as PPV, SVV, IVC collapsibility, and changes in aortic blood flow with PLR have been shown to more accurately predict fluid responsiveness with sensitivities and specificities often over 90%. However, factors like arrhythmias, spontaneous breathing, and suboptimal ventilator settings can limit the reliability of dynamic parameters in some clinical situations.
Recruitment maneuvers in ards
1) Recruitment maneuvers (RMs) aim to reopen collapsed alveoli in ARDS patients through temporarily increasing transpulmonary pressure. Common types include sighs, sustained inflations, and stepwise increases in pressure.
2) While RMs often improve short-term oxygenation, clinical trials have found no evidence of reduced mortality or improved outcomes. One large trial found RMs may actually increase mortality.
3) Not all ARDS patients respond equally to RMs due to factors like etiology, severity, and lung recruitability. RMs should only be considered for hypoxemic individuals based on an individual risk-benefit assessment.
Cardiac output & monitoring
This document discusses cardiac output and methods for monitoring it. It begins by defining cardiac output and factors that influence it, such as stroke volume, preload, afterload, and contractility. Both invasive and minimally invasive methods for monitoring cardiac output are described, including pulmonary artery catheters and techniques such as thermodilution that use temperature sensors. The principles behind various monitors that can measure cardiac output and its determinants using methods such as Fick's principle and thermodilution are explained. The document also discusses using echocardiography to monitor cardiac output and principles guiding fluid therapy.
PiCCO Monitor
This document discusses PiCCO (Pulse Contour Cardiac Output) monitoring. PiCCO enables assessment of a patient's hemodynamic status by measuring various volumetric and cardiac parameters. It requires a central venous pressure catheter and arterial line. PiCCO works by transpulmonary thermodilution, using cold saline injections to calculate volumes, and pulse contour analysis of the arterial waveform to provide continuous cardiac output monitoring. The document defines various parameters measured by PiCCO like preload, contractility, lung function, and afterload, and provides normal ranges. It also outlines indications, contraindications and the decision tree for hemodynamic monitoring using PiCCO.
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This document provides an overview of congenital heart disease (CHD) in children, including:
- The incidence of CHD is 7-10 per 1000 live births, with some forms being more common in premature infants. The most common types are ventricular septal defects and atrial septal defects.
- CHD can be classified based on the direction of blood shunting (left-to-right or right-to-left), presence of mixing lesions, or obstructive lesions. Examples of different types of CHD are provided with diagrams.
- Management of CHD depends on whether the heart defect is uncorrected, partially corrected, or completely corrected. A multidisciplinary approach is needed and
PEEP:Bring the Evidence to the Bedside
This document discusses the use of positive end-expiratory pressure (PEEP) in patients receiving mechanical ventilation. It describes a 19 year old female patient with immunosuppression and CMV pneumonia who requires intubation and mechanical ventilation. The goal of using PEEP in this patient is to decrease the risk of ventilator-induced lung injury while also aiming to increase oxygen levels and decrease the need for high oxygen supplementation. The document then reviews evidence and controversies around optimizing PEEP levels to reduce lung injury and improve outcomes in acute lung injury and acute respiratory distress syndrome patients.
Cardiomyopathy and anesthetic concern
Cardiomyopathies are diseases of the heart muscle that cause it to be structurally and functionally abnormal without other known causes like coronary artery disease. There are several types including dilated, hypertrophic, restrictive, arrhythmogenic right ventricular, and Takotsubo cardiomyopathy. Anesthesia management aims to minimize negative inotropic effects, maintain appropriate preload and afterload, and prevent hypotension, arrhythmias, and tachycardia. Goals depend on the type of cardiomyopathy and whether systolic or diastolic dysfunction predominates. Close monitoring is important due to potential hemodynamic instability from anesthesia and surgery.
Approach to Mechanical ventilation
Mechanical ventilation can be used to support or replace spontaneous breathing in patients unable to maintain adequate ventilation on their own. It aims to facilitate carbon dioxide release and maximize oxygen delivery. Modes include controlled mandatory ventilation where the ventilator controls both tidal volume and rate, and assist-control where the ventilator provides a minimum rate with additional breaths triggered by the patient. Synchronized intermittent mandatory ventilation delivers mandatory breaths at set intervals while allowing spontaneous breathing in between to reduce asynchrony.
cardiac output monitoring
Cardiac output monitoring provides important information about a patient's hemodynamic status. There are several invasive and non-invasive methods to measure cardiac output. Invasive methods include thermodilution, Fick method, lithium dilution. Thermodilution, using a pulmonary artery catheter, is considered the clinical gold standard but has fallen out of favor due to risks. Non-invasive options include esophageal Doppler, bioreactance, pulse contour analysis, and partial CO2 rebreathing. Choice of monitoring method depends on the patient's condition and goals of therapy.
Basic Of Mechanical Ventilation
This document provides an overview of ventilator basics, including:
1) It describes common ventilator parameters such as tidal volume, flow, and phase variables that control the start and end of breaths.
2) It outlines basic ventilator modes like control, assist-control, SIMV, PCV, PSV, and BiPAP that deliver mandatory or assisted breaths through different control variables.
3) It discusses settings, adjuncts and complications associated with mechanical ventilation to safely manage patients on ventilators.
Vsd,Asd &Anaesthesia
This document provides an overview of the classification, pathophysiology, preoperative evaluation, and anesthetic management considerations for patients undergoing surgery with congenital heart defects such as atrial septal defects (ASD) and ventricular septal defects (VSD). It discusses the pathophysiology of left-to-right and right-to-left shunting, preoperative assessment including history, examination, investigations, and risk factors. It also outlines goals and techniques for anesthesia including bubble avoidance, optimizing oxygen delivery and ventilation, and avoiding hypovolemia and increases in left-to-right shunting. Specific considerations for inhalational and intravenous induction agents, central neuraxial blockade, pregnancy, and Eisenmenger
Fluid responsiveness in pratice
This document discusses fluid responsiveness and methods for assessing preload responsiveness. It summarizes that dynamic indices of preload responsiveness like pulse pressure variation (PPV) and stroke volume variation (SVV) can help identify patients who will respond to fluid by increasing their stroke volume. However, these indices have limitations and may not be reliable in patients with spontaneous breathing, arrhythmias, low tidal volumes, low lung compliance, high frequency ventilation, open chest conditions, or severe right ventricular failure. In these situations where the indices cannot be interpreted reliably, other dynamic tests are needed to assess fluid responsiveness.
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The document provides an overview of mechanical ventilation, including its history and various modes. It begins with the origins of negative-pressure ventilators like iron lungs and the later development of positive-pressure ventilators. The main goals of ventilation are to facilitate carbon dioxide release and oxygen delivery. Various modes are described that can be used for invasive or non-invasive ventilation. Settings like PEEP, respiratory rate, tidal volume, and FiO2 are outlined that can be adjusted to optimize oxygenation and ventilation. Indications for intubation and criteria for safely extubating patients are also reviewed.
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This document discusses low-flow and minimal-flow anesthesia techniques. It begins by defining low-flow as a fresh gas flow of 1 L/min and minimal-flow as 0.5 L/min. Rebreathing systems allow reuse of exhaled gases after removal of carbon dioxide. Using these techniques can reduce costs by 55-75% and minimize environmental pollution from volatile anesthetic gases. Proper monitoring and maintenance of breathing gas conditions is important for patient safety when using low fresh gas flows.
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This document discusses anesthetic considerations for laparoscopic cholecystectomy in a patient with COPD. It provides background on the patient's history and comorbidity of COPD. It then summarizes the key respiratory effects of pneumoperitoneum during laparoscopy including increased airway pressures and changes in ventilation. It also discusses the cardiovascular effects, including a transient increase then decrease in cardiac output due to changes in venous return. Finally, it notes other potential risks such as respiratory acidosis, endobronchial intubation, subcutaneous emphysema, and hypothermia that the anesthesiologist must consider in a patient with COPD undergoing laparoscopic surgery.
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The document discusses methods for predicting fluid responsiveness in critically ill patients. It describes how static parameters like central venous pressure and pulmonary artery occlusion pressure are poor predictors on their own. Dynamic parameters that measure stroke volume variation with respiration are better predictors if the patient is mechanically ventilated. The ability to predict fluid responsiveness is important to optimize fluid administration and prevent under- or over-hydration in critically ill patients.
PRVC
PRVC (Pressure Regulated Volume Control) is a mode of mechanical ventilation that uses pressure control adjusted breath-to-breath to deliver a set tidal volume. It sets a minimum respiratory rate, target tidal volume, and maximum pressure limit. The ventilator measures the tidal volume on each breath and adjusts the inspiratory pressure up or down as needed to try and deliver the set tidal volume with each subsequent breath. This allows the ventilator to compensate for changes in lung compliance to help guarantee tidal volume delivery while limiting pressures. However, tidal volumes can still vary with intermittent patient effort.
Airway Pressure Release Ventilation
APRV (Airway Pressure Release Ventilation) is a ventilation mode that applies continuous positive airway pressure (CPAP) for a prolonged high-pressure phase (T high) to recruit and maintain lung volume. It then has a brief low-pressure release phase (T low) where most ventilation and CO2 removal occurs. Compared to conventional ventilation, APRV may cause less ventilator-induced lung injury due to maintaining higher end-expiratory lung volumes without repetitive opening/closing of alveoli. It also allows for spontaneous breathing which improves patient comfort and outcomes. While APRV does not reduce mortality, it can improve other outcomes such as shorter ventilation times and ICU stays.
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This document discusses the management of hypotension and hypoperfusion. It begins with an overview of fluid, vasopressor, and inotropic therapy and the importance of matching oxygen delivery to demand. It then presents a case of a patient with peritonitis and hypotension and discusses the pathophysiology of hypoperfusion, including situations where blood pressure may be normal but microcirculation is impaired. The document emphasizes optimizing both the macrocirculation and microcirculation in management. It discusses various fluid resuscitation endpoints and techniques to assess fluid responsiveness to guide fluid administration. Finally, it addresses the use of vasopressors and inotropes in the context of sepsis.
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Cardiac output monitoring
Cardiac output can be measured through various invasive and non-invasive methods. The pulmonary artery catheter using thermodilution is still considered the gold standard but is invasive. Minimally invasive methods include lithium dilution, pulse contour analysis devices, esophageal Doppler, and transesophageal echocardiography. Non-invasive methods include partial gas rebreathing, thoracic bioimpedance, and Doppler ultrasound. The ideal monitor is accurate, continuous, non-invasive and provides reliable measurements during different physiological states.
Fluid responsiveness - an ICU phoenix
Fluid administration is commonly used to resuscitate ICU patients, but determining which patients will respond to fluids, known as fluid responsiveness, remains challenging. Static parameters like CVP are poor predictors of fluid responsiveness. Dynamic parameters that measure beat-to-beat variations related to mechanical ventilation, such as PPV, SVV, IVC collapsibility, and changes in aortic blood flow with PLR have been shown to more accurately predict fluid responsiveness with sensitivities and specificities often over 90%. However, factors like arrhythmias, spontaneous breathing, and suboptimal ventilator settings can limit the reliability of dynamic parameters in some clinical situations.
Recruitment maneuvers in ards
1) Recruitment maneuvers (RMs) aim to reopen collapsed alveoli in ARDS patients through temporarily increasing transpulmonary pressure. Common types include sighs, sustained inflations, and stepwise increases in pressure.
2) While RMs often improve short-term oxygenation, clinical trials have found no evidence of reduced mortality or improved outcomes. One large trial found RMs may actually increase mortality.
3) Not all ARDS patients respond equally to RMs due to factors like etiology, severity, and lung recruitability. RMs should only be considered for hypoxemic individuals based on an individual risk-benefit assessment.
Cardiac output & monitoring
This document discusses cardiac output and methods for monitoring it. It begins by defining cardiac output and factors that influence it, such as stroke volume, preload, afterload, and contractility. Both invasive and minimally invasive methods for monitoring cardiac output are described, including pulmonary artery catheters and techniques such as thermodilution that use temperature sensors. The principles behind various monitors that can measure cardiac output and its determinants using methods such as Fick's principle and thermodilution are explained. The document also discusses using echocardiography to monitor cardiac output and principles guiding fluid therapy.
PiCCO Monitor
This document discusses PiCCO (Pulse Contour Cardiac Output) monitoring. PiCCO enables assessment of a patient's hemodynamic status by measuring various volumetric and cardiac parameters. It requires a central venous pressure catheter and arterial line. PiCCO works by transpulmonary thermodilution, using cold saline injections to calculate volumes, and pulse contour analysis of the arterial waveform to provide continuous cardiac output monitoring. The document defines various parameters measured by PiCCO like preload, contractility, lung function, and afterload, and provides normal ranges. It also outlines indications, contraindications and the decision tree for hemodynamic monitoring using PiCCO.
Anesthesia for children with Congenital Heart Disease
This document provides an overview of congenital heart disease (CHD) in children, including:
- The incidence of CHD is 7-10 per 1000 live births, with some forms being more common in premature infants. The most common types are ventricular septal defects and atrial septal defects.
- CHD can be classified based on the direction of blood shunting (left-to-right or right-to-left), presence of mixing lesions, or obstructive lesions. Examples of different types of CHD are provided with diagrams.
- Management of CHD depends on whether the heart defect is uncorrected, partially corrected, or completely corrected. A multidisciplinary approach is needed and
PEEP:Bring the Evidence to the Bedside
This document discusses the use of positive end-expiratory pressure (PEEP) in patients receiving mechanical ventilation. It describes a 19 year old female patient with immunosuppression and CMV pneumonia who requires intubation and mechanical ventilation. The goal of using PEEP in this patient is to decrease the risk of ventilator-induced lung injury while also aiming to increase oxygen levels and decrease the need for high oxygen supplementation. The document then reviews evidence and controversies around optimizing PEEP levels to reduce lung injury and improve outcomes in acute lung injury and acute respiratory distress syndrome patients.
Cardiomyopathy and anesthetic concern
Cardiomyopathies are diseases of the heart muscle that cause it to be structurally and functionally abnormal without other known causes like coronary artery disease. There are several types including dilated, hypertrophic, restrictive, arrhythmogenic right ventricular, and Takotsubo cardiomyopathy. Anesthesia management aims to minimize negative inotropic effects, maintain appropriate preload and afterload, and prevent hypotension, arrhythmias, and tachycardia. Goals depend on the type of cardiomyopathy and whether systolic or diastolic dysfunction predominates. Close monitoring is important due to potential hemodynamic instability from anesthesia and surgery.
Approach to Mechanical ventilation
Mechanical ventilation can be used to support or replace spontaneous breathing in patients unable to maintain adequate ventilation on their own. It aims to facilitate carbon dioxide release and maximize oxygen delivery. Modes include controlled mandatory ventilation where the ventilator controls both tidal volume and rate, and assist-control where the ventilator provides a minimum rate with additional breaths triggered by the patient. Synchronized intermittent mandatory ventilation delivers mandatory breaths at set intervals while allowing spontaneous breathing in between to reduce asynchrony.
cardiac output monitoring
Cardiac output monitoring provides important information about a patient's hemodynamic status. There are several invasive and non-invasive methods to measure cardiac output. Invasive methods include thermodilution, Fick method, lithium dilution. Thermodilution, using a pulmonary artery catheter, is considered the clinical gold standard but has fallen out of favor due to risks. Non-invasive options include esophageal Doppler, bioreactance, pulse contour analysis, and partial CO2 rebreathing. Choice of monitoring method depends on the patient's condition and goals of therapy.
Basic Of Mechanical Ventilation
This document provides an overview of ventilator basics, including:
1) It describes common ventilator parameters such as tidal volume, flow, and phase variables that control the start and end of breaths.
2) It outlines basic ventilator modes like control, assist-control, SIMV, PCV, PSV, and BiPAP that deliver mandatory or assisted breaths through different control variables.
3) It discusses settings, adjuncts and complications associated with mechanical ventilation to safely manage patients on ventilators.
Vsd,Asd &Anaesthesia
This document provides an overview of the classification, pathophysiology, preoperative evaluation, and anesthetic management considerations for patients undergoing surgery with congenital heart defects such as atrial septal defects (ASD) and ventricular septal defects (VSD). It discusses the pathophysiology of left-to-right and right-to-left shunting, preoperative assessment including history, examination, investigations, and risk factors. It also outlines goals and techniques for anesthesia including bubble avoidance, optimizing oxygen delivery and ventilation, and avoiding hypovolemia and increases in left-to-right shunting. Specific considerations for inhalational and intravenous induction agents, central neuraxial blockade, pregnancy, and Eisenmenger
Fluid responsiveness in pratice
This document discusses fluid responsiveness and methods for assessing preload responsiveness. It summarizes that dynamic indices of preload responsiveness like pulse pressure variation (PPV) and stroke volume variation (SVV) can help identify patients who will respond to fluid by increasing their stroke volume. However, these indices have limitations and may not be reliable in patients with spontaneous breathing, arrhythmias, low tidal volumes, low lung compliance, high frequency ventilation, open chest conditions, or severe right ventricular failure. In these situations where the indices cannot be interpreted reliably, other dynamic tests are needed to assess fluid responsiveness.
Basics of mechanical ventilation
The document provides an overview of mechanical ventilation, including its history and various modes. It begins with the origins of negative-pressure ventilators like iron lungs and the later development of positive-pressure ventilators. The main goals of ventilation are to facilitate carbon dioxide release and oxygen delivery. Various modes are described that can be used for invasive or non-invasive ventilation. Settings like PEEP, respiratory rate, tidal volume, and FiO2 are outlined that can be adjusted to optimize oxygenation and ventilation. Indications for intubation and criteria for safely extubating patients are also reviewed.
Low flow Anaesthesia & Gas Monitoring
This document discusses low-flow and minimal-flow anesthesia techniques. It begins by defining low-flow as a fresh gas flow of 1 L/min and minimal-flow as 0.5 L/min. Rebreathing systems allow reuse of exhaled gases after removal of carbon dioxide. Using these techniques can reduce costs by 55-75% and minimize environmental pollution from volatile anesthetic gases. Proper monitoring and maintenance of breathing gas conditions is important for patient safety when using low fresh gas flows.
ANESTHETIC MANAGEMENT LAP CHOLECYSTECTOMY WITH COPD
This document discusses anesthetic considerations for laparoscopic cholecystectomy in a patient with COPD. It provides background on the patient's history and comorbidity of COPD. It then summarizes the key respiratory effects of pneumoperitoneum during laparoscopy including increased airway pressures and changes in ventilation. It also discusses the cardiovascular effects, including a transient increase then decrease in cardiac output due to changes in venous return. Finally, it notes other potential risks such as respiratory acidosis, endobronchial intubation, subcutaneous emphysema, and hypothermia that the anesthesiologist must consider in a patient with COPD undergoing laparoscopic surgery.
Anaesthesia for patient with pacemaker
A patient with pacemaker presents a complex challenge to the attending anaesthesiologist. The mode of management will be according to the type of pacemaker implanted. This presentation discusses in brief the peri-operative consideration in a patient with pacemaker.
Fluid responsiveness in Paediatrics
The document discusses methods for predicting fluid responsiveness in critically ill patients. It describes how static parameters like central venous pressure and pulmonary artery occlusion pressure are poor predictors on their own. Dynamic parameters that measure stroke volume variation with respiration are better predictors if the patient is mechanically ventilated. The ability to predict fluid responsiveness is important to optimize fluid administration and prevent under- or over-hydration in critically ill patients.
PRVC
PRVC (Pressure Regulated Volume Control) is a mode of mechanical ventilation that uses pressure control adjusted breath-to-breath to deliver a set tidal volume. It sets a minimum respiratory rate, target tidal volume, and maximum pressure limit. The ventilator measures the tidal volume on each breath and adjusts the inspiratory pressure up or down as needed to try and deliver the set tidal volume with each subsequent breath. This allows the ventilator to compensate for changes in lung compliance to help guarantee tidal volume delivery while limiting pressures. However, tidal volumes can still vary with intermittent patient effort.
Airway Pressure Release Ventilation
APRV (Airway Pressure Release Ventilation) is a ventilation mode that applies continuous positive airway pressure (CPAP) for a prolonged high-pressure phase (T high) to recruit and maintain lung volume. It then has a brief low-pressure release phase (T low) where most ventilation and CO2 removal occurs. Compared to conventional ventilation, APRV may cause less ventilator-induced lung injury due to maintaining higher end-expiratory lung volumes without repetitive opening/closing of alveoli. It also allows for spontaneous breathing which improves patient comfort and outcomes. While APRV does not reduce mortality, it can improve other outcomes such as shorter ventilation times and ICU stays.
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The document discusses awake intubation, including indications, patient preparation, pharmacological considerations like using lidocaine to anesthetize the airway via various methods to block different nerves, equipment needs, and personnel requirements to safely perform an awake intubation. It also reviews closed claims analyses related to airway management and difficult intubation, and the ASA's difficult airway algorithm.
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This document discusses political action for nurse anesthetists in North Carolina. It outlines the various groups involved in state-level political action, including the NCANA Board of Directors, lobbyists, Government Relations Committee, and PAC. It also discusses the legislative process in North Carolina and how nurse anesthetists can get involved through activities like supporting candidates, attending Capitol Day, and contributing to the PAC. The goal is to advocate for issues important to CRNAs like supervision requirements and reimbursement rates.
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- 1. 1 Using Arterial Pressure-Based Cardiac Output to Guide Therapy Chris Saraceno, DNAP, CRNA District 3 & 4 Meeting February 4th , 2017
- 2. FloTrac-EV1000™ 78 y.o. Male Severe sepsis 2° LLL pneumonia h/o TB 30 yrs ago MAP 58/ HR 135/ RR 42/ Temp 39.1/ UOP~5 2
- 3. Intubated, arterial line with Vigileo, CVP 7.30/41/78 (70%)/28/-10/ Lactate 4.2 SVV 18% 3
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- 13. Arterial Based C.O. Monitoring • LiDCO – London group – Lithium • PiCCO – Manual calibration – Thermodilution via central venous line • Sets parameters • Requires femoral arterial line 13
- 14. Stroke Volume Variation (SVV) Minimally invasive • WORKING arterial line • Zero arterial line anesthesia monitor & EV1000 Enter HT, WT, age and gender • Baseline vascular resistance database 14
- 15. SVV Displays hemodynamic parameters continuously (20 sec) • 100 pressure points over 10 seconds (2000 data points) • Calculates std of arterial waveform X compliance No manual calibration • Calibrates q 1 minute 15
- 16. SVV calculation % SVV = SVmax-SVmin /SVmean 16
- 17. SVV Evolving technology - Vigileo • 3 generations EV 1000 • 4th generation 17
- 18. Limitations Intubated, sedated, paralyzed • Required • Spontaneously breathing- naturally varies Severe arrythmias Have to have a pulse rate • IABP • Ventricular assist devices Vasodilation therapy- consider in “big picture” 18
- 19. Case Study # 1 78 y.o. male • HTN • Atherosclerosis • EVAR- AAA GA with Aline/Flotrac • 134/78 • 64 bpm • C.O. 4.5 • SVV 7% 19
- 20. Case Study # 1 1 hour into case • 110/60 • 76 bpm • C.O. 3.1 L/min • SVV 35% Dye study- no leak 3u PRBCs, 500 mL 5% albumin, 500 mL crystalloid “covert” blood loss ~ 750mL 20
- 22. Case Study #2 32 yo male • Type 2 DM • Idiopathic dilated CMO – EF 20% • Meds – Torsemide – Ramipril – Carveilol – Digoxin – Insulin 22 BiV pacemaker • GA • CVP • A line • 500 LR • 300 EBL • 1200 UOP
- 23. Case Study #2 5 hour case Dopamine 5-8 mcg/kg/min for BP • ABG: 7.19 74 62 28.3 100% O2 ICU - intubated 23
- 24. Case Study # 2 Post BiV: • 84/50 with MAP of 61 mmHg • 130 bpm • CVP 18-20 mmHg Questions • Fluid: worsen pulmonary edema • Increase Dopamine: worsen tachycardia • NTG, NTP or Dobutamine: wosen HOTN 24
- 25. Case Study # 2 FloTrac connected to existing Aline Patient ventilated and sedated CO 4.7 L/min SVV 20-22% Fluid challenge: CO 5 L/min, MAP inc to 66 mmHg Fluid until SVV < 15% 25
- 26. Case Study # 2 Vitals normalized Extubated within 24 hours EF 25% 26
- 27. Case Study #3 18 y.o. male MVA No PMH MVA with prolonged extraction SBP 70 HR 160 Abdomen firm Pelvic fracture FloTrac in ER • SVI: 14 mL/m2 • SVV: 40-45% OR • Splenectomy • SMV repair • 12 units PRBCs • 14 L NaCl 27
- 28. Case Study #3 ICU- • 23 L of NaCl • 16 u PRBCs • SVI 66 ml/m2 • Furosemide 28
- 29. Extremes in Cases DIEP Flap • Young, healthy – Fluid – Flap integrity Open AAA repair • Comorbidities – HTN – CKD 29
- 30. What else can EV1000 monitor tell us? Another piece of the puzzle 30
- 31. Case Study #4 54 yo male for liver resection Hepatocellular carcinoma A-line 150/85 HR 66 GA CVP = 8 mmHg 2 hours into surgery: • BP 95/44 • HR 126 • CVP= 7 mmHg 31
- 32. Case Study #4 Flo Trac connected to existing arterial line: • SVV 20% • SV 25 mL • CO 1.9 • Fluid given: SVV to 10%, but SV low = 35 mL • Epi gtt started – Titrated to 1mcg/kg/min – Vitals improved 32
- 33. Case Study # 4 Left intubated at the end of the case Troponin I and CK levels elevated MI 33
- 35. Thank you 35
Editor's Notes
- normal range 5-10mmHg Exaggerated indicates