Download - Hemodynamic monitoring
HEMODYNAMIC HEMODYNAMIC MONITORINGMONITORING
IRVAN SETIAWANIRVAN SETIAWAN
IntroductionIntroduction
Hemodynamic:Hemodynamic:– study of the motion of blood through the bodystudy of the motion of blood through the body– Measurement & interpretation of biological Measurement & interpretation of biological
systems that describe performance of the systems that describe performance of the cardiovascular systemcardiovascular system
Oxygen Delivery is the GoalOxygen Delivery is the Goal
Oxygen DeliveryOxygen Delivery DO2 = CO x CaO2 x 10DO2 = CO x CaO2 x 10 CO = HR x SV CO = HR x SV CaO2 = [1.34 x Hb x SaO2 ] + [0.003 x CaO2 = [1.34 x Hb x SaO2 ] + [0.003 x
PaO2]PaO2]
Oxygen ConsumptionOxygen Consumption CVO2 = [1.34 x Hb x SvO2 ] + [.003 x PVO2]CVO2 = [1.34 x Hb x SvO2 ] + [.003 x PVO2] VO2 = CO x 3(CaO2 –CvO2 ) x 10VO2 = CO x 3(CaO2 –CvO2 ) x 10
Methods of Hemodynamic MonitoringMethods of Hemodynamic Monitoring
Arterial Blood PressureArterial Blood Pressure– Non-invasiveNon-invasive– Direct arterial pressure measurementDirect arterial pressure measurement
Central Venous PressureCentral Venous Pressure The Pulmonary Artery CatheterThe Pulmonary Artery Catheter Cardiac Output MeasurementCardiac Output Measurement Tissue OxygenationTissue Oxygenation
Non-invasive Blood Pressure MonitoringNon-invasive Blood Pressure Monitoring
Limitations of Non-invasive Blood Limitations of Non-invasive Blood Pressure MonitoringPressure Monitoring
Cuff must be placed correctly and must be Cuff must be placed correctly and must be appropriately sizedappropriately sized– Auscultatory method is very inaccurate Auscultatory method is very inaccurate
Korotkoff sounds difficult to hearKorotkoff sounds difficult to hear– Significant underestimation in low-flow (i.e. Significant underestimation in low-flow (i.e.
shock) statesshock) states Oscillometric measurements also Oscillometric measurements also
commonly inaccurate (> 5 mm Hg off commonly inaccurate (> 5 mm Hg off directly recorded pressures)directly recorded pressures)
Direct Arterial Blood Pressure Direct Arterial Blood Pressure MeasurementMeasurement
Indications for Arterial CatheterizationIndications for Arterial Catheterization
Need for continuous blood pressure Need for continuous blood pressure measurementmeasurement– Hemodynamic instabilityHemodynamic instability– Vasopressor requirementVasopressor requirement– Respiratory failure Respiratory failure Frequent arterial blood Frequent arterial blood
gas assessmentsgas assessments Most common locations: radial, femoral, Most common locations: radial, femoral,
axillary, and dorsalis pedisaxillary, and dorsalis pedis
Complications of Arterial CatheterizationComplications of Arterial Catheterization
HemorrhageHemorrhage HematomaHematoma ThrombosisThrombosis Proximal or distal embolizationProximal or distal embolization PseudoaneurysmPseudoaneurysm InfectionInfection
Limitations of Arterial CatheterizationLimitations of Arterial Catheterization
Pressure does not accurately reflect flow Pressure does not accurately reflect flow when vascular impedance is abnormalwhen vascular impedance is abnormal
Systolic pressure amplificationSystolic pressure amplification– Mean pressure is more accurateMean pressure is more accurate
Recording artifactsRecording artifacts– UnderdampingUnderdamping– OverdampingOverdamping
Central Venous CatheterizationCentral Venous Catheterization
Central venous pressureCentral venous pressure– Right atrial (superior vena cava) pressureRight atrial (superior vena cava) pressure– Limited by respiratory variation and PEEPLimited by respiratory variation and PEEP
Central venous oxygen saturationCentral venous oxygen saturation– SCvO2SCvO2– Correlates with SMVO2 assuming stable Correlates with SMVO2 assuming stable
cardiac functioncardiac function– Goal-directed resuscitation in severe sepsis Goal-directed resuscitation in severe sepsis
and septic shock (Rivers, et al)and septic shock (Rivers, et al)
Central Venous CanulationCentral Venous Canulation
IndicationsIndications– Measure central venous pressureMeasure central venous pressure– Access for resuscitationAccess for resuscitation– Selected drug administrationSelected drug administration– Placement of pulmonary artery catheterPlacement of pulmonary artery catheter
ComplicationsComplications– Hematoma/vessel injury/blood lossHematoma/vessel injury/blood loss– Pneumothorax/hemothoraxPneumothorax/hemothorax– Cardiac arrhythmiasCardiac arrhythmias– InfectionInfection
LevelingLeveling
MeasurementMeasurement
Central Venous Pressure WaveformCentral Venous Pressure Waveform
The Pulmonary Artery CatheterThe Pulmonary Artery Catheter
HJC Swan and Santa Monica Bay sailboats (NEJM HJC Swan and Santa Monica Bay sailboats (NEJM 1970)1970)
Widespread use in critically ill patientsWidespread use in critically ill patients– Remains controversialRemains controversial– Lack of prospective, randomized trialsLack of prospective, randomized trials– PAC data are only as good as the clinicians’ PAC data are only as good as the clinicians’
interpretation and applicationinterpretation and application Measures CVP, PAP, PAOP, Cardiac Index and Measures CVP, PAP, PAOP, Cardiac Index and
SVO2SVO2 Approximately 1 million PACs placed annuallyApproximately 1 million PACs placed annually
Pulmonary Artery CatheterPulmonary Artery Catheter
Pulmonary Artery Catheter InsertionPulmonary Artery Catheter Insertion
Normal Hemodynamic ValuesNormal Hemodynamic Values
Pulse OximetryPulse Oximetry
Estimates HbOEstimates HbO22 as SpO as SpO22
HR displayed shoud be = pulse rateHR displayed shoud be = pulse rate
Oximeter sensorsOximeter sensors
Source of ErrorSource of Error
Physiologic/anatomicalPhysiologic/anatomical
– Vasoconstriction/poor perfusionVasoconstriction/poor perfusion
– Abnormal hemoglobinAbnormal hemoglobin
– Skin pigmentationSkin pigmentation ExternalExternal
– Motion of sensorMotion of sensor
– Extraneous lightExtraneous light
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