hemodinamik periop cb2013
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Perioperative Hemodynamic
Monitoring
Cindy E. BoomRS.Pusat Jantung dan Pembuluh DarahHarapan Kita Jakarta
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- Seorang pria 70 tahun, datang dengan keluhan
tidak bisa BAB, perut kembung, tidak dapatmakan sudah 3 hari
- Pola napas terengah-engah, gelisah
- Posisi setengah duduk
- Kulit pucat, akral dingin
- Nadi: 130 x/menit. TD : 90/35 mmHg
- Respirasi : 35 40 x/mnt
- Auskultasi : rales +, wheezing
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Instability Hemodynamic
A clinical state
Systemic blood pressure
Cardiac output
Organ function
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Low Cardiac Output Syndrome ( LCOS)MAP < 65mmHg
Oliguria (
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Adequate Oxygen Delivery?
ConsumptionDemand
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+ Adequate Balance of Tissue Oxygenation
Preload
AfterloadHeart RateContractility
Demand
O2ExtractionDiastolic Time
Diastolic PressureCoronary Artery
Flow
Supply
Myocardial Oxygen Balance
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Oxygen Delivery
Arterial
Blood
Gas
Hb
PaO2
Oxygen
Content
Oxygen
Delivery
Cardiac
Output
Oxygen
Content= X
Hemodynamic
Monitors
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Low Cardiac Output SyndromeLCOSFirst Step Clinical Evaluation
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LCOS
MAP < 65mmHg
Oliguria (
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+Resuscitation
Goal Oriented Hemodynamic Therapy
Volume Medikamentosa Mechanical
How?
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Hemodynamic Management of LCOS
Second Step : CVP / Scv O2Myocardial and/ or Vascular Dysfunction
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Insert
CVP/ScvO2
ScvO2 >70% SvO2
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CVP
MAP
ScvO2
CRYSTALLOID
VASOACTIVE
AGENT
PRBC to Hct 30 %
INOTROPE(S)
< 8 mmHg
8-12 mmHg
< 65 mmHg
> 90 mmHg
> 65 mmHg
< 90 mmHg
< 70%
< 70%
GOAL
> 70%
GDT
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F R
MAP
ScvO2
CRYSTALLOID
VASOACTIVE AGENT
PRBC to Hct 30 %
INOTROPE(S)
positive
negative
< 75 -85mmHg
> 75-85 mmHg
< 70%
< 70%
P(cv-a)CO2
> 70%
GDT
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Indices of Fluid
ResponsivenessCrystalloid
MAP
ScvO2
P(cv-a)CO2
Goals
achieced
Vasopressor
Weaning trial
Decrease O2Consumption
Vasoactive
agent(s)
Packed red blood
Cells to Hct > 30%
Inotrope(s)
positive
< 75-85 mmHg
> 75-85 mmHg
< 70%
< 70% > 70%> 70%
> 6
Yes
No
No
Refining the Toolsfor Early Goal-directed
Therapy
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Hemodynamic Management of LCOS
Third Step: Echocardiography
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Echocardiography
Predominent left
ventricular failure
Echocardiographic guided
pericardiocentesisor surgical
intervention
Massive mitral
regurgitation ?
Pulmonaryhypertension?
Pulmonary
vasodilators
RV ischaemia?
Reduce RV afterload, avoid
excess volume, use
inotropes if CO low
Mebazaa et al. I ntensive Care Med, 2004;30:185-96
LV dysfunction
No
Any CO
Monitoring,
ideally non
invasive
Optimise LV pre- and afterload,
Inotropes if required
Predominent right
ventricular failure
TAMPONADE ?
Yes
Globalheart
failure
PA catheter
No
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Hemodynamic Management of LCOS
Fourth Step: Pulmonary Artery Catheter
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LCOS
MAP < 65mmHg
Oliguria (
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O2uptake O2transport O2extraction O2utilisation
Optimize Oxygenation
-
Oxygen Delivery Oxygen Comsumption
ScvO2Cardiac Output Arterial Oxygen
Content
Stroke
VolumeHeart
RateOxgenation
SaO2
Hemoglobin
Hb
Preload After Load Contractiliy
Volume Vasopressors Inotropes Red Blood Cells+- +- + - +
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+Pemantauan Kardiovaskuler
CO (cardiac output) = SV (stroke volume) x HR (heart rate)
MAP (mean arterial pressure) = (Sistolik + 2x Diastolik)/ 3
Atau MAP= Diast+ (Sist-Diast)/3
Besar MAP orang dewasa normal : 60-70 mmHg.
PP ( pulse pressure) adalah selisih antara tekanan sistolik dan
diastolik.
PP = Sist- Diast, atau PP= 3x ( MAP-Diast)
Fungsi utama sistem Kardiovaskuler: menjamin kecukupan pasokan
dan kebutuhan sel-sel tubuh akan O2 dan membawa sisa metabolismeuntuk diekskresikan.
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+Saturasi Oksigen dan Oksigenasi
Jaringan ( SaO2dan DO
2)
Delivery Oxygen (DO2) adalah jumlah oksigen yang harus
tersedia bagi jaringan tubuh per menit.
DO2= CO x CaO2( oxygen content)
CaO2= (1,34 x Hb x SaO2) + (0,0031x PaO2)
DO2 = CO x (( 1,34 x Hb x SaO2) + ( 0,0031 x PaO2))
DO2 = delivery oxygen
CO = cardiac output
CaO2 = arterial oxygen content
PaO2 = tekanan parsial oksigen di dalam darah arteri
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FLUID RESUSCITATION AND
ORGAN PERFUSION
A. GENERAL
B. URINE PRODUCTION
C. ACID BASE BALANCE
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RESPONSE TO EARLY FLUID
RESUSCITATION
A. IMMEDIATE RESPONSE
B. TEMPORARY RESPONSE
C. MINIMALLY / NO RESPONSE
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RESPON TERHADAP TERAPI CAIRAN AWAL
Tanda Vital RESPON RESPON TANPACEPAT SEMENTARA RESPON
Dugaan Minimal Sedang, masih ada BeratKehilangan Darah (10 - 20%) (20 - 40 % ) ( > 40 % )
Kebutuhan Sedikit Banyak BanyakKristaloid
Kebutuhan Darah Sedikit Sedang - Banyak Segera
Persiapan Darah Type Specific dan Type Specific Emergency
CrossmatchOperasi Mungkin Sangat Mungkin Hampir Pasti
Kehadiran Dini Ahli Perlu Perlu PerluBedah
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Pulmonary edema
Myocardium edema
Mesenteric effects
Central nervous system effects
Fluid Resuscitation Complication
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CVP : 15 mmHg
Wedge pressure : 10 -12 mm Hg
Cardiac index : > 3 L/min/m2
Oxygen uptake (V02) : > 100 mL/min/m2
Blood lactate : 4 mmol/L
Base deficit :3 mmol/L
Urine : 0.5 1ml/kgbb/hr
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HEMODYNAMIC MONITORING DEVICES
ECG monitoring
Arterial Catheter
Pulmonary Arterial Catheter
Central Venous Catheter
Urinary Catheter
Thermodilution Continuous Cardiac Output
Transesophageal echocardiography (TEE)
Transthorasic echocardiography (TTE)
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Blood Pressure
Cardiac Output / CO Systemic VascularResistance / SVR
Stroke Volume / SV Heart Rate
Preload
Contractility Afterload
HYPOVOLEMI SHO K
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Blood
Pressure
Cardiac Output / CO SystemicVascular
Resistance / SVRStroke Volume / SV Heart Rate
Preload
Contractility
Afterload
CARDIOGENIC SHOCK
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Cardiac Output / CO
Systemic Vascular
Resistance / SVR
Stroke Volume / SV HeartRate
PreloadContractility
Afterload
CIRCULATORY SHOCK
Blood Pressure
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+ CO = HR x SV
Preload Contractility fterload
Vasoconstriction
Tissue Perfusion
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Hemodynamic profiles
of the shock states
Physiologicvariable
PreloadPump
functionAfterload
Tissueperfusion
Clinicalmeasurement
Pulmonarycapillarywedge
pressure
Cardiac outputSystemicvascular
resistance
Mixed venousoxygen
saturation
Hypovolemic Decreased Decreased Increased Decreased
Cardiogenic Increased Decreased Increased Decreased
Distributive Decreased Increased Decreased Increased
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+Hemodynamic Monitoring Parameters
1. Non Invasive Blood Pressure (BP)
Mean Arterial Pressure (MAP)
Heart Rate (HR)
Peripheral Oxygen Saturation (SpO2)
2. Invasive CVP (central venous pressure) PCWP (pulmonary catheter wedge pressure)
RVEDVI (right ventricle end diastolic volume index) LVSVI (left ventricle stroke volume index) LVP (left ventricle pressure) SvO2 (mixed vein oxygen saturation)
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Why SvO2?
22
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+Transport Oksigen
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+Transport Oksigen
venaarteri
CO CO tetap
Hb Hb tetap
SaO2 SvO2 berubah
Konsumsi O2 = CO x Hb x (SaO2 - SvO2) x 1.34
Konsu
msi
Teta
p
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Berapa harga normal SvO2?
Harga normal SvO2 adalah 68 - 77%
Nilai < 50% sudah mengkhawatirkan
Nilai
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+Oxygen Delivery Optimalisation
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+Oxygen Delivery Optimalisation
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+Oxygen Delivery Optimalisation
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+Oxygen Delivery Optimalisation
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+Oxygen Delivery Optimalisation
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Monitor
HemodinamikYang Mana ?
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+ASA Basic Intraoperative Monitoring
1. Standard I : Qualified anesthesia personel
2. Standard II:
Oxygenation : inspired gas, blood oxygenation, pulse
oxymetri
Ventilation : end-tidal CO2- capnograph, alarmdetecting disconnect from ventilator.
Circulation : ECG, every 5 min (arterial blood pressure,heart rate), pulse palpation, auscultatio of heart sound,intraarterial pressure
Body Temprature
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Arterial Line
+
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+ ARTERIAL LINE PURPOSESContinue BP monitoring
Early detected of HD
HD controlled
Blood Gas Analysis
+
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+Arterial Line Inserting Techniques
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Arterial Line Waveform
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CENTRAL VENOUS PRESSURE
Tekanan Vena Sentral
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entral Venous Pressure Monitoring
Better than Regular Manometer :
Continue monitoring of venous pressure.
Give us more reliable data of CVP
Pressure vs Volume
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Central Venous Pressure Waveform
3 positive waveforms : a, c dan v
2 negative waveforms : x, y
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CVP Inserting Technique
+
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+VCS/ VCI
A. Pulmonalis
Trikuspid
V. Pulmonalis
Mitral
Aorta
Atrium Kanan
Ventrikel Kanan
Paru-paru
Atrium Kiri
Ventrikel Kiri
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PAC PURPOSES
Pulmonary Arterial Pressure : S/ D/ M
Wedge Pressure (PCWP)
Cardiac Output / Cardiac Index (CO/CI)
Systemic Vascular Resistance (SVR/I)
and Pulmonary Vascular Resistance (PVR/I)
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PAC Waveform
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- Seorang pria 70 tahun, datang dengan keluhan tidak
bisa BAB, perut kembung, tidak dapat makan
sudah 3 hari.
- Pola napas terengah-engah, gelisah.
- Posisi setengah duduk
- Kulit pucat, dingin, akral dingin.
- Nadi: 130 x/menit. TD : 90/35 mmHg.
- Respirasi : 3540 x/mnt.
- Auskultasi : rales +, wheezing -.
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Titik Akhir Terapeutik
Capillary refill time < 2 detik
Ekstremitas hangat, kering dan kemerahan
Produksi urine > 1 ml/kg/jam
Status mental normal
Laktat menurun
Saturasi vena sentral > 70%
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Masalah-masalahdalam
pelaksanaan
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Saya tidak punyamonitoring ScvO2!
Gunakan pemeriksaan AGD serial
dari darah kateter vena sentral
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+Saya Tidak Punya Monitor
CVP/ Kateter TVS
Anda Sedang Berhadapan Dengan Masalah Serius
Segera rujuk ke rumah sakit terdekat
Lakukan
RESUSITASI CAIRAN SEMAKSIMAL MUNGKIN
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With an Excellent Teamwork WeDo Our Best to
Save the Patients Life
Terima Kasih