monitoring hemodynamic utk mahasiswa

7/26/2019 Monitoring Hemodynamic Utk Mahasiswa

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Monitoring Hemodynamic

Suparto

Anesthesia Department FK UKRIDA


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Objectives

Understands basic cardiopulmonary anatomy and

physiology

Determinates of cardiac output and their relationships to

each other

List indications for hemodynamic monitoring Demonstrates monitor system and set up


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Introduction

Hemodynamics, by definition, is the study of the motion

of blood through the body.

In simple clinical application this may include the

assessment of a patients heart rate, pulse quality, blood

pressure, capillary refill, skin color, skin temperature, and

other parameters.


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Introduction

Monitoring is never therapeutic

It must be integrated with patient assessment and clinicaljudgement to determine optimal care.

The goals are to recognize physiologic abnormalities and

to guide interventions to ensure adequate blood flow

and oxygen utilization for maintenance of cellular andorgan function


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Cardiopulmonary anatomy

and physiology


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Respiration 3 processes for adequate oxygenation and acid-base

balance Ventilation: Gas distribution into and out of the

pulmonary airways

Pulmonary perfusion: blood flow from the right side

of the heart, through the pulmonary circulation, andinto the left side of the heart

Diffusion: Gas movement from an area of greater to

lesser concentration through a semipermeable

membrane


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Cardiac system

Carries life sustaining

O2 and nutrients in the

blood to all cells of the

body

Removes metabolicwaste products in the

blood from the cells


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Mnemonic:

Some Believe In ActingBadly Before

Performing

Sinoatrial node

Bachmanns bundle

Internodal pathways

Atrioventricular node

Bundle of His

Bundle branches

Purkinje fibers


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Cardiac output

Heart Rate X Stroke

Volume Think of the heart as a

baloon

Stroke volume depends

on: Preload

Contractility

Afterload

Normal CO: 4-8 L/min

Normal Stroke Volume:50-100 ml/beat

Preload

Stretching of muscle fibers inthe ventricle .

Starlings law

Contractility

Ability of the myocardium to

contract

Influenced by preload

Afterload

Pressure that the ventricle

muscles must generate toovercome the higherpressure in the aorta


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Blood circulation

preloadcontractility - afterload


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Systemic vascular resistance

The resistance against

which the left ventriclemust pump to moveblood throughoutsystemic circulation.

Normal SVR: 7701,500dynes/sec/cm-5

Affected by:

Tone and diameter bloodvessel

Viscosity of the blood Resistance from the inner

lining of the blood vessels

SVR include:

Hypothermia Hypovolemia

Stress response

Syndrome of low CO

SVR include: Anaphylactic and

neurogenic shock

Anemia

vasodilation

MAP- CVP X 80

CO


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Effects of preload and afterload on the heart

Factor Increased preload

Possible cause

fluid volume

Vasoconstriction

Effects on heart

stroke volume

vent work

myocardial O2 req

Factor Decreased preload

Possible cause

Hypovolemia

Vasodilation

Effects on heart

stroke volume

vent work

myocardial O2 req (incompensatory range)


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Factor

Increased afterload

Possible cause

Hypovolemia

Vasoconstriction

Effects on heart

strokevolume

vent work

myocardial O2 req

Factor

Decreased afterload

Possible cause

Vasodilation

Effects on heart

stroke volume

vent work

myocardial O2 req


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Therapeutic Interventions

FluidsLow PreloadHighDiuretics,Venodilators

AtropineLow Heart Rate HighBlocker

VasopressorsLowAfterloadHighArterialdilator,ACE inhibitors

InotropicsLow Contractility


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Tujuan utama: Keselamatan pasien

Pemantauan adalah

Menginterpretasikan data yang ada untuk

membantu mengenali kelainan atau kondisi sistem

yang tidak diharapkan, yang sedang atau akan

terjadi (D. John Doyle, MD. Cleveland Clinic Foundation)


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Standar Perilaku untuk Pemantauan Anestesia

1. Anestesiologis harus hadir dan menjagakeselamatan pasien sepanjang prosedur anestesia

2. Semua peralatan harus diperiksa sebelum

digunakan

3. Alat pantau harus terpasang sejak sebelum induksi

hingga pulih dari anestesia

4. Selama prosedur, semua parameter harus dievaluasi

ulang5. Standar ini berlaku untuk semua tindakan anestesia

(MAC, Sedasi, Anestesia regional, Anestesia umum)


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6. Data yang diperoleh dari alat pantau harus terekam

dalam rekaman medis anestesia


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Standard Monitoring

ASA standard: Oxygenation, ventilation, circulation,

and temperature

Standard for General Anesthesia:

ASA standard (Pulse Oximetry, Capnography, minute

ventilation, ECG, BP, temp if necessary Standard for MAC and Regional Anesthesia:

Pulse Oximetry, RR, ECG, BP, temp if necessary

Additional: Arterial line, CVP, NMBA monitor Preparation before induction: Anesthesia Mechine,

ECG Monitor


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Clinical Signs and Symptoms of Perfusion Abnormalities

CNS: mental status changes, neurologic deficits

CVS: Chest pain, Shortness of breath, ECG

abnormalities, wall motion abnormalities on echo

Renal: UO, BUN, creatinine

Gastrointestinal: Abdominal pain, bowel sounds,

bleeding

Peripheral: cool limbs, poor capillary refill,diminished pulses.


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Cardiovascular system

O2 delivery CO = SV x HR

ECG

Determine HR

Detect and diagnose

dysrhytmia

Myocardial ischemia

Electrolyte imbalance

(hipo/hyperkalemia)


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Manual Blood Pressure

BP = CO x SVR

Measures systolic dandiastolic BP byauscultation of korotkoffsound, palpation

Cuff width should cover

2/3 of upper arm orthigh

Palpation:

A. radial (80mmHg)

A. femoral (60mmHg)A. Carotid (50mmHg)

Mean Arterial Pressure

MAP = sis + 2 Dias/ 3

Normal: 60-70mmHg


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Arterial BP indication

Tight BP control

Unstable patient

Arterial blood sampling

CVP M i i


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CVP Monitoring

The theory is that as fluid

volume in chamber

increases, so too will the

pressures measured in

the chamber.

This correlation is true

only in a limited sense

The key to remember is

that pressure is not equal

to volume.

The pressure is trended

as an indicator of volume

status, but must becorrelated to physical

assessment findings and

the patients history to

come to an accurateclinical impression.


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CVP Monitoring

Pressure at end diastole

reflects back to the

catheter

When connected to a

transducer or

manometer, the cathetermeasures CVP, a direct

reflection of right atrial

pressure and an indirect

measure of preload of theright ventricle.

Help us to

learn a patients cardiac

function,

evaluate venous return,

indirectly gauge how well the

heart is pumping,

access to fluid administration,

obtain blood samples.


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CVP Monitoring

Signs of inadequate preloadinclude

Poor skin turgor

Dry mucous membranes,

Low urine output

Tachycardia

Thirst

Weak pulses

Flat neck veins.

Signs of excess preload withadequatecardiac function:

Distended neck veins Crackles in the lungs

Bounding pulses

With poorcardiac function:

Crackles in the lungs, an S3 heart sound,

Low urine output,

Tachycardia,

Cold clammy skin with weak

pulses, Edema.


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CV and PA catheter insertion

Sterile procedure

Insertion site: Internal jugular vein

External jugular vein

Subclavian vein

Femoral vein


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Causes of Increased

pressure Right sided heart failure

Volume overload

Tricuspid valve stenosis

or insufficiency Constrictive pericarditis

Pulmonary hypertension

Cardiac tamponade

Right ventricularinfarction

Normal values

Normal mean pressureranges from 2-6 mmHg(3-8 cmH2O)

Causes of decreased

pressure Reduced circulating

blood volume


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Contraindication CVC insertion:

1. Tumor at RA

2. Tricuspid vegetation3. Post carotid endarterectomy ipsilateral

4. Coagulopathy


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Cm H2O : 1.36 = mmHg mmHg X 1.36 = cm H2O


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Minimizing complications of CVP monitoring

Infection

Sign & symptoms: Local rash, fever, leukocytosis

Causes: lack of sterile technique, immunosuppression

Interventions: Re-dress the site using sterile

technique, possibly use antibiotic ointment loccaly,catheter may be removed then culture its tip

Prevention: maintain sterile technique, observe

dressing-change protocols, change a wet or soiled

dressing immediately


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Penumothorax, hemothorax

Sign & symptoms: decreased breath sounds, abnormalchest X-ray

Causes: Repeated or long term use of same vein, large

blood vessel puncture

Interventions: set up and assist with chest tubeinsertion, administer oxygen

Prevention: patients position during insertion,

immobilized patient, ultrasound guided


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Air embolism

Sign & symptoms: respiratory distress, loss ofconsciousness, unequal breath sounds

Causes: intake of air into the CV system during

catheter insertion

Intervention: turn the patient on his left side, headdown, so that air can enter the right atrium and

maintain this position for 20-30 min, life support

Prevention: purge all air from the tubing before

hookup


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Thrombosis

Sign & symptoms: ipsilateral swelling of arm, neck and

face, pain along vein, dyspnea, cyanosis

Causes: Sluggish flow rate, hypercoagulable state of

patient

Interventions: possibly remove the catheter, apply warm,

wet compresses locally, dont use the limb on the affectedside for venipuncture or blood measurement, life support

Prevention: Maintain a steady flow rate with the infusion

pump, or flush the catheter at regular intervals


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Removal of Central Venous Catheter

Obtain clean gloves and sterile gloves, sterile gauze

squares, and materials for a dressing Place the patient flat to minimize the risk of air aspiration

Remove the dressing carefully and cleanse the site with

sterile saline if needed. If sutures are in place, remove

them carefully.


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Instruct the patient to take a deep breath and hold it. If thepatient is unable to perform a breath hold, time the removalof the catheter to coincide with a period of positive

intrathoracic pressure (In spontaneously this will occur duringexhalation. In mechanically ventilated positive intrathoracicpressure occurs when the ventilator delivers a breath)

While the patient holds his/her breath, remove the cathetersmoothly. Once the catheter has been removed, applymoderate pressure with sterile gauze and tell the patient toresume breathing.

After a minute or two, gently release the pressure.

If there is no bleeding or swelling, apply a sterile dressing to

the site


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PA catheter insertion

Swan-Ganz catheter

PAP and PAWP provideinformation about LV

function


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Pulmonary Artery Pressure (PA Pressure):Blood pressure in the pulmonary artery.Increased pulmonary artery pressure may

indicate: a left-to-right cardiac shunt,

pulmonary artery hypertension,

COPD or emphysema,

pulmonary embolus, pulmonary edema

left ventricular failure.


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Mengetahui fungsi jantung kiri

Mengetahui adanya hipertensi pulmonal

Mengukur cardiac ouput, systemic vascular

resistance (SVR), pulmonary vascular

resistance (PVR), pulmonary capillary wedgepressure (PCWP, PAOP)

Normal PAP systolic15-30 mmHg and diastolic

5-12 mmHg. PAOP 5-12 mmHg


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Pulmonary Capillary Wedge Pressure (PCWP or

PAWP):PCWP pressures are used to approximate

LVEDP (left ventricular end diastolic pressure).Reflecting left arterial pressure and left

ventricular preload

High PCWP may indicate left ventricle failure, increase

in end diastolic volume, decrease compliance, mitral

valve pathology, cardiac insufficiency, cardiac

compression post hemorrhage.

Low PCWP can be due to decrease end diastolicvolume, increase in compliance


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Respiratory System

Pulse Oxymetri

Normal: 96%-99%

88% acceptable for

patient with lung disease

High pulse ox indicates:

O2 available in the lung,

taken up in the blood,

delivered to distal

tissues.

Low pulse ox Problem along the above

pathway or due to error


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Capnography

Ventilation Assessment

Confirmation

endotracheal intubation

Normal: PetCO2 is

2-5mmHg lower than

arterial PCO2, so typicalrange 30-40 mmHg

under General

anesthesia


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Suhu tubuh

normal 365-375 C

Suhu nasofaringeal mendekati suhu inti

Peningkatan menandakan meningkatnya

metabolisme sel

Suhu produksi CO2

Produksi Urine

Dewasa: 0.5-1cc/Kg/jam

Pediatrik: 1-2cc/Kg/jam


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Pemantauan sistem saraf

Bispectral Index, utk

mengetahui kedalaman

anesthesia dari

mendeteksi dan rekaman

gelombang

elektroensefalogram

(EEG)

Tingkat anestesi nilainya

40-60 (100 artinya sadar

penuh)


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Train of Four

Mengukur tingkat

blokade oleh

pelumpuh otot memberikan 4

stimulus berturutan

dengan frekwensi 2

Hz selama 2 detik

monitoring hemodynamic utk mahasiswa

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