Invasive Hemodynamic Monitoring my seminar2.ppt

INVASIVE HEMODYNAMIC
MONITORING
By
Gowtham Krishna J.
Resident III rd year
PG Guide :
Dr. Nimisha Brahmbhatt
Associate Professor
Department of Anaesthesiology
Medical College , Baroda
1

 All science is measurement
- Helmholtz
2

Hemodynamic monitoring truth
 No monitoring device, no matter how simple or
complex, invasive or non-invasive, inaccurate or
precise will improve outcome. Unless coupled to a
treatment, which itself improves outcome
Pinsky & Payen. Functional Hemodynamic Monitoring, Springer, 2004
3

Definition
Measuring and monitoring the factors that influence the force and flow of
blood.
Hemodynamic monitoring includes pressure measurement in the pulmonary
artery, central venous system, and arterial system and the measurement of
cardiac output. *
Purpose (Why to monitor)
•To assure the adequacy of perfusion.
•Early detection of inadequacy of perfusion.
•To titrate therapy to specific hemodynamic end point.
•To differentiate among various organ system dysfunctions.
• The closer the resuscitation is to the insult, the greater the benefit.
• Preoptimization for high-risk surgery patients treated in the operating
room
*-Friesinger GC, Williams SV, Achord JL, Klocke FJ, Leonard JJ, Popp RL, Reynolds WA, Ryan TJ, Schlant RC,
Winters WL. Clinical competence in hemodynamic monitoring. Circulation. 1990 Jun 1;81(6):2036-40.
HEMODYNAMIC MONITORING
4

INDICATIONS-HEMODYNAMIC MONITORING
 To establish or assist in establishing a "specific" diagnosis
 To help direct management in medical patients in whom knowledge of
intravascular pressures and flow will alter treatment when clinical
estimates (e.g., by bedside examination, chest x-ray, or fluid challenge) are
not reliable.
 To assist management of surgical patients. (Careful, systematic assessment
of risk in cardiac patients with particular attention to recent or recurrent
ischemia, ventricular function, and arrhythmias is important. Problems in fluid
and electrolyte management are important considerations in many of these
patients.)
 To assses the effectiveness of intervention.
Freisinger et al JAMA 1990; 15:1460
5

6
GEF – Global EF
CFI – Cardiac function index
dPmx – LV contractility
ELWI-extravascular lung water
index
PVPI-pulmonary vascular
permeability index

Noninvasive Hemodynamic
Monitoring methods:
•Clinical Assessment
• Pulse Rate
• Blood Pressure
• Capillary Refill time
• Pulse oximetery
• Mentation
• UOP-Normal is 1ml/kg/h
METHODS OF HEMODYNAMIC
MONITORING
Invasive Hemodynamic Monitoring
methods:
• Pulmonary Artery Catheter
• Central Venous Line
• Arterial Catheter
Minimally invasive measurements
• Transpulmonary thermpodilution
• Lithium dilution CO monitoring
• Esophageal doppler
• Bioimpedance CO monitoring
7

INVASIVE BLOOD PRESSURE MONITORING
8

Indications
 Continuous, real time ,beat-to-beat blood pressure monitoring.
 Planned pharmacological or mechanical cardiovascular manipulation.
 Repeated blood sampling
 Failure of indirect arterial blood pressure measurement
 Supplementary diagnostic information from the arterial waveform
Advantages of IBP measurement
 Continuous blood pressure recording and possible diagnostic information
 Accurate blood pressure recording even when patients are profoundly
hypotensive vs NIBP which is difficult or inaccurate.
 Real time Visual Display
Disadvantages of IBP measurement
 Potential complications
 Skilled technique
 Expensive 9

CHOICE OF ARTERIAL SITE
 The radial artery has low complication rates compared with other
sites.
 It is a superficial artery which aids insertion, and also makes it
compressible for haemostasis
 Alternative sites
 ulnar,
 brachial, axillary (longer catheters)
 Dorsalis pedis, posterial tibial, superficial temporal
 femoral arteries(more closer to aortic pressure)
 With cental arteries the risk of distal ischemia decreases but chances of
atherosclerotic plaque embolisation is increased with initial vessel
manipulation.
 With pediatric patients more pedal arteries are preferred.
10

The
Palmar
Arch
Allen Test
• The idea here is to figure out if the
ulnar artery will supply the hand with
enough blood, if the radial artery is
blocked with an a-line.
•The test is performed by asking the patient to
clench their hand. The ulnar and radial arteries
are occluded with digital pressure.
•The hand is unclenched and pressure over the
ulnar artery is released. If there is good collateral
perfusion, the palm should flush in less than 6
seconds.
 The diagnostic accuracy of the modified Allen
test with a 5 second threshold is only 80% with
76% sensitivity and 82% specificity.
 Unfortunately the use of pulse oximetry ,
doppler, plethysmography as adjuncts to visual
inspection of the palm does not seem to
improve its accuracy
11

EQUIPMENT
Arterial cannula
 Made from polytetrafluoroethylene (‘Teflon’) to minimize the risk of
clot formation
 20G (pink) cannula - adult patients
22G (blue)- paediatrics
24G (yellow) - neonates and small babies
 Larger gauge cannulae increase the risk of thrombosis, smaller
cannulae cause damping of the signal.
 The cannula is connected to an arterial giving set.
13

 Arterial set.
 Specialized plastic tubing, short and stiff to reduce resonance, connected to a 500 ml bag of saline.
 Saline bag
-500 ml 0.9% saline( pressurized to 300 mmHg using a pressure bag, i.e. a pressure higher
than arterial systolic pressure to prevent backflow from the cannula into the giving set. )
-The arterial set and pressurized saline bag with 500units Heparin incorporate a continuous slow
flushing system of 3–4 ml per hour to keep the line free from clots.
-The arterial set and arterial line should be free from air bubbles.
- The line is attached to a transducer.Do not allow the saline bag to empty
 Transducer, amplifier and electrical recording equipment.
 An arm board or towel roll
 Opsite or Tegaderm cover dressing/Dynaplast
 Local anesthetic (1% or 2% lidocaine ,lidocaine cream)
 Suture material for femoral arterial line placement (2.0 silk)
 Scissors
 Monitor cable for transducing arterial waveform.
 Benzoin solution
14

POSITIONING
For the radial artery, the arm is
restrained, palm up, with an
armboard to hold the wrist
dorsiflexed
INSERTION TECHNIQUES
.
.
.
.
.
.
Direct cannulation
Transfixation – puncture the front and back walls
Seldinger technique
Doppler assisted technique
Two dimentional USG assisted method
Surgical cutdown
15

Step 1:
Enter the skin at approximately a 45 degree angle
Once the needle has been introduced through the skin, begin
applying suction or negative pressure by pulling back on the
plunger of the syringe .
Once blood starts to enter into the syringe, stop advancing
the needle .Hold or stabilize the needle in place with your non-
dominant hand and then remove the syringe. Using the same
hand that is stabilizing the needle in place, place the thumb
over the hub to prevent both blood loss as well as prevent air
from entering into the needle and creating an air embolism if
negative pressure is created.
Step 2:
While stabilizing the needle in place, insert the guide wire into
the hub of the needle and advance the guide wire. The
length of advancement of the guide wire is based on the
anatomical location and type of IV line being placed.
Step 3:
Once the guide wire has been advanced to an appropriate
length, continue to hold onto the guide wire and retract the
needle from the puncture site.
Step 4:
If placing a larger catheter or Cordis, enlargement of the
insertion site is needed using a #11 blade scalpel (Used in case
of a central line)
Step 5:
While still holding onto the guide wire, place the distal aspect
of the Arterial/Venous catheter over the tip of the guide wire
and advance the catheter until the guide wire comes out of
the catheter and then advance the catheter into the vessel
while still holding onto the guide wire.
Step 6:
Once the catheter is in the vessel, gently pull the guide wire
out.
Check placement of the IV catheter by placing a syringe to
the end of the catheter and pulling back on the plunger to
verify blood return and then flush all ports with normal saline.
Secure the IV catheter in place.

Seldinger technique
Wire through needle
16

A, Supine/prone. the intersection of 2 reference lines: first, an imaginary line from the
fourth intercostal space at the point where the space joins the sternum, drawn out to
the side of the body; second, a line drawn midway between the anterior and posterior
surfaces of the chest.
B, Supine with the head of the bed elevated. The phlebostatic level is a horizontal line
through the phlebostatic axis.
C, 30° lateral position. The reference point is one-half the distance from the left sternal
border to the surface of the bed.
D, 90° lateral position. In the 90° right lateral position, the reference point is the
intersection of the fourth intercostal space at the midsternum. In the 90° left lateral
position, the reference point is the intersection of the fourth intercostal space at the left
parasternal border.
18

•Leveling
•Leveling matches the reference point to a specific point in the body.
• Critical when physiologic ranges are narrow(cardiac filling pressures).
•Arterial pressure transducer must be placed at the best level to estimate the
aortic root pressure since the midchest position often overestimates cardiac
filling pressures. 5 cm posterior to the sternal border is the preferred
landmark.
•Raising the height of the bed relative to the transducer causes overestimation
of blood pressure and vice versa on lowering the patient
19

Zeroing
 The air fluid interface at the level of the stopcock is the zero pressure locus.
 The appropriate stopcock must be opened and the transducer exposed to the
atmosphere after which the zero command is executed.(Varies according to
manufacturer)
 If a significant or unexpected change in pressure occurs zeroing can be done
by opening the stopcock to ensure the value is zero at bedside.
20

TRANSDUCER-HOW IT WORKS ???
Mechanism of action
 A transducer is a device that reads
the fluctuations in pressure – it
doesn’t matter if it’s arterial, or
central venous, or PA
 The column of saline in the arterial
set transmits the pressure changes to
the diaphragm in the transducer
 The transducer reads the changing
pressure, and changes it into an
electrical signal that goes up and
down as the pressure does which is
displayed as an arterial waveform
 The transducer connects to the
bedside monitor with a cable, and the
wave shows up on the screen, going
from left to right 21

Pressure measurement - Principles
 A catheter introduced into a vein or artery and made vertical will show the mass of the blood
rise in the catheter.
 But it will have to overcome the gravitational pressure and frictional forces. Hence the
measured pressure is always lower than the actual pressure.
 The pressure hence exerted is calculated as height*density*gravitational constant.
Dynamics Pressure measurement
 Fluctuating driving pressure(ABP) on diaphragm of transducer-Mass spring Harmonic
oscillator(Mass-weight of the fluid, Spring – Elasticity of tubing and transducer) – Figure
 A pressure transducer changes the electrical resistance or capacitance in response to changes
in pressure in a solid state device.(Wheatstone Bridge)
 Natural/Resonant Frquency - Rubber band with weight model(Stiffer bands and smaller
weights – Stiffer tubings of shorter length is required).Catheter tubing systems are
generally underdamped with an acceptable frequency of >12 Hz.
 Natural frquency of most systems – 10-12 Hz but our heart has 1-2 Hz(60-120 beats/min).
 Arterial wave form – Fourier series/Whip
22

FORM
 The arterial pressure wave consists of a fundamental wave and a series of harmonic
waves(smaller waves whose frequecies are multiples of fundamental frequencies).
 Process of analysing complex waveforms in terms of its constituent sine waves(propagated
and reflected) is Fourier analysis.
 As such it is a mathematical recreation of the original complex pressure wave created by
stroke volume ejection.
 As a general rule 6-10 harmonics(waveforms)are required to give a distortion free
reproductions of most arterial waveforms. Hence accurate arterial blood pressure
measurement in a patient with a pulse rate of 120/min(2Hz or 2 cycles per second)requires a
monitoring system dynamic response of 12-20 Hz(10 waveforms*2Hz).Dynamic response
increases with increased heart rate and systolic upstroke.
24

TYPICAL ARTERIAL
WAVEFORM
:
 The highest point - systolic
pressure,
-the lowest is the diastolic.
Everybody see the little notch
on the diastolic downslope? –
there’s one in each beat.
 A little after the beginning of
diastole – the start of the
downward wave – the aortic
valve flips closed, generating
a little back-pressure bump:
called the “dicrotic notch”..
26

FAST FLUSH TEST/
SQUARE WAVE TEST
 To asses dynamic
response of the system
and signal distortion
•Method:
•Activating the fast flush
•Observe arterial waveform
square off at the top and
then drop to zero as the
flush is released.
•Normal- Immediate
downstroke with just 1 or
2 oscillations within
0.12 seconds and
rapid return to baseline.
27

Underdamping Overdamping
•long tubing
•overly stiff, non-compliant tubing
•increased vascular resistance
•reverberations in tubing causing
harmonics that distort the trace (i.e. high
systolic and low diastolic)
•non-fully opened stopcock valve
•air bubbles
•overly compliant, distensible tubing
•catheter kinks
•clots
•injection ports
•low flush bag pressure or no fluid in the
flush bag
•Improper scaling
•Severe hypotension if everything else is
ruled out
SBP &DBP
MAP - N
DBP
31

32
Optimal damping coefficient range – 0.45-0.6
Optimal natural frequency – 12-20 Hz

ARTERIAL PRESSURE
GRADIENT
 Procedure and position – Gradients change according to
procedure(ex.clamp on descending thoracic aorta)and
position(ex.regional arterial compression,surgical retraction)
 Condition - Patients in septic shock and in vasopressor
infusion therapy have femoral pressures 50mmHg more than
that radial artery pressure
 Temperature – Hypothermia causes increase in radial artery
pressure whereas increased temperature reverses it. 34

ARTERIAL BLOOD PRESSURE GRADIENTS
35

INTRAVASCULAR VOLUME
RESPONSIVENESS
PPV (Early inspiration)
Increases LV preload Increases Lung volume
Increases cardiac output
Decreases Systemic venous return
Decreases RV preload
Increased RV afterload(LV inc.)
•During early expiration the situation is reversed.
•This cyclic variation in systemic arterial pressure is known as systolic
pressure variation(SPV)
36

SYSTOLIC PRESSURE VARIATION
• Systolic pressure variation-measuring the increase( ^Up) or decrease(^ Down)
relative to end expiratory, apnoeic baseline pressure.
• Inspiratory
• Expiratory
• In a mechanically ventilated patient normal SPV is 7-10 mmHg with ^Up being
2-4 mmHg and ^Down being 5-6 mmHg.
• Hypovolemia causes a dramatic increase in the SPV particularly the down
component. The Down component is a better predictor than wedge
pressure(Coriat et al.) and LV end diastolic cross sectional area(Echo/Preload).
(Tavernier et al.- Both) of hypovolemia.
• More accurate to say that patients identified by the SPV changes have a Residual
preload reserve.
• Residual preload reserve is a physiological state in which intravascular volume
expansion or fluid challenge shifts the patient upward on the Frank Starling Curve
resulting in increased CO and SV as long as the SVR is unchanged.
• Another dynamic marker of preload reserve is Pulse pressure variation.PPV should
not exceed 13-17%.
• Another method is Stroke volume variation(SVV)-Normal is 10-13%. Greater
variability predicts volume responsiveness.
37

HOW TO REMOVE THE LINE?
• Disconnect the cable from the monitor which will automatically turn off the
alarms.
• Take out the sutures in the usual way with a fresh sterile kit.
• Have a gauze piece ready, pull the catheter, and manually compress the site
for at least 3 to 5 minutes.
• Make sure the patient’s hand is still perfused.
• Check for hematoma or bleeding, put a compression dressing on the site (not
too tight!), which you can then take off after about an hour.
• Recheck the site hourly for a few hours afterwards – a hematoma could still
form, and since there isn’t a whole lot of room in a wrist, you’d definitely want
to know!
39

COMPLICATIONS
 Haemorrhage may occur if there are leaks in the system. Connections must be tightly secured and
the giving set and line closely observed..
 Emboli. Air or thrombo emboli may occur. Care should be taken to aspirate air bubbles
 Accidental drug injection may cause severe, irreversible damage to the hand.
-No drugs should be injected via an arterial line
 Arterial vasospasm
 Partial occlusion due to large cannula width, multiple attempts at insertion and long duration of use
 Permanent total occlusion
 Sepsis or bacteraemia secondary to infected radial arterial lines is very rare (0.13%);
-local infection is more common.
-if the area looks inflamed the line site should be changed.
 Distal ischemia , pseudoaneurysm, A-V fistula,Peripheral neuropathy
40

• Concentration of a
drug into the tissues
served by the
cannulated artery can
result in cell death
• Skin necrosis, severe
gangrene, limb
ischemia, amputation
& permanent
disabilities
41

CENTRAL VENOUS PRESSURE
The normal value for CVP
ranges from 8-12cm of
H2O(recorded at midpoint
of x descent.)
Non invasive assessment of
central venous pressure
43

INDICATIONS
• CVP Monitoring
• Pulmonary artery catheterisation and monitoring
• Transvenous cardiac pacing
• Temporary hemodialysis
• Drug administration
˗ Concentrated vasoactive drugs
˗ Hyperalimentation
˗ Chemotherapy
˗ Agents irritating peripheral veins
˗ Prolonged antibiotic therapy
• Rapid infusion (Trauma/Major Surgery)
• Aspiration of air emboli
• Inadequate peripheral venous access
• Sampling site for repeated blood testing 44

CHOOSING THE CATHETER
 According to the purpose of catheterization(CVP monitoring/therapeutic/Short or
long term use).
 Most commonly used catheter is a 7Fr ,20 cm multiport catheter that allows
simultaneous CVP monitoring and infusion of drugs.
 Rapid intravascular infusion is better done with large bore peripheral lines
compared to a central line as individual lumina are narrower increaser the
resistance to flow
 An alternative method is to employ a large introducer sheath with one or two
integrated ports for multiple drug infusions combined with a single lumen
catheter inserted through the homeostasis valve for continuous CVP monitoring.
This method also helps in rapid placement of pacing wire and pulmonary artery
catheter should the need arise.
46

TYPES OF CVP CATHETERS
 Non tunneled catheters
 Tunneled catheters
 Peripherally inserted central catheters
 Implanted ports
 Single and multi lumen are available in all catheter types.
 Every lumen must be considered as a seperate catheter.
 Made of silicone or polyurethane
 Might be coated with
 Antimicrobial/antiseptic coating/Heparin coated
 Radioopaque to confirm tip placement
 Catheters may be
 Open ended –
 Open at the distal tip
 Requires clamping before entry into the system
 Clamps are built into the catheter
 Requires periodic flushing
 Close ended –
 Valve at the tip of the catheter(Groshong) or at the hub(PAS-V - automatically close
and remain closed when not in use and automatically open for infusion or sampling.)
 Clamping is not required as the valve is closed except during aspiration and infusion.
47

Non tunneled catheter Tunneled catheter
•Also called subclavian,
percutaneous, acute care or short term
catheters.
•Used for days or weeks.
•For all types of IV therapy to draw
blood and CVP monitoring.
•May be placed bedside or if
necessary in emergency without
sedation
•Designed for long term and frequent
venous access.
•Provide more reliable IV access.
•Used for extended source of
antibiotics,chemotherapy, parenteral
nutrition,dialysis.
•Surgically inserted.
48

PERIPHERALLY INSERTED CENTRAL CATHETERS
 Often used when a catheter is needed less than 6 months or when accessss to
jugular and subclavian vein is unavailable.
 Can be used for most IV therapies and blood draws in different care settings for
many types of patients.
 May be placed beside or in an outpatient setting.
49

IMPLANTED PORTS
 Consists of two attached parts : the catheter and the portal body with
reservoir
 Long term dwell capacity requiring little maintenance when not in use
 Used for cylindrically infused therapies such as chemotherapy
 Blood draws may be done through the port surgically inserted
50

Choosing the insertion site
(Pressure monitoring vs Drug or fluid administration)
 Most commonly preferred site by the anaesthetist is – Right internal jugular vein because it is
 Consistent
 Predictable anatomic location of IJV
 Readily identifiable and palpable surface landmarks
 Short straight course into the SVC
 Left internal Jugular Vein(less preferred)
 Cupola of pleura is higher
 Thoracic duct injury(enters at junction of left IJV and subclavian veins.
 Left IJV is smaller than right and considerable overlap of adjacent carotid artery.
 Must enter the innominate(brachiocephalic) vein and enter SVC perpendicularly
impinging on the right lateral wall of SVC increasing chances of vascular injury.
 Less experience of operators.
 Subclavian vein
 Common among surgeons and physicians
 Less infection than femoral site. Conveneient for cervical collar,increased patient comfort
for long term therapy. 51

 External jugular vein
 Technically challenging(superficial)
 No risk of pneumothorax or arterial puncture
 Modified seldinger technique preferred with a J tip guidewire as EJV course is torturous
 Femoral vein
 Useful in emergenies(CPR)
 No risk of pneumothorax
 Longer catheters are used(40 cm-In IVC)or shorter catheters (15-20 cm –in Common iliac) used.
 Increased risk of thromboembolism,intraabdominal and retroperitoneal hemorrhage,difficulty to
ambulate.
 Axillary vein
 Useful in burns but not able to validate superiority over conventional CVC.
 Other peripheral lines used
 Basillic vein: More commonly used as more linear course
 Cephalic vein
 All PICC have the risk of advancing into the heart as the arm is abducted causing risk of cardiac
perforation and arrythmias.
o Severe bleeding diathesis/Emphysema/compromised pneumthorax - – Internal or external Jugular
vein
o Transvenous cardiac pacing – Right internal jugular vein
o Trauma with neck immobilised – Femoral or Subclavian
52

CHOOSING THE CENTRAL VENOUS
CANNULATION METHOD
 Landmark technique
 Ultrasound guided Central venous cannulation
(Agency of healthcare research and Quality has listed the use of real time USG guidance as one of
the 11 practices to improve healthcare.)
 Uses a 7.5-10 Mhz transducer
 Trendlenberg position
 Site prepped and draped
53

LANDMARK METHOD
 Place the guide wire, dilator, catheter, and scalpel on the sterile drape for easy
reach when needed.
 Have the patient turn head in the opposite direction
 Using the 18 ga finder needle and a small syringe, enter the skin at the top of the
jugular triangle. In obese patients where the landmarks are not discernable, a
reasonable rule of thumb is to go three finger breadths lateral from the tracheal
midline, and three finger breadths up from the clavicle.
 Palpate for the carotid impulse an make sure you are lateral to this.
 Insert the needle at 30 degrees and aim for the ipsilateral nipple.
54

Invasive Hemodynamic Monitoring my seminar2.ppt

COMPLICATIONS
 Mechanical
 Vascular injury
 Arterial
 Venous
 Cardiac tamponade
 Respiratory compromise
 Airway compression from hematoma
 Pneumothorax
 Nerve injury
 Arrythmias
 Thromboembolic
 Venous thrombosis
 Pulmonary embolism
 Arterial thrombosis and embolism
 Catheter or guidewire embolism
 Infectious
 Insertion site infection
 Catheter infection
 Bloodstream infection
 Endocarditis
 Misinterpretation of data
 Misuse of equipment 58

• Obtain verbal consent
• Position patient supine or semi recumbent to 30-45 degree
elevation
• Prime pressure tubing with Sodium chloride 0.9%, close connection
• Check flushing mechanism
• Apply the pressure bag and inflate to 300mmHg
• Connect to monitor transducer cable
• Calibrate zero and level the transducer to the phlebostatic axis
TRANSDUCER METHOD
61

PRECAUTIONS WHILE HANDLING
CENTRAL LINE
• Hand hygiene before and after any manipulation
of vascular access devices or catheter
• An aseptic technique
• Standard precautions.
• Sterile disposable transducers, pressure tubing
and line are replaced at 96 hour intervals
62

NORMAL CVP WAVEFORM
‘c’ wave has a slightly complex origin.It
represents both arterial and venouas
origin.It is also due to early pressure
transmission of pressure from the carotid
artery.Hence it is called the carotid
impact wave.
63

 ‘x’ descent can be divided into two portions – x and x’ corresponding to segments before and
after the c wave.
 ‘h’ wave is not normally seen unless the heart rate is slow and the venous pressure is increased
 The CVP if compared with the arterial pressure trace becomes confusing as the arterial
pressure upstroke occurs 200 msec after the ECG R wave.(Ventricular depolarisation-60 msec,
isovolumetric LV contraction-60 msec, transmission of aortic pressure to radial artery 50msec,
transmission from radial artery to fluid filled transducer 10 msec.
 Short PR interval – ac wave
 Tachycardia – av wave(decreases length of diastole and y descent)
 Bradycardia – x & x’ , h wave.
 Normal CVP measured at end expiration(pleural pressure is close to atmospheric pressure) in
ventilatory cycle and at the end of ‘c’ wave (before the onset of ventricular systole) in the
cardiac cycle
64

Onset of inspiration causes a
reduction in intrathoracic
pressure causing a reduction in
CVP.CVP must be measured at
end expiration – 8mmHg
Onset of inspiration
increases intrathoracic
pressure.CVP still
measured at end expiration
– 14 mmHg
66

 Conditions reducing right ventricular compliance
like right ventricular ischemia, pulmonary
hypertension, pulmonic valve stenosis, may
produce prominent end diastolic a wave but may
not attenuate the y descent.
 Traditionally the CVP was believed to correlate
with the circulating blood volume.
 However various studies have proved poor
corelation between them as well as the inability
of static CVP value to predict the hemodynamic
response to fluid challenge.
69

The double lumen balloon flotation catheter and its placement at the
bedside without fluoroscopy and by monitoring intracardiac pressures.
70

NS
• Diagnostic:
– Differentiation among causes of shock
– Differentiation between mechanisms of pulmonary edema
– Evaluation of pulmonary hypertension
– Diagnosis of pericardial tamponade
– Diagnosis of right to left intracardiac shunts
– Unexplained dyspnea
• Therapeutic:
– Management of perioperative patients with unstable cardiac status
– Management of complicated myocardial infarction
– Management of patients following cardiac surgery/high risk surgery
– Management of severe preecclampsia
– Guide to pharmacologic therapy
– Burns/ Renal Failure/ Heart failure/Sepsis/ Decompensated cirrhosis
– Assess response to pulmonary hypertension specific therapy
72

• Relative:
 Coagulopathy
 Thrombocytopenia
 Electrolyte disturbances
(K/Mg/Na/Ca)
 Severe Pulmonary HTN
CONTRAINDICATI
ONS
• Absolute:
 Infection at insertion site
 Presence of RV assist
device
 Insertion during CPB
 Lack of consent
73

PREPARATI
ON
• Patient has to be monitored with continuous ECG
throughout the procedure, in supine position regardless
of the approach
• Aseptic precautions must be employed
• Cautions should be taken while cannulating via IJV/
Subclavian vein
74

• Equipments:
– 2% chlorhexidine skin preparation solution
– Sterile gown, gloves, face shield and cap
– Sterile gauze pads
– 1% lidocaine -5 cc
– Seeker needle 23G
– Introducer needle  18G
– J-tip guidewire
– Transduction tubing
– Sterile catheter flush solution
– Sheath
– Pulonary catheter
– Sterile sleeve for catheter
– 2-0 silk suture
– Sterile dressing 75

PULMONARY ARTERY
CATHETERISATION
 The standard PAC has a 7.0-9.0 Fr circumference, is
110 cm long and marked at 10 cm intervals and
contains four internal lumina.
 The distal port at the catheter tip is used for
pulmonary arterial pressure monitoring, the second
port 30 cm proximal is used for CVP monitoring.
 The third lumen leads to baloon near the tip and
the fourth houses wires for temperature thermistor
the end of which lies just proximal to the balloon.
 PAC s can be inserted from any central venous site
but right IJV most preferred.
76

E
1. Aseptic precautions undertaken
2. Local infiltration done
3. Check balloon integrity by inflating with 1.5ml of air
4. Check lumens patency by flushing with saline 0.9%
5. Cover catheter with sterile sleeve provided
6. Cannulate vein with Seldinger technique connected to the transducer..
7. Place sheath
8. Pass catheter through sheath(upto 20 cm) with the curvature of the PAC
oriented to point just leftward of the sagital plane(11 ‘o’ clock position) as
viewed from the patients head,to facilitate travel through the anteromedially
located tricuspid valve.
9. Inflate balloon at right atrium and advance it through the tricuspid valve into
the right ventricle,pulmonic valve ,pulmonary artery and finally to the wedge
position.
10. The progress of the catheter through right atrium and ventricle into
pulmonary artery and wedge position can be monitored by changes in pressure
trace
11. After acquiring wedge pressure deflate balloon
78

ADDITIONAL GUIDELINES FOR PAC
INSERTION
o When advancing catheter- always inflate tip
o When withdrawing catheter- always deflate
o Once in pulmonary artery - NEVER INFLATE AGAINST RESISTANCE
- RISK OF PULMONARY ARTERY RUPTURE.
o Right atrium – 20-25 cm add 5-10 for Left IJV,EJV & R EJV.
o Right ventricle – 30-35cm 15 cm for femoral veins.
o Pulmonary artery – 40-45 cm 30-35 cm for antecubital veins.
o Pulmonary wedge – 45-55 cm
o The tip of the PAC should be within 2 cm of the cardiac silhoutte in a AP
chest xray.
82

ANAMOLIES
 If repeated attempts fail then abnormal venous
anatomy has to be considered – most common is Left
Superior vena cava(LSVC)[0.2% general population;9%
in congenital heart disease]
 The persistent LSVC descends into the left
mediastinum and empties into a dilated coronary
sinus.
 Absent SVC where the right IJV joins the persistent
left SVC by an inominate vein
 A rare form of ASD called unroofed coronary sinus
where PAC enters left atrium and systemic circulation.
83

ADDITIONAL POINTS
 The air filled balloon floats in the non dependent portion.
 Positioning the patient in the head down position will aid in
floatation past the tricuspid valve
 Tilting the patient onto right side and head up will
encourage floatation out of right ventricle.
 Deep inspiration during spontaneous ventilation increases
venous return may facilitate catheter floatation in patient
with low cardiac output
 Catheter may be floated to proper position when stiffened by
injecting ice cold solution through the distal lumen.
 A catheter that is difficult to place always becomes easier
once the hemodynamics of the patient improves. 84

COMPLICATIONS
 Catheterisation.
 Arrythmias,ventricular fibrillation
 RBBB,Complete heart block
 Catheter residence.
 Mechanical ,catheter knots
 Thromboembolism
 Pulmonary infarction
 Infection,Endocarditis
 Endocardial damage,cardiac valve injury
 Pulmonary artery rupture
 Pulmonary artery pseudoaneurysm
 Misinterpretation of data.
 Misuse of equipment.
85

NORMAL PULMONARY ARTERY
PRESSURES AND WAVEFORMS
A CVP with characteristic a,c,v waves
and low mean pressures is observed
confirming placement in right atrium
Rapid systolic upstroke,wide pulse
pressure and low diastolic pressure
confirms position in right ventricle. Later
as the catheter enters the RVOT and hits
the infundibular part, premature
contraction are seen.
86

•During diastole the PAP falls because of interruption of flow due to
pulmonic valve closure but the pressure in right ventricle increases
because of diastolic filling. Also seen is the diastolic pressure of RV
increases and PAP falls.
•Even though the PAP upstroke precedes the radial artery upstroke due
to longer duration of LV isovolumic contraction and time rquired for
pressure wave propagation to a distal site.
87

Even though the wedge pressure is expected to represent a venous
waveform, owing to the pulmonary vascular bed interposed between the
PAC tip and left atrium it represents a delayed damped representation of
LA pressure.(compared to right-CVP)
 Atrial depolarisation - SA node
 LA pressure wave – 160 msec
•As ‘a’ consequence the wedge a wave is slightly delayed and becomes a
early systolic wave .
•‘v’ wave taller on the left compared to right-LA less distensible than
right.
•‘a’ and ‘c’ waves are separate in right because the ventricular contraction
is slower in right than left by 40 msec.Seen as composite ‘a-c’ on the left.
88

COMPOSITE WAVE
 LA wave is retrograde wave
which superimposes on the
antegrade PA waveform.
 The ‘a’ wave of the LAP
distorts the systolic upstroke
and the ‘v’ wave distorting
the dicrotic notch.
 We have to inflate the ballon
to see the the wedge
waveform after which it is
wise to follow the wedged
pressure in the unwedged
waveform. 89

• Final position of the catheter within PA must be such that PCOP tracing
is obtained whenever 75-100% of 1.5ml maximum volume of balloon is
insufflated
– If < 1ml of air is injected and PAOP is seen then it is overwedged -
needs to be withdrawn
– If after maximal inflation fails to result in PCOP tracing or after 2-3
seconds delay - too proximal
– advanced with balloon inflated
• PAWP/PAOP -interprets Left atrial pressures – LVEDP
– Best measured in
• Supine position
• At end of expiration
• Zone 3 (most dependent region)
– Normal PAWP- 6-15 mmHg ; Mean :9mmHg
Synonyms and confusion
− PAWP-Pulmonary artery wedge pressure
− PAOP- Pulmonary artery occlusion pressure
− PCP-Pulmonary capillary pressure
− PCWP- wrong term not to be used
90

ABNORMAL WAVEFORMS -
ARTIFACTS
 Because the PAC is longer and passes through cardiac chambers, it is
more prone to form clot or airbubbles and motion related artifacts are
more common.
 Excessive catheter motion at the onset of systole – may produce an
artificially low pressure or pressure peak.Repositioning solves the
problem.
91

 Over wedging- Overinflation, distal catheter migration and
eccentric balloon inflation as this causes the distal tip to be
blocked the catheter records a gradually increasing pressure.
 Over wedged pressure is devoid of pulsatality.
 Must be corrected by catheter withdrawal
 With each PAC balloon inflation and wedge presssure
measurement the catheter is displaced distally.
92

MITRAL REGURGITATION
PAWP waveform
 Fusion of ‘c’ and ‘v’ waves and obliteration of ‘x’ descent as there is no
isovolumic phase in MR.
 Prominent v wave in early systole
 The mean wedge pressure overestimates LVEDP which is better estimated
by the pressure value before the onset of the regurgitant wave.
PAP waveform
 Larger the regurgitant v wave the PAP shows a bifid appearance and
obscures dicrotic notch.
Steep pressure
upstroke
Reaches peak
later in the
cardiac cycle
after the ECG ‘T’
wave.
Bifid
appearance
obscures
dicrotic notch
93

LA Volume
LA Compliance
LA regurgitant
volume
Wedge pressure ‘v’ waves are neither sensitive nor
specific indicators of MR severity.Also seen in
•Inc.LA pressure
•Hypervolemia
•CHF
•VSD
94
VOL

MITRAL STENOSIS
 While MR affects the systolic
portion of the PAWP MS affects
the diastolic portion.
 Mean wedge pressure is
increased , tall end diastolic ‘a’
wave and slurred early diastolic
‘y’ descent.
 Also seen in LV infarction,
pericardial constriction, aortic
stenosis , systemic hypertension.
Coexisting
AF
95

MYOCARDIAL ISCHEMIA
Left Ventricle
 Ischemia causes diastolic dysfunction(demand ischemia-tachycardia or
atrial pacing)-less compliant ventricle-LVEDP increased.
 Causes ‘a’ & ‘v’ waves to increase.
 Changes in wedge pressures are more striking than the PAP.
 LVEDP increased but LVEDV is decreased(Diagnostic and therapeutic
errors)
 Systolic dysfunction(supply ischemia):rise –LVEDP,LVEDV,Pulmonary
diastolic and wedge pressures ; fall:BP,EF.
 Regional ischemia: papillary muscle-functional MR(best noted by PAC
monitoring).
 Corelate clinically for best results.
96

Right ventricle
 Ischemia causes changes in the CVP
 A tall ‘a’ wave and a tall ‘v’ wave are seen more
commonly referred to as the ‘M’ or ‘W’ configuration.
This is more prominent in CVP as there is damping
effect of pulmonary vasculature on left sided filling
pressures.
 One of the instances where wedge pressure is more
than CVP.
 Pulmonary hypertension can result in similar findings
but can be differentiated by PAP and calculated
pulmonary vascular resistance.
 Despite reduced cardiac volumes,filling pressures are
markedly elevated and equal in all four chambers of
the heart at end diastole.
 Early diastolic filling of the ventricles is unimpeded
and abnormally rapid, but late diastolic filling is
abbreviated and halts abruptly when total cardiac
volume expands to the volume limit set by the stiff
pericardium. The pressure in the late diastole
elevates and plateaus in accordance with the
pericardial compression.
97

CARDIAC TAMPONADE
 Attenuated ‘y’ descent.
 Other clinical findngs (ex.pulsus paradoxus)
helps distinguish between these two conditions.
98

PRESSURE
 Alternative to PAWP and continuously available.
 When pulmonary venous resistance is low the pressure in pulmonary artery at the
end of diastole will equilibrate with downstream pressure in the pulmonary veins
and left atrium.
 For this value to be valid the column of blood connecting both must be continuous and
static but the pulmonary capillaries are subject to external compression by alveoli.
 A PAC positioned in both zone 1&2 will be highly susceptible to alveolar pressure
with measurements reflecting airway/alveolar pressures rather than LV filling
pressure.
 Zone 3 would be the most appropriate and supine position favours it.Lateral or semi
upright position favours zone 2(expands significantly).Generally zones 1&2 are
extensive when LA pressure is low.
99

 All transmural pressures are
measured best at end
expiratory phase.
 The most reliable method for
measuring central vascular
pressures at end expiration is
examination of waveforms on a
calibrated screen or paper
recording.
100

USE OF CENTRAL FILLING
PRESSURES TO ESTIMATE LEFT
VENTRICULAR PRELOAD
Cardiac anesthesia by Mathew Bernard
and Bruce Martin
101

 Shared septum between the ventricles and pericardial
presence lead to further interpretative problems in the
use of CVP to assess ventricular preload. Causing a
secondary and opposite change for any primary change.
 Ex. Acute PHT increases RVEDV and pressure shifting
septum leftward increasing LVEDP while decreasing
LVEDV.
 All these considerations suggest that BOTH CVP AND
PAWP DO NOT CORRELATE WITH BLOOD
VOLUME AND DO NOT PREDICT THE CARDIAC
OUTPUT RESPONSE TO AN INTRAVENOUS
FLUID CHALLENGE. 102

PULMONARY ARTERY CATHETER –
DERIVED VARIABLES.
 Calculations of SVR and PVR are based on hydraulic fluid
model that assumes continuous , laminar flow through a series
of rigid pipes.
 A more physiological model considers the vasculature to be a
series of collapsing vessels with intrinsic tone suggesting an
critical closing pressure-Vascular waterfall.
 Hence therapy focussed on SVR is misleading and must be
avoided.
 PVR more dependent on tone,recruitment and rheologic
changes than volume.Better to evaluate end diastolic gradient
between pulmonary artery diastolic and wedge pressure.
 Another set of derived variables adjusts these indices for BSA.
 SVI
 CI
 PVRI
 Little evidence to show indexing helps to normalize adjustments.
Therapy should not be directed soley at achieving normal indices.
103

SPECIAL TYPES OF PAC
 Extra lumen for use as IV infuion
 Temporary endocardial pacing/intracardiac ECG
 Bipolar ventricular,atrial,A-V pacing,
 Dual chamber sequential pacing.
 Mixed venous oximetry PAC
 RVEF PAC
104

MIXED VENOUS OXIMETRY PAC
 Rearranging the Ficks equation for cardiac output we get:
 Svo2=Sao2-Vo2/Q*1.36*Hb
 Svo2-Mixed venous Hb saturation
 Sao2-Arterial hemoglobin saturation
 Vo2-oxygen consumption
 Q-Cardiac output
 Hb-Hemoglobin
 This value not only gives the cardiac output value but also
adequacy of cardiac output compared with tissue
requirements.
 Can be done with normal PAC also but a special
PAC(Fiberoptic technology) can give continuous information
based on the principles of reflectance oximetry.
 Calibrated with pulmonary artery gas sample or at bed side.
Recalibration should be done every 24 hrs. 105

 Mvo2 measurements reflect global,whole body
measurements.Regionally inadequate blood flow
and inadequate oxygen delivery can coexist with
a normal or high Mvo2.
 Normal values range from 75% in PAC and 70%
in CVC.
106

RIGHT VENTRICULAR EJECTION
FRACTION -PAC
 Used in
 COPD
 ARDS
 PHT
 Right ventricular infarction and ischemia.
 Critically ill with respiratory failure
 Special PAC with a rapid response thermistor that detects
and quantifies minimal changes in pulmonary artery blood
temperature.
 Will mot work if the ECG ‘R’ wave cannot be detected
accurately (Irregular rhythm, Tachycardia etc.)
 RVEF is an extremely load dependent measurement
ultimately to measure RVEDV.(SV/RVEF)
 RVEDV correlates much better with volume status than the
CVP and PAWP.(Remains unproven) 107

CARDIAC OUTPUT MONITORING
 Methods for measuring cardiac output
 Ficks principle
 Thermodilution method
108

FICK PRINCIPLE
 The Fick principle assumes that the quantity of oxygen
delivered to an organ is equal to the amount of oxygen
consumed by that organ plus the amount of oxygen
carried away from that organ.
 Fick principle assumes that the rate at which oxygen is
consumed is a function of the rate of blood flow times the
rate of oxygen pickup by the red blood cells
 The basic assumption is that the flow of blood in a given
period of time is equal to the amount of substance
entering the stream of flow in the same period of time
divided by the difference between the concentrations of
the substance in the blood upstream and downstream
from its point of entry into the circulation.
 The same number of red blood cells that enter the lung
must leave the lung if no intracardiac shunt is present.
109

THE FICK PRINCIPLE
 Thus, if certain parameters were known (the number of oxygen
molecules that were attached to the red blood cells entering the lung,
the number of oxygen molecules that were attached to the red blood
cells leaving the lung, and the number of oxygen molecules consumed
during travel through the lung), the rate of flow of these red blood
cells as they pass through the lung could be determined.
 It is not confused by low output states, valvular regurgitation, shunts
or arrhythmias. The major source of error is the act of measuring the
amount of exhaled oxygen, and the change in cardiac output over the
period of measurement.
110
Braunwalds Heart disease 7 th edition

THERMODILUTION METHOD
 Clinical standard/variant of indicator dilution
method.
 Principle: If some measurable indicator(eg. bolus of
dye , thermal pulse , oxygen consumption, CO2
production) is injected into a flow and its
concentration is measured as a function of time at a
point downstream then the volume can be calculated
by integration.
 A known volume of Iced or room temperature fluid is
injected into the proximal lumen of the PAC and the
resulting change in blood temperature is measured at
catheter tip(thermistor).
 Room temperature fluids preferred as injectates(10
ml in adults and 0.15 ml/kg in children).
 Three measurements in rapid succession are
averaged to give the result. 111

 Factors influencing accuracy of thermodilution
CO
 Intracardiac shunt
 TR/PR
 Inadequate delivery of thermal indicator
 Warming of iced injectate
 Central venous injection site within catheter introducer
sheath
 Thermistor malfunction from fibrin or clot
 Pulmonary artery blood temperature fluctuations
 Following CPB
 Rapid IV fluid administrations
 Respiratory cycle influences.
112

CONTINUOUS THERMODILUTION
CARDIAC MONITORING
 An electric filament (10 cm) at 15-25 cm from the catheter tip
(removes errors of fluid injectate technique -small volumes of
injectate overestimate the flow) but requires the need for
averaging(previous 3-6 minutes) the signal over a longer time
interval-display every 30-60 seconds(5-15 minute delay to
abrupt changes in environment)
 Heating filament is cycled on and off in a pseudorandom
binary sequence and CO is derived from the cross correlation
from the measured pulmonary artery temperature with the
known sequence of heating filament activation.
 Considered continual rather than continuous as it is slower
than other methods.
 Provides beat to beat variations in SV that occur during a
single respiratory cycle hence better for patients on PPV. 113

TRANSPULMONARY
THERMODILUTION CARDIAC
OUTPUT
 Ice cold saline injected into CV line and temperature
measured in a large peripheral
artery(femoral,axillary,brachial).
 Extravascular lung water is a measure of pulmonary
edema and can be used to guide fluid therapy in acute
lung injury and sepsis.
 Other derived indices include Global end diastolic
volume , intrathoracic blood volume - better measure of
cardiac preload.
 CO/intrathoracic blood volume-cardiac function index it
correlates with Echocardiography derived LVEF.
114

LITHIUM DILUTION CARDIAC
OUTPUT MONITORING
 Involves administering Lithium chloride through
a peripheral IV cannula and measured by an ion
sensitive electrode in an arterial line.
 Avoids a central line
 Cannot be used in
 People on treatment with lithium
 Pt given NDMR
116

LiDCO
– LiCl: 0.002mmol/l injected
into central vein (peripheral
administration possible as
well)
– Arterial plasma conc.
measured by withdrawing
blood across lithium selective
electrode at 4ml/min
– CO calculated from Li dose
and area under primary
concentration-time curve
before re-circulation
Cardiac Output = (Lithium Dose x 60)/(Area x (1-PCV))
PCV is packed cell volume which may be calculated as hemoglobin concentration (g/dl) / 34
15
117

OTHER METHODS FOR
MONITORING CARDIAC OUTPUT
AND PERFUSION
 Esophageal doppler cardiac monitoring
 Minimally invasive,safe,easy to use
 Continous monitoring of CO by doppler shift of the
interogated blood flow in the descending thoracic aorta.
 Inserted 35 cm from incisor teeth at T5-6 level interspace or
third sternocostal junction(esophagus and descending aorta
parallel in this location).
 Correction constant 1.4 as it can measure only the fraction in
descending aorta.
 Peak blood flow velocity,flow acceleration,heart rate corrected
flow time-these provide information regardibng fluid
responsiveness,contractility and SVR.
118

 Bioimpedence cardiac output monitoring
 Based on electrical impedence of thoracic cavity
 Electrodes are placed on the neck and lower left thorax.
(volume of thoracic cavity is calculated.
 Not reliable in critically ill,sepsis,AR,pulmonary
regurgitation.
119

GASTRIC TONOMETRY
 Gastric circulation as an indication of splanchnic
hypoperfusion.
 Balloon tipped tube inserted and the saline or air
in the balloon is allowed to equillibrate with the
Co2 in gastric lumen.
 Saline or air is aspirated and measured for
co2.with hypoperfusion the clearance of co2
decreases but co2 production increases.
 Therapy guided by tonometry improves clinical
outcome.
120

PARTIAL CO2 REBREATHING
CARDIAC OUTPUT MONITORING
 Restatement of Fick equation for CO2 elimination rather than
O2 uptake.
 Q=Vco2/(Cvco2-Caco2)
 Q=cardiac output
 Vco2-rate of co2 elimination
 Cvco2-co2 content of mixed venous blood
 Caco2-co2 content of arterial blood
 Change in Co2 production and the end tidal Co2 concentration
in response to a brief change in minuteventilation.
 Every 3 minute dead space increased for 50 seconds(partial
rebreathing of exhaled gases).
 Entirely noninvasive but require tracheal intubation.
 Contraindicated in increased intracranial pressure(increased
PaCo2)
121

PICCO SYSTEM
 Combination of pulse contour analysis and
transpulmonary dilution method.
122

PULSE CONTOUR CARDIAC OUTPUT
MONITORING
 Noninvasive,continuous,beat to beat (stroke volume variation)
 Stroke volume determined from area under aterial pressure
waveform or even a spo2 waveform.
 Recalibration every 8-12 hrs(change in vascular characteristics.)
 Arterial waveform with a dicrotic notch required which is not
seen in tachycardia,dysrhythmia or low output states.
 Goal directed therapy for improving pulse contour derived Co or
minimising SVV results in improved perioperative outcome.
123

ITTV-intrathoracic thermal volume
PTV-pulmonary thermal volume
DSt-downslope time
MTt-mean transit time
124

Parameters measured with the PiCCO
The PiCCO measures the following parameters:
Thermodilution Parameters
• Cardiac Output CO
• Global End-Diastolic Volume
• Intrathoracic Blood Volume
• Extravascular Lung Water
• Pulmonary Vascular Permeability Index
• Cardiac Function Index
GEDV
ITBV
EVLW*
PVPI*
CFI
• Global Ejection Fraction GEF
Pulse Contour Parameters
• Pulse Contour Cardiac Output
• Arterial Blood Pressure
• Heart Rate
PCCO
AP
HR
SV
• Stroke Volume
• Stroke Volume Variation
• Pulse Pressure Variation
• Systemic Vascular Resistance
• Index of Left Ventricular Contractility
SVV
PPV
SVR
dPmx*
125

Decision tree for hemodynamic / volumetric monitoring
CI (l/min/m2
) <3.0 >3.0
R
E
S
U
L
T
S
GEDI (ml/m2
)
or ITBI (ml/m2
)
<700
<850
>700
>850
<700
<850
>700
>850
ELWI* (ml/kg) <10
V+
>10 <10
Cat
>10 <10
V+
>10 <10 >10
V-
V+!
Cat
Cat
V-
V+!
T GEDI (ml/m2
)
or ITBI (ml/m2
)
>700
>850
700-800
850-1000 >850
>700 700-800
850-1000 >850
>700 700-800
850-1000
700-800
850-1000
H 1.
E
T
R 2. Optimise to SVV** (%<) 10 <10 <10 <10 <10 <10 <10 <10
A
A
R
P
G
Y CFI (1/min)
or GEF (%)
>5.5
>30
>4.5
>25
>5.5
>30
>4.5
>25
E
OK!
T
ELWI* (ml/kg)
(slowly responding)
10 10 10 10
V+ = volume loading (! = cautiously) V- = volume contraction Cat = catecholamine / cardiovascular agents
** SVV only applicable in ventilated patients without cardiac arrhythmia
23
ELWI – extravascular lung water index;GEDI-global end diastolic volume index;CFI-Cardiac function index;
126

TRANSESOPHAGEAL ECHO
127
• left lateral decubitus position with
head end elevated to 30 degree (avoid
aspiration)
•Patient head is minimally flexed
•Imaging surface of the transducer on
the tongue and kept centrally to avoid
entering piriform fossa.
•Very difficult to do in conscious
patient
•Start with mid esophagus view
•GE sphincter is reached when tube is
advanced 40 cm from the teeth.
•Descending thoracic and arch of aorta
visualised at end of study.
• if intubated introduced in supine position after retracting mandible and if
resistance felt at 25-30 cm then ET cuff deflated.
•Basal views-probe in mid esophagus
•Four chamber view-middle to lower esophagus
•Transgastric view-slight resistance and liver
•MV-at GE junction

130
Complications
•Injury from direct trauma to airway and esophagus
•Esophageal bleeding,burning,tearing
•Dysphagia
•Laryngeal discomfort
•Bacteremia
•Vocal cord paralysis
•Indirect effects
•Hemodynamic and pulmonary effects of airway manipulation
•Distraction from patient.
Limitations
•Incompatibility – induction,laryngoscopy,intubation,emergence,extubation
•Artificial Interface – electronic,septum,bundle branch block
•Lack of specificity – tethering effect,scar,afterload changes,stunned
myocardium
•Most obvious limitation of TEE - ischemia cannot be detected during critical
periods - induction/ laryngoscopy/ intubation/ emergence/extubation.4
•In addition, the adequacy of RWMA analysis may be influenced by artifact.

ABSOLUTE CONTRAINDICATIONS TO TEE IN INTUBATED
PATIENTS
 Oesophageal stricture
 Diverticula
 Tumor
 Recent suture lines
 Known esophageal interruption.
Relative contraindications:
 Symptomatic hiatal hernia
 Oesophagitis
 Coagulopathy
 Oesophageal varices
 Unexplained upper GI bleeding 131

REFERENCES
 Wylie and Churchill
 Miller’s Anesthesia-8 th edition
 Textbook of critical care-Shoemaker 4 th edition
 Anesthesia update-2017
 https://www.maquet.com / globalassets /downloads / products
/ picco- technology /
mpi8102en_r04_picco_brochure_160615_low.pdf ? Lang =
en&src = /int/products/picco-technology/? ccid=40
 Internet
132

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