REVIEW OF HEMODYNAMIC MONITORING
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1. Clinical examination alone is not sufficient to assess hemodynamic status in critically ill patients as individual vital signs do not reflect overall status. 2. Arterial lines can be used to monitor blood pressure, heart rate, and derive parameters like cardiac output but waveforms require interpretation and may be affected by various artifacts. 3. Pulmonary artery catheters can measure central venous and pulmonary artery pressures as well as cardiac output but have potential complications and their use remains controversial with no proven benefits shown in large trials.
![EQUATIONS
• Cardiac Output=Fick equation [VO2 = QT x
(CaO2-CvO2)]](https://image.slidesharecdn.com/fellowhdlecture-150922195043-lva1-app6892/85/REVIEW-OF-HEMODYNAMIC-MONITORING-37-320.jpg)
REVIEW OF HEMODYNAMIC MONITORING
- 1. REVIEW OF HD MONITORING DR GHALEB ALMEKHLAFI MD,SFCCM,EDIC
- 2. HEMODYNAMICS • DEFENITION-MOVEMENT • COMPONENTS-CIRCULATION • TARGETS-PERFUSION • PHYSIOLOGY/PATHOPHYSIOLOGY • METHODS OF MONITORING PARAMETERS AND VALIDITY DIAGNOSIS OR TREATMENT WHICH METHOD AND WHEN?
- 3. 1-Myocardial contraction &heart rate 2-Vasoactivity 4factors that affecting the hemodynamic conditions 3-volume C.O.= HR x Stroke Volume (60-130 Ml/beat) Stroke Volume has three components 1. Preload 2. Afterload 3.Contractility 4-MICROCIRCULATION/PERFUSION
- 4. hypovolemia vascular tone depression myocardial depression Importance of assessing the degree of each component to select and apply the best therapeutic option vasopressors inotropes Hemodynamic failure in critically ill patients: 3 components fluids presence of associated lung injury
- 5. methods Clinical methods • Physical examination: systemic clinical examination • V/S:NI-BP, Heart rate • Skin, extremities • Urine output • Mental status Classic methods • A-LINE • Pulse waveform analysis • Invasive BP • CVP • PAC Advanced methods Non invasive invasiveLAB: SCVO2,LA
- 6. • Clinical examination remains an important initial step in the diagnosis and risk stratification of critically ill patients. • Individual vital signs often do not reflect hemodynamic status. • High or low pulse rate is neither sensitive nor specific for the diagnosis of hemodynamic instability. • Respiratory rate lacks adequate specificity or sensitivity to serve as a test for hemodynamic instability. • Skin or toe temperature is not a sensitive indicator of hemodynamic instability. • Oliguria may have causes other than renal Hypoperfusion. • TRENDS
- 13. 20 40 60 80 100 120 140 0 Arterial Pressure (mmHg) DAP: reflection of vasomotor tone DAP
- 14. 20 40 60 80 100 120 140 0 Arterial Pressure (mmHg) DAP: reflection of vasomotor tone DAP: driving pressure for left coronary circulation DAP
- 16. 20 40 60 80 100 120 140 0 MAP Arterial Pressure (mmHg) MAP: driving pressure for perfusion of important organs (e.g. brain, kidney)
- 17. 20 40 60 80 100 120 140 0 Arterial Pressure (mmHg) MAP: important hemodynamic target of resuscitation of shock states MAP
- 18. MAP is a goal of resuscitation • Correction of hypotension with a vasopressor allows improving organ perfusion and microcirculation Which MAP value to target?
- 19. Target MAP • increasing MAP above 65 mmHg results in little benefit • Probably higher target value if: 1. History of chronic hypertension 2. Elevated CVP 3. Elevated abdominal pressure
- 20. Target blood pressure in circulatory shock • We recommend individualizing the target blood pressure during shock resuscitation. Recommendation Level 1: QoE moderate (B) • We recommend to initially target a MAP of ≥ 65 mmHg. Recommendation: Level 1; QoE low (C) • We suggest a higher MAP in septic patients with a history of hypertension. Recommendation: Level 2; QoE low (B)
- 21. arterial line waveform Slowed upstroke – AS – LV failure • sharp vertical in hyperdynamic states – Anemia – Hyperthermia – Hyperthyroidism – SNS – Aortic regurg Age effect
- 22. arterial waveforms –differential iagnosis . Pulsus alternance Seen in:LVD/cardiomyopathies, HTN,AS,Normal hearts with SVT pulsus bisfrenus is a sign of combined aortic valve lesion, also seen in hypertrophic obstructive cardiomyopathy (HOCM), patent ductus arteriosus, arteriovenous fistulas and normal hearts in a hyperdynamic state hyperdynamic states AR AS LV failure
- 23. COMPLICATIONS ARTERIAL LINE • Thrombosis/embolus • Hematoma • Infection • Nerve damage/palsy • Disconnect=blood loss • Fistula • Aneurysm • Digital ischemia mlr/2007
- 24. mlr/2007 LOSS OF WAVEFORM •asystole • Stopcock • Monitor not on correct scale • Nonfunctioning monitor • Nonfunctioning transducer • Kinked/clotted catheter
- 26. resonance artifacts DAMPENED WAVEFORM • Air bubble/blood in line • Clot • Disconnect/loose tubing • Underinflated pressure bag • Catheter tip against wall • Compliant tubing UNDERDAMPED WAVEFORM • Too many stopcocks • Long tubing • Air bubbles • Defective transducer
- 27. Arterial line dynamic response testing
- 28. Other functions of A-line • Blood extraction • pulse rate and rhythm • effects of dysrhythmia on perfusion • ECG lead disconnection • continuous cardiac output using pulse contour analysis • pulse pressure variation (suggests fluid responsiveness) • steeper upstroke of pulse pressure = increased contractility • area under upstroke = SV • steep down stroke = low SVR
- 29. classification of cardiac output monitoring systems. INVASIVE-PAC LESS INVASIVE - PCM: pulse contour method - TPD :transpulmonary dilution - TED :trans esophageal Doppler NONINVASIVE - PCM - TTE/US - BIOEMPEDANCE,BIOREACTANCE - NICO
- 30. PULMONARY ARTERY CATHETER Markings on catheter. 1. Each thin line= 10 cm. 2. Each thick line= 50 cm. CVP Proximal (pressure line - injectate port for CO)-BLUE PA Distal (Pressure line hook up)- Yellow Extra port - usually- Clear Thermistor – Red Cap
- 31. PA Catheter Timeline Swan HJ, Ganz W, Forrester J. NEJM.Aug, 1970 Iberti TJ, Fischer EP, Leibowitz AB, et al. Pulmonary Artery Catheter Study Group. JAMA. Dec, 1990 1970 19901980 2000 2005 Connors AF, et al. JAMA. Sept, 1996 1995 PA Catheters Are Good PA Catheters Might be Bad PA Catheters Are Bad MDs Are Ignorant Rhodes A. Int Care Med. Feb, 2002 French PAC Study Group JAMA. Nov, 2003 Founding of the Society of Critical Care Medicine PACMAN, Escape, ARDSnet 2004 -2006
- 32. EBM Overall Conclusion: 1. No difference in LOS in the ICU 2. No difference in Mortality 3. No benefit, no harm • “There is no guided therapy tailored towards PAC use.” • “PAC is a diagnostic tool, not a therapeutic one
- 33. Advances-PCM • beat-to beat stroke volume analysis is based on the Windkessel model, which was described by Otto Frank in1899 • In 1993 Wesseling et al described a method of using the finger cuff arterial pressure wave to derive cardiac output“ Model Flow ” Currently the Nexfin • In 1997 the first commercial system, the PiCCO (Pulsion, Munich, Germany) was released • in 2002 the LiDCO-plus (and later rapid), (LiDCO Ltd., Cambridge, England) • In 2004 the FloTrac-Vigileo, (Edwards Lifesciences, Irvine, CA, USA). Then volume view in 2010
- 35. Pulmonary Artery Catheter indications Diagnostic Diagnosis of shock states high- versus low-pressure pulmonary edema primary pulmonary hypertension valvular disease, intracardiac shunts, cardiac tamponade, and pulmonary embolus (PE) Monitoring complicated AMI hemodynamic instability after cardiac surgery Therapeutic - Aspiration of air emboli - local thromplytics Contra-indications: • Tricuspid or pulmonary valve mechanical prosthesis • Right heart mass (thrombus and/or tumor) • Tricuspid or pulmonary valve endocarditis
- 36. PAC parameters and NL values Measured values • CVP: 2-6mmHg • PAWP: 8-12mmHg • PAP: 25/10mmHg • SvO2: 0.65-0.70 • Temperature • Q: 4-8L/min • CI: 2.5-4L/min Derived values – use of formula: Q = MAP-CVP/SVR • SV: 50-100mL/beat • SVI: 25-45mL/beat/m2 • SVR: 900-1300 dynes- sec/cm5 • SVRI: 1900-2400 dyne- sec/cm5 • PVR: 40-150 dyne- sec/cm5 • PVRI: 120-200 dynes- sec/c
- 37. EQUATIONS • Cardiac Output=Fick equation [VO2 = QT x (CaO2-CvO2)]
- 38. Change in pressure / total blood flow Systemic Vascular Resistance Index =SVRI = (MAP ) = (MAP-CVP)(80)/CI Pulmonary Vascular Resistance Index = PVRI = (MPAP-PAOP)(80)/CI 80 converts mm Hg 80 converts mm Hg- min-m2/liters to dynes*sec/*cm-5 SVR: 900-1300 dynes-sec/cm5 SVRI: 1900-2400 dyne-sec/cm5 PVR: 40-150 dyne-sec/cm5 PVRI: 120-200 dynes-sec/c
- 39. PAC WAVES
- 40. PAWP
- 42. How to measure the PAOP?
- 43. HOW TO LOCALIZE DURING SPONTANEOUS VENT.?
- 44. ALL PA measurements are calculated at end expiration because the lungs are at their most equal - (negative vs. positive pressures)
- 45. HOW TO LOCALIZE DURING MECH. VENT.?
- 46. PAW WAVEFORM WITH MECHANICAL VENTILATION
- 51. What is the abnormality?
- 52. What is the abnormality?
- 53. What is the abnormality?
- 55. Pericardial tamponade: high PCWP, high SVR, CVP = PCWP Right heart failure: high CVP, low CI, high PVR
- 56. Complications of PAC • Venous access complications - include arterial puncture - hemothorax - Pneumothorax • Arrhythmias - PVCs or nonsustained VT - Significant VT or ventricular fibrillation • Right bundle-branch block (RBBB) • PA rupture • PAC related infection • Pulmonary infarction
- 57. SUGGESTED APPROACH TO PAC USE • potentially useful in undifferentiated, multi-factorial shock states (for Q and ScVO2) • useful in right heart pathology and pulmonary hypertension • requires careful patient selection (including a contraindication assessment) • don’t wedge (PADP can usually be used to estimate PAOP) • monitor for complications (predominantly on insertion) • remove after 72 hours
- 59. ARTERIAL WAVEFORM ANALYSIS TECNIQUES other devices PRAM: Pressure Recording Analytical Method SD of 2000 arterial waveform points Statistical analysis of Arterial Pressure
- 60. Pulse Contour Parameters Pulse Contour Cardiac Output PCCO • Arterial Blood Pressure AP • Heart Rate HR • Stroke Volume ,CO SV • Stroke Volume Variation SVV • Pulse Pressure Variation PPV • Systemic Vascular Resistance SVR • Index of Left Ventricular Contractility dPmx* MANY OTHER PARAMETERS AWAITING VALIDATION
- 61. Non invasive PCM
- 62. CALIBRATION FOR PCM Cardiac output is measured by another more accurate modality to initially calibrate the PCA system and then for recalibration as needed 1-Transpulmonary Thermodilution Methods: • PiCCO (Pulsion Medical Systems&GE technology) • Volume View (Edwards Life Sciences) 2-Lithium Dilution Technique: • LiDCO /LiDCOplus/LiDCOrapid ( LiDCO limited) 3-Ultrasound Indicator Dilution :COstatus (Transonic Systems, Inc.) Device that do not need calibration: -FLOTRAC/VIGILEO: estimate CO by the standard deviation of pulse pressure sampled during a time window of 20 seconds -PRAM :estimate cardiac output using frequency of 1000 HZ 62
- 63. Transpulmonary thermodilution-PICCO and Edward / Volume View TM • . 63
- 64. Advanced Thermodilution Curve Analysis Transpulmonary thermodilution: Volumetric curve Mtt: Mean Transit time time when half of the indicator has passed the point of detection in the artery DSt: Down Slope time exponential downslope time of the thermodilution curve For the calculations of volumes… ln Tb injection recirculation MTt t e-1 DSt Tb …and… All volumetric parameters are obtained by advanced analysis of the thermodilution curve: ITTV = CO * MTt PTV = CO * DSt
- 65. ITTV = CO * MTt PTV = CO * DSt ITBV = 1.25 * GEDV EVLW* = ITTV - ITBV GEDV = ITTV - PTV RAEDV RVEDV LAEDV LVEDV RAEDV RVEDV LAEDV LVEDVPBV RAEDV RVEDV LAEDV LVEDVPTV PTV EVLW* EVLW* Calculation of volumes
- 66. Transpulmonary thermodilution monitors are not only CO monitoring devices
- 67. Transpulmonary thermodilution 2- Global end-diastolic volume (GEDV) 1- Cardiac outputGEDV marker of cardiac preload
- 68. Extravascular lung water (EVLW) • Normal – 3-7 mL/kg • Increased > 7 mL/kg • Pulmonary edema > 10 mL/kg
- 69. . Pulmonarv Blood Volume Hydrostatic pulmonary edema Permeability pulmonary edema PVPI = PBV EVLW* normal elevated elevated PVPI* = PBV EVLW* elevated elevated normal PVPI= PBV EVLW* normal normal normal PBV PBV PBV Normal Lung Extra Vascular Lung Water Pulmonary Vascular Permeability Index-PVPI • It allows to identify the type of pulmonary oedema
- 70. PARAMETERS Definitions • LVSWI = SVI × (MAP – PAOP) × 0.0136 • CP = MAP × CO/451 • ITTV = CO × MTt • PTV = CO × DSt • GEDV = ITTV - PTV = CO × (MTt - DSt) • ITBV = 1.25 × GEDV • CFI = (CO/GEDV) × 103 • GEF = SV/(GEDV/4) • EVLW = ITTV - ITBV • PVPI = EVLW/PBV
- 71. Normal ranges PARAMETER RANGE UNIT CI 3.0 – 5.0 l/min/m2 SVI 40 – 60 ml/m2 GEDI 680 – 800 ml/m2 ITBI 850 – 1000 ml/m2 ELWI* 3.0 – 7.0 ml/kg PVPI* 1.0 – 3.0 SVV 10 % PPV 10 % GEF 25 – 35 % CFI 4.5 – 6.5 1/min MAP 70 – 90 mmHg SVRI 1700 – 2400 dyn*s*cm-5*m 71
- 72. Transpulmonary thermodilution 2- Global end-diastolic volume (GEDV) 4- Extravascular lung water (EVLW) 1- Cardiac output 3- Cardiac function index (CFI) 5- Pulmonary vascular permeability index Pulse contour analysis 1- Continuous cardiac output (CCO) 2- Stroke volume variation (SVV) 3- Pulse pressure variation (PPV) ScvO2 Complete picture of the patient’s hemodynamic status
- 73. Clinical application What is the current situation?.………..……..………….Cardiac Output! What is the preload?.……………….....…Global End-Diastolic Volume! What is the afterload?……………..…..Systemic Vascular Resistance! What about the contractility?........................ dPmx* LV pressure velocity What about the Perfusion ?............................central venous saturation Will volume increase CO?...fluid response….Stroke Volume Variation! Are the lungs still dry?...…….……...…..….Extravascular Lung Water!* pulmonary vascular permeability index… Dx of p.edema
- 74. hypovolemia vascular tone depression myocardial depression vasopressors inotropesfluids presence of associated lung injury Hemodynamic failure in critically ill patients: 3 components
- 75. Myocardial depression inotropes + CFI (PiCCO) Echocardiography Hemodynamic failure in critically ill patients: 3 components
- 76. vascular tone depression vasopressors Arterial catheter (DAP ++) Hemodynamic failure in critically ill patients: 3 components
- 77. hypovolemia fluids Prediction of fluid responsiveness • PPV, SVV • PLR or end-expiratory occlusion test if SB, arrhythmias, low TV or low lung compliance Evaluation: real-time CO Lung tolerance PAOP EVLW presence of associated lung injury Hemodynamic failure in critically ill patients: 3 components
- 78. First, try to perform echocardiography to assess cardiac function Normal cardiac fonction Lung injury ? ABG, Chest X-ray Abnormal cardiac function no yes CVC CVP SvcO2 Art cath AP PPV PiCCO CO GEDV, EVLW, CFI PPV, SVV ScvO2 Basic monitoring + advanced monitoring yes considered valid? no only Patient with circulatory failure VolumeViewPAC CO PAOP RAP, PAP SvO2
- 82. Which measurement is most reliable for predicting fluid responsiveness in a patient with septic shock requiring mechanical ventilation? Pick one best answer • A. Central venous pressure (CVP) • B. Pulmonary artery occlusion pressure (PAOP) • C. Pulse pressure variation (ΔPP) • D. Mixed venous oxygen saturation (SvO2)
- 84. vpw • measured by 1, dropping a perpendicular line from the point at which the left subclavian artery exists the aortic arch and 2, measuring across to the point at which the superior vena cava crosses the right mainstem bronchus.
- 85. 71 mm and 62 mm for supine and erect CRs, respectively.