Chang. Hemodynamic Monitoring

7/27/2019 Chang. Hemodynamic Monitoring

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Hemodynamic monitoringAll about the Swan


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Indications for pulmonary artery

catheterization in the ICU:

Establish diagnosis of shock and/or respiratoryfailure

Guide therapy of shock and/or respiratory failure

By improving oxygen delivery


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Information derived from PA catheter

Directly measured

CVP

PAOP

Pulmonary artery

pressure

SvO2

Cardiac output

Calculated

Systemic vascular

resistance

Pulmonary vascularresistance

Stroke volume

Oxygen delivery


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Normal values

Directly measured

CVP 2-4 mm Hg

PA 25/10 PAOP 8-12

SvO2 60-75%

Cardiac output 4-8

L/m

Cardiac index 2.5-4.0

L/min/M2

Calculated

SVR 900-1200 dynes

sec/cm5

PVR 50-140

SV = 50-100mL

SV index 25-45


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Insertion of Swan Ganz

Ask why?

Then immediately ask why not:

Coagulopathy Ventricular ectopy

LBBB

Pacemaker? Defibrillator?

Large pulmonary embolism

Severe pulmonary arterial hypertension


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Swan complications

Associated with cordis placement

Ventricular arrhythmias requiring treatment 1.3 1.5%

Right bundle branch block ~0.5 -5%

Pulmonary artery rupture ~0.06 to 0.2% Pulmonary artery pseudoaneurysm formation

Pulmonary infarction ~ 1.4%

Thromboembolic events ~1.6%

Mural thrombi Sterile cardiac valve vegetation

Endocarditis esp of the pulmonic valve


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So much information, why dont weSwan more often?

1996 observational study Swan within the first 24 hours of ICU admission associated with

increased 30d hospital mortality (OR 1.24)

Association with poor outcome highest in the least sick pts

Meta-analysis of RCTs: no benefit but no harm ESCAPE trial in patients with heart failure: no mortality

benefit

RCT of peri-operative use in high risk pts undergoingcardiac, vascular or orthopedic surgery: no benefit

FACCT study of ARDS pts: no benefit of Swan v. CVPmonitoring in managing vasoactive agents and fluidstatus


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Nevertheless

PAC can be occasionally useful in the

carefully selected patient


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Insertion sites

Insertion

site

RA RV PA PAOP

Comments

IJ 15-20

30 40 45-50 Easy to float especially from right.Carotid puncture/PTX

SC 15-

20

30 40 45-50 Easy to float esp from left.Highest risk PTX

Fem 40-45

50-55

60-65

65-70 Most difficult to floatHighest risk of infection and DVT

Rule of 10s


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Musts

Full barrier precautions for maximal sterile technique

Flush and zero catheter prior to insertion at the phlebostatisaxis

Remember catheter sheath

Once catheter tip is in the right atrium, always advance thecatheter with the balloon inflated.

Always watch the waveforms transduced from the distal endof the catheter while advancing

Always withdraw catheter with the balloon deflated Advance the catheter quickly while in the right ventricle

Advance slowly once the distal tip is in the pulmonary artery


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Waveforms


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X descent: fall n right atrial pressure following atrial contraction

Y descent: call in right atrial pressure following opening of the tricuspid valve and

passive ventricular filling


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ECG correlation is mandatory for correct identification of the right atrial wave forms


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Elevations in RAP

Hypervolemia

Right ventricular infacrtion

Impaired RV contraction Pulmonary hypertension

Pulmonic stenosis

Left to right shunts

Tricuspid valve disease

Cardiac tamponade


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Overwedging


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Abnormal waveforms


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Seen with non compliant ventricle Mitral or tricuspid stenosis


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Seen with tricuspid valve regurgitation Ventricular ischemia

Ventricular failure

Hypervolemia


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Right ventricular pressure

Peak systolic pressure

RV end-diastolic pressure

Early rapid filling (~60% of filling) Slow phase (25% filling)

Atrial systolic phase


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Left to right shunts

Arterial sampling from RA, RV, and PA

Detection og an oxygen saturation step-

up allows confirmation and determinationof its location

Definition of step-up = >10% rise in

oxygen saturation


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Equalization of pressures

RAP = RVed= PCWP

Cardiac tamponade

Constrictive pericardial disease

Restrictive cardiomyopathies


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Cardiac output


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Thermodilution

Saline injected through the proximal port

Thermistor at the distal end of catheter

measures the change in blood temperatureover time


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Area under the curve is inversely proportional to the rate of bloodflow past the pulmonary artery

This rate is equivalent to cardiac output


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Should not differ by more than 10%


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Factors that decrease accuracy ofthermodilution cardiac output

Tricuspid regurgitation

Septal defects

Technical issues Sensor malfunction

Improper injectate


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Continuous thermodilution cardiacoutput

10 cm thermal filament located 15-25 cm

from the catheter tip.

It generates low-energy head pulsestransmitted to surrounding blood


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Interpretation of the data


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Case 2

30F with flank pain, dysuria, fever to 104.

T 104 BP 70/35 HR 140

Exam: Flushed, warm, bounding pulses


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MAP 47

CVP 2

PA 20/5

PAOP 5 CO 7

SvO2 75%

SV ?

SVR ?

What kind of shock?


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Case 3

55M intermittent chest pains for last 24

hours presents with progressive shortness

of breath and weakness

T 96 BP 80/60 HR 120 RR 28 SpO2 88%

Exam: Dyspneic, diaphoretic. Poor capillary

refill. He has JVD, a gallop, soft murmur.

Very little edema


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Case 4

60M feeling bad and losing weight last 8

months. Hasnt seen an MD in 30 years.

Present with progressive weakness,

shortness of breath, and edema.

T 96 BP 75/60 HR 120 RR 24 SpO2 92%

Exam: Cachectic. JVD. Distant heart

sounds. Generalized edema. Thready

pulses, poor capillary refill


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MAP = 70

CVP 24

PA 40/24

PAOP 24 CO 2.4

SvO2 45%

SV?

SVR?


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Case 5

46 F presents with worsening shortness of breath

and chest pains over a 5 days period.

T 98 BP 78/62 HR 130 RR 28 pulse ox 84%

Exam: Tachypneic, dyspneic. JVD. Lungs clear.

Heart sounds tacycardic with RV heave,

pronounced S2, II/VI systolic murmur at LLSB.


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MAP = 67

CVP 14

PA 60/28

PAOP 6 CO 3.5

SvO2 48%

SVR?

PVR?

SV?

What is going on?


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Case 6

36M admitted to the ICU with lobar pneumonia,septic shock.

Given 8 Liters of normal saline over 3 hours, butremains in refractory shock, requiring initiation ofnorephinephrine. Develops progressivehypoxemia and intubated. Post intubation CXRdemonstrates bilateral pulmonary infiltrates

Exam T 103 BP 95/50 HR 120 RR 28 on vent

SpO2 98% Intubated, sedation. Warm and flushed with brisk

capillary refill and bounding pulses.


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MAP 65

CVP 9

PA 35/18

PAOP 16 CO 9.0

SvO2 80%

SVR?

SV?

Clinical scenario?

Documents

Chang. Hemodynamic Monitoring