Embed Size (px)
Citation preview
HEMODYNAMIC MONITORING
OBJECTIVES
The student will review cardiac and pulmonary considerations
for invasive monitoring Procedural considerations for invasive
monitoring Waveform identification related to
invasive monitors
mlr/2007
EVALUATING THE PATIENT – A REVIEW
PULMONARY Breath sounds Level of mentation Oxygenation
cyanosis Edema Chest circumference
mlr/2007
EVALUATING THE PATIENT - CARDIOVASCULAR
Pain issues Skin color/temp Weakness/fatigue Urinary output HR, rhythm, JVP
mlr/2007
EVALUATING THE PATIENT
JVP supine
Sl distention Head up
No distention
mlr/2007
NONINVASIVE MONITORS
Routine NIBP EKG Pulse ox Temperature Urine
mlr/2007
CARDIAC FUNCTIONAL ANATOMY
Low pressure system Right heart Pulmonary
High pressure system Left heart Systemic
mlr/2007
CARDIAC CONDUCTION
Atrial depolarization SA nodethru atria
Ventricular depolarization AV nodebundlespurkinjes
Atrial repolarization Ventricular repolarization
mlr/2007
MECHANICS OF CARDIAC CYCLE Isovolumetric phase
Active-requires energy Ventricular ejection (rapid) Ventricular ejection (reduced) Isovolumetric relaxation Rapid ventricular filling
Beg when ventric pressure <atrial pressure End diastole = atrial kick
mlr/2007
WHAT ABOUT CARDIAC OUTPUT?
CO=HR X SV
mlr/2007
CARDIAC OUTPUT
Determined by Preload Afterload Contractility
EF=SV/EDV X 100
mlr/2007
FRANK-STARLING
Described in early 1900s Relationship between myocardial
muscle LENGTH and force of contraction
More diastolic stretch = more ventricular vol = stronger contraction
True to a limit (physiological)
mlr/2007
FRANK-STARLING
Resting length affected by degree of preload
CO begins to fall in CHF b/o inc preload
mlr/2007
CARDIAC COMPENSATION
Contractility HR Arteriolar responses Venuole responses
mlr/2007
INOTROPES
Sympathomimetic amines Phosphodiesterase inhibitors Calcium chloride Digitalis glycosides glucagon
mlr/2007
SYMPATHOMIMETIC AMINES
Catecholamines Epinephrine Norpinephrine Dopamine dobutamine
mlr/2007
NONCATECHOLAMINES
Ephedrine Metaraminol Phenylephrine Methoxamine
mlr/2007
PHOSPHODIESTERASE INHIBITORS
Amrinone Milrinone
20X more potent than amrinone aminophylline
mlr/2007
INOTROPES
Calcium Chloride Glucagon Digitalis
Slows HR, conduction Inc contractility
mlr/2007
VASODILATORS
Nitroprusside NTG Phentolamine Hydralazine captopril
mlr/2007
WHAT IS PRELOAD? End diastolic length of myocardial
fiber(wall stress) Amount of volume in ventricle at end
diastole Muscle wall compliance important factor Normal ventricle:lge inc volume = small
inc pressure Stiff ventricle: small inc in volume =
large inc pressure
mlr/2007
WHAT IS AFTERLOAD?
Pressure that has to be overcome by LV for ejection of ventricular volume
Resistance, impedance, pressure SVR PVR Inc resistancedec contractility/SV
mlr/2007
AFTERLOAD
Volume of blood ejected Size & thickness ventricular wall Impedance of vessels
mlr/2007
DYNAMICS OF VENTRICULAR FUNCTION Rate Rhythm Preload Afterload Contractility
Expressed as EF SV/EDV LVEF 60-70% RVEF 45-50%
Heerdt, 2000
mlr/2007
WHAT ABOUT CONTRACTILITY? Inotropism Shortening of muscle fibers without
altering fiber length or preload Effected by
ANS Positive Inotropes Acidosis (dec) Negative inotropes (dec)
mlr/2007
ISSUES OF MYOCARDIAL O2
Uses 65-80% No direct method of measurement Supply and demand Disease states
May not be able to inc supply May have greater demand Poor reserve = ischemia/infarct risk
mlr/2007
CORONARY PERFUSION
Occurs during diastole LV thick wall
Endocardium flow influence during systole
RV wall less thick RCA and RV flow during systole
Diastolic pressure provides flow thru aortic root into coronaries
mlr/2007
WHAT ABOUT SVO2? Mixed venous oxygen saturation Reflect O2 reserve Samples from PA catheter <60% (nl 60-80%)
Dec O2 delivery Anemia Low CO states Hypovolemia Hypoxia
mlr/2007
DECREASING SVO2 Also b/o O2 demand increase
Hyperthermia Seizures Pain Shivering/agitation Exercise Burns hyperthyroidism
mlr/2007
HOW DO WE INCREASE SVO2?
Increase O2 delivery Decrease O2 demand
mlr/2007
INCREASE O2 DELIVERY
Increase FIO2 Increase CO
mlr/2007
HOW DO WE DECREASE O2 DEMAND?
Hypothermia Anesthesia Neuromuscular blockade Early stages of sepsis Hypothyroidism Shock states
mlr/2007
INVASIVE CARDIAC MONITORING
Swan-Ganz catheter Developed 1960’s Assess cardiopulmonary function
Cardiac disease LV function Valves Issues of CHF, tamponade, cor pulmonale
mlr/2007
SWAN GANZ MONITORING Pulmonary issues
ARDS/respiratory failure Severe COPD
Complex fluid management Shock Sepsis ARF Burns
mlr/2007
SWAN-GANZ ADDITIONAL INDICATIONS CABG/RECENT MI AAA Sitting cranis Unstable sepsis Liver tx/shunts High risk OB PE Pts on IABP
mlr/2007
SWAN-GANZ RELATIVE CONTRAINDICATIONS
LBBB WPW syndrome Ebstein’s malformation
Tachyarrythmias Hypercoagulation Sepsis
Site of infection
mlr/2007
SWAN-GANZ CATHETER
mlr/2007
PLACEMENT GUIDELINES
What’s the distance to SVC/RA junction? IJ 15-20 cm SVC 10-15 cm Femoral 30 cm RAC 40 cm LAC 50 cm
mlr/2007
PLACEMENT
mlr/2007
BALLOON PEARLS
1-1.5 cc used to wedge <1 cc=too far::pull back Wedge time <10-15 sec Never flush with inflated balloon PCWP = LVEDP (normal heart)
PCWP = LV function RA = RV function
mlr/2007
PLACEMENT
mlr/2007
PLACEMENT
mlr/2007
PLACEMENT
mlr/2007
WEDGE
mlr/2007
PCWP WAVEFORM
A=contraction After QRS
C=closure mitral valve May not see easily
V=atrial filling (MV closed) Late T-P interval
mlr/2007
PCWP>LVEDP
Mitral stenosis LA myxoma PE Mitral regurgitation
mlr/2007
PCWP<LVEDP
Decreased LV compliance Stiff ventricle LVEDP >25 mmHg Aortic regurg
mlr/2007
PAD AND PCWP
If not = (1-4 mmHg) Inc PVR Cor pulmonale PE CHD Causing Pul HTN
Eisenmengers
mlr/2007
RA READING
High RV failure Tamponade Pulmonary HTN COPD Chronic LV failure Volume overload
mlr/2007
RA READING
Low readings Hypovolemia Sepsis Cirrhosis anemia
mlr/2007
RV
ESSENTIALLY SAME AS RA Additional high
VSD
mlr/2007
PA SYSTOLIC
High Shunts Constrictive pericarditis Hypoxemia ARDS LV failure overload
mlr/2007
PA SYSTOLIC
Low Hypovolemia Sepsis Cirrhosis anemia
mlr/2007
PAD
High Inc PVR PE COPD ARDS LV failure overload
mlr/2007
PAD
Low Hypovolemia Sepsis Cirrhosis anemia
mlr/2007
PCWP High
LV failure Overload Mitral v. issues Tamponade Pericardial effusion Stiff LV PPV
mlr/2007
PCWP
Low Hypovolemia Sepsis Cirrhosis anemia
mlr/2007
PA COMPLICATIONS Dysrhythmias RBBB/CHB in pt with LBBB PA/RA/RV rupture Knot/kink/coil catheter Infection Balloon rupture Thrombus Air embolus Pneumo Phrenic n. block Horner’s
R/T stellate ganglion damage Eyelid ptosis
mlr/2007
MORE PA COMPLICATIONS Pulmonary infarct
Balloon overinflation Prolonged wedge Vigorous flushing Thrombus formation Catheter migration Pulmonary HTN
Death
mlr/2007
CENTRAL VENOUS PRESSURE MONITORING Indirect measure of volume RAP reflects RVEDP CVP INDICATIONS
Cardiac disease Expected volume shifts Hypovolemia Shock states Massive trauma
mlr/2007
CVP ACCESS
RIJ EJ Subclavian Antecubital Femoral
mlr/2007
CVP PLACEMENT
RIJ benefits Access Landmarks
Risks Carotid Brachial plexus trauma pneumothorax
mlr/2007
CVP PLACEMENT
EJ benefits Superficial Safe
Risks Low success rate Sheath kinking at SC v. Subclavian trauma
mlr/2007
CVP PLACEMENT Subclavian benefits
Accessible Good landmarks
Risks Pneumo Hemothorax Chylothorax Pleural effusion
mlr/2007
CVP PLACEMENT
Antecubital benefits Low complication rate
Risks Lowest success Thrombosis/thrombophlebitis Catheter shearing
mlr/2007
CVP PLACEMENT
Femoral advantages High success
Risks Sepsis thrombophlebitis
mlr/2007
CVP PLACEMENT
mlr/2007
CVP WAVEFORMS
A=RA contraction After P wave of EKG
C=closure tricuspid Near end QRS
V=atrial filling/tricuspid v closed Early T-P interval
mlr/2007
COMPLICATIONS Arterial puncture
Hematoma False aneurysm Fistula
Catheter position during placement Wall perf/tamponade Dysrhythmias
Catheter shear Brachial plexus injury Thoracic duct injury
mlr/2007
READING THE CVP
5 cm below sternum 4 ICS, mid axillary End expiration Supine PPV adds 8-12 cm to reading!
mlr/2007
HIGH READINGS
Ventricular failure (R/L) SVC obstruction Tricuspid regurg Tamponade Pulmonary HTN Overload glomerulonephritis
mlr/2007
LOW READINGS PERIPHERAL VASODILATION hemorrhage hypovolemia Addisonian crisis Sepsis Regional anesthesia Polyuria Sympathetic dysfunct
mlr/2007
INVASIVE MONITORING READINGS
Normal CVP/RAP 1-6 mm Hg PCWP 8-12 mm Hg PA 25/10 mm Hg
mlr/2007
ARTERIAL LINE Beat to beat measurement of B/P Upstroke of wave
Related to velocity of blood ejected Slowed upstroke
AS LV failure
Inc sharp vertical in hyperdynamic states Anemia Hyperthermia Hyperthyroidism SNS Aortic regurg
mlr/2007
ARTERIAL LINE MONITORING SITES Radial
Low complications Allen’s test Poss median n damage b/o dorsiflexion
Ulnar Primary source hand flow Low complications Poss median n. damage
mlr/2007
ARTERIAL LINE MONITORING SITES
Brachial Medial to biceps tendon Potential median n damage
Axillary At junction pectoralis major & deltoid Safer than brachial Low thromboembolic issues
mlr/2007
ARTERIAL LINE MONITORING SITES Femoral
Easy access in shock states Potential hemorrhage (local/retroperitoneal) Requires longer catheter
Doralis Pedis Post tibial collateral circ Estimates systolic higher Contraind in DM & PVD
mlr/2007
ALLEN’S TEST
OCCLUDE ulnar and radial arteries Have pt clench fist until hand
blanches Release ulnar a with hand open Color return within 5 sec =
adequate collateral circ
mlr/2007
MODIFIED ALLEN’S TEST
Elevate arm above heart Have pt open and close fist several
times Tightly clench fist Occlude radial and ulnar a Lower hand, open fist, release ulnar
a Color return within 7 sec = OK
mlr/2007
RELATIVE CONTRAINDICATIONS
Inadequate circulation Infection at the site Recent cannulation same artery
mlr/2007
COMPLICATIONS ARTERIAL LINE Thrombosis/embolus Hematoma Infection Nerve damage/palsy Disconnect=blood loss Fistula Aneurysm Digital ischemia
mlr/2007
ARTERIAL LINE
SV: systolic ejection area under waveform
Seen from upsweep to dicrotic notch End of systole Closure aortic valve
mlr/2007
ARTERIAL LINES
mlr/2007
ARTERIAL LINE ISSUES
READINGS May be 20-40 mmHg higher and cuffs More peripheral vessel = higher
systolic, narrower waveform, delayed/lower dicrotic notch
Dorsalis pedis/femoral = 20-40 mmHg higher than brachial/radial
mlr/2007
LOSS OF WAVEFORM
Stopcock Monitor not on correct scale Nonfunctioning monitor Nonfunctioning transducer Kinked/clotted catheter asystole
mlr/2007
DAMPENED WAVEFORM
Air bubble/blood in line Clot Disconnect/loose tubing Underinflated pressure bag Catheter tip against wall Compliant tubing
mlr/2007
UNDERDAMPED WAVEFORM
Too many stopcocks Long tubing Air bubbles Defective transducer
mlr/2007
PULSUS PARDOXUS
Inspiration Dec systolic >10 mmHg
Expiration Inc systolic
mlr/2007
PULSUS ALTERNANS
Regular alteration in amplitude radial pulse waveforms
Seen in LVD/cardiomyopathies HTN AS Normal hearts with SVT
