Monitoring Hemodynamic

8/11/2019 Monitoring Hemodynamic

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Monitoring HemodynamicSuparto

Anesthesia Department FK UKRIDA


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Preoperatif: Anamnesis

Riwayat Keluarga Riwayat operasi sebelumnya Riwayat perokok, alkohol? Alergi? Mengkonsumsi obat-obat rutin?

Pemeriksaan Fisik Pemeriksaan lab: DR, PT, aPTT, elektrolit Pemeriksaan radiologis, EKG Edukasi tentang prosedur Inform Consent, ASA atau physical status Instruksi: Premedikasi, puasa

Pemeriksaan Fisik


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A.S.A (American Society of Anesthesiology) Class I Tidak ada kelainan organ fisiologi, biologi dan

psikiatri Class II Mild to Moderate systemic disturbance Class III Moderate to severe systemic disturbance Class IV Life threatening Class V Moribund, pasien yang tidak diharapkan

hidup dalam 24 jam, Tidak perlu dioperasi Operasi Emergency (E)


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Intraoperative Anestesi umum/ Anestesi Regional

Monitoring hemodinamik Perioperative fluid requirement:

Hitung preoperative Defisit cairan:(kebutuhan cairan/jam x jam puasa)

Koreksi defisit cairanJam I: 50% defisit + maintenance

Jam II: 25% defisit + maintenance

Jam III: 25% defisit + maintenance


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Third-space losses Operasi besar (Eks laparatomi bowel surgery, Hip

replacement, cardio thorasic surgery, vascular surgery): 6-10 ml/kg/jam

Operasi sedang (Ekstremities surgery, appendectomy,TURP, breast surgery, obgyn surgery) : 4-6 ml/kg/jam

Operasi kecil (cataract surgery) : 2-4 ml/kg/jam Estimasi volume darah:

Adult 70 cc/kg Maximal allowable blood loss:

15-20% dari estimasi volume darah


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Estimasi darah yang hilang

Darah yang tertampung di botol penampung Kain kasa, kain penutup

Replacing blood loss: Crystalloid, colloid

Hb 7-8 g/dL (Ht 21-24%) Elderly Hb 10 g/dL

1 unit of red blood cells : Hb 1 g/dL and Ht 2 -3% inadults

10 ml/Kg transfusion of red blood cells Hbconcentration by 3 g/dL and Ht by 10%


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Post Operative Cairan maintenance Pain control : NSAID, Opioid


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Tujuan utama: Keselamatan pasien Pemantauan adalah

Menginterpretasikan data yang ada untukmembantu mengenali kelainan atau kondisi sistemyang tidak diharapkan, yang sedang atau akanterjadi (D. John Doyle, MD. Cleveland Clinic Foundation)


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Standar Perilaku untuk Pemantauan Anestesia

1. Anestesiologis harushadir dan menjagakeselamatan pasien

sepanjang proseduranestesia


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2. Semua peralatan harusdiperiksa sebelumdigunakan


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3. Alat pantau harusterpasang sejaksebelum induksi hingga

pulih dari anestesia


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4. Selama prosedur, semua parameter harusdievaluasi ulang


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5. Data yang diperoleh dari alat pantau harus terekamdalam rekaman medis anestesia


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6. Standar ini berlaku untuk semua tindakan

anestesia (MAC, Sedasi, Anestesia regional,Anestesia umum)


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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 HRDetect and diagnosedysrhytmiaMyocardial 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 cover2/3 of upper arm orthigh

Palpation:A. radial (80mmHg)

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

Mean Arterial PressureMAP = sis + 2 Dias/ 3Normal: 60-70mmHg


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Mean Arterial Pressure (MAP): Reflectschanges in the relationship between cardiacoutput (CO) and systemic vascular resistance(SVR) and reflects the arterial pressure in the

vessels perfusing the organs. A low MAP indicates decreased blood flow

through the organs.

A high MAP indicates an increased cardiacworkload.


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Cardiac Output (CO): The volume of bloodpumped by the heart in one minute.

Increased cardiac output may indicate a highcirculating volume.

Decreased cardiac output indicates a decrease incirculating volume or a decrease in the strength of

ventricular contraction.


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Systemic Vascular Resistance (SVR) : Themeasurement of resistance or impediment ofthe systemic vascular bed to blood flow.

An increased SVR can be caused byvasoconstrictors, hypovolemia, or late septicshock.

A decreased SVR can be caused by early septic

shock, vasodilators, morphine, nitrates, orhypercarbia.


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Stroke Volume (SV): The amount of bloodpumped by the heart per cardiac cycle. It ismeasured in ml/beat.

A decreased SV may indicate impaired cardiaccontractility or valve dysfunction and may result inheart failure.

An increased SV may be caused by an increase incirculating volume or an increase in inotropy.


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Joint National Commitee 7 th ,2004


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Arterial BP indication Tight BP control Unstable patient Arterial blood sampling


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Central Venous Catheter CVP (Central Venous

Pressure) At the vena cava or

Right atrium Measurement of right

filling pressure to assessintravascular volumeand right heart function

Drug administration IV access Accsess for insertion

PAC (using introducer)


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Normal CVP is 2 to 12mmHg

Complication: Dysrhythmias Arterial puncture Pneumothorax Hemothorax Infection, air embolism


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Contraindication CVC insertion:1. Tumor at RA

2. Tricuspid vegetation3. Post carotid endarterectomy ipsilateral4. Coagulopathy


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Causes of increased pressure: Right sided heart failure Volume overload Tricuspid valve insufficiency or stenosis

Pulmonary hypertension Cardiac tamponadeCauses of decreased pressure Reduced circulating blood volume


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Pulmonary Artery Catheter


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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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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 distaltissues.

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 mmHgunder Generalanesthesia


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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 kedalamananesthesia darimendeteksi dan rekamangelombangelektroensefalogram(EEG)

Tingkat anestesi nilainya40-60 (100 artinya sadarpenuh)


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Train of Four Mengukur tingkat

blokade oleh

pelumpuh otot memberikan 4

stimulus berturutandengan frekwensi 2Hz selama 2 detik

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Monitoring Hemodynamic