Hemodynamic monitoring

hemostatic monitoring

hematologic monitoring
Hemodynamic monitoring

INTRODUCTION:

Hemodynamic are the forces which circulate blood through the

body. Specifically, hemodynamics is the term used to describe
the intravascular pressure and flow that occurs when the heart
muscle contracts and pumps blood throughout the body.
 Definition:

– Hemodynamic monitoring refers to measurement of pressure ,flow

and oxygenation of blood within the cardiovascular system.
Or
– Hemodynamic monitoring is the measurement and interpretation
of biological systems that describes the performance of
cardiovascular system.
Purpose :

o Evaluate cardiovascular system

– Pressure ,flow, resistance.
o Establish baseline values and evaluate trends.
– Determine presence and degree of dysfunction
o Implement and guide intervention early to prevent problems.
o Evaluate the patient's immediate response to treatment such as drugs and
mechanical support.
o Evaluate the effectiveness of cardiovascular function such as cardiac output and
index.
 Components:

– Heart rate
– Blood pressure and MAP
– CVP
– Pulmonary artery pressure
– Systemic vascular pressure
– Pulmonary vascular pressure
– Cardiac output / Cardiac index
– Stroke volume
 Heart rate
Heart rate is the speed of the heartbeat measured by the number
of contractions of the heart permit .The heart rate can vary
according to the body's physical needs , including the need to
absorb oxygen and excrete cardon dioxide .It is usually equal or
close to the pulse measured at any peripheral point. A normal
resting heart rate for adult's ranges from 60 to 100 beats per
minute.
 Blood pressure
❑ BP is the pressure of circulating blood on the walls of blood vessels. Most of this
pressure is due to work done by the heart by pumping blood .
TYPES OF BLOOD PRESSURE:-
▪ Systolic BP:
It is specifically the maximum arterial pressure during contraction of heart. Normal
systolic pressure is 120mm of Hg.
▪ Diastolic BP:
it refers to the lowest pressure within the arterial blood stream due to expansion of
heart. The normal diastolic pressure is 80 mm of Hg
 Mean arterial pressure
▪ The mean arterial pressure( MAP) is defined as the average arterial pressure during a single
cardiac cycle.
▪ As blood is pumped out of left ventricle into the arteries pressure is generated. The MAP is
determined by Cardiac output (CO),Systemic vascular resistance(SVR) and Central venous
pressure(CVP).
▪ MAP =(CO×SVR)+CVP
(As CVP is near 0 mm of Hg relationship can be simplified as below)
▪ MAP = CO ×SVR
▪ Normal range is 70 to 110 mm of Hg
 Central Venous Pressure
▪ CVP is the pressure measured at the junction of the superior vena cava
and the right atrium.
▪ It reflects the driving force for filling of the right atrium and ventricle.
▪ It reflects the relationship of blood volume to the capacity of the venous
system.
▪ Normal CVP in awake , spontaneously breathing patient is 1 to 7 mm of Hg
▪ In mechanical ventilation, it is 3 to 5 cm of H2O
▪ In Cardiopulmonary bypass patient’s CVP is always zero
INDICATIONS:

– Fluid administration
– TPN hypertonic solutions
– Vasoactive infusions
– Monitoring for right atrial pressure (CVP)

SITES:

– Internal jugular
– Subclavian
– Brachial
– Femoral
 Pulmonary Artery Pressure

The PA pressure is a measure of the blood pressure found in the

main pulmonary artery .This is measured by inserting a catheter
into the main pulmonary artery. The mean pressure is typically 9
to 18 mm of Hg, and the wedge pressure measured in the left
atrium may be 6 to 12 mm of Hg.
 Systemic Vascular Pressure (SVR)
SVR refers to the resistance to blood flow offered by all the systemic vasculature ,
excluding the pulmonary vasculature . SVR can be calculated by cardiac output , mean arterial
pressure, and central venous pressure are known .

Pulmonary Vascular Pressure (PVR)

It is the resistance to the flow of the blood through the pulmonary circulation is known as
pulmonary vascular resistance
▪ The ratio of pulmonary to systemic vascular resistance is approximately 1:6.
▪ It is because the vascular resistance to flow that we need the heart in the cardiovascular
system .
 Cardiac Output
▪ Volume of blood pumped by each ventricle in one minute.
▪ CO = Heart rate (HR)×Stroke volume(SV)
▪ Normal cardiac output is about 5 to 6 liters of blood every minute when a person is resting

Cardiac Index (CI)

▪ Cardiac index is a hemodynamic parameter that relates the cardiac output from left ventricle in one minute to body surface
area , thus relating heart performance to the size of the individual .
▪ CI = CO/BSA = (SV ×HR)/BSA
▪ The normal CI is 2.5 to 4.5 L/min/M2
▪ This is a more accurate indicator of cardiac function than cardiac output
▪ A minimum of 2.0L/min/M2 is required to maintain life without mechanical support
 Stroke Volume
▪ Stroke volume (SV)is the volume of blood pumped out of each ventricle per beat or
contraction .
▪ As the stroke volume increases ,the cardiac output also increases
▪ Stroke volume depends upon
• End diastolic volume (EDV)
• Contractility
SV = EDV- ESV
(ESV=end systolic volume)
Continuous monitoring during CPB

❑ Reservoir level
❑ Blood flow at proper rate / flow rate
❑ Pressure line /arterial line pressure
❑ Blood pressure /patients' arterial pressure 50-90
mm of Hg
❑ Oxygen saturation
❑ Temperature appropriate
❑ ECG
❑ Venous oxygen saturation 65%-75%
Intermittent monitoring during CPB

❑Blood gas
❑Urine output minimal 0.5-1 ml/Kg/min
❑Electrolyte
❑ACT
 ❑ MAP =70-90 mm of Hg
❑ CI= 2.2-4.0 L/min
❑ CO= 4-8 L/min
❑ CVP (Also known as right atrial pressure)
= 2-8 mm of Hg
Normal ❑ Pulmonary Artery pressure (PA) =

values ▪ PAS=20-30 mm of Hg
▪ PAD= 4-12mm of Hg
▪ Mean=15-25 mm of Hg
❑ Pulmonary capillary wedge pressure
(PWCP)= 6-12 mm of Hg
❑ Systemic vascular resistance (SVR)= 800-
1200
 INTRODUCTION:
– The hemostatic management of patients undergoing
cardiac surgery is a complex issue because there exists the
need to maintain a delicate balance between :
Hemostatic ANTICOAGULATION FOR CARDIOPULMONARY BYPASS and
HEMOSTASIS after CPB.
monitoring – These two opposing goals must be managed carefully and
modified with the respect of the patient's initial
hematologic status , specific time during surgery and
desired hemostatic outcome.
– After surgery coagulation abnormalities, platelet
dysfunction and fibrinolysis can occur, creating a situation
whereby hemostatic integrity must be restored.
 Normal coagulation pathway

The coagulation pathway is a cascade of events that leads to hemostasis. The intricate
pathway allows for rapid healing and prevention of spontaneous bleeding .
Two paths, intrinsic and extrinsic , originate separately but converge at specific point ,leading
fibrin activation . The purpose is to ultimately stabilize the platelets with a fibrin mesh.
The function of the coagulation pathway is to keep hemostasis, which is the blockage of the
bleeding or hemorrhage.
 Heparin
It is also known as unfractionated heparin , is a medication and naturally occurring glycosaminoglycan . As a medication it
is used as an anticoagulation agent.
❑ Found most in mast cells
❑ Strongest macromolecular acid in the body
SOURCES OF HEPARIN
▪ First isolated from liver extract
▪ Porcine intestinal mucosa
▪ Bovine lung
❑ Heterogenous mixture of molecules from 3000 to 40000 Dalton
❑ Batch to batch heparin preparation may have different activity level per milligram .
❑ Standardized activity levels reported in units 100units = 1mg
MECHANISM OF ACTION OF HEPARIN
❑ Heparin act as a catalyst for antithrombin (3) to accelerate the neutralization of
• Thrombin
• 10a
• 9a
• 10a
• 11a
• 12a/TF complex

DOSAGE OF HEPARIN
❑ The initial dose for 200 to 400 units/Kg
❑ The maintenance dose is 50 to 100 units /Kg ( administered any where between 30 min
to 2 hour)
❑ The extracorporeal circulation was primed with bank blood that was heparinized in the
dose of 2500 to 5000 units /unit of blood
 Monitoring of Heparin effect
❑ The anticoagulant effect of heparin should be monitoring functionally before
instituting CPB.
❑ The administration of heparin does not guarantee that all patients will be
adequately anticoagulated because there are differences in levels of circulating
co-factors and inhibitors that can alter the pharmacokinetics and
pharmacodynamics of the drug

HEPARIN RESISTANCE
❑ Heparin resistance is documented by an inability to raise the ACT to expected
levels despite an adequate dose and plasma concentration of heparin .
❑ Heparin resistance occurs in up to 22% of patients undergoing cardiac surgery
requiring cardiopulmonary bypass and it is associated with decreased levels of
antithrombin .Treatment options for heparin resistance include administration
of antithrombin or fresh frozen plasma.
Adverse effects of heparin

❑ Bleeding
❑ Deep vein thrombosis
❑ Heparin induced hyperkalemia
❑ Heparin induced thrombocytopenia
ALTERNATIVES OF HEPARIN
❑ Low molecular weight heparin (LMWH)
❑ Dermatan sulphate
❑ Hirudin
❑ Ancrod
❑ Streptokinase and urokinase
HEPARIN COATED SURFACE
❑ Binding of heparin to the internal surface of the CPB circuit ,the need for
heparinization during CPB may be reduced .
❑ The use of heparin coated circuit in combination with full systemic
heparinization has been shown to better than uncoated circuit in terms of
platelet preservation and postoperative bleeding
 Activated Clotting Time

❑ Functional tests of heparin activity are related to the whole blood clotting time .
❑ The whole blood clotting time required that whole blood placed in a glass tube
,maintained at 37℃ , and manually titled until blood fluidity was no longer detected .
❑ Glass tube containing diatomaceous earth (ciliate ),kaolin or a combination of activators .
❑ The presence of an activator augments the contact activation phase of coagulation ,
which stimulates the intrinsic coagulation pathway.
❑ Detection of ACT values can be performed manually but is more commonly by
automated method , as in Hemochron and Hemo Tec systems.
MONITERING OF ACT
❑ Bull et al (1975) recommended structured approach using ACT monitoring.
❑ They adopted ACT of 480 sec as safe value
▪ ACT below 180 sec – life threatening
▪ Between 180 to 300 sec – questionable
▪ ≥600 – unwise
❑ Monitor ACT in every 30 min during CPB
❑ If ACT decreases below desired min. value , doses of heparin of 50 to 100 units /Kg given .

LIMITATION OF ACT
❑ ACT values may prolong by following factors
▪ Hypothermia
▪ Hemodilution
❑ Aprotinin : A serine protease inhibitor , is used for blood conversation during open heart
surgery . Maintain ACT value ˃ 750 when aprotinin is used
 protamine

– Protamine is used after cardiopulmonary bypass to reverse the anticoagulant effect of heparin restore
coagulation.
– Convincing evidence from in-vitro and in-vivo studies suggest that an overdose of protamine has
anticoagulant effects which might lead to bleeding complication
– 1 to 1.3 mg protamine is administrated for each 100 units of heparin .
– Protamine should not administrate faster than 5mg per minute or average dose not greater than 200mg
in 40 minutes.
– The sight of administration should be left side of circulation (LA , aorta ) or peripheral subsequent
dilution
Other agents

– Platelet factor 4
– Aprotinin
– Desmopressin acetate
– Epsilon aminocaproic acid and tranexamic acid
– EACA is used to treat excessive bleeding after CPB
– TA also show reduced chest drainage and blood transfusion requirement.
Evaluation of coagulation
abnormalities
❑ Test for coagulation mechanism
– Whole blood clotting time
– ACT
– Protamine titration test
– PT
– APPT
❑ Test for platelet function
– Platelet count
– Bleeding time
– Platelet aggregation and adhesion
❑ Test for fibrinolysis
– Fibrinogen and fibrin degradation
product
– thromboelastographic
 Hematological monitoring mainly includes the
monitoring of the components of the blood and
HEMATOLOGICAL its necessary correction . The main changes that
MONITERING can take place in blood concentration is its pH
leading to acidosis or alkalosis . This can be
monitored by the help of Blood gas analysis.
Variables get from a blood gas analyzer

▪ Temperature - 37˚c
▪ PH - 7.35 -7.45
▪ PCO2 - 35 - 45 mm of Hg
▪ PO2 - 100 -150 mm of Hg
▪ Bicarbonate - 22 – 26 mm of Hg
▪ Saturated bicarbonate (SBC) - 22 – 26 mm of Hg
▪ Bases excess - -2 to +2
▪ Oxygen saturation - ˃ 95%
▪ Hemoglobin (HB) - 11.5 – 13.5 g/dL
 Blood gas interpretation
❑ ACIDOSIS
It is the condition of having a lower pH than the normal pH of blood . The PH of blood is
below 7.35 . The types are
▪ Metabolic acidosis – metabolic acidosis is fall in pH due to loss of HCO3-
▪ Respiratory acidosis – respiratory acidosis is fall in pH due to rise in PCO2
❑ ALKALOSIS
It is the condition having a higher pH than the normal pH of the blood. The pH of blood is
above 7.45. The types are
▪ Metabolic alkalosis – metabolic alkalosis is rise in PH due to rise in HCO3-
▪ Respiratory alkalosis – respiratory alkalosis is rise in pH due to fall in PCO2
Respiratory acidosis and alkalosis is treated by adjusting the oxygen blunder and sweep gas .
– Metabolic acidosis is treated with NaCo3
– Sweep = gas rate (L/min)
– Increase sweep to lower PCO2
– Decrease to raise PCO2
 ABG (Arterial Blood Gas)

❑ An arterial blood gas test measures the amounts of arterial gases , such as oxygen
and carbon dioxide . An ABG test requires that a small volume of blood be drawn from
the radial artery with a syringe and a thin needle , but sometimes the femoral artery in
the groin or another site is used .
❑ Arterial blood gas analysis is an essential part for diagnosing and managing the patient’s
oxygenation status , ventilation status ,and acid –base balance .
 ▪ Temperature – 37 c ▪ SBE 3.8(-3 - +3)m mol/l
▪ pH- 7.35 -7.45 ▪ HCT 35 -45
▪ PCO2 -35- 45 mm of Hg ▪ HCo3 22 – 26 m mol/l
▪ PO2 100 -150 mm of Hg ▪ Ca2+ - 1.15-1.29 m mol /l
▪ Hb 12-17g /dl ▪ Urea 15 – 25 m mol/l
Normal ▪ SO2 95-100% ▪ Creatine 0.5 -1.5

ABG values ▪ Na+136-146 m Eq/l

▪ K+3.5-4.5 m Eq/l
▪ Cl- 92-108 m Eq/l
▪ Lac 0.5-1.5 m Eq/l
▪ ABE 3.6
▪ Base 3.6(-2 - +2)m mol/l