Hemodynamic

Monitoring
RESOURCE PERSON:

PRESENTED BY:
ADHYTYA PRATAMA AHMADI ; MUTHIA SYARIFA YANI

DEPARTEMEN KARDIOLOGI DAN KEDOKTERAN VASKULAR

FAKULTAS KEDOKTERAN UNIVERSITAS INDONESIA
AGUSTUS 2021
 Outline

DEFINITION PRINCIPLES METHODS NON-INVASIVE INVASIVE

METHODS METHODS
DEFINITION
The term hemodynamics describes the physical factors
governing blood flow within the circulatory system.

Optimal cardiac function ensures adequate

perfusion and oxygenation of other organ systems

Hemodynamic instability, causing a mismatch

between oxygen delivery and demand, is a major
contributive factor for organ failure

Critically ill pts => not adequate standard vital sign

monitoring
Mixed Venous Oxygen Saturation (SvO2): assess adequacy tissue perfusion and
oxygenation
Monitor the SvO2 in the pulmonary artery: PA catheter
Goal SvO2 >60%
fall in SvO2 generally → decreased oxygen delivery / increased oxygen
extraction by tissues → suggestive of a reduction in CO
 CO = SV x HR

SV= LVEDV – LVESV

Preload assessed by measurement of left-sided filling
pressures using pulmonary artery catheter (Swan-Ganz)
Pulmonary artery diastolic (PAD) pressure
Pulmonary capillary wedge pressure (PCWP)
Intraventricular systolic pressure and wall thickness
Determined by Preload (Laplace’s law relating radius to wall tension)
& SVR
Laplace relationship
P= Ventricular Pressures
r= Ventricular chamber radius
h= Ventricular wall thickness

SVR measurements obtained from the Swan-Ganz catheter (indirect)

Reflects systolic function as assessed by the ejection fraction, but is only
indirectly related to the cardiac output.
Improved by increasing preload or heart rate, decreasing the afterload, or using
inotropic.
Assessed by Ejection Fraction
Lilly LS, Pathophysiology of Heart Disease. Philadephia: Wolters Kluwer.
PROBLEM MONITOR

Adequate
Tissue
Oxygen
Hypoperfusion
Delivery
 Central
Venous Heart Rate
Pressure

Blood Pressure
-Invasive
-Noninvasive
 • Tachycardia, Tachypnea
• Prolonged Capillary Refill
• Increased Temperature
Difference
• Reduced Level of Consciousness
Clinical • Decreased Urine Output
• Diaphoresis
Estimation • Cool Peripheries

• Lactate
Lab Values • Base Excess

Measurement of • Invasive &

Non-Invasive
CO and/or SvO2% • New vs. Old
Vincent JL, et al. Clinical review: Update on hemodynamic monitoring - a consensus of 16. Critical Care 2011;15:229.
 Clinical Variables

Blood Pressure

ECG

O2 Saturation
Non-invasive
Echocardiography
Hemodinamic
Monitoring
Techniques Thoracic Electrical Bioimpendance

Partal Carbon Dioxide Rebreathing

Central Venous Catheter

Invasive
Pulmonary Artery Catheter

Arterial Catheterization
 1. Clinical variables
2. Blood Pressure
3. ECG
4. O2 saturation
5. Echocardiography
6. Thoracic Electrical Bioimpedance
7. Partial Carbon Dioxide Rebreathing

Vincent JL, et al. Clinical review: Update on hemodynamic monitoring - a consensus of 16. Critical Care 2011;15:229.
o Performed and interpreted bedside
o Advantage:
o Anatomy & Function
o Etiology
o CO, SVR, SV, eRAP
o Guide the management of critically ill
patients
o Disadvantage:
o Not continuous
o Operator dependent
o Time consuming
Vincent JL, et al. Clinical review: Update on hemodynamic monitoring - a consensus of 16. Critical Care 2011;15:229.
Porter TR, Shillcutt SK, Adams MS, et al. Guidelines for the Use of Echocardiography as a Monitor for Therapeutic Intervention in Adults:
A Report from the American Society of Echocardiography. J Am Soc Echocardiogr 2015;28:40-56.
Huang SJ, McLean AS. Appreciating the Strengths and Weaknesses of Transthoracic Echocardiography in Hemodynamic
Assessments. Cardiology Research and Practice 2011;2012:1-7.
M-MODE, 2D, DOPPLER
 DETERMINANTS OF
CARDIAC
PERFORMANCE
Preload
• Estimated by end-diastolic volume
(pressure)
• CVP for RVEDV, PAOP (wedge) for
LVEDV
Afterload
• SVR = [MAP-CVP]/CO x 80

Contractility

Calculated Monitoring
Parameters:
Stroke Volume (SV), Cardiac Output (CO),
and SVR Calculations Hollenberg SM. Hemodynamic Monitoring. CHEST 2013;143(5): 1480–8.
 Oxygen
Delivery

Cardiac Arterial Oxygen

Output (CO) Content (CaO2)

Stroke
Heart Rate Hemoglobin SaO2 PaO2
Volume

Preload Afterload Contractility

(IVC) (SVR) (LVEF)

Klabunde RE. Cardiovascular Physiology Concepts Second Edition. Philadelphia: Lippincott Williams & Wilkins.
  PW Doppler Mode → SV
through a site (such as
the RV outflow tract
[RVOT] or LV outflow
tract [LVOT]) can be
calculated using two
variables:
 the velocity-time integral (VTI),
or stroke distance,
 the cross sectional area of the
site (RVOT or LVOT)

SV = LVOT diameter (cm2) x VTI (cm)

Cardiac Output = SV X HR
 SVR CALCULATIONS

 Using IVC collapsibility indices to estimate RAP, and

arm blood pressure measurements to calculate mean
arterial pressure, SVR (in Wood units) can be calculated:


SVR = MAP – RAP (mmHg) x 80
CO (L/min)
 To convert this to conventional SVR units
(dynes.sec/cm5) this value should be multiplied by 80
 Hypovolemic →
 size
 collapsibility of the IVC for
estimation of RAP (2D & M-
Mode)
 Exaggerated response in
IVC collapse occurs in
patients in the
hypovolemic state during
inspiration

Porter TR, Shillcutt SK, Adams MS, et al. Guidelines for the Use of Echocardiography as a Monitor for Therapeutic Intervention in Adults: A Report from the American
Society of Echocardiography. J Am Soc Echocardiogr 2015;28:40-56.
 IVC collapse will not occur in patients on positive
pressure ventilation → should not be used to
monitor RAP

Porter TR, Shillcutt SK, Adams MS, et al. Guidelines for the Use of Echocardiography as a Monitor for Therapeutic Intervention in Adults: A
Report from the American Society of Echocardiography. J Am Soc Echocardiogr 2015;28:40-56.
  Dimension:
 Examination of volume status.
 A small LV internal diameter at end-
diastole (LVIDD) → hypovolemia.
 LVEF – systolic function
 Regional Wall Motion Abnormality
– infarct? Contractility cause?

Reference ranges for LVIDD are 3.9 to 5.3 cm in

women and 4.2 to 5.9 cm in men.

Porter TR, Shillcutt SK, Adams MS, et al. Guidelines for the Use of Echocardiography as a Monitor for Therapeutic Intervention in Adults: A
Report from the American Society of Echocardiography. J Am Soc Echocardiogr 2015;28:40-56.
 Mitral inflow velocities:
1. peak early diastolic
velocity (E) – preload
dependent
2. late diastolic velocity
(A) – LA compliance &
affected by changes in
LV diastolic function

Determine patterns of
diastolic dysfunction,
& serially monitor LAP

Mitral inflow
velocities (E wave, A
wave, DT, and E/A
ratio) are measured in
the apical 4C view
using PW Doppler

Porter TR, Shillcutt SK, Adams MS, et al. Guidelines for the Use of Echocardiography as a Monitor for Therapeutic Intervention in Adults: A
Report from the American Society of Echocardiography. J Am Soc Echocardiogr 2015;28:40-56.
Tissue Doppler Imaging (TDI)
• Sensitive indicator of LV diastolic function
• Serial assessment of LAP to guide fluid therapy (when systolic function is
normal)

RV Systolic Function
• TAPSE, RVIDD & FAC

PA Systolic Pressure
• PASP= RAP + RV-RA gradient
(4x peak tricuspid regurgitant jet velocity – CW Doppler)

Porter TR, Shillcutt SK, Adams MS, et al. Guidelines for the Use of Echocardiography as a Monitor for Therapeutic Intervention in Adults: A
Report from the American Society of Echocardiography. J Am Soc Echocardiogr 2015;28:40-56.
Assesment View Modality Measurement
Filling Status A4C 2D LV Area/ Volume

IVC Dimension; respiration

variation of Doppler LVOT
Fluid Responsiveness Subcostal; A5C 2D, PW Doppler
velocity in mechanically
ventilated patient

Mitral and pulmonary vein

LV filling pressure A4C PW Doppler; TDI Doppler indices; Diastolic
velocity of Mitral Ann (TDI)

LVOT diameter;
Cardiac Output PLAX & A4C 2D; PW Doppler
LVOT Doppler VTI
PASP PSAX & A4C CW doppler TR peak velocity
PVR PSAX PW Doppler Pulm. Acc Time
 Porter TR, Shillcutt SK, Adams MS, et al. Guidelines for the
Use of Echocardiography as a Monitor for Therapeutic
Intervention in Adults: A Report from the American Society
of Echocardiography. J Am Soc Echocardiogr 2015;28:40-56.
Porter TR, Shillcutt SK, Adams MS, et al. Guidelines for the Use of Echocardiography as a Monitor for Therapeutic Intervention in Adults: A Report from the American
Society of Echocardiography. J Am Soc Echocardiogr 2015;28:40-56.
M-mode/2D findings Hemodynamic Abnormality
Fluttering of mitral valve Aortic regurgitation
Midsystolic aortic valve closure Dynamic obstruction of LV outflow tract
Midsystolic pulmonary valve closure Pulmonary hypertension
Dilated RV & D-shape LV Increased RV systolic pressure
Dilated IVC with lack of inspiratory Increased RA pressure
collapse
Persistent bowing of atrial septum
To RA Increased LA pressure
To LA Increased RA pressure
Diastolic RA & RV wall inversion/collapse Cardiac Tamponade

Porter TR, Shillcutt SK, Adams MS, et al. Guidelines for the Use of Echocardiography as a Monitor for Therapeutic Intervention in Adults: A
Report from the American Society of Echocardiography. J Am Soc Echocardiogr 2015;28:40-56.
Bioimpedance is based on the
fact that the conductivity of a high-
frequency, low-magnitude alternating
current passed across the thorax
changes as blood flow varies with each
cardiac cycle
 Electrodes placed on a patient’s chest
and used to generate a waveform from
which cardiac output can be calculated
Bioreactance measures changes
in the frequency of the electrical
currents transversing the chest → less
sensitive to noise

Hollenberg SM. Hemodynamic Monitoring. CHEST 2013;143(5): 1480–8.

 CO2 rebreathing systems, based
on the Fick principle
 Using CO2 sensor, a disposable
air flow sensor and a
disposable rebreathing loop
 CO2 production is calculated from
minute ventilation and its CO2
content
 Arterial
CO2 content is estimated
from end-tidal CO2
 Estimate Cardiac Output but
does not provide information
on the intravascular volume
status or fluid responsiveness.
Hollenberg SM. Hemodynamic Monitoring. CHEST 2013;143(5): 1480–8.
• Central Venous
Catheter
• Pulmonary Artery
Catheter
• Arterial
Catheterization
  One of the most commonly performed
procedures in the ICU
 CVC insertion site
 Internal jugular vein
 External jugular vein
 Subclavian vein
 Femoral vein
 Antecubiti vein

Richard SI, James MR, Alan L. Stephen O. Procedure, technique, and minimally invasive monitoring in
intensive care in intensive care medicine, 4th edition. Lipincott Williams & Wilkins. 2008
  Invasive haemodynamic monitoring.
 Measure right atrial pressure (RAP)
 Assess blood volume; reflects preload to the right side of the heart

 Assess right ventricular function

 Infusion site for large fluid volume

 Infusion site for hypertonic solutions
 Access, e.g. for pacing wire insertion.
 Emergency access when peripheral circulation is ‘shut down’ .
 Renal replacement therapy, plasmapheresis, exchange
transfusion.

Richard SI, James MR, Alan L. Stephen O. Procedure, technique, and minimally invasive monitoring in
intensive care in intensive care medicine, 4th edition. Lipincott Williams & Wilkins. 2008
 Relative contraindication:
 At sites with anatomic distortion
 Area with indwelling intravascular hardware
 Vascular injury proximal to the insertion
 Coagulopathy and/or thrombocytopenia

UpTodate. Central venous catheter.

2016
 Pressure at Central Vein

Normal : • 2-6 mmHg

Low : • hypovolemia
• extreme vasodilatation

• fluid overload
High: • pulmonary hypertension
• severe vasocontriction,

Richard SI, James MR, Alan L. Stephen O. Procedure, technique, and minimally invasive monitoring in
intensive care in intensive care medicine, 4th edition. Lipincott Williams & Wilkins. 2008
 Observe morphology of trace
 The classic ‘a, c, v’ pattern may not always be obvious.
CVP morphology may give a clue to an underlying
pathological process.
 CVP CLASSIC TRACE

COMPLICATION
Immediate
Bleeding
Arterial puncture
Arrhythmia
Air embolism
Thoracic duct injury (with left SC or left IJ
approach)
Catheter malposition
Pneumothorax or hemothorax
Delayed
Infection
Venous thrombosis, pulmonary emboli
Catheter migration
Catheter embolization
Myocardial perforation
Nerve injury
UpTodate. Central venous catheter. 2016
  Pulmonary artery catheters
(PACs; also called Swan-Ganz
catheters)
 The routine use of PAC has
fallen out of favour

Richard SI, James MR, Alan L. Stephen O. Procedure, technique, and minimally invasive monitoring in intensive care in intensive care medicine, 4th edition.
Lipincott Williams & Wilkins. 2008
 Cardiogenic
(acute MI)  Monitoring the effectiveness of therapy
 Pulmonary artery hypertension
Many critically  Monitoring severe underlying
ill patients cardiopulmonary disease who are
exhibit elements
of more than 1 Hypovolemic undergoing corrective or other surgery
shock Identification
classification of the type
of shock

Obstructive
Distributiv
(PE, Cardiac
e (septic) Tamponade)

UpTodate. Pulmonary Artery catheter.

2016
 Central venous pressure (CVP)

Right-sided intracardiac pressures (right atrium,

right ventricle)

Pulmonary arterial pressure (Pap)

Direct measurements

Pulmonary capillary occlusion pressure (PCOP; pulmonary

capillary wedge pressure [PCWP])

Cardiac output (CO)

Mixed venous oxyhemoglobin saturation (SvO2)

UpTodate. Pulmonary Artery catheter.
2016
 Proximal port – [Blue] used to
measure CVP/RAP and injectate
port for measurement of CO
 Distal
port – [Yellow] used to
measure PAP
 Balloonport – [Red] used to
determine PCWP
 Infusion port – [White] used for
fluid infusion
 Thermistorport – measure core
body temprature

Robin Mathews, David L. Brown. Invasive Hemodynamic Monitoring in the Cardiac Intensive Care Unit. In Cardiac Intensive Care
2nd edition. 2010
PAC monitor the:
 Pressure
 Waveform

Stultz D, Introduction to Swan Ganz Catheterization, 2003

 RA pressure
Elevated at:
• Decreased right (or single) ventricle compliance
• Tricuspid valve disease
• Intravascular volume overload
• Cardiac tamponade
• Tachyarrhythmia
Reduced at
• low intravascular volume status
• inadequate preload

Richard SI, James MR, Alan L. Stephen O. Procedure, technique, and minimally invasive monitoring in
intensive care in intensive care medicine, 4th edition. Lipincott Williams & Wilkins. 2008
 Abnormal RA waveforms include the
following:
 Tall v waves
 Tricuspid regurgitation
 Giant/cannon a waves – Conditions
associated with atrioventricular
dissociation
 Ventricular tachycardia or ventricular
pacing
 Complete heart block
 AV nodal tachycardia
 Tricuspid stenosis
 Loss of a waves
 Atrial fibrillation
 Atrial flutter

Update. Pulmonary Arterial Catheter. 2016

 Elevated RV systolic pressure:  Elevated RV end-diastolic pressure:
 Pulmonary hypertension  Cardiomyopathy
 Pulmonic stenosis  RV ischemia
 Pulmonary embolism  RV infarction
 cardiac constrictio
 cardiac tamponade
 RV failure secondary to
pulmonary hypertension

UpTodate. Pulmonary Arterial Catheter.

2016
 ARTERY

The mean PA pressure can be

elevated by:
• pulmonary hypertension
• hypoxemic-induced
vasoconstriction in a
patient with underlying
chronic cardiopulmonary
disease

UpTodate. Pulmonary Arterial Catheter.

2016
➢Estimates the left atrial
pressure → estimated left
ventricular end diastolic ●Hypervolemia
pressure ●Large right-to-left shunts
➢Pulmonary artery wedge ●Cardiac tamponade, constrictive
pressure elevated at: and restrictive cardiomyopathies
●Left ventricular systolic
heart failure
●Left ventricular diastolic ➢Pulmonary artery wedge pressure
heart failure decreases at:
●Mitral and aortic valve ●Hypovolemia
disease ●Obstructive shock due to large
●Hypertrophic pulmonary embolism
cardiomyopathy

UpTodate. Pulmonary Arterial Catheter.

 Pneumothorax

Arterial Injury

Infection

Thrombosis and embolization

Arrhytmias (ventricular irritation)

Pulmonary Artery Rupture

Pulmonary infarct

Robin Mathews, David L. Brown. Invasive Hemodynamic Monitoring in the Cardiac Intensive Care Unit. In Cardiac Intensive Care 2nd
edition. 2010
• Arterial Line Catheterization is
a cannula that inserted in
peripheral artery
• Common locations: radial,
femoral, axillary, dorsalis pedis

Slideshare.net. Hemodynamic monitoring

  Need for continuous blood pressure measurement
 Hemodynamic instability
 Vasopressor requirement
 major surgery
 hypertensive emergency

 Frequent arterial blood gas assessments

 Respiratory failure
 Continuous monitoring of cardiac output and stroke volume are needed but it is impractical
to place a pulmonary artery catheter

 Common locations: radial, femoral, axillary, dorsalis pedis

Robin Mathews, David L. Brown. Invasive Hemodynamic Monitoring in the Cardiac Intensive Care Unit. In Cardiac Intensive Care 2nd edition.
2010
  Hemorrhage
 Hematoma
 Thrombosis
 Embolization
 Pseudoaneurysm
 Infection

Robin Mathews, David L. Brown. Invasive Hemodynamic Monitoring in the Cardiac Intensive Care Unit. In Cardiac Intensive Care 2nd edition.
2010
Giraud R, Bendjelid K. Hemodynamic monitoring in the ICU. Geneva:Springer International Publishing. 2016.