You are on page 1of 89

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

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 No distention

Head up

mlr/2007

NONINVASIVE MONITORS

Routine

NIBP EKG Pulse ox Temperature Urine

mlr/2007

CARDIAC FUNCTIONAL ANATOMY

Low pressure system


Right heart Pulmonary Left heart Systemic

High pressure system


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 RCA and RV flow during systole

RV wall less thick

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 1960s 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 Shock Sepsis ARF Burns


mlr/2007

Complex fluid management


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 Ebsteins malformation

Tachyarrythmias

Hypercoagulation Sepsis

Site of infection
mlr/2007

SWAN-GANZ CATHETER

mlr/2007

PLACEMENT GUIDELINES

Whats the distance to SVC/RA junction?


IJ SVC Femoral RAC LAC

15-20 cm 10-15 cm 30 cm 40 cm 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


Late T-P interval

V=atrial filling (MV closed)

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 Horners

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 Carotid Brachial plexus trauma pneumothorax


mlr/2007

Risks

CVP PLACEMENT

EJ benefits

Superficial Safe Low success rate Sheath kinking at SC v. Subclavian trauma


mlr/2007

Risks

CVP PLACEMENT

Subclavian benefits

Accessible Good landmarks Pneumo Hemothorax Chylothorax Pleural effusion


mlr/2007

Risks

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


Early T-P interval

V=atrial filling/tricuspid v closed

mlr/2007

COMPLICATIONS

Arterial puncture

Catheter position during placement


Hematoma False aneurysm Fistula

Catheter shear Brachial plexus injury Thoracic duct injury


mlr/2007

Wall perf/tamponade Dysrhythmias

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 Anemia Hyperthermia Hyperthyroidism SNS Aortic regurg


mlr/2007

Inc sharp vertical in hyperdynamic states


ARTERIAL LINE MONITORING SITES

Radial

Low complications Allens test Poss median n damage b/o dorsiflexion Primary source hand flow Low complications Poss median n. damage
mlr/2007

Ulnar

ARTERIAL LINE MONITORING SITES

Brachial

Medial to biceps tendon Potential median n damage At junction pectoralis major & deltoid Safer than brachial Low thromboembolic issues
mlr/2007

Axillary

ARTERIAL LINE MONITORING SITES

Femoral

Easy access in shock states Potential hemorrhage (local/retroperitoneal) Requires longer catheter Post tibial collateral circ Estimates systolic higher Contraind in DM & PVD

Doralis Pedis

mlr/2007

ALLENS 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 ALLENS 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


mlr/2007