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CLINICAL MEASUREMENT

Prof. Serban Bubenek MD
ESA - EDA Basic Sciences Course
PARIS 2012

Monitoring in Anaesthesia
and Intensive Care

2

Monitoring: A
Definition
• ... interpret available clinical
data to help recognize present or
future mishaps or unfavorable
system conditions
• ... not restricted to anesthesia
(change “clinical data” above to “system
data” to apply to aircraft and nuclear power
plants)

evaluation. Severity assessment. interpretation. decision • Problem seeking. Therapeutic assessment. Evaluation of Anesthetic interventions .What is monitoring? • Physiologic parameter & Patient safety parameter • Clinical skills & Monitoring equipment • Data collection.

differential diagnosis and response algorithm formulation) . such as BP or HR) • Things you observe (e. unilateral air entry may mean endobronchial intubation) • Planning to get out of trouble (e.g.Patient Monitoring and Management Involves … • Things you measure (physiological measurement.g.g. planning induction of anesthesia or planning extubation) • Inferring diagnoses (e. observation of pupils) • Planning to avoid trouble (e.g.

Level of monitoring • Routine / Specialize / Extensive • Non-equipment / Non-invasive / Minimally invasive / Penetrating / Invasive / Highly invasive • Systematic – Respiratory / Cardiovascular / Temperature/Fetal – Neurological / Neuro-muscular / Volume status & Renal • Standards for basic intraoperative monitoring ( ASA) .

MAC Standard II – During all anesthetics. oxygenation). RA.Standards for basic intraoperative monitoring ( ASA : American Society of Anesthesiologists) Standard I – Qualified anesthesia personnel shall be present in the room throughout the conduct of all GA. circulation and temperature shall be continually evaluated . the patient’s respiratory (ventilation.

values) 2. limitations.Monitoring in Anesthesia OBJECTIVES: 1. Insertion sites. limitations. Oxygenation. Temperature) 2. Guidelines to the practice of anesthesia and patient monitoring 2.3. Ventilation. central venous line and pressure (methods.1. Limitations) 2. Pulse Oximetry ( Function. ECG 2. Circulation. Insertion sites and it's advantages. values) 8 . indications.4. Elements to monitor (Anesthesia depth.2. indications. Complications. Values. Blood Pressure (methods.

Values. O2-Content of Blood) 2. Measurement.7. key values.Monitoring in Anesthesia OBJECTIVES: 2.6.5. sites) 3. values.8. factors affecting EtCO2) 2. Cyanosis 2. The oxyhemoglobin dissociation curve (interpretation. Temperature ( Methods. causes of Left and right shifting . Normal values for a healthy adult undergoing anesthesia 9 . Capnography and EtCO2 (Uses.

Visual monitoring of respiration and overall clinical appearance 2. Blood pressure 10 . Finger on pulse 3.Guidelines to the practice of anesthesia and patient monitoring: Monitoring in the Past 1.

Monitoring in the Past Finger on the pulse .

Harvey Cushing Not just a famous neurosurgeon … but the father of anesthesia monitoring • Invented and popularized chart the anesthetic • Recorded both BP and HR • Emphasized the relationship between vital signs and neurosurgical events ( increased intracranial pressure leads to hypertension and bradycardia ) .

NPO policy) 13 . Qualified anesthesia personnel shall be present in - the room throughout the conduct of : all general anesthetics regional anesthetics monitored anesthesia care 2. physical exam. lab investigations. (history. A completed pre-anesthetic checklist.Guidelines to the practice of anesthesia and patient monitoring: 1.

the patient’s - oxygenation ventilation circulation temperature shall be continously evaluated ! 14 . or monitored IV conscious sedation HR and BP should be measured every 5 min.Guidelines to the practice of anesthesia and patient monitoring: 3. - in general anaesthesia. During all anesthetics. An anesthetic record. - also time. dose and route of drugs and fluids should be charted 4. regional anesthesia.

MONITORING HR O2 sat RR BP Temp MAP 15 .

in addition to loss of blink reflex to light touch. hypercapnia and hypoxemia when muscle relaxants is not given. tachycardia. tearing or sweating. And also may result in hypoventilation. • Inadequate anesthesia can be signaled by : Facial grimacing or movement of arm or leg.Elements to Monitor : I. and Hypotension. bradycardia. • Onset of general anesthesia signaled by lack of response to verbal commands. it can be signaled by : Hypertension. Anesthetic Depth: • Patients with local or regional anesthesia provide verbal feedback regarding well being. But with muscle relaxants ( fully paralysis). 16 . • Excessive anesthesia can be signaled by : Cardiac depression.

Elements to Monitor : II. Oxygenation: • Clinically. monitored by patient color ( with adequate illumination ) and pulse oximetry. III. • Quantitavely monitored by using oxygen analyzer. 17 . equipped with an audible low oxygen concentration alarm. Temperature • Continuous temperature measurements monitoring is mandatory if changes in temperature are anticipated or suspected.

V. Circulation: • Clinically. • Arterial blood gas analysis for assessing both oxygen and ventilation. monitored through a correctly positioned endotracheal tube. equipped with an audible disconnection alarm. • Quantitavely using ECG signals and arterial blood pressure measurements every 5 min. reservoir bag displacement.Elements to Monitor : IV. and breath sounds over both lungs. 18 . • Quantitavely by ETCO2 analysis. Ventilation • Clinically. heart auscultation and monitoring intra-arterial pressure or oximetry. monitored by pulse palpation. also observing chest excursions.

v2.Monitoring: Electrocardiogram ECG: • A 3 or 5 lead electrode system is used for ECG monitoring in the OR. Lead II is usually monitored by this system. • II and V5 very important ! • ST segment 19 . referred to as V5 ). • The 3 lead system has electrodes positioned on the right arm. ( placed in the left anterior axillary line at the 5 th interspace. v3. AVR. AVL. • The 5 lead system adds a right leg and left leg electrodes. AVF and V5. which allows monitoring v1. left arm and chest position.

20 . ( Dep.Monitoring: Electrocardiogram ECG: • Identification of P waves in lead II and it’s association with the QRS complex is useful in distinguishing a sinus rhythm from other rhythms.-ischemia / elev. of leads II and V5.-infarction ) • Over 85% of ischemic events can be detected by monitoring ST seg. • Analysis of ST segment is used as an indicator of MI.

comparing measured values. • Red and Infra-red light frequencies transmitted through a translucent portion. then determining concentrations of oxygenated and deoxygenated forms. (finger-tip or earlobe) • Microprocessors then analyze amount of light absorbed by the 2 wavelengths.Monitoring: Pulse Oximetry: • Allows beat to beat analysis of oxygenation. • Depends on differences in light absorption between oxyHb and deoxyHb.and deoxy-) 21 . (oxy.

Hb has a higher absorption at 660 nm (red light) • the light signal following transmission through the tissues has a pulsatile component - . at different wavelengths by the various states of oxyhaemoglobin .PULSEOXIMETRY is for OXYGENATION Principle : Spectrophotometry & Plethysmography • relies on the differing absorption of light.HbO2 has a higher absorption at 940 nm (blue light) .

on the other side of the finger : photo sensor (photocell) detects the transmitted light .the LEDs are switched on and off at 30 Hz to detect the cyclical changes in the signal due to pulsatile arterial blood flow - by calculating the absorption at the two wavelengths the processor can compute the proportion of haemoglobin which is oxygenated S p O2  C HbO2 C HbO2  C Hb ..two LEDs : one emitting red light (660 nm) and the other a blue light (940nm) on the finger nail .

and as each molecule of oxygen contains two atoms of oxygen (O2). averaged over 5 to 20 seconds.Pulse oximeters measure: 1. each of which can carry 4 molecules of oxygen.in beats per minute. This makes haemoglobin a very efficient means of oxygen transport: each gram of haemoglobin can carry 1. The oxygen saturation of haemoglobin in arterial blood .which is a measure of the average amount of oxygen bound to each haemoglobin molecule . The pulse rate . Each globin chain is linked to one atom of iron.34ml of oxygen. . each haemoglobin molecule can carry 8 atoms of oxygen. 2.Haemoglobin is a compound of iron (haem) and globin chains.

.A pulse oximeter is affected by : • ambient light • shivering • abnormal haemoglobins ( carboxyhaemoglobin. low CO. dyes as methylene blue and bilirubin ) • pulse rate and rhythm • vasoconstriction • poor tissue perfusion ( shock. cold extremities ) •NOT affected by : dark skin or anaemia. methaemoglobin.

A pulse oximeter gives no information about :
•The oxygen content of the blood
•The amount of oxygen dissolved in the blood
•The respiratory rate or tidal volume i.e. ventilation
•The cardiac output or blood pressure

?

Monitoring:

Blood Pressure BP:

o Methods of BP measurement:

1. Simplest method of BP measurement,
estimating the SBP, is by palpating the return
of arterial pulse as cuff is deflated (RivaRocci).

2. auscultation of the Kortokoff sounds on deflation
(providing both SBP and DBP)
Mean Arterial Pressure
MAP = DBP + 1/3(SBP – DBP)
MAP = ( SBP + 2 DBP ) / 3
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MEASUREMENT OF ARTERIAL
PRESSURE
• INDIRECT measurement (non-invasive)
- signals generated by the occlusion of a major artery using a cuf
- gives not continous but intermittent measurements

- palpation method ( Riva Rocci)
- auscultation of the Korotkoff sounds
- osccilometry method

• DIRECT measurement (invasive and
continous)

Riva Rocci: simplest method of BP measurement. 2. Auscultation of the Korotkoff sounds (1905) on deflation created by the turbulent blood flow in the artery (providing both SBP and DBP) Mean Arterial Pressure (MAP) = DBP + 1/3(SBP – DBP) . is by palpating the return of arterial pulse as cuff is deflated.o Indirect Methods of BP measurement (1) 1. estimating only the SBP.

. OSCCILOMETRY .DAP corresponds to the onset of rapidly decreasing oscillations LIMITATIONS: - tendency to overestimate at low pressures and underestimate at high pressures . arrhythmias or BP fluctuations .compressive peripheral nerve injuries (repeated measurements ) .rapid.Indirect Methods of BP measurement (2) 3. accurate (± 9 mmHg) measurements of SBP. DINAMAP . MAP and HR - SAP corresponds to the onset of rapidly increasing oscillations MAP corresponds to the maximal oscillation at the lowest cuff pressure .a pressure transducer that digitalizes signals ( microprocesor). DBP.a microprocessor controlled oscillometer.errors : movements.

Cuff Size • Too small cuff will result in false high blood pressure reading fr o m B ar ba ra B at es : A G ui de to Ph ys ic al Ex a mi na ti on • Too large cuff will result in false low blood pressure reading .

Liquid manometers (obsolete) 3. 2.and then electronically converted and displayed as : SAP. open Liquid column method (obsolete) . H2O = 10 mm.4 cm. .DIRECT Measurement of the BP • invasive : catheter into the artery METHODS 1.conversion of mechanic signal into an electric signal .DAP and MAP . Electromechanical transducers : . measures only MAP 13.Hg.

based upon strain gauge principle : stretching (by PRESSURE ) a wire or silicone crystal changes its electrical resistance .connected to a wheatstone bridge circuit : so that the voltage output is proportionate to the pressure applied it .Electromechanical TRANSDUCERS • The diaphragm : .should be thin. small and rigid ! • Transducers : .is moved by arterial pulsations which push the saline column .

Inadequate dynamic response of system : RF and damping Resonant (natural) Frequency (RF) = frequency at which a system oscillates when stimulated.e.The 3 major problems may occur : 1. pressure waveform) approaches the RF of a system : progressive amplification of the output signal occurs.if the frequency of an input signal (i. . Improper zeroing and zero drift 2. a phenomenon known as ringing. .. Improper transducer / monitor calibration 3.

) • physiologic peripheral arterial waveforms have a FF = 3 to 5 Hz MONITORING SYSTEM • The RF should be at least at least 5 times higher than the highest frequency in the input signal or better : approx.10 times the FF at least FR >20 Hz to avoid ringing and systolic overshoot .The ARTERIAL PRESSURE Waveform ARTERIAL WAVEFORM is a complex sine-wave • The fundamental frequency (FF) or the 1-st harmonic is equal to the HR ( ex: for HR 60 b/min = 1 beat / sec = 1 cycle/sec = 1Hz.

both cases however MAP is relatively accurate .overdamping = underestimates SAP and overestimates DAP .underdamping = overestimates SAP and underestimates DAP .The ARTERIAL PRESSURE Waveform • • The damping coefficient (DC) is a measure of how quickly an oscillating system comes to rest method to test the DC: the fast-flush test ( square wave test) optimal damping .

REDUCING ARTIFACTS IN A-LINES • Lines free of kinks and clots • Air Bubbles : small amount may augment systolic pressure reading. while large amount cause an over-damped system • One stopcock per line • Heparinized saline flushed maintaining patency • Transducer should be electronically balanced or re-zeroed because the zero point may drift if the room temperature changes • • to have an adequate damping = flushing TEST Short and rigid : catheter and lines .

Monitoring: Blood Pressure BP: o Methods of BP measurement: 3. METHODOLOGY: a microprocessor controlled oscillometer (Dinamap®) which is used routinely intraoperatively. 3 – 5 minutes intervals is recommended to prevent compressive peripheral nerve injury due to repeated rapid measurements. sending readings into a pressure transducer that digitalizes them. It allows automatic inflation of the BP cuff at preset time intervals. 38 . accurate (± 9 mmHg) measurements of SBP. This technique gives rapid. MAP and HR several times a minute. LIMITATIONS: Errors occur due to movements. arrhythmias or BP fluctuations due to respiration. DBP. Automated non-invasive BP measurements.

(Arterial BP): Indications: – – – – Rapid moment to moment BP changes Frequent blood sampling Major surgeries (cardiac. Invasive BP measurements. Alternatives are femoral.Monitoring: Blood Pressure BP: o Methods of BP measurement: 4. morbid obesity – Sever metabolic abnormalities – Major trauma The radial artery at the wrist is the most common site for an arterial catheter. deliberate hypotension – Failure of indirect BP: burns. brachial and dorsalis pedis. 39 . thoracic. vascular) Circulatory therapies: vasoactive drugs.

40 . BP and CVP response to a volume infusion (100 – 500 ml) is also a useful test of right ventricular performance. venous tone and right ventricular performance.Central Venous line and Pressure (CVP) • Catheter inserted into the SVC providing an estimate of the right atrial and ventricular pressures. • Serial CVP measurements are more useful than a single value in order to assess blood volume. HR.

Central Venous line and Pressure (CVP) • Indications: – CVP monitoring provides Right Atrial and Right Ventricle pressures – Advanced Cardiopulmonary disease + major operation – Secure vascular access for drugs – Secure access for fluids + traumatic pts – Aspiration of entrained air: sitting craniotomies – Inadequate peripheral IV access 41 .

scalpel blade.Central Venous Line: PERFORMANCE of Right Internal Jugular Vein • Internal jugular (Int. dilator and catheter • Observe ECG and maintain control of guide-wire • Ultrasound guidance. Chest-Xray post insertion. 18 G needle.) vein lies in groove between sternal and clavicular heads of sternocleidomastoid muscle • It is lateral and slightly anterior to carotid artery • Aseptic technique. guidewire. head down • Insert needle towards ipsilateral nipple • Seldinger method: 22 G finder. Jug. 42 .

Jug.Advantages of Right Int. 90-99% 43 . vein • • • • Consistent. predictable anatomic location Readily identifiable landmarks Short straight course to Superior Vena Cava Easy access for anesthesiologist at patient’s head • High success rate.

Complications of Central lines (jugular): • Bleeding • Injury to surrounding structures as carotid artery • Pneumothorax • Arrhythmia 44 .

no risk of pneumothoroax. Int. – Higher Risk of pneumothorax. high risk or bleeding 20%: cannot access central circulation 45 .2% • External jugular: – – – – Easy to cannulate if visible. Jug. vein – Better patient comfort v.Central Venous line Alternative Sites • Subclavian vein: – Easier to insert versus Int. Jug.

Central Venous Pressure (CVP ) Monitoring • Reflects pressure at junction of vena cava + RA • CVP is driving force for filling RA + RV • CVP provides estimate of: – Intravascular blood volume – RV preload • Trends in CVP are very useful • Measure at end-expiration • Central Venous Pressure (CVP): 1-10 mmHg 46 .

SWAN GANZ = PA CATHETER .

SWAN-GANZ catheter Waveform during Insertion .

PA CATHETER .

(PAand PV exceed Palv) .PA CATHETER • Zone III allows for uninterrupted blood flow and a continuous communication with distal intracardiac pressures.

.

the area under the curve ( PAC measures the Pulm.CO = Global CO if no intracardiac shunt ) .PAC-Thermodilution • The change of the blood’s temperature in is measured in the pulmonary artery using the PAC thermistor • The thermistor records the temperature change and the monitor electronically displays a temperature/time curve.the temperature change . • The CO is inversely proportional to : .

53 . • Capnogram: refers to the continuous display of the CO 2 concentration waveform sampled from the patient’s airway during ventilation. • Capnography: is the continuous monitoring of a patient’s capnogram.Capnography and EtCO2 • Capnometry: is the numerical measurement of CO2 concentration during inspiration and expiration.

recognition of a partial airway obstruction. and indirect measurement of airway reactivity (bronchospasm). • It helps in assessment of the adequacy of ventilation and an indirect estimate of PaCO2. • ETCO2 levels have also been used to predict outcome of resuscitation. • It is an important safety monitor and a valuable monitor of the patient’s physiologic status. .Capnography and EtCO2 • End-tidal CO2 monitoring is standard for all patients undergoing GA with mechanical ventilation. • Also it aids in diagnosis of PE. and it has been an important factor in reducing anesthesiarelated mortality and morbidity. • CO2 monitoring is considered the best method for verifying successful intubation and extubation procedures.

alveolar ventilation and pulmonary circulation. excluding inspired CO2). . inspired CO 2 value should be near zero.Capnography and EtCO2 Measurement of ETCO2 • Sampling the patient’s respiratory gases near the airway. • Provided that when sampling. • Using infra-red gas analysis or mass spectrometry on the values and concentrations obtained. difference between PaCO2 and ETCO2 is about 5 mm Hg (PaCO2 = 40 mmHg. with absence of ventilation perfusion abnormalities.e. ETCO2 value is a function of CO2 production. (i. ETCO2 = 35 mmHg) • Increases or decreases in ETCO2 values maybe the result of increases or decreases in production and elimination. • During general anesthesia.

or removal of vascular cross-clamps. . release of extremity tourniquets.Capnography and EtCO2 Factors affecting ETCO2: Increased ETCO2 Decreased ETCO2 Changes in CO2 Production •Hyperthermia •Sepsis •Thyroid storm •Malignant Hyperthermia •Muscular Activity •Hypothermia •Hypometabolism Changes in CO2 Elimination •Hypoventilation •Rebreathing •Partial airway obstruction •Exogenous CO2 absorption (laparoscopy) •Hyperventilation •Hypoperfusion •Embolism •Transient increases in ETCO2 may be noted after: IV bicarbonate administration.

Capnography and EtCO2 • Normal • Esophageal 0 ! > 4 curves ! • Cardiac arrest • Curare cleft • bronhospasm spontaneous .

exhausted CO2 absorber • IMV • Expiratory Valve • Inspiratory valve • Hyper and hypo VENTILATION .

• In anemic patients the oxygen tension at which cyanosis is detectable will be even lower. – i.Cyanosis: • Defined as the presence of 5 g.e. Hb level = 10 gm/dL. . Hb level = 15 g/dL. – i.e. 5 gm/dL release O2 – SaO2 = OxyHb / (oxyHb + DeoxyHb) = 5 / (5 + 5) = 50% – SaO2 of 50% corresponds to PaO2 of only 27 mmHg. 5 g/dL release O2 which leaves 10 g/dL of oxyhemoglobin – SaO2 = OxyHb / (OxyHb + DeoxyHb) = 10 / (10 + 5) = 66% – SaO2 of 66% corresponds to PaO2 of 35mmHg./dL of deoxygenated hemoglobin (deoxy Hb).

explaining the sharp sloping . • When PaO2 is low. the hemoglobin affinity to oxygen falls rapidly .The oxyhemoglobin dissociation curve • It is a sigmoid curve that describes the relationship between oxygen tension (PaO2) and binding (SpO2).(PaO2< 60 mmHg) .

Increased affinity of Hb for O2. PCO2 •Hyperthermia •Acidosis •Increased altitude •Increased 2. • The lowest acceptable O2 saturation level is 90%. PCO2 •Hypothermia •Alkalosis •Fetal hemoglobin •Decreased 2. Causes: •Inc.3-DPG •Carboxyhemoglobin •Methemoglobin .3-DPG •Sickle Cell Anemia •Inhalational anesthetics Causes: •Dec.The oxyhemoglobin dissociation curve • A decrease in PaO2 of less than 60 mmHg (corresponding to SpO 2 90 %) results in a rapid fall in the oxygenation saturation. Left And Right Shifts of the Oxyhemoglobin Dissociation Curve Right Left Decreased affinity of Hb for O2.

Hb 75% saturation. c. Oxygen content of blood: • is the total amount of O2 carried in blood. Hb 100% saturation. • The dissolved O2 isn’t measured by oximetry but by blood gas analysis. including bound and dissolved O2.The oxyhemoglobin dissociation curve Key Values: a. Hb 50% saturation. At PO2 27 mmHg. b. At PO2 40 mmHg. . O2 content = (O2-binding capacity * % saturation) + O 2 dissolved O2-binding capacity = maximal amount of O2 bound to Hb at 100 % sat. At PO2 100 mmHg.

Monitoring Temperature Objective  aid in maintaining appropriate body temperature Application  readily available method to continuously monitor temperature if changes are intended. anticipated or suspected Methods   thermostat temperature sensitive chemical reactions .

Monitoring Temperature • Potential heat loss or risk of hyperthermia necessitates continuous temperature monitoring • Normal heat loss during anesthesia averages 0. but usually not more that 2 -3C • Temperature below 34C may lead to significant morbidity .5 .1 C per hour.

burn patients neonates.Monitoring Temperature • Hypothermia develops when thermoregulation fails to control balance of metabolic heat production and environment heat loss • Normal response to heat loss is impaired during anesthesia • Those at high risk are elderly. spinal cord injuries .

Monitoring Temperature • • • • Hyperthermia Causes Malignant hyperthermia Endogenous pyroxenes (IL1) Excessive environmental warming Increases in metabolic rate secondary to: – – Thyrotoxicosis Pheochromocytoma .

Monitoring Temperature Monitoring Sites • • • • Tympanic Esophagus Rectum Nasopharynx 67 .

Normal values for a healthy adult
undergoing anesthesia
 Systolic Blood Pressure
 Diastolic Blood Pressure
 Heart Rate
 Respiratory Rate
 Oxygen sat. by oximetry
 End Tidal Carbon Dioxide
tension
 Skin appearance
 Color
 Temperature
 Urine Production

SBP
DBP
HR
RR
SpO2
ETCO2

 Central Venous Pressure
 Pulmonary Artery Pressure
 Pulmonary Capillary Wedge
Pressure

CVP
PAP
(mean)

PCWP

85 –
160
50 – 95
50 –
100
8 – 20
95 –
100
33 – 45
warm,
dry
pink
36 –
37.5
>= 0.5

mmHg
mmHg
bpm
rpm
%
mmHg

1 – 10
10 – 20
5 – 15
75

mmHg
mmHg
mmHg
%

C
ml.kg1
.min-1
O

68

THANK
YOU
69

Clinical measurement
is limited by 4 major constraints:
1. Feasibility
2. Reliability
3.

Interpretation

4.

Value

electrical.extract and magnify the relevant features of the signal and reduce unwanted noise • Display and Storage : the output of the instrument is presented to the operator . electromagnetic.4 mandatory steps in clinical measurement: • Detection : sensing device ( biological signal : mechanical. usually to continuous electrical signal • Amplification and signal processing : . chemical or thermal energy) • Transduction : the output is converted into another form.

Mechanical versus Digital instruments • Mechanical instruments .use the natural signal energy to drive a display.higher accuracy and precision . .non-electrical signals are converted by a transducer to an electrical signal suitable for electronic processing by digital computers. .with minimal intermediate processing • Digital instruments .

Essential requiremets for CLINICAL MEASUREMENT • Accuracy is the difference between the measurements and the real biological signal. or in practice. between a certain techique and a superior 'gold standard‘ technique. . • Precision describes the reproducibility of repeated measurements of the same biological signal.calibration is important ( against predetermined signals or for absolute measurements to zero) .

MECHANICAL SIGNALS: MEASUREMENT OF ARTERIAL PRESSURE a wide range of instruments are used to measure pressure : • liquid column manometers : height. zero point. fluid density • mechanical pressure gauges : aneroid manometer • diafragm gauges (coupled to transducers) .

MEASUREMENT OF BLOOD FLOW: CARDIAC OUTPUT The Nexfin HD A truly noninvasive CCO monitor .

Potential Methods To Measure Cardiac Output • • • • Fick metdod Indicator dilution Pulse waveform ( pulse contour) methods ULTRASOUNDS ( 2D-Echo and Doppler techique) • Bioimpedance • ANGIOGRAPHY • MRI .

Ideal Cardiac Output Monitoring Technique • • • • • • • • Precise and No bias Non-invasive Continous and instantaneous Automatic Operator independent Cheap Easy available in the ICU Leads to treatment changes / improvement in outcome IT DOES NOT EXIST ! Use the Best Compromise : feasibility –precision – patient ! .

The FICK principle • defines flow by the ratio of the uptake or clearance of a tracer within an organ to the arterio-venous diference in concentration CO = VO2 / [CaO2 – CvO2])*100 • • • VO2 per minute using a spirometer + Douglas bag CvO2 is taken from the pulmonary artery CaO2 a cannula in a peripheral artery .

but no integrated system available modified Fick equation : continous CO by NICO2 apparatus .accurate VO2 samples are difficult to acquire discontinous CO : Deltatrac (Datex) continous CO : possible.The FICK method • considered to be the most accurate method for CO • but : .invasive. time consuming .

INDICATOR DILUTION • Chemical indicator dilution (dye) • Thermal indicator dilution ( Thermodilution ) the widest used : PAC = Swan Ganz .

INDICATOR DILUTION CO measurement by indicator dilution has 3 phases : (a) an indicator is brought into the circulation (injection) (b) the indicator mixes with the bloodstream (mixing and dilution) (c) the concentration of the indicator is measured downstream (detection). .

not affected by arterial saturation .nontoxic.short half-life. safe . inert. Indocyanine green : .Chemical indicator dilution The Stewart-Hamilton formula (time-concentration curve) • using indocyanine green as indicator was the conventional indicator dilution method used to measure CO in ICU until the 1970’s. .

TRANSPULMONARY Thermodiution (TP-TD) . PULMONARY Thermodilution (P-TD) 1. TD Methods : 1.The Thermodilution (TD) method • Thermodilution = indicator is the change in blood temperature • An injectate of known volume and temperature is injected into the right atrium and the cooled blood traverses a thermistor in a major vessel branch downstream over a duration of time.

The CLINICAL STANDARD is the PAC ! Pulmonary -TD .

PAC-Thermodilution • The change of the blood’s temperature in is measured in the pulmonary artery using the PAC thermistor • The thermistor records the temperature change and the monitor electronically displays a temperature/time curve. • The CO is inversely proportional to : .CO = Global CO if no intracardiac shunt ) .the area under the curve ( PAC measures the Pulm.the temperature change .

IC shunts : false high CO values Tricuspid regurgitation : false low CO values Fluctuations in baseline temperature .Sources of measurement error for P-TD • • • • • Loss of indicator Variation of injectate temperature and volume Recirculation .

...• .......... • cold • optimal < 4 sec............. false low CO ! at least 3 measurements and ∆ less than < 10 % between them .. • > 4-5 sec.. • 10 ml.

PAOP. SvO2. • The modified PAC may provide CCO - • thermal indicator : intermitent heating of a resistace 44°C for 1-4 sec each 30-60 sec Not really continous : mean of 3-4 min ! expensive The PAC provides. in addition.Advantages of P-TD • The standard method for clinical CO measurement • Simple and Repeated measurements possible. RVEF and RVEDV. and optionally. . PA pressures.

PULMONARY Thermodilution Thermodiution TRANSPULMONARY • The pulmonary artery TD curve appears earlier and has a higher peak temperature than the femoral artery TD curve. . but does NOT give : SvO2 an PAP values ! . • TP-TD is less invasive than P-TD.

LiDCO-Pulse CO • PiCCO and LiDCO-Pulse CO are able after the initial calibration.O. using : the Pulse Contour method . to measure in a continous manner ( beat by beat ) the C.The Clinical USE of TP-TD • Mainly : as a “ calibration method” for other systems : PiCCO.

The Pulse Contour method 1. CALIBRATED techniques PiCCO LiDCO – Pulse CO 2. NON-CALIBRATED techniques Flow-Track VIGILEO Nexfin .

directly with Left Ventricular STROKE VOLUME .inversely with aortic impedance SV • For calibrated techiques : the Aortic impedance is estimated from AP and CO pre-measured values ( calibration : CO is ussualy measured by TP-TD) .CCO by the pulse contour method The area under the systolic part of the AP waveform correlates : .

PiCCO Continous pulse contour analysis with intermittent TPTD calibration.central venous catheter . Enables continuous hemodynamic monitoring using: .femoral or axillary artery catheter .

real-time cardiovascular monitoring .LiDCO – Pulse CO • the independent calibration technique is : Lithium indicator Dilution • safe and minimally invasive : peripheral venous and arterial catheters • The PulseCO algorithm used by LiDCO is based on pulse power derivation. • Continuous.

only arterial line • NEXFIN .Pulse Contour NON-CALIBRATED techniques • Flow-Track VIGILEO .totally non-invasive .

blood. muscle. etc) have different electric proprieties blood is the most conductive tissue ( Na+ and Cl-) pulsatile modification of ITBV → Δ TB Δ TB ~ Δ stroke volume SV = K x (dZ / dt) / Zo x TEV Δ TB is measured by : producing and transmiting electricity ( high υ = 70 kHz low A = 2.5 mA ) betwwen 2 pairs of electrodes .BIOIMPEDANCE • • • bio tissues (bone.

Echocardiography for measuring the CO • 2 D – method • Doppler .method .

the wavelength (distance between successive peaks) . size and movement of tissue interfaces. US have frequencies > 20.000 cycles /sec ( 20 KHz) diagnostic US uses frequencies in the range of 1-10 MHz.000 Hz. .frequency (inversely proportional to wavelength. of cycles / second ) • • • human ear can detect frequencies : 20-20.amplitude of oscillation (delta pressure : ambient to peak) dB . especially soft tissues and blood (RBC) • US are defined by : .) • US techniques can detect : the shape.Ultrasounds (1. nr.

• Amplitude determines the intensity of the ultrasound beam and therefore the sensitivity of the instrument.Ultrasounds (2. .generate and sense US .) • Transducers : .are made from ceramic materials able to transform mechanical energy (pressure) to electrical energy and vice versa ( the piezoelectric effect ) .Transducers : generates ultrasound of the same frequency as the applied voltage • Shorter wavelengths and higher frequencies improve the resolution of distance. but tissue penetration is simultaneously reduced.

which is the summation of the volume of stacked cylinders within the LV at end-diastole and end-systole 150 ml .2-D Method Principle Stroke volume= End diastolic volume – End systolic volume LV volumes estimated by Simpson’s method.52 ml= 98 ml .

Doppler Effect (1) • frequency of US waves reflected from a stationary object is the same as that transmited • frequency of transmitted US is altered as it is reflected from a moving object there is an increase in the observed frequency of a signal when the signal source approaches the observer e.g. ambulance siren .

3 • Doppler effect represented by: V= _ΔF .Doppler Effect . c _ 2 F0 cos θ Where V = velocity of object ΔF = frequency shift c = speed of sound in medium (body tissue here) F0 = frequency of emitted sound cos θ = angle between sound wave and flow (RBC) cos 90◦ = 0 so the US beam should be parallel to RBC Maximum angle = 20◦ .

785 3.Doppler Method Principle Flow (stroke volume)=Area x Velocity CO=Stroke volume * Heart rate Area of left ventricular outflow tract Obtain LVOT dimension in parasternal long axis view Flow Velocity at LVOT Pulsed wave Doppler at LVOT in apical 5 chamber view D=2.1 cm Simplified formula= (2.1cm)2 * 0.46cm 2 Velocity time integral 25 cm X 25cm = 87 cm3 .

OESOPHAGEAL DOPPLER Measurement of blood flow velocity in the descending aorta at the tip of the flexible probe 4 MHz continuous or 5 MHz pulsed wave   CO (cardiac output)  SV (stroke volume) FTc (corrected f low time)  PV (peak velocity)  MD (minute distance)  HR (heart rate) .

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