REVIEW OF HD MONITORING

DR GHALEB ALMEKHLAFI
MD,SFCCM,EDIC
 HEMODYNAMIC COMPONENTS
2-C.O.= HR x Stroke
Volume (60-130 Ml/beat)
Stroke Volume has
three components
1. Preload
2. Afterload
3.Contractility
1-IV VOLUME
• PRELOAD
• FLUID
-RESPONSIVENESS 3-VASOACTIVITY
-LIMITS Afterload
SVR

5-PERFUSION MARKERS
SCVO2
LA PERFUSION 4-MICROCIRCULATION
REGIONAL PCO2
MACROCIRCULATION MONITORING: 3 components

vascular tone myocardial

hypovolemia
depression depression

FR

fluids vasopressors inotropes

LIMITS
 Assessment Parameters

Static Dynamic
• CVP • SVV

• • PPV
PAOP
• SPV
• RVEDV
• IVC/SVC collapsibility
• LVEDA
• PLR
• GEDV & ITBV
• OTHERS:RM.EOT,ETCO
,FC
 MACROCIRCULATION MONITORING: 4 components

vascular tone myocardial

hypovolemia
depression depression

responsiveness

fluids vasopressors inotropes

 Limitations of PPV as a marker of fluid responsiveness

False negative
 Small tidal volume
 Low airway pressure PPV false positive is (10-20%)
 High aortic compliance Therefore, echocardiographic
False positive of PPV or SVV examination should be
 Measurement of cardiac output performed in patient before
 Right ventricular dilation or right ventricular systolic
dysfunction
fluid infusion to assess in
 Delta up association with PPV fluid needs
Special conditions :
 Arrhythmia
 Spontaneously ventilated patients
 ARDS
 Norepinephrine infusion
 In infant and small children : SVV or PPV?
 Open chest

up to 20% of patients receiving i.v. fluid may be

subject to inappropriate fluid therapy.
MACROCIRCULATION MONITORING: 3 components

vascular tone myocardial

hypovolemia
depression depression

fluids vasopressors inotropes

Fluid therapy limits

 HD monitoring methods
Clinical methods
• Physical examination:
systemic clinical intrventional methods

•
Classic m ethods

examination A-LINE
• V/S:NI-BP, Heart rate • Pulse waveform analysis
• Skin, extremities • Invasive BP
• Urine output • CVP
• Mental status • PAC

LAB: Advanced methods

Hb,PO2,SCVO2,LA
REGIONAL PCO2
Non invasive
invasive
• Clinical examination remains an important initial step in the
diagnosis and risk stratification of critically ill patients.
Individual vital signs often do not reflect hemodynamic status.
• High or low pulse rate is neither sensitive nor specific for the
diagnosis of hemodynamic instability.
• Respiratory rate lacks adequate specificity or sensitivity to serve as
a test for hemodynamic instability.
• Skin or toe temperature is not a sensitive indicator of
hemodynamic instability.
• Oliguria may have causes other than renal Hypoperfusion.
• TRENDS
• A 68-year-old woman was admitted to the intensive care unit with
respiratory failure and hypotension. Her blood pressure was 70/50 mm
Hg, and her heart rate was 125 beats per minute.
• Physical examination revealed skin mottling on the legs (Panel A).
• Laboratory values were notable for an arterial-blood lactate level of 4.5
mmol per liter (normal value, <2.0), a cardiac troponin T level of 0.43 ng
per milliliter (normal value, <0.014), an N-terminal pro–brain natriuretic
peptide level of 24,500 pg per milliliter (normal value, <900), and a
positive polymerase-chain-reaction assay for adenovirus in
bronchoalveolar-lavage fluid and blood.
• No other viruses or bacteria were found.
• Transthoracic echocardiography revealed a left ventricular ejection
fraction of 25%..
 Skin mottling
• a common clinical sign in patients in shock, is a violaceous
discoloration of the skin that is due to skin hypoperfusion.
• It most often manifests in the area around the knees but can also
be seen in the ears and fingers.
• The patient received a diagnosis of acute myocarditis due to
adenovirus, complicated by cardiogenic shock.
• She was treated with supportive care including mechanical
ventilation, plasma volume expansion, and inotropic agents.
• The skin mottling disappeared within 24 hours after treatment ,
and the left ventricular ejection fraction increased to 60% by day 3
of treatment.
• The patient had a full recovery
0 – No mottling
1 – Coin sized mottling area
on the knee.
2 – To the superior area of
the knee cap.
3 – Mottling up to the
middle thigh
4 – Mottling up to the fold
of the groin
5 – Severe mottling that
extends beyond the the
groin.
Mottling score
Livedo reticularis
ARTERIAL LINE

mlr/2007
Equipment needed:
- Pressure bag, 500cc bag
0.9% NS,
- Transducer tubing,
- #20 angiocath,
- dressing supplies, dead
end caps.
Ensure ALL air removed
from system to include
flush bag and stopcocks
 Patient Monitoring
• Inflate pressure bag to 300mm.to provide a
continuous saline flush at 3-6cc/hr that will
overcome the patient’s systolic blood pressure.
• ZERO the system by having transducer at
(phlebostatic axis) right atrium, open stopcock to
atmospheric pressure, Zero monitor.
• Once zeroed, turn stopcock back to patient
monitoring and replace cap.

21
Arterial waveform components
Arterial pressure (mmHg)

SAP
140

120

100 PP
MAP
80

60 DAP

40
SAP: reflection of LV afterload
20

0
Arterial Pressure (mmHg)

140

120

100

80

60 DAP

40 DAP: reflection of vasomotor tone

20

0
Time
Arterial Pressure (mmHg)

140

120

100

80

60 DAP

40 DAP: reflection of vasomotor tone

20 DAP: driving pressure
for left coronary circulation
0
Time
Arterial Pressure (mmHg)

140

120

100

MAP
80

60

40
MAP: driving pressure for perfusion
20 of important organs (e.g. brain, kidney)
0
Time
Arterial Pressure (mmHg)

140

120

100

MAP
80

60

40
MAP: important hemodynamic target
20 of resuscitation of shock states
0
Time
Target blood pressure in circulatory shock

• We recommend individualizing the target blood pressure during shock resuscitation.

Recommendation Level 1: QoE moderate (B)

• We recommend to initially target a MAP of ≥ 65 mmHg.

Recommendation: Level 1; QoE low (C)

• We suggest a higher MAP in septic patients with a history of hypertension.

Recommendation: Level 2; QoE low (B)
 Target MAP
• increasing MAP above 65 mmHg results in
little benefit
• Probably higher target value if:
1. History of chronic hypertension
2. Elevated CVP
3. Elevated abdominal pressure
4. High ICP
 Arterial pressure (mmHg)
SAP
140

120

100 PP
MAP
80

60 DAP

40
A low PP (30 mmHg)
20
suggests that the stroke volume Is
0 low
 arterial line waveform
Slowed upstroke
– AS
– LV failure
• sharp vertical in
hyperdynamic states
– Anemia
– Hyperthermia
– Hyperthyroidism
– SNS stimulation
– Aortic regurg Age effect
arterial waveforms –differential diagnosis

.
AS
LV failure

hyperdynamic states
AR

pulsus bisfrenus is a sign of combined aortic

valve lesion, also seen in hypertrophic
obstructive cardiomyopathy (HOCM), patent
ductus arteriosus, arteriovenous fistulas and
normal hearts in a hyperdynamic state
Pulsus alternance Seen
in:LVD/cardiomyopathies, HTN,AS,Normal
hearts with SVT
 COMPLICATIONS OF ARTERIAL LINE

• Thrombosis/embolus • Disconnect=blood loss

• Hematoma • Fistula
• Infection • Aneurysm
• Nerve damage/palsy • Digital ischemia

mlr/2007
 LOSS OF WAVEFORM

• asystole
• Stopcock
• Monitor not on correct scale
• Nonfunctioning monitor
• Nonfunctioning transducer
• Kinked/clotted catheter

mlr/2007
Technical issues/resonance artifacts
 resonance artifacts
DAMPENED WAVEFORM UNDERDAMPED WAVEFORM
• Air bubble/blood in line • Too many stopcocks
• Clot
•
• Long tubing
Disconnect/loose tubing
• Underinflated pressure bag • Air bubbles
• Catheter tip against wall • Defective transducer
• Compliant tubing

HOW TO TEST FOR THAT?

Arterial line dynamic response testing
 Other functions of A-line

• Blood extraction • pulse pressure variation

• pulse rate and rhythm (suggests fluid
• effects of dysrhythmia responsiveness)
on perfusion • steeper upstroke of pulse
• ECG lead disconnection pressure = increased
contractility
• continuous cardiac
output using pulse
contour analysis
 classification of cardiac output monitoring
systems.
 INVASIVE-PAC
 LESS INVASIVE
- PCM: pulse contour method
- TPD :transpulmonary dilution
- TED :trans esophageal Doppler
 NONINVASIVE
- PCM
- TTE/US
- BIOEMPEDANCE,BIOREACTANCE
- NICO
 PULMONARY ARTERY CATHETER

Markings on catheter. CVP Proximal (pressure line - injectate port for

1. Each thin line= 10 cm. CO)-BLUE
2. Each thick line= 50 PA Distal (Pressure line hook up)- Yellow
Extra port - usually- Clear
cm. Thermistor – Red Cap
 PA Catheter Timeline
PA Catheters MDs Are PA Catheters PA Catheters
Are Good Ignorant Might be Bad Are Bad

970 1980 1990 1995 2000 2005

Swan HJ, Iberti TJ, Fischer EP, Rhodes A. PACMAN,

Ganz W, Leibowitz AB, et al. Escape, ARDSnet
Int Care Med.
Forrester J. Pulmonary Artery Catheter 2004 -2006
Feb, 2002
NEJM.Aug, Study Group.
1970 JAMA. Dec, 1990

Connors AF, et al.

Founding of the JAMA. Sept, 1996 French PAC Study Group
Society of Critical JAMA. Nov, 2003

Care Medicine
 EBM
Overall Conclusion:
1. No difference in LOS in the ICU
2. No difference in Mortality
3. No benefit, no harm
• “There is no guided therapy tailored towards
PAC use.”
• “PAC is a diagnostic tool, not a therapeutic
one
 Pulmonary Artery Catheter
indications Contra-indications:
Diagnostic • Tricuspid or pulmonary valve
Diagnosis of shock states mechanical prosthesis
high- versus low-pressure pulmonary edema • Right heart mass (thrombus and/or
primary pulmonary hypertension valvular disease, tumor)
intracardiac shunts, cardiac tamponade, and
• Tricuspid or pulmonary valve
pulmonary embolus (PE)
endocarditis
Monitoring complicated AMI
hemodynamic instability after cardiac surgery
Therapeutic
- Aspiration of air emboli
- local thromplytics
 PAC parameters and NL values
Measured values Derived values – use of formula:
• Q: 4-8L/min Q = MAP-CVP/SVR
• CI: 2.5-4L/min • SV: 50-100mL/beat
• SVI: 25-45mL/beat/m2
PRESSURES RESISTANCE
• CVP: 2-6mmHg • SVR: 900-1300 dynes-
• PAWP: 8-12mmHg sec/cm5
• PAP: 25/10mmHg • SVRI: 1900-2400 dyne-
sec/cm5
• SvO2: 0.65-0.70 • PVR: 40-150 dyne-sec/cm5
• Temperature • PVRI: 120-200 dynes-sec/c
 Change in pressure / total blood flow

Systemic Vascular Resistance Index

=SVRI = (MAP ) = (MAP-CVP)(80)/CI
80 converts mm Hg-min-m2/liters to dynes*sec/*cm-5

SVR: 900-1300 dynes-sec/cm5

SVRI: 1900-2400 dyne-sec/cm5
PVR: 40-150 dyne-sec/cm5
PVRI: 120-200 dynes-sec/c
Hemodynamic PARAMETERS:PAC

vascular tone myocardial

hypovolemia
depression depression
CVP CO
PCWP CI
DBp
SVR
FR?

fluids vasopressors inotropes

F-limits?
PAC WAVES
PAWP
How to measure the PAOP?
HOW TO LOCALIZE DURING SPONTANEOUS VENT.?
ALL PA measurements are calculated at end expiration
because the lungs are at their most equal -
(negative vs. positive pressures)
PAW WAVEFORM WITH MECHANICAL
VENTILATION
What is the abnormality?
What is the abnormality?
Pericardial tamponade: high PCWP, high SVR, CVP = PCWP

Right heart failure: high CVP, low CI, high PVR

 Complications of PAC
• Venous access • Right bundle-branch
complications block (RBBB)
- include arterial
• PA rupture
puncture
- hemothorax • PAC related infection
- Pneumothorax • Pulmonary infarction
• Arrhythmias
- PVCs or nonsustained
VT
- Significant VT or
ventricular fibrillation
 Advanced methods
• beat-to beat stroke volume analysis is based on the
Windkessel model, which was described by Otto Frank in 1899
• In 1993 Wesseling et al described a method of using the finger
cuff arterial pressure wave to derive cardiac output“ Model
Flow ” Currently the Nexfin
• In 1997 the first commercial system, the PiCCO (Pulsion,
Munich, Germany) was released
• in 2002 the LiDCO-plus (and later rapid), (LiDCO Ltd.,
Cambridge, England)
• In 2004 the FloTrac-Vigileo, (Edwards Lifesciences, Irvine, CA,
USA). Then volume view in 2010
 ARTERIAL WAVEFORM ANALYSIS TECNIQUES

other devices
PRAM: Pressure Recording
Analytical Method
Statistical analysis of
Arterial Pressure

SD of 2000 arterial
waveform points
 Pulse Contour Parameters
Pulse Contour Cardiac Output PCCO
• Arterial Blood Pressure AP
• Heart Rate
HR
• Stroke Volume ,CO SV
• Stroke Volume Variation SVV
• Pulse Pressure Variation PPV
• Systemic Vascular Resistance SVR
• Index of Left Ventricular Contractility dPmx*

MANY OTHER PARAMETERS AWAITING VALIDATION

DP/dtmax
is the maximal slope of the tangent
line along the systolic upstroke of the
pressure waveform (corresponds to
the first derivative of the function).
 Hemodynamic monitoring parameters: PCA

vascular tone myocardial

hypovolemia
depression depression

CO
CI
DBp
SVV SVR
dpmx
PPV
SPV
fluids vasopressors inotropes

FLUI LIMITS?
Non invasive PCM
 CALIBRATION FOR PCM
 Cardiac output is measured by another more accurate modality to
initially calibrate the PCA system and then for recalibration as needed
1-Transpulmonary Thermodilution Methods:
• PiCCO (Pulsion Medical Systems&GE technology)
• Volume View (Edwards Life Sciences)
2-Lithium Dilution Technique:
• LiDCO /LiDCOplus/LiDCOrapid ( LiDCO limited)
3-Ultrasound Indicator Dilution :COstatus (Transonic Systems, Inc.)
Device that do not need calibration:
-FLOTRAC/VIGILEO: estimate CO by the standard deviation of pulse pressure sampled during a time
window of 20 seconds
-PRAM :estimate cardiac output using frequency of 1000 HZ

70
 Transpulmonary thermodilution-PICCO
and Edward / Volume View TM
• .

71
 Transpulmonary thermodilution: Volumetric curve

All volumetric parameters are obtained by advanced analysis of the thermodilution

curve:
For the calculations of volumes… Advanced Thermodilution Curve Analysis
Mtt: Mean Transit time Tb injection
time when half of the indicator recirculation
has passed the point of detection in
the artery ln Tb
…and… e -1
DSt: Down Slope time t
exponential downslope time of the MTt DSt
thermodilution curve ITTV = CO * MTt
PTV = CO * DSt
Transpulmonary thermodilution

monitors are not only

CO monitoring devices
 PARAMETERS
• ITTV = CO × MTt
• PTV = CO × DSt
• GEDV = ITTV - PTV = CO × (MTt - DSt)
• ITBV = 1.25 × GEDV
• CFI = (CO/GEDV) × 103
• GEF = SV/(GEDV/4)
• EVLW = ITTV - ITBV
• PVPI = EVLW/PBV
Transpulmonary thermodilution

GEDV
1- Cardiac output
2- Global end-diastolic volume (GEDV)

marker of
cardiac preload
 Extravascular lung water (EVLW)
• Normal – 3-7 mL/kg
• Increased > 7 mL/kg
• Pulmonary edema > 10
mL/kg
 Pulmonary
. Vascular Permeability Index-PVPI
• It allows to identify the type of pulmonary oedema
normal
EVLW*
PBV PVPI= Normal Lung


normal PBV
Extra Vascular Pulmonarv Blood normal
Lung Water Volume

elevated
EVLW* Hydrostatic
PBV PVPI =


normal PBV pulmonary edema
elevated

elevated
EVLW* Permeability
PBV PVPI* =


elevated PBV pulmonary edema
normal
 Normal ranges
PARAMETER RANGE UNIT

 CI 3.0 – 5.0
l/min/m2
 SVI 40 – 60
ml/m2
 GEDI 680 – 800
ml/m2
 ITBI 850 – 1000
ml/m2
 ELWI* 3.0 – 7.0
ml/kg
 PVPI* 1.0 – 3.0
 SVV  10

%
 PPV  10
%
78
 GEF 25 – 35
Transpulmonary thermodilution
1- Cardiac output

Complete picture
2- Global end-diastolic volume (GEDV)
3- Cardiac function index (CFI)
4- Extravascular lung water (EVLW)
5- Pulmonary vascular permeability index
of the patient’s
Pulse contour analysis
1- Continuous cardiac output (CCO)
2- Stroke volume variation (SVV)

hemodynamic status
3- Pulse pressure variation (PPV)

ScvO2
 Hemodynamic questions
What is the current situation?.………..……..………….Cardiac Output!
What is the preload?.……………….....…Global End-Diastolic Volume!
What is the afterload?……………..…..Systemic Vascular Resistance!
What about the contractility?........................ dPmx* LV pressure velocity
What about the Perfusion ?............................central venous saturation
Will volume increase CO?...fluid response….Stroke Volume Variation!
Are the lungs still dry?.tissue edema...….Extravascular Lung Water!*

pulmonary vascular permeability index……….. Dx of p.edema

 Hemodynamic PARAMETERS: ADVANCED METHODS

vascular tone myocardial

hypovolemia
depression depression
GEDV CO
CI
dBp
GEF
SVV SVR CFI
PPV dpmx
SPV
fluids vasopressors inotropes

EVLW presence of associated lung injury PVPI

 Decision tree for hemodynamic / volumetric monitoring

CI (l/min/m2) <3.0 >3.0

R
E GEDI (ml/m2) <700 >700 <700 >700
S or ITBI <850 >850 <850 >850
U (ml/m2)
L
T ELWI* (ml/kg) <10 >10 <10 >10 <10 >10 <10 >10
S

V+ V+! Cat Cat V+ V+! V-

Cat V-

T GEDI (ml/m2) >700 700-800 >700 700-800 >700 700-800 700-800

H 1. or ITBI (ml/m2) >850 850-1000 >850 850-1000 >850 850-1000 850-1000
E
R T 2. Optimise to SVV** (%)<10 <10 <10 <10 <10 <10 <10
A <10
A
P R
Y G CFI (1/min)
E >4.5 >5.5 >4.5 >5.5
T or GEF (%) >25 >30 >25 >30 OK!
ELWI* (ml/kg) 10 10 10 10
(slowly responding)

V+ = volume loading (! = cautiously) V- = volume contraction Cat = catecholamine / cardiovascular agents

** SVV only applicable in ventilated patients without cardiac arrhythmia
 FLUID RESPONSIVENESS
HEART LUNG INTERACTION
• Dominant factor in heart-lung interaction is change
in pleural pressure (Ppl) relative to atmosphere
• Increase Ppl decreases venous return and cardiac
output
• Decreased Ppl increases venous return and cardiac
output
• fluid status influence the magnitude of pressure
change and VR
SVV/SPV

Limitations
APPROACH TO FLUID RESPONSIVENESS
ASSESSMENT
 Patient with circulatory failure

First, try to perform echocardiography to assess cardiac function

Normal Abnormal
cardiac fonction cardiac function

Lung injury ?
ABG, Chest X-ray

no yes

Basic advanced
yes no PiCCO
monitoring monitoring
only VolumeView
PAC
CVC + Art cath CO CO
CVP AP PAOP GEDV, EVLW, CFI
SvcO2 PPV considered valid? RAP, PAP PPV, SVV
SvO2 ScvO2
Which measurement is most reliable for
predicting fluid responsiveness in a patient with
septic shock requiring mechanical ventilation?
Pick one best answer
• A. Central venous pressure (CVP)
• B. Pulmonary artery occlusion pressure (PAOP)
• C. Pulse pressure variation (ΔPP)
• D. Mixed venous oxygen saturation (SvO2)
• 1. Shock is best defined as:
• A. Hypotension with tachycardia
• B. Hypotension with tachycardia with cold
extremities and low urine output
• C. Low cardiac output and oxygen delivery
• D. Oxygen supply inadequate for demand of
tissues
• 2. CVP measurement should be made at:
• A. End-inspiration
• B. End-expiration
• C. At the beginning of inspiration
• D. Mid-inspiration
• E. Mid-expiration
• 3. To remove the effect of PEEP on CVP:
• A. PEEP value should be subtracted from CVP
• B. The patient should be disconnected from
the ventilator at frequent intervals
• C. PEEP value should be added to CVP
• D. Serial trends of CVP should be used instead
of single values
• 4. Dynamic parameters of fluid responsiveness
do not include:
• A. Systolic pressure variation
• B. Stroke volume variation
• C. Heart rate variability
• D. Pulse pressure variation
• 6. The following are good indicators of the
balance between oxygen supply and demand,
• except:
• A. Arterial lactate
• B. Cardiac output
• C. ScvO2
• D. Oxygen consumption measurement
ANSWERS
1. D
2. B
3. D
4. C
5. C
 Terminology

• Fluid bolus:
rapid infusion to correct hypotensive shock. It typically includes
the infusion of at least 500 ml over a maximum of 15 min
• Fluid challenge:
100–200 ml over 5–10 min with reassessment to optimize tissue
perfusion
• Fluid overload:
cumulative fluid balance expressed as a proportion of baseline
body weight. A value of 10% is associated with adverse
outcomes
 PHASES
• Resuscitation:
administration of fluid for immediate management of life-
threatening conditions associated with impaired tissue
perfusion
• Titration:
adjustment of fluid type, rate and amount based upon
context to achieve optimization of tissue perfusion
• De-escalation:
minimization of fluid administration; mobilization of extra
fluid to optimize fluid balance