Hemodynamic Monitoring

Vital Signs & Urine Output

Noninvasive Arterial Blood Pressure (BP)
Monitoring

• The level of the sampling site

relative to the heart affects the
measurement of BP because of
the effect of gravity
• In patients with severe
peripheral vascular disease,
there may be significant
differences in BP measurements
among the extremities. The
greater value should be used in
these patients.
Invasive Arterial Blood Pressure Monitoring
• Indications
• Current or anticipated hypotension
or wide blood pressure deviations,
• Contraindications
• end-organ disease necessitating
precise beat-to-beat blood • Smaller end arteries lacking
pressure regulation, collateral blood flow
• the need for multiple arterial blood • In extremities where there is a
gas or other blood analyses. suspicion of preexisting vascular
insufficiency.
Interpreting an Arterial Waveform
EKG
Systemic arterial waveform is
characterized by:
1. A rapid upstroke & downslope
(systolic ejection)
2. A dicrotic notch (closure of the
aortic valve)
3. Smooth progressive runoff
(diastole)
Jugular venous pressure (JVP)
• Cardinal aspect of the cardiovascular examination in the assessment
of volume status in patients in general, & in those with ADHF in
particular.
• Abnormally elevated JVP: > 5  cmH2O
• Patient is sitting at a 45 degree angle to the bed, there should be no
visible pulsations above the angle of Louis.
• JVP reflects right atrial (RA) pressure. It is often used as a surrogate
for LV filling pressure; however right heart failure is often absent in
patients with left-sided heart failure
Hepatojugular reflux (HJR)
• Jugular venous distension induced by firm pressure over the liver.
• An increase in JVP >3 cm by this maneuver is a positive HJR, which is a
sign of right-sided volume overload.
The third heart sound (S3)
• Occurs in early diastole due to abrupt cessation of rapid early diastolic
left ventricular inflow as a consequence of increased LV filling
pressures and an abnormally stiff, non-compliant left ventricle
• It is a fairly specific marker for LV dysfunction and correlates with BNP
levels.
Echocardiography
• Intracardiac pressures, cardiac output, vascular resistance, shunt
fractions, & valve lesions can be assessed by using a combination of
two-imensional imaging, color Doppler, pulse & continuous wave
Doppler, and tissue Doppler.
• Measuring of CO with echo:
VTI (velocity time integral)
• A VTI variation of > 12% predicts fluid
responsiveness (defined as an increase
in CO by at least 15% in response to a
standard fluid bolus)  sensitivity of
100% & specificity of 89%.
• The maximum and minimum peak
velocities (Vmax) is an alternative to
tracing the VTI. This is quicker and
easier, and again. > 12% variation
suggests fluid responsiveness
Collapsibility index ≈ fluid status
(Dmax-Dmin) In spontaneous breathing:
• IVC < 2 cm with > 50% collapse ≈ CVP < 10
Dmax x 100% • IVC > 2 cm with > 50% collapse ≈ CVP > 10
Central venous catheter (CVC)
• Indications
• CVP monitoring
• Central access  caustic agent, rapid
hydration, TPN
• Aspiration of air emboli, insertion of
transcutaneous pacing leads, gaining
venous access in patients with poor
peripheral veins
• Access
• V. subclavian
• V. jugularis interna/externa
• V. femoralis
• Relative contraindications:
• Tumors, clots, or tricuspid valve
vegetations that could be
dislodged/embolized during
cannulation.
• Relate to the cannulation site. Ex:
subclavian vein cannulation relatively
contraindicated in patients receiving
anticoagulants (if bleeding occurs 
inability to direct compression).
Clinical Importance of CVC

• Monitoring of CVP & be an

additional parameter for
volume status
• In normal cardiac compliance
 CVP approximates RA
pressure
• With specialized catheters, CVC
can be used for continuous
monitoring of central venous
oxygen saturation (Scvo2 )
Jugular venous pressure waveforms
Consists of 2 distinct positive waves (a & v wave) & 2 negative waves (x & y
descent).
• a wave occurs with RA systole & follows the P wave on EKG, precedes the S1.
• x descent occurs as RA pressure falls after the a wave & ventricular systole pulls
the tricuspid valve & the RA downward.
• c wave interrupts the x descent during early ventricular systole as the tricuspid
valve is briefly pushed in to the RA as the ventricle begins contracting, thereby
elevating RA pressure briefly.
• v wave occurs with RA filling at the end of ventricular systole, just after the S2.
• y descent follows the v wave & occurs with fall in RA pressure after the tricuspid
valve opens and fills the RV in diastole
Factors that make up SVO2
• Cardiac output
• SaO2
• VO2 (oxygen consumption)
• Hemoglobin

Normal values: 60-75%

Decreased values indicate:
• ↓ oxygen delivery
• ↑ oxygen demands
Causative Factors Clinical Conditions
 O2 Delivery - Anemia
 Hb concentration - Hemorrhage
Oxygen saturation - Hypoxemia
(SaO2) - Lung disease
- Low FIO2

 Cardiac Output - LV dysfunction (cardiac disease, drugs)

- Shock – cardiac/septic (late)
- Hypovolemia
- Cardiac Dysrhythmias

 Oxygen consumption - Fever, infection

- Seizures, agitation
- Shivering
-  Work of Breathing
- Suctioning, bathing, repositioning
PA Catheter
• Functions:
• Measure CO (thermodilution) & pulmonary artery occlusive pressure (PAOP)
• Measure LVEDP & ventricular volume
• Predict SV
• Measure SVR

 Find out the specific cause of

the patient's hemodynamic
instability
Other functions of PA Catheter
• Vascular tone, myocardial
contractility, & fluid balance can
be correctly assessed and
managed
• Measures CVP & allows for
hemodynamic calculated values.
• SvO2 monitoring (Fiber optic).
• Transvenous pacing.
• Fluid administration
PA Catheter
RED

KEEP
COVERED KEEP LOCKED

BLUE

Clear

YELLOW Markings on catheter.

1. Each thin line= 10 cm.
2. Each thick line= 50 cm.
 Relative
Indications for PA catheter
contraindications
In patients whose cardiopulmonary
pressures, flows, and circulating
volume require precise, intensive
management • LBBB (because of the concern about
complete heart block)
MI – cardiogenic shock - CHF
Shock - all types • Conditions associated with a greatly
increased risk of arrhythmias
Valvular dysfunction (consider a catheter with pacing
Preoperative, Intraoperative, and capability)
Postoperative Monitoring • A PA catheter may serve as a nidus of
ARDS, Burns, Trauma, Renal Failure infection in bacteremic patients or
thrombus formation in patients prone
to hypercoagulation
Other methods of measuring cardiac output
• PA catheter: associated with worse outcome
• Less invasive methods
• Thermodilution
• Dye dilution
• Pulse contour device
• Esophageal doppler
• Thoracic bioimpendance
• Echocardiography
Thank you