Advance in Hemodynamic

Monitoring
By Dr H P Shum
 Outline
• Introductions
• What we have previously – A line /
CVC/ PAC
• Advance techniques for haemodynamic
monitoring
 Introductions
• Hemodynamics is concerned with the forces
generated by the heart and the resulting
motion of blood through the cardiovascular
system
• Hemodynamic monitoring is the intermittent
or continuous observation of physiological
parameters pertaining to the circulatory
system with a view to early detection of need
for therapeutic interventions
4 factors that
affecting the
haemodynamic
conditions
Myocardial
contraction
and heart rate

Vasoactivity
Intravascular volume
 Old equipments
• Arterial line
– Real time SBP, DBP, MAP
– Pulse pressure variation (PP)

• ΔPP (%) = 100 × (PPmax - PPmin)/([PPmax + PPmin]/2)

• >= 13% (in septic pts,) discriminate between fluid responder and
non respondaer (sensitivity 94%, specificity 96%)
Am J Respir Crit Care Med 2000, 162:134-138
 Arterial line
• Advantages
– Easy setup
– Real time BP monitoring
– Beat to beat waveform display
– Allow regular sampling of blood for lab tests
• Disadvantages
– Invasive
– Risk of haematoma, distal ischemia,
pseudoaneurysm formation and infection
 Old equipments
• Central venous catheter
– Measurement of CVP, medications infusion
and modified form allow for dialysis
 Limitation of CVP
Obstruction of the
great veins

Mechanical
ventilation

Decrease right
ventricular
compliance

Tricuspid regurgitation
Systemic venoconstriction
 Central venous catheter
• Advantages
– Easy setup
– Good for medications infusion
• Disadvantages
– Cannot reflect actual RAP in most
situations
– Multiple complications
• Infections, thrombosis, complications on
insertion, vascular erosion and electrical shock
 Old equipment
• Pulmonary arterial catheter
Indications for PAP monitoring
• Shock of all types
• Assessment of cardiovascular function
and response to therapy
• Assessment of pulmonary status
• Assessment of fluid requirement
• Perioperative monitoring
 Clinical applications of PAC
PAC can generate large numbers of
haemodynamic variables
• Central venous pressure (CVP)
• Pulmonary arterial occlusion pressure (PAOP) =LAP = LVEDP
• Cardiac output / cardiac index (CO / CI)  By thermodilution
• Stroke volume (SV)
• R ventricle ejection fraction/ end diatolic volume (RVEF /
RVEDV)
• Systemic vascular resistance index (SVRI)
• Pulmonary vascular resistance index (PVRI)
• Oxygen delivery / uptake (DO2 / VO2)
Area under curve is
inversely proportion to rate
of blood flow in PA ( = CO)
 Patient with hypotension
Hypovolemia Cardiogenic Vasogenic
• Low CVP • High CVP • Low CVP
• Low CI • Low CI • High CI
• High SVRI • High SVRI • Low SVRI

 Consider fluid  Consider  Consider

challenge inotopic / IABP vasopressor
 Mixed Venous Saturation SvO2
• Measured in pulmonary artery blood
• Marker of the balance between whole body O2
delivery (DO2) and O2 consumption (VO2)
• VO2 = DO2 * (SaO2 – SvO2)
• In fact, DO2 determinate by CO, Hb and SaO2.
Therefore, SvO2 affected by
– CO
– Hb
– Arterial oxygen saturation
– Tissue oxygen consumption
 Mixed Venous Saturation SvO2

• Normal SvO2 70-75%

Decreased SvO2 Increased SvO2

• increased consumption • Increased delivery
• pain, hyperthermia • high CO
• decreased delivery • hyperbaric O2
• low CO • Low consumption
• anemia • sedation
• hypoxia • paralysis
• cyanide toxicity
 PAC
• Advantages
– Provide lot of important haemodynamic parameters
– Sampling site for SvO2
• Disadvantages
– Costly
– Invasive
– Multiple complications (eg arrhythmia, catheter looping,
balloon rupture, PA injury, pulmonary infarction etc)
– Mortality not reduced and can be even higher
Crit Care Med 2003;31: 2734-2741
JAMA 1996;276 889-897
Advance in haemodynamic assessment

• Modification of old equipment

• Echocardiogram and esophageal
doppler
• Pulse contour analysis and
transpulmonary thermodilution
• Partial carbon dioxide rebreathing with
application of Fick principle
• Electrical bioimpedance
truCCOMS system
As CO increase, blood
flow over the heat
transfer device increase
and the device require
more power to keep the
temp. difference
Therefore, provide
continuous CO data
Objective  To compare measurements of cardiac output using a new pulmonary artery catheter with
those obtained using two " gold standard " methods: the periaortic transit time ultrasonic flow probe
and the conventional pulmonary artery thermodilution.Design  Prospective clinical
trial.Setting  Cardiac surgery operating room and surgical ICU in a university hospital.Material and
methods  In the operating room, a new pulmonary artery catheter (truCCOMS system) was inserted in
eight patients. A periaortic flow probe was inserted in four of them. Measurements of cardiac output
obtained with the truCCOMS catheter and with the flow probe were compared at different phases of
the surgical procedure. In the intensive care unit, the cardiac output displayed by the truCCOMS
monitor was compared with the value obtained after bolus injection performed
subsequently.Results  In the operating room (70 measurements), the coefficient of correlation between
cardiac output measured by the flow probe and the truCCOMS system was r2 = 0.79, the bias was
+0.11 l/min with a precision of 0.47 l/min, and limits of agreement –0.83 to +1.05 l/min. In the intensive
care unit (108 measurements), the coefficient of correlation between cardiac output measured by
thermodilution and the truCCOMS system was r2 = 0.56, the bias was –0.07 l/min, the precision was
0.66 l/min, and the limits of agreement were –1.39 to +1.25 l/min.Conclusion  The truCCOMS system
is a reliable method of continuous cardiac output measurement in cardiac surgery patients.
 TruCCOMS system
• Advantage
– Continuous CO monitoring
– Provision of important haemodynamic
parameter as PAC
• Disadvantage
– Invasive
– Costly
– Complications associated with PAC use
 Transthoracic echo
• Assessment of cardiac structure,
ejection fraction and cardiac output
• Based on 2D and doppler flow
technique
 Echo doppler ultrasound
• Measure blood flow velocity in heart and great
vessels
• Based on Doppler effect  “ Sound freq. increases
as a sound source moves toward the observer and
decreases as the soure moves away”
 For transthoracic echo
• Haemodynamic assessment for SV and CO
– Flow rate = CSA x flow velocity
– Because flow velocity varies during ejection,
individual velocities of the doppler spectrum need
to be summed
– Sum of velocities called velocity time integral (VTI)
– SV = CSA x VTI
– CSA =( LVOT Diameter /2 )2 * 
– Therefore SV = D2 * 0.785 * VTI
– CO = SV * HR
 Transthoracic echo
• Advantages
– Fast to perform
– Non invasive
– Can assess valvular structure and myocardial
function
– No added equipment needed
• Disadvantages
– Difficult to get good view (esp whose on
ventilator / obese)
– Cannot provide continuous monitoring
 Transesophageal echo
• CO assessment by Simpson or doppler
flow technique as mentioned before
• Better view and more accurate than
TTE
• Time consuming and require a high
level of operator skills and knowledge
Esophageal aortic doppler US
• Doppler assessment of
decending aortic flow
• CO determinate by measuring
aortic blood flow and aortic CSA
• Assuming a constant partition
Decending between caudal and cephalic
aorta blood supply areas
• CSA obtain either from
nomograms or by M-mode US
• Probe is smaller than that for TEE
• Correlate well with CO measured
by thermodilution
Crit Care Med 1998 Dec;26(12):2066-72
Normovolemia
 Esophageal aortic doppler US
• Advantages
– Easy placement, minimal training needed (~ 12 cases)
– provide continuous, real-time monitoring
– Low incidence of iatrogenic complications
– Minimal infective risk
• Disadvantages
– High cost
– Poor tolerance at awake patient, so for those intubated
– Probe displacement can occur during prolonged monitoring
and patient’s turning
– High interobserver variability when measuring changes in SV
in response to fluid challenges
 Pulse contour analysis
• Arterial pressure waveform determinate
by interaction of stroke volume and SVR
 Pulse contour analysis
• Because vascular impedance varies between
patients, it had to be measured using another
modality to initially calibrate the PCA system
• The calibration method usually employed was
arterial thermodilution or dye dilution technique
• PCA involves the use of an arterially placed
catheter with a pressure transducer, which can
measure pressure tracings on a beat-to-beat basis
• PiCCO and LiDCO are the two commonly used
model
 What is the PiCCO-Technology?

The PiCCO-Technology is a unique combination of 2 techniques

for advanced hemodynamic and volumetric management without
the necessity of a right heart catheter in most patients:

T
Transpulmonary Thermodilution injection

CV t
Bolus
injection
CALIBRATIO
N
PULSIOCATH P

Pulse Contour Analysis

t
 Parameters measured with the PiCCO-Technology

The PiCCO measures the following parameters:

Thermodilution Parameters
• Cardiac Output CO
• Global End-Diastolic Volume GEDV
• Intrathoracic Blood Volume ITBV
• Extravascular Lung Water EVLW*
• Pulmonary Vascular Permeability Index PVPI*
• Cardiac Function Index CFI
• Global Ejection Fraction GEF

Pulse Contour Parameters

• Pulse Contour Cardiac Output PCCO
• Arterial Blood Pressure AP
• Heart Rate HR
• Stroke Volume SV
• Stroke Volume Variation SVV
• Pulse Pressure Variation PPV
• Systemic Vascular Resistance SVR
• Index of Left Ventricular Contractility dPmx*
 3How does the PiCCO-Technology work?

Most of hemodynamic unstable and/or severely hypoxemic patients are

instrumented with:

Central venous line (e.g. for vasoactive agents administration…)

Arterial line (accurate monitoring of arterial pressure, blood samples…)

The PiCCO-Technology uses any standard CV-line and a thermistor-

tipped arterial PiCCO-catheter instead of the standard arterial line.
 PiCCO Catheter

Central venous line (CV) CV

A
PULSIOCATH thermodilution catheter
with lumen for arterial pressure measurement B

Axillary: 4F (1,4mm) 8cm R

Brachial: 4F (1,4mm) 22cm
Femoral: 3-5F (0,9-1,7mm) 7-20cm F
Radial: 4F (1,4mm) 50cm

r !
ete
at h
art C
t He
g h
Ri
No
 A. Thermodilution parameters

PiCCO Catheter
Bolus e.g. in femoral
Injection artery
Transpulmonary thermodilution
measurement only requires Lungs
central venous injection of a cold
(< 8°C) or room-tempered
(< 24°C) saline bolus…

Right Left Heart

Heart EVLW
RA RV *
PBV LA LV
EVLW
*
 Transpulmonary thermodilution: Cardiac Output

After central venous injection of the indicator, the thermistor at the tip of the arterial
catheter measures the downstream temperature changes.
Cardiac output is calculated by analysis of the thermodilution curve using a modified
Stewart-Hamilton algorithm:

injection
CO Calculation:
 Area under the
Tb
Thermodilution Curve

Tb = Blood temperature
(Tb  Ti )  Vi  K Ti = Injectate temperature
COTDa  Vi = Injectate volume
 Tb  dt ∫ ∆ Tb . dt = Area under the thermodilution curve
K = Correction constant, made up of specific weight and
specific heat of blood and injectate
 Transpulmonary thermodilution: Volumetric parameters 1

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

…are important.
 Transpulmonary thermodilution: Volumetric parameters 2

After injection, the indicator passes the following intrathoracic compartments:

ITTV
PTV
Thermodilution curve
CV Bolus Injection measured with arterial
catheter

RAEDV RVEDV Lungs LAEDV LVEDV

Right Heart Left Heart

The intrathoracic compartments can be considered as a series of “mixing chambers” for

the distribution of the injected indicator (intrathoracic thermal volume).

The largest mixing chamber in this series are the lungs, here the indicator (cold) has its
largest distribution volume (largest thermal volume).
 Calculation of volumes

ITTV = CO * MTtTDa RAEDV RVEDV PTV LAEDV LVEDV

PTV = CO * DStTDa PTV

GEDV = ITTV - PTV RAEDV RVEDV LAEDV LVEDV

ITBV = 1.25 * GEDV RAEDV RVEDV PBV LAEDV LVEDV

EVLW*

EVLW* = ITTV - ITBV

EVLW*
 Pulmonary Vascular Permeability Index
Pulmonary Vascular Permeability Index (PVPI*) is the ratio of Extravascular
Lung Water (EVLW*) to pulmonary blood volume (PBV). It allows to identify the
type of pulmonary oedema.

normal
EVLW*
PBV PVPI* Normal Lung


Extra Vascular Pulmonarv Blood
normal
=PBV
normal
Lung Water Volume

elevated
EVLW* Hydrostatic
PBV PVPI


pulmonary edema
normal
*PBV
elevated
=
elevated
EVLW* Permeability
PBV PVPI* =


elevated PBV pulmonary edema
normal
 Global Ejection Fraction

Ejection Fraction: Stroke Volume related to End-Diastolic Volume

Lungs
Right Heart Left Heart
EVLW*

PBV

RAED RVED EVLW* LAED LVED

V V V V
Stroke Volume SV

1 & 2  3
4 x SV
GEF =
GEDV
SV SV
RVEF = LVEF =
RVEDV LVEDV Global Ejection Fraction (GEF)
RV ejection fraction (RVEF) LV ejection fraction (LVEF) (transpulmonary thermodilution)
(pulmonary artery thermodilution) (echocardiography)
 Pulse Contour Analysis - Principle

P [mm Hg]

t [s]

 P(t) dP
PCCO = cal • HR • ( + C(p) • ) dt
 SVR dt
Systole Shape of
Patient-specific calibration factor Heart Area under Aorticpressure curve
(determined by thermodilution) rate pressure curve compliance
 Index of Left Ventricular Contractility*

dPmx* = dP/dtmax of arterial pressure curve

P [mm Hg]

t [s]

dPmx* represents left ventricular pressure velocity increase and thus is a

parameter of myocardial contractility
 Stroke Volume Variation: Calculation

Stroke Volume Variation (SVV) represents the variation of stroke volume (SV) over the
ventilatory cycle.
SVmax
SVmin

SVmean

SVmax – SVmin
SVV =
SVmean
SVV is...
... measured over last 30s window
… only applicable in controlled mechanically ventilated patients with regular heart rhythm
 Pulse Pressure Variation: Calculation

Pulse pressure variation (PPV) represents the variation of the pulse pressure
over the ventilatory cycle.

PPmean

PPmax PPmin

PPmax – PPmin
PPV =
PPmean
PPV is...
…measured over last 30s window
…only applicable in controlled mechanically ventilated patients with regular beat rhythm
 Clinical application

CO GEDV SVV SVR EVLW*

gs
Dru

Volume

What is the current situation?.………..……..………….Cardiac Output!

What is the preload?.……………….....…Global End-Diastolic Volume!
Will volume increase CO?....………...……….Stroke Volume Variation!
What is the afterload?……………..…..Systemic Vascular Resistance!
Are the lungs still dry?...…….……...…..….Extravascular Lung Water!*
 Global End-Diastolic Volume, GEDV and Intrathoracic Blood Volume, ITBV have
shown to be far more sensitive and specific to cardiac preload compared to the standard
cardiac filling pressures CVP + PCWP as well as right ventricular enddiastolic volume.

The striking advantage of GEDV and ITBV is that they are not adversely influenced by
mechanical ventilation

Crit Care 4, 2000

Int Care Med 2002
Eur J Anaesth 19, 2002
Anesth Analg 95, 2002
 Extravascular Lung Water, EVLW* has shown to have a clear correlation to severity of
ARDS, length of ventilation days, ICU-Stay and Mortality and is superior to assessment of
lung edema by chest x-ray and clearly indicates fluid overload

Mortality as function of ELWI* in 373 critically

ill ICU patients
Sakka et al , Chest 2002
 Relevance of EVLW- Management

n=101 Ventilation days ICU days

* *

PAC group EVLW* group PAC group EVLW* group

22 days 9 days 15 days 7 days

101 patients with pulmonary edema were randomized to a pulmonary artery catheter (PAC)
management group in whom fluid management decisions were guided by PCWP
measurements and to an Extravascular Lung Water (EVLW*) management group using a
protocol based on the bedside measurement of EVLW *.
ICU days and ventilator-days were significantly shorter in patients of the EVLW* group.
Mitchell et al, Am Rev Resp Dis 145: 990-998, 1992
 SVV and PPV – Clinical Studies

SVV and PPV are excellent predictors of volume responsiveness.

1
Sensitivity

0,8

Central Venous Pressure (CVP) can not

0,6
predict whether volume load leads to an
increase in stroke volume or not.
0,4

- - - CVP Berkenstadt et al, Anesth Analg 92: 984-989,

0,2 __
2001
SVV

0 0,5 1
Specificity
 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 %
 GEF 25 – 35 %
 CFI 4.5 – 6.5 1/min
 MAP 70 – 90 mmHg
 SVRI 1700 – 2400 dyn*s*cm-
5*m
 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
LiDCO system
 Pulse contour analysis
• Advantages
– Almost continuous data of CO / SV / SV variation
– Provide information of preload and EVLW
• Disadvantages
– Minimal invasive
– Optimal arterial pulse signal required
• Arrhythmia
• Damping
• Use of IABP
 Partial carbon dioxide rebreathing
with application of Fick principle
• Fick principle is used for CO measurement
• CO = VO2 / (CaO2 – CvO2) = VCO2 / (CvCO2
– CaCO2)
• Based on the assumption that blood flow
through the pulmonary circulation kept constant
and absence of shunt
• Proportional to change of CO2 elimination
divided by change of ETCO2 resulting from a
brief rebreathing period
• The change was measured by NICO sensor
assume that the mixed venous co2
concentration (Cvco2) remains
unchanged between baseline and
rebreathing conditions

S = slope of CO2 dissociation curve

 Partial carbon dioxide rebreathing
with application of Fick principle
• Advantages
– Non invasive
• Disadvantages
– Only for those mechanically ventilated
patient
– Variation of ventilation modality and
presence of significantly diseased lung
affect the CO reading
– Not continuous monitoring
 Electrical bioimpedance
• Made uses of constant electrical current
stimulation for identification of thoracic
or body impedance variations induced
by vascular blood flow
• Electrodes are placed in specific areas on the neck and thorax
• A low-grade electrical current, from 2 - 4 mA is emitted, and
received by the adjacent electrodes
• Impedance to the current flow produces a waveform
• Through electronic evaluation of these waveforms, the timing of
aortic opening and closing can be used to calculate the left
ventricular ejection time and stroke volume
 Electrical bioimpedance
• Some report same clinical accuracy as thermodilution
technique
Crit Care Med 22: 1907-1912
Chest 111: 333-337
Crit Care Med 14: 933-935

• Other report poor agreement in those

haemodynamically unstable and post cardiac surgery
Crit Care Med 21:1139-1142
Crit Care Med 23: 1667-1673

• Newly generation EB device using upgraded computer

technology and refined algorithms to calculate CO and
get better results
Curr Opin Cardio 19:229-237
Int Care Med 32:2053-2058
 Electrical bioimpedance
• Advantage
– Non invasive
• Disadvantage
– Reliability in critically ill patients still not
very clear
 In conclusion
• Haemodynamic monitoring enable early
detection of change in patient’s
conditions
• New techniques provide reasonably
good results and less invasive
• Always correlate the readings / findings
with clinical pictures in order to provide
the best treatment options
The End