Functional Hemodynamic

Monitoring

NEANA Spring Meeting

April 2016

Donna Adkisson, R.N., M.S.N.

Clinical Educator
LiDCO, Limited
Functional Hemodynamic
Monitoring

Objectives

Describe the physiology of heart lung

interactions that cause hemodynamic
changes throughout respiration.

List 3 parameters used to predict

patient response to volume.

Explain normal parameters and

intraoperative application of
functional hemodynamic monitoring

Define afterload and contractility of

the heart.
 Anatomy & Physiology Review

Blood Flow in the Heart

 From the body
 Right side of the Heart
 To the lungs for Oxygenation
 Air in via trachea
 Bronchus
 Bronchioles
 Alveoli
 Capillaries
 Oxygen in
 Carbon Dioxide out

 Left side of the Heart

 Out the aorta
 Anatomy & Physiology Review

Cardiac Cycle

Diastole – relaxation or filling

 Preload coming into right side of the heart
 70% of blood flows into the ventricles passively
 Other 30% from atrial kick
Systole – contraction or pumping
 Atrial Systole = Ventricular Diastole
 30% of blood flows into the ventricles from the atrial
contraction

 Ventricular Systole
 How well can the heart pump – Ejection or Stroke
Volume
 What is the heart pumping against - SVR
 Cardiac Output

CO = SV x HR

 Cardiac output is the volume of blood pumped by the heart per minute. For an average
size of adult (70 kg) at rest this would be about 5 liters/min. During severe exercise it
can increase to over 30 liters/min.

 Cardiac output is frequently necessary to assess the state of a patient's circulation.

The simplest measurements, such as heart rate and blood pressure, may be adequate
for many patients, but if there is a cardiovascular abnormality then more detailed
measurements are needed.
 Beat-to-Beat Continuous Cardiac Output

Pulse Power waveform analysis continuously

assesses the patient's hemodynamic status by
analyzing and processing
the arterial pressure signal obtained from the
primary blood pressure monitor.

www.lidco.com
 CO = SV x HR

Stroke Volume
The volume of blood from the LV per beat/cycle of the heart

Effected by:
Amount of Blood coming into the heart – Preload
How well the heart works – Contractility
How much pressure or resistance the heart has to work against -
Afterload
 Functional Hemodynamic Monitoring

Q: What do you expect to happen to the below during induction in some if not most of
your cases?

Stroke Volume
Heart Rate
Cardiac Output
Systemic Vascular Resistance
Mean Arterial Pressure
Functional Hemodynamic Monitoring

Cardiac Output - decreases

Systemic Vascular Resistance - little change

Mean Arterial Pressure – decreases

Stoke Volume - decreases

Heart Rate - increases
 Ventricular Preload and Fluid Responsiveness

 Fluid Resuscitation is not without risk

 Less than 50% of patients respond to a fluid bolus.
 The heart performs more efficiently when appropriately filled.

 The term preload refers to maximum stretch on the heart's

muscle fibers at the end of diastolic filling. The degree of stretch
is determined by the volume of blood contained in the ventricle
at that time.

 Fluid Resuscitation is the primary treatment of many shock states

 Ventricular Preload and Fluid Responsiveness

Functional Hemodynamic Indices are predictors of fluid responsiveness

 Reflect the effect of positive pressure ventilation on preload and SV

 Pulse Pressure Variation
 Stroke Volume Variation
 Systolic Pressure Variation

Commonly used static preload measurement are not sensitive or specific

predictors of a patient's ability to respond to fluid bolus

 CVP
 PAOP
 Best Preload Responsiveness - PPV

Michard et al (1999) found PPV gave a

more accurate measure of fluid

responsiveness when compared to SPV,

which it turn was a better measure

than CVP and PAOP.

Michard F., Boussat S, Chemla D, et al.

Relation between respiratory changes in
arterial pulse pressure and fluid
responsiveness in septic patients with acute
circulatory failure. American Journal of
Respiratory and Critical Care Medicine. Jul
2000;162(1):134-138
 PPV, SVV & PLR

The main limitations to the use of dynamic parameters in patients have

been summarized as ‘SOS’.

The first ‘S’ stands for: Small tidal volume or Spontaneous breathing
activity. The ‘O’ stands for Open chest and the last ‘S’ stands for: not in
Sinus rhythm.

PLR – Passive Leg Raise (when appropriate) can be used when PPV or SVV
can not. PLR is reversible and equated to a positive Fluid Challenge when
observing an increase of 10%+ in Stroke Volume during the maneuver.
 Hemodynamic Monitoring

Arterial Waveform Analysis

Preload indicator - looks at the variation from inspiration
to expiration of the patient

 PPV - Pulse Pressure Variation

» Greater than 13% patient
preload responsive
 SVV - Stroke Volume Variation
Greater than 10% patient
preload responsive
 SPV - Systolic Pressure Variation
» Greater than 5mmHg patient
preload responsive
 Frank Starling’s Law

 The greater the ventricle is filled during diastole, the

more the muscle fibres are stretched, the greater is
the force of contraction.

 This is true to a defined point of stretch above which

point contraction force will not increase further.
 Frank Starling Curve

Frank-Sartling's Curve

90
Patient B
Patient A is preload responsive
80 
 SV
SV
 On steep part of curve
70
 Preload

60
 Set preload results in
Significant increase in SV
Stroke Volume

50

40 Patient B is not preload responsive

Patient A
30  An equal preloading does not
 SV
20
result in a great increase in SV

10  Preload
 This patient does not require
fluid resuscitation
0
1 3 5 7 9 11 13 15 17 19
Preload
 Functional Hemodynamic Monitoring

What do you expect

to happen during long
surgical case where
there is significant blood loss
Fluid replacement therapy
 Afterload

Systemic Vascular Resistance

 The amount of pressure the heart must work against
 Decreases as CO & CI increases
 Can be controlled with medications

 Vasoconstrictor – Increases SVR & BP

 Vasodialators – Decreases SVR & BP
 Functional Hemodynamic Monitoring

What do you expect to

happen during surgical
cases when the patient
is Hypo or
hypertensive –
using fluids and
vasoactive drugs to
control the blood
pressure
 Contractility

Muscle Compliance (EF)

 The ability of the muscle fiber to stretch and contract

Myocardial Contractility

 Is the power of contraction

 Is independent of preload or afterload
 At a constant preload
 positive inotropic agents > contractility > SV
 Functional Hemodynamic Monitoring

What do you expect to

happen during surgical
cases where the
surgeon wants the
patient dry?
 CO = SV x HR

Heart Rate

HR < 60 beats per minute

HR > 100 beats per minute
 Bradycardia – pacemaker, Atropine, Epinephrine

 Tachycardia – Cardioversion, Digoxin,

Treat fever or shock causing ↑ HR
 Functional Hemodynamic Monitoring

Positioning and Procedural factors can also have a major impact on flow.

Think About

The impact of flow during a severe Trendelenburg position in a long robotic procedure

Insuflation during a Laproscopic procedure.

 Cardiac Output Changes

Cardiac Output Decreases Cardiac Output Increases

 Decrease in blood volume  Vasodilation
 Increase in PPV or SVV  Decrease in SVR
 Decrease in ejection fraction  Increase in Contractility
 Decrease in SV  Increase SV
 Decrease in Heart Rate  Increase in Heart Rate
 Bradycardia  Tachycardiac
 Question?

Which indicator is the most sensitive and specific for preload responsiveness?

a. Central Venous Pressure (CVP)

b. Pulse Pressure Variation (PPV)

c. Pulmonary Artery Occlusion Pressure (PAOP)

 Question?

An 86 year old woman for exploratory lap has a Cardiac Output of 3.6,
Cardiac Index of 1.8, SVR of 1530, Stroke Volume of 45, BP 74/56, pulse 64 and
Pulse Pressure Variation of 36%.
What should you do?

a. Give 250ml of IV fluid

b. Give Levophed IV

c. Continue to monitor her vital signs

Question?
 Functional Hemodynamic Monitoring

Hemodynamic monitoring has traditionally involved the

placement of a pulmonary artery catheter

Minimally invasive/non-invasive Cardiac Output Monitoring eliminates

the complications of the pulmonary artery catheter

Which includes:

Complications Related to Catheter

Vascular Complications
 NEANA

Thank You for the invitation!