advances in haemodynamic monitoring

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  • Advances in Hemodynamic MonitoringBY Mohamed A. AliSecurity Forces Hospital MAKKAH

  • IntroductionHemodynamics 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 related to the circulatory system that lead to early detection of the need for therapeutic interventions.

  • 1- Intravascular volume2-Myocardial contraction 3- heart rate4- Vasoactivity

  • Old equipmentsArterial lineReal time SBP, DBP, MAPPulse pressure variation (PP)

    PP (%) = Respiratory-induced pulse pressure variations obtained with an arterial line which indicate fluid responsiveness in mechanically ventilated patients

  • Advantage

    Easy setupReal time BP monitoringBeat to beat waveform displayAllow regular sampling of blood for lab tests

    Disadvantages

    InvasiveRisk of haematoma, distal ischemia, pseudoaneurysm formation and infection

  • 2. Central venous catheter

    Measurement of CVP, medications infusion and modified form allow for dialysis

    AdvantagesEasy setupGood for medications infusion

    DisadvantagesCannot reflect actual RAP in most situationsMultiple complicationsInfections, thrombosis, complications on insertion, vascular erosion and bleeding

  • Limitation of CVP

  • 3. Pulmonary arterial catheter

  • Indications for PAP monitoringShock of all typesAssessment of cardiovascular function and response to therapyAssessment of pulmonary statusAssessment of fluid requirementPerioperative monitoring

  • Clinical applications of PACPAC can generate large numbers of haemodynamic variablesBasic parametersCentral venous pressure (CVP)Pulmonary artery pressure (PAP)Pulmonary arterial occlusion pressure (PAOP)Cardiac output (CO)Derived parameters cardiac index (CI)Stroke volume (SV) Rt ventricle ejection fraction/ end diastolic volume (RVEF / RVEDV)Systemic vascular resistance index (SVRI)Pulmonary vascular resistance index (PVRI)Oxygen delivery / uptake (DO2 / VO2)

  • Patient with hypotension

  • Mixed Venous Saturation (SvO2)Measured in pulmonary artery bloodMarker of the balance between whole body O2 delivery (DO2) and O2 consumption (VO2) VO2 = DO2 * (SaO2 SvO2)In fact, DO2 is determined by CO, Hb and SaO2. Therefore, SvO2 affected byCOHbArterial oxygen saturationTissue oxygen consumption

  • Normal SvO2 = 70-75%

    Decreased SvO2

    Increased consumption Pain, Hyperthermia Decreased delivery Low CO Anemia Hypoxia

  • Advantages

    Provide lot of important haemodynamic parametersSampling site for SvO2

    Disadvantages

    CostlyInvasiveMultiple complications (eg. arrhythmia, catheter looping, balloon rupture, PA injury, pulmonary infarction)

  • Advance in haemodynamic assessmentModification of old equipmentEchocardiogram and esophageal dopplerPulse contour analysis and transpulmonary thermodilutionPartial carbon dioxide rebreathing with application of Fick principleElectrical bioimpedance

  • truCCOMS systemReal Time Continuous Cardiac Output Monitoring 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

  • Advantage

    Continuous CO monitoringProvision of important haemodynamic parameter as PAC

    Disadvantage

    InvasiveCostlyComplications associated with PAC use

  • echoAssessment of cardiac structure, ejection fraction and cardiac outputBased on 2D and doppler flow techniqueEF (%) = [(EDV - ESV) / EDV] x 100

  • Echo doppler ultrasoundMeasure blood flow velocity in heart and great vesselsBased on Doppler effect Sound freq. increases as sound source moves toward the observer and decreases as the sound moves away

  • Transthoracic echoAdvantages Fast to performNon invasiveCan assess valvular structure and myocardial functionNo added equipment needed

    Disadvantages Difficult to get good view (esp. whose on ventilator / obese)Cannot provide continuous monitoring

  • Esophageal aortic doppler USDoppler assessment of decending aortic flowCO is determined by measuring aortic blood flow assuming a constant partition between caudal and cephalic blood supply areasProbe is smaller than that of TEECorrelate well with CO measured by thermodilutionDecending aorta

  • Advantages

    Easy placement, minimal training needed (~ 12 cases)Provide continuous, real-time monitoring Low incidence of iatrogenic complicationsMinimal infective risk

    Disadvantages

    High costPoor tolerance at awake patient, so its used for those intubatedProbe displacement can occur during prolonged monitoring and patients turningHigh inter-observer variability when measuring changes in SV in response to fluid challenges

  • Pulse contour analysisArterial pressure waveform is determined by interaction of stroke volume and SVR

  • Pulse contour analysisPiCCO and LiDCO are the two commonly used model on basis of PCA

    PCA involves the use of an arterially placed catheter with a pressure transducer, which can measure pressure tracings on a beat-to-beat basis

  • The PiCCO Technology uses any standard CV-line without the need for Rt. Heart catheter (PAC) and a thermistor-tipped arterial PiCCO catheter instead of the standard arterial line.How does the PiCCO-Technology work?Parameters measured with the PiCCO-Technology Thermodilution Parameters

    Cardiac Output CO Global End-Diastolic Volume GEDV Intrathoracic Blood Volume ITBV Extravascular Lung WaterEVLWCardiac Function IndexCFI Global Ejection FractionGEF Pulmonary Vascular Permeability IndexPVPI*

    Pulse Contour Parameters

    Pulse Contour Cardiac OutputPCCO Arterial Blood PressureAP Heart RateHR Stroke VolumeSV Stroke Volume VariationSVV Pulse Pressure VariationPPV Systemic Vascular ResistanceSVR Index of Left Ventricular ContractilitydPmx*

  • CVABFRPiCCO Catheter Central venous line (CV)

    PULSIOCATH thermodilution catheter with lumen for arterial pressure measurementAxillary: 4F (1,4mm) 8cmBrachial: 4F (1,4mm)22cm Femoral: 3-5F (0,9-1,7mm) 7-20cm Radial: 4F (1,4mm)50cm

    No Right Heart Catheter !

  • LungsThermodilution parameters

  • Cardiac OutputAfter 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:

  • Advanced Thermodilution Curve AnalysisVolumetric parametersFor the calculations of volumesinjectionrecirculationMTttDStAll volumetric parameters are obtained by advanced analysis of the Thermodilution Curve:

  • RAEDVLVEDVRVEDVLungsAfter injection, the indicator passes the following intrathoracic compartments: 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).

    PBVEVLWEVLW

  • ITTV = CO * MTtTDaPTV = CO * DStTDaITBV = 1.25 * GEDVEVLW = ITTV - ITBVGEDV = ITTV - PTVRAEDVRVEDVLAEDVLVEDVRAEDVRVEDVLAEDVLVEDVPTVPTVVolume calculations

  • Pulmonary Vascular Permeability IndexPulmonary 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.Pulmonarv Blood VolumeHydrostatic Pulmonary OdemaPermeabilitypulmonary edemaPVPI=PBVEVLWNormalElevatedElevatedPVPI=PBVEVLWElevatedElevatedNormalPVPI=PBVEVLWNormalNormalNormalPBVPBVPBVNorma LungExtra Vascular Lung Water

  • Global Ejection Fraction (GEF)(Transpulmonary Thermodilution)GEF =GEDV4 x SVRV ejection fraction (RVEF)(Pulm. Artery Thermodilution)LV ejection fraction (LVEF)(Echocardiography)12&3Global Ejection FractionRAEDVRVEDVLVEDVStroke Volume SVLAEDVPBVEVLWEVLW

  • Index of Left Ventricular Contractility dPmx* -- It represents left ventricular pressure velocity increase and thus is a parameter of myocardial contractility

    dtmax of arterial pressure curve

    dPdPmx* =

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

    SVV is...

    1- measured over last 30s window 2- only applicable in controlled mechanically ventilated patients with regular heart rhythm

  • Pulse Pressure VariationPPmax PPminPPV =PPmeanPPmaxPPmeanPPmin Pulse pressure variation (PPV) represents the variation of the pulse pressure over the ventilatory cycle.

    PPV is...

    1- measured over last 30s window 2- only applicable in controlled mechanically ventilated patients with regular heart rhythm

  • SVV and PPV Clinical StudiesSensitivity Specificity Central Venous Pressure (CVP) can not predict whether volume load leads to an increase in stroke volume or not. - - - CVP__ SVV 1 0,2 0,4 0,60,8 1 0,5 0 0 SVV and PPV are excellent predictors of volume responsiveness.

  • 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!

    Clinical application

  • G

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