Hemodynamic MonitoringDr. Siti Habibah, SpAn

Defininsi HemodinamikSistem aliran darah kardiovaskular yang memperlihatkan sistem kerja kardiovaskular (jantung dan pembuluh darah)

Tujuan Pemantauan HemodinamikMemelihara perfusi organ yang adekuat

Flow = (Parterial Pvenous)/ResistanceMAP ~ tekanan perfusiAutoregulasi

Parameter yang dipantauPreload, kontraktilitas, afterload (sirkulasi sistemik/pulmonal)Siklus jantung: Sistolik dan diastolikMAP, CVP, SV, PAP, PCWPCurah jantung (CO), CIIndeks Tahanan Pembuluh Sistemik (SVRi)Indeks Tahanan Pembuluh Pulmonal (PVRi)Oksigenasi jaringan: CaO2, DO2, VO2, O2ER

Hemodynamic MonitoringNon Invasive MonitoringII. Invasive MonitoringMinimally Invasive MonitoringMonitoring Tissue Perfusion

I. Noninvasive MonitoringNIBP1. Prinsip kerja: suara korotkoff (manual)/ oscillatory (automated)2. Nilai MAP lebih berguna3. Lebih rendah dari invasive4. Penting ukuran cuffECG continuous, pulse oxymetry, UO, core body temperature

Invasive MonitoringDirect Arterial Pressure MonitoringIndication: a. Continuous (beat to beat) BP b. Frequent blood samplingc. NIBP not possible/reliableLocation: Radial,brachial,femoral,axillary,dorsalis pedisContraindication: Infection at the cannulation site, lack of collateral, arterial insufficiency at site, lymphatic disruption

Hemodynamic MonitoringInterpretationZeroingTroubleshooting: overdamped/underdamped

ComplicationHematomaCatheter related bacterial colonizationLocal infectionBleedingSepsisPseudoaneurysmPermanent hand ischemia

Central Venous PressureIndication:Measurement of CVPMeasurement of ScvO2Use for pulse wave analysis Access for administration of drugs or parenteral nutrition, intravenous pacing, PACIntravenous access in patients with difficult peripheral access

Tujuan klinis CVPMenginformasikan fungsi jantung kananMengetahui volume intravaskular bila EF>= 40% dan tidak ada kelainan katup CVP=PCWP

Lokasi Pemasangan CVCVena antecubital (PICC)Vena subclaviaVena jugularVena femoralVena brachialis

End Tip CVC on CXR

InterpretationA wave: atrial contraction ~ P wave on ECGC wave: early ventricle contaction ~ QRS on ECGX descent: downward movement during contraction ~ before T waveV wave: pressure produced when the blood filling the right atrium ~ T waveY descent: tricuspid valve open

Anomalies and problemsAtrial fibrillation absence of a waveC wave and x descent is replaced by large positive wave of tricuspid regurgitationNot accurate predict of fluid responsivenessImpaired RV function, severe pulmonary disease, valvular disease affect the CVP reading

KomplikasiPneumothoraxDistritmia Thrombus/embolismHydrothoraxPerdarahanInfeksi

Pulmonary Artery CatheterGold standard for cardiac output determinationProvide information: (1) Intrathoracic intravascular pressure(2) Cardiac output(3) SvO2Thermodilution technique

IndicationDifferentiation of types of shockAssesment of pulmonary edema (ARDS vs cardiogenic)Diagnosis and monitoring of PHDiagnosis of cardiac tamponade, pulmonary embolism, valvular diseaseAssessment of hemodynamic response to therapiesMonitorung and management for patients with heart failure

ContraindicationCoagulopathyProsthetic right heart valvesLBBBRight-sided endocarditisPoorly controlled dysrhytmiasRight ventricular thrombusEndocardial pacemaker/defibrillator (relative CI)

ComplicationPneumothoraxRBBBDysrhytmiasPulmonary artery ruptureInfectionThrombosisEndocarditisKnotting catheter

Interpretation of PAC findings

Condition/Type of ShockPAOPCO/CISVRDistributive shockNormal/CardiogenicHypovolemicObstructivePulmonary embolismNormal/

Pericardial tamponade= CVP

CVP locationPA cath locationA. pulmonalisRight Atrium

III. Minimally invasive Monitoring

1. CO2 rebreathing (NiCCO)2. Pulse wave analysis (LiDCO)3. Esophageal doppler4. Plethysmography/thoracic electrical bioimpedance5.Echocardiography6. Arterial pressure waveform analysis7. Systolic Pulse Contour Analysis with Transpulmonary Thermodilution calibration (PiCCO)

IV. Monitoring tissue perfusionMetabolic acidemiaSerum lactateSvO2Gastric mucosal pH ~ intracellular pH

Variabel hemodinamik

Variabel hemodinamik

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