haemodynamic monitoring
DESCRIPTION
Haemodynamic Monitoring. Theory and Practice. Haemodynamic Monitoring. Physiological Background Monitoring Optimizing the Cardiac Output Measuring Preload Introduction to PiCCO Technology Practical Approach Fields of Application Limitations. Monitoring. Monitoring the Vital Parameters. - PowerPoint PPT PresentationTRANSCRIPT
Haemodynamic Monitoring
Theory and Practice
2
Haemodynamic Monitoring
A. Physiological Background
B. Monitoring
C. Optimizing the Cardiac Output
D. Measuring Preload
E. Introduction to PiCCO Technology
F. Practical Approach
G. Fields of Application
H. Limitations
3
Monitoring the Vital Parameters
Monitoring
Respiration Rate
Temperature
4
Monitoring the Vital Parameters
Monitoring
ECG
• Heart Rate
• Rhythm
Respiration Rate
Temperature
5
Monitoring the Vital Parameters
Monitoring
Blood Pressure (NiBP)
• no correlation with CO
• no correlation with oxygen deliveryECG
Respiration Rate
Temperature
6
DO2 ml*m-2*min-1100 300 500 70030
60
90
120
150
MAP mmHg
n= 1232
Monitoring the Vital Parameters
Monitoring
MAP: Mean Arterial Pressure, DO2: Oxygen Delivery
The Mean Arterial Pressure does not correlate with Oxygen Delivery!
Reinhart K in: Lewis, Pfeiffer (eds): Practical Applications of Fiberoptics in Critical Care Monitoring, Springer Verlag Berlin - Heidelberg - NewYork 1990, pp 11-23
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Monitoring the Vital Parameters
Monitoring
Blood Pressure (NiBP)
• No correlation with CO
• No correlation with oxygen delivery
• No correlation with volume status
ECG
Respiration Rate
Temperature
8
Monitoring the Vital Parameters
80% of blood volume is found in the venous blood vessels,
only 20% in the arterial blood vessels!
Monitoring
9
Monitoring the Vital Parameters
Monitoring
Blood Pressure (NiBP)
ECG
Respiration Rate
Temperature • No correlation with CO
• No correlation with oxygen delivery
• No correlation with volume status
• No evidence of what is the ‘right’ perfusion pressure
10
Standard Monitoring
Monitoring
Oxygen Saturation
NIBP
ECG
Respiration Rate
Temperature• No information re the O2 transport capacity
• No information re the O2 utilisation in the tissues
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Standard Monitoring
Monitoring
Respiration Rate
NIBP
ECG
Temperature
Urine Production
Oxygen Saturation
Blood Circulation(clinical assessment)
12
What other parameters do I need?
Advanced Monitoring
Monitoring
The standard parameters do not give enough information in unstable patients.
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Advanced Monitoring
Monitoring
Invasive Blood Pressure (IBP)
• Continuous blood pressure recording• Arterial blood extraction possible• Limitations as with NiBP
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Advanced Monitoring
Monitoring
IBP Arterial BGA
Information re:
• Pulmonary Gas exchange
• Acid Base Balance
No information re oxygen supply at the cellular level
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Advanced Monitoring
Monitoring
IBP Lactate
Marker for global metabolic situation
Significant limitations due to:
• Liver metabolism
• Reperfusion effects
Arterial BGA
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Advanced Monitoring
Monitoring
IBP CVP
Arterial BGA
Lactate
• central venous blood gas analysis possible
• When low: hypovolaemia probable
• When high: hypovolaemia not excluded
• Not a reliable parameter for volume status
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Advanced Monitoring
Monitoring
IBP ScvO2
• Good correlation with SvO2 (oxygen consumption)
• Surrogate parameter for oxygen extraction
• Information on the oxygen consumption situation
• When compared to SvO2 less invasive (no pulmonary artery catheter required)
Arterial BGA
Lactate
CVP
Reinhart K et al: Intensive Care Med 60, 1572-1578, 2004; Ladakis C et al: Respiration 68, 279-285, 2000
Monitoring
n = 29r = 0.866ScvO2 = 0.616 x SvO2 + 35.35
ScvO2
SvO2
r = 0.945
30
50
70
90
70 9050
SvO2 (%)
65
70
85
70 90
90
30 6040 80
80
ScvO2 (%)
40
60
80
806040
75
6050
Monitoring of the central venous oxygen saturation
The ScvO2 correlates well with the SvO2!
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avDO2 ml/dl
Monitoring
Monitoring of the central venous oxygen saturation
30 40 50 60 70 80 90 100
7.0
6.0
7.0
4.0
3.0
2.0
1.0
0
r= -0.664
n= 1191
avDO2= 12.7 -0.12*ScvO2
ScvO2 %
A low ScvO2 is a marker for increased global oxygen extraction!
avDO2: arterial-venous oxygen content difference, ScvO2: central venous oxygen saturation
Reinhart K in: Lewis, Pfeiffer (eds): Practical Applications of Fiberoptics in Critical Care Monitoring, Springer Verlag Berlin - Heidelberg - NewYork 1990, pp 11-23
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Monitoring
Monitoring of the central venous oxygen saturation
avDO2 ml/dl
7.0
6.0
7.0
4.0
3.0
2.0
1.0
r= -0.664
n= 1191
avDO2= 12,7 -0.12*ScvO2
Consumption VO2: VO2 = CO x Hb x 1.34 x (SaO2 - S(c)vO2)
Delivery DO2: DO2 = CO x Hb x 1.34 x SaO2
CO
Hb
Mixed / Central Venous Saturation S(c)vO2
SaO2
avDO2: arterial-venous oxygen content difference, ScvO2: central venous oxygen saturation 30 40 50 60 70 80 90 100
0 ScvO2 %
Reinhart K in: Lewis, Pfeiffer (eds): Practical Applications of Fiberoptics in Critical Care Monitoring, Springer Verlag Berlin - Heidelberg - NewYork 1990, pp 11-23
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Early goal-directed therapyRivers E et al. New Engl J Med 2001;345:1368-77
O2- Therapy and SedationIntubation + Ventilation
Central Venous CatheterInvasive Blood Pressure Monitoring
CVP
MAP
ScVO2
Cardiovascular Stabilisation
Volume therapy
8-12 mmHg
< 8 mmHg
65 mmHg
Inotropes
>70%70%
< 70%
no Therapy maintenance,regular reviews
< 65 mmHgVasopressors
Blood transfusion to Haematocrit 30%
Monitoring
Monitoring of the central venous oxygen saturation
< 70%
Goal achieved?yes
ScVO2
Hospital 60 days
Mo
rtal
ity
Monitoring
Monitoring of the ScvO2 – Clinical Relevance
Significance of the ScvO2 for therapy guidance
22
Monitoring of the ScvO2 – Clinical Relevance
Monitoring
Early monitoring of ScvO2 is crucial for fast and effective
hemodynamic management!
23
Monitoring ScvO2 – therapeutic consequences in the example of sepsis
Pt unstable
ScvO2 < 70%
Volume bolus
(when absence of contraindications)
ScvO2 > 70% or < 80%
Re - evaluation
Continuous ScvO2 monitoring – CeVOX
Advanced Monitoring - PiCCO
Volume / Catecholamine
Erythrocytes
Monitoring
ScvO2 < 70%
24
Tissue hypoxia despite ”normal“ or high ScvO2?
?Microcirculation disturbances
in SIRS / Sepsis
Monitoring ScvO2 – Limitations
Monitoring
25
SxO2 in %
modified from:Reinhart K in: Lewis, Pfeiffer (eds): Practical Applications of Fiberoptics in Critical Care Monitoring, Springer Verlag Berlin - Heidelberg - NewYork 1990, pp 11-23
Monitoring ScvO2 – therapeutic consequences in the example of sepsis
ScvO2
Pt unstable ScvO2 < 70%
Re- evaluation
Monitoring
ScvO2 > 80%
Tissue hypoxia despite „normal“ or high ScvO2?
?
Volume administration (when absence of
contraindications)
ScvO2 > 70% but < 80% ScvO2 < 70%
Advanced Monitoring
cont. ScvO2 monitoring
Volume / Catecholamine / Erythrocytes
Pt unstable
ScvO2 > 80%
ScvO2 < 80% but > 70%
Re-evaluation
Monitoring
ScvO2 > 80%
Tissue hypoxia despite ”normal“ or high ScvO2?
Microcirculation?
Organ perfusion?
Further information neededMacro-haemodynamics (PiCCO)
Liver function (PDR – ICG)Renal function
Neurological assessment
Volume bolus
(when absence of contraindications)
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Monitoring ScvO2 – therapeutic consequences in the example of sepsis
Monitoring
Summary and Key Points
• Standard monitoring does not give information re the volume status or the adequacy of oxygen delivery and consumption.
• The CVP is not a valid parameter to measure volume status
• The measurement of central venous oxygen saturation gives important information re global oxygenation balance and oxygen extraction
• Measuring the central venous oxygenation can reveal when more advanced monitoring is indicated
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