haemodynamic monitoring-minati

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1. Hemodynamic Monitoring in operating Room and Intensive care unit Dr Minati Choudhury Professor Cardiothoracic Sciences Centre AIIMS New Delhi 2. What I intend to discuss Why to monitor? What to monitor? How to monitor What is the evidence that what we are doing actually makes a difference 3. 3 Cant I look at my patient and tell if they are OK? NO! Physical Assessment is often inaccurate, slow to change and difficult to interpret 4. Why to monitor? Respiration and circulation ..Essential for sustaining life Oxygen ,,,,,, the real necessity for organ function To gather information that will indicate whether the conditions that are required to maintain tissue perfusion are adequately maintained. 5. To assure the adequacy of perfusion Early detection of inadequacy of perfusion To titrate therapy to specific hemodynamic end point To differentiate among various organ system dysfunctions 6. Why hemodynamic monitoring? Preoptimization for high-risk surgery patients treated in the operating room EGDT (< 12 h) resuscitation in septic patients treated in the emergency department reduce morbidity, mortality, and resource use. The closer the resuscitation is to the insult, the greater the benefit. Focus of these monitoring protocols .......... to establish a mean arterial pressure > 65 mm Hg and then to increase DO2 to 600 mL/min/m2 within the first few minutes to hours of presentation. 7. Adequate Oxygen Delivery? ConsumptionDemand 8. Oxygen Delivery Arterial Blood Gas Hemoglobin PaO2 Oxygen Content Oxygen Delivery Cardiac Output Oxygen Content= X Hemodynamic Monitors 9. Oxygen Consumption Oxygen Delivery Oxygen Consumed Remaining Oxygen to Heart = + Oxygen Uptake by Organs & Tissues Oxygen Content in CVP & PA 10. Hemodynamic Monitoring Truth No monitoring device, no matter how simple or complex, invasive or non-invasive, inaccurate or precise will improve outcome Unless coupled to a treatment, which itself improves outcome Pinsky & Payen. Functional Hemodynamic Monitoring, Springer, 2004 11. Different Environments Demand Different Rules Emergency Department Trauma ICU Operation Room ICU & RR Rapid, invasive, high specificity Somewhere in between ER and OR Accurate, invasive, high specificity Close titration, zero tolerance for complications Rapid, minimally invasive, high sensitivity 12. Traditional Monitoring Electrocardiography HR, dysrhythmnias, HR variability Pulse oxymetry NIBP Arterial blood pressure Central venous pressure 13. Pulse Oxymetry ABSORBTION SPECTRO PHOTOMETRY BEER LAMBERT LAW LAMBERTS LAW states that when a light falls on a homogenous substance,intensity of transmitted light decreases as the distance through the substance increase BEERS LAW states that when a light is transmitted through a clear substance with a dissolved solute ,the intensity of transmitted light decreases as the concentration of the solute increases Uses two lights of wavelengths 660nm deoxy Hb absorbs ten times as oxy hb 940 nm absorption of oxyHb is greater Lab oximeters use 4 wavelengths to measure 4 species of haemoglobin It =I o e Ecd [Ecd absorbance] 14. Oxygen desaturation Saturation is defined as is a relative measure of the amount of oxygen that is dissolved or carried in a given medium(percentage). Desaturation leads to Hypoxemia a relative deficiency of O2 in arterial blood. PaO2 < 80mmHg hypoxemia Oxygen saturation will not decrease until PaO2 is below 85mmHg. Rough guide for PaO2 between saturation of 90%-75% is,, PaO2 = SaO2 - 30. SaO2< than 76% is life threatening. 15. PaO2 [mmHg] SaO2 [%] Normal 97 to 80 97 to 95 Hypoxia < 80 < 95 Mild 60-79 90-94 Moderate 40 59 75 89 Severe 80 No change Reflex 60-80 No change Direct than true O2 saturation (10- 20% in heavy smokers) Methaemoglobinemia absorbs equal amount of red &infra red light (SpO2 to move towards 85%) Endo / exogenous dyes interfere Blue ,Black ,Green nail polishes Diathermy leads to disturbance in monitor 18. Problems False positives and negatives Burn injury Pressure injuries 19. Invasive Arterial pressure 20. Normal arterial wave form 21. Dampened trace Arterial catheter Fling Air bubble/blood in line Clot Disconnect/loose tubing Underinflated pressure bag Catheter tip against wall Compliant tubing 22. ARTERIAL LINE MONITORING SITES Radial Low complications Allens test Poss median n damage b/o dorsiflexion Ulnar Primary source hand flow Low complications Poss median n. damage 23. ARTERIAL LINE MONITORING SITES Brachial Medial to biceps tendon Potential median n damage Axillary At junction pectoralis major & deltoid Safer than brachial Low thromboembolic issues 24. ARTERIAL LINE MONITORING SITES Femoral Easy access in shock states Potential hemorrhage (local/retroperitoneal) Requires longer catheter Doralis Pedis Post tibial collateral circ Estimates systolic higher Contraind in DM & PVD 25. ALLENS TEST OCCLUDE ulnar and radial arteries Have pt clench fist until hand blanches Release ulnar a with hand open Color return within 5 sec = adequate collateral circ 26. MODIFIED ALLENS TEST Elevate arm above heart Have pt open and close fist several times Tightly clench fist Occlude radial and ulnar a Lower hand, open fist, release ulnar a Color return within 7 sec = OK 27. RELATIVE CONTRAINDICATIONS Inadequate circulation Infection at the site Recent cannulation same artery Peripheral vascular disease 28. COMPLICATIONS ARTERIAL LINE Thrombosis/embolus Hematoma Infection Nerve damage/palsy Disconnect=blood loss Fistula Aneurysm Digital ischemia 29. mlr/2007 LOSS OF WAVEFORM Stopcock in wrong position Monitor not on correct scale Nonfunctioning monitor Nonfunctioning transducer Kinked/clotted catheter Asystole 30. Patient effect on arterial pressure Tachycardia Hypotension Atrial fibrillation Wave form quality Crisp: sharp, clear lines, flowing ideal Dampened: blunted, smooth Low flow states, air in line Hyperdynamic: spikes Pinched, compliant tubing 31. Patient effect on arterial pressure Upstroke of wave Related to velocity of blood ejected Slowed upstroke AS LV failure Inc sharp vertical in hyperdynamic states Anemia Hyperthermia Hyperthyroidism SNS Aortic regurg 32. CENTRAL VENOUS PRESSURE MONITORING Usually put in coditions where. Rapid administration of fluids and blood products in patients with any form of shock Administration of vasoactive and caustic drugs Administration of parenteral nutrition, electrolytes or hypertonic solutions Venous access for monitoring CVP and assessing the response to fluid or vasoactive drug therapy Insertion of transvenous pacemaker Lack of accessible peripheral veins Hemodynamic instability 33. CVP ACCESS RIJ (OR) EJ Subclavian(ICU) Antecubital Femoral 34. mlr/2007 CVP ACCESS 35. Central venous pressure monitoring kit 36. Typical CVP wave form 37. Elevations in Central venous pressure Hypervolemia Right ventricular infarction Impaired RV contraction Pulmonary hypertension Pulmonic stenosis Left to right shunts Tricuspid valve disease Cardiac tamponade 38. Low Central venous pressure Hypovolemia Dehydration Poor vascular tone Peripheral vasodilation Hemorrhage Addisonian crisis Sepsis Regional anesthesia Polyuria Sympathetic dysfunct 39. Contraindication Coagulopathies or bleeding disorders (monitor platelet count, PT, PTT) Current or recent use of fibrinolytics or anticoagulants Insertion sites that are infected or burned, or where previous vascular surgery has been performed, or involve catheter placement through vascular grafts Patients with suspected or confirmed vena cava injury 40. Central venous pressure Limitations..... Evaluate as a trend Systemic vasoconstriction can present a CVP elevated despite hypovolemia Mechanical ventilation Positive pressure ventilation thoracic and central venous pressures Measure at end-expiration Complication Arterial puncture Hematoma False aneurysm Fistula Catheter position during placement Wall perf/tamponade Dysrhythmias Catheter shear Brachial plexus injury Thoracic duct injury 41. Direct monitoring of Cardiac output Invasive PA catheter Ficks method Dye dilution Thermo dilution Non-invasive and semi invasive Echocardiography Oesophageal doppler Aortovelography Transthoracic impedance Arterial pulse contour analysis (PiCCO) Arterial pulse power analysis (LiDCO) Flotrac-vigileo 42. PA Catheter Swan-Ganz Catheter Swan 43. Use in MI with complications CHF Pulmonary HTN Respiratory failure Shock Sepsis Trauma Hemodynamic instability High risk cardiac surgery Peripheral vascular surgery Aortic surgery Neuro surgery DO NOT USE INCASE OF Tricuspid or pulmonary valve mechanical prosthesis Right heart mass (thrombus and/or tumor) Tricuspid or pulmonary valve endocarditis 44. PA Catheter on float 45. Waveforms during PAC insertion and distance from skin insertion 46. Proximal port in Right atrium 47. Right ventricular port (orange) 48. Distal port (yellow) Normal values PA systolic pressure = 20- 30 mm Hg PA diastolic pressure = 8- 12 mm Hg Mean PAP=12-15 mmHg 49. Measurements that can be done from PA catheter CVP Rt ventricular pressure PAP PCWP CO CI = CO/BSA, L/min/m2 Stroke volume= CO/HR 1,000, mL/min Stroke index = stroke volume/BSA, mL/m2 LV stroke work= stroke volume (MAP- Ppao), mL mm Hg LV stroke work index= LV stroke work/BSA, mL mm Hg/m2 50. Derived Hemodynamic Parameters From Hemodynamic Monitoring* Systemic vascular resistance= (MAP- Pra)/CO 80,dyne s/cm5 RV stroke work = stroke volume (MPAP- Pra), mL mm Hg RV stroke work index= RV stroke work/BSA, mL mm Hg/m2 Pulmonary vascular resistance= [(MPAP Ppao)/CO] 80,dyne s/cm5 51. Derived Hemodynamic Parameters From Hemodynamic Mo

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