Advanced haemodynamics

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  • 1. Introduction to HEMODYNAMIC MONITORING
  • 2. DEFINITION HEMODYNAMIC MONITORING DEFINITION Measuring and monitoring the factors that influence the force and flow of blood. PURPOSE To aid in diagnosing, monitoring and managing critically ill patients. 2
  • 3. INDICATIONS To diagnose shock states To determine fluid volume status To measure cardiac output To monitor and manage unstable patients To assess hemodynamic response to therapies To diagnose primary pulmonary hypertension, valvular disease, intracardiac shunts, cardiac tamponade, and pulmonary embolus 3
  • 4. CONTRAINDICATIONS for an invasive PA Catheter Tricuspid or pulmonary valve mechanical prosthesis Right heart mass (thrombus and/or tumor) Tricuspid or pulmonary valve endocarditis 4
  • 5. Clinical Scenario Use of PAC Management of complicated MI Assessment of respiratory distress Cardiogenic/hypovolemic/septic Tamponade Pulmonary embolism Severe dilated cardiomyopathy Management of Pulmonary Hypertension Management of high-risk surgical patients Cardiogenic vs non-cardiogenic pulmonary edema Assessment/Diagnosis of shock/ cardiac dysfunction Severe LVF/RMI (precise management of heart failure) CABG, vascular, valvular, aneurysm repair Management of volume requirements in the critically ill ARF, GI bleed, trauma, sepsis (precise management) 5
  • 6. Hemodynamic Values CO / CI SV / SVI or SI SVO 2 Cardiac Output/Cardiac Index VO 2 / VO 2 I DO 2 / DO 2 I Oxygen Consumption Oxygen Delivery Stroke Volume/Stroke Volume Index Mixed Venous Saturation RVEDVI or EDVI RV End-Diastolic Volume Systemic Vascular Resistance SVR / SVRI Pulmonary Vascular Resistance PVR / PVRI RV Ejection Fraction RVEF PAOP CVP PAP Pulmonary Artery Occlusive Pressure Central Venous Pressure Pulmonary Artery Pressure 6
  • 7. Index Values Values normalized for body size (BSA) CI is 2.5 4.5 L/min/m2 SVRI is 1970 2390 dynes/sec/cm-5/m2 SVI or SI is 35 60 mL/beat/m2 EDVI is 60 100 mL/m2 7
  • 8. Importance of Index Values Mr. Smith 47 y/o male 60 kg CO = 4.5 6 ft tall (72 inches) BSA = 1.8 CI = 2.5 L/min/m 2 Mr. Jones 47 y/o male 120 kg CO = 4.5 6 ft tall (72 inches) BSA = 2.4 CI = 1.9 L/min/m2 8
  • 9. Basic Concepts Cardiac Output - amount of blood pumped out of the ventricles each minute Stroke Volume - amount of blood ejected by the ventricle with each contraction CO = HR x SV Decreased SV usually produces compensatory tachycardia.. So. . .changes in HR can signal changes in CO 9
  • 10. Basic Concepts Systemic Vascular Resistance Measurement of the resistance (afterload) of blood flow through systemic vasculature *Increased SVR/narrowing PP = vasoconstriction *Decreased SVR/widening PP = vasodilation Blood Pressure BP = CO x SVR ** SVR can increase to maintain BP despite inadequate CO Remember CO = HR x SV 10
  • 11. Basic Concepts BP = CO x SVR CO and SVR are inversely related CO and SVR will change before BP changes * Changes in BP are a late sign of hemodynamic alterations 11
  • 12. Stroke Volume Components Stroke Volume Preload: the volume of blood in the ventricles at end diastole and the stretch placed on the muscle fibers Afterload: the resistance the ventricles must overcome to eject its volume of blood Contractility: the force with which the heart muscle contracts (myocardial compliance) 12
  • 13. Stroke Volume Preload Afterload Contractility Filling Pressures & Volumes Resistance to Outflow Strength of Contraction CVP PVR, MPAP RVSV PAOP (PAD may be used to estimate PAOP) Fluids, Volume Expanders SVR, MAP LVSV Vasoconstrictors Inotropic Vasodilators Medications Diuretics 13
  • 14. Clinical Measurements of Preload Right Side: CVP/RAP * filling pressures Left Side: PAOP/LAP PAD may be used to estimate PAOP in the absence of pulmonary disease/HTN The pulmonary vasculature is a low pressure system in the absence of pulmonary disease These pressures are accurate estimations of preload only with perfect compliance of heart and lungs 14
  • 15. Clinical Measurements of Afterload RV Afterload MPAP PVR = 150-250 dynes/sec/cm-5 PVRI = 255-285 dynes/sec/cm-5/m2 LV Afterload MAP SVR = 8001300 dynes/sec/cm-5 SVRI = 1970-2390 dynes/sec/cm-5/m2 15
  • 16. Clinical Estimation of Contractility Cardiac Output * flow Normal = 4-8 L/min Cardiac Index Normal = 2.5-4.5 L/min/m2 Stroke Volume *pump performance Normal = 50-100 ml/beat Stroke volume Index Normal = 30-50 ml/beat/m2 16
  • 17. Ventricular Compliance Ability of the ventricle to stretch Decreased with LV hypertrophy, MI, fibrosis, HOCM *If compliance is decreased, small changes in volume produce large changes in pressure 17
  • 18. The PA Catheter 18
  • 19. Pulmonary Artery Catheters 19
  • 20. The Pulmonary Artery Catheter 20
  • 21. Swan-Ganz PA Catheter Large Markers = 50cm Small Markers = 10cm 10 cm between small black markers on catheter Several types Thermodilutional CO CCO Precep NICCO Multiple lumens 21
  • 22. BREAK Take 5 MINUTES 22
  • 23. Demonstration of PA catheter and Hands-on practice 23
  • 24. Risks With The PA Catheter Bleeding Infection Dysrhythmias Pulmonary Artery Rupture Pneumothorax Hemothorax Valvular Damage Embolization Balloon Rupture Catheter Migration 24
  • 25. 25
  • 26. Hemodynamic Waveforms
  • 27. PA-Catheter Positioning Right Atrium Pulmonary Pulmonary Right Artery Ventricle Artery Occlusion Pressure 27
  • 28. PAC Insertion Sequence 28
  • 29. Post PA Catheter Insertion Assess ECG for dysrhythmias. Assess for signs and symptoms of respiratory distress. Ascertain sterile dressing is in place. Obtain PCXR to check placem