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Hemodynamic monitoring

Hemodynamic monitoring. Magdy M Khalil, MD, EDIC. Tissue perfusion. Oxygen delivery = CO x arterial oxygen content CO = (SV x HR) x {(Hb x 1.39 x SaO 2 ) + (0.003 x PaO 2 )} Arterial pressure (AP) = CO x SVR. Diagnosis of tissue malperfusion. Clinical assessment Basic monitoring

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Hemodynamic monitoring

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  1. Hemodynamic monitoring Magdy M Khalil, MD, EDIC

  2. Tissue perfusion • Oxygen delivery = CO x arterial oxygen content CO = (SV x HR) x {(Hb x 1.39 x SaO2) + (0.003 x PaO2)} • Arterial pressure (AP) = CO x SVR

  3. Diagnosis of tissue malperfusion • Clinical assessment • Basic monitoring • Preload monitoring • Minimally invasive cardiac output/cardiac contractility assessment • Invasive; pulmonary artery catheter • Assessment of tissue perfusion

  4. Clinical assessment • Thirst, • Cold mottled extremities, • Poor peripheral pulses, • Impaired capillary refill, • Tachypnoea, • Tachycardia, • Altered mentation, or • Oliguria.

  5. Basic monitoring • Electrocardiography (ECG), • Arterial blood pressure (AP), • Pulse oximetry (SpO2) monitoring, • Baseline serum lactate.

  6. Arterial blood pressure Measurement • Non-invasive • Invasive Indications for invasive arterial pressure monitoring: • Labile blood pressure • Severe hypotension • Use of rapidly acting vasoactive drugs • Frequent sampling of arterial blood. Relative indications : • Severe hypertension • Presence of an intra-aortic balloon pump • Morbid obesity.

  7. SpO2 monitoring • The SpO2 signal is often inaccurate in the presence of altered skin perfusion

  8. Serum lactate • Normal level in resting humans 1 mmol/l (0.7-1.3). • Same in venous or arterial blood • Factors affecting serum lactate level: • Tissue hypoxia • Liver dysfunction • Catecholamines

  9. Venous oxygen saturation Factors affecting SvO2: (N: 70%) • Cardiac output • Hypoxemia • Anaemia • Pain, shivering and increased work of breathing • Carbon monoxide poisoning /cyanide poisoning • Intra-cardiac shunt ScvO2

  10. Preload monitoring • Examination of the right internal jugular vein • Central venous pressure (CVP). • Catheter in SVC An elevated intracardiac pressure may be due to an elevated volume or an elevated resistance (Acute heart failure, cardiac tamponade, constrictive pericarditis, restrictive cardiomyopathy, tricuspid stenosis or regurgitation) • Estimated from respiratory motion of IVC (SB). • End-diastolic volumes (TTE /TOE)

  11. Predicting fluid responsiveness Change in CO in response to a change in preload • Fluid challenge while monitoring: • AP, • heart rate, • CVP and • urine output.

  12. Predicting fluid responsiveness Static parameters • GEDV is the volume of blood contained in the four chambers of the heart at end diastole. • ITBV is the volume of blood in the four chambers and the blood volume in the pulmonary vessels at end diastole Dynamic parameters • Pulse pressure variation (PPV) ≥13% , • Systolic pressure variation (SPV) > 10 mmHg on MV • Stroke volume variation (SVV).

  13. Minimally invasive CO/CC assessment Indications • Hypotension despite fluid resuscitation, or • Continued evidence of global tissue hypoperfusion Low CO + elevated measures of preload in ventricular failure High CO+ tissue hypoperfusion, e.g. septic shock.

  14. Minimally invasive methods of CO measurement • Echocardiography (EF >55%) • Pulse contour analysis: measuries SV on a beat-to-beat basis from the arterial pulse pressure waveform. • Oesophageal Doppler: measures blood flow velocity) in the descending aorta (70% of total CO) • Methods using the Fick principle (Patient on MV) Contraindications to oesophageal Doppler : • Unexplained history of dysphagia • Oesophageal pathology e.g. varices, stricture, oesophagitis • Oropharyngeal pathology • Unstable cervical spine injury

  15. Transpulmonary thermodilutioncardiac output and volumetric parameters • Global end-diastolic volume (GEDV): ITTV – PTV (600-800 ml/m 2) • Intrathoracic thermal blood volume (ITBV): 1.25 x GEDV ( 850-1000 ml/m 2) • Pulmonary blood volume (PBV): ITBV – GEDV • Extravascular lung water (EVLW): ITTV – ITBV ( 3.0-7.0 ml/kg). • Pulmonary vascular permeability index (PVPI) : EVLW /PBV ( 1.0-3.0), reflects the permeability of the alveolar–capillary barrier. PVPI is higher in ALI/ARDS

  16. Pulmonary artery catheter Continuous monitoring of : • RAP • PAP • PAOP (5-12 mmHg) • CO • SvO2. Indications: • Circulatory shock with evidence of tissue hypoperfusion not responding to therapy. • Management of severe pulmonary oedema. • Difficulty evaluating right and left ventricular preload in the presence of oliguria.

  17. Interpreting haemodynamic data • Is there evidence of tissue hypoperfusion? • Is there a reduction in arterial oxygen content? • Is there a question regarding optimal preload? • Is there a question regarding stroke volume/cardiac contractility? • Is there a need for PAC?

  18. Best wishesMagdy Khalil

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