Cardiovascular Monitoring

1. Cardiovascular Monitoring Clinical Monitoring Arterial Blood Pressure Monitoring: Non invasive Invasive Usefulness for predicting fluid responsiveness Dr. Monica University College of Medical Sciences & GTB Hospital, Delhi

2. Monitoring in the past Finger on the Pulse

3. ASA Monitoring Guidelines • Standard I: Qualified anaesthesia personnel shall be present in the room throughout the conduct of all general anaesthetics, regional anaesthetics and monitored anaesthesia care. • Standard II: During all anaesthetics, the patient’s oxygenation, ventilation, circulation and temperature shall be continually evaluated.

4. High Tech Patient Monitoring

5. Who is the best Monitor in the operating room? The Anaesthesiologist The monitors however extend their range and increase their efficacy.

6. Clinical Monitoring of Cardiovascular system • Inspection, palpation and auscultation are fundamental elements of perioperative cardiovascular monitoring. Inspection : • Mucous membranes, Skin color and Skin turgor provide clues about hydration, oxygenation and perfusion. • Pallor • Cyanosis (peripheral/ central)

7. Inspection of neck veins • s/o low, normal or high JVP. Elevated JVP: • Congestive heart failure, Corpulmonale • Pulmonary embolism, Tamponade • Iatrogenic fluid overload in surgical patients. • Right ventricular infarction Simple clinical techniques like: • Empirical estimation of fluid deficits and blood loss. • Measurement of urine output • Detection of altered mental status.

8. Palpation: • Coldness of extremities: sign of reduced cardiac output. • Oedema : Pitting oedema is a cardinal feature of CHF. • Palpation of accessible peripheral pulse • Examination of cardiac rate and rhythm: Tachycardia :light anaesthesia, hypotension drug induced (atropine, glycopyrrolate). Bradycardia: increased vagal tone, inhalant anaesthetic overdose. Irregular rhythm: Atrial fibrillation, frequent ectopic beats or self limiting paroxysmal arrhythmias.

9. Pulse characteristics Bounding pulse: Hyperdynamic circulation Slow rising: Aortic stenosis Water hammer: Aortic regurgitation Bifid pulse: HOCM, severe AR, AS+ AR Dicrotic pulse: severe Heart failure Pulsusalternans: Heart failure • Symmetry: Radial, Brachial, Carotid, Femoral, Popliteal and pedal pulses . Reduced or absent pulse indicates obstruction proximally in arterial tree usually by thromboembolism or aortic dissection.

10. Palpation of any artery within the surgical field by the surgeon in case of hemodynamic instability. • Capillary Refill Time : normal < 2 sec. • >2 sec. suggestive of inadequate tissue perfusion. Auscultation/ Stethoscopy: • Intraoperative monitoring with either precordial or esophageal stethoscope are the most common simple methods for monitoring circulation and ventilation in anaesthetized patients. • 2 types: Precordial Esophageal

11. 2 types: Precordial Esophageal Precordial stethoscopy • Simple, highly effective device. • Monitors heart and respiratory function • Heavy metal bell or accumulator attached to length of rubber or plastic extension tubing and monoaural earpiece. • Electrically amplified stethoscope available which improve quality and clarity of heart and breath sounds.

12. Precordial Stethoscopes.

13. Esophageal StethoscopySoft, plastic catheter with a balloon covered distal opening.

14. Advantages of esophageal stethoscopy • Breath and heart sounds heard clearly. • Detects apnea, myocardial depression, arrythmias, endobronchial intubation, airway secretions, wheeze, air embolus etc. • Temperature probe, ECG leads and atrial pacemaker electrodes can be incorporated. Limitation: can be used only in intubated patients

15. Complications • Hypoxemia : • Unintended tracheobronchial placement or compression of membranous posterior trachea in infants. • Loss down the esophagus • Detachment of accousticcuff Contraindication: Esophageal varices or strictures • The current role of intra operative stethoscopy as a continuous monitor has become limited to special applications (Pediatric Anaesthesiaand to institutions with limited resouces).

16. Heart Rate / Pulse Rate Monitoring • Heart Rate measured from the ECG trace and Pulse Rate from a selectable pulse source, most common being pulse oximeter/IABP waveform / Automatic NIBP. • Problems in HR monitoring: interference by artifacts caused by electrosurgical unit. • Paced rhythms can cause problems. • Pulse oximeter is of limited value in pts. with arterial occlusive disease or peripheral vasoconstriction. • Pulse deficit – extent to which pulse rate is less than the heart rate. Example Atrial fibrillation, Electrical – mechanical dissociation or Pulseless electrical activity.

17. Blood Pressure • Force exerted by circulating blood against any unit area of the vessel wall. • One of the principal vital sign • Depends on the Cardiac output and Peripheral resistance. Blood Pressure Monitoring: Indirect cuff devices Direct arterial cannulation and pressure transduction Noninvasive BP monitoring: Manual Intermittent techniques Automated Intermittent techniques Automated Continuous techniques

18. Manual Intermittent Techniques: Palpatory Auscultatory Palpatory methods • Rely on sphygmomanometer and mercury manometer to measure cuff pressure • Riva- Rocci method:SBP measured by determining pressure at which palpated radial pulse disappeared as cuff was inflated. • Return to flow technique: variation of Riva-Rocci method. • SBP recorded during cuff deflation at which pulse reappears and is detected by palpation. • Can be used with pulse oximeter or indwelling arterial catheter in ipsilateral arm.

19. Auscultatory method • Originally described by Korotkoff in 1905. • Most commonly used. • Uses Sphygmomanometer, cuff and stethoscope. • Measures both SBP and DBP by auscultating sounds produced by arterial blood flow. Korotkoff sounds: • Very low frequency sounds (25-50 Hz) produced by turbulent blood flow beyond the partially occluded cuff. • Failure to identify initial Korotkoff sounds results in falsely low BP.

20. Phases of Korotkoff sounds: 1.First appearance of sounds marking SBP. IIand III- Increasingly loud sounds. IV. Abrupt muffling of sounds V. No sounds Phase V provides better measure of DBP. Phase IV may be used in conditions where Korotkoff sounds remain audible despite complete deflation of cuff. Eg. AR, AV fistula and pregnancy.

21. Technical aspects • Length of the cuff should be 80% and width should be 40% of the circumference of the arm. • Cuff should be applied snugly, with bladder centred over the artery. • Rate of cuff deflation should be 2-3mmHg per heart beat Miscuffing: • Use of inappropriate sized cuffs. • Most common source of error . • Too small cuff leads to false high BP and too large cuff will produce little error .

22. Adequate size of cuffs

23. Limitations of auscultatory method • Conditions of decreased peripheral flow or high dose vasopressor infusion can attenuate the sounds and underestimate the BP. • Shivering decreases compliance of tissues under the cuff leading to Pseudohypertension.

24. Discrepancy between Direct and Indirect BP measurements in shock(from Cohn JN. Blood pressure measurement in shock. JAMA 1967)

25. Automated Intermittent Techniques (Oscillometry) • Provide frequent, regular BP measurement. • Utilize the Oscillometryprinciple. • Arterial pulsation —› variation in cuff pressure during cuff deflation —› sensed by sensor —› used to measure BP. • Point of maximum amplitude of arterial pulsations corresponds to MAP. • SBP and DBP calculated from increasing and decreasing magnitude of oscillations acc. to empirically derived algorithm.

26. SBP identified as pressure at which pulsations are increasing and are at 25-50% of the maximum. • DBP is the most unreliable oscillometric measurement. Advantages: • Uniform compression of the artery is not necessary • No interference with noise • Not sensitive to electrosurgical interference • Work well with peripheral vasoconstriction Limitation : sensitive to patient’s arm movement.

28. Factors affecting BP determination • Cuff arm relationship: too small cuff overestimates BP. • Site: cuff placed peripherally leads to increased SBP and decreased DBP. • Arm Position: each 10cm vertical height above or below heart level, 7.5mm Hg should be added or subtracted. • Arrhythmias: vulnerable to error.

29. Complications of non invasive BP measurement • Pain • Petechiae and ecchymosis (patients on anti inflammatory drugs, steroids, anticoagulants) • Limb edema • Venous stasis and thrombophlebitis • Peripheral neuropathy (median, ulnar, radial) • Compartment syndrome (more common after prolonged periods of frequent cycles of measurement, trauma or impaired limb perfusion)

30. Finger BP measurement (Finapress)- Automated continuous technique. -Uses Penaz technique(arterial volume clamp method).- Device tends to track the MAP in digital arteries underlying the cuff by keeping the volume of the finger constant and thus nulling the transmural pressure.-Waveform displayed on screen.

31. Advantages: • It is an attempt to improve on the rapidity of determination of NIBP • Correlates well with invasive BP in patients not in shock. Disadvantages: • Compression of digital veins leads to suffusion of finger, temporary numbness. • Less reliable when peripheral perfusion decreased. • Very sensitive to correct placement on middle phalanx.

32. Vasotrac systemMost advanced BP measurement device. Accurately measures SBP, DBP, MAP by waveform analysis. Continuous, non invasive. Variable pressure applied by pressure sensing mechanism directly over artery.Counterpressure in artery produces waveform.

33. Invasive BP Monitoring • Arterial cannulation with continuous pressure transduction with waveform display is the accepted reference standard for BP monitoring. • Catheter over needle technique by Barr in 1961.

34. Indications for Direct Arterial BP Monitoring • Small change in arterial perfusion pressure increases patient’s risk requiring beat to beat assessment (CAD, valvular heart disease). • Wide variation in BP or intravascular volume is anticipated. • Frequent blood sampling, especially ABG analysis is required. • Assessment of BP can’t be done by other methods. Eg. – Cardiopulmonary bypass (nonpulsatile flow), dysrhythmias, marked obesity.

35. Contraindications • Local infection • Coagulopathy: may result in hematoma formation. • Proximal obstruction: Thoracic outlet syndrome, Coarctation of aorta. • Raynaud’s syndrome and Buerger’s disease

36. Radial Artery cannulation Various techniques: • Direct cannulation • Transfixation • Seldinger’s technique • Doppler assisted • 2-D USG assisted • Surgical cutdown

37. Arterial cannulation

38. Transfixation technique

39. Alternative sites for arterial pressure monitoring • Ulnar artery • Brachial artery • Dorsalispedis, Posterior tibial artery( generally for pediatric patients , Neurosurgery) and superficial temporal artery. • Axillary artery and Femoral artery (safe, comfortable but increased risk of atherosclerotic embolization)

41. Complications of arterial pressure monitoring • Distal ischemia (0.1%) • Pseudoaneurysm, arteriovenous fistula. • Hemorrhage, hematoma • Arterial embolization • Local infection, sepsis • Peripheral neuropathy • Misinterpretation of data (equipment misuse)

42. Arterial Pressure waveform • Results from ejection of blood from the LV into aorta during systole f/b peripheral arterial runoff of SV during diastole. • Systolic components follow R wave in ECG. Consists of: • Steep Pressure upstroke • Peak • Decline

43. Downslope interrupted by dicrotic notch, then continues to decline during diastole after T wave of ECG.Dicrotic notch directly in central aorta is called incisura(rel. to closure of aortic valve).Systolic upstroke of radial artery trace 120 -180 msec after R wave of ECG (time to travel from heart to radial artery to transducer).MAP by area under arterial pressure wave divided by beat period.

44. Distal Pulse AmplificationCentral Aorta to periphery:- Arterial upstroke becomes steeper- Systolic peak higher- Dicrotic notch appears later- Diastolic wave more prominent- End diastolic pressure becomes lower

45. Arteriolar level is major site of resistance to blood flow.Causes augmentation of upstream pressure pulsations because of wave reflection.

46. Elderly patients: • Decreased arterial distensibility leads to: • Early return of reflected pressure wave causing increasing Pulse pressure. • Late systolic pressure peak. • Disappearance of diastolic pressure wave.

47. Interpretation of Arterial tracings • Contains a great deal of hemodynamic information. • Heart rate and rhythm: role in patients with pacemaker or electrocautery which can distort ECG. • Pulse pressure: information about fluid status and valvular competence . • Respiratory variation and volume status

48. Qualitative estimation of hemodynamic indicesContractility: rate of pressure rise during systole Stroke volume: area under aortic pressure curve Vascular resistance: presence of dicrotic notch

49. Components of IABP system • Intra-arterial cannula • Coupling system • Pressure transducer • Infusion flushing system • Signal processor, amplifier and display