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REVIEW OF HD MONITORING
DR GHALEB ALMEKHLAFIMD,SFCCM,EDIC
HEMODYNAMICS
• DEFENITION-MOVEMENT• COMPONENTS-CIRCULATION• TARGETS-PERFUSION• PHYSIOLOGY/PATHOPHYSIOLOGY• METHODS OF MONITORING PARAMETERS AND VALIDITY DIAGNOSIS OR TREATMENT WHICH METHOD AND WHEN?
1-Myocardial contraction &heart rate
2-Vasoactivity
4factors that affecting the hemodynamic conditions
3-volume
C.O.= HR x Stroke Volume (60-130 Ml/beat)
Stroke Volume has three components 1. Preload 2. Afterload
3.Contractility
4-MICROCIRCULATION/PERFUSION
hypovolemia vascular tone depression
myocardial depression
Importance of assessing
the degree of each component
to select and apply the best therapeutic option
vasopressors inotropes
Hemodynamic failure in critically ill patients: 3 components
fluids
presence of associated lung injury
methodsClinical methods• Physical examination:
systemic clinical examination
• V/S:NI-BP, Heart rate• Skin, extremities• Urine output• Mental status
Classic methods
• A-LINE• Pulse waveform analysis• Invasive BP• CVP • PAC
Advanced methodsNon invasiveinvasiveLAB:
SCVO2,LA
• Clinical examination remains an important initial step in the diagnosis and risk stratification of critically ill patients.
• Individual vital signs often do not reflect hemodynamic status.• High or low pulse rate is neither sensitive nor specific for the
diagnosis of hemodynamic instability.• Respiratory rate lacks adequate specificity or sensitivity to serve
as a test for hemodynamic instability.• Skin or toe temperature is not a sensitive indicator of
hemodynamic instability.• Oliguria may have causes other than renal Hypoperfusion.
• TRENDS
Mottling score
mlr/2007
ARTERIAL LINE
Arterial waveform components
20
40
60
80
100
120
140
Time0
Arterial Pressure (mmHg)
DAP: reflection of vasomotor tone
DAP
20
40
60
80
100
120
140
Time0
Arterial Pressure (mmHg)
DAP: reflection of vasomotor tone
DAP: driving pressure for left coronary circulation
DAP
20
40
60
80
100
120
140
Time0
PP
Arterial Pressure (mmHg)
20
40
60
80
100
120
140
Time0
MAP
Arterial Pressure (mmHg)
MAP: driving pressure for perfusion of important organs (e.g. brain, kidney)
20
40
60
80
100
120
140
Time0
Arterial Pressure (mmHg)
MAP: important hemodynamic target of resuscitation of shock states
MAP
MAP is a goal of resuscitation
• Correction of hypotension with a vasopressor allows improving organ perfusion and microcirculation
Which MAP value to target?
Target MAP
• increasing MAP above 65 mmHg results in little benefit
• Probably higher target value if: 1. History of chronic hypertension2. Elevated CVP3. Elevated abdominal pressure
Target blood pressure in circulatory shock
• We recommend individualizing the target blood pressure during shock resuscitation. Recommendation Level 1: QoE moderate (B)
• We recommend to initially target a MAP of ≥ 65 mmHg. Recommendation: Level 1; QoE low (C)
• We suggest a higher MAP in septic patients with a history of hypertension. Recommendation: Level 2; QoE low (B)
arterial line waveformSlowed upstroke
– AS– LV failure
• sharp vertical in hyperdynamic states
– Anemia– Hyperthermia– Hyperthyroidism– SNS– Aortic regurg
Age effect
arterial waveforms –differential iagnosis
.
Pulsus alternance Seen in:LVD/cardiomyopathies, HTN,AS,Normal hearts with SVT
pulsus bisfrenus is a sign of combined aortic valve lesion, also seen in hypertrophic obstructive cardiomyopathy (HOCM), patent ductus arteriosus, arteriovenous fistulas and normal hearts in a hyperdynamic state
hyperdynamic statesAR
ASLV failure
mlr/2007
COMPLICATIONS ARTERIAL LINE
• Thrombosis/embolus• Hematoma• Infection• Nerve damage/palsy
• Disconnect=blood loss• Fistula• Aneurysm• Digital ischemia
mlr/2007
LOSS OF WAVEFORM
•asystole• Stopcock• Monitor not on correct scale• Nonfunctioning monitor• Nonfunctioning transducer• Kinked/clotted catheter
Technical issues/resonance artifacts
resonance artifacts
DAMPENED WAVEFORM• Air bubble/blood in line• Clot• Disconnect/loose tubing• Underinflated pressure bag• Catheter tip against wall• Compliant tubing
UNDERDAMPED WAVEFORM
• Too many stopcocks• Long tubing• Air bubbles• Defective transducer
Arterial line dynamic response testing
Other functions of A-line
• Blood extraction• pulse rate and rhythm• effects of dysrhythmia
on perfusion• ECG lead disconnection• continuous cardiac
output using pulse contour analysis
• pulse pressure variation (suggests fluid responsiveness)
• steeper upstroke of pulse pressure = increased contractility
• area under upstroke = SV• steep down stroke = low SVR
classification of cardiac output monitoring systems.
INVASIVE-PAC LESS INVASIVE - PCM: pulse contour method - TPD :transpulmonary dilution - TED :trans esophageal Doppler NONINVASIVE - PCM - TTE/US - BIOEMPEDANCE,BIOREACTANCE - NICO
PULMONARY ARTERY CATHETER
Markings on catheter.1. Each thin line= 10 cm.2. Each thick line= 50 cm.
CVP Proximal (pressure line - injectate port for CO)-BLUE PA Distal (Pressure line hook up)- Yellow Extra port - usually- ClearThermistor – Red Cap
PA Catheter Timeline
Swan HJ, Ganz W, Forrester
J. NEJM.Aug
, 1970
Iberti TJ, Fischer EP, Leibowitz AB, et al. Pulmonary Artery
Catheter Study Group. JAMA. Dec, 1990
1970 19901980 2000 2005
Connors AF, et al. JAMA. Sept, 1996
1995
PA Catheters Are Good
PA Catheters Might be Bad
PA CathetersAre Bad
MDs AreIgnorant
Rhodes A. Int Care Med.
Feb, 2002
French PAC Study GroupJAMA. Nov, 2003
Founding of the Society of Critical Care Medicine
PACMAN, Escape, ARDSnet
2004 -2006
EBM
Overall Conclusion:1. No difference in LOS in the ICU2. No difference in Mortality3. No benefit, no harm• “There is no guided therapy tailored towards
PAC use.”• “PAC is a diagnostic tool, not a therapeutic
one
Advances-PCM• beat-to beat stroke volume analysis is based on the
Windkessel model, which was described by Otto Frank in 1899• In 1993 Wesseling et al described a method of using the finger
cuff arterial pressure wave to derive cardiac output“ Model Flow ” Currently the Nexfin
• In 1997 the first commercial system, the PiCCO (Pulsion, Munich, Germany) was released
• in 2002 the LiDCO-plus (and later rapid), (LiDCO Ltd., Cambridge, England)
• In 2004 the FloTrac-Vigileo, (Edwards Lifesciences, Irvine, CA, USA). Then volume view in 2010
Pulmonary Artery CatheterindicationsDiagnostic Diagnosis of shock states high- versus low-pressure pulmonary edema primary pulmonary hypertension valvular disease,
intracardiac shunts, cardiac tamponade, and pulmonary embolus (PE)
Monitoring complicated AMI hemodynamic instability after cardiac surgery Therapeutic - Aspiration of air emboli - local thromplytics
Contra-indications:• Tricuspid or pulmonary valve
mechanical prosthesis • Right heart mass (thrombus and/or
tumor) • Tricuspid or pulmonary valve
endocarditis
PAC parameters and NL values
Measured values• CVP: 2-6mmHg• PAWP: 8-12mmHg• PAP: 25/10mmHg• SvO2: 0.65-0.70• Temperature• Q: 4-8L/min• CI: 2.5-4L/min
Derived values – use of formula: Q = MAP-CVP/SVR• SV: 50-100mL/beat• SVI: 25-45mL/beat/m2• SVR: 900-1300
dynes-sec/cm5• SVRI: 1900-2400 dyne-
sec/cm5• PVR: 40-150 dyne-sec/cm5• PVRI: 120-200 dynes-sec/c
EQUATIONS
• Cardiac Output=Fick equation [VO2 = QT x (CaO2-CvO2)]
Change in pressure / total blood flow
Systemic Vascular Resistance Index =SVRI = (MAP ) = (MAP-CVP)(80)/CI Pulmonary Vascular Resistance Index = PVRI = (MPAP-PAOP)(80)/CI 80 converts mm Hg 80 converts mm Hg-min-m2/liters to dynes*sec/*cm-5
SVR: 900-1300 dynes-sec/cm5SVRI: 1900-2400 dyne-sec/cm5PVR: 40-150 dyne-sec/cm5PVRI: 120-200 dynes-sec/c
PAC WAVES
PAWP
How to measure the PAOP?
HOW TO LOCALIZE DURING SPONTANEOUS VENT.?
ALL PA measurements are calculated at end expiration because the lungs are at their most equal -(negative vs. positive pressures)
HOW TO LOCALIZE DURING MECH. VENT.?
PAW WAVEFORM WITH MECHANICAL VENTILATION
What is the abnormality?
What is the abnormality?
What is the abnormality?
Pericardial tamponade: high PCWP, high SVR, CVP = PCWP
Right heart failure: high CVP, low CI, high PVR
Complications of PAC• Venous access
complications - include arterial
puncture - hemothorax - Pneumothorax • Arrhythmias - PVCs or nonsustained
VT - Significant VT or
ventricular fibrillation
• Right bundle-branch block (RBBB)
• PA rupture • PAC related infection • Pulmonary infarction
SUGGESTED APPROACH TO PAC USE
• potentially useful in undifferentiated, multi-factorial shock states (for Q and ScVO2)
• useful in right heart pathology and pulmonary hypertension
• requires careful patient selection (including a contraindication assessment)
• don’t wedge (PADP can usually be used to estimate PAOP)• monitor for complications (predominantly on insertion)• remove after 72 hours
ARTERIAL WAVEFORM ANALYSIS TECNIQUES
other devicesPRAM: Pressure Recording Analytical Method
SD of 2000 arterialwaveform points
Statistical analysis of Arterial Pressure
Pulse Contour Parameters Pulse Contour Cardiac Output PCCO• Arterial Blood Pressure AP• Heart Rate HR• Stroke Volume ,CO SV• Stroke Volume Variation SVV• Pulse Pressure Variation PPV• Systemic Vascular Resistance SVR• Index of Left Ventricular Contractility dPmx*
MANY OTHER PARAMETERS AWAITING VALIDATION
Non invasive PCM
CALIBRATION FOR PCM Cardiac output is measured by another more accurate modality to
initially calibrate the PCA system and then for recalibration as needed
1-Transpulmonary Thermodilution Methods:• PiCCO (Pulsion Medical Systems&GE technology) • Volume View (Edwards Life Sciences) 2-Lithium Dilution Technique:• LiDCO /LiDCOplus/LiDCOrapid ( LiDCO limited) 3-Ultrasound Indicator Dilution :COstatus (Transonic
Systems, Inc.) Device that do not need calibration: -FLOTRAC/VIGILEO: estimate CO by the standard deviation of pulse
pressure sampled during a time window of 20 seconds -PRAM :estimate cardiac output using frequency of 1000 HZ
62
Transpulmonary thermodilution-PICCO and Edward / Volume View TM
• .
63
Advanced Thermodilution Curve Analysis
Transpulmonary thermodilution: Volumetric curve
Mtt: Mean Transit time time when half of the indicator has passed the point of detection in the artery
DSt: Down Slope time exponential downslope time of the thermodilution curve
For the calculations of volumes…
ln Tb
injectionrecirculation
MTtt
e-1
DSt
Tb
…and…
All volumetric parameters are obtained by advanced analysis of the thermodilution curve:
ITTV = CO * MTt PTV = CO * DSt
ITTV = CO * MTt
PTV = CO * DSt
ITBV = 1.25 * GEDV
EVLW* = ITTV - ITBV
GEDV = ITTV - PTV RAEDV RVEDV LAEDV LVEDV
RAEDV RVEDV LAEDV LVEDVPBV
RAEDV RVEDV LAEDV LVEDVPTV
PTV
EVLW*
EVLW*
Calculation of volumes
Transpulmonary thermodilution
monitors are not only
CO monitoring devices
Transpulmonary thermodilution
2- Global end-diastolic volume (GEDV)
1- Cardiac outputGEDVmarker of
cardiac preload
Extravascular lung water (EVLW)
• Normal – 3-7 mL/kg• Increased > 7 mL/kg• Pulmonary edema > 10
mL/kg
.
Pulmonarv Blood Volume
Hydrostaticpulmonary edema
Permeabilitypulmonary edema
PVPI =PBV
EVLW*normal
elevated
elevated
PVPI* =PBVEVLW*
elevated
elevated
normal
PVPI=PBV
EVLW*normal
normal
normal
PBV
PBV
PBV Normal Lung
Extra Vascular Lung Water
Pulmonary Vascular Permeability Index-PVPI
• It allows to identify the type of pulmonary oedema
PARAMETERS Definitions• LVSWI = SVI × (MAP – PAOP) × 0.0136• CP = MAP × CO/451• ITTV = CO × MTt• PTV = CO × DSt• GEDV = ITTV - PTV = CO × (MTt - DSt)• ITBV = 1.25 × GEDV• CFI = (CO/GEDV) × 103• GEF = SV/(GEDV/4)• EVLW = ITTV - ITBV• PVPI = EVLW/PBV
Normal rangesPARAMETER RANGE UNIT
CI 3.0 – 5.0l/min/m2
SVI 40 – 60ml/m2
GEDI 680 – 800ml/m2
ITBI 850 – 1000ml/m2
ELWI* 3.0 – 7.0ml/kg
PVPI* 1.0 – 3.0 SVV 10
% PPV 10
% GEF 25 – 35
% CFI 4.5 – 6.5
1/min MAP 70 – 90
mmHg
SVRI 1700 – 2400 dyn*s*cm-5*m
71
Transpulmonary thermodilution
2- Global end-diastolic volume (GEDV)
4- Extravascular lung water (EVLW)
1- Cardiac output
3- Cardiac function index (CFI)
5- Pulmonary vascular permeability index
Pulse contour analysis1- Continuous cardiac output (CCO)
2- Stroke volume variation (SVV)
3- Pulse pressure variation (PPV)
ScvO2
Complete picture
of the patient’s
hemodynamic status
Clinical application
What is the current situation?.………..……..………….Cardiac Output!
What is the preload?.……………….....…Global End-Diastolic Volume!
What is the afterload?……………..…..Systemic Vascular Resistance!
What about the contractility?........................ dPmx* LV pressure velocity
What about the Perfusion ?............................central venous saturation
Will volume increase CO?...fluid response….Stroke Volume Variation!
Are the lungs still dry?...…….……...…..….Extravascular Lung Water!*
pulmonary vascular permeability index… Dx of p.edema
hypovolemia vascular tone depression
myocardial depression
vasopressors inotropesfluids
presence of associated lung injury
Hemodynamic failure in critically ill patients: 3 components
Myocardial depression
inotropes
+ CFI (PiCCO)
Echocardiography
Hemodynamic failure in critically ill patients: 3 components
vascular tone depression
vasopressors
Arterial catheter (DAP ++)
Hemodynamic failure in critically ill patients: 3 components
hypovolemia
fluids
Prediction of fluid responsiveness
• PPV, SVV • PLR or end-expiratory occlusion test
if SB, arrhythmias, low TV or low lung compliance
Evaluation: real-time CO
Lung tolerance
PAOP EVLW
presence of associated lung injury
Hemodynamic failure in critically ill patients: 3 components
First, try to perform echocardiography to assess cardiac function
Normal cardiac fonction
Lung injury ?ABG, Chest X-ray
Abnormal cardiac function
no yes
CVCCVP
SvcO2
Art cath
AP PPV
PiCCO
COGEDV, EVLW, CFI
PPV, SVVScvO2
Basic monitoring
+
advancedmonitoringyes
considered valid?
no
only
Patient with circulatory failure
VolumeViewPAC
COPAOP
RAP, PAPSvO2
Which measurement is most reliable for predicting fluid responsiveness in a patient with septic shock requiring mechanical ventilation? Pick one best answer• A. Central venous pressure (CVP)• B. Pulmonary artery occlusion pressure (PAOP)• C. Pulse pressure variation (ΔPP)• D. Mixed venous oxygen saturation (SvO2)
vpw
• measured by 1, dropping a perpendicular line from the point at which the left subclavian artery exists the aortic arch and 2, measuring across to the point at which the superior vena cava crosses the right mainstem bronchus.
71 mm and 62 mm for supine and erect CRs, respectively.