Hemodynamic Assessment and Invasive Monitoring. Kevin M. Creamer M.D. Pediatric Critical Care Walter Reed AMC. Introduction Hemodynamic Determinants & Assessment Monitoring Considerations A Cautionary Tale. Monitoring indications “Normal Values” Complications Hemodynamic scenarios.
Kevin M. Creamer M.D.
Pediatric Critical Care
Walter Reed AMC
Hemodynamic Determinants & Assessment
A Cautionary Tale
Fitzgerald, Br Med J, 1999
Its only algorithm: I must maintain CO!
Continuous HR, RR, Pulse ox, intermittent NIBP
Consider foley for any patient whose UOP is questionable or to monitor CO
Frequent sampling needs require either a large PIV, Art line or CVC
Some children who need reliable IV access may need a PIC or central lineMonitoring Indications
Newman, J Ped Surg, 1986
(MAP – CVP) / CO
(MPAP – PCWP) / CO
CI = CO BSA
SVRI = (MAP - CVP) CI x 80
PVRI = (MPAP - PCWP) CI X 80
3-5 mm Hb
800 - 1600 dyne-sec/cm5/m2
80 -240dyne-sec/cm5/m2“Normal” Values
CaO monitored2 = (Hg X 1.34 X Sat%) + (PaO2 X 0.003)
DO2 = CI X CaO2
VO2 = CI X avDo2
17-20cc O2 /dL
400-600 ml X min / M2
140-160 ml X min / M2“Normal” Values
< 3 wo 120-130 ml/min/m2
> 3 wo 150-160 ml/min/m2
Salzman 1995 Adv. Ped. Inf., Odetola,CCM(A), 2001,
Dis,Luyt, S. Africa 1996, Smith-Wright, CCM, 1984
Maki, CCM(A),2001,Pierce, ICM,2000 Darouiche, NEJM, 1999
After 5 then 10 mcg/kg/min dopamine your HR 115, BP 90/50, CVP 10, PCWP 10, CI 3.9, SVRI 1000, Warm extremities, CRT 2-3 secsCongratulations Doctor!
The astute nurse asks why you would want to change afterload when Dr Creamer always says fix preload first then address contractility? You decide to reassess.
10 yo with status epilepticus developed aspiration pneumonia and respiratory arrest in hospital. Patient was resuscitated but not intubated and spent 4-6 hours in shock prior to a cardiopulmonary arrest. She has been subsequently resuscitated with 3 liters of NS and 2u PRBCs. She is currently on 10 mcg/kg/min of Dopamine and .5 mcg/kg/min of Epinephrine.You place an Arterial line and PA catheter.
I’d humbly like to go back in time and try another approach
Norepinephrine added at .1 then .3 mcg/kg/min, HR 135, BP 130/70, CVP 12, PCWP 12, CI 6.5, SVRI 1000, Liver 2 cm below RCM, warm extremities, CRT 2-3 secsI think we are really close and it may be time to back off ?
Dopamine is decreased to 3mcg/kg/min, HR 90, BP 105/55, CVP 10, PCWP 10, CI 4.5, SVRI 900, warm extremities, CRT 2 secsCongratulations Doctor, it was a pleasure to work with you!!
S/p 20 cc/kg of Hespan HR 145, BP 145/85, CVP 13, PCWP 16, CI 7.5, SVRI 1300, Liver 2 cm below RCM, warm, CRT 2-3 secs I think we are really close and it may be time to back off ?