Hemodynamic monitoring
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Hemodynamic Monitoring. Khaled O. Hadeli 12/7/99. DO2 = CO x 13.4 x Hb x SaO2 DO2 = (SV x HR) 13.4 x Hb x SaO2. MR. RVF. Hypovolemic shock. Acute bronchospasm. Busy Tracing. Cardiac performance CO/CI CVP/RAP/RVP/PAP/ Pcwp RVEF SVR/PVR. O2 transport parameters

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Hemodynamic Monitoring

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Hemodynamic monitoring

Hemodynamic Monitoring

Khaled O. Hadeli

12/7/99


Hemodynamic monitoring

DO2 = CO x 13.4 x Hb x SaO2

DO2 = (SV x HR) 13.4 x Hb x SaO2


Hemodynamic monitoring

MR


Hemodynamic monitoring

RVF


Hypovolemic shock

Hypovolemic shock


Acute bronchospasm

Acute bronchospasm


Busy tracing

Busy Tracing


Hemodynamic monitoring

Cardiac performance

CO/CI

CVP/RAP/RVP/PAP/ Pcwp

RVEF

SVR/PVR

O2 transport parameters

DO2

SvO2

VO2

O2ER

PAC


Physiology of cardiac performance

Physiology of cardiac performance

  • Pre-Load

    • contractility: Frank-Starling Law, ( within physiologic limits the strength of muscle contraction is directly related to the length of the muscle fiber)

    • compliance


After load

After-Load

  • It is the opposing force that determines the force of muscle contraction needed to initiate muscle shortening

  • Laplace Law: T=Pr

    T=Pr/t


After load cont

After-Load cont.

  • SVR = MABP-CVP/CO

  • PVR = MPBP-LAP/CO


Clinical applications

CLINICAL APPLICATIONS

THE WEDGE PRESSURE


The wedge pressure

The wedge pressure

  • Pcwp

  • LAP

  • LVED

  • LVEDV

  • Preload

  • SV--->CO


Cardiac out put

Cardiac out put

TEMP.

TIME

CO=Amount of indicator injected / Area under the curve


Hemodynamic monitoring

  • DO2 = (SV x HR) 13.4 x HB x SaO2


Complications

Complications

  • General

    • Delays in starting necessary treatment

    • Inaccurate measurements and false interpretations

    • Preoccupation with instrumentation


Complications1

Complications

  • Related to central venous cannulation

    • arterial puncture/hematoma 8%

    • pnemothorax 2-4%

    • others ( hemothorax, brachial plexus damage, air embolism, phrenic nerve damage, sheared cath…etc.) <1%


Complications2

Complications

  • Related to passage of catheter

    • Arrhythmia 13- 70% (1%)

    • RBBB

    • Cardiac perforation & tamponade (1%)

    • Over wedging leading to Pulmonary infarction (pt with severe MR)


Complications3

Related to presence of the cath. In circulation

Infection

colonization 40%

sepsis 4-6%

Thrombotic

autopsy 66%

clinical <1%

Pulmonary

infarction <1 - 7%

artery rupture <1%

Cardiac

endocardial damage 35%

valve damage <1%

endocarditis 0 - 7%

Mechanical

Balloon rupture <4%

knotting <1%

Complications


Limitation of hemodynamic monitoring

Limitation of Hemodynamic monitoring

  • Cost

  • Incorrect measurement of data

    • calibration, damping, zeroing

    • transient respiratory muscle activity

    • reliance on digital readout

    • failure to wedge

    • non zone-III region


Hemodynamic monitoring

Cont.

  • Incorrect interpretation of data

    • ventricular compliance

    • valve disease

    • SCDs and false reading of CO

  • Improper therapeutic strategies - poor application of data on over zealous goals/targets


Physician knowledge of pac

Physician Knowledge of PAC

PGY1 2-3 4-6 Staff Expert

Iberti, JAMA 264:2928,1990


Open vs closed icus

Open Vs. Closed ICUs

Significant improvement in mortality subsequent to the presence of CCM specialist in the ICU

despite increased use of PAC

Reynolds et. Al. JAMA1988:260;3446-50


Rhc vs no rhc

RHC vs.. NO RHC

Connors, JAMA 276;889,1996


Is it time to pull the pac

Is it time to pull the PAC?

  • Moratorium on the use of PAC until a (RCT) provides more evidence*

  • ATS consensus statement against the moratorium, but use with caution untill (RCT) provides more evidence

*Dalen et.al. JAMA 1996:276;916-8


Media

MEDIA

  • “…….1000$ procedure leads to increased mortality in our ICUs”

  • “…….are you safe if you stay in the ICU”

  • “ The pulmonary catheter cult”


Pac use

PAC use

1,000,000 RHC every year

2 Billion Dollars / year(1990)*

  • CT surgery 30%

  • high risk surgery 10%

  • cardiac cath. Lab 25%

  • MICU 15%

  • others20%

*Shoemaker et al.


Why do we need pac

Why do we need PAC

  • In cardiac cases (AMI) clinical criteria where predictive of pcwp and CO in 81% & 85% of the subjects, respectively

  • In ICU the estimates of pcwp & CO where 42%-44%. And another study 30%-50%.

  • In ICU the planned therapy was changed in 50% of patients after PAC was placed


Potential impact on therapy

Potential impact on therapy

  • Hemodynamic profiles predicted in 56%

  • PAC derived profiles changed therapy in 50%

  • No change in over all mortality!

  • Improvement in mortality of Pts. With shock not responding to usual measures

Mimoz et.al.CCM 1994;22:573-9


Pac in ards

PAC in ARDS

  • Optimize intervascular volume

  • Improved survival with high DO2*

    • Mean DO2 491ml/min/m2 in nonsurvivors

    • Mean DO2 718 ml/min/m2 in survivors

  • No benefit and some possible harm from non specific augmentation of DO2 in pts with ARDS**

*Russell et a.

**Gattinoni/Hayes, NEJM 1995/1994


Pac a diagnostic toll or a therapeutic modality

PAC, a diagnostic toll or a therapeutic modality?


Hemodynamic monitoring

In the critically ill patient hemodynamic monitoring is aimed to optimize which of the following?

a. CO/CI

b. Pcwp

c. BP

d. DO2


Hemodynamic monitoring

CASE

A 65yr old male 4 days post-op developed sudden onset of fever, chills and SOB. Vitals show HR 130, BP 85/55 mmHg, RR40/min, PaO2 40mmHg.

He was intubated and given 500cc NS, started on vasoactive therapy, and referred to MICU.


Current hemodynamic data

Current hemodynamic data

  • BP 130/90 HR 120

  • CO 11 l/min

  • SaO2 93% on 60% Fio2

  • Urine out put 10cc/hr

  • Pcwp 12


Hemodynamic monitoring

Your immediate action should be:

A. give volume

B. diurese

C. leave volume status as is

And / Or

A. give more vasopressor therapy

B. Taper vasopressor therapy

C. leave vasoactive therapy as is


Recommendations

Recommendations

  • PAC should be used when there is a question of diagnosis and management

  • Like all information it must be adequately processed

  • DON’T FORGET

    • what we measure is not always what we think it is

    • DO2 = SV x HR x 13.4 x Hb x SaO2


Hemodynamic monitoring

A searchlight cannot be used effectively without a fairly thorough knowledge of the territory to be searched.

Fergus Macartney, FRCP


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