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Cardiovascular Monitoring II. Dr CH Koo QEH. www.anaesthesia.co.in anaesthesia.co.in@gmail.com. Invasive CVS monitoring Overview. a. Arterial line b. Central venous pressure c. Pulmonary artery catheter d. Transoesophageal echocardiography Indications What is being measured

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cardiovascular monitoring ii

Cardiovascular Monitoring II

Dr CH Koo

QEH

www.anaesthesia.co.in

anaesthesia.co.in@gmail.com

invasive cvs monitoring overview
Invasive CVS monitoringOverview

a. Arterial line

b. Central venous pressure

c. Pulmonary artery catheter

d. Transoesophageal echocardiography

  • Indications
  • What is being measured
  • Technique- Positioning, sites
  • Complications
arterial line
Arterial Line
  • Direct measurement of blood pressure
  • most accurate technique
  • continuous haemodynamic information
  • blood gas measurement
how accurate
How accurate?
  • Depend on the setup
    • Use correct tubing
    • Bubbles free (tips)
    • Tight connections
    • Zero calibration
    • Level of transducer
  • Heparin or not?
indications
Indications
  • Patient factors
    • Patient with severe sepsis or shock
    • Cardiac diseases such as unstable angina, recent AMI, current congestive heart failure or cardiac arrhythmias or on pacemaker
  • Surgical considerations
    • Cardiac surgery
    • Major surgery on aorta or carotid artery
    • Neurosurgery such as craniotomy or aneurysm clipping
    • Major surgery with expected blood loss more than 1 blood volume
indications cont d
Indications(Cont’d)
  • Anaesthetic considerations
    • Controlled hypotensive techniques
    • Inability to measure blood pressure non-invasively
    • Frequent blood sampling required during and after operation
setting up an arterial line
Setting up an arterial line
  • Equipment
    • Pressure bag
    • Collapsible 0.9% 500cc Normal saline bag with air expelled
    • Pressure transducer and infusion set
    • Cannula
    • + heparin (1-2 units /ml)
steps
Steps

1. Set up the pressure measurement system and pressurized the bag to 300 mmHg

2. Cannulate an artery

3. Connect to the pressure measurement system

4. Fix the cannula securely

5. Zeroing the transducer

6. Fix the transducer at the heart level

7. Start measurement

complications
Complications
  • 1. Blood loss due to disconnection
  • 2. Arterial thrombosis
  • 3. Infection
  • 4. Haematoma formation
  • 5. True and false aneurysm formation
  • 6. Distal and central embolisation
central venous pressure monitoring
Central venous pressure monitoring

Introduction

  • Monitoring of intracardiac pressures
  • ventricular dysfunction due to ischaemia, valvular abnormalities or primary myocardial disease
  • allow differentiation between hypovolaemia and myocardial depression
indications1
Indications

1. Assessment of preload in patients with hypovolaemia / septic shock / valvular problems / congestive heart failure

2. Assessment of right ventricular dysfunction associated with severe lung disease, pulmonary hypertension, cardiac tamponade

3. Craniotomy in the sitting position

4. Major surgery with expected blood loss >1 blood volume

5. Difficult intravenous access

setting up the cvp manometer
Setting up the CVP manometer
  • Normal Saline or Dextrose 5% solution
  • Simple IV set
  • Prime the CVP manometer tubing
  • Run at least 10 cm of water into the manometer
  • Remove all bubbles in the water column
type of cvp cannula
Type of CVP cannula
  • Single lumen
    • long angiocath (16G,14G),
    • catafix (375mm, 475mm),
    • percutaneous sheath (7F, 8.5F)
    • Swan sheath (8.5F)
  • Multiple lumens
    • 2-,3-,4- lumen
steps in setting up cvp monitoring line
Steps in setting up CVP monitoring line

1. Prime the CVP manometer or set up the pressure transducer

2. Choose the site of central vein insertion

3. Position the patient- shoulder support and head down and turn to opposite side for IJV and SCV cannulation,

4. Sterilise the area with aseptic solution and create a sterile field

5. Local the vein with seeker needle

6. Use Seldinger technique to canulate the vein

7. Connect to the CVP manometer or transducer

8. Fix the cannula securely

9. Back flow of blood

vein or artery
Vein or artery ?

Artery Vein

Colour of blood Bright red Dark red

Pressure High Low

Plunger push

back

Rapid back flow

of blood

Blood gas High PaO2

complications of cvp
Complications of CVP

1. Carotid artery puncture

2. Pneumothorax

3. Air embolism

4. Arrhythmia

5. Perforation of SVC or R atrium/ventricle -> cardiac tamponade

6. Brachial plexus, vagus nerve, phrenic nerve injury

7. Thoracic duct perforation (usually left side) -> chylothorax

8. Retroperitoneal haematoma

complications of cvp cont d
Complications of CVP (Cont’d)

9. Infection

10. Pleural effusion

11. Airway obstruction- extravasation of infusate or bleeding from puncture artery

12. Allergic reaction to substance impregnated on the catheter

pulmonary artery pressure monitoring
Pulmonary artery pressure monitoring
  • Allow measurement of pressures close to the left ventricle
  • LVEDV – LVEDP – LAV – LAP – PCWP – RVEDV – RVEDP – RAV - RAP – CVP
indications2
Indications

1. Ischaemic heart disease with recent myocardial infarction

2. Symptomatic valvular heart disease

3. Cardiomyopathy

4. Congestive heart failure and low ejection faction

5. Shock- septic or hypovolaemic

6. Pulmonary hypertension

7. Cardiac surgery with poor ventricular function

what is being measured by pafc
What is being measured by PAFC?

1. Central venous pressure

2. Pulmonary artery systolic and diastolic pressure

3. Pulmonary capillary wedge pressure

4. Cardiac output

5. Mixed venous oxygen saturation

6. Derived values such as stroke volume, cardiac index, ventricular stroke work, systemic and pulmonary vascular resistance

technique of insertion
Technique of insertion

1. Choose the site of line insertion

2. Position the patient- should support and head down and turn to opposite side for IJV and SCV cannulation,

3. Sterilise the area with aseptic solution and create a sterile field

4. Local the vein with seeker needle

5. Use Seldinger technique to cannulate the vein with the swan sheath

6. Fix the swan sheath securely by stitches

7. The PAFC is flushed with saline through each of its ports and the balloon at the tip tested

technique of insertion cont d
Technique of insertion (Cont’d)

8. The transducers are zeroed and calibrated

9. The PAFC is introduced into the sheath and advanced to the 20cm mark.

10.The balloon at the tip is inflated with 1.5 ml of air and kept inflated.

11.The catheter is slowly advanced to obtain right ventricular tracing. Further advance the catheter into the pulmonary artery which occurs when the diastolic pressure increases. At this point the catheter is slowly advanced to a wedge position with the waveform changed to that similar to the atrial tracing. The balloon is then deflated and a PA tracing will appear.

technique of insertion cont d1
Technique of insertion (Cont’d)

12. The transducers are placed at the right atrial level. Haemodynamic measurements and thermodilution cardiac outputs are performed and derived variables calculated.

13. CXR should be obtained if complication is suspected or after surgery

measurement of cardiac output using pafc
Measurement of cardiac output using PAFC

1. Ensure correct positioning of the PAFC in the heart- proximal opening in R ventricle and distal thermister in pulmonary artery

2. Measure the PCWP

3. Press the CO measurement button and observe that the temperature baseline is stable

4. Withdraw 10 ml of normal saline or dextrose at room temperature into syringe

5. Press the start button and inject the 10 ml of fluid as fast as possible

6. A temperature change curve will be observed

7. Repeat the measurement 3-4 times

8. Select the 3 best temperature curve and press calculate

complications1
Complications
  • Similar to that of CVP insertion
  • Additional complications are:

1. Arrhythmogenesis,

2. Thrombosis and embolism,

3. Pulmonary infarction or haemorrhage,

4. Endocarditis,

5. Perforation of atrium, ventricle and pulmonary artery,

6. Intracardiac knotting

transoesophageal echocardiography
Transoesophageal echocardiography
  • Indications
  • American Society of Anaesthesiologists practice guidelines for perioperative TEE
  • Category I indications - supported by strongest evidence or expert opinion
  • Category II indications - supported by weaker evidence or expert consensus
  • Category III indications – Little current scientific or expert support
contraindications
Contraindications
  • Patient with oesophageal stricture
  • Patient with history of oesophageal tumour
  • Patient with oesophageal varices
  • Patient with severe coagulalopathy preop
what is being measured
What is being measured?
  • Ischaemic state via measurement of regional wall motion and wall thickening changes
  • Ventricular function via measurement of ejection fraction, wall shortening and ventricular volumes
  • Valvular function
  • Intracardiac air and masses (eg. thrombus, tumour, etc)
technique
Technique
  • Turn on the TEE machine
  • Put in a suitable month gag between patient’s teeth
  • Lubricate the first 20-30 cm of the TEE probe with lubricant jelly
  • Insert the TEE probe through the month gag into the patient’s month and then gently into the appropriate position in the oesophagus
  • Connect the TEE probe to the TEE machine and select the appropriate probe setting
complications2
Complications
  • Oesophageal perforation
  • GI bleeding
  • Oesophageal burn
  • Transient vocal cord oedema
slide33

Any Questions?

www.anaesthesia.co.in

anaesthesia.co.in@gmail.com