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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.

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hemodynamic assessment and invasive monitoring

Hemodynamic Assessment and Invasive Monitoring

Kevin M. Creamer M.D.

Pediatric Critical Care

Walter Reed AMC

overview
Introduction

Hemodynamic Determinants & Assessment

Monitoring Considerations

A Cautionary Tale

Monitoring indications

“Normal Values”

Complications

Hemodynamic scenarios

Overview
seven alternatives to evidence based medicine
Seven Alternatives to Evidence Based Medicine
  • Eminence Based Medicine
  • Vehemence Based Medicine
  • Eloquence Based Medicine
  • Providence Based Medicine
  • Diffidence Based Medicine
  • Nervousness Based Medicine
  • Confidence Based Medicine
eminence based medicine
Eminence Based Medicine
  • Experience is worth any amount of evidence
  • “making the same mistakes with increasing confidence over an impressive number of years”

Fitzgerald, Br Med J, 1999

introduction
Introduction
  • Purpose of repeated hemodynamic assessment and continuous monitoring
    • Gain an understanding of the patient’s physiologic status
    • Make timely interventions
    • Assess effectiveness of therapies
    • Provide warning of hemodynamic changes that may be dangerous
hemodynamic determinants

Hemodynamic Determinants

Preload

Afterload

Contractility

Heart Rate

Rhythm

hemodynamic determinants1
Hemodynamic Determinants
  • Ohm’s Law (V= I X R)
    • BP = CO X SVR
  • Important Physiologic principle
    • manipulation of variables can alter hemodynamics
    • Ex. BP can be normal in the face of low CO when….
hemodynamic determinants2
Hemodynamic Determinants
  • Preload: volume indirectly generates a pressure based on compliance
    • This is why normal CVP is not an absolute
  • Afterload: any factor that resists ejection of blood from the heart
    • Impedance, Inertia, Ejection pressure, Ventricular outflow tract obstruction, and wall stress
    • SVR is a gross approximation of afterload
slide10
Preload

HR

CO

Contractility

SV

DO2

Afterload

Hg

CaO2

PaO2

Sat %

starling s law
Starling’s Law

3

Cardiac performance

2

1

Preload

hemodynamic determinants3
Hemodynamic Determinants
  • CO = HR X SV
    • Preload -Volume
    • Afterload -Resistance to LV emptying
    • Contractility -Squeeze
    • Heart Rate - rate =  SV
    • Rhythm -Atrial kick 10% CO
cardiac output i
Cardiac output I
  • Pulse quality
  • Central vs. Peripheral pulses
  • Differential Temperatures
    • Dipstick of SVR and indirectly CO
    • Capillary refill time (CRT)
cardiac output ii
Cardiac output II
  • Organ Perfusion
      • CNS – Alert > Verbal > Pain > Unresponsive ?
      • Renal - UOP
        • only organ with easily measured output
        • Foley catheter is a poor smart man’s PA catheter
  • Acidosis?
hemodynamic assessment1
Hemodynamic Assessment
  • Stroke volume - pulse quality
  • Preload - Liver size, CXR - heart size
    • Relative liver size may be better than CVP for initial assessment of preload
  • SVR - CRT, Pulse pressure, differential temperatures
inadequate hemodynamics
Inadequate Hemodynamics
  • Common features
    • Elevated HR - attempt to  CO
    • Elevated RR - beware Resp. alkalosis
    • Decreased pulses -  CO
    • Depressed LOC -  CO
    • Acidosis -  CO
    • Falling UOP -  CO
monitoring considerations
Monitoring Considerations
  • Minimal risk to patient
  • Noninvasive and painless if possible
  • Data should be reproducible, relevant and understandable
  • Provide easy visual or auditory queues
a cautionary tale
A Cautionary Tale
  • Virginia PICU 1989 to 1993,
    • Two separate groups of Intensivists
    • 78 Infants with RSV disease
      • Group 1 - (n=38) invasive monitoring
      • Group 2 - (n=40) less monitoring
        • Groups comparable re: age, gender, disease severity, and medical Hx.
  • D. Wilson, (J.Pediatr 1996:128:357-62)
monitoring indications
All children with concerning hemodynamics should be monitored

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 line

Monitoring Indications
paid advertisement
Paid Advertisement

Newman, J Ped Surg, 1986

slide25
Indications
  • Unstable BP: Arterial line
  • Vasoactive infusion or CVP monitoring: Central Line
  • Ventricular dysfunction and vascular collapse: Art line and PA Catheter
pa catheter measures
PA Catheter Measures
  • CO via thermodilution
  • PA Pressures
  • Preload to right (CVP) and Left (PCWP) heart
  • Allows for calculation of resistances by rearranging Ohm’s law
  • Most useful in determining which of 3 determinants needs fixing: Preload, Afterload, Contractility

CVP

PAP

T

PCWP

vascular resistance
Vascular resistance
  • SVR

(MAP – CVP) / CO

  • PVR

(MPAP – PCWP) / CO

δBP

SVR

=

CO

normal values
CVP

CI = CO BSA

PAOP (PCWP)

SVRI = (MAP - CVP)  CI x 80

PVRI = (MPAP - PCWP)  CI X 80

3-5 mm Hb

3.5-5.5 L/min/m2

4-12mm Hb

800 - 1600 dyne-sec/cm5/m2

80 -240dyne-sec/cm5/m2

“Normal” Values
normal values1
CaO2 = (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
estimate cardiac index
Estimate Cardiac Index
  • Normal O2 Consumption

< 3 wo 120-130 ml/min/m2

> 3 wo 150-160 ml/min/m2

  • CI = VO2 / (A-v DO2 X 10)
    • Arterial O2 content - venous
complications i
Complications I
  • Bleeding - SC > IJ > Fem
  • Infection - PAC > CVL > Art (Femoral not worse)
  • Thrombosis - >1wk 1/3 Femoral
  • Arrhythmia
  • Pneumothorax
  • Vascular erosion
complications ii
Complications II
  • CVL – 0.24-0.52 infections/100 days
  • CVL - 241 CVL, 23% minor bleeding, 7 major complications, 5% septicemia
  • Prospective study of 774 catheters in children
    • 7/774 significant bleeding (1%)
    • 3/377 arterial thrombosis (1%)
    • 11/774 sepsis (1.5%)

Salzman 1995 Adv. Ped. Inf., Odetola,CCM(A), 2001,

Dis,Luyt, S. Africa 1996, Smith-Wright, CCM, 1984

catheter risk
Catheter Risk
  • Meta-analysis found duration >7days, replacement over wire, multi vs. single lumen all independent predictors of CRBSI
  • Biopatch  CRBSI 3.3% to 1.2%
  • RCT Heparin bonded catheter in 209 pediatric patients
    • Infection  4% and thrombosis 0%
  • Mino/Rif impregnated lines  BSI .3%

Maki, CCM(A),2001,Pierce, ICM,2000 Darouiche, NEJM, 1999

caveats
Caveats
  • If your patient has:
    • UOP > 1cc/kg/hr
    • No metabolic acidosis
    • A good hemodynamic exam
  • Think twice about interventions to “fix” the numbers
treatment priorities
Treatment priorities

Preload

Contractility

Afterload

inotropes
Inotropes
  • Dopamine - 5 to 10 mcg/kg/min
  • Dobutamine - 2 to 20 mcg/kg/min
  • Milrinone - 50 to 75 mcg/kg load over 10 to 20 minutes, then 0.5 to 1 mcg/kg/min (inodilator)
  • Epinephrine - 0.1 to 0.3 mcg/kg/min
vasopressors
Vasopressors
  • Dopamine - 10 to 20 mcg/kg/min
  • Epinephrine - 0.3 to 2 mcg/kg/min
  • Norepinephrine - 0.05 to 1 mcg/kg/min
scenario i
Scenario I
  • A 12yo diabetic with DKA and a pH 7.15 and glucose level of 600 is admitted from the ED. She is is tachycardic with an otherwise normal hemodynamic exam and has two large bore IVs. The PICU nurses wants to know if you are going to place and Arterial Line? YOU REPLY ???
scenario i1
Scenario I
  • NOT NECESSARILY, Does one of the PIV’s draw blood?
  • The need is for frequent labs and not ABGs or BP monitoring
scenario ii
Scenario II
  • A 4mo with HIV, RSV and ARDS has poor perfusion, a HR 180, BP 60/30, and CVP 14 after 80cc/kg of fluid and is on Dopamine and Dobutamine (each at 10mcg/kg/min)
  • What do you do next?
scenario ii1
Scenario II
  • Do you fix preload, afterload or contractility next ?
  • An ECHO may help but to titer therapy a PA catheter is indicated
scenario iii
Scenario III
  • A 12 yo s/p ASD repair has hemodynamic changes 2 hours after surgery. Initially he was warm with HR 90, BP 110/60 and CVP 10, now HR has jumped to 125, BP is 90/70 and CVP is 22 with 1+ pulses and cool extremities
  • What is going on?
scenario iii1
Scenario III
  • Cardiac Tamponade !! Diminished CO with elevated CVP and narrow pulse pressure
  • Volume may help transiently but patient needs emergent pericardiocentesis or trip to OR.
scenario iv
Scenario IV
  • A 10 yo febrile neutropenic patient has a HR 160, BP 80/40, and CVP 5 with warm extremities 1+ pulses, no UOP and no palpable liver after 40cc/kg of saline, 1u PRBCs and 1 pheresis pack of platelets.What is the Dx?
  • What should be done for monitoring and management?
scenario iv1
Scenario IV
  • You can safely call this an unstable BP and this patient would benefit from continuous arterial monitoring
  • The patient still requires more preload prior to the initiation of Inotropes
scenario v
Scenario V
  • A 2yo with meningococcemia has a HR of 174, BP 66/28, CVP 10, PCWP 8, CI 5.5, PVRI 160, and SVRI 500 with warm ruddy extremities and 1+ pulses on Dopamine 10mcg/kg/min
  • What is your assessment?
  • What does the patient need?
scenario v1
Scenario V
  • Vascular tone!! The patient has adequate CO but no vascular tone. Epinephrine or norepinephrine added would help improve BP and vital organ perfusion
interactive scenario choices
Interactive Scenario Choices
  • 2yo with Meningococcemia
  • 10yo with Pneumonia s/p Cardiac Arrest
  • Done with scenarios
slide51
2yo Meningococcemia with HR 140, BP 65/35, CVP 6, PCWP 7, CI 2.5, SVRI 800, Cold extremities, no palpable Liver, CRT 10 secs

Increase Preload

Increase Contractility

Change Afterload

slide52
S/p 20 cc/kg NS x 3, HR 130, BP 80/45, CVP 11, PCWP 13, CI 3.0, SVRI 900, Liver 2 cm below RCM, Cool extremities, CRT 5 secs
  • Increase Preload
  • Increase Contractility
  • Change Afterload
slide53
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!
slide54
After 5 then 10 mcg/kg/min dopamine HR 135, BP 70/38, CVP 6, PCWP 6, CI 2.8, SVRI 1000, no palpable Liver, Cold extremities, CRT 10 secs
  • Increase Preload
  • Increase Contractility
  • Change Afterload
slide55
S/p 20 cc/kg NS x 3, HR 115, BP 90/50, CVP 10, PCWP 10, CI 3.9, SVRI 1000, Warm extremities, CRT 2-3 secsCongratulations Doctor!
slide56
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.
slide57
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.
slide58
At this point Hr 145, BP 65/35, CVP 7, PCWP 7, CI 8, SVRI 400, no Liver palpable, cool extremities, CRT 5 secs
  • Increase Preload
  • Change Contractility
  • Change Afterload
change contractility
Change contractility
  • Increase
  • Decrease
  • Why would I want to change contractility yet in a patient still in shock but with a CO that is twice normal! Can I go back?
slide60
S/p 20cc/kg of Hespan, HR 135, BP 75/45, CVP 12, PCWP 12, CI 9.5, SVRI 500, Liver 2 cm below RCM, cool extremities, CRT 5 secs
  • Increase Preload
  • Change Contractility
  • Change Afterload
change afterload
Change Afterload
  • Increase
  • Decrease
epinephrine decreased to 1mcg kg min patient develops refractory hypotension arrests and dies
Epinephrine decreased to .1mcg/kg/min patient develops refractory hypotension, arrests and dies

I’d humbly like to go back in time and try another approach

slide63
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 ?
slide64
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!!
change afterload1
Change Afterload
  • Increase
  • Decrease
slide66
Norepinephrine is added .1 then .3 mcg/kg/min HR 130, BP 140/80, CVP 7, PCWP 7, CI 7, SVRI 1300, no liver palpable, warm, CRT 3 secs
  • Increase Preload
  • Change Contractility
  • Change Afterload
slide67
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 ?
conclusion i
Conclusion I
  • Hemodynamic assessment and monitoring are used to provide timely information concerning the patient’s vital organ perfusion and should help direct therapy and assess results of interventions
  • Although the complication rate is low the longer the invasive catheters remain the higher the risk. If you don’t need it take it out!
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