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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

Hemodynamic Monitoring

Khaled O. Hadeli

12/7/99

slide2
DO2 = CO x 13.4 x Hb x SaO2

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

slide15
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

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
slide29
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

slide40
In the critically ill patient hemodynamic monitoring is aimed to optimize which of the following?

a. CO/CI

b. Pcwp

c. BP

d. DO2

slide41
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
slide43
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
slide45
A searchlight cannot be used effectively without a fairly thorough knowledge of the territory to be searched.

Fergus Macartney, FRCP

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