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HEMODYNAMIC MONITORING

Course in pediatriccardiology, anaesthesia and cardiac surgery

Cattaneo SergioOO.RR. Bergamo

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INTRAVASCULAR PRESSURE MONITORING

Physiology Monitor

Mechanical

energy

Transducersystem

Electronic

signal

Transducer system

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COMPONENTS:1. Transducer

Change mechanical energy to electronic signal.

2. Continuos washing systemSaline solution in a pressure bag (300mmHg) or

infusion pump (less fluid volume!!!)

3. Proximal stopcock

Useful to set Zero.

4. Connection to catheterTransfer pressure pulse from caterer to transducer

5. Distal stopcockUseful to take out blood sample.

2

4 5

1

3


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Transducer

system

Resonance Damping

CONNECTION LINE:SHORTER , BIGGER and STIFFER!


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Calibration - ZERO

WHY: remove atmospheric pressure interference (~760mmHg)

WHEN: connection from transducer to monitor

Not when you change transducer position!!!

TEST: Open Proximal Stopcock to connect transducer to air ,monitor must show a plan line and measure zero.

Measured pressureis always relative to

a reference point.

Its a difference!


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Level:

Reference pointRIGHT ATRIUM

=

Mean Axillary Line

Supine position

WHEN: Every time patient moves(Otherwise measurement is not right!!!)


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RAPID FLUSH TEST

To determinatethe dynamic response

of catheter and

transducer system

Overdamped


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Invasive arterial pressure

WHEN:

HEMODYNAMIC MONITORING

Cardiac arrest Shock syndrome

Hypertensive crisis

Use of vasoactive drugs

Use on IABP

MULTIPLE BLOOD GAS ANALYSIS

Mechanical Ventilation

Respiratory failure

Sepsis


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9MONITORAGGIO EMODINAMICO: TEORIA, METODICHE TRADIZIONALI E NUOVE TECNILOGIE

WHERE:

1. Radial Artery2. Femoral Artery

3. Brachial Artery

4. Axillary Artery

90%

TECHNIQUE OF

CANNULATION:

- Use always

Seldinger Technique

Invasive arterial pressure - 2


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MAP = PAd + (PAs-PAd) / 3

Pulse Pressure : PAs-PAd



dP/dt

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NORMAL RANGE BLOOD PRESSURE:

Age Wt mmHg

Term 3.4kg 40-60

3 mo 6kg 45-75

6 mo 7.5kg 50-90

1 yr 10kg 50-100

3yr 14kg 50-1007yr 22kg 60-90

10yr 30kg 60-90

12yr 38kg 65-95

14yr 50kg 65-95

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RESPIRATORY CHANGES IN ARTERIAL WAVE

FORM IN MECHANICALLY VENTILATED

PATIENTS:

SYSTOLIC PRESSURE VARIATION - SPV

PULSE PRESSURE VARIATION - PPV

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The difference between the maximal and minimal value of

systolic blood pressure during one mechanical breath.

SPV can be divided into two components by interposing a brief

(5sec) apnea, and using the systolic body pressure during apnea

as a reference value:

down

up The difference between the maximal systolic valueand the systolic body pressure during apnea.

The difference between the apneic systolic body

pressure and the minimal systolic value.

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Downreflects the expiratory decrease in

LV preload and SV related to theinspiration decrease in RVSV

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Perel A. et al.-Anesthesiology 1987:67;498-502

Pizov R. et al.-Anesth Analg 1988:67;170-174

Preisman S. et al.-Int Care Med1997:23;651-657

During hypovolemia, as during hemorrage

SPV by Down

The amount of blood loss was closely correlated

with SPV and Down

Volume expansion SPV and Down

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PULSE PRESSURE

The difference between systolic

and diastolic arterial pressure

In mechanically ventilated patients:

PP is maximum at the end of inspiratory period

PP is minimum during the expiratory period

Respiratory changes in LVSV are reflected by

respiratory changes in PP.

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PP (%) = (PPmax- PPmin) / ((Ppmax+Ppmin)/2)*100

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Michard et al.: Am J Resp Crit Care Med 2000; 162:134-138

PPV before volume expansion can accurately predict the effect of

volume expansion on CO

PPV is a more reliable indicator of fluid responsiveness than PS

A patients with a baseline PPV value of more than 13% was very likely

to respond to volume expansion by increasing CO by 15% (positive

predicted value 94%).

By contrast, if PPV 13%, the patients was unlikely to respond to fluid

challenge (negative predictive value 96%).

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Central Venous Pressure - 1WHEN:

Pre-operative preparation

Total parenteral nutrition Pulmonary artery catheter

Emergency management

Use of vasoactive drugs

Cardiac arrest


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WHERE:

Depend on surgery plan!!

Internal Jugular vein

Not in these cases:

GLENN and FONTAN OPERATIONS,

NORWOOD and DAMUS-KAYOPERATION,RIGTH AXILLARY- PULMUNARY SHUNT

2. Femoral vein

TECHNIQUE OF

CANNULATION:

- Use always

Seldinger Technique


1. 5Kg 4 Fr 5cm bi-lumen

5,5Fr 5cm triple-lumen

2. 5-10 Kg 4 Fr 8cm triple-lumen

5,5Fr 5cm triple-lumen

3. 10-20 Kg 5,5 Fr 8 cm triple-lumen

4. 20 Kg 5.5 Fr 8 - 13cm triple-lume

Central Venous Pressure - 2

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CVP Central Venous Pressure / Right Atrium

waveform

A wave

Atrium Sistole C wave Tricuspid valve closure

X wave Atrial relaxation

V wave Atrial filling with tricuspid valve closed

Y wave

Ventricular filling after ticuspid valve opening


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Spontaneous Breathing Mechanical Ventilation

( = Inspiration)

Central Venous Pressure / Ventilation


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TRICUSPID REGURGITATION:

Elevated CVP

Evident positive V wave

CARDIAC TAMPONADE:

Elevated CVP

Damping or absence of Y wave

Equalization of CVP,

diastolic PAP and PAWP

CVP Central Venous Pressure / Right Atrium

waveform


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Superior Vena Cava>Tricuspid Valve

> Right Ventricle

> Pulmonary Artery

PULMUNARY ARTERY CATHETER - SWAN-GANZ

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SWAN-GANZ CATHETER

1. Distal lumen

2. Proximal lumen

3. Balloon inflation

lumen

1

2

3

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WHEN:

Complicated MI

Shock (cardiogenic-hypovolemic-Septic)

Respiratory distress (cardiogenic noncardiogenic)

Management post-cardiac surgery patient

Others


Pulmunary Artery Catheter - 1

LIMITATIONS Size of catheter in children!Shunts in congenital heart disease!

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CONTROINDICATIONS:Stenosi tricuspideo polmonare

Massa o trombo atriale

Protesi tricuspidale

Inserction:Arrhythmias (TV, FV) 0.3-63 %

Right bundle branch (0.1-4.3 %),

Total AVB (0-8.5 %)Intracardiac and valve damage

Tromboembolic complication

Knotting (loop)

After inserction:Infection (0-22%)

Septicemia

Endocarditis (2.2 -100%)Pulmonary infarction (0.1 -7 %)

Pulmonary artery perforation (0.06-0.2 %)

Balloon rupture

COMPLICATION:



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Insertion technique

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Insertion technique

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MEASUREMENTS: Cardiac Output

Thermodilution (Fegler G., 1954/Ganz W, 1971)

Cold solution in injected into right atrium.

The thermistor records blood temperature change on the top of

pulmonary artery catheter.

Stewart-Hamilton formula

CO = Vol injected x (TB-TF)1.08K/ ? ? TB(t)dt

TB, TF = Blood and cold fliud temperature

?? TB(t)dt = under-curve area

K = computational constants



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MEASUREMENTS: Pulmonary Artery Occlusion Pressure (PAOP)



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In Pediatric CardiacSurgery you can put a

catheter direct In

Left Atrium

LVEDPLAP

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Error in interpretation Damped PAP

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Error in interpretation Overwedging

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Error in interpretation

Mitral regurgitation

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38avDO2= CaO2 - CvO2 (3-5 ml/dl)

CI= CO/BSA (2.8-4,2L/min/m2)SV= CO/HRSVI= CI/HR (30-65 ml/beat/ m2)

SVR= (MAP-CVP)/COX79,9 (900-1400 dyne.sec.cm-5

)PVR= (MAP-PCWP)/ COX79,9 (150-250 dyne.sec.cm-5)

LVSWI= SIX(MAP-POAP)X0,0136 (43-61 g/m/m2)

RVSWI= SIX

(PAP-CVP)X

0,0136 (7-12 g/m/m

2

)CaO2= [Hb]xSaO2x1.34 + (PaO2x0.003)

CvO2= [Hb]xSvO2x1.34 + (PvO2x0.003)



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Do2= CO x Cao2 x 10 (640 1200 ml O2/min)

Vo2= CO x avDo2 x 10 (180 280 ml O2/min)

Vo2/Do2= CO x (Cao2-Cvo2)/CO x Cao2

= (Cao2-Cvo2)/Cao2 (0,22 0,30)



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MEASUREMENTS: Mixed Venous Oxygen Saturation (SvO2)



SvO2Also from central venous catheter!!!

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The PiCCO Technology is a combination of 2 techniques for advancedhemodynamic and volumetric management without the necessity of a

pulmonary artery catheter in most patients:

a. Transpulmonary thermodilution b. Arterial pulse contour analysis

t

-T

t

-T

PiCCO

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Central Venous Line

Arterial Catheter (5-3 F)

with termistor on the tip

femoral artery

Central

Venous

Line

Arterial

Line

PiCCO

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Temperature Sensor

PC80109

PCCI

AP13.03 16.28TB37.0

AP 140

117 92

(CVP) 5

SVRI 2762

PC

CI 3.24

HR 78

SVI 42

SVV 5%

dPmx 1140

(GEDI)625

Transdutor PULSION PV8115

Arterial

Pressure

line

PiCCO

The system setup:

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Transpulmonary thermodilution

measurement simply requires the central venous injectionof a cold (

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PiCCO

After central venous injection of the indicator, the thermistor in the tip

of the arterial cathetermeasures the temperature changes

The cardiac output is calculated by analysis of the thermodilution

curve using a modified Stewart-Hamilton algorithm:

Injection

t

-Tb

Transpulmonary thermodilution

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PiCCO

Arterial Pulse Contour AnalysisArterial pulse contour analysis provides continuous beat-by-beat

parameters obtained from the shape of the arterial pressure wave.

The algorithm is capable of computing each single stroke volume

(SV) after being calibrated by an initial transpulmonarythermodilution.

t

-T

t

-T

Calibration

t [s]

P [mm Hg] SV

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PiCCO

Arterial Pulse Contour Analysis

CO is calculated as stroke volume x heart rate

SVR is calculated as (mean arterial pressure - central venous

pressure) / CO

As pulse contour analysis continuously measures

stroke volume and arterial pressurecardiac output (CO) and systemic vascular resistance (SVR)

are computed as follows:

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PiCCO

Stroke Volume Variation (SVV)

SVV reflects the sensitivity of the heart to the cyclic changes in

cardiac preload induced by mechanical ventilation.

SVV can predict whether stroke volume will increase with volume

expansion.

In mechanically ventilated patients without arrhythmia,

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PiCCO

Global Enddiastolic Volume GEDV

Intrathoracic Blood Volume ITBV

Extravascular Lung Water EVLW

Volumetric Parameters

These volumetric parameters are obtained by advancedanalysis of the thermodilution curve.

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PiCCO

Global Enddiastolic Volume(GEDV) is the volume of

blood contained in the 4 chambers of the heart.


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PiCCO

Intrathoracic Blood Volume (ITBV)is the volume of the 4 chambers of

the heart + the blood volume in the pulmonary vessels.


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PiCCO

ExtraVascular Lung Water (EVLW) is the amount of water content in the

lungs. It allows bedside quantification of the degree of pulmonary edema.


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PiCCO

Volumetric Parameters / CARDIAC

PRELOAD

Intrathoracic Blood Volume, ITBV and Global Enddiastolic Volume,

GEDV have shown to be far more sensitive and specific to cardiac

preload than the standard cardiac filling pressures CVP + PCWP butalso than right ventricular enddiastolic volume.

The striking advantage ofITBV and GEDV is that they are not wrongly

influenced by mechanical ventilation and give correct information on

the preload status under any condition.

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PiCCO

Parameters Range

Cardiac Index CI 3.0

5.0 l/min/m2

Global Enddiastolic Blood Volume Index GEDI

680 800 ml/m2

Intrathoracic Blood Volume Index ITBI 850

1000 ml/m2

Stroke Volume Variation SVV 10

%

Extravascular Lung Water Index* ELWI* 3.0

7.0 ml/kg

CONCLUSIONS

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Central Venous Line

CVP

Blood gas (ScvO2)

Arterial line

Continuous Blood Pressure

SPV / PPV

Pulmonary Artery Catheter (PAC)

Occlusion pressure, PAP

C.O. / SVR / PVR

SvO2

DO2 / VO2

PiCCO

SVV

GEDV

ITBV

EVLW

DRUGS?

VOLUME?

CONTRACTION

PRELOAD

AFTERLOAD

ECHO!!!

CONCLUSIONS

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HEMODINAMIC MONITORING

Course in pediatriccardiology, anaesthesia and cardiac surgery

Cattaneo SergioOO.RR. Bergamo

Date post:	03-Apr-2018
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