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Hemodynamic monitoring Magdy M Khalil, MD, EDIC. Tissue perfusion Oxygen delivery = CO x arterial oxygen content CO = (SV x HR) x {(Hb x 1.39 x SaO 2.

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Presentation on theme: "Hemodynamic monitoring Magdy M Khalil, MD, EDIC. Tissue perfusion Oxygen delivery = CO x arterial oxygen content CO = (SV x HR) x {(Hb x 1.39 x SaO 2."— Presentation transcript:

1 Hemodynamic monitoring Magdy M Khalil, MD, EDIC

2 Tissue perfusion Oxygen delivery = CO x arterial oxygen content CO = (SV x HR) x {(Hb x 1.39 x SaO 2 ) + (0.003 x PaO 2 )} Arterial pressure (AP) = CO x SVR

3 Diagnosis of tissue malperfusion Clinical assessment Basic monitoring Preload monitoring Minimally invasive cardiac output/cardiac contractility assessment Invasive; pulmonary artery catheter Assessment of tissue perfusion

4 Clinical assessment Thirst, Cold mottled extremities, Poor peripheral pulses, Impaired capillary refill, Tachypnoea, Tachycardia, Altered mentation, or Oliguria.

5 Basic monitoring Electrocardiography (ECG), Arterial blood pressure (AP), Pulse oximetry (SpO 2 ) monitoring, Baseline serum lactate.

6 Arterial blood pressure Measurement Non-invasive Invasive Indications for invasive arterial pressure monitoring: Labile blood pressure Severe hypotension Use of rapidly acting vasoactive drugs Frequent sampling of arterial blood. Relative indications : Severe hypertension Presence of an intra-aortic balloon pump Morbid obesity.

7 SpO 2 monitoring The SpO 2 signal is often inaccurate in the presence of altered skin perfusion

8 Serum lactate Normal level in resting humans 1 mmol/l ( ). Same in venous or arterial blood Factors affecting serum lactate level:

9 Venous oxygen saturation Cardiac output hypoxia and anaemia also affect the ScvO 2. pain, shivering and increased work of breathing can also affect the ScvO 2 value. carbon monoxide poisoning, cyanide poisoning, and intra-cardiac shunt The normal range of ScvO 2 in critically ill patients is 70-75%

10 Preload monitoring Examination of the right internal jugular vein Central venous pressure (CVP). ▫Catheter in SVC An elevated intracardiac pressure may be due to an elevated volume or an elevated resistance (Acute heart failure, cardiac tamponade, constrictive pericarditis, restrictive cardiomyopathy, tricuspid stenosis or regurgitation) ▫Estimated from respiratory motion of IVC (SB). End-diastolic volumes (TTE /TOE)

11 Predicting fluid responsiveness Change in CO in response to a change in preload Fluid challenge while monitoring: ▫ AP, ▫heart rate, ▫CVP and ▫urine output.

12 Predicting fluid responsiveness Static parametersGEDV is the volume of blood contained in the four chambers of the heart at end diastole. ITBV is the volume of blood in the four chambers and the blood volume in the pulmonary vessels at end diastole Dynamic parameters pulse pressure variation (PPV) ≥13%, systolic pressure variation (SPV) greater than 10 mmHg on MVand stroke volume variation (SVV). The normal healthy heart is fluid responsive. The demonstration of fluid responsiveness is not an indication, by itself, to administer fluids

13 Minimally invasive CO/CC assessment Indications Hypotension despite fluid resuscitation, or Continued evidence of global tissue hypoperfusion Low CO + elevated measures of preload=ventricular failure. High CO+ tissue hypoperfusion, e.g. septic shock.

14 Minimally invasive methods of CO measurement Echocardiography ( EF >55%) Pulse contour analysis: measuries SV on a beat-to-beat basis from the arterial pulse pressure waveform. Oesophageal Doppler: measures blood flow velocity) in the descending aorta (70% of total CO) Methods using the Fick principle (Patient on MV) Contraindications to oesophageal Doppler : Unexplained history of dysphagia Oesophageal pathology e.g. varices, stricture, oesophagitis Oropharyngeal pathology Unstable cervical spine injury

15 Transpulmonary thermodilution; cardiac output and volumetric parameters Global end-diastolic volume (GEDV): ITTV – PTV ( ml/m 2) Intrathoracic thermal blood volume (ITBV): 1.25 x GEDV ( ml/m 2) Pulmonary blood volume (PBV): ITBV – GEDV Extravascular lung water (EVLW): ITTV – ITBV ( ml/kg). Pulmonary vascular permeability index (PVPI) ( ): EVLW /PBV reflects the permeability of the alveolar–capillary barrier. PVPI is higher in ALI/ARDS

16 Pulmonary artery catheter Continuous monitoring of : RAP PAP PAOP (5-12 mmHg) CO SvO2. Indications: Circulatory shock with evidence of tissue hypoperfusion not responding to therapy. Management of severe pulmonary oedema. Difficulty evaluating right and left ventricular preload in the presence of oliguria.

17 Interpreting haemodynamic data Is there evidence of tissue hypoperfusion? Is there a reduction in arterial oxygen content? Is there a question regarding optimal preload? Is there a question regarding stroke volume/cardiac contractility? Is there a need for PAC?

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