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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. 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

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  1. Cardiovascular Monitoring II Dr CH Koo QEH www.anaesthesia.co.in anaesthesia.co.in@gmail.com

  2. 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

  3. Arterial Line • Direct measurement of blood pressure • most accurate technique • continuous haemodynamic information • blood gas measurement

  4. How accurate? • Depend on the setup • Use correct tubing • Bubbles free (tips) • Tight connections • Zero calibration • Level of transducer • Heparin or not?

  5. 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

  6. Indications(Cont’d) • Anaesthetic considerations • Controlled hypotensive techniques • Inability to measure blood pressure non-invasively • Frequent blood sampling required during and after operation

  7. 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)

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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

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

  19. 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

  20. 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

  21. 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

  22. 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.

  23. 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

  24. 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

  25. 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

  26. 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

  27. Contraindications • Patient with oesophageal stricture • Patient with history of oesophageal tumour • Patient with oesophageal varices • Patient with severe coagulalopathy preop

  28. 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)

  29. 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

  30. Complications • Oesophageal perforation • GI bleeding • Oesophageal burn • Transient vocal cord oedema

  31. Any Questions? www.anaesthesia.co.in anaesthesia.co.in@gmail.com

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