1 / 69

Hemodynamic monitoring

. . . Indications for pulmonary artery catheterization in the ICU:Establish diagnosis of shock and/or respiratory failureGuide therapy of shock and/or respiratory failureBy improving oxygen delivery. . Oxygen delivery = CaO2 x COCardiac output = HR x SVSV is determined by:Preload (end-diastolic volume)Cardiac contractilityAfterload .

johana
Download Presentation

Hemodynamic monitoring

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

    1. Hemodynamic monitoring All about the Swan

    3. Indications for pulmonary artery catheterization in the ICU: Establish diagnosis of shock and/or respiratory failure Guide therapy of shock and/or respiratory failure By improving oxygen delivery

    4. Oxygen delivery = CaO2 x CO Cardiac output = HR x SV SV is determined by: Preload (end-diastolic volume) Cardiac contractility Afterload

    5. Information derived from PA catheter Directly measured CVP PAOP Pulmonary artery pressure SvO2 Cardiac output Calculated Systemic vascular resistance Pulmonary vascular resistance Stroke volume Oxygen delivery

    6. Normal values Directly measured CVP 2-4 mm Hg PA 25/10 PAOP 8-12 SvO2 60-75% Cardiac output 4-8 L/m Cardiac index 2.5-4.0 L/min/M2 Calculated SVR 900-1200 dynes sec/cm5 PVR 50-140 SV = 50-100mL SV index 25-45

    8. Insertion of Swan Ganz Ask why? Then immediately ask why not: Coagulopathy Ventricular ectopy LBBB Pacemaker? Defibrillator? Large pulmonary embolism Severe pulmonary arterial hypertension Sustain VT (>30 beat run0 occurs in up to 3% pts RBBB can occur in 5% catheter insertion Pulmonary artery rupture: 30% mortality Pulmonary artery pseudoaneurysmSustain VT (>30 beat run0 occurs in up to 3% pts RBBB can occur in 5% catheter insertion Pulmonary artery rupture: 30% mortality Pulmonary artery pseudoaneurysm

    9. Swan complications Associated with cordis placement Ventricular arrhythmias requiring treatment 1.3 – 1.5% Right bundle branch block ~0.5 -5% Pulmonary artery rupture ~0.06 to 0.2% Pulmonary artery pseudoaneurysm formation Pulmonary infarction ~ 1.4% Thromboembolic events ~1.6% Mural thrombi Sterile cardiac valve vegetation Endocarditis esp of the pulmonic valve

    10. So much information, why don’t we Swan more often? 1996 observational study Swan within the first 24 hours of ICU admission associated with increased 30d hospital mortality (OR 1.24) Association with poor outcome highest in the least sick pts Meta-analysis of RCTs: no benefit but no harm ESCAPE trial in patients with heart failure: no mortality benefit RCT of peri-operative use in high risk pts undergoing cardiac, vascular or orthopedic surgery: no benefit FACCT study of ARDS pts: no benefit of Swan v. CVP monitoring in managing vasoactive agents and fluid status

    11. Nevertheless… PAC can be occasionally useful in the carefully selected patient

    12. Insertion sites

    13. Musts Full barrier precautions for maximal sterile technique Flush and zero catheter prior to insertion at the phlebostatis axis Remember catheter sheath Once catheter tip is in the right atrium, always advance the catheter with the balloon inflated. Always watch the waveforms transduced from the distal end of the catheter while advancing Always withdraw catheter with the balloon deflated Advance the catheter quickly while in the right ventricle Advance slowly once the distal tip is in the pulmonary artery

    18. Waveforms

    24. Elevations in RAP Hypervolemia Right ventricular infacrtion Impaired RV contraction Pulmonary hypertension Pulmonic stenosis Left to right shunts Tricuspid valve disease Cardiac tamponade

    31. Overwedging

    39. Abnormal waveforms

    41. Seen with non compliant ventricle Mitral or tricuspid stenosis

    44. Seen with tricuspid valve regurgitation Ventricular ischemia Ventricular failure Hypervolemia

    47. Right ventricular pressure Peak systolic pressure RV end-diastolic pressure Early rapid filling (~60% of filling) Slow phase (25% filling) Atrial systolic phase

    48. Left to right shunts Arterial sampling from RA, RV, and PA Detection og an oxygen saturation “step-up” allows confirmation and determination of its location Definition of “step-up” = >10% rise in oxygen saturation

    49. Equalization of pressures RAP = RVed= PCWP Cardiac tamponade Constrictive pericardial disease Restrictive cardiomyopathies

    50. Cardiac output

    51. Thermodilution Saline injected through the proximal port Thermistor at the distal end of catheter measures the change in blood temperature over time

    52. Area under the curve is inversely proportional to the rate of blood flow past the pulmonary artery This rate is equivalent to cardiac output

    53. Should not differ by more than 10%

    54. Factors that decrease accuracy of thermodilution cardiac output Tricuspid regurgitation Septal defects Technical issues Sensor malfunction Improper injectate

    55. Continuous thermodilution cardiac output 10 cm thermal filament located 15-25 cm from the catheter tip. It generates low-energy head pulses transmitted to surrounding blood

    56. Interpretation of the data

    57. Cases

    58. Case 1 20M presents post-MVA with abdominal pain. T 97 BP 70/55 HR 130 RR 24 Exam: Alert, pale, diaphoretic. Extremities cool and clammy with poor capillary refill. Abdomen is distended and tender.

    59. MAP = 60 CVP = 2 PA = 15/3 PAOP = 4 CO = 3 SvO2 50% SVR? SV? What kind of shock?

    60. Case 2 30F with flank pain, dysuria, fever to 104. T 104 BP 70/35 HR 140 Exam: Flushed, warm, bounding pulses

    61. MAP 47 CVP 2 PA 20/5 PAOP 5 CO 7 SvO2 75% SV ? SVR ? What kind of shock?

    62. Case 3 55M intermittent chest pains for last 24 hours presents with progressive shortness of breath and weakness T 96 BP 80/60 HR 120 RR 28 SpO2 88% Exam: Dyspneic, diaphoretic. Poor capillary refill. He has JVD, a gallop, soft murmur. Very little edema

    63. MAP 67 CVP 10 PA 42/28 PAOP 29 CO 2.5 SvO2 55% SV? SVR? What kind of shock?

    64. Case 4 60M feeling bad and losing weight last 8 months. Hasn’t seen an MD in 30 years. Present with progressive weakness, shortness of breath, and edema. T 96 BP 75/60 HR 120 RR 24 SpO2 92% Exam: Cachectic. JVD. Distant heart sounds. Generalized edema. Thready pulses, poor capillary refill

    65. MAP = 70 CVP 24 PA 40/24 PAOP 24 CO 2.4 SvO2 45% SV? SVR?

    66. Case 5 46 F presents with worsening shortness of breath and chest pains over a 5 days period. T 98 BP 78/62 HR 130 RR 28 pulse ox 84% Exam: Tachypneic, dyspneic. JVD. Lungs clear. Heart sounds tacycardic with RV heave, pronounced S2, II/VI systolic murmur at LLSB.

    67. MAP = 67 CVP 14 PA 60/28 PAOP 6 CO 3.5 SvO2 48% SVR? PVR? SV? What is going on?

    68. Case 6 36M admitted to the ICU with lobar pneumonia, septic shock. Given 8 Liters of normal saline over 3 hours, but remains in refractory shock, requiring initiation of norephinephrine. Develops progressive hypoxemia and intubated. Post intubation CXR demonstrates bilateral pulmonary infiltrates Exam T 103 BP 95/50 HR 120 RR 28 on vent SpO2 98% Intubated, sedation. Warm and flushed with brisk capillary refill and bounding pulses.

    69. MAP 65 CVP 9 PA 35/18 PAOP 16 CO 9.0 SvO2 80% SVR? SV? Clinical scenario?

More Related