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Advance in Hemodynamic Monitoring

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Title: Advance in Hemodynamic Monitoring


1
Advance in Hemodynamic Monitoring
  • By Dr H P Shum

2
Outline
  • Introductions
  • What we have previously A line / CVC/ PAC
  • Advance techniques for haemodynamic monitoring

3
Introductions
  • Hemodynamics is concerned with the forces
    generated by the heart and the resulting motion
    of blood through the cardiovascular system
  • Hemodynamic monitoring is the intermittent or
    continuous observation of physiological
    parameters pertaining to the circulatory system
    with a view to early detection of need for
    therapeutic interventions

4
4 factors that affecting the haemodynamic
conditions
Myocardial contraction and heart rate
Vasoactivity
Intravascular volume
5
Old equipments
  • Arterial line
  • Real time SBP, DBP, MAP
  • Pulse pressure variation (?PP)
  • ?PP () 100 (PPmax - PPmin)/(PPmax
    PPmin/2)
  • gt 13 (in septic pts,) discriminate between
    fluid responder and non respondaer (sensitivity
    94, specificity 96)
  • Am J Respir Crit Care Med 2000, 162134-138

6
Arterial line
  • Advantages
  • Easy setup
  • Real time BP monitoring
  • Beat to beat waveform display
  • Allow regular sampling of blood for lab tests
  • Disadvantages
  • Invasive
  • Risk of haematoma, distal ischemia,
    pseudoaneurysm formation and infection

7
Old equipments
  • Central venous catheter
  • Measurement of CVP, medications infusion and
    modified form allow for dialysis

8
Limitation of CVP
Obstruction of the great veins
Mechanical ventilation
Decrease right ventricular compliance
Tricuspid regurgitation
Systemic venoconstriction
9
Central venous catheter
  • Advantages
  • Easy setup
  • Good for medications infusion
  • Disadvantages
  • Cannot reflect actual RAP in most situations
  • Multiple complications
  • Infections, thrombosis, complications on
    insertion, vascular erosion and electrical shock

10
Old equipment
  • Pulmonary arterial catheter

11
Indications for PAP monitoring
  • Shock of all types
  • Assessment of cardiovascular function and
    response to therapy
  • Assessment of pulmonary status
  • Assessment of fluid requirement
  • Perioperative monitoring

12
Clinical applications of PAC
  • PAC can generate large numbers of haemodynamic
    variables
  • Central venous pressure (CVP)
  • Pulmonary arterial occlusion pressure (PAOP)
  • Cardiac output / cardiac index (CO / CI)
  • Stroke volume (SV)
  • R ventricle ejection fraction/ end diatolic
    volume (RVEF / RVEDV)
  • Systemic vascular resistance index (SVRI)
  • Pulmonary vascular resistance index (PVRI)
  • Oxygen delivery / uptake (DO2 / VO2)

LAP LVEDP
? By thermodilution
13
Area under curve is inversely proportion to rate
of blood flow in PA ( CO)
14
Patient with hypotension
  • Vasogenic
  • Low CVP
  • High CI
  • Low SVRI
  • ? Consider vasopressor
  • Cardiogenic
  • High CVP
  • Low CI
  • High SVRI
  • ? Consider inotopic / IABP
  • Hypovolemia
  • Low CVP
  • Low CI
  • High SVRI
  • ? Consider fluid challenge

15
Mixed Venous Saturation SvO2
  • Measured in pulmonary artery blood
  • Marker of the balance between whole body O2
    delivery (DO2) and O2 consumption (VO2)
  • VO2 DO2 (SaO2 SvO2)
  • In fact, DO2 determinate by CO, Hb and SaO2.
    Therefore, SvO2 affected by
  • CO
  • Hb
  • Arterial oxygen saturation
  • Tissue oxygen consumption

16
Mixed Venous Saturation SvO2
  • Normal SvO2 70-75
  • Increased SvO2
  • Increased delivery
  • high CO
  • hyperbaric O2
  • Low consumption
  • sedation
  • paralysis
  • cyanide toxicity
  • Decreased SvO2
  • increased consumption
  • pain, hyperthermia
  • decreased delivery
  • low CO
  • anemia
  • hypoxia

17
PAC
  • Advantages
  • Provide lot of important haemodynamic parameters
  • Sampling site for SvO2
  • Disadvantages
  • Costly
  • Invasive
  • Multiple complications (eg arrhythmia, catheter
    looping, balloon rupture, PA injury, pulmonary
    infarction etc)
  • Mortality not reduced and can be even higher
  • Crit Care Med 200331 2734-2741
  • JAMA 1996276 889-897

18
Advance in haemodynamic assessment
  • Modification of old equipment
  • Echocardiogram and esophageal doppler
  • Pulse contour analysis and transpulmonary
    thermodilution
  • Partial carbon dioxide rebreathing with
    application of Fick principle
  • Electrical bioimpedance

19
truCCOMS system
20
As CO increase, blood flow over the heat transfer
device increase and the device require more power
to keep the temp. difference Therefore, provide
continuous CO data
21
Objective  To compare measurements of cardiac
output using a new pulmonary artery catheter with
those obtained using two " gold standard "
methods the periaortic transit time ultrasonic
flow probe and the conventional pulmonary artery
thermodilution.Design  Prospective clinical
trial.Setting  Cardiac surgery operating room and
surgical ICU in a university hospital.Material
and methods  In the operating room, a new
pulmonary artery catheter (truCCOMS system) was
inserted in eight patients. A periaortic flow
probe was inserted in four of them. Measurements
of cardiac output obtained with the truCCOMS
catheter and with the flow probe were compared at
different phases of the surgical procedure. In
the intensive care unit, the cardiac output
displayed by the truCCOMS monitor was compared
with the value obtained after bolus injection
performed subsequently.Results  In the operating
room (70 measurements), the coefficient of
correlation between cardiac output measured by
the flow probe and the truCCOMS system was r2
0.79, the bias was 0.11 l/min with a precision
of 0.47 l/min, and limits of agreement 0.83 to
1.05 l/min. In the intensive care unit (108
measurements), the coefficient of correlation
between cardiac output measured by thermodilution
and the truCCOMS system was r2 0.56, the bias
was 0.07 l/min, the precision was 0.66 l/min,
and the limits of agreement were 1.39 to
1.25 l/min.Conclusion  The truCCOMS system is a
reliable method of continuous cardiac output
measurement in cardiac surgery patients.
22
TruCCOMS system
  • Advantage
  • Continuous CO monitoring
  • Provision of important haemodynamic parameter as
    PAC
  • Disadvantage
  • Invasive
  • Costly
  • Complications associated with PAC use

23
Transthoracic echo
  • Assessment of cardiac structure, ejection
    fraction and cardiac output
  • Based on 2D and doppler flow technique

24
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25
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26
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27
Echo doppler ultrasound
  • Measure blood flow velocity in heart and great
    vessels
  • Based on Doppler effect ? Sound freq.
    increases as a sound source moves toward the
    observer and decreases as the soure moves away

28
For transthoracic echo
  • Haemodynamic assessment for SV and CO
  • Flow rate CSA x flow velocity
  • Because flow velocity varies during ejection,
    individual velocities of the doppler spectrum
    need to be summed
  • Sum of velocities called velocity time integral
    (VTI)
  • SV CSA x VTI
  • CSA ( LVOT Diameter /2 )2 ?
  • Therefore SV D2 0.785 VTI
  • CO SV HR

29
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30
Transthoracic echo
  • Advantages
  • Fast to perform
  • Non invasive
  • Can assess valvular structure and myocardial
    function
  • No added equipment needed
  • Disadvantages
  • Difficult to get good view (esp whose on
    ventilator / obese)
  • Cannot provide continuous monitoring

31
Transesophageal echo
  • CO assessment by Simpson or doppler flow
    technique as mentioned before
  • Better view and more accurate than TTE
  • Time consuming and require a high level of
    operator skills and knowledge

32
Esophageal aortic doppler US
  • Doppler assessment of decending aortic flow
  • CO determinate by measuring aortic blood flow and
    aortic CSA
  • Assuming a constant partition between caudal and
    cephalic blood supply areas
  • CSA obtain either from nomograms or by M-mode US
  • Probe is smaller than that for TEE
  • Correlate well with CO measured by thermodilution
  • Crit Care Med 1998 Dec26(12)2066-72

Decending aorta
33
Normovolemia
34
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35
Esophageal aortic doppler US
  • Advantages
  • Easy placement, minimal training needed ( 12
    cases)
  • provide continuous, real-time monitoring
  • Low incidence of iatrogenic complications
  • Minimal infective risk
  • Disadvantages
  • High cost
  • Poor tolerance at awake patient, so for those
    intubated
  • Probe displacement can occur during prolonged
    monitoring and patients turning
  • High interobserver variability when measuring
    changes in SV in response to fluid challenges

36
Pulse contour analysis
  • Arterial pressure waveform determinate by
    interaction of stroke volume and SVR

37
Pulse contour analysis
  • Because vascular impedance varies between
    patients, it had to be measured using another
    modality to initially calibrate the PCA system
  • The calibration method usually employed was
    arterial thermodilution or dye dilution technique
  • PCA involves the use of an arterially placed
    catheter with a pressure transducer, which can
    measure pressure tracings on a beat-to-beat basis
  • PiCCO and LiDCO are the two commonly used model

38
What is the PiCCO-Technology?
  • The PiCCO-Technology is a unique combination of
    2 techniques
  • for advanced hemodynamic and volumetric
    management without
  • the necessity of a right heart catheter in
    most patients
  • Transpulmonary Thermodilution

CV Bolus injection
CALIBRATION
PULSIOCATH
  • Pulse Contour Analysis

39
Parameters measured with the PiCCO-Technology
The PiCCO measures the following parameters
  • Thermodilution Parameters
  • Cardiac Output CO
  • Global End-Diastolic Volume GEDV
  • Intrathoracic Blood Volume ITBV
  • Extravascular Lung Water EVLW
  • Pulmonary Vascular Permeability Index PVPI
  • Cardiac Function Index CFI
  • Global Ejection Fraction GEF
  • Pulse Contour Parameters
  • Pulse Contour Cardiac Output PCCO
  • Arterial Blood Pressure AP
  • Heart Rate HR
  • Stroke Volume SV
  • Stroke Volume Variation SVV
  • Pulse Pressure Variation PPV
  • Systemic Vascular Resistance SVR
  • Index of Left Ventricular Contractility dPmx

40
3How does the PiCCO-Technology work?
  • Most of hemodynamic unstable and/or severely
    hypoxemic patients are
  • instrumented with

Central venous line (e.g. for vasoactive agents
administration)
Arterial line (accurate monitoring
of arterial pressure, blood samples)
  • The PiCCO-Technology uses any standard CV-line
    and a thermistor-
  • tipped arterial PiCCO-catheter instead of the
    standard arterial line.

41
PiCCO Catheter
CV
  • Central venous line (CV)
  • PULSIOCATH thermodilution catheter with
    lumen for arterial pressure measurement
  • Axillary 4F (1,4mm) 8cm
  • Brachial 4F (1,4mm) 22cm
  • Femoral 3-5F (0,9-1,7mm) 7-20cm
  • Radial 4F (1,4mm) 50cm

A
B
R
F
No Right Heart Catheter !
42
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43
A. Thermodilution parameters
PiCCO Catheter e.g. in femoral artery
Bolus Injection
  • Transpulmonary thermodilution
  • measurement only requires
  • central venous injection of a cold
  • (lt 8C) or room-tempered
  • (lt 24C) saline bolus

Lungs
44
Transpulmonary thermodilution Cardiac Output
  • After central venous injection of the
    indicator, the thermistor at the tip of the
    arterial catheter measures the downstream
    temperature changes.
  • Cardiac output is calculated by analysis of the
    thermodilution curve using a modified
    Stewart-Hamilton algorithm

injection
CO Calculation ? Area under the Thermodilution
Curve
Tb
t
Tb Blood temperature Ti Injectate
temperature Vi Injectate volume ? ? Tb . dt
Area under the thermodilution curve K
Correction constant, made up of specific weight
and specific heat of blood and injectate
45
Transpulmonary thermodilution Volumetric
parameters 1
  • All volumetric parameters are obtained by
    advanced analysis of the thermodilution curve

For the calculations of volumes
Advanced Thermodilution Curve Analysis
Tb
Mtt Mean Transit time time when half of the
indicator has passed the point of detection in
the artery
injection
recirculation
ln Tb
and
-1
e
DSt Down Slope time exponential downslope
time of the thermodilution curve
t
MTt
DSt
are important.
46
Transpulmonary thermodilution Volumetric
parameters 2
After injection, the indicator passes the
following intrathoracic compartments
ITTV
PTV
Thermodilution curve measured with arterial
catheter
CV Bolus Injection
RVEDV
LVEDV
RAEDV
Lungs
Left Heart
Right Heart
  • The intrathoracic compartments can be
    considered as a series of mixing chambers for
    the distribution of the injected indicator
    (intrathoracic thermal volume).
  • The largest mixing chamber in this series are
    the lungs, here the indicator (cold) has its
    largest distribution volume (largest thermal
    volume).

47
Calculation of volumes
ITTV CO MTtTDa
RAEDV
RVEDV
LAEDV
LVEDV
PTV
PTV CO DStTDa
PTV
GEDV ITTV - PTV
RAEDV
RVEDV
LAEDV
LVEDV
ITBV 1.25 GEDV
EVLW ITTV - ITBV
48
Pulmonary Vascular Permeability Index
  • Pulmonary Vascular Permeability Index (PVPI)
    is the ratio of Extravascular
  • Lung Water (EVLW) to pulmonary blood volume
    (PBV). It allows to identify the
  • type of pulmonary oedema.

normal
EVLW
EVLW
PBV
PVPI
Normal Lung
?
PBV
normal
Extra Vascular Lung Water
Pulmonarv Blood Volume
normal
elevated
EVLW
EVLW
Hydrostatic pulmonary edema
PBV
PVPI
?
PBV
normal
elevated
elevated
Permeability pulmonary edema
EVLW
EVLW
PVPI
?
PBV
PBV
elevated
normal
49
Global Ejection Fraction
  • Ejection Fraction Stroke Volume related to
    End-Diastolic Volume

Lungs
Left Heart
Right Heart
EVLW
PBV
RAEDV
RVEDV
EVLW
LAEDV
LVEDV
Stroke Volume SV
2
3
1

?
4 x SV
GEF
GEDV
Global Ejection Fraction (GEF) (transpulmonary
thermodilution)
RV ejection fraction (RVEF) (pulmonary artery
thermodilution)
LV ejection fraction (LVEF) (echocardiography)
50
Pulse Contour Analysis - Principle
P mm Hg
t s
Shape of pressure curve
Heart rate
Aortic compliance
Area under pressure curve
Patient-specific calibration factor (determined
by thermodilution)
51
Index of Left Ventricular Contractility
  • dPmx dP/dtmax of arterial pressure curve
  • dPmx represents left ventricular pressure
    velocity increase and thus is a
  • parameter of myocardial contractility

52
Stroke Volume Variation Calculation
  • Stroke Volume Variation (SVV) represents the
    variation of stroke volume (SV) over the
    ventilatory cycle.

SVmax
SVmin
SVmean
  • SVV is...
  • ... measured over last 30s window
  • only applicable in controlled mechanically
    ventilated patients with regular heart rhythm

53
Pulse Pressure Variation Calculation
  • Pulse pressure variation (PPV) represents the
    variation of the pulse pressure
  • over the ventilatory cycle.

PPmean
PPmax
PPmin
PPmax PPmin
PPV
PPmean
  • PPV is...
  • measured over last 30s window
  • only applicable in controlled mechanically
    ventilated patients with regular beat rhythm

54
Clinical application
CO GEDV SVV
SVR EVLW
What is the current situation?......Cardi
ac Output! What is the preload?......Globa
l End-Diastolic Volume! Will volume increase
CO?........Stroke Volume Variation! What is
the afterload?....Systemic Vascular
Resistance! Are the lungs still
dry?..........Extravascular Lung Water!

55
  • Global End-Diastolic Volume, GEDV and
    Intrathoracic Blood Volume, ITBV have shown to be
    far more sensitive and specific to cardiac
    preload compared to the standard cardiac filling
    pressures CVP PCWP as well as right ventricular
    enddiastolic volume.
  • The striking advantage of GEDV and ITBV is that
    they are not adversely influenced by mechanical
    ventilation
  • Crit Care 4, 2000
  • Int Care Med 2002
  • Eur J Anaesth 19, 2002
  • Anesth Analg 95, 2002

56
  • Extravascular Lung Water, EVLW has shown to
    have a clear correlation to severity of ARDS,
    length of ventilation days, ICU-Stay and
    Mortality and is superior to assessment of lung
    edema by chest x-ray and clearly indicates fluid
    overload

Mortality as function of ELWI in 373 critically
ill ICU patients Sakka et al , Chest 2002
57
Relevance of EVLW- Management
Ventilation days
ICU days
n101


EVLW group
PAC group
EVLW group
PAC group
22 days
15 days
9 days
7 days
101 patients with pulmonary edema were randomized
to a pulmonary artery catheter (PAC) management
group in whom fluid management decisions were
guided by PCWP measurements and to an
Extravascular Lung Water (EVLW) management group
using a protocol based on the bedside measurement
of EVLW . ICU days and ventilator-days were
significantly shorter in patients of the EVLW
group. Mitchell et al, Am Rev Resp Dis 145
990-998, 1992
58
SVV and PPV Clinical Studies
  • SVV and PPV are excellent predictors of volume
    responsiveness.

1
Sensitivity
0,8
Central Venous Pressure (CVP) can not predict
whether volume load leads to an increase in
stroke volume or not.
0,6
0,4
Berkenstadt et al, Anesth Analg 92 984-989, 2001
- - - CVP __ SVV
0,2
0
0,5
1
0
Specificity
59
Normal ranges
  • Parameter Range Unit
  • CI 3.0 5.0 l/min/m2
  • SVI 40 60 ml/m2
  • GEDI 680 800 ml/m2
  • ITBI 850 1000 ml/m2
  • ELWI 3.0 7.0 ml/kg
  • PVPI 1.0 3.0
  • SVV ? 10
  • PPV ? 10
  • GEF 25 35
  • CFI 4.5 6.5 1/min
  • MAP 70 90 mmHg
  • SVRI 1700 2400 dynscm-5m

60
Decision tree for hemodynamic / volumetric
monitoring
CI (l/min/m2)
gt3.0
lt3.0
R E S U L T S
lt700 lt850
gt700 gt850
lt700 lt850
GEDI (ml/m2) or ITBI (ml/m2)
gt700 gt850
ELWI (ml/kg)
lt10
gt10
lt10
lt10
lt10
gt10
gt10
gt10
V
V-
V
V!
V!
Cat
Cat
Cat
V-
T H E R A P Y
700-800 850-1000
700-800 850-1000
700-800 850-1000
gt700 gt850
700-800 850-1000
gt700 gt850
GEDI (ml/m2) or ITBI (ml/m2)
gt700 gt850
1.
T A R G E T
lt10
2.
lt10
lt10
Optimise to SVV ()
lt10
lt10
lt10
lt10
lt10
CFI (1/min) or GEF ()
gt4.5 gt25
gt5.5 gt30
gt4.5 gt25
gt5.5 gt30
OK!
?10
?10
?10
?10
ELWI (ml/kg) (slowly responding)
V volume loading (! cautiously)
V- volume contraction
Cat catecholamine / cardiovascular agents
SVV only applicable in ventilated patients
without cardiac arrhythmia
61
LiDCO system
62
Pulse contour analysis
  • Advantages
  • Almost continuous data of CO / SV / SV variation
  • Provide information of preload and EVLW
  • Disadvantages
  • Minimal invasive
  • Optimal arterial pulse signal required
  • Arrhythmia
  • Damping
  • Use of IABP

63
Partial carbon dioxide rebreathing with
application of Fick principle
  • Fick principle is used for CO measurement
  • CO VO2 / (CaO2 CvO2) VCO2 / (CvCO2 CaCO2)
  • Based on the assumption that blood flow through
    the pulmonary circulation kept constant and
    absence of shunt
  • Proportional to change of CO2 elimination divided
    by change of ETCO2 resulting from a brief
    rebreathing period
  • The change was measured by NICO sensor

64
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65
assume that the mixed venous co2 concentration
(Cvco2) remains unchanged between baseline and
rebreathing conditions
S slope of CO2 dissociation curve
66
Partial carbon dioxide rebreathing with
application of Fick principle
  • Advantages
  • Non invasive
  • Disadvantages
  • Only for those mechanically ventilated patient
  • Variation of ventilation modality and presence of
    significantly diseased lung affect the CO reading
  • Not continuous monitoring

67
Electrical bioimpedance
  • Made uses of constant electrical current
    stimulation for identification of thoracic or
    body impedance variations induced by vascular
    blood flow

68
  • Electrodes are placed in specific areas on the
    neck and thorax
  • A low-grade electrical current, from 2 - 4 mA is
    emitted, and received by the adjacent electrodes
  • Impedance to the current flow produces a
    waveform
  • Through electronic evaluation of these
    waveforms, the timing of aortic opening and
    closing can be used to calculate the left
    ventricular ejection time and stroke volume

69
Electrical bioimpedance
  • Some report same clinical accuracy as
    thermodilution technique
  • Crit Care Med 22 1907-1912
  • Chest 111 333-337
  • Crit Care Med 14 933-935
  • Other report poor agreement in those
    haemodynamically unstable and post cardiac
    surgery
  • Crit Care Med 211139-1142
  • Crit Care Med 23 1667-1673
  • Newly generation EB device using upgraded
    computer technology and refined algorithms to
    calculate CO and get better results
  • Curr Opin Cardio 19229-237
  • Int Care Med 322053-2058

70
Electrical bioimpedance
  • Advantage
  • Non invasive
  • Disadvantage
  • Reliability in critically ill patients still not
    very clear

71
In conclusion
  • Haemodynamic monitoring enable early detection of
    change in patients conditions
  • New techniques provide reasonably good results
    and less invasive
  • Always correlate the readings / findings with
    clinical pictures in order to provide the best
    treatment options

72
The End
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