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contractility)
SV is measured by stroke distance x aortic root diameter
stroke distance (AUC) x HR, linear cardiac output parameter,
distance moved by a column of blood through aorta in 1 minute
(1200cm = high flow state)
corrected (systolic) flow time (FTc)
indicates preload
normal = 0.33-0.36s
interpretation of FTc and PV indicates afterload
peak velocity (PV)
indicates contractility
normal range is age related (20yrs 90-120 cm/sec, 90 yrs 3060 cm/sec)
interpretation of FTc and PV indicates afterload
heart rate
METHOD OF USE
Technique
uses a 2 MHz probe (low frequency)
probe on temporal bone -> measure flow in MCA
phase shift is proportional to the speed of blood
paralysis
avoid hyperthermia
treat seizures
barbiturate coma
osmotherapies:
mannitol 0.25 to 1 g/kg, target Osm 300-320 mOsm/kg
hypertonic saline, target Na+ 145-155
Repeat CT scan to exclude a new mass lesion
Consider hypothermia (decrease cerebral metabolism, possible
neuroprotection)
Adverse outcome in paediatric TBI RCT from CCCTG
McIntyre MA suggesting titrated to ICP and prolonged
duration maybe beneficial
Ongoing trials including POLAR in ANZ
Consider surgical techniques (to reduce volume in the box, or
to open the box):
EVD (if already present, ensure patent and draining)
haematoma evacuation
decompressive craniectomy (controversial)
Decompressive craniotomy is contentious
DECRA showed decreased ICP and reduced ICU length of stay
but no mortality benefit and a greater number of patients with an
unfavourable neurological outcome in those who received
decompressive craniectomy
Patients with mass lesions(unless too small to require surgery)
were excluded
Only a single surgical intervention was used
Codman ICP Monitor
intracranial pressure monitor
aka bolt
USES/INDICATIONS
Suspected raised intracranial pressure
severe head injury
unable to monitor neurologically
GCS < 8 and abnormal CT
GCS <8 and normal CT with 2/3 of: age >40y, motor
posturing and SBP <90 mmHg
stroke
cerebral edema
hydrocephalus
hepatic encephalopathy
DESCRIPTION
strain gauge tipped catheter or fiberoptic device
Interpretation of Waveforms
High amplitude of 50-100mmHg sustained for 15 min (A
waves) raised ICP
Saw tooth with small changes in pressure every 0.5-2 minutes
(B waves) poor intracranial compliance
Low amplitude oscillations up to 20mmHg for 1 min (C waves)
normal
Flat ICP trace compression or kinking of transducer
Rounded appearance of the waveform raised ICP
ADVANTAGES
easy to insert (can be done at bedside)
less invasive than EVD
more accurate ICP measurements than extradural bolt
produces high fidelity wave forms
small
DISADVANTAGES/ COMPLICATIONS
infection
transducer tip may rest on brain and obstruct
aspiration of CSF not possible
tends to under-read pressures > 20mmHg
intracranial transducer cannot be calibrated once in situ
baseline drift (especially after 5 days)
remember they dont give an indication of infratentorial pressure
no RCT evidence of benefit
External Ventricular Drain
ICP monitor than allows CSF drainage
USES
measurement and treatment of raised ICP
hydrocephalus of at risk of hydrocephalus following TBI
DESCRIPTION
gold standard of ICP measurement
catheter inserted in lateral ventricle at operation via a burr hole
passes through brain tissue
transducer is usually remote but catheter tip transducer also
available
zero level is the external auditory meatus
Components
Sampling port
Connector for transducer cable
Safety pin to attach to pillow
Filter
Transducer
Collection tubing
Collecting chamber
Level marker connected to chamber
Measuring column (in centimetres)
Collecting bag
METHOD OF USE
ADVANTAGES
gold standard
ventricular pressure considered more reflective of global ICP
than subdural, extradural or subarachnoid pressure
less prone to occlusion
allows therapeutic withdrawal of CSF
compliance can be measured
zero calibration
cheap
new devices are antibiotic impregnated to reduce the risk of
infection (e.g. Clindamycin/Rifampicin)
DISADVANTAGES/ COMPLICATIONS
more difficult to insert than a Codman
infection (ventriculitis)
haemorrhage
damage to brain
accidental venting of CSF
cannot be inserted in coagulopathy
no RCT evidence of benefit
Intra-Aortic Balloon Pump
Intra-Aortic Balloon Pump (IABP) or intra-aortic
counterpulsation device
the balloon is inflated during diastole to increase coronary
perfusion and then deflated during systole to decrease afterload
This aims to improve myocardial oxygenation, increase cardiac
output and organ perfusion with a reduction in left ventricular
workload
INDICATIONS
IABP is used as a supportive treatment tool in a clinical context
that will improve (bridging therapy) due to recovery or treatment
cardiogenic shock
post bypass
post MI
cardiomyopathy
severe IHD awaiting surgery or stenting
severe acute MR awaiting surgery
prophylactically in high risk patient pre-stenting/ cardiac surgery
miscellaneous (i.e. post myocardial contusion which is expected
to recover with time)
Intra-Aortic Balloon Pumps have also been inserted as a last
ditch measure to stop haemorrhage from the aorta or its branches
(e.g. massive GI haemorrhage)
CONTRAINDICATIONS
aortic regurgitation
aortic dissection
severe aorto-iliac or PVD
aneurysm or other anatomical disease of aorta
prosthetic aortic tree grafts
local sepsis
lack of experience with management
severe coagulopathy
not effective in a setting of a CI of < 1.2 and tachyarrhythmias
DESCRIPTION
The IABP has two parts:
(1) a large bore catheter with a long sausage-shaped balloon at
the distal tip, and
(2) a console containing a pump that inflates the balloon
balloon is made of a polyurethane membrane mounted on a
vascular catheter
various catheter sizes usually 7.5 F with the balloon size
chosen according to height (2550 cc)
may be sheathed or sheathless
some newer catheters have fibreoptics that assist pressure
waveform detection and timing
helium is used to inflate the balloon as its low viscosity means
there is little turbulent flow so the balloon can inflate fast and
deflate slowly. It is also relatively benign and eliminated quickly
if there is a leak or the balloon ruptures
when inflated the balloon occludes 80-90% of the aorta
INSERTION
Preparation
patient positioned supine
sterile technique (gowns, gloves, mask, drapes, sterile prep
solution)
check for bleeding diathesis and other complications
Method
fully collapse balloon applying vacuum with 60 ml syringe; some
kits require that the plunger is completely pulled out to achieve
this
percutaneous Seldinger technique or surgical
with or without sheath
access femoral artery at 45 degrees with needle
pass guidewire through needle and advance until tip is is in
thoracic aorta. Wire should pass very easily
pass sheath over wire in similar manner to insertion of PA
catheter sheath (sheath is not always used)
Pass balloon through sheath over guidewire and insert estimated
distance measure from sternal angle to umbilicus then to
femoral artery. Must be inserted to at least the level of the
manufacturers mark (usually double line) to ensure that entire
balloon has emerged from sheath
Balloon should be positioned so that the tip is about 1 cm distal
to the origin of the left subclavian artery
watch for loss of right radial pulse (too high)
Efficiency affected by
timing of inflation and deflation
assist ratio
heart rate (tachycardia > 130/min reduces benefit of IABP)
gas loss from balloon
CI of 1.2-1.4 required for IABP to be effective
COMPLICATIONS
During insertion
failure to advance catheter beyond iliofemoral system because of
atherosclerotic disease (common)
aortic dissection and arterial perforation may cause
retroperitoneal hemorrhage
malposition
accidental femoral vein cannulation and damage to local
structures
During use
thrombosis at the insertion site causing limb ischemia
peripheral embolisation and end organ ischaemia (e.g. limb
ischaemia with compartment syndrome, gut, kidneys and spine)
incorrect positioning with vascular occlusion (e.g. SCA, renal
arteries and other aortic branches)
infection
perforation
balloon rupture (look for presence of blood in the connecting
tubing)
gas embolisation
haemolysis and thrombocytopaenia
peripheral neuropathy
timing errors
During or after removal
haemorrhage particularly with the sheathed sets, consider
surgical repair of insertion sites in sheathed balloons
pseudoaneurysm
AV fistula
entrapment leading to inability to remove (may be due to small
performation allowing blood to enter balloon, may require
aortotomy)
OTHER INFORMATION
Catheter types
balloon size based on height (25-50cc)
sheathed or sheathless kits
new fibreoptic catheters that improve arterial pressure waveform
detection and timing
Anticoagulation
controversial if routinely required during first the 24 hours
low dose heparin infusion often prescribed; some units infuse
heparinised saline through the transducer set
Causes of decreased augmentation
balloon not needed any longer (myocardial recovery)
balloon rupture
distributive shock (sepsis)
Management of helium embolus
immediate cessation of counterpulsation
placement of the patient head down
IAB removal
Consider giving broad spectrum antibiotics as the gas chamber of
the balloon is not sterile
Weaning
should be considered when inotropic requirements are minimal
achieved gradually (over 612 h) reducing the ratio of
augmented to non-augmented beats from 1:1 to 1:2 or less (1:3