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Course in pediatric cardiology, anaesthesia and cardiac surgery

HEMODYNAMIC MONITORING
Cattaneo Sergio
OO.RR. Bergamo

INTRAVASCULAR PRESSURE MONITORING

Transducer system
Physiology Monitor

Transducer system
Mechanical energy Electronic signal
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INTRAVASCULAR PRESSURE MONITORING

COMPONENTS:
1. Transducer
Change mechanical energy to electronic signal.

2. Continuos washing system


Saline solution in a pressure bag (300mmHg) or infusion pump (less fluid volume!!!)

3. Proximal stopcock
Useful to set Zero.

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4. Connection to catheter
Transfer pressure pulse from caterer to transducer

1
3

5. Distal stopcock
Useful to take out blood sample.

INTRAVASCULAR PRESSURE MONITORING

Transducer system
Resonance

Damping

CONNECTION LINE: SHORTER , BIGGER and STIFFER!


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INTRAVASCULAR PRESSURE MONITORING


Measured pressure is always relative to a reference point. Its a difference!

Calibration - ZERO

WHY: remove atmospheric pressure interference (~760mmHg) WHEN: connection from transducer to monitor Not when you change transducer position!!! TEST: Open Proximal Stopcock to connect transducer to air ,
monitor must show a plan line and measure zero.
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INTRAVASCULAR PRESSURE MONITORING

Level:
Reference point RIGHT ATRIUM = Mean Axillary Line Supine position

WHEN:

Every time patient moves (Otherwise measurement is not right!!!)


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INTRAVASCULAR PRESSURE MONITORING

RAPID FLUSH TEST


To determinate the dynamic response of catheter and transducer system
Overdamped

INTRAVASCULAR PRESSURE MONITORING

Invasive arterial pressure


WHEN:
HEMODYNAMIC MONITORING Cardiac arrest Shock syndrome Hypertensive crisis Use of vasoactive drugs Use on IABP MULTIPLE BLOOD GAS ANALYSIS Mechanical Ventilation Respiratory failure Sepsis
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INTRAVASCULAR PRESSURE MONITORING

Invasive arterial pressure - 2


WHERE:
1. 2. Radial Artery Femoral Artery

TECHNIQUE OF CANNULATION:
90%
Use always Seldinger Technique

3. 4.

Brachial Artery Axillary Artery

MONITORAGGIO EMODINAMICO: TEORIA, METODICHE TRADIZIONALI E NUOVE TECNILOGIE

INTRAVASCULAR PRESSURE MONITORING

Invasive arterial pressure - 3


dP/dt

MAP = PAd + (PAs-PAd) / 3 Pulse Pressure : PAs-PAd


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INTRAVASCULAR PRESSURE MONITORING

Invasive arterial pressure - 4


NORMAL RANGE BLOOD PRESSURE:
Age Term 3 mo 6 mo 1 yr 3yr 7yr 10yr 12yr 14yr Wt 3.4kg 6kg 7.5kg 10kg 14kg 22kg 30kg 38kg 50kg mmHg 40-60 45-75 50-90 50-100 50-100 60-90 60-90 65-95 65-95
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INTRAVASCULAR PRESSURE MONITORING

Invasive arterial pressure


RESPIRATORY CHANGES IN ARTERIAL WAVE FORM IN MECHANICALLY VENTILATED

PATIENTS:
SYSTOLIC PRESSURE VARIATION - SPV

PULSE PRESSURE VARIATION - PPV

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INTRAVASCULAR PRESSURE MONITORING

Invasive arterial pressure


SYSTOLIC PRESSURE VARIATION - SPV
The difference between the maximal and minimal value of systolic blood pressure during one mechanical breath. SPV can be divided into two components by interposing a brief (5sec) apnea, and using the systolic body pressure during apnea as a reference value:
The difference between the maximal systolic value and the systolic body pressure during apnea.

up

down

The difference between the apneic systolic body pressure and the minimal systolic value.

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INTRAVASCULAR PRESSURE MONITORING

Invasive arterial pressure


SYSTOLIC PRESSURE VARIATION - SPV

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INTRAVASCULAR PRESSURE MONITORING

Invasive arterial pressure


SYSTOLIC PRESSURE VARIATION - SPV

Down
reflects the expiratory decrease in LV preload and SV related to the

inspiration decrease in RVSV

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INTRAVASCULAR PRESSURE MONITORING

Invasive arterial pressure


SYSTOLIC PRESSURE VARIATION - SPV During hypovolemia, as during hemorrage SPV by Down The amount of blood loss was closely correlated with SPV and Down

Volume expansion SPV and Down


Perel A. et al.-Anesthesiology 1987:67;498-502 Pizov R. et al.-Anesth Analg 1988:67;170-174 Preisman S. et al.-Int Care Med1997:23;651-657
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INTRAVASCULAR PRESSURE MONITORING

Invasive arterial pressure


PULSE PRESSURE VARIATION - PPV PULSE PRESSURE The difference between systolic and diastolic arterial pressure

Respiratory changes in LVSV are reflected by respiratory changes in PP.


In mechanically ventilated patients: PP is maximum at the end of inspiratory period PP is minimum during the expiratory period
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INTRAVASCULAR PRESSURE MONITORING

Invasive arterial pressure


PULSE PRESSURE VARIATION - PPV

PP (%) = (PPmax- PPmin) / ((Ppmax+Ppmin)/2)*100

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INTRAVASCULAR PRESSURE MONITORING

Invasive arterial pressure


PULSE PRESSURE VARIATION - PPV PPV before volume expansion can accurately predict the effect of volume expansion on CO PPV is a more reliable indicator of fluid responsiveness than PS
A patients with a baseline PPV value of more than 13% was very likely to respond to volume expansion by increasing CO by 15% (positive predicted value 94%). By contrast, if PPV 13%, the patients was unlikely to respond to fluid challenge (negative predictive value 96%).
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Michard et al.: Am J Resp Crit Care Med 2000; 162:134-138

INTRAVASCULAR PRESSURE MONITORING

Central Venous Pressure - 1


WHEN:
Pre-operative preparation

Total parenteral nutrition


Pulmonary artery catheter Emergency management Use of vasoactive drugs Cardiac arrest

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INTRAVASCULAR PRESSURE MONITORING

Central Venous Pressure - 2


WHERE:
Depend on surgery plan!! Internal Jugular vein
Not in these cases:
GLENN and FONTAN OPERATIONS, NORWOOD and DAMUS-KAYOPERATION, RIGTH AXILLARY- PULMUNARY SHUNT

TECHNIQUE OF CANNULATION:
Use always Seldinger Technique
4 Fr 5cm bi-lumen 5,5Fr 5cm triple-lumen 2. 5-10 Kg 4 Fr 8cm triple-lumen 5,5Fr 5cm triple-lumen 3. 10-20 Kg 5,5 Fr 8 cm triple-lumen 4. 20 Kg 5.5 Fr 8 - 13cm triple-lume
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1. 5Kg

2. Femoral vein

INTRAVASCULAR PRESSURE MONITORING CVP Central Venous Pressure / Right Atrium waveform

A wave Atrium Sistole

C wave Tricuspid valve closure


X wave Atrial relaxation V wave Atrial filling with tricuspid valve closed Y wave Ventricular filling after ticuspid valve opening
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INTRAVASCULAR PRESSURE MONITORING


Central Venous Pressure / Ventilation
( = Inspiration)

Spontaneous Breathing

Mechanical Ventilation
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INTRAVASCULAR PRESSURE MONITORING CVP Central Venous Pressure / Right Atrium waveform
TRICUSPID REGURGITATION: Elevated CVP Evident positive V wave

CARDIAC TAMPONADE: Elevated CVP Damping or absence of Y wave Equalization of CVP, diastolic PAP and PAWP

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PULMUNARY ARTERY CATHETER - SWAN-GANZ

Superior Vena Cava >Tricuspid Valve > Right Ventricle > Pulmonary Artery
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SWAN-GANZ CATHETER

1. Distal lumen 2. Proximal lumen

2
1

3. Balloon inflation lumen

3
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INTRAVASCULAR PRESSURE MONITORING

Pulmunary Artery Catheter - 1


WHEN:

Complicated MI
Shock (cardiogenic-hypovolemic-Septic) Respiratory distress (cardiogenic noncardiogenic) Management post-cardiac surgery patient Others

LIMITATIONS Size of catheter in children! Shunts in congenital heart disease!


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INTRAVASCULAR PRESSURE MONITORING

Pulmunary Artery Catheter - 2


CONTROINDICATIONS:
Stenosi tricuspideo polmonare Massa o trombo atriale Protesi tricuspidale

Inserction:

Arrhythmias (TV, FV) 0.3-63 % Right bundle branch (0.1-4.3 %), Total AVB (0-8.5 %) Intracardiac and valve damage Tromboembolic complication Knotting (loop)

COMPLICATION: After inserction:


Infection (0-22%) Septicemia Endocarditis (2.2 -100%) Pulmonary infarction (0.1 -7 %) Pulmonary artery perforation (0.06-0.2 %) Balloon rupture
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INTRAVASCULAR PRESSURE MONITORING

Pulmunary Artery Catheter - 3


Insertion technique

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INTRAVASCULAR PRESSURE MONITORING

Pulmunary Artery Catheter - 4

Insertion technique
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INTRAVASCULAR PRESSURE MONITORING

Pulmunary Artery Catheter - 5

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INTRAVASCULAR PRESSURE MONITORING

Pulmunary Artery Catheter - 6


MEASUREMENTS: Cardiac Output Thermodilution (Fegler G., 1954/Ganz W, 1971) Cold solution in injected into right atrium. The thermistor records blood temperature change on the top of pulmonary artery catheter.

Stewart-Hamilton formula

CO = Vol injected x (TB-TF)1.08K/ ? ? TB(t)dt


TB, TF = Blood and cold fliud temperature ?? TB(t)dt = under-curve area K = computational constants

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INTRAVASCULAR PRESSURE MONITORING

Pulmunary Artery Catheter - 7


MEASUREMENTS: Pulmonary Artery Occlusion Pressure (PAOP)

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INTRAVASCULAR PRESSURE MONITORING

Pulmunary Artery Catheter - 7


MEASUREMENTS: Pulmonary Artery Occlusion Pressure (PAOP)

In Pediatric Cardiac Surgery you can put a catheter direct In Left Atrium

LVEDP
LAP

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INTRAVASCULAR PRESSURE MONITORING

Pulmunary Artery Catheter - 8


MEASUREMENTS: Pulmonary Artery Occlusion Pressure (PAOP)

Error in interpretation Damped PAP

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INTRAVASCULAR PRESSURE MONITORING

Pulmunary Artery Catheter - 9


MEASUREMENTS: Pulmonary Artery Occlusion Pressure (PAOP)

Error in interpretation Overwedging

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INTRAVASCULAR PRESSURE MONITORING

Pulmunary Artery Catheter - 10


MEASUREMENTS: Pulmonary Artery Occlusion Pressure (PAOP)

Error in interpretation

Mitral regurgitation

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INTRAVASCULAR PRESSURE MONITORING

Pulmunary Artery Catheter - 11 CI= CO/BSA (2.8-4,2 2) SV= CO/HR L/min/m SVI= CI/HR (30-65 ml/beat/ m2) SVR= (MAP-CVP)/COX79,9 (900-1400 dyne.sec.cm-5) PVR= (MAP-PCWP)/ COX79,9 (150-250 dyne.sec.cm-5)
LVSWI= SIX(MAP-POAP)X0,0136 (43-61 g/m/m2) RVSWI= SIX(PAP-CVP)X0,0136 (7-12 g/m/m2) CaO2= [Hb]xSaO2x1.34 + (PaO2x0.003) CvO2= [Hb]xSvO2x1.34 + (PvO2x0.003) avDO2= CaO2 - CvO2 (3-5 ml/dl)
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INTRAVASCULAR PRESSURE MONITORING

Pulmunary Artery Catheter - 12 Do2= CO x Cao2 x 10 (640 1200 ml O2/min) Vo2= CO x avDo2 x 10 (180 280 ml O2/min) Vo2/Do2= CO x (Cao2-Cvo2)/CO x Cao2 = (Cao2-Cvo2)/Cao2 (0,22 0,30)

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INTRAVASCULAR PRESSURE MONITORING

Pulmunary Artery Catheter - 11


MEASUREMENTS: Mixed Venous Oxygen Saturation (SvO2)

SvO2
Also from central venous catheter!!!
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PiCCO
The PiCCO Technology is a combination of 2 techniques for advanced hemodynamic and volumetric management without the necessity of a pulmonary artery catheter in most patients:
a. Transpulmonary thermodilution
-T

b. Arterial pulse contour analysis


-T

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PiCCO

Central Venous Line

Central Venous Line

Arterial Catheter (5-3 F) with termistor on the tip femoral artery

Arterial Line

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PiCCO
The system setup:
13.03 16.28 TB37.0

AP

AP 117

140 92

(CVP) 5 SVRI PC CI HR 3.24 78 42 2762

PCCI

SVI

SVV 5% dPmx 1140 (GEDI) 625

Temperature Sensor PC80109

Arterial Pressure line

Transdutor PULSION PV8115

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PiCCO
Transpulmonary thermodilution
measurement simply requires the central venous injection of a cold (<8C) or room-tempered (<24C) saline bolus

CV Bolus Injection

Lungs Right Heart Left Heart


PiCCO Catheter e.g. in femoral artery
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PiCCO
Transpulmonary thermodilution
After central venous injection of the indicator, the thermistor in the tip of the arterial catheter measures the temperature changes The cardiac output is calculated by analysis of the thermodilution curve using a modified Stewart-Hamilton algorithm:

-Tb

Injection

t
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PiCCO
Arterial Pulse Contour Analysis
Arterial pulse contour analysis provides continuous beat-by-beat parameters obtained from the shape of the arterial pressure wave. The algorithm is capable of computing each single stroke volume (SV) after being calibrated by an initial transpulmonary thermodilution.
- T - T

Calibration SV

P [mm Hg]

t [s]

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PiCCO
Arterial Pulse Contour Analysis
As pulse contour analysis continuously measures

stroke volume and arterial pressure


cardiac output (CO) and systemic vascular resistance (SVR) are computed as follows: CO is calculated as stroke volume x heart rate

SVR is calculated as (mean arterial pressure - central venous pressure) / CO


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PiCCO
Stroke Volume Variation (SVV)
In mechanically ventilated patients without arrhythmia,

SVV reflects the sensitivity of the heart to the cyclic changes in


cardiac preload induced by mechanical ventilation.

SVV can predict whether stroke volume will increase with volume
expansion.

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PiCCO
Volumetric Parameters Global Enddiastolic Volume GEDV Intrathoracic Blood Volume ITBV Extravascular Lung Water EVLW

These volumetric parameters are obtained by advanced analysis of the thermodilution curve.

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PiCCO
Volumetric Parameters
Global Enddiastolic Volume (GEDV) is the volume of blood contained in the 4 chambers of the heart.

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PiCCO
Volumetric Parameters
Intrathoracic Blood Volume (ITBV) is the volume of the 4 chambers of the heart + the blood volume in the pulmonary vessels.

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PiCCO
Volumetric Parameters
ExtraVascular Lung Water (EVLW) is the amount of water content in the lungs. It allows bedside quantification of the degree of pulmonary edema.

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PiCCO
Volumetric Parameters / CARDIAC PRELOAD
Intrathoracic Blood Volume, ITBV and Global Enddiastolic Volume, GEDV have shown to be far more sensitive and specific to cardiac preload than the standard cardiac filling pressures CVP + PCWP but also than right ventricular enddiastolic volume. The striking advantage of ITBV and GEDV is that they are not wrongly influenced by mechanical ventilation and give correct information on the preload status under any condition.

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PiCCO
Parameters Range
Cardiac Index 5.0 CI l/min/m2 GEDI 850 3.0

Global Enddiastolic Blood Volume Index 680 800 ml/m2 Intrathoracic Blood Volume Index 1000 ml/m2 ITBI

Stroke Volume Variation %


Extravascular Lung Water Index* 7.0 ml/kg

SVV
ELWI*

10
3.0
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CONCLUSIONS
Central Venous Line CVP Blood gas (ScvO2) Arterial line Continuous Blood Pressure SPV / PPV Pulmonary Artery Catheter (PAC) Occlusion pressure, PAP C.O. / SVR / PVR SvO2 DO2 / VO2 PiCCO SVV GEDV ITBV EVLW

CONTRACTION PRELOAD AFTERLOAD

ECHO!!!

DRUGS? VOLUME?
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Course in pediatric cardiology, anaesthesia and cardiac surgery

HEMODINAMIC MONITORING
Cattaneo Sergio
OO.RR. Bergamo

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