Hemodynamic Monitoring

The study of the motion of blood through the body. In simple clinical application this may include the assessment of a patients:
heart rate pulse quality blood pressure capillary refill, skin color skin temperature and other parameters.

Basic Hemodynamic Parameters

CardiacOutput/Cardiac Index Heart Rate StrokeVolume/Stroke Volume Index Ejection Fraction Afterload (Vascular Resistance) Preload(CVP, Wedge pressures)

CARDIAC OUTPUT
The amount of blood ejected by the ventricles in one minute (ecxpressed in liters per minute) Formnula: Heart Rate x Stroke Volume Normal range: 4-8 L/min

Cardiac Index
Relates the cardiac output to body surface area, thus relating heart performance to the size of the individual. Formula: Cardiac output/ Body Surface Area Normal range: 2.5-4.3 L/mm/m3

Heart Rate
Number of cardiac cycles in one minute (expressed in beats per minute) Normal range: 60-100bpm Tachycardia Decreased ventricular filling time Less preload, less cardiac output Bradycardia if contractility remains strong (e.g.athletic heart)= normal CO. If contractility also decreases= decreased CO

Stroke Volume
Amount of blood ejected from the left ventricle L & R ventricle eject nearly the same amount Formula: Difference between End Diastolic volume (EDV) and End Systolic Volume (ESV) Normal range: 50-100ml/beat

Stroke Volume Index

Relation of stroke volume to the size of the person Formula: Stroke volume/ Body surface area Normal Range: 35-60 ml/beat/m3

Ejection Fraction
Stroke volume that is expressed as a percentage of the end diastolic volume Formula: Stroke volume/EDV x 100 Normal range: Greater than 60%

Determinants of Stoke Volume

1. Preload 2. Afterload 3. Contractility

Preload
Amount of blood that stretches the ventricles at the end of diastole (just before contraction) Right Ventricular Preload is measured by CVP. Normal CVP range= 510 cmH2O or 28 mmHg Left Ventricular Preload is measured by PA catheters. Normal PAOP range= 8-12mmHg

Afterload
Amount of resistance against ventricular emptying Influenced by: Length of blood vessels Diameter of blood vessels Blood Viscosity Heart Valves Right ventricular afterload is measured by the Pulmonary vascular resistance (Normal range: 100-250 dynes/sec/cm-5) Left ventricular afterload is measured by the Systemic vascular resistance (Normal range: 800-1200 dynes/sec/cm-5)

Contractility
Inotropy: the force of myocardial contraction Affected by preload (Frank-Starlings Law) The amount of myocardial stretch is a determinant on how strong the next contraction will be Affected by the: - Sympathetic responses: catecholamines - Myocardial wall condition - Electrolytes: Potassium, Magnesium, Calcium - Electrical conduction of the heart - Preload - Metabolic acidosis - Drugs (vasopressors, digitalis)

Indirect Hemodynamic Monitoring

Sphygmomanometry
Measures Systemic Circulation Methods: Auscultatory, Palpatory, Oscillometry

Direct Monitoring Methods

1. Central Venous Pressure (CVP) - Measures pressure of the right side of the heart 2. Arterial Line (A-Line) - Measure Systemic circulation 3. Pulmonary Artery Catheter (PA- Catheter) - Measure pressure of both sides of the heart and pulmonary circulation

Principles of Invasive Hemodynamic Monitoring

Referencing: Eliminates effect of the height of the trasnducer on the readings. Placed on phlebostatic axis (4TH ICS, RMCL) Zeroing: Confirms that pressure within the system is zero. Stopcock close to patient, open to room air, and turn monitor to zero level

 Dynamic Response Test/Square Wave Test: Identifies any distortion in the signal being read. Performed by activating the fast flush mechanism so that the pressured fluids empty to the outside. The monitor should produce a distortion free-square wave

Central Venous Pressure

Measurement of the pressure in the vena cava or right atrium Single lumen or multi-lumen catheter is threaded through the external jugular, antecubital or femoral vein Normal CVP: 2-6mmHg

Arterial Pressure

Uses an Arterial Line inserted through the peripheral artery Systolic peak and end diastole corresponds to systolic and diastolic blood pressure readings Means for continuous arterial blood sampling and arterial pressure monitoring Allens test is performed before inserting arterial lines

Pulmonary Artery Pressure

Assess left ventricular function Swan-Ganz Catheter Usually inserted through large veins: Antecubital, subclavian, femoral, and jugular Classic 4 lumen catheter:
1. Proximal lumen (blue)- CVP measurement, IV infusion/ Injections, Venous Sampling 2. Distal Lumen (yellow)-for PAP, PAOP measurement

3. Balloon inflation lumen (red) 4. Thermistor lumen= for thermodilution method of cardiac output determination

 The catheter is passed through the vena cava and right atrium Procedure can be done in operating room, cardiac catheterization lab or bedside ICU guided by a fluoroscopy In the right atrium the balloon tip is inflated and is carried rapidly by the flow of blood through the tricuspid valve, into the right ventricle, into a branch of the pulmanry artery Sutured in place once pulmonary artery is reached

 Bedside monitor id observed for pressure wave form changes during insertion as well as dydrhytmias Once in place the ff can be measured:
Right atrial pressure Pulmonary artery systolic pressure Pulmonary artery diastolic pressure Mean pulmonary artery pressure Pulmonary artery wedge pressure