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CLINICAL MEASUREMENT

Prof. Serban Bubenek MD


ESA - EDA Basic Sciences Course
PARIS 2012

Monitoring in Anaesthesia
and Intensive Care

Monitoring: A Definition
... interpret available clinical data to help
recognize present or future mishaps or
unfavorable system conditions

... not restricted to anesthesia


(change clinical data above to system data to apply to
aircraft and nuclear power plants)

What is monitoring?
Physiologic parameter & Patient safety parameter
Clinical skills & Monitoring equipment
Data collection, interpretation, evaluation, decision
Problem seeking, Severity assessment, Therapeutic
assessment, Evaluation of Anesthetic interventions

Patient Monitoring and Management


Involves
Things you measure (physiological measurement, such as
BP or HR)

Things you observe (e.g. observation of pupils)


Planning to avoid trouble (e.g. planning induction of
anesthesia or planning extubation)

Inferring diagnoses (e.g. unilateral air entry may mean


endobronchial intubation)

Planning to get out of trouble (e.g. differential diagnosis


and response algorithm formulation)

Level of monitoring
Routine / Specialize / Extensive
Non-equipment / Non-invasive / Minimally invasive
/ Penetrating / Invasive / Highly invasive

Systematic
Respiratory / Cardiovascular / Temperature/Fetal
Neurological / Neuro-muscular / Volume status & Renal
Standards for basic intraoperative monitoring ( ASA)

Standards for basic intraoperative monitoring


( ASA : American Society of Anesthesiologists)
Standard I
Qualified anesthesia personnel shall be present in the
room throughout the conduct of all GA, RA, MAC

Standard II
During all anesthetics, the patients respiratory
(ventilation, oxygenation), circulation and temperature
shall be continually evaluated

Monitoring in Anesthesia
OBJECTIVES:
1. Guidelines to the practice of anesthesia and patient monitoring
2. Elements to monitor
(Anesthesia depth, Oxygenation, Ventilation, Circulation, Temperature)
2.1. ECG
2.2. Pulse Oximetry ( Function, Values, Limitations)
2.3. Blood Pressure (methods, indications, limitations, Insertion sites, values)
2.4. central venous line and pressure (methods, indications, limitations,
Insertion sites and it's advantages, Complications, values)

Monitoring in Anesthesia
OBJECTIVES:
2.5. Capnography and EtCO2 (Uses, Measurement, values, factors
affecting EtCO2)
2.6. Cyanosis
2.7. The oxyhemoglobin dissociation curve (interpretation, causes of
Left and right shifting , key values, O2-Content of Blood)
2.8. Temperature ( Methods, Values, sites)

3. Normal values for a healthy adult undergoing anesthesia

Guidelines to the practice of anesthesia and


patient monitoring:

Monitoring in the Past


1. Visual monitoring of
respiration and overall
clinical appearance

2. Finger on pulse
3. Blood pressure
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Monitoring in the Past

Finger on the pulse

Harvey Cushing
Not just a famous neurosurgeon
but the father of anesthesia monitoring
Invented and popularized the anesthetic chart
Recorded both BP and HR
Emphasized the relationship between vital signs and
neurosurgical events
( increased intracranial pressure leads to hypertension and bradycardia )

Guidelines to the practice of anesthesia and


patient monitoring:

1. Qualified anesthesia personnel shall be present in


-

the room throughout the conduct of :


all general anesthetics
regional anesthetics
monitored anesthesia care

2. A completed pre-anesthetic checklist.


(history, physical exam, lab investigations, NPO
policy)
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Guidelines to the practice of anesthesia and patient


monitoring:

3. An anesthetic record.
-

in general anaesthesia, regional anesthesia, or monitored IV


conscious sedation HR and BP should be measured every 5
min.

also time, dose and route of drugs and fluids should be charted

4. During all anesthetics, the patients


-

oxygenation
ventilation
circulation
temperature

shall be continously evaluated

!
14

MONITORING
HR
O2 sat
RR

BP

Temp

MAP

15

Elements to Monitor :
I. Anesthetic Depth:
Patients with local or regional anesthesia provide verbal
feedback regarding well being.
Onset of general anesthesia signaled by lack of response to
verbal commands, in addition to loss of blink reflex to light
touch.
Inadequate anesthesia can be signaled by : Facial grimacing
or movement of arm or leg. But with muscle relaxants ( fully
paralysis), it can be signaled by : Hypertension, tachycardia,
tearing or sweating.
Excessive anesthesia can be signaled by :
Cardiac depression, bradycardia, and Hypotension.
And also may result in hypoventilation, hypercapnia and
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hypoxemia when muscle relaxants is not given.

Elements to Monitor :
II. Oxygenation:
Clinically, monitored by patient color ( with adequate
illumination ) and pulse oximetry.
Quantitavely monitored by using oxygen analyzer, equipped
with an audible low oxygen concentration alarm.

III. Temperature
Continuous temperature measurements monitoring is
mandatory if changes in temperature are anticipated or
suspected.

17

Elements to Monitor :
IV. Circulation:
Clinically, monitored by pulse palpation, heart auscultation
and monitoring intra-arterial pressure or oximetry.
Quantitavely using ECG signals and arterial blood pressure
measurements every 5 min.

V. Ventilation
Clinically, monitored through a correctly positioned
endotracheal tube, also observing chest excursions, reservoir
bag displacement, and breath sounds over both lungs.
Quantitavely by ETCO2 analysis, equipped with an audible
disconnection alarm.
Arterial blood gas analysis for assessing both oxygen and
ventilation.
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Monitoring:

Electrocardiogram ECG:

A 3 or 5 lead electrode system is used for ECG monitoring in the OR.


The 3 lead system has electrodes positioned on the right arm, left arm and chest
position. ( placed in the left anterior axillary line at the 5th interspace, referred
to as V5 ). Lead II is usually monitored by this system.
The 5 lead system adds a right leg and left leg electrodes, which allows
monitoring v1, v2, v3, AVR, AVL, AVF and V5.
II and V5 very important !
ST segment

19

Monitoring:

Electrocardiogram ECG:

Identification of P waves in lead II and its association with the QRS


complex is useful in distinguishing a sinus rhythm from other
rhythms.
Analysis of ST segment is used as an indicator of MI. ( Dep.-ischemia
/ elev.-infarction )
Over 85% of ischemic events can be detected by monitoring ST seg.
of leads II and V5.

20

Monitoring:

Pulse Oximetry:

Allows beat to beat analysis of oxygenation.


Depends on differences in light absorption between oxyHb and
deoxyHb.
Red and Infra-red light frequencies transmitted through a
translucent portion. (finger-tip or earlobe)
Microprocessors then analyze amount of light absorbed by the 2
wavelengths, comparing measured values, then determining
concentrations of oxygenated and deoxygenated forms. (oxy- and
deoxy-)

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PULSEOXIMETRY is for OXYGENATION


Principle : Spectrophotometry & Plethysmography
relies on the differing absorption of light, at different wavelengths by the various
states of oxyhaemoglobin
- HbO2 has a higher absorption at 940 nm (blue light)

Hb has a higher absorption at 660 nm (red light)

the light signal following transmission through


the tissues has a pulsatile component

two LEDs : one emitting red light (660 nm) and the
other a blue light (940nm) on the finger nail

on the other side of the finger : photo sensor


(photocell) detects the transmitted light

the LEDs are switched on and off at 30 Hz to detect


the cyclical changes in the signal due to pulsatile
arterial blood flow

by calculating the absorption at the two


wavelengths the processor can compute the
proportion of haemoglobin which is oxygenated

S pO2

CHbO2
CHbO2 CHb

Pulse oximeters measure:


1. The oxygen saturation of haemoglobin in arterial blood
- which is a measure of the average amount of oxygen bound to each
haemoglobin molecule
- Haemoglobin is a compound of iron (haem) and globin chains.
Each globin chain is linked to one atom of iron, each of which can carry 4
molecules of oxygen, and as each molecule of oxygen contains two atoms of
oxygen (O2), each haemoglobin molecule can carry 8 atoms of oxygen.
This makes haemoglobin a very efficient means of oxygen transport: each gram of
haemoglobin can carry 1.34ml of oxygen.

2. The pulse rate - in beats per minute, averaged over 5 to 20


seconds.

A pulse oximeter is affected by :


ambient light
shivering
abnormal haemoglobins
( carboxyhaemoglobin, methaemoglobin, dyes as methylene blue and bilirubin )

pulse rate and rhythm


vasoconstriction
poor tissue perfusion ( shock, low CO, cold extremities )
NOT affected by :

dark skin or anaemia.

A pulse oximeter gives no information about :


The oxygen content of the blood
The amount of oxygen dissolved in the blood
The respiratory rate or tidal volume i.e. ventilation
The cardiac output or blood pressure

Monitoring:

Blood Pressure BP:

o Methods of BP measurement:

1. Simplest method of BP measurement,


estimating the SBP, is by palpating the return
of arterial pulse as cuff is deflated (RivaRocci).

2. auscultation of the Kortokoff sounds on deflation


(providing both SBP and DBP)
Mean Arterial Pressure
MAP = DBP + 1/3(SBP DBP)
MAP = ( SBP + 2 DBP ) / 3
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MEASUREMENT OF ARTERIAL PRESSURE


INDIRECT measurement (non-invasive)
- signals generated by the occlusion of a major artery using a cuff
- gives not continous but intermittent measurements

- palpation method ( Riva Rocci)


- auscultation of the Korotkoff sounds
- osccilometry method

DIRECT measurement (invasive and continous)

o Indirect Methods of BP measurement (1)


1. Riva Rocci: simplest method of BP measurement, estimating only
the SBP, is by palpating the return of arterial pulse as cuff is
deflated.
2. Auscultation of the Korotkoff sounds (1905)
on deflation created by the turbulent blood flow in the artery
(providing both SBP and DBP)
Mean Arterial Pressure (MAP) = DBP + 1/3(SBP DBP)

Indirect Methods of BP measurement (2)


3. OSCCILOMETRY
- a microprocessor controlled oscillometer. DINAMAP
- a pressure transducer that digitalizes signals ( microprocesor).
- rapid, accurate ( 9 mmHg) measurements of SBP, DBP, MAP and HR
- SAP corresponds to the onset of rapidly increasing oscillations
- MAP corresponds to the maximal oscillation at the lowest cuff pressure
- DAP corresponds to the onset of rapidly decreasing oscillations

LIMITATIONS:
-

tendency to overestimate at low pressures and underestimate at high pressures

- errors : movements, arrhythmias or BP fluctuations


- compressive peripheral nerve injuries (repeated measurements )

Cuff Size
Too small cuff will result in false high blood pressure reading

Too large cuff will result in false low blood pressure reading

f
r
o
m

DIRECT Measurement of the BP


invasive : catheter into the artery

METHODS

1. open Liquid column method (obsolete) , measures only MAP


13.4 cm. H2O = 10 mm.Hg.
2. Liquid manometers (obsolete)
3. Electromechanical transducers :
- conversion of mechanic signal into an electric signal
- and then electronically converted and displayed as :
SAP,DAP and MAP.

Electromechanical - TRANSDUCERS
The diaphragm :
- is moved by arterial pulsations which push the saline column
- should be thin, small and rigid !
Transducers :
- based upon strain gauge principle : stretching (by PRESSURE ) a wire or
silicone crystal changes its electrical resistance
- connected to a wheatstone bridge circuit : so that the voltage output is
proportionate to the pressure applied it

The 3 major problems may occur :


1. Improper zeroing and zero drift
2. Improper transducer / monitor calibration
3. Inadequate dynamic response of system : RF and damping
Resonant (natural) Frequency (RF) = frequency at which a system oscillates when
stimulated.
- if the frequency of an input signal (i.e., pressure waveform) approaches the RF of a
system : progressive amplification of the output signal occurs,
a phenomenon known as ringing.

The ARTERIAL PRESSURE Waveform


ARTERIAL WAVEFORM is a complex sine-wave
The fundamental frequency (FF) or the 1-st harmonic is equal to the HR
( ex: for HR 60 b/min = 1 beat / sec = 1 cycle/sec = 1Hz.)
physiologic peripheral arterial waveforms have a FF = 3 to 5 Hz

MONITORING SYSTEM
The RF should be at least at least 5 times higher than the highest frequency in the
input signal or better : approx.10 times the FF
at least FR >20 Hz to avoid ringing and systolic overshoot

The ARTERIAL PRESSURE Waveform


The damping coefficient (DC) is a measure of how quickly an oscillating system
comes to rest

method to test the DC: the fast-flush test ( square wave test)

optimal damping
- underdamping = overestimates SAP and underestimates DAP
- overdamping = underestimates SAP and overestimates DAP

- both cases however MAP is relatively accurate

REDUCING ARTIFACTS IN A-LINES


Lines free of kinks and clots
Air Bubbles : small amount may augment systolic pressure reading, while large
amount cause an over-damped system
One stopcock per line

Heparinized saline flushed maintaining patency


Transducer should be electronically balanced or re-zeroed because the zero
point may drift if the room temperature changes

to have an adequate damping = flushing TEST

Short and rigid : catheter and lines

Monitoring:

Blood Pressure BP:

o Methods of BP measurement:

3. Automated non-invasive BP measurements.


METHODOLOGY: a microprocessor controlled oscillometer
(Dinamap) which is used routinely intraoperatively. It
allows automatic inflation of the BP cuff at preset time
intervals, sending readings into a pressure transducer that
digitalizes them. This technique gives rapid, accurate ( 9
mmHg) measurements of SBP, DBP, MAP and HR several
times a minute. LIMITATIONS: Errors occur due to
movements, arrhythmias or BP fluctuations due to
respiration. 3 5 minutes intervals is recommended to
prevent compressive peripheral nerve injury due to repeated
rapid measurements.
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Monitoring:

Blood Pressure BP:

o Methods of BP measurement:

4. Invasive BP measurements.
(Arterial BP):
Indications:

Rapid moment to moment BP changes


Frequent blood sampling
Major surgeries (cardiac, thoracic, vascular)
Circulatory therapies: vasoactive drugs, deliberate
hypotension
Failure of indirect BP: burns, morbid obesity
Sever metabolic abnormalities
Major trauma
The radial artery at the wrist is the most
common site for an arterial catheter.
Alternatives are femoral, brachial and
dorsalis pedis.

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Central Venous line and Pressure (CVP)

Catheter inserted into the SVC providing an estimate of


the right atrial and ventricular pressures.

Serial CVP measurements are more useful than a single


value in order to assess blood volume, venous tone and
right ventricular performance. HR, BP and CVP
response to a volume infusion (100 500 ml) is also a
useful test of right ventricular performance.

40

Central Venous line and Pressure (CVP)


Indications:
CVP monitoring provides Right Atrial and Right
Ventricle pressures
Advanced Cardiopulmonary disease + major
operation
Secure vascular access for drugs
Secure access for fluids + traumatic pts
Aspiration of entrained air: sitting craniotomies
Inadequate peripheral IV access
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Central Venous Line:


PERFORMANCE of Right Internal Jugular Vein
Internal jugular (Int. Jug.) vein lies in groove
between sternal and clavicular heads of
sternocleidomastoid muscle
It is lateral and slightly anterior to carotid artery

Aseptic technique, head down


Insert needle towards ipsilateral nipple
Seldinger method: 22 G finder; 18 G needle,
guide-wire, scalpel blade, dilator and catheter
Observe ECG and maintain control of guide-wire

Ultrasound guidance; Chest-Xray post insertion.

42

Advantages of Right Int. Jug. vein

Consistent, predictable anatomic location


Readily identifiable landmarks
Short straight course to Superior Vena Cava
Easy access for anesthesiologist at patients
head
High success rate, 90-99%

43

Complications of Central lines (jugular):


Bleeding
Injury to surrounding
structures as carotid artery
Pneumothorax
Arrhythmia

44

Central Venous line Alternative Sites


Subclavian vein:
Easier to insert versus Int. Jug. vein
Better patient comfort v. Int. Jug.
Higher Risk of pneumothorax- 2%

External jugular:

Easy to cannulate if visible.


no risk of pneumothoroax,
high risk or bleeding
20%: cannot access central circulation

45

Central Venous Pressure (CVP )


Monitoring
Reflects pressure at junction of vena cava + RA
CVP is driving force for filling RA + RV
CVP provides estimate of:
Intravascular blood volume
RV preload
Trends in CVP are very useful
Measure at end-expiration
Central Venous Pressure (CVP): 1-10 mmHg

46

SWAN GANZ = PA CATHETER

SWAN-GANZ catheter
Waveform during Insertion

PA CATHETER

PA CATHETER
Zone III allows for
uninterrupted blood
flow and a continuous
communication with
distal intracardiac
pressures. (PAand PV
exceed Palv)

PAC-Thermodilution

The change of the bloods temperature in is measured in the pulmonary artery


using the PAC thermistor
The thermistor records the temperature change and the monitor electronically
displays a temperature/time curve.
The CO is inversely proportional to :
- the temperature change
- the area under the curve
( PAC measures the Pulm.CO = Global CO if no intracardiac shunt )

Capnography and EtCO2

Capnometry: is the numerical measurement of CO2 concentration


during inspiration and expiration.
Capnogram: refers to the continuous display of the CO2
concentration waveform sampled from the patients airway during
ventilation.
Capnography: is the continuous monitoring of a patients
capnogram.

53

Capnography and EtCO2


End-tidal CO2 monitoring is standard for all patients undergoing
GA with mechanical ventilation.
It is an important safety monitor and a valuable monitor of the patients
physiologic status, and it has been an important factor in reducing
anesthesia-related mortality and morbidity.
CO2 monitoring is considered the best method for verifying successful
intubation and extubation procedures.
It helps in assessment of the adequacy of ventilation and an indirect
estimate of PaCO2.
Also it aids in diagnosis of PE, recognition of a partial airway obstruction,
and indirect measurement of airway reactivity (bronchospasm).
ETCO2 levels have also been used to predict outcome of resuscitation.

Capnography and EtCO2


Measurement of ETCO2
Sampling the patients respiratory gases near the airway.
Using infra-red gas analysis or mass spectrometry on the values and
concentrations obtained.
Provided that when sampling, inspired CO2 value should be near
zero. (i.e. ETCO2 value is a function of CO2 production, alveolar
ventilation and pulmonary circulation; excluding inspired CO2).
During general anesthesia, with absence of ventilation perfusion
abnormalities, difference between PaCO2 and ETCO2 is about 5 mm
Hg (PaCO2 = 40 mmHg, ETCO2 = 35 mmHg)
Increases or decreases in ETCO2 values maybe the result of
increases or decreases in production and elimination.

Capnography and EtCO2 Factors affecting ETCO2:


Increased ETCO2

Decreased ETCO2

Changes in CO2 Production


Hyperthermia
Sepsis
Thyroid storm
Malignant Hyperthermia
Muscular Activity

Hypothermia
Hypometabolism

Changes in CO2 Elimination


Hypoventilation
Rebreathing
Partial airway obstruction
Exogenous CO2 absorption
(laparoscopy)

Hyperventilation
Hypoperfusion
Embolism

Transient increases in ETCO2 may be noted after: IV bicarbonate


administration, release of extremity tourniquets, or removal of vascular crossclamps.

Capnography and EtCO2

Normal
Esophageal 0 !

Cardiac arrest

Curare cleft

> 4 curves !

bronhospasm

spontaneous

exhausted CO2 absorber

IMV

Expiratory Valve
Inspiratory valve
Hyper and hypo VENTILATION

Cyanosis:
Defined as the presence of 5 g./dL of deoxygenated
hemoglobin (deoxy Hb).
i.e. Hb level = 15 g/dL, 5 g/dL release O2 which leaves 10 g/dL of
oxyhemoglobin
SaO2 = OxyHb / (OxyHb + DeoxyHb) = 10 / (10 + 5) = 66%
SaO2 of 66% corresponds to PaO2 of 35mmHg.

In anemic patients the oxygen tension at which cyanosis is


detectable will be even lower.
i.e. Hb level = 10 gm/dL, 5 gm/dL release O2
SaO2 = OxyHb / (oxyHb + DeoxyHb) = 5 / (5 + 5) = 50%
SaO2 of 50% corresponds to PaO2 of only 27 mmHg.

The oxyhemoglobin dissociation curve

It is a sigmoid curve that describes the relationship between


oxygen tension (PaO2) and binding (SpO2).
When PaO2 is low, the hemoglobin affinity to oxygen falls
rapidly , explaining the sharp sloping .(PaO2< 60 mmHg)

The oxyhemoglobin dissociation curve


A decrease in PaO2 of less than 60 mmHg (corresponding to SpO2
90 %) results in a rapid fall in the oxygenation saturation.
The lowest acceptable O2 saturation level is 90%.

Left And Right Shifts of the


Oxyhemoglobin Dissociation Curve
Right

Left

Decreased affinity of Hb for O2.

Increased affinity of Hb for O2.

Causes:
Inc. PCO2
Hyperthermia
Acidosis
Increased altitude
Increased 2,3-DPG
Sickle Cell Anemia
Inhalational anesthetics

Causes:
Dec. PCO2
Hypothermia
Alkalosis
Fetal hemoglobin
Decreased 2,3-DPG
Carboxyhemoglobin
Methemoglobin

The oxyhemoglobin dissociation curve


Key Values:
a. At PO2 100 mmHg, Hb 100% saturation.
b. At PO2 40 mmHg, Hb 75% saturation.
c. At PO2 27 mmHg, Hb 50% saturation.

Oxygen content of blood:


is the total amount of O2 carried in blood, including bound and
dissolved O2.
O2 content = (O2-binding capacity * % saturation) + O2 dissolved
O2-binding capacity = maximal amount of O2 bound to Hb at 100 % sat.

The dissolved O2 isnt measured by oximetry but by blood gas


analysis.

Monitoring Temperature
Objective

aid in maintaining appropriate body temperature

Application

readily available method to continuously monitor


temperature if changes are intended, anticipated or
suspected

Methods

thermostat
temperature sensitive chemical reactions

Monitoring Temperature
Potential heat loss or risk of hyperthermia
necessitates continuous temperature
monitoring
Normal heat loss during anesthesia averages
0.5 - 1 C per hour, but usually not more that 2 3C
Temperature below 34C may lead to
significant morbidity

Monitoring Temperature
Hypothermia develops when thermoregulation
fails to control balance of metabolic heat
production and environment heat loss
Normal response to heat loss is impaired
during anesthesia
Those at high risk are elderly, burn patients
neonates, spinal cord injuries

Monitoring Temperature

Hyperthermia Causes
Malignant hyperthermia
Endogenous pyroxenes (IL1)
Excessive environmental warming
Increases in metabolic rate secondary to:

Thyrotoxicosis
Pheochromocytoma

Monitoring Temperature
Monitoring Sites

Tympanic
Esophagus
Rectum
Nasopharynx

67

Normal values for a healthy adult undergoing


anesthesia
Systolic Blood Pressure
Diastolic Blood Pressure
Heart Rate
Respiratory Rate
Oxygen sat. by oximetry
End Tidal Carbon Dioxide tension
Skin appearance
Color
Temperature
Urine Production

SBP
DBP
HR
RR
SpO2
ETCO2

Central Venous Pressure


Pulmonary Artery Pressure
Pulmonary Capillary Wedge Pressure
Mixed venous oxygen saturation
Cardiac Output
Mean Arterial Pressure
*MAP = DBP + 1/3 ( SBP DBP )

CVP
PAP (mean)
PCWP
SvO2
CO
MAP

85 160
50 95
50 100
8 20
95 100
33 45
warm, dry
pink
36 37.5
>= 0.5

mmHg
mmHg
bpm
rpm
%
mmHg

1 10
10 20
5 15
75
4.5 6
80 120

mmHg
mmHg
mmHg
%
1.Min-1
mmHg

C
ml.kg-1.min-1

68

THANK
YOU
69

Clinical measurement
is limited by 4 major constraints:

1. Feasibility
2. Reliability
3. Interpretation

4. Value

4 mandatory steps in clinical measurement:


Detection

: sensing device ( biological signal : mechanical, electrical, electromagnetic


chemical or thermal energy)

Transduction : the output is converted into another form, usually to a


continuous electrical signal

Amplification and signal processing :


- extract and magnify the relevant features of the signal and reduce unwanted noise

Display and Storage : the output of the instrument is presented to the operator

Mechanical versus Digital instruments


Mechanical instruments ;
- use the natural signal energy to drive a display,with minimal intermediate
processing

Digital instruments
- non-electrical signals are converted by a transducer to an electrical signal suitable

for electronic processing by digital computers.


- higher accuracy and precision

Essential requiremets for CLINICAL MEASUREMENT


Accuracy is the difference between the measurements and the real biological
signal, or in practice, between a certain techique and a superior 'gold standard
technique.
Precision describes the reproducibility of repeated measurements of the same
biological signal.

calibration is important
( against predetermined signals or for absolute measurements to zero)

MECHANICAL SIGNALS:
MEASUREMENT OF ARTERIAL PRESSURE
a wide range of instruments are used to measure pressure :
liquid column manometers : height, zero point, fluid density

mechanical pressure gauges : aneroid manometer

diafragm gauges (coupled to transducers)

MEASUREMENT OF BLOOD FLOW:


CARDIAC OUTPUT

The Nexfin HD
A truly noninvasive CCO
monitor

Potential Methods To Measure Cardiac Output

Fick metdod
Indicator dilution
Pulse waveform ( pulse contour) methods
ULTRASOUNDS ( 2D-Echo and Doppler techique)
Bioimpedance

ANGIOGRAPHY
MRI

Ideal Cardiac Output Monitoring Technique

Precise and No bias


Non-invasive
Continous and instantaneous
Automatic
Operator independent
Cheap
Easy available in the ICU
Leads to treatment changes / improvement in outcome
IT DOES NOT EXIST !

Use the Best Compromise : feasibility precision patient !

The FICK principle


defines flow by the ratio of the uptake or clearance of a tracer within an organ to
the arterio-venous difference in concentration

CO = VO2 / [CaO2 CvO2])*100

VO2 per minute using a spirometer + Douglas bag


CvO2 is taken from the pulmonary artery
CaO2 a cannula in a peripheral artery

The FICK method


considered to be the most accurate method for CO

but : - invasive, time consuming

- accurate VO2 samples are difficult to acquire

discontinous CO : Deltatrac (Datex)

continous CO : possible, but no integrated system available


modified Fick equation : continous CO by NICO2 apparatus

INDICATOR DILUTION
Chemical indicator dilution (dye)

Thermal indicator dilution


( Thermodilution )
the widest used : PAC = Swan Ganz

INDICATOR DILUTION

CO measurement by indicator dilution has 3 phases :


(a) an indicator is brought into the circulation (injection)

(b) the indicator mixes with the bloodstream


(mixing and dilution)
(c) the concentration of the indicator is measured downstream
(detection).

Chemical indicator dilution


The Stewart-Hamilton formula (time-concentration curve)

using indocyanine green as indicator was the conventional indicator dilution


method used to measure CO in ICU until the 1970s.
Indocyanine green :

- nontoxic, inert, safe


- short half-life,
- not affected by arterial saturation

The Thermodilution (TD) method

Thermodilution = indicator is the change in blood temperature

An injectate of known volume and temperature is injected into the right


atrium and the cooled blood traverses a thermistor in a major vessel branch
downstream over a duration of time.

TD Methods :
1.

PULMONARY Thermodilution (P-TD)

1.

TRANSPULMONARY Thermodiution (TP-TD)

The CLINICAL STANDARD is the PAC !


Pulmonary -TD

PAC-Thermodilution

The change of the bloods temperature in is measured in the pulmonary artery


using the PAC thermistor
The thermistor records the temperature change and the monitor electronically
displays a temperature/time curve.
The CO is inversely proportional to :
- the temperature change
- the area under the curve
( PAC measures the Pulm.CO = Global CO if no intracardiac shunt )

Sources of measurement error for P-TD

Loss of indicator
Variation of injectate temperature and volume
Recirculation - IC shunts : false high CO values
Tricuspid regurgitation : false low CO values
Fluctuations in baseline temperature

...........................

10 ml.
cold
optimal < 4 sec.
> 4-5 sec. false low CO
! at least 3 measurements and less than < 10 % between them

Advantages of P-TD
The standard method for clinical CO measurement
Simple and Repeated measurements possible.
The modified PAC may provide CCO
-

thermal indicator : intermitent heating of a resistace


44C for 1-4 sec each 30-60 sec
Not really continous : mean of 3-4 min !
expensive

The PAC provides, in addition, PA pressures, PAOP, SvO2, and optionally,


RVEF and RVEDV.

PULMONARY Thermodilution

TRANSPULMONARY Thermodiution

The pulmonary artery TD curve appears earlier and has a higher peak temperature than
the femoral artery TD curve.

TP-TD is less invasive than P-TD, but does NOT give : SvO2 an PAP values !
,

The Clinical USE of TP-TD


Mainly : as a calibration method for other
systems : PiCCO, LiDCO-Pulse CO
PiCCO and LiDCO-Pulse CO are able after the initial calibration, to
measure in a continous manner
( beat by beat ) the C.O, using :

the Pulse Contour method

The Pulse Contour method

1. CALIBRATED techniques
PiCCO
LiDCO Pulse CO
2. NON-CALIBRATED techniques
Flow-Track VIGILEO
Nexfin

CCO by the pulse contour method


The area under the systolic part of the AP waveform correlates :
- directly with Left Ventricular STROKE VOLUME
- inversely with aortic impedance

SV

For calibrated techiques : the Aortic impedance is estimated from AP and CO premeasured values

( calibration : CO is ussualy measured by TP-TD)

PiCCO

Continous pulse contour analysis with intermittent TP-TD calibration.


Enables continuous hemodynamic monitoring using:
- femoral or axillary artery catheter
- central venous catheter

LiDCO Pulse CO
the independent calibration technique is : Lithium indicator Dilution

safe and minimally invasive : peripheral venous and arterial catheters


The PulseCO algorithm used by LiDCO is based on pulse power derivation.
Continuous, real-time cardiovascular monitoring

Pulse Contour NON-CALIBRATED techniques


Flow-Track VIGILEO
- only arterial line

NEXFIN
- totally non-invasive

BIOIMPEDANCE

bio tissues (bone, muscle,blood, etc) have different electric proprieties


blood is the most conductive tissue ( Na+ and Cl-)
pulsatile modification of ITBV TB

TB ~ stroke volume
SV = K x (dZ / dt) / Zo x TEV

TB is measured by : producing and transmiting electricity


( high = 70 kHz low A = 2,5 mA ) betwwen 2 pairs of electrodes

Echocardiography for measuring the CO


2 D method

Doppler - method

Ultrasounds (1.)
US techniques can detect : the shape, size and movement of tissue
interfaces, especially soft tissues and blood (RBC)

US are defined by :
- amplitude of oscillation (delta pressure : ambient to peak) dB
- the wavelength (distance between successive peaks)
- frequency (inversely proportional to wavelength, nr. of cycles / second )

human ear can detect frequencies : 20-20,000 Hz.


US have frequencies > 20,000 cycles /sec ( 20 KHz)
diagnostic US uses frequencies in the range of 1-10 MHz.

Ultrasounds (2.)
Transducers :
- generate and sense US
- are made from ceramic materials able to transform mechanical energy (pressure) to
electrical energy and vice versa ( the piezoelectric effect )
-

Transducers : generates ultrasound of the same frequency as the applied voltage

Shorter wavelengths and higher frequencies improve the resolution of distance,


but tissue penetration is simultaneously reduced.

Amplitude determines the intensity of the ultrasound beam and therefore the
sensitivity of the instrument.

2-D Method
Principle

Stroke volume= End diastolic volume End systolic volume


LV volumes estimated by Simpsons method, which is the summation of
the volume of stacked cylinders within the LV at end-diastole and endsystole

150 ml - 52 ml= 98 ml

Doppler Effect (1)


frequency of US waves reflected from a stationary object is the same as that
transmited
frequency of transmitted US is altered as it is reflected from a moving object

there is an increase in the observed frequency of a signal when


the signal source approaches the observer

e.g. ambulance siren

Doppler Effect - 3
Doppler effect represented by:
V=

_F . c _

2 F0 cos
Where

V = velocity of object
F = frequency shift
c = speed of sound in medium (body tissue here)
F0 = frequency of emitted sound
cos = angle between sound wave and flow (RBC)

cos 90 = 0 so the US beam should be parallel to RBC


Maximum angle = 20

Doppler Method
Principle

Flow (stroke volume)=Area x Velocity


CO=Stroke volume * Heart rate
Area of left ventricular outflow tract
Obtain LVOT dimension in parasternal long axis view

Flow Velocity at LVOT


Pulsed wave Doppler at LVOT in apical
5 chamber view

D=2.1 cm
Velocity time integral 25 cm
Simplified formula= (2.1cm)2 * 0.785

3.46cm

X 25cm = 87 cm3

OESOPHAGEAL DOPPLER
Measurement of blood flow velocity in the descending aorta at
the tip of the flexible probe

4 MHz continuous or 5 MHz pulsed wave

CO (cardiac output)
SV (stroke volume)
FTc (corrected f low time)
PV (peak velocity)
MD (minute distance)
HR (heart rate)

THANKS for your attention !