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Monitoring Hemodynamic

Suparto
Anesthesia Department FK UKRIDA

Objectives
Understands basic cardiopulmonary anatomy
and physiology
Determinates of cardiac output and their
relationships to each other
List indications for hemodynamic monitoring
Demonstrates monitor system and set up

Introduction
Hemodynamics, by definition, is 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.

Introduction
Monitoring is never therapeutic
It must be integrated with patient assessment
and clinical judgement to determine optimal
care.
The goals are to recognize physiologic
abnormalities and to guide interventions to
ensure adequate blood flow and oxygen
utilization for maintenance of cellular and
organ function

Cardiopulmonary anatomy
and physiology

Respiration
3 processes for adequate oxygenation and
acid-base balance
Ventilation: Gas distribution into and out of the
pulmonary airways
Pulmonary perfusion: blood flow from the right
side of the heart, through the pulmonary
circulation, and into the left side of the heart
Diffusion: Gas movement from an area of
greater to lesser concentration through a
semipermeable membrane

Cardiac
system
Carries life
sustaining O2 and
nutrients in the
blood to all cells of
the body
Removes metabolic
waste products in
the blood from the
cells

Mnemonic:
Some Believe In
Acting Badly Before
Performing
Sinoatrial node
Bachmanns bundle
Internodal pathways
Atrioventricular
node
Bundle of His
Bundle branches
Purkinje fibers

Cardiac
output

Heart Rate X Stroke Preload


Stretching of muscle
Volume
fibers in the ventricle .
Think of the heart as
Starlings law
a baloon
Contractility
Stroke volume
Ability of the
depends on:
Preload
Contractility
Afterload

myocardium to contract
Influenced by preload

Afterload
Normal CO: 4-8 L/min Pressure that the
ventricle muscles must
Normal Stroke
generate to overcome
Volume: 50-100
the higher pressure in
ml/beat
the aorta

Blood circulation
preload contractility - afterload

Systemic vascular
resistance
The resistance against
which the left ventricle
must pump to move
blood throughout
systemic circulation.
Normal SVR: 770
1,500 dynes/sec/cm-5
Affected by:
Tone and diameter
blood vessel
Viscosity of the blood
Resistance from the
inner lining of the blood
vessels

SVR include:

Hypothermia
Hypovolemia
Stress response
Syndrome of low CO

SVR include:
Anaphylactic and
neurogenic shock
Anemia
vasodilation

MAP- CVP X 80
CO

Effects of preload and afterload on the


heart
Factor
Increased preload
Possible cause
fluid volume
Vasoconstriction
Effects on heart
stroke volume
vent work
myocardial O2 req

Factor
Decreased preload
Possible cause
Hypovolemia
Vasodilation
Effects on heart
stroke volume
vent work
myocardial O2 req
(in compensatory
range)

Factor
Increased afterload
Possible cause
Hypovolemia
Vasoconstriction
Effects on heart
strokevolume
vent work
myocardial O2
req

Factor
Decreased afterload
Possible cause
Vasodilation
Effects on heart
stroke volume
vent work
myocardial O2 req

Therapeutic Interventions
AtropineLow

Heart Rate High


Blocker

Preload High Diuretics,


Venodilators
Vasopressors Low Afterload High
Fluids Low

Arterialdilator,
Inotropics inhibitors
Low

Contractility

ACE

Tujuan utama: Keselamatan pasien


Pemantauan adalah
Menginterpretasikan data yang ada
untuk membantu mengenali kelainan
atau kondisi sistem yang tidak
diharapkan, yang sedang atau akan
terjadi (D. John Doyle, MD. Cleveland Clinic Foundation)

Standar Perilaku untuk Pemantauan


Anestesia
1. Anestesiologis harus hadir dan menjaga
keselamatan pasien sepanjang prosedur
2. anestesia
Semua peralatan harus diperiksa
sebelum digunakan
3. Alat pantau harus terpasang sejak
sebelum induksi hingga pulih dari
4. anestesia
Selama prosedur, semua parameter
harus dievaluasi ulang
5. Standar ini berlaku untuk semua
tindakan anestesia (MAC, Sedasi,
Anestesia regional, Anestesia umum)

6. Data yang diperoleh dari alat pantau


harus terekam dalam rekaman medis
anestesia

Standard Monitoring
ASA standard: Oxygenation, ventilation,
circulation, and temperature
Standard for General Anesthesia:
ASA standard (Pulse Oximetry, Capnography,
minute ventilation, ECG, BP, temp if necessary
Standard for MAC and Regional Anesthesia:
Pulse Oximetry, RR, ECG, BP, temp if
necessary
Additional: Arterial line, CVP, NMBA monitor
Preparation before induction: Anesthesia
Mechine, ECG Monitor

Clinical Signs and Symptoms of Perfusion


Abnormalities
CNS: mental status changes, neurologic
deficits
CVS: Chest pain, Shortness of breath, ECG
abnormalities, wall motion abnormalities on
echo
Renal: UO, BUN, creatinine
Gastrointestinal: Abdominal pain, bowel
sounds, bleeding
Peripheral: cool limbs, poor capillary refill,
diminished pulses.

Cardiovascular system
O2 delivery
CO = SV x HR
ECG
Determine HR
Detect and diagnose
dysrhytmia
Myocardial ischemia
Electrolyte imbalance
(hipo/hyperkalemia)

Manual Blood
Pressure
BP = CO x SVR
Measures systolic dan
diastolic BP by
auscultation of
korotkoff sound,
palpation
Cuff width should
cover 2/3 of upper
arm or thigh
Palpation:
A. radial (80mmHg)
A. femoral (60mmHg)
A. Carotid (50mmHg)

Mean Arterial
Pressure
MAP = sis + 2 Dias/ 3
Normal: 60-70mmHg

Arterial BP indication
Tight BP control
Unstable patient
Arterial blood
sampling

CVP Monitoring
The theory is that as
fluid volume in
chamber increases, so
too will the pressures
measured in the
chamber.
This correlation is true
only in a limited
sense
The key to remember
is that pressure is
not equal to volume.

The pressure is
trended as an
indicator of volume
status, but must be
correlated to
physical assessment
findings and the
patients history to
come to an accurate
clinical impression.

CVP Monitoring
Help us to
Pressure at end
learn a patients cardiac
diastole reflects back
function,
to the catheter
evaluate venous return,
When connected to a
indirectly gauge how
transducer or
well the heart is
manometer, the
pumping,
catheter measures
access to fluid
CVP, a direct
administration,
reflection of right
atrial pressure and an
obtain blood samples.
indirect measure of
preload of the right
ventricle.

CVP Monitoring
Signs of excess preload
Signs of inadequate with adequate cardiac
preload include
function:
Poor skin turgor
Distended neck veins
Dry mucous
Crackles in the lungs
membranes,
Bounding pulses
Low urine output
With poor cardiac function:
Tachycardia
Crackles in the lungs,
Thirst
an S3 heart sound,
Weak pulses
Low urine output,
Flat neck veins.
Tachycardia,
Cold clammy skin with
weak pulses,
Edema.

CV and PA catheter
insertion

Sterile procedure
Insertion site:

Internal jugular vein


External jugular
vein
Subclavian vein
Femoral vein

Causes of Increased Normal values


pressure
Normal mean
Right sided heart
pressure ranges
failure
from 2-6 mmHg (3 Volume overload
8 cmH2O)
Tricuspid valve stenosis

or insufficiency
Constrictive pericarditis
Pulmonary
hypertension
Cardiac tamponade
Right ventricular
infarction

Causes of
decreased pressure
Reduced circulating
blood volume

Contraindication CVC insertion:


1.Tumor at RA
2.Tricuspid vegetation
3.Post carotid endarterectomy ipsilateral
4.Coagulopathy

Cm H2O : 1.36 =
mmHg

mmHg X 1.36 = cm H2O

Minimizing complications of CVP


monitoring
Infection
Sign & symptoms: Local rash, fever,
leukocytosis
Causes: lack of sterile technique,
immunosuppression
Interventions: Re-dress the site using sterile
technique, possibly use antibiotic ointment
loccaly, catheter may be removed then
culture its tip
Prevention: maintain sterile technique,
observe dressing-change protocols, change a
wet or soiled dressing immediately

Penumothorax, hemothorax
Sign & symptoms: decreased breath
sounds, abnormal chest X-ray
Causes: Repeated or long term use of same
vein, large blood vessel puncture
Interventions: set up and assist with chest
tube insertion, administer oxygen
Prevention: patients position during
insertion, immobilized patient, ultrasound
guided

Air embolism
Sign & symptoms: respiratory distress, loss
of consciousness, unequal breath sounds
Causes: intake of air into the CV system
during catheter insertion
Intervention: turn the patient on his left
side, head down, so that air can enter the
right atrium and maintain this position for
20-30 min, life support
Prevention: purge all air from the tubing
before hookup

Thrombosis
Sign & symptoms: ipsilateral swelling of arm, neck
and face, pain along vein, dyspnea, cyanosis
Causes: Sluggish flow rate, hypercoagulable state
of patient
Interventions: possibly remove the catheter, apply
warm, wet compresses locally, dont use the limb
on the affected side for venipuncture or blood
measurement, life support
Prevention: Maintain a steady flow rate with the
infusion pump, or flush the catheter at regular
intervals

Removal of Central Venous Catheter


Obtain clean gloves and sterile gloves, sterile
gauze squares, and materials for a dressing
Place the patient flat to minimize the risk of
air aspiration
Remove the dressing carefully and cleanse
the site with sterile saline if needed. If sutures
are in place, remove them carefully.

Instruct the patient to take a deep breath and hold it.


If the patient is unable to perform a breath hold, time
the removal of the catheter to coincide with a period
of positive intrathoracic pressure (In spontaneously
this will occur during exhalation. In mechanically
ventilated positive intrathoracic pressure occurs when
the ventilator delivers a breath)
While the patient holds his/her breath, remove the
catheter smoothly. Once the catheter has been
removed, apply moderate pressure with sterile gauze
and tell the patient to resume breathing.
After a minute or two, gently release the pressure.
If there is no bleeding or swelling, apply a sterile
dressing to the site

PA catheter insertion
Swan-Ganz
catheter
PAP and PAWP
provide information
about LV function

Pulmonary Artery Pressure (PA


Pressure): Blood pressure in the
pulmonary artery. Increased
pulmonary artery pressure may
indicate:
a left-to-right cardiac shunt,
pulmonary artery hypertension,
COPD or emphysema,
pulmonary embolus, pulmonary edema
left ventricular failure.

Mengetahui fungsi jantung kiri


Mengetahui adanya hipertensi pulmonal
Mengukur cardiac ouput, systemic
vascular resistance (SVR), pulmonary
vascular resistance (PVR), pulmonary
capillary wedge pressure (PCWP, PAOP)
Normal PAP systolic15-30 mmHg and
diastolic 5-12 mmHg. PAOP 5-12 mmHg

Pulmonary Capillary Wedge


Pressure (PCWP or PAWP): PCWP
pressures are used to approximate
LVEDP (left ventricular end diastolic
pressure). Reflecting left arterial
pressure and left ventricular preload
High PCWP may indicate left ventricle
failure, increase in end diastolic volume,
decrease compliance, mitral valve
pathology, cardiac insufficiency, cardiac
compression post hemorrhage.
Low PCWP can be due to decrease end
diastolic volume, increase in compliance

Respiratory System
Pulse Oxymetri
Normal: 96%-99%
88% acceptable for
patient with lung
disease

High pulse ox
indicates:
O2 available in the lung,
taken up in the blood,
delivered to distal
tissues.

Low pulse ox
Problem along the above
pathway or due to error

Capnography
Ventilation
Assessment
Confirmation
endotracheal
intubation
Normal: PetCO2 is
2-5mmHg lower
than arterial PCO2,
so typical range 3040 mmHg under
General anesthesia

Suhu tubuh
normal 365-375 C
Suhu nasofaringeal mendekati suhu inti
Peningkatan menandakan meningkatnya
metabolisme sel
Suhu produksi CO2

Produksi Urine
Dewasa: 0.5-1cc/Kg/jam
Pediatrik: 1-2cc/Kg/jam

Pemantauan sistem
saraf
Bispectral Index, utk
mengetahui
kedalaman anesthesia
dari mendeteksi dan
rekaman gelombang
elektroensefalogram
(EEG)
Tingkat anestesi nilainya
40-60 (100 artinya
sadar penuh)

Train of Four
Mengukur tingkat
blokade oleh
pelumpuh otot
memberikan 4
stimulus
berturutan
dengan
frekwensi 2 Hz
selama 2 detik