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Hemodynamic Monitoring

BP & CVP

J Kayle Lee MD
11.19.2009
Objectives
arterial pressure monitoring
noninvasive methods
invasive arterial monitoring
arterial waveform interpretation

central venous pressure monitoring


contributing factors
CVP waveform & examples
Palpation Method
traditionally
radial >80 mmHg
femoral >70 mmHg
carotid >60 mmHg

combine palpation with sphygmomanometer


deflate cuff and note when radial pulse returns
actual SBP is >10mmHg greater
Arterial Pressure Monitoring
sphygmomanometry
manual cuff listen for Korotkoff sounds
mercury (gold standard)
aneroid
oscillometry
detect oscillations when flow is present
digital pressure transducer
measure mean pressure
derives systolic & diastolic
Noninvasive Arterial Monitoring
tonometry arterial compression
pressure transducer waveform
dopplers/ultrasound
measures systolic
operator dependant
impedance plethysmography
electrical impedance changes
reflect volume changes
Continuous Noninvasive Arterial
Pressure Monitors
based on photoplethysmography
light diode
volume differences during cardiac cycle
occlusion pressure
Finapres , CNAP, Nexfin HD, etc
limited application
inaccuracy w hypovolemia
& vascular insufficiency
Inaccuracy of NIBP monitoring
inappropriate size cuff
obesity
arrhythmias
vasculitis/calcification
vascular insufficiency
vasoconstriction
Invasive Arterial Pressure Monitoring
indications
NIBP is not an option
continuous, dynamic, accurate BP monitoring
blood draw access
pulse waveform analysis
ABGs
Arterial Lines
placed retrograde position
by direct cannulization or with a guidewire

radial, femoral, brachial, DP, or axillary artery


check for collateral flow

pressure transducer
zeroed at level of aortic root
continuous infusion of saline +/- heparin
Sites

AANA Journal/August 2004/Vol. 72, No. 4


Complications
bleeding, hematoma
thrombosis, dissection
pseudoaneurysm, AV fistula
ischemia, necrosis
retrograde flow, embolism, stroke
neuropathy, nerve injury
infection
Radial Site Complications
Reference Cases Permanent ischaemic Temporary occlusion (n) Sepsis (n) Local infection (n) Pseudoaneurysm (n) Haematoma (n) Bleeding (n)
damage (n)

[9]* 80 1 9 0 0 - - -
[9]* 34 1 10 0 2 - - -
[10] 100 0 35 - - - - -
[11] 148 0 27 - - - - -
[12] 29 0 5 - - - - -
[13] 62 0 16 0 0 - - -
[14] 333 0 100 0 16 - 29 -
[15] 40 0 2 - - - - -
[16] 100 2 14 0 1 - 31 -
[17] 197 0 3 3 4 2 - 1
[18] 178 0 7 1 3 - - 1
[5] 1699 0 360 0 1 - 206 -
[19] 26 0 6 0 1 1 1 -
[20] 100 0 14 - - - - -
[21] 100 0 33 0 1 - 13 -
[22] 118 0 18 0 0 - 21 -
[23] 200 0 15 - - - 61 -
[24] 25 0 3 0 0 - - -
[25] 200 0 60 0 0 - 32 -
[26] 193 0 50 0 4 - - -
[27] 88 0 15 - - - - -
[28] 2900 - - 4 12 5 - -
[29] 38 0 3 - - - 5 -
[30]* 45 0 4 - - - 10 -
[30]* 44 0 11 - - - 9 -
[31] 12,500 - - - - 6 - -
[32] 40 0 11 - - - - -

Mean incidence (%) 0.09 (4/4217) 19.7 (831/4217) 0.13 (8/6245) 0.72 (45/6245) 0.09 (14/15,623) 14.40 (418/2903) 0.53 (2/375)
Femoral Site Complications
Permanent
Temporary Pseudoaneurysm
Reference Cases ischaemic damage Sepsis (n) Local infection (n) Haematoma (n) Bleeding (n)
occlusion (n) (n)
(n)

[49] 46 - - 0 - - - -

[50] 50 0 1 0 - - 5 -

[51] 85 0 0 0 - - 10 -

[17] 113 0 0 0 0 - - 4

[52] 89 - - 0 0 - - 1

[53] 2100 - - 6 - 6 - -

[18] 114 0 4 2 0 - - 0

[54] 42 0 1 0 1 - 3 -

[55] 220 0 1 4 4 - 8 -

[19] 64 0 3 1 0 - 2 -

[56] 976 3 - - - - - -

Mean incidence (%) 0.18 (3/1664) 1.45 (10/688) 0.44 (13/2923) 0.78 (5/642) 0.3 (6/2100) 6.1 (28/461)
1.58 (5/316)
Arterial Waveform Analysis
a systolic upstroke
contractility
b area under the curve
stroke volume
c systole
myocardial O2 consumption
c/d jn dicrotic notch
closure of AV
d diastole
myocardial O2 supply
Peripheral Artery Waveform
dicrotic notch is less pronounced peripherally
radial SBP is ~20mmHG higher than aorta
MAP is nearly equal

positive pressure ventilation


>10% variability in SBP/PP
-> poss hypovolemia
Dynamic Response
resonant frequency
high enough to avoid ringing & amplification
damping coefficient
underdamped low compliance
stiff, short, narrow tubing
systolic reads higher, diastolic lower
overdamped high compliance
clot, air, kink, large/long tubing
systolic lower, diastolic higher
Snap Test
rapid flush test
flush oscillations baseline

catheter whip
esp w femoral artery
MAP should be reliable
Central Venous Pressure
estimate with JVP
5 + ht above angle of Louis
measure with CVC, PICC, or PAC
tubing, manometer, or digital transducer
phlebostatic axis
MAL & ICS 4

ideally with a CVC at SVC/RA jn


Central Venous Pressure
normal CVP 2-6 mmHg
right sided heart function RA, TV, RV, etc
vascular tone, regional compliance
fluid status
central venous blood volume
venous return
intrathoracic pressure
CVP Waveform
a wave atrial contraction
z point CVP, TV open, RVEDV
c wave TV closure and bulging into RA from RV contraction
x descent RA relaxation
v wave RA filling
y descent TV opens
Clinical Example
a wave - atrial contraction
large with resistance to RV filling
pHTN, TS, dec RV compliance
canon a wave closed TV
AV dissociation, ventricular pacing
absent in Afib
c wave more prominent
Clinical Example

c wave TV closure & bulging in RV from systole


after QRS
v wave RA filling

large waves with TR


augmented RA blood during systole
sometimes fused
Respiratory Variation
ideal measurement at end expiration
pleural & pericardial pressures are closest to atmospheric
spontaneous respiration
inspiration dec CVP
mechanical ventilation
inspiration inc CVP
PEEP inc CVP