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Basic Hemodynamic

Monitoring

Dr. Husnul, M.Kes., Sp.An

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Objectives
• Review:
– Biological sensors and monitoring
– Pulse oximetry
– Automated blood pressure devices
– Arterial, central venous, and pulmonary
artery catheters
– Cardiac output and oxygen delivery variables

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Cardiovascular system

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Macro Circulation Monitoring
• Traditional Clinical Parameter
– Heart Rate
– Blood Pressure
– Urine Output
– Hemodynamic Measurement
• CVP
• PAWP
• RVEDVI

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Micro Circulation Monitoring
• Global Parameter
–Oxygen Delivery Index ( DO2I )
–Oxygen Consumption Index (Vo2I)
–Mixed Vein O2 Saturation ( SvO2 )
–Serum Lactate
–Base Deficit
–Arterio-Venous Carbon Dioxide
Gradient ( AVPCO2 )

• Organ Specific
– Gastric Chronometry
– Sublingual Capnometry
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Parameter Singkatan Rumus Rentang Normal
Indeks jantung CI CO/BSA ÷ 1000 2,5-4,3 L/menit/m2
Tekanan arteri rata-rata MAP 2(DBP) + SBP 3 70-105 mmHg
Tekanan arteri kanan RAP cm H2O = mmHg × 1,34 2-8 mmHg

Tekanan oklusi arteri pulmoner PAOP 8-12 mmHg


Diastolik arteri pulmoner PAD 10-15 mmHg
Resistensi vaskular pulmoner PVR PAM-PAOP × 80 CO 100-250 dynes/sec/cm-5

Index resistensi vaskular pulmoner PVRI PAM-PAOP × 80 CI 255-285 dynes/sec/m2-cm-5

Rerata arteri pulmoner PAM 15-20 mmHg


Resistensi vaskular sistemik SVR MAP-RAP × 80 CO 800-1200 dynes/sec/cm-5

Index resistensi vaskular sistemik SVRI MAP-RAP × 80 CI 1970-2390 dynes/sec/m2-cm-


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Index kerja sekuncup ventrikular kanan RVSWI (PAD-RAP) SV × 0,0138 BSA 7-12 g.m/m2

Index kerja sekuncup ventrikular kiri LVSWI (MAP-PAOP) SV × 0,0138 BSA 35-85 g.m/m2

Pengiriman oksigen DO2 CaO2 × CO × 10 900-1100 mL/menit


Index pengiriman oksigen DO2I CI × 1,38 × Hgb × Sao2 × 10 360-600 mL/menit/m2

Konsumsi oksigen VO2 C(a-v)O2 × CO ×10 200-250 mL/menit


Index konsumsi oksigen VO2I CI × 1,38(Sao2-Svo2) × (Hgb) 108-165 mL/menit/m2
(10)
Volume sekuncup SV SV = EDV = ESV CO/HR × 1000 50-100 mL/beat

Index volume sekuncup SVI SV/BSA CI/HR × 1000 35-60 mL/beat/m2


Volume diastolik- akhir ventrikular kanan RVEDV SV/EF 100-160 mL

Index volume diastolik- akhir ventrikular RVEDVI EDV/BSA 60-100 mL/m2


kanan
Volume sistolik- akhir ventrikular kanan RVESV EDV-SV 50-100 mL

Index volume sistolik- akhir ventrikular RVESVI ESV/BSA 30-60 mL/m2


kanan
Fraksi ejeksi ventrikular kanan RVEF SV/EDV EDV-ESV/EDV 40-60%

Saturasi vena campuran Svo2 60-75%


Rasio ekstraksi oksigen O2ER (Cao2-Cvo2)/ Cao2 × 100 22-30%
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Index ekstraksi oksigen O2EI Sao2-Svo2/Sao2 × 100 20-25%
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Monitored Variables

• Continuous vs. intermittent


• Invasive vs. noninvasive
• Never therapeutic, rarely diagnostic
• Pulse oxymetry, blood pressure, CVP, PA

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Pulse Oximetry

• Estimates oxyhemoglobin as
SpO2 – goal 92%–94%
• Heart rate displayed should be
same as pulse rate or ECG
heart rate

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Oxyhemoglobin Saturation Curve

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Oximeter Sensors

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Pulse Oximetry - Sources of Error

• Physiologic/anatomical
– Vasoconstriction/poor perfusion
– Abnormal hemoglobin
– Skin pigmentation
• External
– Motion of sensor
– Extraneous light
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Automated Blood Pressure
Devices
• Non-Invasive monitoring
• Intermittent measurements
• Appropriate cuff size necessary
• Less accurate during
hypotension, arrhythmias

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Arterial Cannulation
• Indications
– Multiple arterial blood samples
– Continuous blood pressure
( invasive arterial monitoring )
• Sites
• Complications
– Hematoma/blood loss
– Thrombosis/distal ischemia
– Arterial injury
– Infection
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Sites and sizes of artery cannulation

artery Diameter ( Gauge )

Dewasa Anak
Radialis 20 – 22 22 – 24
Femoralis 20 -18 20 -22
Axillary 20 -
Dorsalis Pedis 20 -22 22 – 24

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Central Venous Cannulation
• Indications
– Measure central venous pressure
– Access for resuscitation
– Selected drug administration
– Placement of pulmonary artery
catheter
• Complications
– Hematoma/vessel injury/blood loss
– Pneumothorax/hemothorax
– Cardiac arrhythmias
– Infection
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Pulmonary Artery Cannulation

• Indications
– Obtain specific hemodynamic data
• Pressure monitoring : RA,RV,PA,PAWP
• Flow monitoring : RV CO
• Oxygen saturation: mixed veins SvO2

• Complications
– Same as central venous cannulation
– Myocardial or pulmonary artery injury
– Catheter knots (rare)
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Pulmonary Artery Catheter Insertion

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Monitoring Components
• Proper catheter position
• Fluid-filled tubing and flush
connections to transducer
• Transduction of pressure
into electrical signal
• Signal processing and
display
• Leveling of transducer
• Appropriate calibration

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Determinants of Cardiac Output
afterload contractility

Cardiac
Output

preload heart rate

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Determinants of CO and their assessment
variable Method of assessment
Heart and Rhytm Finger on the pulse
Pulse oxymetry
ECG
Preload
Right Heart Neck Vein distension, Liver enlargement
CVP

Left Heart Apnea on exertion, orthopneu


Arterial BP
Pulmonary artery occlusion pressure
Arterial pressure waveform analysis

Afterload ( left heart ) Mean Arterial BP


Systemic vascular resistance

Contractility Ejection Fraction


Echocardiography
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Assessment Goals
• Determinants of cardiac output
– Preload – CVP, PAOP
– Afterload – SVR
– Heart rate
– Contractility – LVSW or ejection
fraction

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Heart rate assessment
• Normally 60-100 beats/min
• Bradycardia
– Parasympathetic stimulation
– Abnormality conduction
– Physiological bradycardia
• Tachycardia
– Heart compensated : hypovolemis, anemia,
fever, anxiety, pain etc
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Oxygen Assessment Goals

Evaluate if oxygen supply (DO2) or oxygen demand
(VO2) are abnormal or imbalanced
• O2 supply

– DO2 = CO  CaO2  10
where: CaO2 = (Hgb x 1.37 x SaO2) + (0.003  PaO2)

• –
• O2 consumption
– – –
– VO2= CO  (CaO2 - CvO2) x 10
where: CvO2 = (Hgb  1.37  SvO2) + (0.003  PvO2)
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Assessment Goals

• Balance of O2 supply (DO2) and O2 demand (V•O2)

• Determinations required
– Arterial and venous O2 content
• Hemoglobin
• Arterial/venous oxygen saturation
• Arterial/venous PO2
– Cardiac output
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Take home message
• Any monitoring devices requires familiar operation and
potensial complication
• Pulse oxymetry should applied to patient with unstable
physiology
• Automated BP less accurate in such clinical situations
like shock, MV and arrhytmia, and arterial cannula need
to establish
• Primary goal of hemodynamic support is oxygen for
cellular and need to analysis oxygen balance
• Risk-Benefit of Pulmonary arterial catheter need to be
considered
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Thank you

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