Hemodynamic Monitoring

1
Hemodynamic Monitoring

• D. Matamis M.D
• Papageorgiou Hospital Thessaloniki Greece.

2
Shock or Hypotension may be due to

• Decrease in cardiac output
• Decrease in preload (hypovolemia - Hemorrhage)
• Decrease in contractility (myocardial ischemia)
• Decrease of the inflow and outflow of blood
• into the cardiac chambers (obstructive
  shock)
• Pulmonary embolism
• HOCM
• Valvular stenosis
• Decrease in peripheral resistances
• Distributive shock (sepsis, allergic reactions)

3
Hemodynamic Evaluation

• Non invasive methods (50)
• ??????? eµpe???a, F?s??? e?etas?, ECG, Rx
  T??a???
• Invasive methods (50)
• ???f??t??, ?etaf??t??, S?sta?t???t?ta t??
  µ???a?d???, ??ast????? ?e?t?????a, ?a?d?a?? ?a????

4
Invasive methods

• PAC
  ECHO
• Preload Y
  Y
• Cardiac Output Y
  ?o
• Afterload Y
  ?o
• Systolic Function ?
  Y
• Diastolic Function No
  Y
• Oxygen Delivery Y
  No
• Oxygen Consumption Y
  No
• Heart-Lung Interactions Y
  Y
• Intrapulmonary Shunt Y
  No

5
The PAC controversy

• The effectiveness of right heart catheterisation
  in the initial care of critically
• ill patients.
• Connors AF, Speroff T, Dawson NV, et al.
  JAMA 1996. 276889-897.
• 5735 critically ill patients (2184 with PAC) in
  15 ICUs
• 1008 pairs of patients matched for disease
  category
• No benefit
• Increased mortality (37.5 vs 33.8 without
  PAC)
• Greater hospital costs (49,300 vs 35,700
  without PAC)
• Longer ICU and hospital stay
• Therapy related mortality - more aggressive level
  of care.

6
The PAC controversy

• A randomized controlled trial of the use of
  pulmonary-artery
• catheters in high-risk surgical patients.
• Sandhham JD et al. N.Engl J Med.20033485-14
• From 1990-1999, surgical patients gt 60 years old,
  ASA class risk III-IV. 997
• patients in each group.
• No benefit
• No difference in mortality or hospital stay.
• Higher rate of pulmonary embolism in the catheter
  group(8 vs 0)

7
The PAC controversy

• A multicenter study of physicians knowledge of
  the
• Pulmonary Artery Catheter
• Iberti TJ, Fischer EP, Leibowitz AB, et al.
  JAMA 1990 264, 2928-32.
• 31 Q.M.C to 496 I.C.U Physicians practicing in
  the US and Canada.
• To quantify the knowledge and ability to
  interpret derived PAC data.
• Results.
• Mean score 20.7(67), range 6-31(19-100)
• Independent of training
• Frequency of use
• Frequency of insertion
• Restrict the use of PAC to individuals with
  documented competency.

8
The PAC controversy

• Intensive care physicians insufficient
  knowledge of right
• heart catheterization at the bedside Time to
  act?
• Gnaegi A, Feihl F, Perret C. Crit. Care Med.
  199725,213-220.
• 31 Q.M.C to 535 I.C.U physicians practicing in
  86 European I.C.Us.
• To quantify the knowledge and ability to
  interpret derived PAC data.
• Results.
• Mean score 72.214.4
• 67.314.7 in training, 76.113 postgraduate
• 50 of the responders did not identify PAOP from
  a clear chart recording
• Positive(loose correlation) with frequency of
  insertion and use.
• Accreditation policies and teaching practicies
  concerning this technique need urgent revision.

9
PAC

• Pulmonary Artery Catheter.
• Does the problem lie in the users?
• Squara P, Bennett D, Perret C. Chest 2002
  121.2009-2015.
• More than 25 years after the introduction of PAC
  and
• despite thousands of scientific publications, our
  data
• showed unacceptable variability in treatments and
  an
• alarmingly high rate of potentially harmful
  treatment
• decisions in participants to three international
  meetings
• in Intensive Care Medicine

10
Comparative studies PAC-ECHO

• ECHO vs PAC
• Evaluation of TEE as diagnostic and therapeutic
  aid in a critical care setting.
• Poelaert JI. Trouerbach J, et al. CHEST
  1995.107 774-779.
• TEE in 103 patients (66 with PAC, 37 without)
• offered useful information in 74 of the
  patients.
• altered the initial therapy in 44 with
  PAC.
• altered the initial therapy in 54 with
  PAC Sepsis
• altered the initial therapy in 41
  without PAC.

11
Comparative studies PAC-ECHO

• Value of 2-D ECHO for Determining the Basis of
  Hemodynamic Compromise in Critically Ill
  Patients. A Prospective Study.
• Sanjiv K, Alexander et al. J. AM. SOC.
  ECHOCARDIOGR. 1994,7 598-606
• TEE in 49 patients with PAC
• Agreement between the two methods in 86 of
  cases.
• TEE in the ICU Setting Luxury or Necessity?
• D. Lagonidis, D. Matamis et al. B.J.A 1997.
  suppl. A46.
• 64 patients. Change in therapy in 23 / 60
  patients (38)

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What can be assessed with ECHO

• Preload
• Systolic function
• Diastolic function
• Heart Valves function
• Pericardial structure-Great vessels

13
Preload Evaluation

• PAC - PCWP (Pressure)
• PCWP LVED Pressure LVED Volume
• Tachycardia, MV disease, LV Compliance
• Lung Hyperinflation(High PEEP,auto PEEP)
• ECHO - LA, LV Volume
• Hypovolemia OK (End systolic collapse)
• Hypervolemia ?
• ECHO gt PAC

14
Preload Evaluation

• 64 year old woman with
• History of CAD, Diabetes mellitus, Resp. Pb for
  10 yrs
• Hypercapnic ARF, CXRay bilateral infiltrates,
• HR135, MAP65mmHg, Temperature 39.5.
• Treatment 40 mg Furosemide, Dobutamine
  5mcg/kg/min
• I.C.U Shock, Intubation, MV, auto PEEP 12 cm
  H2O.
• PAC Findings
• HR 130, MAP 60 mmHg, PAP 55/25, PAOP 20mmHg
  , 16mmHg end expiration, C.O 6.5lit/min,
  (a-v)DO2 5.8
• 1. You are happy with the hemodynamic status of
  the patient
• 2. You will increase the dose of Dobutamine to
  increase C.O.
• 3. You will add Nitroglycerine to decrease PAOP
• 4. You will ask for an ECHO study

15
Preload Evaluation
16
Preload Evaluation

• In the post operative period a 42 year old woman
  with
• Pulmonary Oedema (clinically, XRay)
• Heart Rate 140 beats/min, MAP 85mmHg,
  ECGST depres.
• Intubation, M.V, PEEP 8cmH2O, FiO260
• PAC findings
• Heart rate140beats/min, SAP85mmHg, PAOP
  34mmHg C.O 3.5
• lit/min
• Treatment
• Dobutamine 8mcg/kg/min, Nitroglycerine
  1mcg/kg/min
• After treatment
• HR 145 b/min, PAOP 30mmHg, C.O 2.5 l/min
• ECHO to assess LV function and Preload.

17
Preload Evaluation
18
Preload evaluation with ECHO

• Non invasive evaluation of pulmonary capillary
  wedge pressure in
• patients with acute myocardial infarction by
  deceleration time of pulmnary
• venous flow velocity in diastole
• Yamamuro A,Yosida K, Hozumi T. JACC 199934.90-94
• A DTd of lt160 ms had 97 sensitivity and 96
  specificity for a
• PCWP of gt18 mmHg
• The deceleration time of pulmonary venous
  diastolic flow is more
• accurate than the pulmonary artery occlusion
  pressure in predicting left
• atrial pressure
• Kinnaid TD, Thomson CR, Munt BI. JACC 200137.
  2025-2030
• A DTd of lt175 ms had 100 sensitivity and 94
  specificity for a PLA of gt17 mmH

19
Preload evaluation with PVF (DTd)
20
Cardiac Output monitoring

• Ideal CO continuous Monitoring
• Minimally invasive, easy to apply Widely
  applicable
• Accurate
• Real time beat - to - beat CO
• Nurse driven
• Easy data interpretation
• Bedside management
• Neonates to adults
• Early warning of deterioration
• Evidence of improved outcome
• Optimum fluid management/drug administration
• Reduced workload of health care staff
• Decreased procedural complications (e.g. bolus
  injections)

21
CO Techniques (non or less invasive)

• Based on
• Echocardiography (TT TEE)
• Esophageal Doppler
• Fick principle CO2 rebreathing
• Pulse contour analysis

22
Doppler Echocardiography(1)Principles for CO
assessment

• Assumptions for accurate measurement
• No rhythm disturbances
• Accurate cross-sectional area measurement!!!
• Laminar flow
• Flat velocity profile
• Parallel angle beam/flow (20o)
• Velocity diameter at the same site
• LVOT or AVA
• (IF No Aortic valvulopathy or HOCM)

23
Esophageal Doppler (EDM)Principles
assumptions for CO monitoring

• Blood flow velocity of the descending aorta (PW
  or CW Doppler)
• Sedated, mech. ventilated pts
• Flexible probe Insertion rotation ?
  Characteristic, clear signal, highest possible
  peak velocity
• Flat velocity profile (same speed of RBC)
• Cross sectional area Constant during systole
  (nomogram or direct measurement)
• Fixed distribution of blood flow Aortic arch?
  30, Descending Aorta ? 70

24
Esophageal Doppler (EDM)Final notes critical
appraisal

• Safe, easy to learn set up apply (even
  nurse driven), reproducible results.
• Real beat to beat CO monitoring in sedated
  mech. ventilated pts
• Monitoring but not diagnostic tool
• Excellent validity concerning the changes of CO
  (vs. PAC)
• Probe displacement usual source of errors
• EDM guided fluid titration in high risk
  surgical pts Evidence for improved outcome (LOS,
  complications post- op)

25
Pulse contour Cardiac Output (PCCO)Principles,
equipment, advantages

• Arterial waveform interaction SV/mechanics of
  arterial tree
• PCCO methods estimation of SV by pressure
  waveform
• PiCCO, PulseCO Waveform analysis (various
  arterial models) indicator dilution technique
  for calibration
• FloTrac, Vigileo Waveform analysis, no need for
  calibration
• Minimally invasive, continuous, real time CO

26
Pulse contour Cardiac Output (PCCO)Flaws
Limitations

• Aortic Valve disease
• Arrhythmias
• Quality of the arterial waveform
• Frequent rapid changes in arterial compliance
• Need for frequent calibrations - every 4h or
  before important acquisitions
• Minimally invasive???

27
Cardiac Output Evaluation

• The absolute value of C.O. is meaningless.(Hypo,
  Hyperthermia, Drugs)
• ICU patients
• Frequent modifications of Mechanical Ventilation
  and PEEP, TR, Sedation,
• General Anesthesia, Surgery, Variations of body
  temperature in the O.R.,
• Substantial blood losses.
• SvO2, ScvO2, (a-v)DO2, DO2, VO2.
• Adequacy of C.O and oxygen transport, quality of
  tissue oxygenation.

28
Contractility Evaluation

• Regional (Myocardial ischemia)
• Correlative study (100 patients) comparing
  PAC, ECG (12 lead), TEE
• M. van Daele et al. Circulation.1990.
• TEE gold standard in detecting RWMA
• ECG Sensitivity 69 Specificity 99
• PAC Sensitivity 25 Specificity 96
• Global
• PAC Ventricular Work PCWP (Ventricular
  Compliance)
• TEE By Eye, Ejection Fraction, Fract.
  Shortening.

29
Contractility Evaluation (global systolic
function) with PAC

• 17 y/o male admitted to the ICU with the
  diagnosis of ARDS due to bilateral
• pneumonia, fever 39 C for a week.
• Upon admission, Bilateral Infiltrates in the
  CXRay, Temp 39.4
• WBC 12000, 85Neutrophils, HR120 b/min, ECGNL,
  MAP110/55
• under 1.2 mcg/kg/min of Noradrenaline.
• Acute Renal Failure due to Rabdomyolysis(CPK35000
  ).
• PAC findings
• C.O. 10 lit/min, PAOP 18mmHg, (a-v)DO2 4.8ml
• 1. Do you consider the systolic function
  normal?
• 2. Do you consider the systolic function
  abnormal?
• 3. You will ask for an ECHO study to assess
  LV systolic function

30
Contractility Evaluation (global systolic
function) with PAC
31
Contractility Evaluation (global systolic
function) with PAC

• -Sepsis
• -Myocarditis
• -Dialated Cardiomyopathy

32
Contractility Evaluation (regional systolic
function) with PAC

• Regional systolic function
• M. Van Daele et al. Circulation 1990
• ECHO, ECG 12 leads, PAC
• ECHO Gold standard
• Sensitivity. Specificity.
• ECG 69 99
• PAC 25 96

33
TEE transversal axis (T)

34
Diastolic dysfunction
35
Diastolic dysfunction

36
Decrease of the inflow and outflow of blood
into the cardiac chambers

• Pulmonary Embolism
• Tamponade
• Valvular stenosis
• Tumors
• HOCM

37
??e??e?t?µata t?? ?pe?????a?d????af?a? st?? ??e?a
??e?µ????? ?µß???

• ??a?s??s?a 80
• ??e?d??e?s? 92-100
• ??e?a-?p??e?a ?.E
• ?a????-?p?µa???? ?.E
• ?a??d???s? t?? Te?ape?a?
• ??tap????s? st? Te?ape?a
• ?a?µ???µ?s? t?? ???d????

Wood K. CHEST 2002121877
38
?µesa e???µata

39
?µµesa ????µata

• ??atas? RV/RA
• S?es? RV/LV
• ?etat?p?s? t?? ???
• ??epa??e?a ???????????
• ?a??t?ta ???? t?? a?epa?????t?? jet t??
  t????????a? lt 3m/sec

40
Case history

• A 73 year-old lady admitted to the hospital for
  surgical repair of hip fracture.
• Preoperative assessment revealed exertional
  dyspnea attributed to
• moderate obesity and reduced physical activity
• Chest X-Ray moderate cardiomegaly
• ECG showed atypical ST segment and T wave
  abnormalities.
• In the immediate post- operative period while
  recovering from regional
• anaesthesia she developed pulmonary oedema and
  acute respiratory
• failure.
• She was intubated and mechanically ventilated and
  a PAC was inserted for
• hemodynamic management.

41

• PAC data
• C.I 1,9 lit/min/m2, PAP55/30-42 mmHg, PAOP28
  mmHg.
• HR 125 b/min, ABP120/90 mmHg
• Initial treatment consisted of diuretics
  (intra-operative fluid
• balance was 1.5 lit positive), dobutamine, and
  nitroglycerine,
• considering that this lady was suffering from
  congestive heart failure
• Despite the above treatment, leading to a
  negative fluid balance of 2,5 lit,
• the patient did not improve
  
• I.C.U

42

• ICU PAC data under
• sedation (Remifentanyl Propofol)
• Dobutamine8 mcg/kg/min, Nitroglycerine 1
  mcg/kg/min
• Furosemide 20 mg/hr
• ABP 110/85 mmHg, HR 135 beats /min
• C.I 1.8 lit/min/m2, PAP 60/35-45 mmHg, PAOP
  30 mmHg
• Suggestions for therapy changes?

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(No Transcript)
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Hypertrophic Cardiomyopathies (HCM)

• Prevalence 0,2, 1/500
• Inherited autosomal dominant trait
• Primary sarcomere disorder
• LVH and Clinical symptoms during any phase of
  life
• Elderly patients gt 75 years compose as much as
  25.
• Clinical course
• Sudden death
• Congestive heart failure

45
Hypertrophic Cardiomyopathies (HCM)

• Non Obstructive (75)

46
Hypertrophic Cardiomyopathies (HCM)

• Obstructive (25)
• Ejection
• Eject
• Venturi effect - SAM
• Obstruct
• Abnormal MV closure
• Leak
• MR

47
Tumors
48
Tamponade

• P.A.C
• Little diagnostic specificity
• Equalization of pressures
• CVP PCWP

• ECHO
• unique tool to
• Diagnose
• Guide the therapy
• Quantity (loculated)
• Quality clear fluid,
• Thrombi.

49
Tamponade

50
Conclusion

• PAC invasive technique but necessary for
  selected patients (need for SvO2)
• Echocardiography (TT TEE) non invasive non
  expensive in every day practice but special
  training is necessary
• Esophageal Doppler non invasive , training is
  necessary, in the OR
• Pulse contour analysis non invasive no special
  training in every day