 Hemodynamics is an important part of

cardiovascular physiology dealing with the

forces the heart as the pump must develop to
circulate blood through the CVS

 It is the study of the movements of the blood

and the forces concerned therein (dynamics
of the blood circulation)
Non-invasive Monitoring (signs of
hypoperfusion)
Look, Listen, and Feel
1. Primary signs (skin and GIT)
◦ Cold, clammy skin
◦ Pale, cyanotic skin
◦ Dec. bowel sounds
◦ Diarrhea/Constipation
◦ Inc. NG output
Non-invasive Monitoring (signs of
hypoperfusion)
Look, Listen, and Feel
2. Secondary signs (Kidney, liver, and lungs)
◦ Inc. RR/Effort
◦ SOB
◦ Dec. arterial O2 pressure and saturation
◦ Dec. Urine output
◦ Inc. BUN/Cr/K+
◦ Inc. AST/ALT
Non-invasive Monitoring (signs of
hypoperfusion)
Look, Listen, and Feel
3. Final signs (Brain and Heart)
◦ Dec level of conscious
◦ Disorientation
◦ Slow pupils
◦ Chest pain/chest pressure
◦ HR changes/arrhythmias
◦ ST-elevation.
▪ Arterial Blood Pressure (ABP) and Mean
arterial blood pressure (MAP)
▪ Body size
▪ Central Venous Pressure
▪ Pulmonary Artery Wedge Pressure
▪ Cardiac Index
▪ Stroke Index
▪ Systemic Vascular Resistance Index
▪ Pulmonary Vascular Resistance Index
Arterial Blood Pressure (ABP)
 The force exerted by the blood on the vessel
wall.
 Systolic blood pressure
 Diastolic blood pressure

 Mean arterial blood pressure

 Mean arterial blood pressure (MAP)
 The Mean Arterial Pressure refers to the
average pressure of the blood circulating
through a person’s arteries, during the
cardiac cycle
 MAP is the driving pressure for peripheral
blood flow (and end-organ perfusion).
Sufficient arterial pressure allows
redistribution of cardiac output (CO) to vital
organs.
 Mean arterial blood pressure (MAP)
 MAP is often derived from the systolic and
diastolic blood pressures (SBP and DBP) as
follows:

MAP = SBP + 2 DBP

3
 Mean arterial blood pressure (MAP)
 MAP = CO X SVR
A. CO: (ml of blood pumped per minute) consists
of stroke volume (SV) (ml of blood ejected from
the left ventricle per beat) and heart rate (HR)
CO = SV X HR
B. SV: is determined by:
 preload (amount of blood available to eject)
 afterload (resistance to ejection), and
 contractility (amount of force generated by the
heart)
 SVR (also termed total peripheral resistance) is the
resistance to flow that must be overcome by the left
ventricle.
 SVR is the major determinant of LV afterload.
 Systemic vasoconstriction increases SVR, whereas
vasodilation decreases SVR.
 Skin temperature may be used as an approximation
(surrogate) of SVR,
• Warm skin temperature suggests decreased SVR
(vasodilation)
• Cold skin temperature suggests increased SVR
(vasoconstriction).
 Conditions that may lower blood pressure
through diminished CO in critically ill patients
include cardiac failure (myocardial infarction,
arrhythmia, acute heart failure, or valvular
disease) and hypovolemia (hemorrhage,
intractable diarrhea, or heat stroke)
 Vasodilatory conditions such as sepsis,
anaphylaxis, pancreatitis, acute hepatic
failure, or neurotrauma, lower blood pressure
by reducing SVR
 Mean arterial blood pressure (MAP)
 The target blood pressure for a patient in
shock is usually a MAP greater than 65 mm
Hg or an SBP greater than 90 mm Hg, but this
must be individualized according to other
clinical/biochemical markers of perfusion.

 MAP alone is an insensitive resuscitation parameter

(e.g., blood pressure may be at goal when CO is
inadequate),
Noninvasive methods
 All noninvasive blood pressure monitoring techniques
depend on the use of an occluding cuff
 The use of narrow cuffs or cuffs applied too loosely can
result in falsely high readings, whereas wide cuffs may
produce falsely low readings
Invasive ABP
measurement (Arterial
line)
 Intraarterial pressure
is typically measured
from the radial,
brachial, axillary, or
femoral arteries
 By arterial cannulation
technique
 Real time monitoring
 The MAP is measured electronically as the
area under the arterial pressure wave, divided
by the duration of the cardiac cycle
 Invasive ABP measurement
 AUC also indicates SV (by integration)
 Blood pressure is the driving force behind
oxygen delivery
 Every organ is able to autoregulate blood
flow, but this ability is generally lost at MAP
values lower than 65 mm Hg
 Therefore, a goal MAP of 65 mm Hg is often
targeted for shock to maintain perfusion
 The numeric difference between your systolic
and diastolic blood pressure is called your
pulse pressure.

 The most important cause of elevated pulse

pressure is stiffness of the aorta.

 Decreased pulse pressure can occurs in

cardiac tamponade
 Hemodynamic parameters are often
expressed in relation to body size
 The popular measure of body size for
hemodynamic measurements is the body
surface area (BSA)
 Parameters that are adjusted for body surface
area are identified by the term “index”
Why not use body weight to adjust for body size? BSA was chosen for
hemodynamic measurements because cardiac output is linked to
metabolic rate, and the basal metabolic rate is expressed in terms of
body surface area. The average-sized adult has a body surface area
of 1.7 m2.
 Used to evaluate cardiac performance & MAP
▪ Central Venous Pressure
▪ Pulmonary Artery Wedge Pressure
▪ Cardiac Index
▪ Stroke Index
▪ Systemic Vascular Resistance Index
▪ Pulmonary Vascular Resistance Index

 Require Invasive Monitoring techniques

e.g: FloTrac system, CVC, PAC
 CO-SV- SVV (stroke volume variation)-MAP

The minimally invasive FloTrac system is a proven solution for advanced hemodynamic
monitoring that automatically calculates key flow parameters every 20 seconds. Continuous
monitoring offers proactive decision support to manage hemodynamic instability and help you
ensure adequate patient perfusion.
Central Venous Catheter

 Central venous pressure, which is a measure of

pressure in the vena cava, can be used as an
estimation of preload and right atrial pressure.
Pulmonary Artery Catheter
Pulmonary Artery Catheter
Pulmonary Artery Catheter
Central Venous Pressure

 a popular measurement in critical care

 When the PA catheter is properly placed, the

proximal port of the catheter should be
situated in the right atrium, and the pressure
recorded from this port should be the right
atrial pressure (RAP)
Central Venous Pressure
 The pressure in the right atrium is the same
as the pressure in the superior vena cava, and
these pressures are collectively called the
central venous pressure (CVP).

 In the absence of tricuspid valve dysfunction,

the CVP should be equivalent to the right
ventricular end diastolic pressure (RVEDP).

 CVP=RAP=RVEDP
Pulmonary Artery Wedge Pressure
 simply the wedge pressure, is a reflection of
the filling pressure on the left side of the
heart
Pulmonary Artery Wedge Pressure

 PCWP or Pulmonary Artery Occlusion Pressure (PAOP)

is the pressure when a balloon is inflated (wedged) in
one of the pulmonary artery branches.
 The PAWP is a measure of left-atrial pressure (LAP),
which is equivalent to the left-ventricular end-
diastolic pressure (LVEDP) when mitral valve function
is normal
 PAWP = LAP = LVEDP
 The wedge pressure is a measure of the left
ventricular filling pressure. The normal range is 6–12
mm Hg
Cardiac Index (CI)
 The thermodilution cardiac output (CO) is the
average stroke output of the heart in one-
minute periods
 It is typically adjusted to body surface area
(BSA), and is called the cardiac index (CI)
CI = CO/BSA
 In the average-sized adult, the normal range
is 2.4–4 L/min/m2
Stroke Index (SI)
 The heart is a stroke pump, and the stroke
volume is the volume of blood ejected in one
pumping cycle.

 The stroke volume is equivalent to the

average stroke output of the heart per minute
(the measured cardiac output) divided by the
heart rate (HR)
Stroke Index
 When cardiac index (CI) is used, the stroke
volume is called the stroke index (SI)
 The stroke index is a measure of the systolic
performance of the heart during one cardiac
cycle
 The normal range in adults is 20–40 mL/m2
Systemic Vascular Resistance Index
 The left ventricle ejects blood through the
aortic valve against the high pressure of the
systemic circulation, also known as systemic
vascular resistance (SVR).

 The right ventricle ejects blood through the

pulmonic valve against the low pressure of
the pulmonary circulation, or pulmonary
vascular resistance (PVR).
Systemic Vascular Resistance Index
 The hydraulic resistance in the systemic
circulation is not a measurable quantity for a
variety of reasons (e.g., resistance is flow-
dependent and varies in different regions)

 Instead, the systemic vascular resistance (SVR) is

a global measure of the relationship between
systemic pressure and flow. The SVR is directly
related to the pressure drop from the aorta to the
right atrium (MAP – CVP), and inversely related to
the cardiac output (CI)
Pulmonary Vascular Resistance Index
 PVR has the same limitations as mentioned for
SVR
 The PVR is a global measure of the relationship
between pressure and flow in the lungs, and is
derived as the pressure drop from the pulmonary
artery to the left atrium, divided by the cardiac
output.
 Because the PAWP is equivalent to the LAP, the
pressure gradient across the lungs can be
expressed as the difference between the mean
pulmonary artery pressure and the wedge
pressure (PAP – PAWP)