HEMODYNAMIC

MONITORING

Moderator : Dr. Anurag Mahajan

Presenter : Dr. Abhishek Yadav
 HOW??

WHY???

Hemodynamic Monitoring

WHAT????
• Real-time( ??) measurement of cardiovascular function.

• Guide for tissue perfusion

• Indicator of tissue oxygenation.

• Implying that if hemodynamics are within normal limits, tissue

oxygenation will be also be normal, assuming normal ventilation.
Cardiac performance depends on three factors –
PRELOAD AFTERLOAD CONTRACTILITY

PRELOAD AFTERLOAD CONTRACTILITY

CVP SVRI ECHO
PAWP
GEDV
LVEDV
PPV
SVV
SPV
IVC
COMPONENTS OF HAEMODYNAMIC
MONITORING
NON INVASIVE INVASIVE
CLINICAL IBP
NIBP CVP
SpO2 PAP
EtCO2 Cardiac Output

Cardiac Output
 Clinical Monitoring

Inspection :
• Mucous membranes, Skin color and Skin turgor
• Clues about hydration, oxygenation and perfusion

• Pallor
• Cyanosis (peripheral/ central)
• Oedema
 Inspection of neck veins

Low, normal or high JVP.

Elevated JVP:
Upper limit is 4cm from sternal angle=9cm above RA= Pressure of 6 mm Hg
• Congestive heart failure, Cor pulmonale
• Tamponade (Kussmaul’s sign – exaggerated rise in JVP during inspiration)
• Iatrogenic fluid overload in surgical patients.
• Right ventricular infarction, Pulmonary embolism
 Palpation:
Coldness of extremities:
• s/o Reduced CO or perfusion
Oedema:
• Pitting oedema -- Cardinal feature of CHF.
Pulse :
Rate
• Tachycardia : hypotension
• Bradycardia : Increased vagal tone, drug induced (atropine, glycopyrrolate).

Rhythm
•Irregular rhythm: Atrial fibrillation, frequent ectopic beats or self limiting paroxysmal
arrhythmias.

Volume – Low or Good

Capillary Refill Time : normal < 3 sec.
 BLOOD PRESSURE
• BP = Cardiac output x Peripheral resistance.
Noninvasive BP monitoring Invasive BP monitoring

Arterial line
Auscultatory/Palpatory Accurate
Not accurate Beat to beat
Not beat to beat measurement
Cuff bladder - 40% of arm circumference
- 80% of length of upper arm
 AUTOMATED INTERMITTENT TECHNIQUES
(OSCILLOMETRY)

• Utilize the Oscillometry principle.

• Arterial pulsation —› variation in cuff pressure during cuff deflation —› sensed
by sensor —› used to measure BP.
• Point of maximum amplitude of arterial pulsations corresponds to MAP.
• SBP and DBP empirically derived algorithm.
• SBP identified as pressure at which pulsations are increasing and are at 25-50%
of the maximum.
• Cuff bladder should be 40% of arm circumference and 80% of length of upper
arm.
• SBP has the poorest agreement with invasive BP values.
Complications of non-invasive BP monitoring

• Pain
• Petechiae and ecchymosis
• Limb edema
• Venous stasis & thrombophlebitis
• Peripheral neuropathy
• Compartment syndrome
 PULSE OXIMETRY
• arterial oxygen saturation in all patient age groups.

• Plethysmographic waveform analysis has been recommended for assessing volume status and fluid responsiveness.
Respiratory variations in systolic pressure and arterial pulse pressure have been shown to be accurate indicators of volume
status and fluid responsiveness in mechanically ventilated patients.
• Variation in the pulse oximeter plethysmograph amplitude is known to be a reliable noninvasive surrogate for change in
arterial pulse pressure as both parameters are dependent on stroke volume.
• Perfusion index is the numerical value of the plethysmograph waveform amplitude. It is the ratio of pulsatile to nonpulsatile
blood flow through the peripheral capillary bed. It indicates the vasomotor tone. Higher the vasomotor tone, i.e. vasoconstriction,
lowers the PI and vasodilatation increases the PI. Pleth variability index is an automatic measure of the dynamic change in PI
that occurs during the respiratory cycle. The greater the PVI, the more likely the patient will respond to fluid administration
 CAPNOGRAPHY
• .

• Capnography has significant clinical applications not just in respiratory monitoring but also in monitoring of cardiac
function like assessment of adequacy of cardiopulmonary resuscitation (CPR) and aid in diagnosis of special situations like
pulmonary embolism.
Cardiopulmonary Resuscitation
The usefulness of capnography and continuous monitoring of EtCO2 during resuscitation has been demonstrated in multiple
studies. Its role in CPR has been widely accepted. These changes are based on the fact that capnography not only confirms
tracheal intubation but also indirectly gives information regarding adequacy of chest compressions. Furthermore, it has been
shown that return of spontaneous circulation is heralded by sudden increase in EtCO2 values, even when other signs like
recordable blood pressure or pulse are absent.

A sudden drop in the end tidal Co2 concentration is

suggestive of a reduction in the pulmonary blood flow. This
can be due to a reduction in cardiac output or due to impaired
pulmonary blood flow due to an embolus.
FRANK – STARLING CURVE

PULMONARY
IF FLUID GIVEN EDEMA
 HEART LUNG INTERACTION

During Mechanical
Ventilation
Systolic Pressure Systolic Pressure
Pulse pressure Pulse pressure
Aortic blood velocity Aortic blood velocity

MAXimum at end of MINimum at end of

inspiratory period inspiratory period
 MEASURES OF PRELOAD
STATIC PARAMETERS DYANAMIC PARAMETERS
PRESSURE VOLUME
PPV
CVP GEDV
PAWP LVEDV
SPV

SVV

IVC---Collapsibility/distensibility

PPV
SPV
SVV
GEDV
CVP/PAOP
PHLEBOSTATIC AXIS
BASIC ASSUMPTIONS
• FOR CVP:- RVEDV=LVEDV
• RV PRELOAD = RVEDV = RVEDP = RAP = CVP

Responsiveness of Vol. as marker LINEAR P-V No A-V VALVE

output to ventri. stretch PATHOLOGY
stretch

FOR PAOP
CENTRAL VENOUS PRESSURE
 TECHNIQUE
• IJV lies in the groove between the sternal and clavicular
heads of sternomastoid muscle, lateral and slightly anterior
to carotid artery.

Rt IJV Central line approach most preferred. WHY ?

• Consistent, predictable anatomical location
• Short straight course to SVC
• Thoracic duct injury on left side
• Higher dome of pleura (Cupula) on left side
• Lt IJV is shorter, closer to the carotid artery
• Any catheter through the Lt IJV must traverse the innominate ( lt
brachiocephalic) vein and enter the SVC perpendicularly
• More user experience with Rt IJV
ALTERNATIVE SITES FOR CENTRAL
VENOUS CANNULATION

1. Left internal jugular vein

2. Subclavian vein
3. External jugular vein
4. Femoral vein
5. Antecubital veins
 ALTERNATIVE TECHNIQUES

Ultrasound guided
1. Fewer needle passes
2. ↓time required for catheterization
3. Overall success rate
4. Fewer complications(carotid artery puncture, brachial
plexus irritation and hematoma formation).
OPTIMUM POSITION
• T4 – T5 SPACE
• ABOVE CARINA
• BELOW CLAVICLE AND ABOVE 3RD RIB
• ECG GUIDANCE
INDICATIONS
• ADMINISTER OF MEDICINES/NUTRITION
• HAEMODYANAMIC MONITORING
• POOR PERIPHERAL VENOUS ACCESS
• HD/UF
• VENOUS SHEATH ACCESS FOR DEVICES like – IVC filters, venous stents
etc.
COMPLICATIONS
• Mechanical vascular injury
1. Arterial – Carotid and Subclavian
2. Venous
3. Cardiac tamponade

• Respiratory compromise
1. Airway compression from hematoma
2. Pneumothorax
3. Heamothorax

• Nerve injury
• Arrhythmias
• Thromboembolic
1. Venous thrombosis
2. Pulmonay embolism
3. Arterial thrombosis and embolism
4. Catheter or guide wire embolism

• Infections
1. Insertion site infection
2. Catheter infection
3. Bloodstream infection
4. Endocarditis
 CVP WAVEFORM COMPONENTS
WAVEFORM Phase of Mechanical event
COMPONENT cardiac cycle

a wave End diastole Atrial contraction

c wave Early systole Tricuspid bulging

v wave Late systole Systolic filling of the atrium

x descent Mid systole Atrial relaxation

y descent Early diastole Early ventricular filling

CVP AND BREATHING
Chapter 34 Millers anesthesia 2020
TR

TS
 AF

ATRIO-VENTRICULAR
DISSOCIATION

VENTRICULAR
PACING
 STUDIES

Data synthesis: The 24 studies included 803 patients

Conclusions: This systematic review demonstrated a very

poor relationship between CVP and blood volume as well as
the inability of CVP/DeltaCVP to predict the hemodynamic
response to a fluid challenge.
Magder et al
Magder and Lagonidis et al
INTRODUCTION
• 1970- H.J. Swan , W. Ganz
• Diagnosis , monitoring and treatment
• Information provided:
1. Right Atrial and Pulmonary Artery pressures
2. Pulmonary Artery Wedge/Occlusion pressures
3. Cardiac output
4. Mixed venous saturation
5. Rt. Ventricular Ejection Fraction
INDICATIONS
• Cardiac disease
• Coronary artery disease with left ventricular dysfunction or recent infarction
• Valvular heart disease
• Heart failure (eg, cardiomyopathy, pericardial tamponade, cor pulmonale)
• Pulmonary disease
• Acute respiratory failure (eg, acute respiratory distress syndrome)
• Severe chronic obstructive pulmonary disease
• Complex fluid management
• Shock
• Acute renal failure
• Acute burns
• Hemorrhagic pancreatitis
• Specific surgical procedures
• Pericardiectomy
• Aortic cross-clamping (eg, thoracic, aortic aneurysm repair)
• Sitting craniotomies
• Portal systemic shunts
• Liver transplants
• High-risk obstetrics
• Severe toxemia
• Placental abruption
Perioperative use of PAC
ACC/AHA perioperative clinical practice guideline
CLASS IIb
1. The use of pulmonary artery catheterization may be
considered when underlying medical conditions that
Significantly affect hemodynamics (i.e., HF, severe
valvular disease, combined shock states) cannot be
corrected before surgery.

CLASS III: NO BENEFIT

1. Routine use of pulmonary artery catheterization in
patients, even those with elevated risk , is not
recommended.
DISTANCES FROM INSERTION SITE
• From Right internal jugular vein
Miller BJA- Dr Tempe
1. Right Atrium 20 – 25 cm
2. Right Ventricle 30 – 35 cm (25 cm)
3. Pulmonary Artery 40 – 45 cm (35 cm)

• From Left Internal Jugular Vein and External Jugular

veins an additional 5 – 10 cm
• From Femoral veins an additional 15 cm
• From antecubital veins an additional 30 – 35 cm
AVERAGE PRESSURES
PRESSURES ( mm of Hg )

RIGHT ATRIUM 0-6

RIGHT VENTRICLE 15-12 / 0-6

PULMONARY ARTERY 15-25 / 6-12

PULMONARY ARTERY OCCLUSION PRESSURE 6-12

PAC IN RT.VENTRICLE

• SUDDEN INCREASE IN SYSTOLIC PRESSURE.

• WIDE PULSE PRESSURE.

• LOW DIASTOLIC PRESSURE.

CONFIRMING ACCURATE PAOP
MEASUREMENT
• CHANGE IN WAVEFORM : P.AP  PAOP (On inflation)
• Po2 wedge position: similar/ increased to arterial blood
• MEAN PAOP < /= DIASTOLIC PAP
• EASY FLUSH
• CARDIAC RIPPLE : a & v waves
 WEST ZONE 3 VERIFICATION

 WEST ZONE 1 – P equivalent to alveolar

pressure.

 PAP(D) > PAOP

 Catheter tip below L.A.

EFFECT OF PEEP
• PEEP INCREASES INTRAPLEURAL PRESSURE
• PAOP IS OVERESTIMATED
• NORMAL LUNG AND CHEST WALL COMPLIANCE ----- 50% of applied
PEEP -------TRANSMITTED.

• PAOP INCREASE ------- 50% of applied PEEP.

INACCURATE PAOP : CONDITIONS
• AR/ MS/MR
• L.A MASS – MYXOMA ; THROMBUS
• OBSTRUCTION PULMONARY VEIN – TUMOR , FIBROSIS
• PEEP/ CPAP
• WEST ZONE 1 & 2.
PAOP AND LVEDP : DISCREPANCY IN
VALUES
• PAOP < TRUE LVEDP : LVH/ MI

• PAOP > TRUE LVEDP : PNEUMONECTOMY, MASSIVE P.E.

STUDIES-

PAC-Man TRIAL
 ARDSNET

 1OOO Patients
 PAC VS CVC
 COMPLICATIONS : PAC > CVC
 VASOPRESSOR REQUIREMENT : PAC > CVC
Pulmonary catheter looks through the pulmonary window into the left atrium
INVASIVE BP MONITORING

Arterial cannulation with continuous pressure

transduction with waveform display is the
accepted reference standard for BP monitoring.
 Indications for Direct Arterial BP Monitoring
1.Continuous real time BP monitoring
•Small change in arterial perfusion pressure increases patient’s risk requiring beat to beat
assessment (CAD, valvular heart disease)
•Wide variation in BP or intravascular volume is anticipated.

2.Planned pharmacologic or mechanical CVS manipulation

o Hypotensive anesthesia

3.Frequent blood sampling, especially ABG analysis is required.

4.Failure of NIBP measurement

oCardiopulmonary bypass (nonpulsatile flow), dysrhythmias, marked obesity, burns.

5.Supplementary diagnostic info from arterial waveform

6.Determination of volume responsiveness from systolic pressure or pulse pressure

variation
Contraindications

• Local infection
• Coagulopathy: may result in hematoma formation.
• Proximal obstruction: Thoracic outlet syndrome,
Coarctation of aorta.
• Raynaud’s syndrome and Buerger’s disease
Radial Artery cannulation
Various techniques:
• Direct cannulation
• Seldinger’s technique
• Doppler assisted
• 2-D USG assisted
• Surgical cutdown
 Alternative sites for arterial pressure
monitoring
Ulnar artery
Brachial artery
Dorsalis pedis, Posterior tibial artery
• Generally for pediatric patients, Neurosurgery
Superficial temporal artery
Axillary artery and Femoral artery (safe, comfortable but increased
risk of atherosclerotic embolization)
Complications of arterial pressure monitoring
Distal ischemia (0.1%)
Pseudoaneurysm, arteriovenous fistula.
Hemorrhage, hematoma
Arterial embolization
Local infection, sepsis
Peripheral neuropathy
Misinterpretation of data (equipment misuse)
Inadverdent injection of drug
ARTERIAL PRESSURE WAVEFORM
• Results from ejection of blood from the LV into aorta during systole
f/b peripheral arterial runoff of SV during diastole.
• Systolic components follow R wave in ECG.
Consists of:
Steep Pressure upstroke
Peak
Decline
FOURIER
ANALYSIS
Components of IBP system
Intra arterial cannula:
• Short, narrow cannula (20G or smaller) made of
Teflon to decrease risk of arterial thrombus
formation.
• Risk of arterial thrombus directly proportional to
diameter of cannula.
Coupling system:
•Consists of pressure tubing, stopcocks and a
continuous flushing device.
•Tubing should be short, wide and non-compliant (stiff)
to reduce damping.
•Major source of distortion of arterial pressure
tracings.
Infusion/ flushing system:

• Plain 0.9% saline pressurized to 300 mmHg and

connected to fluid filled tubing via flush system.

• Slow infusion at 1-3 ml/hr to maintain patency.

• Intermittent flushing with 2-3ml can be done.

• Dilute concentration of heparin (1-2 U/ml).

Adverse effect- Heparin induced Thrombocytopenia

UNDERDAMPED

OVERDAMPED
NORMAL RANGE

9% -13%
>13% - FLUID RESPONSIVE
< 9% - NON RESPONSIVE
B/W 9-13 : GRAY AREA

10%-13%
TARGET SVV < 13%
PREREQUISITES ARE THE LIMITATIONS
• Mechanical ventilation with tidal volume of 8 to 10 mL/kg,
• Positive end-expiratory pressure ≥ 5 mm Hg,
• Regular cardiac rhythm
• Normal intraabdominal pressure
• Closed chest
END OF PART - 1

THANK YOU
 Cardiac output monitoring
• Cardiac output is the volume of blood pumped into the aorta each minute by the left
ventricle.

• It is the determinant of global oxygen transport to the body

• It reflects the efficiency of cardiovascular system

• In many critically ill patients, low cardiac output leads to significant morbidity and
mortality.
 When should we monitor?
• High risk critically ill surgical patients in whom large fluid shifts are expected along with
bleeding and hemodynamic instability

• As a important component of goal directed therapy (GDT), i.e., when a monitor is used
in conjunction with administration of fluids and vasopressors to achieve set therapeutic
endpoints thereby improving patient care and outcome
Features of an ideal Cardiac Output monitor
• Safe and accurate

• Quick and easy to use both in terms of set-up and

interpretation of information

• Operator independent i.e. the skill of the operator doesn’t affect the
information collected

• Provide continuous measurement

• Reliab le during various physiological states

 Methods of measuring cardiac output

• CO(L/min) = HR(beats /min) x SV(L/beat.)

• SV: volume ejected during each beat
• CO (at rest) = 4 - 6.5 L/min.
• CO increases as per metabolic need (eg. Exercise), therefore, HR or SV or both
can increase.
Fick Principle: “Gold standard”

The total uptake of a substance by peripheral tissue is equal to

the product of blood flow to the peripheral tissue and arterial
– venous concentration difference of the substance
Mixed venous blood is usually obtained
Through a catheter inserted into:
• Through the subclavian vein
• Down to the right atrium
• The right ventricle or pulmonary artery

Systemic arterial blood can then be obtained from any systemic artery in the body

This technique is used infrequently because of difficulty in collecting and analyzing exhaled gas
concentration in critically ill patients who may not have normal VO2 value.
 Methods of measuring cardiac output

Invasive Non-Invasive
• Pulmonary Artery Catheter (dyes, • TEE / Esophageal Doppler
thermodilution) (minimally invasive)
• Fick Principle • Trans Thoracic
Echocardiography (TTE)
• Bioimpedance/
Bioreactance
• Pulse contour analysis
• PWTT
• CO2 rebreathing
Trans Esophageal Echocardiography (TEE) / Doppler

• A widely used monitor in perioperative setting

• Is an important tool for the assessment of cardiac structures, filling status and cardiac
contractility
• Aortic pathology can also be detected by TEE

• Doppler technique is used to measure CO by Simpson’s rule measuring SV multiplied by

HR
• Measurement can be done at the level of pulmonary artery, mitral or aortic valve

• TEE can quantify Cardiac Output more precisely by measuring both the velocity and the
cross-sectional area of blood flow at appropriate locations in the heart or great vessels
i.e. Flow = CSA X Velocity
SV= flow X ET (Systolic Ejection time)
CO=SV X HR
 Measured Variables

• CO
• SV (stroke distance x aortic root diameter)
• Stroke distance is AUC
• FTc (Heart rate corrected flow time): indicates preload
• Peak blood flow velocity: indicates contractility
• HR

• Flow acceleration
 Advantages Disadvantages

• Minimally invasive • May require sedation

• Minimal interference form bone, lungs and • User dependent

soft tissue (as seen with transthoracic route) • Contraindicated in Esophageal

• Quickly inserted and analyzed Surgeries

• Little training required • Depends on accurate probe

• Very few complications positioning

 PULSE CONTOUR CARDIAC OUTPUT MONITORING
• Determine stroke volume from computerized analysis of the area under the arterial pressure waveform
recorded from an arterial catheter or non invasive finger blood pressure waveform.
• Non invasive, continuous, beat to beat cardiac output monitoring. SVV can be used to evaluate
volume status.
• Baseline calibration is required, recalibration required every 8-12 hours to account for change in
vascular characteristics over time.
• Use of vasopressors might affect the accuracy.
• A well defined arterial waveform is required with a discernible dicrotic notch which might not exist
under severe tachycardia or dysrhythmias.
• Provide an acceptable level of accuracy with a bias of <0.5L/min compared to thermodilution CO
measurements. SVV > 10% is a useful predictor of fluid responsiveness.
 BIOIMPEDANCE
• Based on changes in electrical impedance of the thoracic cavity or the whole body occurring
with ejection of blood during systole.
• Blood has a significantly lower electrical resistance compared to tissues, and changes in
impedance to electric flow reflect a change in blood volume, which can then be used to
calculate stroke volume.
• Disposable electrodes applied to skin surface, a high frequency low amplitude electrical
current is applied and voltage change is measured.
• Patient height, weight and gender are used to calculate volume of the thoracic cavity.
• Bioimpedance cardiac output is computed for each cardiac cycle and continuously displayed
as an average value over several heart beats.
BIOREACTANCE
• Developed due to reduced reliability of bioimpedance method in surgical and critically ill patients
• Measures not only the amplitude change of received signal, but also its phase shift compared to the applied
electrical signal.
• 4 dual electrode patches are applied, 2 on each side of the body.
 PULSE WAVE TRANSIT TIME
• Pulse Wave Transit Time, PWTT, is defined as the time from the ECG R-wave peak to the pulse wave
rise point. The pulse wave rise point is defined as the point where the differentiated pulse wave reaches
30% of its peak amplitude
• PWTT consists of three intervals: pre-ejection period (PEP), pulse wave transit time through elastic
artery (T1), and pulse wave transit time through peripheral arteries (T2)
• PEP reflects cardiac contractility and preload and shortens as cardiac contractility and preload

increase.

• T1 depends on arterial compliance, and it shortens when blood pressure increases.

• T2 reflects vascular resistance as blood vessel dilates.

• It was observed that PWTT and stroke volume (SV) show a good correlation.
 PARTIAL CO2 REBREATHING CARDIAC OUTPUT MONITORING

• Based on a restatement of the Fick equation for CO2 elimination rather than oxygen uptake.

• Uses the change in CO2 production and EtCO2 concentration in response to a brief, sudden

change in minute ventilation.

• Changes in EtCO2 in response to the rebreathing maneuver are used to calculate CO by a

differential version of the Fick equation for CO2.

• Rebreathing periods are well tolerated in most patients, with EtCO2 rising by less than 3 mmHg.

• Requires tracheal intubation for precise measurement of exhaled gases. Changing pattern of

ventilation may have unpredictable influence on measurements.

VCO2 – Rate of CO2
elimination

CvCO2- CO2 content

of mixed venous
blood
CaCO2- CO2 content
of arterial blood
THANK
YOU!