Hemodynamic Monitoring

Charles E. Smith, MD Professor of Anesthesia Director, Cardiothoracic Anesthesia MetroHealth Medical Center Case Western Reserve University Cleveland, Ohio
Email: [email protected]

Siegel JH et al: Trauma: Emergency Surgery + Critical Care, 1987:201-284

Definition of Monitoring
Continuous or repeated observation + vigilance in order to maintain homeostasis ASA Standards: I. II. III. IV. Qualified personnel Oxygenation: SaO2, FiO2 Ventilation: ETCO2, stethoscope, disconnect alarm Circulation: BP, pulse, ECG

Other monitors: T, Paw, Vt, ABG

Objectives
Arterial line Systolic pressure variation Central venous pressure Pulmonary artery catheterization Cardiac output Mixed venous oxygen

Basic Concepts
BP = CO x SVR CO = SV x HR DO2 = (CO x CaO2 x 10) + (PaO2 x 0.003) CaO2 = Hg x 1.39 x O2 sat; or CaO2 = Hct/2

Assume CO 5 L/min, 100% sat Hct 40 CaO2 20 CO Hct 30 CaO2 15 CO Hct 20 CaO2 10 CO

5 5 5

DO2 DO2 DO2

1000 750 500

Arterial Line
Indications:
Rapid moment to moment BP changes Frequent blood sampling Circulatory therapies: bypass, IABP, vasoactive drugs, deliberate hypotension Failure of indirect BP: burns, morbid obesity Pulse contour analysis: SPV, SV

Radial Artery Cannulation

Technically easy Good collateral circulation of hand Complications uncommon except:
vasospastic disease prolonged shock high-dose vasopressors prolonged cannulation

Alternative Sites
Brachial:
Use longer catheter to traverse elbow joint Postop keep arm extended Collateral circulation not as good as hand

Femoral:
Use guide-wire technique Puncture femoral artery below inguinal ligament (easier to compress, if required)

Pulsus Paradoxus

Exaggerated inspiratory fall in systolic BP during spontaneous ventilation, > 10-12 mmHg Cardiac tamponade, severe asthma

Systolic Pressure Variation

Difference between maximal + minimal values of systolic BP during PPV ( down: ~ 5 mm Hg due to q venous return SPV > 15 mm Hg, or ( down > 15 mm Hg:
highly predictive of hypovolemia

Marik: Anaesth Intensive Care 1993;21:405. Coriat: Anesth Analg 1994;78:46

Gardner, in Critical Care, 3rd ed. Civetta. 1997, p 851

Pulse Contour Analysis

1. Transform BP waveform into volume time waveform 2. Derive uncalibrated SV
SV x HR = CO

3. May calibrate using Li indicator [LidCO] or assume initial SV based on known EF from echo Assumptions: PPV induces cyclical changes in SV Changes in SV results in cyclical fluctuation of BP or SPV
Linton R: 1997, 1998, 2000

PulseCO SPV + SV
Predicts SV o in response to volume after cardiac surgery + in ICU [Reuter: BJA 2002; 88:124; Michard: Chest 2002;
121:2000]

Similar estimates of preload v. echo during hemorrhage [Preisman: BJA 2002; 88: 716] Helpful in dx of hypovolemia after blast injury
[Weiss: J Clin Anesth 1999; 11:132]

Pitfalls with SPV + SV

Inaccurate if
AI IABP

Problems if
pronounced peripheral arterial vasoconstriction damped art line arrhythmias

Central Venous Line

Indications:
CVP monitoring Advanced CV disease + major operation Secure vascular access for drugs: TLC Secure access for fluids: introducer sheath Aspiration of entrained air: sitting craniotomies Inadequate peripheral IV access Pacer, Swan Ganz

Central Venous Line: RIJ

IJ vein lies in groove between sternal + clavicular heads of sternocleidomastoid muscle IJ vein is lateral + slightly anterior to carotid Aseptic technique, head down Insert needle towards ipsilateral nipple Seldinger method: 22 G finder; 18 G needle, guidewire, scalpel blade, dilator + catheter Observe ECG + maintain control of guide-wire Ultrasound guidance; CXR post insertion

Advantages of RIJ
Consistent, predictable anatomic location Readily identifiable landmarks Short straight course to SVC Easy intraop access for anesthesiologist at patients head High success rate, 90-99%

Types of Central Catheters

Variety of lengths, gauges, composition + lumens depending on purpose Introducer sheath (8-8.5 Fr): Permits rapid fluid/blood infusion or Swan Trauma triple-lumen (12 Fr): Rapid infusion via 12 g x 2; 16 g for CVP monitoring MAC 2: (9 Fr): Rapid infusion via distal port; 12 g for CVP Also allows for Swan insertion More septations + stiffer plastic

Alternative Sites
Subclavian:
Easier to insert v. IJ if c-spine precautions Better patient comfort v. IJ Risk of pneumo- 2%

External jugular:
Easy to cannulate if visible, no risk of pneumo 20%: cannot access central circulation

Double cannulation of same vein (RIJ)

Serious complications: vein avulsion, catheter entanglement, catheter fracture

CVP Monitoring
Reflects pressure at junction of vena cava + RA CVP is driving force for filling RA + RV CVP provides estimate of: Intravascular blood volume RV preload Trends in CVP are very useful Measure at end-expiration Zero at mid-axillary line

Zero @ Mid-Axillary Line

CVP Waveform Components

Component
a wave c wave x descent v wave y descent

Phase of Cycle
End diastole Early systole Mid systole Late systole Early diastole

Event
Atrial cont Isovol vent cont Atrial relaxation Filling of atrium Vent filling

Mark JB, CV Monitoring, in Miller 5th Edition, 2000, pg 1153

Pulmonary Artery Catheter

Introduced by Swan + Ganz in 1970 Allows accurate bedside measurement of important clinical variables: CO, PAP, PCWP, CVP to estimate LV filling volume, + guide fluid / vasoactive drug therapy Discloses pertinent CV data that cannot be accurately predicted from standard signs + symptoms

PAC Waveforms

Indications: ASA Task Force

Original practice guidelines for PAC- 1993; updated 2003
[Anesthesiology 2003;99:988]

High risk patient with severe cardiopulmonary disease Intended surgery places patient at risk because of magnitude or extent of operation Practice setting suitable for PAC monitoring: MD familiarity, ICU, nursing PAC Education Project: www.pacep.org web based resource for learning how to use PAC

Roizen et al: Anesthesiology 1993;78:380. ASA Newsletter, Aug 2002;66(8):7

PAC and Outcome

Early use of PAC to optimize volume status + tissue perfusion may be beneficial PAC is only a monitor. It cannot improve outcome if disease has progressed too far, or if intervention based on PAC is unsuccessful or detrimental Many confounding factors: learning bias, skill, knowledge, usage patterns, medical v. surgical illness
Connors: JAMA 1996;276:916. Mark JB: in Anesthesia 5th Ed. Miller. 2000: pp 1178-80

PAC: Complications
Minor in 50%, e.g., arrhythmias Transient RBBB- 0.9-5% External pacer if pre-existing LBBB Misinformation Serious: 0.1-0.5%: knotting, pulmonary infarction, PA rupture (e.g., overwedge), endocarditis, structural heart damage Death: 0.016%
Mark JB, in Anesthesia 5th Edition. Miller 2000, pg 1117-1206

Problems Estimating LV Preload

Cardiac Output
Important feature of PAC Allows calculation of DO2 Thermodilution: inject fixed volume, 10 ml, (of room temp or iced D5W) into CVP port at endexpiration + measure resulting change in blood temp at distal thermistor CO inversely proportional to area under curve

Cardiac Output: Technical Problems

Variations in respiration:
Use average of 3 measures

Blood clot over thermistor tip: inaccurate temp Shunts: LV + RV outputs unequal, CO invalid TR: recirculation of thermal signal, CO invalid Computation constants: Varies for each PAC, check package insert + manually
enter

Continuous Mixed Venous Oximetry

Fick Equation
VO2 = CO [CaO2 - CvO2] CvO2 ~ SvO2 b/c most O2 in blood bound to Hg

If O2 sat, VO2 + Hg remain constant, SvO2 is indirect indicator of CO Can be measured using oximetric Swan or CVP, or send blood gas from PA / CVP Normal SvO2 ~ 65% [60-75]

Mixed Venous Oximetry

SvO2 [> 75%]

Wedged PAC: reflects LAP saturation Low VO2: hypothermia, general anesthesia, NMB Unable to extract O2 : cyanide, Carbon monoxide High CO: sepsis, burns, L R shunt AV fistulas

Mixed Venous Oximetry

SvO2 [< 60%]

Hg- bleeding, shock VO2: fever, agitation, thyrotoxic, shivering SaO2 : hypoxia, resp distress CO: MI, CHF, hypovolemia

Summary
Invasive monitoring routinely performed
Permits improved understanding of BP, blood flow, + CV function Allows timely detection of hemodynamic events + initiation of treatment Requires correct technique + interpretation Complications occur from variety of reasons Risk: benefit ratio usually favorable in critically ill patients