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ARTERIAL

LINE
Defining:
o Consists of an electromechanical transducer that is coupled to the patient via
a fluid column that is generally composed of NS and heparin (4 units/ml)
[sodium citrate has been used as a substitute for heparin in flush in cases of
HIT]
o An arterial line is an invasive monitor that provides:
Beat-to-beat numeric blood pressure values
A waveform with arterial pressures (y axis) as a function of time (x
axis)
A means to attain ABG sampling
Arterial waveform is expressed as a summation of simple harmonic waves (according
to Fourier theorem)
For accurate measurement: the catheter-tubing-transducer system must be capable
of responding adequately to the highest frequency of the arterial waveform (16-24
Hz)
Catheter-tubing-transducer system must also prevent hyperresonance.
A damping coefficient of 0.6-0.7 is optimal.
Most transducers are resistance types that are based on the strain gauge principles
(consisting of stretching wires and sensing elements arranged in Wheatstone bridge
circuit)
Physiology:
o Important things to consider:
Arterial waveform is a measure of pressure and doesnt necessarily
correlate to CO (flow), eg. in patients with poor CO and high SVR,
pressure will be normal but perfusion inadequate.


o Anacrotic limb:
First phase
Represents the ventricular ejection of blood
Highest point corresponds to SBP
Steep slopes:
Increase in HR
Inotropic effect
Dampened slopes:
Decrease in HR
Decrease in contractility
o Dicrotic limb:
Represents the downstroke
Begins at peak, continues through dicrotic notch and ends at diastolic
baseline.
o Dicrotic Notch:
Coincides with closure of aortic valve and end of LV ejection.
Result of reflection of pressure wave when forward flow of
blood out of LV stops and elastic recoil of aorta forces blood
against the closed aortic valve.
Problems:
o In patients with severe AR, indistinct dicrotic notch.
o A flat of absent notch suggests low IV volume
o A low or late notch may correlate to decreased SVR
o Pressure Decay:
Drop in pressure over time (dP/dT) from dicrotic notch to diastolic
pressure
It is a function of SVR
Steep slopes:
Decreased SVR/afterload, narrow waveform
Dampened slopes:
Increased SVR/afterload, waveform widened.
o Highest fidelity of readings when:
Largest diameter of catheter which doesnt obstruct the lumen of the
vessel.
Shortest length of high pressure tubing between the transducer and
the patient
Tubing that is free of gas bubbles.
Tubing that is free of other obstructions such as clotted blood.
Catheter that is placed closer to the central vascular tree.
o Reflections and deflections affect the accuracy
o The further away from heart, the more waves are reflected off the wall of
arteries and result in increased systolic and decreased diastolic pressures
however, mean pressure is only minimally affected.
o However, if the vessels were straight, had no branches, flow would be
laminar and pressures would not change in more distal arteries.
Problems:
o Dampened waveform:
Result in underestimation of BP and seen in:
Lumen occlusion d/t thrombosis, clots, air bubbles, or kinking.
Low backpressure from flush solution
Tubing: overly compliant, distensible, incorrect tubing
Troubleshooting:
Inspection of the system
Opening the transducer to air: reading should be zero
o If not, baseline drift has occurred and system should be
re-zeroed
Next: system should be flushed
o If the reading doesnt move over 300 mm Hg, then
pressure bag should be checked.
o Underdampened or resonant waves:
Result in overestimation of BP and occur in:
Tubing: long, noncompliant, overly stiff
Ringing: exaggerated highs and lows that occur when
measurement system comes close to the natural underlying
harmonic frequency of the waveform.
Increasd SVR
o SVV:
Changes in systolic and diastolic pressure that correlate with
respiratory cycle.

CO MONITORING
1. Thermodilution:
a. Injection of a fixed quantity of fluid that is below the body temperature (iced
or room temperature) into right atrium
b. Measurement of change in temperature of the blood with thermistor tip of
the PA catheter.
c. Temperature change is inversely proportional to the CO.
d. Temperature plotted as a function of time thermodilution curve.
e. CO determined by computer by integrating area under the curve.
f. TR and cardiac shunts invalidate the results because only right ventricular
output into PA is being measured.
g. Modification of thermodilution technique:
i. Catheter technique:
Continuous CO measurement with special catheter and
monitor system.
Catheter consists of thermal filament that introduces small
pulses of heat into the blood proximal to the pulmonic valve
and thermistor measures changes in temperature in PA blood.
ii. Transpulmonary thermodilution (PiCCO):
Doesnt require PA catheter.
Central line and thermistor equipped arterial catheter (femoral
esp)
Also permits the calculation of both the global end diastolic
volume and extravascular lung water by calculating mean transit
time (MTT) of indicator and its exponential decay time (EDT).
Intrathoracic thermal volume (ITTV)= CO x MTT
Pulmonary thermal volume (PTV) = CO x EDT
ITTV PTV = Global end diastolic volume (GEDV) [is the
hypothetical volume that assumes that all of the hearts chambers
are simultaneously full in diastole)
EVLW (Extravascular Lung water) = ITTV-ITBV (Intrathoracic blood
volume) where, ITBV= GEDV x 1.25
An increase in EVLW indicative of fluid overload.
It also calculates SVV and PPV through pulse contour analysis
determine fluid responsiveness.


2. Dye dilution:
a. ICG or other dye (like lithium) injected through CVP and appearance in
systemic circulation analyzed (eg. densitometer for ICG)
b. Area under dye indicator curve is CO
c. Lithium based (LiDCO) also calculate beat-to-beat SV- calculate the decay in
lithium concentration over time
d. Pulse contour analysis of waveform
e. NDMR blockers may affect lithium sensor.
3. Pulse contour devices:
a. Use the arterial pressure tracing to determine parameters like PP and SVV
with mechanical ventilation.
b. Measure the area of systolic portion of arterial pressure trace from end
diastole to end of ventricular ejection.
c. FloTrac doesnt require calibration with other measure.
4. Esophageal Doppler:
a. Doppler principle: measuring velocity of blood flow in the descending
thoracic aorta.
b. As red cells travel in aorta they reflect a frequency shift depending upon
direction and velocity of their movement.
c. When blood flows towards the transducer, its reflected frequency is higher
than that which was transmitted by the probe.
5. Thoracic Bioimpedance:
a. Change in thoracic volume causes changes in thoracic resistance
(bioimpedance) to low amplitude, high frequency currents.
b. But several problems.
6. Fick Principle:
a. Amount of oxygen consumed by individual equals the difference between
arterial and venous (a-v) oxygen content (CaO2 and CvO2) multiplied by
CO.
b. Mixed venous: PA catheter, arterial oxygen: arterial line.
7. Echocardiography:
a. TEE is the most powerful tool intraop to diagnose and assess cardiac
function.