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Suparto
Anesthesia Department FK UKRIDA
Objectives
Understands basic cardiopulmonary anatomy and
physiology
Determinates of cardiac output and their relationships to
each other
List indications for hemodynamic monitoring
Demonstrates monitor system and set up
Introduction
Hemodynamics, by definition, is the study of the motion
of blood through the body.
In simple clinical application this may include the
assessment of a patients heart rate, pulse quality, blood
pressure, capillary refill, skin color, skin temperature, and
other parameters.
Introduction
Monitoring is never therapeutic
It must be integrated with patient assessment and clinical
judgement to determine optimal care.
The goals are to recognize physiologic abnormalities and
to guide interventions to ensure adequate blood flow
and oxygen utilization for maintenance of cellular and
organ function
Cardiopulmonary anatomy
and physiology
Respiration
3 processes for adequate oxygenation and acid-base
balance
Ventilation: Gas distribution into and out of the
pulmonary airways
Pulmonary perfusion: blood flow from the right side
of the heart, through the pulmonary circulation, and
into the left side of the heart
Diffusion: Gas movement from an area of greater to
lesser concentration through a semipermeable
membrane
Cardiac system
Carries life sustaining
O2 and nutrients in the
blood to all cells of the
body
Removes metabolic
waste products in the
blood from the cells
Mnemonic:
Some Believe In Acting
Badly Before
Performing
Sinoatrial node
Bachmanns bundle
Internodal pathways
Atrioventricular node
Bundle of His
Bundle branches
Purkinje fibers
Cardiac output
Preload
Heart Rate X Stroke
Stretching of muscle fibers in
Volume
the ventricle .
Think of the heart as a
Starlings law
baloon
Stroke volume depends Contractility
Ability of the myocardium to
on:
Preload
Contractility
Afterload
contract
Influenced by preload
Afterload
Pressure that the ventricle
muscles must generate to
overcome the higher
pressure in the aorta
Blood circulation
preload contractility - afterload
SVR include:
Hypothermia
Hypovolemia
Stress response
Syndrome of low CO
SVR include:
Anaphylactic and
neurogenic shock
Anemia
vasodilation
MAP- CVP X 80
CO
Factor
Decreased preload
Possible cause
Hypovolemia
Vasodilation
Effects on heart
stroke volume
vent work
myocardial O2 req (in
compensatory range)
Factor
Increased afterload
Possible cause
Hypovolemia
Vasoconstriction
Effects on heart
strokevolume
vent work
myocardial O2 req
Factor
Decreased afterload
Possible cause
Vasodilation
Effects on heart
stroke volume
vent work
myocardial O2 req
Therapeutic Interventions
AtropineLow Heart Rate High Blocker
Standard Monitoring
ASA standard: Oxygenation, ventilation, circulation,
and temperature
Standard for General Anesthesia:
ASA standard (Pulse Oximetry, Capnography, minute
ventilation, ECG, BP, temp if necessary
Standard for MAC and Regional Anesthesia:
Pulse Oximetry, RR, ECG, BP, temp if necessary
Additional: Arterial line, CVP, NMBA monitor
Preparation before induction: Anesthesia Mechine,
ECG Monitor
Cardiovascular system
O2 delivery
CO = SV x HR
ECG
Determine HR
Detect and diagnose
dysrhytmia
Myocardial ischemia
Electrolyte imbalance
(hipo/hyperkalemia)
Arterial BP indication
Tight BP control
Unstable patient
Arterial blood sampling
CVP Monitoring
The theory is that as fluid The pressure is trended
as an indicator of volume
volume in chamber
status, but must be
increases, so too will the
correlated to physical
pressures measured in
assessment findings and
the chamber.
the patients history to
This correlation is true
come to an accurate
only in a limited sense
clinical impression.
The key to remember is
that pressure is not equal
to volume.
CVP Monitoring
Pressure at end diastole Help us to
learn a patients cardiac
reflects back to the
function,
catheter
evaluate venous return,
When connected to a
indirectly gauge how well the
transducer or
heart is pumping,
manometer, the catheter
access to fluid administration,
measures CVP, a direct
obtain blood samples.
reflection of right atrial
pressure and an indirect
measure of preload of the
right ventricle.
CVP Monitoring
Causes of Increased
pressure
Normal values
Normal mean pressure
ranges from 2-6 mmHg
(3-8 cmH2O)
Penumothorax, hemothorax
Sign & symptoms: decreased breath sounds, abnormal
chest X-ray
Causes: Repeated or long term use of same vein, large
blood vessel puncture
Interventions: set up and assist with chest tube
insertion, administer oxygen
Prevention: patients position during insertion,
immobilized patient, ultrasound guided
Air embolism
Sign & symptoms: respiratory distress, loss of
consciousness, unequal breath sounds
Causes: intake of air into the CV system during
catheter insertion
Intervention: turn the patient on his left side, head
down, so that air can enter the right atrium and
maintain this position for 20-30 min, life support
Prevention: purge all air from the tubing before
hookup
Thrombosis
Sign & symptoms: ipsilateral swelling of arm, neck and
face, pain along vein, dyspnea, cyanosis
Causes: Sluggish flow rate, hypercoagulable state of
patient
Interventions: possibly remove the catheter, apply warm,
wet compresses locally, dont use the limb on the affected
side for venipuncture or blood measurement, life support
Prevention: Maintain a steady flow rate with the infusion
pump, or flush the catheter at regular intervals
Instruct the patient to take a deep breath and hold it. If the
patient is unable to perform a breath hold, time the removal
of the catheter to coincide with a period of positive
intrathoracic pressure (In spontaneously this will occur during
exhalation. In mechanically ventilated positive intrathoracic
pressure occurs when the ventilator delivers a breath)
While the patient holds his/her breath, remove the catheter
smoothly. Once the catheter has been removed, apply
moderate pressure with sterile gauze and tell the patient to
resume breathing.
After a minute or two, gently release the pressure.
If there is no bleeding or swelling, apply a sterile dressing to
the site
PA catheter insertion
Swan-Ganz catheter
PAP and PAWP provide
information about LV
function
Respiratory System
Pulse Oxymetri
Normal: 96%-99%
88% acceptable for
patient with lung disease
Low pulse ox
Problem along the above
pathway or due to error
Capnography
Ventilation Assessment
Confirmation
endotracheal intubation
Normal: PetCO2 is
2-5mmHg lower than
arterial PCO2, so typical
range 30-40 mmHg
under General
anesthesia
Suhu tubuh
normal 365-375 C
Suhu nasofaringeal mendekati suhu inti
Peningkatan menandakan meningkatnya
metabolisme sel
Suhu produksi CO2
Produksi Urine
Dewasa: 0.5-1cc/Kg/jam
Pediatrik: 1-2cc/Kg/jam
Train of Four
Mengukur tingkat
blokade oleh
pelumpuh otot
memberikan 4
stimulus berturutan
dengan frekwensi 2
Hz selama 2 detik