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Monitoring Hemodynamic

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

Normal CO: 4-8 L/min


Normal Stroke Volume:
50-100 ml/beat

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

Systemic vascular resistance


The resistance against
which the left ventricle
must pump to move
blood throughout
systemic circulation.
Normal SVR: 770 1,500
dynes/sec/cm-5
Affected by:
Tone and diameter blood
vessel
Viscosity of the blood
Resistance from the inner
lining of the blood vessels

SVR include:

Hypothermia
Hypovolemia
Stress response
Syndrome of low CO

SVR include:
Anaphylactic and
neurogenic shock
Anemia
vasodilation

MAP- CVP X 80
CO

Effects of preload and afterload on the heart


Factor
Increased preload
Possible cause
fluid volume
Vasoconstriction
Effects on heart
stroke volume
vent work
myocardial O2 req

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

Fluids Low Preload High Diuretics,


Venodilators
Vasopressors Low Afterload High Arterialdilator,
ACE inhibitors
Inotropics Low Contractility

Tujuan utama: Keselamatan pasien


Pemantauan adalah
Menginterpretasikan data yang ada untuk
membantu mengenali kelainan atau kondisi sistem
yang tidak diharapkan, yang sedang atau akan
terjadi (D. John Doyle, MD. Cleveland Clinic Foundation)

Standar Perilaku untuk Pemantauan Anestesia


1. Anestesiologis harus hadir dan menjaga
keselamatan pasien sepanjang prosedur anestesia
2. Semua peralatan harus diperiksa sebelum
digunakan
3. Alat pantau harus terpasang sejak sebelum induksi
hingga pulih dari anestesia
4. Selama prosedur, semua parameter harus dievaluasi
ulang
5. Standar ini berlaku untuk semua tindakan anestesia
(MAC, Sedasi, Anestesia regional, Anestesia umum)

6. Data yang diperoleh dari alat pantau harus terekam


dalam rekaman medis anestesia

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

Clinical Signs and Symptoms of Perfusion Abnormalities


CNS: mental status changes, neurologic deficits
CVS: Chest pain, Shortness of breath, ECG
abnormalities, wall motion abnormalities on echo
Renal: UO, BUN, creatinine
Gastrointestinal: Abdominal pain, bowel sounds,
bleeding
Peripheral: cool limbs, poor capillary refill,
diminished pulses.

Cardiovascular system
O2 delivery
CO = SV x HR
ECG
Determine HR
Detect and diagnose
dysrhytmia
Myocardial ischemia
Electrolyte imbalance
(hipo/hyperkalemia)

Manual Blood Pressure


BP = CO x SVR
Measures systolic dan
diastolic BP by
auscultation of korotkoff
sound, palpation
Cuff width should cover
2/3 of upper arm or
thigh
Palpation:
A. radial (80mmHg)
A. femoral (60mmHg)
A. Carotid (50mmHg)

Mean Arterial Pressure


MAP = sis + 2 Dias/ 3
Normal: 60-70mmHg

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

Signs of excess preload with


Signs of inadequate preload
adequate cardiac function:
include

Distended neck veins


Poor skin turgor
Crackles in the lungs
Dry mucous membranes,
Bounding pulses
Low urine output
With poor cardiac function:
Tachycardia
Crackles in the lungs,
Thirst
an S3 heart sound,
Weak pulses
Low urine output,
Flat neck veins.
Tachycardia,
Cold clammy skin with weak
pulses,
Edema.

CV and PA catheter insertion


Sterile procedure
Insertion site:

Internal jugular vein


External jugular vein
Subclavian vein
Femoral vein

Causes of Increased
pressure

Normal values
Normal mean pressure
ranges from 2-6 mmHg
(3-8 cmH2O)

Right sided heart failure


Volume overload
Tricuspid valve stenosis Causes of decreased
pressure
or insufficiency
Reduced circulating
Constrictive pericarditis
blood volume
Pulmonary hypertension
Cardiac tamponade
Right ventricular
infarction

Contraindication CVC insertion:


1. Tumor at RA
2. Tricuspid vegetation
3. Post carotid endarterectomy ipsilateral
4. Coagulopathy

Cm H2O : 1.36 = mmHg

mmHg X 1.36 = cm H2O

Minimizing complications of CVP monitoring


Infection
Sign & symptoms: Local rash, fever, leukocytosis
Causes: lack of sterile technique, immunosuppression
Interventions: Re-dress the site using sterile
technique, possibly use antibiotic ointment loccaly,
catheter may be removed then culture its tip
Prevention: maintain sterile technique, observe
dressing-change protocols, change a wet or soiled
dressing immediately

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

Removal of Central Venous Catheter


Obtain clean gloves and sterile gloves, sterile gauze
squares, and materials for a dressing
Place the patient flat to minimize the risk of air aspiration
Remove the dressing carefully and cleanse the site with
sterile saline if needed. If sutures are in place, remove
them carefully.

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

Pulmonary Artery Pressure (PA Pressure):


Blood pressure in the pulmonary artery.
Increased pulmonary artery pressure may
indicate:
a left-to-right cardiac shunt,
pulmonary artery hypertension,
COPD or emphysema,
pulmonary embolus, pulmonary edema
left ventricular failure.

Mengetahui fungsi jantung kiri


Mengetahui adanya hipertensi pulmonal
Mengukur cardiac ouput, systemic vascular
resistance (SVR), pulmonary vascular
resistance (PVR), pulmonary capillary wedge
pressure (PCWP, PAOP)
Normal PAP systolic15-30 mmHg and diastolic
5-12 mmHg. PAOP 5-12 mmHg

Pulmonary Capillary Wedge Pressure (PCWP or


PAWP): PCWP pressures are used to approximate
LVEDP (left ventricular end diastolic pressure).
Reflecting left arterial pressure and left
ventricular preload
High PCWP may indicate left ventricle failure, increase
in end diastolic volume, decrease compliance, mitral
valve pathology, cardiac insufficiency, cardiac
compression post hemorrhage.
Low PCWP can be due to decrease end diastolic
volume, increase in compliance

Respiratory System
Pulse Oxymetri
Normal: 96%-99%
88% acceptable for
patient with lung disease

High pulse ox indicates:


O2 available in the lung,
taken up in the blood,
delivered to distal
tissues.

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

Pemantauan sistem saraf


Bispectral Index, utk
mengetahui kedalaman
anesthesia dari
mendeteksi dan rekaman
gelombang
elektroensefalogram
(EEG)
Tingkat anestesi nilainya
40-60 (100 artinya sadar
penuh)

Train of Four
Mengukur tingkat
blokade oleh
pelumpuh otot
memberikan 4
stimulus berturutan
dengan frekwensi 2
Hz selama 2 detik

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