Pelatihan Perawat ICU

Hemodinamik Monitoring

TEAM ICU
Putu Agus Surya Panji
 ICU
Intensive Care Unit
99 % keberhasilan perawatan di ICU
adalah peran perawat

100 % CARE
DO I REALLY NEED TO KNOW
HEMODYNAMICS?
HEMODYNAMIC
What is hemodynamic?
Hemodynamic is blood flow within the
cardiovascular system, it reflex cardiovascular
performance
Dynamic state, have an autoregulatory
mechanism
Multiparameter
Adequate blood circulation is vital for
maintenance of adequate tissue metabolism
HOW TO MEASURE???
 History of Monitoring
1960s: golden age of vasopressors
Press1970s: golden era arterial line & CVP
1970s: golden age of inotropes
Cardiac output, PA catheter
1980s:
SvO2 , relative balance between oxygen supply and
demand
1990s till now:
Better understanding of tissue oxygenation, right
ventricular function
Functional monitoring, PiCCO, continuous CO
Less invasive, TEE
GOALS OF MONITORS
To assure the adequacy of perfusion

Early detection of inadequacy of perfusion

To titrate therapy to specific hemodynamic end point

To differentiate among various organ system dysfunctions

Hemodynamic monitoring for individual patient should be

physiologically based and goal oriented
DIFFERENT ENVIRONMENTS
DEMAND DIFFERENT RULES
Emergency Department
Rapid, minimally invasive, high sensitivity

Trauma ICU
Rapid, invasive, high specificity

Operation Room
Accurate, invasive, high specificity
Close titration, zero tolerance for complications

ICU & RR
Somewhere in between ER and OR
Civetta. Textbook of Critical Care 2009
Blood pressure
Urine production Skin perfusion Mental status
Central venous pressure

Clinical assessment
+
Blood lactate level
+
Cardiac output Systemic and OPS techniques
regional
SvO2
haemodynamic and Tissue PO2
Psl CO2 oxygenation variable

Comprehensive assessment

Vincent JL.25 Years of Progress and Innovation in Intensive Care Medicine.ESICM

2007
 Stroke volume

Preload Contractility Afterload

myocardial fibers
circulating volume contractility SVR
venous tone
atrial contraction myocardial mass
intrathoracic sympathoadrenal
pressure
activation

TTE, TEE, PiCCO

Fluid
CVP, PA cateter,
TTE, TEE,
Inotropic
(SV/CO), Vigelio
TTE, TEE, PiCCO,
Vasoactive
PiCCO (PPV), IABP
(SV/CO) Vigelio (SVR)
Vigelio (SVV)
BAGAIMANA MENGUKUR CARDIAC OUTPUT????
(PRELOAD)

STATIS DINAMIS
Pressure Pressure
CVP PPV (PiCCO)
Swan Ganz

Volume Volume
Echocardiography SVV (Vigileo, EV 1000)
TTE
TEE

Setiap parameter memiliki keterbatasan dan

rambu2 yang harus diperhatikan
 Noninvasive Hemodynamic Monitoring

Noninvasive BP Skin Temperature

Heart Rate, pulses

Capillary Refill
Mental Status
Urine Output
Mottling (absent)
Proper Fit of a Blood Pressure Cuf

Width of bladder = 2/3 of upper arm

Length of bladder encircles 80% arm

Lower edge of cuf approximately 2.5 cm above

the antecubital space
Why A Properly Fitting Cuf?

Too small causes false-high reading

Too LARGE causes false-low reading

Indications for
Arterial Blood Pressure

Frequent titration of vasoactive drips

Unstable blood pressures

Frequent ABGs or labs

Unable to obtain Non-invasive BP

Potential Complications
Associated With Arterial Lines

Hemorrhage

Air Emboli

Infection

Altered Skin Integrity

Impaired Circulation
Central Venous Pressure Assesses . . .

Intravascular volume status

Right ventricular function

Patient response to drugs &/or fluids

Central Venous Pressure (CVP)
Central line or pulmonary artery catheter

Normal values = 2 8 mm Hg

Low CVP = hypovolemia or venous return

High CVP = over hydration, venous return,

or right-sided heart failure
Leveling and Zeroing

Leveling
Before/after insertion
After patient, bed or transducer move
Aligns transducer with catheter tip

Zeroing
Performed before insertion & readings

Level and zero transducer at the phlebostatic axis

Phlebostatic Axis

4 th
intercostal space, mid-axillary line

Level of the atria

(Edwards Lifesciences, n.d.)

 More on Leveling and Zeroing

HOB 0 60 degrees

No lateral positioning

Phlebostatic axis with any

position (dotted line)

(Edwards Lifesciences, n.d.)

PAC
Advantages
Provide lot of important haemodynamic
parameters
Sampling site for SvO2
Disadvantages
Costly
Invasive
Multiple complications (eg arrhythmia,
catheter looping, balloon rupture, PA
injury, pulmonary infarction etc)
Mortality not reduced and can be even
higher
 Indications
for PAP monitoring

Shock of all types

Assessment of cardiovascular function and response to therapy

Assessment of pulmonary status

Assessment of fluid requirement

 Old Equipment
Pulmonary Arterial Catheter
Functional Hemodynamic Monitors
Arterial pulse contour analysis
A better monitors for preload
responsiveness:
a significant correlation between the
increase of cardiac index by fluid
loading by pulse pressure variation
and stroke volume variation
Peripheral continuous cardiac output system
(PiCCO): arterial pulse contour and
transpulmonary thermal injection:
intrathoracic volume and
extravascular lung water
 Pulse Pressure Variation:
Calculation
Pulsepressure variation (PPV) represents the variation of the pulse pressure over
the ventilatory cycle

PPmean

PPmax PPmin
PPmax PPmin
PPV
PPV =
:
PPmean
measured over last 30s window

only applicable in controlled mechanically ventilated patients with regular beat

rhythm
 Stroke Volume Variation :
Calculation
StrokeVolume Variation (SVV) represents the variation of stroke volume
(SV) over the ventilatory cycle

SVmax
SVmin

SVmean

SVmax
SVV : SVV
SVmin
SV
measured over last 30s=window mea

only
applicable in controlled mechanically
n ventilated patients with regular
heart rhythm
 SPONTANEOUS BREATHING
Heart Lung Interaction

normal individual who breath spontaneously, blood pressure decreases on inspiration

e normal range of variation in spontaneously breathing is 5-10mmHg
Reverse Pulsus Paradoxus
(Mechanical Ventilation)

Stroke Volume Variation

(SVV)

Pulse Pressure Variation

(PPV)

Systolic Pressure Variation

Paradoxical Pulsus

Respiratory Paradox
Vigileo / FloTrac Sensor

Calibration is not needed

Vigileo
+ central venous oxygen
saturation
Derived from high fidelity
oxygen saturation sensor
at the tip of CVP catheter
 Positive Pressure Ventilation

SV

Inspiration
Fluid Responsiveness
SVV >13
LVEDP
 Positive Pressure Ventilation

SV
Inspiration
SVV <13 Fluid Non-responsiveness
Inotropic Needed

LVEDP
 Positive Pressure Ventilation

SV Inspiration
SVV <13
Worse

LVEDP
 Transthoraci
c Echo

Assessment of cardiac structure, ejection fraction

and cardiac output
Based on 2D and doppler flow technique
TRANSTHORACIC ECHO

Advantages
Fast to perform
Non invasive
Can assess valvular structure and myocardial function
No added equipment needed

Disadvantages
Difficult to get good view (esp whose on ventilator /
obese)
Cannot provide continuous monitoring
 TRANSESOPHAGEAL ECHO

CO assessment by Simpson or doppler

flow technique as mentioned before
Better view and more accurate than TTE
Time consuming and require a high level
of operator skills and knowledge
e pyramid of echocardiography skills in ICU
Bagaimana pada pasien
ARDS, ACS, aritmia???
In conclusion
Choosing the methods in monitoring
depend the environments
Most trials of cardiac output
measurement devices identified by
systematic review and new
techniques provide good results, less
invasive
Always correlate the
reading/finding with clinical
pictures
 No gold standard for
measurement of
BE WISE
cardiac output in
patients with shock
Matur Suksma