cvs monitoring

8/12/2019 CVS Monitoring

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Cardiovascular Monitoring II

Dr CH Koo

QEH

www.anaesthesia.co.in

[email protected]
http://www.anaesthesia.co.in/mailto:[email protected]:[email protected]://www.anaesthesia.co.in/


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Arterial Line

Direct measurement of blood pressure

most accurate technique

continuous haemodynamic information blood gas measurement


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Indications

Patient factors Patient with severe sepsis or shock Cardiac diseases such as unstable angina, recent AMI,

current congestive heart failure or cardiac arrhythmias or onpacemaker

Surgical considerations

Cardiac surgery

Major surgery on aorta or carotid arteryNeurosurgery such as craniotomy or aneurysm clipping

Major surgery with expected blood loss more than 1 bloodvolume


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Indications(Contd)

Anaesthetic considerations

Controlled hypotensive techniques

Inability to measure blood pressure non-

invasively

Frequent blood sampling required during and

after operation


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Setting up an arterial line

Equipment

Pressure bag

Collapsible 0.9% 500cc Normal saline bag with air

expelledPressure transducer and infusion set

Cannula

+ heparin (1-2 units /ml)
http://localhost/var/www/apps/conversion/tmp/scratch_3/Cannulation%20siteshttp://www.anaesthesia.co.in/


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Steps

1. Set up the pressure measurement system andpressurized the bag to 300 mmHg

2. Cannulate an artery

3. Connect to the pressure measurement system4. Fix the cannula securely

5. Zeroing the transducer

6. Fix the transducer at the heart level

7. Start measurement


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Central venous pressure monitoring

Introduction

Monitoring of intracardiac pressures

ventricular dysfunction due to ischaemia,valvular abnormalities or primary

myocardial disease

allow differentiation between hypovolaemiaand myocardial depression


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Indications

1. Assessment of preload in patients withhypovolaemia / septic shock / valvular problems /congestive heart failure

2. Assessment of right ventricular dysfunctionassociated with severe lung disease, pulmonaryhypertension, cardiac tamponade

3. Craniotomy in the sitting position

4. Major surgery with expected blood loss >1 bloodvolume

5. Difficult intravenous access


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Setting up the CVP manometer

Normal Saline or Dextrose 5% solution

Simple IV set

Prime the CVP manometer tubing Run at least 10 cm of water into the

manometer

Remove all bubbles in the water column


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Type of CVP cannula

Single lumen

long angiocath (16G,14G),

catafix (375mm, 475mm),

percutaneous sheath (7F, 8.5F)Swan sheath (8.5F)

Multiple lumens

2-,3-,4- lumen


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Steps in setting up CVP

monitoring line1. Prime the CVP manometer or set up the pressure transducer

2. Choose the site of central vein insertion

3. Position the patient- shoulder support and head down and turn to

opposite side for IJV and SCV cannulation,

4. Sterilise the area with aseptic solution and create a sterile field

5. Local the vein with seeker needle

6. Use Seldinger technique to canulate the vein

7. Connect to the CVP manometer or transducer8. Fix the cannula securely

9. Back flow of blood


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Complications of CVP

1. Carotid artery puncture

2. Pneumothorax

3. Air embolism

4. Arrhythmia5. Perforation of SVC or R atrium/ventricle ->

cardiac tamponade

6. Brachial plexus, vagus nerve, phrenic nerve injury

7. Thoracic duct perforation (usually left side) ->chylothorax

8. Retroperitoneal haematoma


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Complications of CVP (Contd)

9. Infection

10. Pleural effusion

11. Airway obstruction- extravasation ofinfusate or bleeding from puncture artery

12. Allergic reaction to substance impregnated

on the catheter


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Pulmonary artery pressure

monitoring

Allow measurement of pressures close to

the left ventricle LVEDV LVEDP LAV LAP PCWP

RVEDV RVEDP RAV - RAP CVP


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Indications

1. Ischaemic heart disease with recent myocardialinfarction

2. Symptomatic valvular heart disease

3. Cardiomyopathy4. Congestive heart failure and low ejection faction

5. Shock- septic or hypovolaemic

6. Pulmonary hypertension

7. Cardiac surgery with poor ventricular function


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What is being measured by PAFC?

1. Central venous pressure

2. Pulmonary artery systolic and diastolic pressure

3. Pulmonary capillary wedge pressure

4. Cardiac output5. Mixed venous oxygen saturation

6. Derived values such as stroke volume, cardiacindex, ventricular stroke work, systemic and

pulmonary vascular resistance


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Technique of insertion

1. Choose the site of line insertion2. Position the patient- should support and head

down and turn to opposite side for IJV and SCVcannulation,

3. Sterilise the area with aseptic solution and create asterile field

4. Local the vein with seeker needle

5. Use Seldinger technique to cannulate the vein with

the swan sheath

6. Fix the swan sheath securely by stitches

7. The PAFC is flushed with saline through each ofits ports and the balloon at the tip tested


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Technique of insertion (Contd)

8. The transducers are zeroed and calibrated9. The PAFC is introduced into the sheath and advanced to the

20cm mark.

10.The balloon at the tip is inflated with 1.5 ml of air and kept

inflated.11.The catheter is slowly advanced to obtain right ventricular

tracing. Further advance the catheter into the pulmonary

artery which occurs when the diastolic pressure increases. At

this point the catheter is slowly advanced to a wedge positionwith the waveform changed to that similar to the atrial tracing.

The balloon is then deflated and a PA tracing will appear.


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Technique of insertion (Contd)

12. The transducers are placed at the right atriallevel. Haemodynamic measurements andthermodilution cardiac outputs are performed and

derived variables calculated.

13. CXR should be obtained if complication issuspected or after surgery


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QuickTime and a

Video decompressorare needed to see this p icture.


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Measurement of cardiac output

using PAFC1. Ensure correct positioning of the PAFC in the heart-

proximal opening in R ventricle and distal thermister inpulmonary artery

2. Measure the PCWP

3. Press the CO measurement button and observe that thetemperature baseline is stable

4. Withdraw 10 ml of normal saline or dextrose at roomtemperature into syringe

5. Press the start button and inject the 10 ml of fluid as fast aspossible

6. A temperature change curve will be observed

7. Repeat the measurement 3-4 times

8. Select the 3 best temperature curve and press calculate


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Complications

Similar to that of CVP insertion

Additional complications are:1. Arrhythmogenesis,

2. Thrombosis and embolism,

3. Pulmonary infarction or haemorrhage,

4. Endocarditis,

5. Perforation of atrium, ventricle and pulmonary artery,6. Intracardiac knotting


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Transoesophageal echocardiography

Indications

American Society of Anaesthesiologists practiceguidelines for perioperative TEE

Category I indications - supported by strongestevidence or expert opinion

Category II indications - supported by weakerevidence or expert consensus

Category III indications Little current scientificor expert support


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Contraindications

Patient with oesophageal stricture

Patient with history of oesophageal tumour

Patient with oesophageal varices Patient with severe coagulalopathy preop


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What is being measured?

Ischaemic state via measurement of regionalwall motion and wall thickening changes

Ventricular function via measurement of

ejection fraction, wall shortening andventricular volumes

Valvular function

Intracardiac air and masses (eg. thrombus,tumour, etc)


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Any Questions?

www.anaesthesia.co.in

anaesthesia co in@gmail com
http://www.anaesthesia.co.in/mailto:[email protected]:[email protected]://www.anaesthesia.co.in/

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