syllabus adv crtcresres_hemodynamics_03-04-08

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Advanced Critical Care Series Module I: Hemodynamics

March 4th, 2008 8:30 AM - 10:00 AM

Presented by: Elizabeth Scruth, RN, MN, CCRN

Eugene Cheng, MD, FCCM

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Advanced Advanced Critical Care Critical Care

SeriesSeriesModule1:

Advanced Hemodynamics

Advanced Advanced HemodynamicsHemodynamics

Elizabeth Scruth, RN, MN, MPH, CCNS, CCRN

Eugene Y Cheng, MD, FCCM

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OutlineOutlineNormal hemodynamic valuesHemodynamic goals for critically ill patientsInsertion sites for invasive hemodynamic cathetersCare and maintenance Interpretation of hemodynamic wave formsInsertion and confirmation of proper catheter placementTissue perfusion and oxygen deliveryCase study

Cardiovascular PhysiologyCardiovascular PhysiologyCardiac outputPreloadAfterloadContractilityConduction pathways

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Review of Selected Review of Selected Hemodynamic PrinciplesHemodynamic Principles

Cardiac output (CO) is the amount of blood ejected over 1 minute

Normal CO in resting adult is 4-6 L/min


CO indexed to pt’s BSA is cardiac index (CI)

Normal CI in resting adult is 2.2-4.0 L/min/m2

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Stroke volume (SV) is amount of blood ejected with each heart beat

SV = CO ÷ HR Example: 4.0L/min ÷ 100 = 40mL/beatNormal range for SV is 60-100 ml

Determinants of Cardiac OutputDeterminants of Cardiac Output

Cardiac OutputCardiac Output

Stroke VolumeStroke Volume Heart RateHeart Rate

PreloadPreload AfterloadAfterload ContractilityContractility

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PreloadPreloadRV preload (RVEDP) measured by CVP

Normal CVP 2-6 mmHg or 3-8 cmH20

LV preload (LVEDP) measured by PAOP, PAD & LAP

Normal PAOP 5-12 mmHgPresence of COPD, ARDS, pulmonary embolism, pulmonary HTN, mitral stenosis/regurgitation alters PAOP accuracy

AfterloadAfterloadRV afterload:

Caused by resistance of pulmonary arteries and arteriolesMeasured by PVR (normal PVR 100-250 dynes/sec/cm-5)

LV afterload Caused by systemic arteries and arteriolesMeasured by SVR (normal SVR 800-1400 dynes/sec/cm-5

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ContractilityContractilityRVSWI & LVSWI are most useful & sensitive measures of contractility

RVSWI measures RV contractility (normal 7.9-9.7g-m/m2)

LVSWI measures LV contractility (normal 50-62g-m/m2)

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Hemodynamic Goals Hemodynamic Goals for Critically Ill for Critically Ill

PatientsPatientsEugene Y Cheng, MD, FCCM

Indication for Invasive Indication for Invasive Hemodynamic MonitoringHemodynamic Monitoring

CardiacComplicated MICHFPulmonary HTN

ARDSPerioperative careShockAcute renal failure

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Therapeutic Hemodynamic GoalsTherapeutic Hemodynamic Goals

PressurePeripheral 65 mmHgCerebral 70 mmHgCoronary 70 mmHgRenal 65 mmHg

AfterloadSystemic 600-800 dyne·sec/cm-5Pulmonary 180-220 dyne·sec/cm-5

Therapeutic Hemodynamic GoalsTherapeutic Hemodynamic Goals

FlowCardiac output >4-6 L/minCardiac index >2-3 L/min

VolumePAOP 8-12 mmHgLV stroke volume 60-80 mL/beat

Tissue perfusionScvO2 65-70%

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Indications for Indications for Arterial CatheterizationArterial Catheterization

Unstable cardiovascular stateContinuous assessment of blood pressure response to therapyNeed for multiple arterial samplesIndicator dilution CO determination

Seldinger TechniqueSeldinger Technique

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Arterial Circulation of the HandArterial Circulation of the Hand

Radial artery first choice for catheterizationAllen test no longer needed prior to catheter insertionUse 20g needle or smaller

Femoral VasculatureFemoral VasculatureFemoral artery catheterization if radial artery not availableMust use longer catheter to prevent dislodgement

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Arterial Circulation of the ArmArterial Circulation of the Arm

Axillary artery third choice Not for coagulopathicpatientsAvoid using brachial artery

Arterial WaveformArterial Waveform

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Complications of Complications of Arterial CatheterizationArterial Catheterization

Hematoma ThrombosisEmbolismHemorrhageInfection

Indications for Central Indications for Central Venous CatheterizationVenous Catheterization

Secure venous accessAssessment of intravascular volumeCO measurementAssessment of tissue oxygenationTitration of fluids and medications

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Additional Hemodynamic Additional Hemodynamic Information from Pulmonary Information from Pulmonary Artery CatheterizationArtery Catheterization

Pulmonary artery pressureRight ventricular pressurePulmonary artery occlusion pressurePVR

CVC OptionsCVC Options

Antimicrobial Triple lumen25 cm

AntimetabolicQuadruple lumen

Antiseptic Double lumen20 cm

Heparin Single lumen15 cm

CoatingLumensLength

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Pulmonary Artery CathetersPulmonary Artery CathetersStandard thermodilution cardiac outputContinuous cardiac outputRight ventricular functionPacing PA catheterPaceport PA catheter

CVC Insertion SitesCVC Insertion SitesSubclavian/Axillary veinInternal/external jugular veinFemoral veinBasilic/Cephalic vein

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Central Venous Central Venous Catheterization ComplicationsCatheterization Complications

HematomaArrhythmiasHemorrhageEmbolizationPneumothorax

Complications of Complications of Right Heart CatheterizationRight Heart Catheterization

RBBBPulmonary artery ruptureRight ventricular perforationCatheter knotting

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Subclavian Vein Site for CVCSubclavian Vein Site for CVCLowest rate of infectionMost comfortable for patientesHighest placement risks

Internal Jugular Site for CVCInternal Jugular Site for CVCSecond best choice for CVCLower insertion risk of pneumothorax

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Femoral Vein Site for CVC Femoral Vein Site for CVC Site of last choice for elective placement of CVCHighest infection rateCannot monitor CVP or ScvO2

Good choice if patient has coagulapathy or during CPR

BasilicBasilic Site for CVCSite for CVCLow riskPoor flow ratesQuestionable accuracy of CVP

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Care and Care and Maintenance of Maintenance of Hemodynamic Hemodynamic

CathetersCatheters

The Institute of Healthcare Improvement has recommended as a bundle to implement the following:

Hand hygieneMaximal sterile barriersChlorhexidine for skin asepsisAvoid femoral linesAvoid/remove unnecessary lines

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A hemodynamic monitoring system contains 2 compartments: the electronic system and the fluid-filled tubing system.

1. Steps should always be followed when setting up for pressure monitoring.

2. Correct setup and maintenance of the tubing setup and the pressure transducer are crucial to avoid errors.

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Leveling and ZeroingLeveling and Zeroing

Leveling and zeroing

Dynamic response testing

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Leveling and Zeroing

Level of the transducer must be at the level of the left atrium- 4th ICS –lateral aspect

Zeroing must be done at time of insertion and then once per day and as needed if numbers seem inaccurate

A dynamic response test is done to determine if a hemodynamic monitoring system can adequately reproduce a patient’s cardiovascular pressuresTest should produce two oscillations-otherwise overdamped or underdamped waveforms appear

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General care of invasive linesGeneral care of invasive linesAlarms are never to be turned off-this is not only a safety requirement, but also a requirement by Joint CommissionLabel all linesDocument the waveform characteristicsDocument the level of the PA catheter at the site of insertionAccurate interpretation of waveforms

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Pressure bag to be inflated at 300 mm Hg at all timesDressing changesBag changes

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Interpretation of Interpretation of hemodynamic hemodynamic

waveformswaveforms

A C V WAVESA C V WAVES-- CVP waveformCVP waveformA wave- occurs after the P wave C wave occurs at the end of the QRS complex in the RST junctionV wave occurs after the T waveFinal filling of the ventricle occurs during atrial contraction- A wave, therefore, to assess final ventricular filling pressures:-average the a wave of the CVP waveform

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Measuring CVPMeasuring CVPThe peak of the “a” wave coincides with the point of maximal filling of the right ventricleTherefore, this is the value which should be used for measurement of RVEDPMachines just “average” the measurementShould be measured at end-expiration

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Reading Pressure Waveforms Reading Pressure Waveforms ––CVP Practice WaveformCVP Practice Waveform

Patient is on ventilator

5-15

Reading Pressure Waveforms Reading Pressure Waveforms ––CVP Practice Waveform AnswerCVP Practice Waveform Answer

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Causes of large V waves in the CVP tracing- tricuspid valve regurgitation

What does it mean when the RA port from a PA catheter is in the RV so you see an RV tracing on the monitor instead of a CVP tracing?

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It means the following:1) If the patient has cardiomyopathy

the CVP port is sitting in the RV2) The PA catheter needs to pulled back

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PAOPPAOPPulmonary arterial occlusion pressure :

Pulmonary arterial occlusion pressure (PAOP) is measured when the balloon on the tip of the PAC is inflated within a pulmonary artery. This enables the catheter to obtain an indirect measurement of left ventricular end diastolic pressure (normal range 6-12 mmHg)

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Instances where PAOP overestimates LVED pressure include those which create an interfering pressure gradient, but do not represent the function of the left ventricle:

Chronic Mitral Stenosis PEEP (Positive end expiration pressure ventilation) Left atrial myxoma Pulmonary Hypertension

Instances where PAOP underestimates LVED pressure include those that increase the pressure in the left ventricle which the catheter tip cannot detect:

Stiff Left Ventricle LVED pressure > 25mmHg Aortic Insufficiency

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Reading Pressure Waveforms Reading Pressure Waveforms -- CVP/PAOPCVP/PAOP

P wave represents atrial contraction

Reading Pressure Waveforms Reading Pressure Waveforms -- CVP/PAOPCVP/PAOP

In T-P intervalNear end of T wave v waveS-T segmentEnd of QRSc waveEnd of QRSIn the P-R intervala wave

PAOPCVPWave

The mean of the peak of the a wave and the bottom of the x descent is the numerical value obtained for CVP/PAOP readings

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Tricuspid and Tricuspid and Mitral Valve PathologyMitral Valve Pathology

Tricuspid and MITRAL VALVE STENOSIS:Look for presence of large A waves on CVP and PAOP tracings

Tricuspid and MITRAL VALVE REGURGITATION:

Look for large V waves

Reading Pressure Waveforms Reading Pressure Waveforms ––PAOP Practice WaveformPAOP Practice Waveform

Patient is breathing spontaneously

E9-9.5

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Reading Pressure Waveforms Reading Pressure Waveforms ––PAOP Practice Waveform AnswerPAOP Practice Waveform Answer

RelationshipRelationship between between Pulmonary Artery Diastolic Pulmonary Artery Diastolic (PAD) and PAOP(PAD) and PAOP

Blood always moves from a higher to a lower pressure

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Relationship between Relationship between Pulmonary Artery Diastolic Pulmonary Artery Diastolic (PAD) and PAOP(PAD) and PAOP

PA mean (PAM) pressure must always be high enough to push blood into LA

Therefore, atrial pressures should never exceed mean arterial pressures


This means PAOP must be lower than PAM pressure

If PAOP is higher than PAM, recheck waveform-make sure correct points are being identified

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PAD is also usually higher than PAOP.

If PAOP equals PAD, the difference needed to move blood forward is very small


Normally, PAD is 1-4 mmHg higher than PAOP

This relationship occurs only in normal situations or passive pulmonary HTN (PAP increase in response to increased LV pressures seen in heart failure)

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Discrepancy seen between PAD and PAOP in pulmonary HTN caused by obstruction or loss of vasculature

Relationship seen between PAD and PAOP in patients with LV failure (PAOP correlated with PAD)

Effects of Lung Zones Effects of Lung Zones on a PAOP Tracing on a PAOP Tracing

Obtaining an PAOP tracing is only possible if an uninterrupted pathway exists from tip of PA catheter and LA

Theoretically, the lung has 3 perfusion zones

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Effects of Lung Zones Effects of Lung Zones on a PAOP Tracingon a PAOP TracingZone III

Effects of Lung Zones Effects of Lung Zones on a PAOP Tracingon a PAOP Tracing

When PA catheter is below the level of the LA, a zone III condition is likely to exist

A lateral chest x-ray is needed to confirm whether the PA line is below the LA

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Insertion and Insertion and Confirmation of Proper Confirmation of Proper

Central Venous Central Venous Catheter PlacementCatheter Placement

Eugene Y Cheng, MD, FCCM

CXR LandmarksCXR Landmarks

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CVC CVC ““In Good PositionIn Good Position””

CVC in the RCVC in the R--AtriumAtrium

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PA Catheter Position ConfirmationPA Catheter Position Confirmation

ItIt’’s All About Mes All About Me

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Oxygen DeliveryOxygen DeliveryCardiac OutputSvO2 (ScvO2)LactateGastric tonometry

Cardiac Output MonitorsCardiac Output MonitorsInvasive Techniques

PA catheter and thermodilutionDirect Fick calculationTranspulmonary TD with arterial pulse contour analysis (PiCCO™)

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Cardiac Output MonitorsCardiac Output MonitorsSemi-Invasive Techniques

Lithium dilution curve with arterial waveform analysis (LIDCO™)Trans-esophageal/gastric doppler ultrasoundIndirect Fick calculation with partial CO2rebreathing

Cardiac Output MonitorsCardiac Output MonitorsNoninvasive Techniques

Electrical bio-impedance cardiography

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22 CaOCOdeliveryO ∗=

)( 222 CvOCaOCOnconsumptioO −∗=

)0031.0()39.1( 22 pOHbcontentO ∗×∗=

Oxygen Supply and DemandOxygen Supply and Demand

Factors Influencing SvOFactors Influencing SvO22 (ScvO(ScvO22))

Cardiac outputOxygen consumptionHemoglobin concentrationArterial oxygen contentVenous oxygen content

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ScvOScvO2 2 MeasurementsMeasurementsNormal 65-70%Mild global ischemia <60%Severe global ischemia <50%

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Case StudyCase Study63 y/o 100 kg male arrives to the ED obtunded and tachypneic. T 38.3oC RR 38/min; HR 120/min SpO2 81%BP 85/30 mmHg

Recommendations?

Assessment and Plan (1h)Assessment and Plan (1h)Patient intubated;

20g L-anticubital iv; NS 500 ml fluid bolus and maintenance infusion NS 100 ml/h

ECG—t wave inversion V2-6;CXR—basilar atelectasis

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Assessment and Plan (1h)Assessment and Plan (1h)Hct 31% lactate 7.3 mmol/LNa+ 138 mEq/L K+ 4.9 mEq/L Scr 1.8 mg/dL pH 7.2 pCO2 45 mmHg pO2 165 mmHg HCO3 20 mmol/L

T 38.1oC

HR 126/min RR 28/min

BP 80/39 mmHg SpO2 99%

Recommendations?

Assessment and Plan (2h)Assessment and Plan (2h)ScvO2 triple lumen CVC inserted 1000 ml NS bolusT 37.5oC RR 28/minHR 121/min SpO2 99%BP 85/39 mmHg CVP 5 mmHg

Recommendations?

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Assessment and Plan (3h)Assessment and Plan (3h)3 L NS given; maintenance iv 200 ml/hT 37.1oC RR 28/minScvO2 55%HR 117/min SpO2 97%BP 87/39 mmHg CVP 9 mmHg

Recommendations?

Assessment and Plan (4h)Assessment and Plan (4h)4 L NS given, iv rate 200 mL/h NE gtt 30 mcg/minT 37.1oC RR 28/min ScvO2 62%HR 117/min SpO2 97%BP 92/35 mmHg CVP 9 mmHgHct 30% lactate 6.3 mmol/LNa+ 138 mEq/L K+ 4.9 mEq/L Scr 1.6 mg/dL pH 7.21 pCO2 42 mmHg pO2 133 mmHgHCO3 20 mmol/LRecommendations?

48

Assessment and Plan (6h)Assessment and Plan (6h)5 L of NS (1 L bolus) given, iv rate 200 mL/h

NE gtt 30 mcg/minDobutamine 5 mcg/kg/min

T 37.1oC RR 28/min ScvO2 60%HR 117/min SpO2 97%BP 97/39 mmHg CVP 7 mmHg

Hct 26% lactate 4.3 mmol/LNa+ 138 mEq/L K+ 4.9 mEq/L Scr 1.5 mg/dLpH 7.19 pCO2 42 mmHg pO2 133 mmHg HCO3 20 mmol/LRecommendations?

Assessment and Plan (8h)Assessment and Plan (8h)6 L of NS (1 L bolus) given, iv rate 200 mL/h

NE gtt 30 mcg/minDobutamine 8 mcg/kg/min2 u PRBCs

T 35.1oC RR 28/min ScvO2 65%HR 126/min SpO2 97%BP 93/39 mmHg CVP 10 mmHgHct 31% lactate 3.3 mmol/LNa+ 138 mEq/L K+ 4.9 mEq/L Scr 1.5mg/dLpH 7.25 pCO2 39 pO2 133 HCO3 20 mmol/L Recommendations?

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Assessment and Plan (8h)Assessment and Plan (8h)Continue current treatment plan

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