3. CVS monitoring.pptx

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1. Cvs Monitoring in Critical Care ISRAR HUSSAIN YOUSAFZAI BS (ANESTHESIA) PGRT MSPH SR. RT, HMC PESHAWAR

2. introduction Most ICUs monitor ECG, HR, BP SpO2 This approach might be inappropriate in the ICU No monitoring device can improve patient outcomes unless it is coupled to a treatment e.g. Hemorrhage often manifests as tachycardia and HTN with low SpO2. Neither B-blockers nor vasodilators are indicated in the initial management of such patients Thus , it is not enough to monitor the patient closely, but also interpret in the context of the pathophysiology and stage of the patient’s disease

3. Purposes To detect an impending CVS crisis before organ damage To monitor the response to CVS therapy To titrated treatments to specific CVS responses To differentiate causes of hemodynamic instability Effectiveness Accuracy of technology Healthcare professional’s ability to diagnose Effective treatment of the underlying diseases for which the monitoring is used

4. common variables Variables Arterial blood pressure ( BP) Heart Rate ( HR) Oxygen saturation ( SpO2) Central venous pressure (CVP ) Pulmonary artery occlusion pressure Cardiac output ( CO) Mixed venous oxygen saturation (SvO2 ) Mode of measurement Invasive and non-invasive Non invasive Non invasive Invasive Invasive Invasive Invasive

5. common variables Threshold values exist such that values above or below them may reflect CVS compromise That usually not tolerated for prolonged intervals without resulting in end-organ dysfunction and/or death e.g. Bradycardia (HR < 45/min) Tachycardia (HR > 130/min) Hypotension (mean BP < 65 mm Hg) Hypertension (mean BP > 180 mm Hg )

6. simplistic statements Tachycardia is never a good thing Hypotension is always pathological There is no such thing as a normal cardiac output CVP is only elevated in disease Peripheral edema is of cosmetic concern

7. Heart Rate monitoring “Finger on pulse” is the easiest, quickest and most accurate method to assess heart rate ECG is most common method to detect heart rate in OT, by measurement of R-R interval ECG can be confounded by electrosurgical instruments, power line noises, twitching and fasciculation, and fluid warmer Beside these pulse oximeter and stethoscope are also used for HR monitoring

8. Arterial blood pressure monitoring Non invasive (indirect method ) Manual Automated Manual Intermittent techniques Automated Intermittent techniques Automated Continuous techniques Invasive (Direct method)

9. NIBP (manual) Sphygmomanometer was used for SBP 1 st time by Riva and Rocci in 1896 (palpatory method ) Karotkoff in 1905 described measurement of diastolic as well (auscultatory method ) Size of cuff should be 40% to 80 % of circumference of arm T oo large can still be accepted but loose give low reading Too small will give high reading Pressure should be released slowly to assess Karotkoff sounds properly Very low frequency sounds (25-50 Hz) produced by turbulent blood flow

10. Nibp (automated) Intermittent based oscillatory method , 1 st described by Marey in 1876 Assess MAP most accurately and SBP and DBP are derived ( DBP least reliable) This method is unreliable , and its use other than upper arm is not validated Complications may occur due to continuous use in patients like: Coagulopathies Arterial and venous insufficiency Thrombolytic therapy Peripheral neuropathies

11. Complications of Nibp (automated) Petachae Limb edema Venous stasis and thrombophlebitis Peripheral neuropathy ( median , ulnar, radial) Compartment syndrome (impaired limb perfusion ) Pain

12. IBP/Direct bp monitoring IBP monitoring is an ideal standard method for BP monitoring Provide timely and crucial information Although it have various complications and need expertise Arterial cannulation can be done in radial, ulnar, brachial, axillary or femoral artery Before cannulation, confirm collateral supply (Allen’s test )

13. Allen’s test

14. IBP/Direct bp monitoring More central the artery, more will be the chances of embolism In radial artery cannulation hyperextension is avoided to prevent median nerve injury In femoral artery cannulation must be done below the inguinal ligament

15. Indications for Arterial Cannulation Need for continuous , real-time and beat to beat BP monitoring Repeated blood sampling Failure of indirect arterial blood pressure measurement Supplementary diagnostic information from the waveform Determination of volume responsiveness from SBP and PP variation

16. Components Intra-arterial cannula Coupling system ( stopcock) Pressure transducer Infusion flushing system Signal processor, amplifier and display

17. Levelling & zeroing Zeroing: For a pressure transducer to read accurately, atmospheric pressure must be discounted This is done by exposing the transducer to atmospheric pressure and calibrating the pressure reading to zero Levelling : The pressure transducer must be set at the appropriate level Patient’s heart , at the 4 th intercostal space, in the mid-axillary line

18. Complications of ibp Monitoring Distal ischemia Arteriovenous fistula Hemorrhage , hematoma – coagulopathy Arterial embolization Local infection, s epsis Peripheral neuropathy Patient on anticoagulant therapy

19. Central venous Pressure monitoring CVP is the pressure measured at the junction of the superior venae cava and the right atrium It reflects the relationship of blood volume to the capacity of the venous system Normal CVP in an awake ,spontaneously breathing patient = 1-7mmHg OR 5-10 cmH 2 O Mechanical ventilation  3-5 cmH 2 O higher

20. Cvp monitoring Veins should be: Right /left internal jugular Right/ left subclavian Femoral Most commonly used size is 7 French , 20cm catheter with 18g introducer needle and a guide wire

21. Indications for cvp Central venous pressure monitoring Temporary hemodialysis Drug administration Concentrated vasoactive drugs Chemotherapy Prolonged antibiotic therapy (e.g., endocarditis) Rapid infusion of fluids Major surgery Trauma Inadequate peripheral intravenous access Sampling for repeated tests Total parenteral nutrition

22. a = Atrial contraction c = Isovolumic ventricular contraction x = Atrial relaxation v = filling of the atria y = ventricular filling h = Diastolic plateau

23. Complications of CVP Vascular injury Hemothorax, Pneumothorax, tamponade Airway compression from hematoma Tracheal, laryngeal injury Nerve injury Arrhythmias Subcutaneous emphysema Thrombosis, embolism Infection

24. Factors that increase CVP Hypervolemia Forced exhalation Tension pneumothorax Heart failure Pleural effusion Cardiac tamponed Positive end-expiratory pressure (PEEP) Mechanical ventilation Pulmonary Hypertension Pulmonary Embolism

25. Factors that decrease CVP Hypovolemia Deep inhalation Distributive shock Decreased cardiac out put

26. Pulmonary Artery Catheter Also called as Swan Ganz catheter It measure pulmonary artery pressure  This is measured by inserting a catheter into the pulmonary artery The mean pressure is typically 9 - 18 mmHg It is used for direct and indirect measurement of different parameters

27. Pulmonary Artery Catheter Direct measurement: Central Venous Pressure (CVP) Right sided Intracardiac pressures (RA/V) Pulmonary artery pressure (Pap) Pulmonary artery occlusion pressure (PAOP) Cardiac Output Mixed Venous Oxygen Saturation (SvO2)

28. Pulmonary Artery Catheter Indirect measurement: Systemic Vascular Resistance Pulmonary Vascular Resistance Cardiac Index Stroke volume index Oxygen delivery Oxygen uptake

29. PAC kit Standard PAC is 7.0, 7.5 or 8.0 French in circumference and 110 cm in length divided in 10 cm intervals It also include: A syringe that can be filled with only 1.5 mL of air to prevent over inflation of the balloon A long plastic sheath that is used to maintain sterility of the PAC as it is advanced and withdrawn

30. PAC kit PAC has 4-5 lumens: Temperature thermistor to measure pulmonary artery blood temperature Proximal port for CVP monitoring, fluid and drug administration Distal port at catheter tip for PAP monitoring Variable infusion port (VIP) for fluid and drug administration Balloon at catheter tip

31. Preparation & insertion Patient has to be monitored with continuous ECG throughout the procedure Supine position regardless of the approach Aseptic precautions must be employed Cau t ions should b e ta k en while cannulation via IJV/ Subcl a vian v ein Local infiltration Check balloon integrity by inflating with 1.5ml of air

32. Preparation & insertion Check lumens patency by flushing with saline 0.9% Pass catheter through sheath with tip curved towards the heart Once tip of catheter passed through introducer sheath, inflate balloon at level of right ventricle Advance the catheter through right atrium and ventricle into pulmonary artery and wedge position can be monitored by changes in pressure trace After acquiring wedge pressure, deflate balloon

33. Indications Diagnostic: Differentiation among causes of shock Differentiation between mechanisms of pulmonary edema Evaluation of pulmonary hypertension Diagnosis of pericardial tamponade Diagnosis of right to left intracardiac shunts Unexplained dyspnea

34. Indications Therapeutic: Management of perioperative patients with unstable cardiac status Management of complicated myocardial infarction Management of patients following cardiac surgery/high risk surgery Guide to pharmacologic therapy Assess response to pulmonary hypertension specific therapy

35. Contraindications Absolute: Infection at insertion site Presence of RV assist device Insertion during CPB Lack of consent Rela t ive: Coagulopathy Thrombocytopenia Electrolyte disturbances Severe Pulmonary HTN

36. Complications General: Immediate: Bleeding Arterial Puncture Air embolism Thoracic duct injury Pneumothorax Hemothorax Delayed: Infections Thrombosis

37. Complications 2. Related to insertion : Arrhythmias (RBBB ) Misplacement Myocardial, valve, vessel rupture 3. Related to maintenance : Pulmonary artery perforation Thromboembolism Infection