NISHI%20-%20CARDIAC%20MONITORING(%20IBP,%20CVP,%20PA).pptx

Invasive blood pressure monitoring, central venous pressure, pulmonary artery

1. CARDIAC MONITORING (IBP,CVP,PA) MODERATOR – DR. AMIT JANGID PRESENTED BY- DR. NISHI

2. INVASIVE ARTERIAL PRESSURE MONITORING

3. INTRODUCTION Intra-arterial blood pressure (IBP) measurement is often considered to be the gold standard of blood pressure measurement. Despite its increased risk, cost, and need for technical expertise for placement and management, its utility in providing crucial and timely information outweighs its risks in many cases 3

4. Indications for Arterial Cannulation Continuous, real-time blood pressure monitoring Planned pharmacologic or mechanical cardiovascular manipulation Repeated blood sampling Failure of indirect arterial blood pressure measurement, e.g. burns or obesity Supplementary diagnostic information from the arterial waveform 4

5. BASIC PRINCIPLES The pressure waveform of the arterial pulse is transmitted via the column of fluid, to a pressure transducer where it is converted into an electrical signal. This electrical signal is then processed, amplified and converted into a visual display by a microprocessor. 5

6. Percutaneous Radial Artery Cannulation The radial artery is the most common site for invasive blood pressure monitoring because it is technically easy to cannulate and complications are uncommon Modified Allen’s test 6

7. 02-05-2024 Dr. Vikram Naidu 7

8. “ Transfixation ” technique Dr. Vikram Naidu 8

9. ULTRASOUND IMAGING 9

10. Alternative Arterial Pressure Monitoring Sites Ulnar Brachial Axillary Femoral – seldinger technique Dorsalis pedis 10

11. Complications of Direct Arterial Pressure Monitoring Hemorrhage Misinterpretation of data Distal ischemia Pseudoaneurysm Arteriovenous fistula Arterial embolization Infection Peripheral neuropathy 11

12. 02-05-2024 Dr. Vikram Naidu 12

13. 13

14. Fourier Analysis The arterial waveform is clearly not a simple sine wave, but it can be broken down into a series of many component sine waves The process of analysing a complex waveform in terms of its constituent sine waves is called Fourier Analysis . 14

15. Properties Natural frequency Damping coefficient 15

16. The natural frequency of a system determines how rapidly the system oscillates after a stimulus The damping coefficient reflects frictional forces acting on the system and determines how rapidly it returns to rest after a stimulus 16

17. Natural Frequency It is important that the IBP system has a very high natural frequency – at least eight times the fundamental frequency of the arterial waveform (the pulse rate). Therefore, for a system to remain accurate at heart rates of up to 180bpm, its natural frequency must be at least: (180bpm x 8) / 60secs = 24Hz. 17

18. Natural Frequency The natural frequency of a system may be increased by: Reducing the length of the cannula or tubing Reducing the compliance of the cannula or diaphragm Reducing the density of the fluid used in the tubing Increasing the diameter of the cannula or tubing Commercially available systems -200Hz 18

19. Damping Anything that reduces energy in an oscillating system will reduce the amplitude of the oscillations. This is termed damping. Some degree of damping is required in all systems ( critical damping ), but if excessive ( overdamping ) or insufficient ( underdamping ) the output will be adversely effected. 19

20. 20 Underdamped arterial pressure waveform Overdamped arterial pressure waveform

21. Factors that cause overdamping include: Friction in the fluid pathway Three way taps Bubbles and clots Vasospasm Narrow, long or compliant tubing Kinks in the cannula or tubing 21

22. FAST-FLUSH TEST Provides a convenient bedside method for determining dynamic response of the system Natural frequency is inversely proportional to the time between adjacent oscillation peaks The damping coefficient can be calculated mathematically, but it is usually determined graphically from the amplitude ratio 22

23. 23

24. COMPONENTS OF AN IBP MEASURING SYSTEM 24

25. COMPONENTS OF AN IABP MEASURING SYSTEM Intra-arterial cannula 25

26. COMPONENTS OF AN IABP MEASURING SYSTEM Intra-arterial cannula Fluid filled tubing 26

27. COMPONENTS OF AN IABP MEASURING SYSTEM Intra-arterial cannula Fluid filled tubing Transducer 27

28. COMPONENTS OF AN IBP MEASURING SYSTEM Intra-arterial cannula Fluid filled tubing Transducer Infusion/flushing system 28

29. COMPONENTS OF AN IBP MEASURING SYSTEM Intra-arterial cannula Fluid filled tubing Transducer Infusion/flushing system Signal processor, amplifier and display 29

30. Levelling and zeroing Zeroing : For a pressure transducer to read accurately, atmospheric pressure must be discounted from the pressure measurement. This is done by exposing the transducer to atmospheric pressure and calibrating the pressure reading to zero. The level of the transducer is not important. 30

31. 31

32. Levelling : The pressure transducer must be set at the appropriate level in relation to the patient in order to measure blood pressure correctly. This is usually taken to be level with the patient’s heart, at the 4th intercostal space, in the mid-axillary line. A transducer too low over reads, a transducer too high under reads. 32

33. 33

34. Normal Arterial Pressure Waveforms The systolic waveform components consist of a steep pressure upstroke, peak, and ensuing decline, and immediately follow the ECG R wave. The downslope of the arterial pressure waveform is interrupted by the dicrotic notch, continues its decline during diastole after the ECG T wave, and reaches its nadir at end-diastole 34

35. 35

36. As the pressure wave travels from the central aorta to the periphery , the arterial upstroke becomes steeper, the systolic peak increases, the dicrotic notch appears later, the diastolic wave becomes more prominent, and end-diastolic pressure decreases. 36

37. 37

38. Arterial Blood Pressure Gradients The nature of the operative procedure is important when choosing the appropriate site Ex: Coarctation of aorta Thoracic and abdominal aortic surgeries Cardiopulmonary bypass 38

39. Cardiopulmonary bypass : The mean radial artery pressure decreases on initiation of bypass and remains less than mean femoral artery pressure throughout the bypass period. Persists in the first few minutes following separation from bypass, often by more than 20 mm Hg. 39

40. 40

41. Abnormal Arterial Pressure Waveforms Morphologic features of individual arterial pressure waveforms can provide important diagnostic information 41

42. 42 Condition Characteristics Aortic stenosis Pulsus parvus (narrow pulse pressure) Pulsus tardus (delayed upstroke) Aortic regurgitation Bisferiens pulse (double peak) Wide pulse pressure Hypertrophic cardiomyopathy Spike and dome (mid-systolic obstruction) Systolic left ventricular failure Pulsus alternans (alternating pulse pressure amplitude) Cardiac tamponade Pulsus paradoxus (exaggerated decrease in systolic blood pressure during spontaneous inspiration)

43. Waveform analysis for prediction of intravascular volume responsiveness Variations in arterial blood pressure observed during positive pressure ventilation, as well as a variety of derived indices, are the most widely studied of these dynamic indicators. They result from changes in intrathoracic pressure and lung volume that occur during the respiratory cycle. 43

44. 44

45. MONITORING OF CENTRAL VENOUS PRESSURE & ITS TECHNIQUES

46. INTRODUCTION The central venous pressure (CVP) is the pressure measured in the central veins close to the heart. It indicates mean right atrial pressure and is frequently used as an estimate of right ventricular preload. CVP reflects the amount of blood returning to the heart and the ability of the heart to pump the blood into the arterial system

47. It is the pressure measured at the junction of the superior vena cava and the right atrium. It reflects the driving force for filling of the right atrium & ventricle. Normal CVP in an awake spontaneously breathing patient : 1-7 mmHg or 5-10 cm H2O. Mechanical ventilation : 3-5 cm H2O higher

48. TYPES OF CENTRAL LINE SINGLE LUMEN DOUBLE LUMEN TRIPLE LUMEN QUADRUPLE LUMEN QUINTUPLE LUMEN PERIPHERALLY INSERTED CENTRAL CATHETERS (PICCS)

49. Single, Double, and Triple Lumen Central Lines

50. Indications Central Venus Line (CVL) Major operative procedures involving large fluid shifts or blood loss Intravascular volume assessment when urine output is not reliable or unavailable Temporary Hemodialysis Surgical procedures with a high risk for air embolism, CVP catheter may be used to aspirate intracardiac air.

51. Frequent venous blood sampling, Inadequate peripheral intravenous access Temporary pacing Venous access for vasoactive or irritating drugs & Chronic drug administration Rapid infusion of intravenous fluids (using large cannula) Total parenteral nutrition

52. Relative Contraindications Bleeding disorders (platelet counts <50,000, bleeding is uncommon and easily managed). Anticoagulation or thrombolytic therapy. Combative patients. Distorted local anatomy. Cellulitis , burns, severe dermatitis at site. Vasculitis .

53. Peripherally Inserted Central Catheters (PICCs) LOCATION OR SITE OF INSERTION INDICATIONS CONTRAINDICATIONS BENEFITS AND RISKS

54. PICC LINE INTRODUCTION A Peripherally Inserted Central Catheter (PICC) is a small gauge catheter that is inserted peripherally but the tip sits in the central venous circulation in the lower 1/3 of the superior vena cava. It is suitable for long term use and there are no restrictions for age, or gender.

55. SITE’S OF INSERTION OF PICC LINE PICCs are commonly placed at or above the antecubital space in the following veins; Cephalic vein Basilic vein Medial- cubital vein

56. INDICATIONS FOR PICC LINE INSERTION PICC lines are suitable for many situations when access is limited or expected to last longer than 2 weeks. Compromised/Inadequate peripheral access Infusion of hyperosmolar solutions or solutions with high acidity or alkalinity (e.g. Total Parenteral Nutrition) Infusion of vesicant or irritant agents ( Inotropes , Chemotherapy) Short or long term intravenous therapy (e.g. Antibiotics)

57. CONTRAINDICATIONS FOR PICC INSERTION Previous upper extremity venous thrombosis (DVT) Trauma or vascular surgeries at or near the site of insertion Presence of a device related infection, cellulitis , or bacteremia at or near the insertion site Lymphedema . Mastectomy surgery with axillary dissection +/- lymphedema on affected side (unless urgent condition requires it) Allergy to materials Irradiation of insertion site

58. Sites for insertion of CVL Internal Jugular Subclavian Femoral External Jugular Basilic Axillary

59. Right IJV is Preferred Consistent, predictable anatomy Alignment with RA Palpable landmark and high success rate No thoracic duct injury

60. CVL Insertion Equipment. Patient position. Procedure. After insertion

61. Equipment Sterile gloves, gown, suture pack. Iodine solution. 10 ml syringe, 2% lidocaine , 10 ml N.S. Catheter special size. H2O manometer. Flush solution with complete CVP line. Dressing set.

62. Patient Position Patient is moved to the side of the bed so physician would not lean over. The bed is high enough so physician would not have to stoop over. Patient should be flat without a pillow, Trendelenburg position if patient is hypovolemic . The head is turned away from the side of the procedure. Wrist restraints if necessary.

63. Procedure Skin preparation: Prepare before putting sterile gloves Allow time for the sterilizing agent to dry Drape: Large enough and Handed sterilely by the assistant. Hole in the area of placement. Prepare the tray: Prepare the equipment before starting. Anesthesia: Use local anesthesia with lidocaine

64. USING THE CENTRAL LINE Flush it, before and after use( with NS). Some places also require heparin flush. Close clamps when not in use. Dressing is usually changed every days. Line can be used for blood drawing –withdraw and waste 10 cc, then withdraw blood for samples. If port becomes clotted, do not use – sometimes ports can be opened up.

65. Immediately Complications of Insertion CVL Hemothorax . Pneumothorax (most common). Bleeding Arterial puncture. Vessel erosion Nerve Injury. Dysrhythmias . Catheter malplacement . Embolus. Cardiac tamponade .

66. Delayed Complications Dysrhythmias Infection (“Femoral > IJ > subclavian ”) Catheter malplacement . Vessel erosion. Embolus. Cardiac tamponade . Thrombosis

67. Factors Affecting CVP Cardiac Function Blood Volume Capacitance of vessel Intrathoracic Pressure Intraperitoneal pressure

68. Causes for Increase in CVP Over hydration. Right-sided heart failure. Cardiac tamponade . Constrictive pericarditis . Pulmonary hypertension. Tricuspid stenosis and regurgitation. Stroke volume is high.

69. Causes for Increase in CVP

70. Decrease of CVP Hypovolemia . Decreased venous return. Excessive veno or vasodilation . Shock. If the measure is less than 5 cm water that mean that the circulating volume is decrease.

71. CENTRAL VENOUS PRESSURE MONITORING

72. Methods to measure CVP Indirect assessment: Inspection of jugular venous pulsations in the neck. Direct assessment: Fluid filled manometer connected to central venous catheter. Calibrated transducer.

73. Inspection of jugular venous pulsations in the neck. No valve between Right atrium & Internal Jugular Vein. Degree of distention & venous wave form reflects information about cardiac function

74. Measuring central venous pressure Using a manometer Line up the manometer arm with the phlebostatic axis ensuring that the bubble is between the two lines of the spirit level

75. Phlebostatic Axis 4 th intercostal space, mid-axillary line Level of the atria

76. Move the manometer scale up and down to allow the bubble to be aligned with zero on the scale. This is referred to as 'zeroing the manometer

77. Turn the three-way tap off to the patient and open to the manometer

78. Turn off the flow from the fluid bag and open the three-way tap from the manometer to the patient

79. The fluid level inside the manometer should fall until gravity equals the pressure in the central veins

80. When the fluid stops falling the CVP measurement can be read. If the fluid moves with the patient's breathing, read the measurement from the lower number.

81. Turn the tap off to the manometer veins

82. Measuring central venous pressure Using a transducer Turn the tap off to the patient and open to the air by removing the cap from the three-way port opening the system to the atmosphere.

83. Press the zero button on the monitor and wait while calibration occurs.

84. When 'zeroed' is displayed on the monitor, replace the cap on the three-way tap and turn the tap on to the patient.

85. Observe the CVP trace on the monitor. The waveform undulates as the right atrium contracts and relaxes, emptying and filling with blood. (light blue in this image)

86. Interpretation from Waveform The CVP waveform consists of five phasic events, three peaks (a, c, v) and two descents (x, y)

87. Mechanical Events

88. ‘a’ wave Atrial Contraction(after P wave) Prominent a wave: resistance in RV filling- RVH, TS, Temponade,PS , Pulmonary hypertension. Cannon A waves occur as the RA contracts against a closed TV: junctional rhythm, CHB,ventricular arrhythmias Absent a wave : Atrial fibrillation or • flutter

89. ‘c’ wave Isovolumic right ventricle contraction, TV bow in RA(after QRS) Early Systole TR: Tall Systolic c-v wave It is call holosystolic cannon v waves

90. ‘x’ descent Atrial Relaxation Mid Systole Dominant x descent –good RV function and vice versa Cardiac Tamponade - X descent is steep & Y descent is diminished

91. ‘v’ wave Filing of RA with venous blood(just after T wave) Late Systole Prominent v wave with increase venous return . ASD, PAPVC or TAPVC, A-V malformation Large V waves may also appear later in systole if the ventricle becomes noncompliant because of ischemia or RV failure. Decrease in RA emptying. TS

92. ‘y’ descent Early ventricular filling, opening of TV Early Diastole Attentuation of y descent: TS, Tachycardia, RVF, Tamponade,PS

93. CVP Changes with Respiration A, During spontaneous ventilation, the onset of inspiration ( arrows) causes a reduction in intrathoracic pressure, which is transmitted to both the CVP and pulmonary artery pressure (PAP) waveforms. CVP should be recorded at end-expiration. B, During positive-pressure ventilation, the onset of inspiration ( arrows) causes an increase in intrathoracic pressure. CVP is still recorded at end-expiration.

94. Kussmaul sign is a paradoxical rise in jugular venous pressure (JVP) on inspiration, or a failure in the appropriate fall of the JVP with inspiration. It can be seen in some forms of heart disease and is usually indicative of limited right ventricular filling due to right heart dysfunction. Hepatojugular Reflex : A positive result is variously defined as either a sustained rise in the JVP of at least 3 cm or more or a fall of 4 cm or more after the examiner releases pressure

95. REMOVAL OF CENTRAL LINE This is an aseptic procedure. The patient should be supine with head tilted down. Ensure no drugs are attached and running via the central line. Remove dressing. Cut the stitches. If there is resistant then call for assistance. Apply digital pressure with gauze until bleeding stops. Dress with gauze and clear dressing.

96. Pulmonary Artery Monitoring

97. Introduction Pulmonary artery catheters (also called as Swan- Ganz catheter) are used for evaluation of a range of condition Although their routine use has fallen out of favour , they are still occasionally placed for management of critically ill patients

98. Physiological Measurements Direct measurements of the following can be obtained from an accurately placed pulmonary artery catheter(PAC) 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)

99. Indirect measurements that are possible: Systemic Vascular Resistance Pulmonary Vascular Resistance Cardiac Index Stroke volume index Oxygen delivery Oxygen uptake

100. 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

101. Therapeutic: Management of perioperative patients with unstable cardiac status Management of complicated myocardial infarction Management of patients following cardiac surgery/high risk surgery Management of severe preecclampsia Guide to pharmacologic therapy Burns/ Renal Failure/ Heart failure/Sepsis/ Decompensated cirrhosis Assess response to pulmonary hypertension specific therapy

102. Contraindications Absolute: Infection at insertion site Presence of RV assist device Insertion during CPB Lack of consent Relative: Coagulopathy Thrombocytopenia Electrolyte disturbances (K/Mg/Na/Ca) Severe Pulmonary HTN

103. Making decision to place pulmonary artery catheter In critically ill or perioperative patients decision to place a pulmonary artery catheter should be based on patient’s hemodynamic status or diagnosis that cannot be answered satisfactory by clinical or non-invasive assessment

104. Preparation Patient has to be monitored with continuous ECG throughout the procedure, in supine position regardless of the approach Aseptic precautions must be employed Cautions should be taken while cannulating via IJV/ Subclavian vein

105. Equipments: 2% chlorhexidine skin preparation solution Sterile gown, gloves, face shield and cap Sterile gauze pads 1% lidocaine -5 cc Seeker needle  23G Introducer needle  18G J-tip guidewire Transduction tubing Sterile catheter flush solution Sheath Pulonary catheter Sterile sleeve for catheter 2-0 silk suture Sterile dressing

106. Technique: Aseptic precautions undertaken Local infiltration done Check balloon integrity by inflating with 1.5ml of air Check lumens patency by flushing with saline 0.9% Cover catheter with sterile sleeve provided Cannulate vein with Seldinger technique Place sheath Pass catheter through sheath with tip curved towards the heart

107. 9. Once tip of catheter passed through introducer sheath  inflate balloon at level of right ventricle 10. The progress of the catheter through right atrium and ventricle into pulmonary artery and wedge position can be monitored by changes in pressure trace 11. After acquiring wedge pressure  deflate balloon

108. Important tip: When advancing catheter- always inflate tip When withdrawing catheter- always deflate Once in pulmonary artery - NEVER INFLATE AGAINST RESISTANCE - RISK OF PULMONARY ARTERY RUPTURE

109. Interpretation of hemodynamic values and waveforms Ensuring accurate measurements: Zeroing and Referencing Correct placement Fast flush test

110. Zeroing and Referencing: PAC must be appropriately zeroed and referenced to obtain accurate readings  in supine position/30 degrees semi-recumbent position Correct placement : By either pressure waveform/ fluoroscopic guidance

111. Rapid flush test:

112. Catheter waveforms and pressures Pressure waveforms can be obtained from Right atrium Right ventricle Pulmonary artery

113. Right atrium: In presence of a a competent tricuspid valve, RA pressure waveform reflect both Venous return to RA during ventricular systole RV End Diastolic Pressure Normal RA pressure: 0-7 mmHg

114. Elevated RA pressure: Diseases of RV( infarction/ cardiomyopathy) Pulmonary hypertension Pulmonic stenosis Left to right shunts Pericardial diseases LV systolic failure Hypervolemia

115. Differentiating among etiologies depends on Clinical Radiographical Echocardiographic features + PAC findings Eg : Increased RA Pressure and Mean pulmonary Pressure  PAH Increased RAP and Normal Pa pressures  RV disease/ Pulmonary stenosis

116. Abnormal RA waveforms: Tall v waves: Tricuspid Regurgitation Giant/ cannon a waves: Ventricular tachycardia Ventricular pacing Complete heart block Tricuspid stenosis Loss of a waves: Atrial fibrillation/ Atrial flutter

117. Right Ventricle: Transitioning from SVC or RA to RV: Once balloon is inflated in the SVC/RA  the catheter is slowly advanced When catheter tip is across tricuspid valve pressure waveform changes and systolic pressure increases 2 pressures are typically measured in right ventricular pressure waveform Peak RV systolic pressure  15-25mmHg Peak RV diastolic pressure  3-12 mmHg

118. As a general rule  elevations in RV pressure: Diseases increasing pulmonary artery pressure Pulmonic valve disorders Diseases affecting right ventricle Pulmonary vascular and pulmonary valve disorders a/w increased RV systolic pressures RV disorders – ischemia/infarction/failure – a/w increased RV End diastolic pressure

119. Pulmonary artery: The risk of arrhythmias is greatest while catheter tip is in RV Thus, catheter should be advanced from RV to PA without delay When catheter tip passes pulmonary valve  Diastolic pressure increases and characteristic dichrotic notch appears in waveform

120. Normal pulmonary artery pressures: Systolic  15-25mmHg Diastolic  8-15 mmHg Mean  16 (10-22mmHg) Main components of PA tracing: Systolic and Diastolic pressure Dichrotic notch(due to closure of pulmonic valve)

121. Increase in mean pulmonary pressure: Acute: Venous Thromboembolism Hypoxemia induced Pulmonary Vasoconstriction Acute on Chronic: Hypoxemia induced pulm VC in patient with chronic cardiopulmonary disease Chronic: Pulmonary hypertension

122. Types of PHT: Primary Due to Heart Disease Due to Lung Disease Due to chronic venous thromboembolism Miscellaneous ( Sickle Cell Anemia)

123. Pulmonary arterial occlusion pressure Once catheter tip has reached PA, it should be advanced until PAOP is identified by decrease in pressure and change in waveform The balloon should then be deflated and PA tracing should reappear If PCOP tracing persists catheter should be withdrawn with definitive PA tracing obtained

124. Final position of the catheter within PA must be such that PCOP tracing is obtained whenever 75-100% of 1.5ml maximum volume of balloon is insufflated If < 1ml of air is injected and PAOP is seen then it is overwedged  needs to be withdrawn If after maximal inflation fails to result in PCOP tracing or after 2-3 seconds delay  too proximal – advanced with balloon inflated

125. PCWP/PAOP  interprets Left atrial pressures more importantly – LVEDP Best measured in Supine position At end of expiration Zone 3 (most dependent region) Normal PCWP- 6-15 mmHg ; Mean :9mmHg

126. Abnormal PAOP: Increased LVEDP  Increased PAOP LV systolic HF LV Distolic HF Mitral and Aortic valve disease Hypertrophic cardiomyopathy Hypervolemia Large R-L shunts Pericardial disease

127. Decreased PCWP: Hypovolemia Obstructive shock due to large pulmonary embolus Abnormal waveforms Large a waves: MS LV systolic /diastolic function LV volume overload MI Large v waves - MR

128. Calculation of cardiac output: 2 methods Thermodilution method Fick’s Method Better measurement with Cardiac index Normal – 2.8- 4.2 l/min/m2

129. Decreased CO: Systolic HF Diastolic HF MR Hypovolemia Pulmonary HT RVF Increased CO: Systemic A-V fistulas Anemia Beriberi Renal Disease Sepsis Other uses of pulmonary artery catheter: Detection of Left to right shunts Estimation of systemic and pulmonary vascular resistance

130. Complications General: Immediate: Bleeding Arterial Puncture Air embolism Thoracic duct injury ( L side) Pneumothorax / hemothorax Delayed: Infections Thrombosis

131. Related to insertion of PAC: Arrhythmias (most common- Ventricular/ RBBB) Misplacement Knotting Myocardial/valve/vessel rupture Related to maintenance and use of PAC: Pulmonary artery perforation Thromboembolism Infection

132. 154