Hemodynamic monitoring

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Hemodynamic monitoring

• All about the Swan

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• Indications for pulmonary artery catheterization
  in the ICU
• Establish diagnosis of shock and/or respiratory
  failure
• Guide therapy of shock and/or respiratory failure
• By improving oxygen delivery

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• Oxygen delivery CaO2 x CO
• Cardiac output HR x SV
• SV is determined by
• Preload (end-diastolic volume)
• Cardiac contractility
• Afterload

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Information derived from PA catheter

• Directly measured
• CVP
• PAOP
• Pulmonary artery pressure
• SvO2
• Cardiac output

• Calculated
• Systemic vascular resistance
• Pulmonary vascular resistance
• Stroke volume
• Oxygen delivery

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Normal values

• Directly measured
• CVP 2-4 mm Hg
• PA 25/10
• PAOP 8-12
• SvO2 60-75
• Cardiac output 4-8 L/m
• Cardiac index 2.5-4.0 L/min/M2

• Calculated
• SVR 900-1200 dynes sec/cm5
• PVR 50-140
• SV 50-100mL
• SV index 25-45

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Insertion of Swan Ganz

• Ask why?
• Then immediately ask why not
• Coagulopathy
• Ventricular ectopy
• LBBB
• Pacemaker? Defibrillator?
• Large pulmonary embolism
• Severe pulmonary arterial hypertension

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Swan complications

• Associated with cordis placement
• Ventricular arrhythmias requiring treatment 1.3
  1.5
• Right bundle branch block 0.5 -5
• Pulmonary artery rupture 0.06 to 0.2
• Pulmonary artery pseudoaneurysm formation
• Pulmonary infarction 1.4
• Thromboembolic events 1.6
• Mural thrombi
• Sterile cardiac valve vegetation
• Endocarditis esp of the pulmonic valve

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So much information, why dont we Swan more often?

• 1996 observational study
• Swan within the first 24 hours of ICU admission
  associated with increased 30d hospital mortality
  (OR 1.24)
• Association with poor outcome highest in the
  least sick pts
• Meta-analysis of RCTs no benefit but no harm
• ESCAPE trial in patients with heart failure no
  mortality benefit
• RCT of peri-operative use in high risk pts
  undergoing cardiac, vascular or orthopedic
  surgery no benefit
• FACCT study of ARDS pts no benefit of Swan v.
  CVP monitoring in managing vasoactive agents and
  fluid status

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Nevertheless

• PAC can be occasionally useful in the carefully
  selected patient

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Insertion sites
Insertion site RA RV PA PAOP Comments
IJ 15-20 30 40 45-50 Easy to float especially from right. Carotid puncture/PTX
SC 15-20 30 40 45-50 Easy to float esp from left. Highest risk PTX
Fem 40-45 50-55 60-65 65-70 Most difficult to float Highest risk of infection and DVT
Rule of 10s
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Musts

• Full barrier precautions for maximal sterile
  technique
• Flush and zero catheter prior to insertion at the
  phlebostatis axis
• Remember catheter sheath
• Once catheter tip is in the right atrium, always
  advance the catheter with the balloon inflated.
• Always watch the waveforms transduced from the
  distal end of the catheter while advancing
• Always withdraw catheter with the balloon
  deflated
• Advance the catheter quickly while in the right
  ventricle
• Advance slowly once the distal tip is in the
  pulmonary artery

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Tip of the catheter should be no more than 3-5
center fro midline. Daily CXRs to monitor for
catheter migration
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Waveforms
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X descent fall n right atrial pressure following
atrial contraction Y descent call in right
atrial pressure following opening of the
tricuspid valve and passive ventricular
filling
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ECG correlation is mandatory for correct
identification of the right atrial wave forms
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Elevations in RAP

• Hypervolemia
• Right ventricular infacrtion
• Impaired RV contraction
• Pulmonary hypertension
• Pulmonic stenosis
• Left to right shunts
• Tricuspid valve disease
• Cardiac tamponade

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Overwedging
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Abnormal waveforms
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• Seen with non compliant ventricle
• Mitral or tricuspid stenosis

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• Seen with tricuspid valve regurgitation
• Ventricular ischemia
• Ventricular failure
• Hypervolemia

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Right ventricular pressure

• Peak systolic pressure
• RV end-diastolic pressure
• Early rapid filling (60 of filling)
• Slow phase (25 filling)
• Atrial systolic phase

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Left to right shunts

• Arterial sampling from RA, RV, and PA
• Detection og an oxygen saturation step-up
  allows confirmation and determination of its
  location
• Definition of step-up gt10 rise in oxygen
  saturation

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Equalization of pressures

• RAP RVed PCWP
• Cardiac tamponade
• Constrictive pericardial disease
• Restrictive cardiomyopathies

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Cardiac output
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Thermodilution

• Saline injected through the proximal port
• Thermistor at the distal end of catheter measures
  the change in blood temperature over time

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• Area under the curve is inversely proportional to
  the rate of blood flow past the pulmonary artery
• This rate is equivalent to cardiac output

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• Should not differ by more than 10

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Factors that decrease accuracy of thermodilution
cardiac output

• Tricuspid regurgitation
• Septal defects
• Technical issues
• Sensor malfunction
• Improper injectate

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Continuous thermodilution cardiac output

• 10 cm thermal filament located 15-25 cm from the
  catheter tip.
• It generates low-energy head pulses transmitted
  to surrounding blood

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Interpretation of the data
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Cases
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Case 1

• 20M presents post-MVA with abdominal pain.
• T 97 BP 70/55 HR 130 RR 24
• Exam Alert, pale, diaphoretic. Extremities cool
  and clammy with poor capillary refill. Abdomen
  is distended and tender.

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• MAP 60
• CVP 2
• PA 15/3
• PAOP 4
• CO 3
• SvO2 50
• SVR?
• SV?

• What kind of shock?

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Case 2

• 30F with flank pain, dysuria, fever to 104.
• T 104 BP 70/35 HR 140
• Exam Flushed, warm, bounding pulses

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• MAP 47
• CVP 2
• PA 20/5
• PAOP 5
• CO 7
• SvO2 75
• SV ?
• SVR ?

• What kind of shock?

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Case 3

• 55M intermittent chest pains for last 24 hours
  presents with progressive shortness of breath and
  weakness
• T 96 BP 80/60 HR 120 RR 28 SpO2 88
• Exam Dyspneic, diaphoretic. Poor capillary
  refill. He has JVD, a gallop, soft murmur. Very
  little edema

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• MAP 67
• CVP 10
• PA 42/28
• PAOP 29
• CO 2.5
• SvO2 55
• SV?
• SVR?

• What kind of shock?

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Case 4

• 60M feeling bad and losing weight last 8 months.
  Hasnt seen an MD in 30 years. Present with
  progressive weakness, shortness of breath, and
  edema.
• T 96 BP 75/60 HR 120 RR 24 SpO2 92
• Exam Cachectic. JVD. Distant heart sounds.
  Generalized edema. Thready pulses, poor capillary
  refill

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• MAP 70
• CVP 24
• PA 40/24
• PAOP 24
• CO 2.4
• SvO2 45
• SV?
• SVR?

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Case 5

• 46 F presents with worsening shortness of breath
  and chest pains over a 5 days period.
• T 98 BP 78/62 HR 130 RR 28 pulse ox 84
• Exam Tachypneic, dyspneic. JVD. Lungs clear.
  Heart sounds tacycardic with RV heave, pronounced
  S2, II/VI systolic murmur at LLSB.

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• MAP 67
• CVP 14
• PA 60/28
• PAOP 6
• CO 3.5
• SvO2 48
• SVR?
• PVR?
• SV?

• What is going on?

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Case 6

• 36M admitted to the ICU with lobar pneumonia,
  septic shock.
• Given 8 Liters of normal saline over 3 hours, but
  remains in refractory shock, requiring initiation
  of norephinephrine. Develops progressive
  hypoxemia and intubated. Post intubation CXR
  demonstrates bilateral pulmonary infiltrates
• Exam T 103 BP 95/50 HR 120 RR 28 on vent SpO2 98
• Intubated, sedation. Warm and flushed with brisk
  capillary refill and bounding pulses.

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• MAP 65
• CVP 9
• PA 35/18
• PAOP 16
• CO 9.0
• SvO2 80
• SVR?
• SV?

• Clinical scenario?