Maintaining ScvO2 >70% with fluids, inotropes, transfusions, etc. can improve tissue oxygenation. However, ScvO2 alone does not distinguish global from regional ischemia.

1. 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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1

2. Advanced
Critical Care
Series
Module1:
Advanced Hemodynamics
Advanced
Hemodynamics
Elizabeth Scruth, RN, MN,
MPH, CCNS, CCRN
Eugene Y Cheng, MD, FCCM
2

3. Outline
Normal hemodynamic values
Hemodynamic goals for critically ill patients
Insertion sites for invasive
hemodynamic catheters
Care and maintenance
Interpretation of hemodynamic wave forms
Insertion and confirmation of proper
catheter placement
Tissue perfusion and oxygen delivery
Case study
Cardiovascular Physiology
Cardiac output
Preload
Afterload
Contractility
Conduction pathways
3

4. Review of Selected
Hemodynamic Principles
Cardiac output (CO) is the amount of
blood ejected over 1 minute
Normal CO in resting adult is 4-6 L/min
Review of Selected
Hemodynamic Principles
CO indexed to pt’s BSA is
cardiac index (CI)
Normal CI in resting adult is 2.2-4.0
L/min/m2
4

5. Review of Selected
Hemodynamic Principles
Stroke volume (SV) is amount of blood
ejected with each heart beat
SV = CO ÷ HR Example: 4.0L/min ÷ 100
= 40mL/beat
Normal range for SV is 60-100 ml
Determinants of Cardiac Output
Cardiac Output
Stroke Volume Heart Rate
Preload Afterload Contractility
5

6. Preload
RV 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 mmHg
Presence of COPD, ARDS, pulmonary
embolism, pulmonary HTN, mitral
stenosis/regurgitation alters PAOP accuracy
Afterload
RV afterload:
Caused by resistance of pulmonary
arteries and arterioles
Measured by PVR (normal PVR 100-250
dynes/sec/cm-5)
LV afterload
Caused by systemic arteries and arterioles
Measured by SVR (normal SVR 800-1400
dynes/sec/cm-5
6

7. Contractility
RVSWI & 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)
7

8. Hemodynamic Goals
for Critically Ill
Patients
Eugene Y Cheng, MD, FCCM
Indication for Invasive
Hemodynamic Monitoring
Cardiac
Complicated MI
CHF
Pulmonary HTN
ARDS
Perioperative care
Shock
Acute renal failure
8

9. Therapeutic Hemodynamic Goals
Pressure
Peripheral 65 mmHg
Cerebral 70 mmHg
Coronary 70 mmHg
Renal 65 mmHg
Afterload
Systemic 600-800 dyne·sec/cm-5
Pulmonary 180-220 dyne·sec/cm-5
Therapeutic Hemodynamic Goals
Flow
Cardiac output >4-6 L/min
Cardiac index >2-3 L/min
Volume
PAOP 8-12 mmHg
LV stroke volume 60-80 mL/beat
Tissue perfusion
ScvO2 65-70%
9

10. Indications for
Arterial Catheterization
Unstable cardiovascular state
Continuous assessment of blood pressure
response to therapy
Need for multiple arterial samples
Indicator dilution CO determination
Seldinger Technique
10

11. Arterial Circulation of the Hand
Radial artery
first choice for
catheterization
Allen test no
longer needed
prior to catheter
insertion
Use 20g needle
or smaller
Femoral Vasculature
Femoral artery
catheterization if
radial artery not
available
Must use longer
catheter to prevent
dislodgement
11

12. Arterial Circulation of the Arm
Axillary artery
third choice
Not for
coagulopathic
patients
Avoid using
brachial artery
Arterial Waveform
12

13. Complications of
Arterial Catheterization
Hematoma
Thrombosis
Embolism
Hemorrhage
Infection
Indications for Central
Venous Catheterization
Secure venous access
Assessment of intravascular volume
CO measurement
Assessment of tissue oxygenation
Titration of fluids and medications
13

14. Additional Hemodynamic
Information from Pulmonary
Artery Catheterization
Pulmonary artery pressure
Right ventricular pressure
Pulmonary artery occlusion pressure
PVR
CVC Options
Length Lumens Coating
15 cm Single lumen Heparin
20 cm Double lumen Antiseptic
25 cm Triple lumen Antimicrobial
Quadruple lumen Antimetabolic
14

15. Pulmonary Artery Catheters
Standard thermodilution cardiac output
Continuous cardiac output
Right ventricular function
Pacing PA catheter
Paceport PA catheter
CVC Insertion Sites
Subclavian/Axillary vein
Internal/external jugular vein
Femoral vein
Basilic/Cephalic vein
15

16. Central Venous
Catheterization Complications
Hematoma
Arrhythmias
Hemorrhage
Embolization
Pneumothorax
Complications of
Right Heart Catheterization
RBBB
Pulmonary artery rupture
Right ventricular perforation
Catheter knotting
16

17. Subclavian Vein Site for CVC
Lowest rate
of infection
Most
comfortable
for patientes
Highest
placement
risks
Internal Jugular Site for CVC
Second best
choice for CVC
Lower insertion
risk of
pneumothorax
17

18. Femoral Vein Site for CVC
Site of last choice
for elective
placement of CVC
Highest infection
rate
Cannot monitor
CVP or ScvO2
Good choice if
patient has
coagulapathy or
during CPR
Basilic Site for CVC
Low risk
Poor flow rates
Questionable
accuracy of
CVP
18

19. Care and
Maintenance of
Hemodynamic
Catheters
The Institute of Healthcare Improvement
has recommended as a bundle to
implement the following:
Hand hygiene
Maximal sterile barriers
Chlorhexidine for skin asepsis
Avoid femoral lines
Avoid/remove unnecessary lines
19

20. 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.
20

21. Leveling and Zeroing
Leveling and zeroing
Dynamic response testing
21

22. 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 pressures
Test should produce two oscillations-
otherwise overdamped or underdamped
waveforms appear
22

23. General care of invasive lines
Alarms are never to be turned off-this is
not only a safety requirement, but also a
requirement by Joint Commission
Label all lines
Document the waveform characteristics
Document the level of the PA catheter at
the site of insertion
Accurate interpretation of waveforms
23

24. Pressure bag to be inflated at 300 mm Hg
at all times
Dressing changes
Bag changes
24

25. Interpretation of
hemodynamic
waveforms
A C V WAVES- CVP waveform
A wave- occurs after the P wave
C wave occurs at the end of the QRS
complex in the RST junction
V wave occurs after the T wave
Final 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
25

26. Measuring CVP
The peak of the “a” wave coincides with
the point of maximal filling of the right
ventricle
Therefore, this is the value which should
be used for measurement of RVEDP
Machines just “average” the measurement
Should be measured at end-expiration
26

27. Reading Pressure Waveforms –
CVP Practice Waveform
Patient is on ventilator
5-15
Reading Pressure Waveforms –
CVP Practice Waveform Answer
27

28. 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?
28

29. It means the following:
1) If the patient has cardiomyopathy
the CVP port is sitting in the RV
2) The PA catheter needs to pulled back
29

30. PAOP
Pulmonary 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)
30

31. 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
31

32. Reading Pressure Waveforms - CVP/PAOP
P wave represents atrial contraction
Reading Pressure Waveforms - CVP/PAOP
Wave CVP PAOP
a wave In the P-R interval End of QRS
c wave End of QRS S-T segment
v wave Near end of T wave In T-P interval
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
32

33. Tricuspid and
Mitral 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 –
PAOP Practice Waveform
Patient is breathing spontaneously
E9-9.5
33

34. Reading Pressure Waveforms –
PAOP Practice Waveform Answer
Relationship between
Pulmonary Artery Diastolic
(PAD) and PAOP
Blood always moves from a higher to a
lower pressure
34

35. Relationship between
Pulmonary Artery Diastolic
(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
Relationship between
Pulmonary Artery Diastolic
(PAD) and PAOP
This means PAOP must be lower than
PAM pressure
If PAOP is higher than PAM, recheck
waveform-make sure correct points are
being identified
35

36. Relationship between
Pulmonary Artery Diastolic
(PAD) and PAOP
PAD is also usually higher than PAOP.
If PAOP equals PAD, the difference
needed to move blood forward is very
small
Relationship between
Pulmonary Artery Diastolic
(PAD) and PAOP
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)
36

37. Relationship between
Pulmonary Artery Diastolic
(PAD) and PAOP
Discrepancy seen between Relationship seen between
PAD and PAOP in PAD and PAOP in patients
pulmonary HTN caused by with LV failure (PAOP
obstruction or loss of correlated with PAD)
vasculature
Effects of Lung Zones
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
37

38. Effects of Lung Zones
on a PAOP Tracing
Zone III
Effects of Lung Zones
on 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
38

39. Insertion and
Confirmation of Proper
Central Venous
Catheter Placement
Eugene Y Cheng, MD, FCCM
CXR Landmarks
39

40. CVC “In Good Position”
CVC in the R-Atrium
40

41. PA Catheter Position Confirmation
It’s All About Me
41

42. Oxygen Delivery
Cardiac Output
SvO2 (ScvO2)
Lactate
Gastric tonometry
Cardiac Output Monitors
Invasive Techniques
PA catheter and thermodilution
Direct Fick calculation
Transpulmonary TD with arterial pulse
contour analysis (PiCCO™)
42

43. Cardiac Output Monitors
Semi-Invasive Techniques
Lithium dilution curve with arterial
waveform analysis (LIDCO™)
Trans-esophageal/gastric doppler
ultrasound
Indirect Fick calculation with partial CO2
rebreathing
Cardiac Output Monitors
Noninvasive Techniques
Electrical bio-impedance cardiography
43

44. Oxygen Supply and Demand
O2 delivery = CO ∗ CaO2
O2 consumption = CO ∗ (CaO2 − CvO2 )
O2 content = ( Hb ∗1.39) × (0.0031∗ pO2 )
Factors Influencing SvO2 (ScvO2)
Cardiac output
Oxygen consumption
Hemoglobin concentration
Arterial oxygen content
Venous oxygen content
44

45. ScvO2 Measurements
Normal 65-70%
Mild global ischemia <60%
Severe global ischemia <50%
45

46. Case Study
63 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)
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
46

47. Assessment and Plan (1h)
Hct 31% lactate 7.3 mmol/L
Na+ 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)
ScvO2 triple lumen CVC
inserted 1000 ml NS bolus
T 37.5oC RR 28/min
HR 121/min SpO2 99%
BP 85/39 mmHg CVP 5 mmHg
Recommendations?
47

48. Assessment and Plan (3h)
3 L NS given; maintenance iv 200 ml/h
T 37.1oC RR 28/min
ScvO2 55%
HR 117/min SpO2 97%
BP 87/39 mmHg CVP 9 mmHg
Recommendations?
Assessment and Plan (4h)
4 L NS given, iv rate 200 mL/h NE gtt 30
mcg/min
T 37.1oC RR 28/min ScvO2 62%
HR 117/min SpO2 97%
BP 92/35 mmHg CVP 9 mmHg
Hct 30% lactate 6.3 mmol/L
Na+ 138 mEq/L K+ 4.9 mEq/L Scr 1.6 mg/dL
pH 7.21 pCO2 42 mmHg pO2 133 mmHg
HCO3 20 mmol/L
Recommendations?
48

49. Assessment and Plan (6h)
5 L of NS (1 L bolus) given, iv rate 200 mL/h
NE gtt 30 mcg/min
Dobutamine 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/L
Na+ 138 mEq/L K+ 4.9 mEq/L Scr 1.5
mg/dL
pH 7.19 pCO2 42 mmHg pO2 133 mmHg
HCO3 20 mmol/L
Recommendations?
Assessment and Plan (8h)
6 L of NS (1 L bolus) given, iv rate 200 mL/h
NE gtt 30 mcg/min
Dobutamine 8 mcg/kg/min
2 u PRBCs
T 35.1oC RR 28/min ScvO2 65%
HR 126/min SpO2 97%
BP 93/39 mmHg CVP 10 mmHg
Hct 31% lactate 3.3 mmol/L
Na+ 138 mEq/L K+ 4.9 mEq/L Scr 1.5mg/dL
pH 7.25 pCO2 39 pO2 133 HCO3 20 mmol/L
Recommendations?
49

50. Assessment and Plan (8h)
Continue current treatment plan
50

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