Advanced monitoring 2024.pptx

Advanced Cardiac Monitoring Vicente Gonzalez, DNP, CRNA Florida International University Department of Nurse Anesthesiology Objectives 1.State indications and contraindications of invasive monitoring 2.Choose different monitoring modalities based on patient condition 3. Evaluate risks...

Advanced Cardiac Monitoring Vicente Gonzalez, DNP, CRNA Florida International University Department of Nurse Anesthesiology Objectives 1.State indications and contraindications of invasive monitoring 2.Choose different monitoring modalities based on patient condition 3. Evaluate risks and benefits of invasive monitoring 4. Evaluate clinical significance of findings Course objectives alignment: This lecture aligns with objectives 1, 2 and 4. Lecture Outline Invasive arterial pressure monitoring Central venous monitoring Pulmonary artery pressure Cardiac Output Interpretation of data Invasive arterial pressure monitoring Indications Contraindications Relative Atherosclerosis Severe peripheral vasoconstriction Compromised collateral circulation Reynaud’s disease Buerger’s disease (thromboangitis) Complications Infection Ischemia Skin Necrosis Bleeding Arteriovenous fistulas Techniques Direct cannulation Catheter over the needle Transfixation Both walls of the artery are penetrated Needle is removed Catheter is slowly withdrawn until blood flows Seldinger Needle and guidewire are advanced until blood flows Guidewire is advanced and catheter is advanced through the wire Locations Clinical Points of Interest Arterial Cannulation Site Needle size Preferred site for monitoring Radial artery 22/24(peds) Nontapered catheters preferred Complication similar to radial Ulnar artery 22 Primary source of hand blood flow Insertion site medial to biceps tendon Brachial artery 18 Median nerve damage is potential hazard Can accommodate 18-gauge cannula Insertion site at junction of pectoralis and deltoid Axillary artery muscles 18 Specialized kits available Easy access in low-flow states Femoral artery 18 Potential for local and retroperitoneal hemorrhage Longer catheters preferred Collateral circulation = posterior tibial artery Dorsalis pedis artery 22 Positioning Central Venous Monitoring Box 36.5 Indications for Central Venous Cannulation ▪ Central venous pressure monitoring ▪ Pulmonary artery catheterization and monitoring ▪ Transvenous cardiac pacing ▪ Temporary hemodialysis ▪ Drug Administration ▪ Concentrated vasoactive drugs ▪ Hyperalimentation ▪ Chemotherapy ▪ Agents irritating to peripheral veins ▪ Prolonged antibiotic therapy (e.g., endocarditis) ▪ Rapid infusion of fluids (via large cannulas) ▪ Trauma ▪ Major surgery ▪ Aspiration of air emboli ▪ Inadequate peripheral intravenous access ▪ Sampling site for repeated blood testing Contraindications Thrombosed veins LBBB Infection at insertion site Cardiac mass Coagulopathies Complications of Central Venous Pressure Monitoring Mechanical Infectious Vascular injury Arterial Insertion site infection Venous Cardiac tamponade Catheter infection Respiratory compromise Bloodstream infection Airway compression from hematoma Pneumothorax Endocarditis Nerve injury Arrhythmias Misinterpretation of data Misuse of equipment Thromboembolic Venous thrombosis Pulmonary embolism Arterial thrombosis and embolism Catheter or guidewire embolism Locations Internal Jugular Vein Right side preferred Subclavian Vein Right side preferred External Jugular (last resort) Techniques Seldinger technique Landmarks Ultrasound Guided Internal Jugular Internal Jugular cont’d Subclavian Vein Ultrasound Guided PA Catheters Complications Arrhythmias (most common) Complete heart block Endobronchial Hemorrhage Pulmonary Infarction Catheter knotting Valve damage Contraindications Similar to those for central line PA Cath Advancement with a Catheter is advanced 5-10 change in waveform could cm at a time. mean coiling Ectopy can occur if you Any issues, deflate stay in the ventricle for an balloon and withdraw extended amount of time. Any resistance during withdrawal, CXR to R/O knotting or entanglement with the chordae tendinae PA Cath Avoid wedging PA cath measures: CO by completely- can rupture thermodilution- More LBBB contraindication- valuable post op when can develop RBBB ie TEE not available; can complete blockage also measure mixed venous saturation Avoid in a patient with pacemaker in the last 6 weeks Cardiac Output Thermodilution Change in temperature sensed by thermistor in PA catheter Continuous Cardiac Output Blood randomly heated and change in temperature measured Arterial pressure cardiac output CO measured from arterial line Good correlation with standard methods. Arterial BP Monitoring Indications Indications for Arterial Cannulation Continuous, real-time blood pressure monitoring Anticipated pharmacologic or mechanical cardiovascular manipulation Repeated blood sampling Failure of indirect arterial blood pressure measurement Supplementary diagnostic information from the arterial waveform Complications Distal ischemia, pseudoaneurysm, arteriovenous fistula Hemorrhage Arterial embolization Infection Peripheral neuropathy Misinterpretation of data Misuse of equipment Interpretation Arterial waveform components Upstroke Systolic peak Gradual downslope Dichrotic notch Arterial waveform Cardiac output from A-line Calibration of transducer is key Note that MAP measure remains accurate in all three situations Systolic Pressure Variation The cycle of increasing and decreasing stroke volume and systemic arterial blood pressure in response to inspiration and expiration is known as the systolic pressure variation (SPV). SPV is often subdivided into inspiratory and expiratory components by measuring the increase (Up) and decrease (Down) in systolic pressure relative to the end-expiratory, apneic baseline pressure In a mechanically ventilated patient, normal SPV is 7 to 10 mm Hg, with Up being 2 to 4 mm Hg and Down being 5 to 6 mm Hg. Values greater than this are felt to indicate hypovolemia. SPV Hypovolemia causes a dramatic increase in SPV, particularly the Down component. Patients who manifest increased SPV during positive pressure mechanical ventilation may be described clinically as having residual preload reserve or being “volume responsive.” Example of SPV Miller’s Anesthesia Cardiovascular Monitoring Pulse Pressure Variation Indicator of Preload preserve Must be used with Aline Normal PPV 10-13% If the patient has greater than 13% they are most likely to have a positive response to volume expansion and an increase in strove volume If the patient is using vasopressors, this number will not be reliable PPV will remain low Pulse Pressure Variation Pulse pressure is proportional to stroke volume. PPV represents an interaction between the lungs and the heart Ventilation (SV or Mechanical) alters the intrathoracic pressure and causes stroke volume to vary Greater variability in stroke volume/increased PPV may suggest fluid responsiveness Pulse Pressure Variation Must have 3 conditions to be reliable Sinus Rhythm i.e. consistent filling time Mechanically ventilated WITHOUT spontaneous ventilation Must not have an open chest If you have an increased BP with respirations causing a high PPV, pulsus paradoxus is the decrease in SBP > 10mmHg with respiration, this is associated with cardiac tamponade Example of PPV Miller’s Anesthesia Cardiovascular Monitoring Central line waveforms a wave= R atrial contraction c wave= R ventricular contraction forces tricuspid valve into atrium x descent= tricuspid valve pulls away during ventricular ejection v wave= atrial filling during late ventricular contraction against closed tricuspid valve y descent= tricuspid valve opens during early diastole Intra Op Monitoring CVP Current research has shown that central Systolic pressure venous pressure (CVP) variation (SPV) and pulse may not accurately pressure variation (PPV) reflect intravascular have been reported as volume status, and is no being able to predict longer recommended as fluid responsiveness a guide for fluid responsiveness. Intra Op Monitoring CVP The CVP reflects right-sided heart function, not left ventricular performance. Catheters for measuring CVP may be placed for thoracotomies, and in particular, patients undergoing pneumonectomy Uses of CVP catheters or large-bore introducers include (1) insertion of a transvenous pacemaker where necessary, (2) infusion of vasoactive drugs, and (3) insertion of a pulmonary artery (PA) catheter, which may subsequently be required during surgery or in the postoperative period  Right internal jugular vein- most successful External Jugular gets kinks with pt turned lateral Intra Op Subclavian- high risk of pneumo- if Monitoring- necessary placed ipsilateral of the surgery CVP Intra Op Monitoring PA Cath Currently, the use of the PA catheter for monitoring during thoracic surgery is generally unnecessary and may be reserved for patients with pulmonary hypertension.  Most reliable when placed in Right Internal Jugular inaccurate readings occur when placed in external jugular or subclavian Intra Op because when patient is placed in lateral position, the PA cath is Monitoring occluded PA Cath  1. Isovolumetric contraction 2. Rapid Ejection 3. Isovolumetric relaxation 4. Atrial systole Dicrotic notch 2 EDP 3 1 4 Preloa d RAP RVP PAP PAOP 15-25 cm 25-35 cm 35-45 cm 40-50 cm Distance from the RT internal jugular vein to distal cardiac and pulmonary structures Picture curtesy of Apex, Data: Nagelhout Pg 279  During a left thoracotomy with OLV, the catheter tip would then be in the dependent lung and should provide accurate hemodynamic Intra Op measurements During a right thoracotomy with OLV, Monitoring the catheter tip would most likely be PA Cath in the nondependent lung, and may not be accurate Occlusion of the main PA, upper safety limits of 33 mmHg for right, and 35 mmHg for left thoracotomy SvO2 Reflects oxygen delivery and uptake of tissue Value can be used as an estimation of cardiac output It is a global measure, not specific to any organ system; thus, you could have ischemia in one area and not have an abnormal value Sampling is continuous using oximetry principles or obtaining a blood gas test. Causes of Decreased SvO2 Causes of Increased SvO2 Discussion Abnormal CVP/PA waveforms and their clinical significance Refer to PDF References Clinical Anesthesia chapter 26 Kaplan’s Cardiac Anesthesia chapter 9