Download Basic Principle in Hemodynamic Monitoring

BasicPrinciplesinHemodynamic
Monitoring
Dr.IrmalitaSpJP
a) systole and diastole of both the atria and ventricles related to time
Siklusjantung
b) pressures in the aorta, atria and ventricles
Aortic Pressure
80
60
Left Ventricular Pressure
40
20
0
Left Atrial Pressure
dicate the following events on the figure above:
Identify
Atrial Systole
ISV Contraction
Rapid Ejection
Reduced Ejection
ISV Relaxation
Rapid Vent. Filling
Reduced Vent. Filling
•  Monitoringhemodinamikmemainkan
perananpen>ngdalamtatalaksanapasien2
kri>s
•  Bilamasalahnyasudahdiketahui,monitoring
dapatmembantuuntukmengetahui
patofisiologiyangmendasarisehinggaterapi
bisalebihtepat.
•  Denganmonitoringdapatdilakukan>ndakan
lebihdinisebelummasalahjadiberat.
Echocardiographyandecho-Doppler
•  Dapatdipakai>dakhanyauntukmengukurCO
tapijugadengantambahanfungsikardiak.
•  Bergunauntukmenegakkandiagnosiskarena
dapatmemvisualisasiruang2jantung,katup2
danpericardium.
•  VentrikelyangkecilSmall(kissingventricles)
perludipikirkanpemberiancairansedangkan
bilakontraksimiokardburuk,pemberianinfus
dobutaminadalahpilihanyanglebihbaik.
Echocardiographyandecho-Doppler
•  Padadilatasiventrikelkananharusdipikirkan
emboliparumassifataumiokardinfark.
•  Adanyacairanperikardharusdipikirkandiagnosis
tamponadeperikard.
•  Kelainankatupyangberatdapatsegeradikenali.
•  Tetapipelayananini>dakselalutersediadimanamana;dikebanyakanins>tusiinimerupakan
domaincardiologistyangperludipanggiluntuk
melakukanpemeriksaanini.
WakelingHGetal:Intraopera)veoesophagealDopplerguidedfluidmanagement
shortenspostopera)vehospitalstaya7ermajorbowelsurgery.
BrJAnaesth2005,95:634-642.
•  Non-invasivesajabukanlahtujuan.Walaupun
lebihdisukainoninvasivetapikadang2itu
>dakmungkindan>dakefek>f.
ll be higher in the pulmonary
le, special attention should be
ssures during insertion. Right
nary artery systolic pressures
Figure 20
Normal Insertion Tracings
TypicalHemodynamicPressureValues
ring them during insertion,
ation between the right
Table 1.
y may be more difficult. By
Typical Hemodynamic Pressure Values
es, a rise in pressure value
nary artery has been reached.
re 18
tery Waveform
still inflated, is now advanced
in a central branch of the
t, right heart pressures and
uded. The catheter tip is
es. The waveform reflected
The pressures recorded will
ht atrium (6 mm Hg to
Location
Normal Values in mm Hg
Right Atrium
Right Atrial (RAP)
Mean (MRAP)
-1 to +7
4
Right Ventricle
Systolic (RVSP)
Diastolic (RVDP)
15 to 25
0 to 8
Pulmonary Artery
Systolic (PASP)
15 to 25
Diastolic (PADP)
8 to 15
Mean (MPAP)
10 to 20
Wedge (PAWP)
6 to 12
Left Atrial (LAP)
6 to 12
Once the wedge position has been identified, the balloon is
deflated by removing the syringe and allowing the back
ArterialPressureMonitoring
•  Theintra-arterialpressureisadynamicpressurethathasvolume
displacementandenergywavecomponents
.
•  Thearterialpressurewaveisaresultofthepressureandvolume
changesproducedbythecardiaccycle.
•  Pressure=FlowXResistance
•  Perfusionismorecloselyrelatedtothemeanbloodpressure
•  Systolicbloodpressureisimportantclinicallybecauseitisanindicator
ofmyocardialworkandoxygendemand.
ynamic status of the
e monitoring. Use of
toring system, and
us observation of the
monitoring
te from the arterial
hich is a common
mic parameters.
result of mechanical function. Arterial waveforms are
produced after electrical activation of the heart. When
evaluating arterial waveforms at the same time as electrical
waves, the electrical activity will be noted first followed by
KomponenkurvaArteri
the mechanical activity.
essures include
ppler devices. If
reflect the patient’s
However, it is
ese methods may
er the transmission
sed to determine
. It is thought that
of the vibration of
w from the cuff that
nder optimal
underestimate the
iastolic pressure by
Figure 39
•  Peaksystolicpressuremenggambarkantekananmaksimum
sistolikventrikelkiri.Dimulaidenganpembukaankatup
aorta.Peningkatanyangtajamdarikurvamenggambarkan
alirandarahkeluardariventrikelkesis>marteri.
•  Dicro8cnotchpadakurvaadalahtempatkatupAorta
menutup.Inimerupakanakhirsistoledanmulainya
diastole.
•  Diastolicpressuretergantungkepadavesselrecoilatau
vasokonstriksidarisis>marteri.Jugaadahubunganantara
tekanandiastolicdanwaktudiastolicdarisiklusjantung.
Bilawaktudiasolicpendek,tekanandiastolicakanlebih
>nggi.
•  Anacro8cNotchterjadisebelumpembukaan
katupAorta.Thiswavetypicallywillbeseenonly
incentralaor>cpressuremonitoring,anaor>c
roottracing,orinsomepathologicalcondi>ons.
•  PulsePressureadalahbedaantarasistolikdan
diastolik.Faktoryangdapatmempengaruhinya
adalahstrokevolume,asnotedinthesystolic
pressure,andalsochangesinvascular
compliance,asseeninthediastolicpressure.
difference between the two called electro-mechanical
coupling, or the excitation-contraction phase. When looking
at a simultaneous recording of the electrocardiogram and
pressure tracing, the ECG will show the appropriate wave
Electricalvs.MechanicalCycle
before the mechanical tracings will.
myocardium is
The second ph
Once the pulm
shorten even m
volume out of
approximately
ECG correlati
As the pressur
ventricular sys
phase, begins.
less volume.
During this ph
increase in atr
inflow. This ri
resultant rise i
atrial wavefor
Figure 2
Electrical vs. Mechanical C ycle
diastolic pressure in the aortic root for both the coronary
arteries to be perfused.
PerfusiArteriKoroner
Figure 10
C oronary Artery Perfusion
umption can be
. Since oxygen
n the demand or
nsate is to
Through hemodynamic monitoring, demand factors such as
preload, afterload, contractility, and heart rate can be altered
by various therapeutic interventions. These interventions
and their effects will be addressed in a later section.
icle occurs
entricular wall
such an extent
endocardium. The
erefore less wall
stance, there is
y artery and into
ust be adequate
h the coronary
Figure 11
•  Pen>nguntukdiingatbahwaTekananDarah
>dakakanberubahkarenaadarespons
simpa>ssebagaikompensasitubuhsampai
kekurangandarahyangcukupdarisirkulasi
yangmenunjukkantubuhsudah>dakdapat
mengkompensasikeadaanitu.
storing potential energy that is released with the “springing back” of the aorta to its
diastolic dimension. This energy ensures that blood flow is maintained in diastole.
As systolic run-off to the peripheries continues it eventually exceeds the input of
volume from the ventricle. As a result pressure falls in the aorta and the aortic valve
closes – the “washback” of pressure against the closed aortic valve results in a small
pressure rise called the “dicrotic notch”. (refer to the figure below)
Volume displacement component
Dicrotic notch
Inotropic component
Reflection waves
As the pressure wave and volume displacement wave move peripherally the waveform
changes as a result “reflection” waves off the periphery. This causes the character of
the “dicrotic” notch to change. Its position and shape, when measured in a peripheral
Haemodynamic Monitoring Learning Package
KurvaArteriRadialis
Radial Artery Trace
Dicrotic notch
Dicrotic notch
Vasoconstricted
Vasodilated
The electronic transducer is a device designed to respond to the frequency
components that make up the arterial pressure wave. However, the transducer
PengukuranCentralVenousPressure
•  IndikatortekananpengisianVentrikelKanan
•  Biladibuatasumsi,bahwaadahubungan
linearantaravolumeventrikel(preload)dan
ventricularpressure,(ieasvolumeincreases
thenpressurewillincrease)makatekanan
ventrikelpadaakhirdiastoladalahend
diastolikvolumventrikelataupreload.
on the ECG represents atrial contraction. Because the pressure waveform
elayed the next positive rise in pressure after the p wave will be the “a” wave
KurvaCVP
wing diagram). The C wave which is not always present in the CVP wave
s after the a wave and followed by the v wave.
P wave
A wave, occurring after the p wave
The effect of intra-thoracic pressure changes on the measurement of C
PAWP
ClinicalUseOfCVPMeasurement
•  TheprimaryuseoftheCVPmeasurementistoprovidean
indica>onofRightVentricularFilling.
•  Inclinicalsitua>onsofinadequate>ssueperfusion–theCVPcan
beusedasaguidefortheadministra>onoffluidvolume.
•  Theaimofthefluidvolumeistoincreaseventricularpreloadand
thusincreaseSVorCO.AnincreasedinCOindicatedbyimproved
urineoutput,improvedperipheralperfusion,improvedmenta>on
etc.
•  Clinically,fluidisgivenandCVPusedasaguidetodeterminethe
degreeofventricularloading.,andtoavoidoverload.
•  Iftheventriclehasbeenjudgedtobeop>mallypreloadedandthe
signsofpoorperfusionremain,indica>nginadequatecardiac
output,thenmedica>onstoincreasecontrac>litymaybeusedeg
adrenaline,dopamine,dobutamineetc)
Algoritmediagnos)kberdasarkan
pemeriksaanechocardiography.
Hemodynamic instability
arterial catheter
central venous catheter
Fluid responsiveness ?
(low CVP ?)
present
absent
echocardiography
hypovolemia likely
fluid challenge
tamponade
small chambers
large ventricles RV dilation
(obstructive)
poor contractile state
valvulopathy
(cardiogenic)
Vincentetal.Cri8calCare201115:229
Faktor2yangmempengaruhi
interpretasicardiacoutput
PAP
RAP
EKG
PAOP
End-diastolic
volumes
Heart rate
Arterial pressure
CO
Microcirculation
(OPS, NIRS, …)
Urine output
Mental status
Cutaneous perfusion
PgCO2
Sublingual capnometry
CO2 gap
SvO2
Lactate
Vincentetal.Cri8calCare201115:229
Algoritmediagnos)kberdasarkan
SvO2andcardiacoutput
CARDIAC OUTPUT
HIGH
LOW
SvO2
SvO2
HIGH
INFLAMMATION
(incl. SEPSIS)
EXCESSIVE
BLOOD FLOW
LOW
ANEMIA
HYPOXEMIA
HIGH VO2
(hypervolemia,
excessive vasoactive therapy)
HIGH
LOW VO2
(anesthesia,
hypothermia,...)
LOW
LOW OUTPUT
SYNDROME
(hypovolemia,
heart failure,
pulm. embolism...)
Vincentetal.Cri8calCare201115:229
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
Kuncisis)mmonitoringhemodinamik
yangideal Pengukuransesuatuyangrelefan
Punyahasilakuratdanbisadiulang Punyadatayangbisadiinterpretasi Mudahdigunakan Mudahdidapat Tidaktergantungoperator
Punyaresponse-8mecepat Tidakmenimbulkanrasasakit
Cost-effec>ve
Memuatinformasiyangdapatmengarahkanterapi Vincentetal.Cri8calCare201115:229
ThankYou