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Cardiac output monitoring

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									            Cardiac output
              monitoring



Inese Kutovaja
  09/07/2008
   ICU RPH
      CARDIAC OUTPUT
        MONITORING
• Invasive
   PA catheter

• Non-invasive
  TOE, Echocardiography
  Oesophageal doppler
  Aortovelography
  Transthoracic impedance
  Arterial pulse contour analysis (PiCCO)
  Arterial pulse power analysis (LiDCO)
PULMONARY ARTHERY
    CATHETER
Also known as:
• PA Catheter
• Swan-Ganz Catheter
• Swan
           PURPOSE

PA catheter is designed to measure:
• intra-cardiac pressures
• pulmonary artery pressures
• cardiac output
• oxygen saturation
            CANDIDATES
•   MI with complications
•   CHF
•   Pulmonary HTN
•   Respiratory failure
•   Shock
•   Sepsis
•   Trauma
•   Hemodynamic instability
•   High risk cardiac surgery
•   Peripheral vascular surgery
•   Aortic surgery
•   Neuro surgery
CONTRAINDICATIONS

• Tricuspid or pulmonary valve mechanical
  prosthesis
• Right heart mass (thrombus and/or
  tumor)
• Tricuspid or pulmonary valve
  endocarditis
FLOAT PA CATHETER
DISTANCE MARKINGS

Site               Distance to PA
Subclavian vein    35-50 cm
Internal Jugular   40-55 cm
Femoral vein       60 cm
PA CATHETER CROSS
     SECTION
PROXIMAL PORT IN RIGHT
       ATRIUM
CVP WAVEFORM
RIGHT VENTRICULAR
   PORT (orange)
DISTAL PORT (yellow)
       PAP WAVEFORM

    Similar in appearance to arterial
    waveform
•   Waves
•   Systolic pressure
•   Dicrotic notch
•   End diastolic pressure
PAP WAVEFORM
                        PAP
    Normal values
    PA systolic pressure = 20-30 mm Hg
    PA diastolic pressure = 8-12 mm Hg
    About 25/10


    Low                           High
•   Volume depletion          •   Pulmonary HTN
•   Drugs                     •   Pulmonary Embolus
                              •   Mitral stenosis
                              •   LV failure
                              •   Septal wall defects
Pulmonary Artery Occlusive
     Pressure (PAOP)

    Also known as:

•   Pulmonary capillary wedge pressure
•   PCWP
•   PWP
•   PAW
•   Wedge pressure
•   Wedge
    Pulmonary Artery
Occlusive Pressure (PAOP)

 Clinical Significance

• Estimates left-sided preload
• Estimates left ventricular end diastolic
  pressure
• Assess extravascular lung water
  accumulation
• Estimate myocardial oxygen consumption
    Pulmonary Artery
Occlusive Pressure (PAOP)

• Normal mean value
  8-12 mm Hg
  Low (< 8 mm Hg)
• hypovolemia
  High (>12 mm Hg)
• hypervolemia
Thermistor / Connector

Thermistor
• Measures temperature of blood
Thermistor connector
• Connects swan to display monitor
• Sends temperature info to monitor
  PA Catheter Complications

• Infection         • Thrombocytopenia
• Air emboli        • Catheter knotting
• Thrombosis        • Ventricular
• PA infarction       Dysrhythmias
• PA rupture        • Hemothorax
• Balloon rupture   • Pneumothorax
                    • Cardiac Tamponade
CO MEASUREMENT USING
     PA CATHETER



1)Fick method/principle
2) Indicator dilution technique
  -dye dilution
CO MEASUREMENT USING
     PA CATHETER
- thermo dilution
Steward-Hamilton equation:
Temperature-versus-time
        curve
NON INVASIVE CARDIAC
 OUTPUT MONITORING
OESOPHAGEAL DOPPLER
Measurement of blood flow velocity in the
  descending aorta at the tip of the flexible probe.

4 MHz continuous or 5 MHz pulsed wave


   CO (cardiac output)
   SV (stroke volume)
   FTc (corrected f low time)
   PV (peak velocity)
   MD (minute distance)
   HR (heart rate)
OESOPHAGEAL DOPPLER
OESOPHAGEAL DOPPLER
            • Principle of stroke
              volume calculation
              from aortic
              velocity (VAo)
              measurements.
            • The area under
              the maximum
              aortic velocity
              envelope (VTI)
              represents the
              stroke distance
OESOPHAGEAL DOPPLER
OESOPHAGEAL DOPPLER




• Normovolaemia : wide bases, tall peaks
OESOPHAGEAL DOPPLER




 • Hypovolaemia: narrow waveform, low corrected
   flow time,
 • Good peak velocity, decreased CO, SV,
   borderline HR
                   LiDCO
•   Lithium Indicator Dilution
•   Continuous, real-time cardiovascular monitoring
•   Minimally invasive
•   Arterial pulse power analysis
    Advantages of the LiDCO


SAFE
-Central/peripheral venous and arterial catheters
-injectate is an isotonic (150 mM) solution of
   lithium chloride
-0.15 -0.30 mmol for an average adult
-patient weight (> 40kg) and absence of renal
   dysfunction or dialysis
ACCURATE
SIMPLE TO USE
                     LiDCO



Cardiac Output = (Lithium Dose x 60)/(Area x (1-PCV))
LiDCO
LiDCO
                 LiDCO




-cardiac shunt
-AF
                     PiCCO
Pulse contour analysis with intermittent
  thermodilution measurement.

Enables continuous hemodynamic monitoring using:
- femoral or axillary artery catheter
-central venous catheter


Adult or pediatric patients who have or may develop
  pulmonary edema or ARDS are likely candidates
                  PiCCO
• via continuous pulse contour analysis

• Continuous pulse contour cardiac analysis
  (PCCO)
• Arterial blood pressure (AP)
• Heart rate (HR)
• Stroke volume (SV)
• Stroke volume variation (SVV)
• Systemic vascular resistance (SVR)
• Index of left ventricular contractility
                    PiCCO
• via intermittent transpulmonary thermodilution

• Transpulmonary cardiac output (C.O.)
• Intrathoracic blood volume (ITBV)
• Extravascular lung water (EVLW) (Not Available in
  United States)
• Cardiac function index (CFI)


•
PiCCO
PiCCO

								
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