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MONITORING HEMODINAMIK

Ezra Oktaliansyah

BAGIAN ANESTESIOLOGI & REANIMASI FAKULTAS


KEDOKTERAN UNPAD / RSHS
BANDUNG

Pendahuluan
Panduan Resusitasi

Hemodinamik
Memahami penyakit, Menentukan & Memantau Terapi

VARIABEL HEMODINAMIK
POMPA
SISTEMIK
SISTEMIK/ SVRI

SIRKULASI

TAHANAN

PULMONER/ PVRI
KELUAR

PULMONER

MAP/ MPAP

TEKANAN
KEDALAM
PAOP/ CVP

Aorta

Right
Atrium

Pulmonal artery

Lung

Pulmonal
vein

Left
atrium

SVR =
Left
ventricle

Systemic
Vascular
Resistance

Right
ventricle

organ

Komponen Hemodinamik
Blood

Pressure (BP)/TD
Central Venous Pressure (CVP)
Right and Left Heart Pressures

WHY?
Untuk optimalisasi konsumsi oksigen & metabolisme
Dan ketersediaan energi

HOW?

Monitoring tekanan arterial

Monitoring tekanan arteri pulmonalis

A-line
PA catheter; Swan Ganz

Monitoring tekanan atrium kanan

RAP; CVP

KRITERIA HEMODINAMIK YG
MEMERLUKAN MONITORING KETAT
MAP

< 65 or > 120 mmHg


CI < 2L/min/m2
PAWP > 15 or < 5 mmHg

Prinsip-prinsip
Tekanan

= aliran x resistensi

> aliran = semakin tinggi tekanan


Semakin > resistensi = semakin tinggi
tekanan

Prisip-prinsip
Tekanan

darah = aliran (cardiac output) x


resistensi (ukuran lumen)
Sistem sirkulasi adalah suatu sirkuit yg
kontinyu
Cairan mengalir dari daerah tekanan
tinggi ke tekanan rendah
Heart pressures

Pressures in Heart

Normal
Vessel

ALIRAN

TEKANAN
ALIRAN =
TAHANAN

VASOCONSTRICTION:
Angiotensin II, ADH, Adrenaline,
NorEphinephrine, Metaraminol

ALIRAN

ALIRAN =

TEKANAN

TAHANAN
ALIRAN

OBSTRUCTION:
Trombus, sclerotic

TEKANAN

ALIRAN

=
TAHANAN

VASODILATATION:
Nitroglyserine,
Nitroppruside,
milrinone, dobutamine

Cardiac Output (curah jantung)


CO

= HR X SV
SV = Preload, afterload, dan
contractility

Preload

Regangan serabut otot sebelum sistole


(volume dalam ruang jantung pada ahir
diastole)
Ditentukan oleh LVEDV/LVEDP
Hukum Starlings

Regangan = volume
(regangan berada dalam batas normal)

Preload/Afterload in Heart

Afterload
Tekanan

atau tahanan yg harus dilawan


oleh ventrikel waktu ejection
Ditentukan oleh resistensi katup aorta,
tek. Arterial sistemik & viskositas
SVR & tek. Arterial Left vent. afterload
PVR & tek. Arteri P Right vent. Afterload

Kontraktilitas

Kekuatan kontraksi ventrikel


Bagaimana jantung memompa dengan baik
No direct measure

Ejection Fraction
Prosentase

vol darah yg
diejeksikan saat sistole
Normal : 60% - 70%

Cardiogenic
Shock

Distributive
Shock

Inotropes

Release
tamponade,etc

Vasopressor

Pipe = Vascular

Arterial pressure

Cardiac Output x SVR

Obstructive
Shock

Volume =
Blood

Fluids

Hypovolemic
Shock

Komponen Monitoring Hemodinamik


Transducer

Merubah peristiwa2 fisiologis kedalam


sinyal2 elektrik (e.g. tekanan,
temperatur, cahaya)
Amplifier
Menangkap sinyal elektrik dan
mentransmisikan kelayar monitor

Components of Hemodynamic
Monitoring
Monitor

Display
Layar monitor (gambaran gelombang,
nilai pressure)
Catheter tubing / flush system
Perawatan kateter
Heparinized solution ( protokol)
Pressure bag

Reliable Measurements
Level

= phlebostatic axis (4th intercostal


space, midaxillary line)
Balance = zero reference (negates
atmosphere pressure)
Calibration = numerical accuracy
How often to check?

Bgm mengukur tekanan darah yg benar?


Ukuran alat yg tepat
Teknik pengukuran yg benar
Interval penilaian
Manual : 15 menit
NIBP : 3 menit
Intra-arterial/invasive : real time/kontinyu

Intraarterial Monitoring
Indikasi

Monitoring kontinyu tekanan darah


Blood sampling
pan tek. Intrakranial
Obat vasoaktive
Sites

Radial
Brachial
Femoral

Allen Test

Nursing interventions
Monitor

bentuk gelombang
Bandingkan dengan nilai cuff

A-line harus lebih akurate

Periksa

sistem koneksi
Periksa kateter arteri & sirkulasi pd
ekstremitas
Set alarms

Komplikasi

Emboli

udara: komplikasi mayor


Perdarahan
Trombosis

Tekanan Atrium Kanan

RV

preload/RVEDP
Right pressure changes usually occur
late

Kateter untuk menilai RAP


Pulmonary

artery catheter (proximal port)


Central line (e.g. triple lumen catheter)
Peripherally inserted central catheter
(PICC) line

Measurement

Measured

via pressure system


Normal value is 0 to 8 mm Hg
Recorded as MEAN value

Nursing implications
Zero/level/balance

Positioning patient
Respiratory cycle

Interpretasi Nilai CVP


CVP Rendah

Hypovolemia
Vasodilation

CVP Tinggi

Hypervolemia
Vasoconstriction
Right CHF
Pulmonary
hypertension

Komplikasi
Pneumo/hemothorax
Perforasi

jantung

Disritmia

What assessments should be done during insertion


and immediately after insertion?
What are important interventions to prevent complications?

Implikasi Perawatan
Zero/balance
Analisa

gelombang
Variasi Respirasi
Monitor komplikasi Infeksi

Central Venous Pressure

TRIPPLE LUMEN CATHETER

16 Ga

18 Ga

18 Ga

INTERPRETATION

Kateter Arteri Pulmonalis


1970
Dr. Swan

and Ganz (Swan-Ganz is a brand)


Menggambarkan tekanan pada jantung
kiri

Description
Balloon-tipped
Measures

PA systolic, diastolic, mean,


and wedge (PCWP; PAWP; PAOP)
Multi-lumen

Proximal (RA)
Proximal injectate
Distal (PA)
Balloon

Insertion
Provide

explanation and obtain


informed consent
Site: usually subclavian or internal
jugular
Incision: guide wire, introducer,
catheter, sheath
Flush lumens

Insertion
Inserted

with balloon down, selected


inflation to get into PA
Waveform changes as catheter
progresses
Check for proper wedging
Secure and dress site

During insertion
Monitor

pressures in each chamber


Record values
Assess for complications

Dysrhythmias
Pneumo/hemothorax

PA Values
Normal

is 25 to 10 with mean is 15

Systolic 15 to 30 mm Hg
Diastolic 4 to 12 mm Hg
PCWP 6 to 12 mm Hg

Diastolic

reflects PCWP unless


pulmonary hypertension present
(mitral valve open during end
diastole; therefore, open circuit)

PA cath location
CVP location

Right
Atrium

A. pulmonalis

Interpretation
Increased

PA pressures = volume
overload, CHF
Decreased PA pressures = volume
depletion

Complications
Infection
Dysrhythmias
Air

embolus
Thromboembolism
PA rupture
Pulmonary infarction

THANK YOU

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