MONITORING HEMODINAMIK

Ezra Oktaliansyah
BAGIAN ANESTESIOLOGI & REANIMASI FAKULTAS
KEDOKTERAN UNPAD / RSHS
BANDUNG
Right
Atrium
Right
ventricle
Left
ventricle
Pulmonal
vein
Lung
Left
atrium
SVR =
organ
Systemic
Vascular
Resistance
WHY?
Untuk optimalisasi konsumsi oksigen & metabolisme
Dan ketersediaan energi
HOW?
Monitoring tekanan arterial
A-line
Monitoring tekanan arteri pulmonalis
PA catheter; Swan Ganz
Monitoring tekanan atrium kanan
RAP; CVP
Prinsip-prinsip
Tekanan = aliran x resistensi
> aliran = semakin tinggi tekanan
Semakin > resistensi = semakin
tinggi tekanan

FLOW =
PRESSURE
RESISTANCE
Normal
Vessel
FLOW
FLOW =
PRESSURE
RESISTANCE
VASOCONSTRICTION:
Angiotensin II, ADH, Adrenaline,
NorEphinephrine, Metaraminol
OBSTRUCTION:
Trombus, sclerotic
FLOW
FLOW
VASODILATATION:
Nitroglyserine,
Nitroppruside,
milrinone, dobutamine
FLOW =
PRESSURE
RESISTANCE
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
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


Cardiac Output x SVR
Volume =
Blood
Hypovolemic
Shock
Cardiogenic
Shock
Distributive
Shock
Inotropes
Vasopressor
Fluids
Obstructive
Shock
Release
tamponade,etc
Arterial pressure
Pipe = Vascular
Ejection Fraction
Prosentase vol darah yg
diejeksikan saat sistole
Normal : 60% - 70%
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?
Intraarterial Monitoring
Indikasi
Monitoring kontinyu tekanan darah
Blood sampling
pan tek. Intrakranial
Obat vasoaktive
Sites
Radial
Brachial
Femoral


Nursing interventions
Monitor waveform
Compare values with cuff
A-line should be more accurate reading
Check connections in system
Check site and circulation to extremities
Set alarms
Complications
AIR Embolus: major complication
Hemorrhage: keep connections tight
Thrombosis
Right Atrial Pressure
RV preload/RVEDP
Right pressure changes usually occur
late
Catheters that Measure 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
Interpretation of Values
Low CVP
Hypovolemia
Vasodilation
High CVP
Hypervolemia
Vasoconstriction
Right CHF
Pulmonary
hypertension

Complications of Insertion
Pneumo/hemothorax
Heart perforation
Dysrhythmias
What assessments should be done during
insertion and immediately after insertion?
What are important interventions to
prevent complications?
Nursing Implications
Zero/balance
Waveform analysis
Respiratory variation
Monitor complications Infection
Correlate values obtained with nursing
assessment
Central Venous Pressure
TRIPPLE LUMEN CATHETER
18 Ga
16 Ga
18 Ga
INTERPRETATION
Pulmonary Artery Catheter
1970
Dr. Swan and Ganz (Swan-Ganz is a brand)
Reflects left heart pressures
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)
Interpretation
Increased PA pressures = volume
overload, CHF
Decreased PA pressures = volume
depletion
Complications
Infection
Dysrhythmias
Air embolus
Thromboembolism
PA rupture
Pulmonary infarction
Critical Thinking Challenge
What nursing interventions can assist in
preventing complications associated with
PA catheters?
Why is a chest x-ray done after the
insertion of a PA catheter?
What symptoms might indicate a
pulmonary infarction?
Cardiac Output vs. Index
Index is a better assessment; based on
body size
Uses body surface area
Calculated on the computer after entering
clients height and weight
SvO
2
monitoring
Measurement of oxygen saturation in PA
Fiberoptic technique
Reflects CO, SaO
2
, Hgb, and VO
2

Reflects overall tissue oxygenation
Rate of greater than 60% is desirable
Can calculate oxygen delivery and
consumption profiles
THANK YOU