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Perioperative Hemodynamic Monitoring

Cindy E. Boom RS.Pusat Jantung dan Pembuluh Darah Harapan Kita-Jakarta

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Seorang pria 70 tahun, datang dengan keluhan tidak bisa BAB, perut kembung, tidak dapat makan sudah 3 hari Pola napas terengah-engah, gelisah Posisi setengah duduk

Kulit pucat, akral dingin

Nadi: 130 x/menit. TD : 90/35 mmHg Respirasi : 35 40 x/mnt Auskultasi : rales +, wheezing

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Instability Hemodynamic
A clinical state

Systemic blood pressure

Cardiac output

Organ function

Low Cardiac Output Syndrome ( LCOS)

MAP < 65mmHg Oliguria (<0.5ml/Kg/hour) Clinical signs of tissue Hypoperfusion

Volemia

Vessel tone

Heart function

BP = CO X SVR
BP : blood pressure CO : cardiac output SVR : systemic vascular resistance

Adequate Oxygen Delivery?

Demand

Consumption

Adequate Balance of Tissue Oxygenation

Myocardial Oxygen Balance

Preload Afterload Heart Rate Contractility

O2 Extraction Diastolic Time Diastolic Pressure Coronary Artery Flow

Demand

Supply

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Oxygen Delivery
Hemodynamic Monitors

Oxygen Delivery

Cardiac Output

Oxygen Content

Arterial Blood Gas

Hb PaO2

Oxygen Content

Low Cardiac Output Syndrome LCOS First Step Clinical Evaluation

LCOS MAP < 65mmHg Oliguria (<0.5ml/Kg/hour) Clinical signs of tissue hypoperfusion

1) Clinical approach

-HR/BP -Peripheral perfusion -Impact of volume loading -Urine output

Resuscitation
Goal Oriented Hemodynamic Therapy

How?

Volume

Medikamentosa

Mechanical

Hemodynamic Management of LCOS

Second Step : CVP / Scv O2 Myocardial and/ or Vascular Dysfunction

Insert CVP/ScvO2
ScvO2 >70% SvO2 <70%

CVP N or low

CVP high

CVP low

Sepsis?

Consider global/right ventricular failure

Hypovolaemic/ Haemorrhagic/ cause?

Repeat Fluid challenge 250ml/ 5mins Continue until normal values obtained

Echocardiography that preceeds cardiac output monitoring

Repeat fluid challenge (250ml/5mins) or transfusion if necessary.

Haemodynamic improvement ?

Continue until normal values obtained No response

Yes

No

Haemodynamic improvement

Vasopressors

Echocardiography that preceeds CO monitoring

GDT
CVP
8-12 mmHg < 8 mmHg

CRYSTALLOID

MAP
> 65 mmHg < 90 mmHg

< 65 mmHg > 90 mmHg

VASOACTIVE AGENT

ScvO2
> 70%

< 70%

PRBC to Hct 30 %
< 70%

GOAL

INOTROPE(S)

GDT
FR
negative positive

CRYSTALLOID

MAP
> 75-85 mmHg

< 75 -85mmHg

VASOACTIVE AGENT

ScvO2
> 70%

< 70%

PRBC to Hct 30 %
< 70%

P(cv-a)CO2

INOTROPE(S)

Indices of Fluid Responsiveness

positive

Crystalloid

< 75-85 mmHg Decrease O2 Consumption MAP

Vasoactive agent(s)

> 75-85 mmHg

ScvO2

< 70%

Packed red blood Cells to Hct > 30% < 70% Inotrope(s) > 70%

> 70%

No

P(cv-a)CO2

>6

No

Goals achieced Yes

Refining the Tools for Early Goal-directed Therapy

Vasopressor Weaning trial

Hemodynamic Management of LCOS

Third Step: Echocardiography

Echocardiography

Predominent right ventricular failure

Global heart failure

Predominent left ventricular failure

TAMPONADE ?

Yes

No

Massive mitral regurgitation ? No

Echocardiographic guided pericardiocentesis or surgical intervention

PA catheter
LV dysfunction

Pulmonary hypertension?

RV ischaemia?
Any CO Monitoring, ideally non invasive Reduce RV afterload, avoid excess volume, use inotropes if CO low Optimise LV pre- and afterload, Inotropes if required

Pulmonary vasodilators

Mebazaa et al. Intensive Care Med, 2004;30:185-96

Hemodynamic Management of LCOS

Fourth Step: Pulmonary Artery Catheter

LCOS MAP < 65mmHg Oliguria (<0.5ml/Kg/hour) Clinical signs of tissue hypoperfusion
1) Clinical approach -HR/BP -Peripheral perfusion -Impact of volume loading -Urine output 2) CVP/SvcO2 3) Echocardiography should proceed any CO monitoring Predominant RVF or global F PAC catheter

Predominant LVF any CO monitoring

Optimize Oxygenation

O2 uptake

O2 transport

O2 extraction

O2 utilisation

Oxygen Delivery

Oxygen Comsumption

ScvO2
Cardiac Output
Stroke Volume Preload Heart Rate After Load Contractiliy Arterial Oxygen Content Oxgenation SaO2 Hemoglobin Hb

- Volume + - Vasopressors

Inotropes

- Red Blood Cells +

Pemantauan Kardiovaskuler
Fungsi utama sistem Kardiovaskuler: menjamin kecukupan pasokan dan kebutuhan sel-sel tubuh akan O2 dan membawa sisa metabolisme untuk diekskresikan.

CO (cardiac output) = SV (stroke volume) x HR (heart rate) MAP (mean arterial pressure) = (Sistolik + 2x Diastolik)/ 3 Atau MAP= Diast+ (Sist-Diast)/3 Besar MAP orang dewasa normal : 60-70 mmHg. PP ( pulse pressure) adalah selisih antara tekanan sistolik dan diastolik. PP = Sist- Diast, atau PP= 3x ( MAP-Diast)

Saturasi Oksigen dan Oksigenasi Jaringan ( SaO2 dan DO2)

Delivery Oxygen (DO2) adalah jumlah oksigen yang harus tersedia bagi jaringan tubuh per menit.
DO2 = CO x CaO2 ( oxygen content) CaO2= (1,34 x Hb x SaO2) + (0,0031x PaO2) DO2 = CO x (( 1,34 x Hb x SaO2) + ( 0,0031 x PaO2)) DO2 = delivery oxygen CO = cardiac output CaO2 = arterial oxygen content PaO2 = tekanan parsial oksigen di dalam darah arteri

FLUID RESUSCITATION AND ORGAN PERFUSION

A. GENERAL

B. URINE PRODUCTION

C. ACID BASE BALANCE

RESPONSE TO EARLY FLUID RESUSCITATION

A. IMMEDIATE RESPONSE B. TEMPORARY RESPONSE C. MINIMALLY / NO RESPONSE

RESPON TERHADAP TERAPI CAIRAN AWAL

Tanda Vital
Dugaan Kehilangan Darah Kebutuhan Kristaloid Kebutuhan Darah Persiapan Darah

RESPON CEPAT Minimal

RESPON SEMENTARA
Sedang, masih ada

TANPA RESPON
Berat ( > 40 % ) Banyak Segera Emergency

(10 - 20%)
Sedikit Sedikit Type Specific dan
Cross match

(20 - 40 % )

Banyak Sedang - Banyak Type Specific

Operasi
Kehadiran Dini Ahli Bedah

Mungkin
Perlu

Sangat Mungkin
Perlu

Hampir Pasti
Perlu

+ Fluid Resuscitation Complication

Pulmonary

edema edema

Myocardium Mesenteric Central

effects

nervous system effects

CVP Wedge pressure Cardiac index

: 15 mmHg : 10 -12 mm Hg : > 3 L/min/m2

Oxygen uptake (V02) : > 100 mL/min/m2

Blood lactate
Base deficit Urine 1ml/kgbb/hr

: 4 mmol/L
: 3 mmol/L : 0.5

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HEMODYNAMIC MONITORING DEVICES

ECG monitoring
Arterial Catheter Pulmonary Arterial Catheter

Central Venous Catheter

Urinary Catheter Thermodilution Continuous Cardiac Output Transesophageal echocardiography (TEE) Transthorasic echocardiography (TTE)

HYPOVOLEMIC SHOCK
Blood Pressure

Cardiac Output / CO
Stroke Volume / SV

Systemic Vascular Resistance / SVR

Heart Rate

Contractility

Afterload

Preload

CARDIOGENIC SHOCK
Blood Pressure

Cardiac Output / CO
Stroke Volume / SV Preload
Heart Rate

Systemic Vascular Resistance / SVR

Afterload

Contractility

CIRCULATORY SHOCK
Blood Pressure

Cardiac Output / CO

Stroke Volume / SV
Preload Contractility
Afterload

Heart Rate

Systemic Vascular Resistance / SVR

CO = HR x SV
Preload Contractility Afterload Vasoconstriction

Tissue Perfusion

Hemodynamic profiles of the shock states

Physiologic variable
Clinical measurement

Preload
Pulmonary capillary wedge pressure

Pump function
Cardiac output

Afterload
Systemic vascular resistance

Tissue perfusion
Mixed venous oxygen saturation

Hypovolemic

Decreased

Decreased

Increased

Decreased

Cardiogenic

Increased

Decreased

Increased

Decreased

Distributive

Decreased

Increased

Decreased

Increased

+Hemodynamic Monitoring Parameters

1.

Non Invasive
Blood Pressure (BP) Mean Arterial Pressure (MAP) Heart Rate (HR) Peripheral Oxygen Saturation (SpO2)

2.

Invasive CVP (central venous pressure) PCWP (pulmonary catheter wedge pressure) RVEDVI (right ventricle end diastolic volume index) LVSVI (left ventricle stroke volume index) LVP (left ventricle pressure) SvO2 (mixed vein oxygen saturation)

Why SvO2?

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Transport Oksigen

Transport Oksigen
arteri
CO Hb SaO2

vena
Konsumsi Tetap

CO Hb

tetap tetap

SvO2 berubah

Konsumsi O2 = CO x Hb x (SaO2 - SvO2) x 1.34

Pada umumnya penurunan SvO2 merupakan indikator dini adanya gangguan oksigenasi jaringan

Berapa harga normal SvO2?

Harga normal SvO2 adalah 68 - 77%
Nilai < 50% sudah mengkhawatirkan Nilai<30% menunjukkan adanya metabolisme anaerobik Lebih berguna mengikuti trend (sebagai respons terhadap perubahan terapi) dibanding hanya melihat nilai pada satu satuan waktu

Oxygen Delivery Optimalisation

+ Oxygen Delivery Optimalisation

+ Oxygen Delivery Optimalisation

+ Oxygen Delivery Optimalisation

+ Oxygen Delivery Optimalisation

Monitor Hemodinamik Yang Mana ?

ASA Basic Intraoperative Monitoring

1.

Standard I : Qualified anesthesia personel

2.

Standard II:
Oxygenation : inspired gas, blood oxygenation, pulse oxymetri

Ventilation : end-tidal CO2- capnograph, alarm detecting disconnect from ventilator.

Circulation : ECG, every 5 min (arterial blood pressure, heart rate), pulse palpation, auscultatio of heart sound, intraarterial pressure Body Temprature

Arterial Line

ARTERIAL LINE PURPOSES

Continue BP monitoring
Early detected of HD HD controlled

Blood Gas Analysis

Arterial Line Inserting Techniques

Arterial Line Waveform

CENTRAL VENOUS PRESSURE Tekanan Vena Sentral

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Central Venous Pressure Monitoring Better than Regular Manometer :

Continue monitoring of venous pressure. Give us more reliable data of CVP Pressure vs Volume

Central Venous Pressure Waveform

3 2

positive waveforms : a, c dan v negative waveforms : x, y

CVP Inserting Technique

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VCS/ VCI Atrium Kanan Trikuspid

Ventrikel Kanan
A. Pulmonalis Paru-paru V. Pulmonalis Atrium Kiri Mitral Ventrikel Kiri Aorta

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PULMONARY ARTERIAL CATHETER (PAC) SWANZ GANZ

PAC PURPOSES

Pulmonary Arterial Pressure : S/ D/ M

Wedge Pressure (PCWP) Cardiac Output / Cardiac Index (CO/CI) Systemic Vascular Resistance (SVR/I)

and Pulmonary Vascular Resistance (PVR/I)

PAC Waveform

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Seorang pria 70 tahun, datang dengan keluhan tidak bisa BAB, perut kembung, tidak dapat makan sudah 3 hari.

Pola napas terengah-engah, gelisah. Posisi setengah duduk

Kulit pucat, dingin, akral dingin.

Nadi: 130 x/menit. TD : 90/35 mmHg.

Respirasi : 35 40 x/mnt.
Auskultasi : rales +, wheezing -.

Titik Akhir Terapeutik

Capillary refill time < 2 detik Ekstremitas hangat, kering Produksi urine > 1 ml/kg/jam Status mental normal Laktat menurun Saturasi vena sentral > 70% dan kemerahan

Masalah-masalah dalam pelaksanaan

Saya tidak punya monitoring ScvO2!

Gunakan pemeriksaan AGD serial dari darah kateter vena sentral

Saya Tidak Punya Monitor CVP/ Kateter TVS

Anda Sedang Berhadapan Dengan Masalah Serius

Segera rujuk ke rumah sakit terdekat

Lakukan

RESUSITASI CAIRAN SEMAKSIMAL MUNGKIN

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Terima Kasih

With an Excellent Teamwork We Do Our Best to

Save the Patients Life