Dr CH Koo QEH
www.anaesthesia.co.in anaesthesia.co.in@gmail.com
Arterial Line
Direct measurement of blood pressure most accurate technique continuous haemodynamic information blood gas measurement
How accurate?
Depend on the setup
Use correct tubing Bubbles free (tips) Tight connections Zero calibration Level of transducer
Heparin or not?
Indications
Patient factors
Patient with severe sepsis or shock Cardiac diseases such as unstable angina, recent AMI, current congestive heart failure or cardiac arrhythmias or on pacemaker
Surgical considerations
Cardiac surgery Major surgery on aorta or carotid artery Neurosurgery such as craniotomy or aneurysm clipping Major surgery with expected blood loss more than 1 blood volume
Indications (Contd)
Anaesthetic considerations
Controlled hypotensive techniques Inability to measure blood pressure noninvasively Frequent blood sampling required during and after operation
Steps
1. Set up the pressure measurement system and pressurized the bag to 300 mmHg 2. Cannulate an artery 3. Connect to the pressure measurement system 4. Fix the cannula securely 5. Zeroing the transducer 6. Fix the transducer at the heart level 7. Start measurement
Complications
1. 2. 3. 4. 5. 6. Blood loss due to disconnection Arterial thrombosis Infection Haematoma formation True and false aneurysm formation Distal and central embolisation
Indications
1. Assessment of preload in patients with hypovolaemia / septic shock / valvular problems / congestive heart failure 2. Assessment of right ventricular dysfunction associated with severe lung disease, pulmonary hypertension, cardiac tamponade 3. Craniotomy in the sitting position 4. Major surgery with expected blood loss >1 blood volume 5. Difficult intravenous access
Multiple lumens
2-,3-,4- lumen
Vein or artery ?
Colour of blood Pressure Artery Bright red Vein Dark red
High Low Plunger push back Rapid back flow of blood High PaO2
Blood gas
Complications of CVP
1. Carotid artery puncture 2. Pneumothorax 3. Air embolism 4. Arrhythmia 5. Perforation of SVC or R atrium/ventricle -> cardiac tamponade 6. Brachial plexus, vagus nerve, phrenic nerve injury 7. Thoracic duct perforation (usually left side) -> chylothorax 8. Retroperitoneal haematoma
Indications
1. Ischaemic heart disease with recent myocardial infarction 2. Symptomatic valvular heart disease 3. Cardiomyopathy 4. Congestive heart failure and low ejection faction 5. Shock- septic or hypovolaemic 6. Pulmonary hypertension 7. Cardiac surgery with poor ventricular function
Technique of insertion
1. Choose the site of line insertion 2. Position the patient- should support and head down and turn to opposite side for IJV and SCV cannulation, 3. Sterilise the area with aseptic solution and create a sterile field 4. Local the vein with seeker needle 5. Use Seldinger technique to cannulate the vein with the swan sheath 6. Fix the swan sheath securely by stitches 7. The PAFC is flushed with saline through each of its ports and the balloon at the tip tested
Technique of insertion
(Contd)
8. The transducers are zeroed and calibrated 9. The PAFC is introduced into the sheath and advanced to the 20cm mark. 10.The balloon at the tip is inflated with 1.5 ml of air and kept inflated. 11.The catheter is slowly advanced to obtain right ventricular tracing. Further advance the catheter into the pulmonary artery which occurs when the diastolic pressure increases. At this point the catheter is slowly advanced to a wedge position with the waveform changed to that similar to the atrial tracing. The balloon is then deflated and a PA tracing will appear.
Technique of insertion
(Contd)
12. The transducers are placed at the right atrial level. Haemodynamic measurements and thermodilution cardiac outputs are performed and derived variables calculated.
13. CXR should be obtained if complication is suspected or after surgery
Complications
Similar to that of CVP insertion Additional complications are:
1. 2. 3. 4. 5. 6. Arrhythmogenesis, Thrombosis and embolism, Pulmonary infarction or haemorrhage, Endocarditis, Perforation of atrium, ventricle and pulmonary artery, Intracardiac knotting
Transoesophageal echocardiography
Indications American Society of Anaesthesiologists practice guidelines for perioperative TEE Category I indications - supported by strongest evidence or expert opinion Category II indications - supported by weaker evidence or expert consensus Category III indications Little current scientific or expert support
Contraindications
Patient with oesophageal stricture Patient with history of oesophageal tumour Patient with oesophageal varices Patient with severe coagulalopathy preop
Technique
Turn on the TEE machine Put in a suitable month gag between patients teeth Lubricate the first 20-30 cm of the TEE probe with lubricant jelly Insert the TEE probe through the month gag into the patients month and then gently into the appropriate position in the oesophagus Connect the TEE probe to the TEE machine and select the appropriate probe setting
Complications
Oesophageal perforation GI bleeding Oesophageal burn Transient vocal cord oedema
Any Questions?
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