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MONITORING

HEMODINAMIK
RSUP. DR. WAHIDIN
SUDIROHUSODO

What is Hemodynamic Monitoring?


Non-invasive = clinical assessment & NBP
Direct measurement of arterial pressure
Invasive hemodynamic monitoring

Noninvasive Hemodynamic Monitoring

Noninvasive BP
Heart Rate, pulses
Mental Status

Skin Temperature
Capillary Refill
Urine Output

Mottling (absent)
4

Proper Fit of a Blood Pressure Cuff


Width of bladder = 2/3 of upper arm
Length of bladder encircles 80% arm
Lower edge of cuff approximately 2.5 cm
above the antecubital space

Why A Properly Fitting Cuff?


Too small causes false-high reading
Too

LARGE causes false-low reading

OBJEKTIF : review
Arterial Line
Tekanan vena sentral
Kateter arteri pulmonal
- Indikasi
- Nilai-nilai & intepretasi gelombang
- Teknik pengukuran
- Problem & pemecahannya
- Komplikasi

Sensor harus mendeteksi signal


secara akurat
Monitoring tidak pernah sebagai
terapeutik
Evaluasi resiko-keuntungan
menggunakan monitor
Monitoring adalah suatu tim proses

Intra arterial pressure


Pengukuran langsung tekanan darah
Teknik lebih akurat
Informasi hemodinamik kontinyu
Pengambilan multipel sampel darah
arteri

Interpretasi gelombang tekanan


darah arteri
Sistol
ik
MA
P
Diastol
Sistoli
ik
k

115
mmHg

Dicrotic
Notch

Diastol
ik

85
mmHg

Pada kondisi apa perlu


pengukuran invasive
Akut
arterial
pressure
?
hipotensi
atau perdarahan
Circulatory or cardiac arrest
Hipertensi krisis
Sepsis
Neurologik injuri
Komplikasi post operasi
Pasien dengan vasoactive drugs
Pasien membutuhkan pemeriksaan
analisa gas darah yang sering

Tergantung setup
- Gunakan tubing yang tepat
- Bebas dari udara
- Koneksi-koneksi kencang
- Zero & kalibrasi
- Posisi dari tranducer
Heparin atau tidak ?

Peralatan
- Pressure bag
- NaCl 0,9 % 500 cc
- Pressure trandsducer and infusion
set
- Kannula
- heparin (1-2 units/ml)

Persiapan Alat:

1. Set sistem pengukur dan pressure bag


300 mmHg
2. Kanulasi arteri
3. Hubungkan ke sistem pengukur tekanan
4. Fiksasi kanula dengan aman
5. Zero transducer & kalibrasi
6. Transducer pada posisi phlebostatic
axis (intersection of the fourth
interrcostal space and midanterior
posterior chest)
7. Mulai pengukuran

Kalibrasi
Aplikasi dari tekanan yang
diketahui kepada sistem untuk
memastikan ketepatan

Komplikasi
Perdarahan
Hematoma
Arterial trombosis
Emoli udara
Infeksi

MASALAH
PENYEBAB
-Darah balik -Sambungan
ke tubing
lepas
-Stopcock
tertutup ke flush
system
-Tidak adekuat
kantong tekanan
-Tidak ada
gambar
gelombang -Sumber listrik
mati
-Transducer
tidak terbuka ke
kateter

PEMECAHAN
-Cek sambungan
dan kencangkan
-Buka Stopcock
-Isi kantong
tekanan 300
mmHg
-Cek aliran
listrik
Cek sistem
Hubungkan
transducer ke
monitor

PENYEBA
B

-Gambar
tekanan
damped

INTERVENSI
-Seleksi skala
tidak benar
-Kateter
tertekuk
-Ada udara
pada sistem
-Bekuan darah
-Koneksi lepas
-Compliant
tubing
-Perubahan
kondisi pasien

PENCEGAHAN
-Set skala tekana
yang tepat
-Reposisi kateter
-Keluarkan udara
dari sistem
-Aspirasi darah
dati kateter, flush
-Kencangkan
koneksi
-Gunakan stiff
tubing
-Kaji dan treat

PENYEBA
B
-Pembacaa
n tidak
adekuat

INTERVENSI
-Perubahan
reference level
tranducer
-Tranducer
diatas reference
point hasil
pembacaan
rendah
-Tranducer
dibawah
reference point
kesalahan hasil
pembacaan

PENCEGAHAN
-Pertahankan
tranducer pada
plebostatic axis
atau kateter tip
level pada saat
melakukan
pembacaan
-Cek sistem
aspirasi udara
atau bekuan dari
sistem

Tekanan Vena Sentral


Memonitor tekanan intracardiac
Tidak berfungsinya Ventrikular yang
berhubungan dengan
ischemia, Varvular tidak normal atau
Primary myocadial disease
Membedakan antara hypovolemia
dan myocardial depression

Tekanan vena
sentral

Letak vena subclavia

Indikasi
1. Penilaian
2. Penilaian dari disfungsi right
ventricular berhubungan dengan
penyakit paru-paru akut, pulmonary
hipertensi, cardiac temponade
3. Bedah umum dengan pengharapan
blood loss > 1 blood volume
4. Kesulitan jalan masuk intravenous

Setting CVP manometer


Salin normal atau larutan Dextrose 5
%
Simple IV set
Memancing CVP manometer tubing
10 cm dari air kedalam
manometer
Pindahkan semua gelembung pada
kolom air

Jenis Kanula CVP


Single Lumen
- Long anglocath (16G, 14G)
- Catafix (37mm, 475mm)
- Percutaneous sheath 97F, 8.5F)
- Swan Sheath (8.5F)
Multiple lumens
- 2-, 3-, 4- lumen

Langkah-langkah Setting
CVP monitorng line
1. Pengadaan ECG monitoring
2. Memancing manometer CVP atau stel tekanan
tranducer
3. Pilih tempat dari central vein insertion
4. Posisikan pasien-sandaran bahu dan kepala
kebawah dan putar pada sisi yang berlawanan
untuk IJV dan kanulasi SCV
5. Sterilisasi area dengan penyelesaian suci hama
6. Local the vein with seeker needle
7. Gunakan teknik Seldinger untuk kanulasi vein
8. Hubungkan ke CVP manometer atau tranducer
9. Perbaiki kanula secara aman

Vein atau Artery ?


Artery
Vein
Colour of blood
Bright red Dark
red
Pressure
High
Low
Rapid back
flow of blod
Blood gas
High PaO2
low PaO2

Komplikasi CVP
Corotid artery puncture
Penumotorax
Air embolism
Arrytmia
Perforation of SVC or
atrium/ventricle>cardiac tamponade
Infeksi

Central Venous Pressure (CVP)


Central line or pulmonary artery catheter
Normal values = 2 8 mm Hg
Low CVP = hypovolemia or venous return
High CVP = over hydration, venous return,
or right-sided heart failure
31

Phlebostatic Axis
4th intercostal space, mid-axillary line
Level of the atria

(Edwards Lifesciences,
n.d.)

32

More on Leveling and Zeroing


HOB 0 60 degrees
No lateral positioning
Phlebostatic axis with
any position (dotted line)
(Edwards Lifesciences, n.d.)
33

Dynamic Flush

Dynamic flush ensures the integrity


of the pressure tubing system.
Notice how it ascends - forms a
square pattern - and bounces below
the baseline before returning to
the original waveform.
Check dynamic flush after zeroing
any pressure tubing system

34

TERIMAKASI
H

Indikasi
1. Shock state-septic or hypovolemic
2. Diagnosa dan evaluasi penyakit
jantung
3. Medical conditions that comprimise
cardiac out put
4. To determine fluid volume status
5. Cardiac surgery with poor
ventricular function

What is being
measured ?

1. Central venous pressure


2. Pulmonary arteri systolic dan
diastolic pressure
3. Pulmonary capillary wedge pressure
4. Cardiac output
5. Mixed venous oxygen saturation
6. Derived values such as stroke
volume, cardiac index, ventricular
stroke work, systemic dan
pulmonary vascular resistance

1. Obtain vital signs and institute ECG


monitoring
2. Choose the site of line insertion
3. Position the patient-should support and
head down and turn to opposite side for IJV
dan SCV cannulation
4. Sterilise the area with aseptic solution and
create a sterile field
5. Local the vein with seeker needle
6. Use seldinger technique to cannulate the
vein with the swan sheath
7. fix the swan sheath
8. The PAC is flushed with saline through each
of tis ports and the balloon at the tip lested

Technique of insertion
(Contd)

1. The tranducer are zerced calibrate


2. The PAC is introduced into the sheath and
advanced to the 20 cm mark
3. The ballon at the tip is inflated with 1.5
ml oar air and kept inlated
4. The catheter is slowly advanced to obtain
right ventricular tracing. Further advance
the catheter into the pulmonary arteru
which occurs when the diastolic pressure
increase. At this point the catheter is
slowly advanced to a wedge position with
the waveform changed to that similar to
the atrial tracing

Technique of insertion
(Contd)

5. The ballon is then deflated and a PA


tracing will appear
6. The tranducer are placed at the
right atrial level. Haemodynamic
meassurements and thermodilution
cardiac outputs are performed and
derived variables caculated
7. CXR should be obtained

Measurement of cardiac
output using PAC
1. Ensure correct positioning of the PAC in the
hearth prodimal opening in R. ventricle and
distal thermister ini pulmonary aretry
2. Measure the PCWP
3. Press the CO measurement button and observe
that the temprature basline is stable
4. Withdraw 10 ml of normal saline or dextrose at
room temprature into syringe
5. Press the start button and inject the 10 ml of
fluid as fast as possible
6. A temprature change curve will be observed
7. Repeat the measurement 3-4 times
8. Select the 3 best temprature curve and press
caculate