How to handle patient with cardiac

problem : do we need invasive

monitoring ?

Andi Mutya Pangerang

WORKSHOP HEART-LUNG INTERACTION

PIB MEDAN OCTOBER 2017
• Less than 15 % surgery in high risk patient —> 80% of patient
deaths
• Peri-operative complication —> increased length of stay,
healthcare cost, decreased long term survival
• Risk of complication :
1. Patient status and co-morbidities
2. Type of surgery and duration
3. Degree of urgency and magnitude of surgery
4. Skill and experience of operating and anesthetic team
• Leading causes hypovolemia and heart dysfunction
• Cardiac complications —> documented or
asymptomatic ischemic heart disease (IHD), Left
Ventricular (LV) dysfunction, Valvular heart
disease (VHD) and arrythmias
• Perioperative myocardial ischemia :
1. Mismatch in supply-demand of blood flow
2. Acute coronary syndrome (ACS) due to stress
induced rupture of atherosclerotic plaque
 SURGICAL RISK
FOR CARDIAC EVENTS
Table 1. Surgical risk estimate according to type of surgery or interventiona,b

•Open vs Endovascular intervention

•Open vs laparoscopy/thoracoscopy
 SURGICAL RISK
FOR CARDIAC EVENTS
Table 2. AHA Cardiac Risk Stratification for non-cardiac surgery
 FUNCTIONAL STATUS
• Duke Activity Status Index
• Canadian Cardiovascular Society’s (CCS)
classification of angina
• New York Heart Association (NYHA),
classification of congestive heart failure (CHF)
• Specific Activity Scale
 FUNCTIONAL CAPACITY
AND CLINICAL RISK FACTORS

Table 3. Clinical risk factors according to the revised

cardiac risk index
Table 4. Clinical predictors of increased peri-operative cardiovascular risk (myocardial
infarction, heart failure, death)
 BASIC PERIOPERATIVE
HEMODYNAMIC MONITORING
• Clinical examination —> initial step
• NIBP, Pulse Oximetry, PetCO2
• Electrocardiography (ECG) : multiple leads (II,
V4,V5) sensitivity >95% to detect myocardial
ischemia/infarction
• Combining and integrating parameters improve
understanding
• Continuous invasive arterial pressure
• Central venous pressure
Vincent et al. Critical Care (2015) 19:224
 CARDIAC OUTPUT
MONITORING
• Doppler Echocardiography (TTE or TEE) : LV
and RV function, fluid status and
responsiveness, estimation of SV, PE, valve
disruptions, etc

• Pulmonary Artery Catheter (PAC) : Continuous

monitoring PAP, right and left sided filling
pressure,CO and SvO2
Vincent et al. Critical Care (2015) 19:224
 OTHER CARDIAC OUTPUT
MONITORING DEVICES
• Pulse contour analysis :
SV estimated by analysis of arterial pressure waveform
1. Calibrated devices (PiCCO, EV1000, LiDCO) : Consist of thermistor-tipped
arterial catheter to measure CO by trans-pulmonary thermo-dilution (or
lithium indicator dilution) to calibrate the pulse contour algorithm
2. Un-calibrated devices (Flo Trac/Vigileo, MostCare) : additional
transducer connected to standard arterial catheter, to calculate vascular
resistance and compliance. Individual demographic variables and a built
in database on CO variables are used to calculate impedance and
estimate SV and CO
3. Non-invasive pulse contour analysis (ClearSight) : reconstructing
brachial artery pressure waveform from a finger clamp probe

Vincent et al. Critical Care (2015) 19:224

 OTHER CARDIAC OUTPUT
MONITORING DEVICES
• Doppler monitoring devices :
1. Esophageal doppler : SV calculated from aorta
cross-sectional area and blood flow velocity
2. Trans-thoracic continuous doppler CO monitor,
USCOM : measuring flow velocity at aortic or
pulmonary valves level, rapid and can be used in
pediatric as well
• Applied Fick principle and dye dilution (NICO,DDG-30)
 OTHER CARDIAC OUTPUT
MONITORING DEVICES
• Bio-impedance, Bio-reactance and Cardiometry :
1. Electrical bio-impedance estimates CO by detecting thoracic and
whole body impedance induced by cyclic changes in blood flow,
using electrodes on skin or endotracheal tube
2. Bio-reactance (NICOM) analyzes variations in frequency spectra
associate with delivery of an oscillating electrical current
3. Electrical cardiometry (ICON) using skin sensors with electrical
velocimetry method to interpret maximum change in thoracic
electrical bio-impedance as the equivalent of aortic blood flow
velocity. Stroke volume and cardiac output are then calculated
 ADDITIONAL
HEMODYNAMIC VARIABLES
• Static Preload Variables : CVP, GEDV, EVLW, ED area
of LV
• Functional (dynamic) hemodynamic variables : SVV,
PPV, Passive leg raising, PVI
• Central Venous Oxygen Saturation (ScvO2) monitoring
—> intermittent or continuous
Limitations of dynamic variables : spontaneous
breathing activity, arrythmias, right heart failure,
decreased chest wall compliance, increased intra-
abdominal pressure, tidal volume < 8 ml/kg
 PITFALLS IN DETECTING
CARDIAC OUTPUT
• Difficult to asses individual optimal CO
• ‘Normal’ or high CO does not preclude
inadequate regional or microcirculatory flow,
while ‘low’ CO might be adequate for low
metabolic demand (general anesthesia)
• Combine/integrate several variable to
correctly interpret the data acquired
 COMPARISON OF CO MONITORING
DEVICES AND ITS LIMITATIONS
Method System CO and Additional Limitations
(Preload) variable

Transcardiac Thermodilution PA catheter SV, CO, PAOP, PAP, SvO2 Invasiveness,

Catheter Combo RVEF, RVEDV Training required

Transpulmonary Indicator
Dilution
(calibrated)
Arterial-pressure waveform
derived
(Un-calibrated)
Doppler’s principle
PiCCO SV, CO, GEDV, EVLW, SVV, PPV Invasiveness,
LiDCO Need for dedicated catheter
Vigileo SV, CO, SVV, dP/dT, CCE, PPV, Need for optimal arterial signal
MostCare SVV
Esophageal CardiacQ SV, CO, Ftc, peakV Partial meassurement of CO
Suprasternal USCOM Estimation of AoCSA

Fick’s principle NiCO CO, Shunt calculation Intubated patients

Less reliable in respiratory
failure

Bioimpedance Lifegard, TEBCO CO, SV Not applicable in

cardiothoracic surg

Cardiometry Osypka SV, CO, FTc, SVV, SVR Applicable for pediatric and
neonates

Modified from George, 2015

 HOW TO SELECT
THE BEST SYSTEM ?
• Are we ready to accept reduced accuracy in
order to limit invasiveness or cost ?
• Do we need continuous, semi-continuous or
intermittent measurement ?
• Are calibrated or non calibrated system
preferable ?
• What kind of monitoring for what kind of
patient ?
 HOW TO SELECT
THE BEST SYSTEM ?
do we need
invasive monitoring ??
 MANAGEMENT STRATEGIES
BASED ON PERIOPERATIVE MONITORING
Table 5. Options to optimize hemodynamic management
in high risk patients

Vincent et al. Critical Care (2015) 19:224

 CONCLUSION
• Cardiovascular monitoring systems play an important role in
optimizing perioperative hemodynamic management

• The most appropriate system for a patient must be selected prior

to surgery according to individual risk and surgery

• The best interpretation of hemodynamic monitoring requires

integration of several variables

• Clinician must understand the advantages and limitations of the

various tools and parameters used during perioperative care
THANK YOU