Hemodynamic Monitoring
D. Matamis M.D
Papageorgiou Hospital Thessaloniki
Greece.
Shock or Hypotension may be due
to:
Decrease in cardiac output
• Decrease in preload (hypovolemia - Hemorrhage)
• Decrease in contractility (myocardial ischemia)
Decrease of the inflow and outflow of blood
into the cardiac chambers (obstructive shock)
• Pulmonary embolism
• HOCM
• Valvular stenosis
Decrease in peripheral resistances
• Distributive shock (sepsis, allergic reactions)
Hemodynamic Evaluation

Non invasive methods (50%)
Κλινικη εμπειρια, Φυσικη εξεταση, ECG, Rx Θωρακος

Invasive methods (50%)
Προφορτιο, Μεταφορτιο, Συσταλτικοτητα του
μυοκαρδιου, Διαστολικη Λειτουργια, Καρδιακη Παροχη
Invasive methods
PAC

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Preload
Y
Cardiac Output
Y
Afterload
Y
Systolic Function
?
Diastolic Function
No
Oxygen Delivery
Y
Oxygen Consumption
Y
Heart-Lung Interactions Y
Intrapulmonary Shunt
Y
ECHO
Y
Νo
Νo
Y
Y
No
No
Y
No
The PAC controversy
“The effectiveness of right heart catheterisation in the initial care of critically
ill patients.”
Connors AF, Speroff T, Dawson NV, et al. JAMA 1996. 276:889-897.
5735 critically ill patients (2184 with PAC) in 15 ICU’s
1008 pairs of patients matched for disease category
No benefit
 Increased mortality (37.5% vs 33.8% without PAC)
 Greater hospital costs (49,300$ vs 35,700$ without PAC)
 Longer ICU and hospital stay
 Therapy related mortality - more aggressive level of care.
The PAC controversy
A randomized controlled trial of the use of pulmonary-artery
catheters in high-risk surgical patients.
Sandhham JD et al. N.Engl J Med.2003;348:5-14
From 1990-1999, surgical patients > 60 years old, ASA class risk III-IV. 997
patients in each group.
No benefit
No difference in mortality or hospital stay.
Higher rate of pulmonary embolism in the catheter group(8 vs 0)
The PAC controversy
“A multicenter study of physicians’ knowledge of the
Pulmonary Artery Catheter”
Iberti TJ, Fischer EP, Leibowitz AB, et al. JAMA 1990: 264, 2928-32.
31 Q.M.C to 496 I.C.U Physicians practicing in the US and Canada.
To quantify the knowledge and ability to interpret derived PAC data.
Results.
 Mean score 20.7(67%), range 6-31(19-100%)
 Independent of training
 Frequency of use
 Frequency of insertion
 Restrict the use of PAC to individuals with documented competency.
The PAC controversy
Intensive care physicians’ insufficient knowledge of right
heart catheterization at the bedside: Time to act?
Gnaegi A, Feihl F, Perret C. Crit. Care Med. 1997:25,213-220.
31 Q.M.C to 535 I.C.U physicians practicing in 86 European I.C.Us.
To quantify the knowledge and ability to interpret derived PAC data.
Results.
 Mean score 72.2±14.4%
 67.3±14.7% in training, 76.1%±13% postgraduate
 50% of the responders did not identify PAOP from a clear chart recording
 Positive(loose correlation) with frequency of insertion and use.
 Accreditation policies and teaching practicies concerning this technique need
urgent revision.
PAC
Pulmonary Artery Catheter.
Does the problem lie in the users?
Squara P, Bennett D, Perret C. Chest 2002: 121.2009-2015.
“More than 25 years after the introduction of PAC and
despite thousands of scientific publications, our data
showed unacceptable variability in treatments and an
alarmingly high rate of potentially harmful treatment
decisions in participants to three international meetings
in Intensive Care Medicine”
Comparative studies PAC-ECHO
ECHO vs PAC
“Evaluation of TEE as diagnostic and therapeutic aid in a critical
care setting.”
Poelaert JI. Trouerbach J, et al. CHEST 1995.107: 774-779.
TEE in 103 patients (66 with PAC, 37 without)
offered useful information in 74% of the patients.
altered the initial therapy in 44% with PAC.
altered the initial therapy in 54% with PAC + Sepsis
altered the initial therapy in 41% without PAC.
Comparative studies PAC-ECHO
“ Value of 2-D ECHO for Determining the Basis of Hemodynamic Compromise in
Critically Ill Patients. A Prospective Study.”
Sanjiv K, Alexander et al. J. AM. SOC. ECHOCARDIOGR. 1994,7: 598-606
TEE in 49 patients with PAC
Agreement between the two methods in 86% of cases.
“TEE in the ICU Setting: Luxury or Necessity?”
D. Lagonidis, D. Matamis et al. B.J.A 1997. suppl. A46.
64 patients. Change in therapy in 23 / 60 patients (38%)
What can be assessed with ECHO

Preload
Systolic function
Diastolic function
Heart Valves function

Pericardial structure-Great vessels



Preload Evaluation
PAC - PCWP
(Pressure)
PCWP = LVED Pressure = LVED Volume
Tachycardia, MV disease, LV Compliance
Lung Hyperinflation(High PEEP,auto PEEP)


ECHO - LA, LV
Hypovolemia
Hypervolemia
ECHO >
Volume
OK (End systolic collapse)
?
PAC
Preload Evaluation
64 year old woman with
History of CAD, Diabetes mellitus, Resp. Pb for 10 yrs
Hypercapnic ARF, CXRay bilateral infiltrates,
HR=135, MAP=65mmHg, Temperature 39.5.
Treatment 40 mg Furosemide, Dobutamine 5mcg/kg/min
I.C.U Shock, Intubation, MV, auto PEEP 12 cm H2O.
PAC Findings
HR= 130, MAP= 60 mmHg, PAP =55/25, PAOP =20mmHg , 16mmHg end
expiration, C.O = 6.5lit/min, (a-v)DO2 = 5.8
1. You are happy with the hemodynamic status of the patient
2. You will increase the dose of Dobutamine to increase C.O.
3. You will add Nitroglycerine to decrease PAOP
4. You will ask for an ECHO study
Preload Evaluation
Preload Evaluation
In the post operative period a 42 year old woman with
Pulmonary Oedema (clinically, XRay)
Heart Rate 140 beats/min, MAP = 85mmHg, ECG=ST depres.
Intubation, M.V, PEEP 8cmH2O, FiO2=60%
PAC findings
Heart rate=140beats/min, SAP=85mmHg, PAOP = 34mmHg C.O = 3.5
lit/min
Treatment
Dobutamine 8mcg/kg/min, Nitroglycerine 1mcg/kg/min
After treatment
HR =145 b/min, PAOP = 30mmHg, C.O = 2.5 l/min
ECHO to assess LV function and Preload.
Preload Evaluation
Preload evaluation with ECHO
“Non invasive evaluation of pulmonary capillary wedge pressure in
patients with acute myocardial infarction by deceleration time of pulmnary
venous flow velocity in diastole”
Yamamuro A,Yosida K, Hozumi T. JACC 1999:34.90-94
A DTd of <160 ms had 97% sensitivity and 96% specificity for a
PCWP of >18 mmHg
«The deceleration time of pulmonary venous diastolic flow is more
accurate than the pulmonary artery occlusion pressure in predicting left
atrial pressure»
Kinnaid TD, Thomson CR, Munt BI. JACC 2001:37. 2025-2030
A DTd of <175 ms had 100% sensitivity and 94% specificity for a PLA of >17 mmH
Preload evaluation with PVF (DTd)
Cardiac Output monitoring
“Ideal” CO continuous Monitoring:
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Minimally invasive, easy to apply: Widely applicable
Accurate
Real time: beat - to - beat CO
Nurse driven
Easy data interpretation
Bedside management
Neonates to adults
Early warning of deterioration
Evidence of improved outcome
Optimum fluid management/drug administration
Reduced workload of health care staff
Decreased procedural complications (e.g. bolus injections)
CO Techniques
(non or less invasive)

Based on:
Echocardiography (TT &TEE)
 Esophageal Doppler
 Fick principle & CO2 rebreathing
 Pulse contour analysis

Doppler Echocardiography(1):
Principles for CO assessment
Assumptions for accurate measurement
 No rhythm disturbances

 Accurate cross-sectional area measurement!!!
 Laminar flow
 “Flat” velocity profile
 Parallel angle beam/flow (≤20o)
 Velocity – diameter at the same site
LVOT or AVA
(IF No Aortic valvulopathy or HOCM)
Esophageal Doppler (EDM):
Principles & assumptions for CO monitoring

Blood flow velocity of the descending aorta
(PW or CW Doppler)

Sedated, mech. ventilated pts

Flexible probe: Insertion & rotation →
Characteristic, clear signal, highest possible
peak velocity

“Flat” velocity profile (same speed of RBC)

Cross – sectional area: Constant during
systole (nomogram or direct measurement**)

Fixed distribution of blood flow: Aortic arch→
30%, Descending Aorta → 70%
Esophageal Doppler (EDM):
Final notes & critical appraisal

Safe, easy to learn & set – up & apply (even nurse driven),
reproducible results.

Real beat to beat CO monitoring in sedated & mech. ventilated pts

Monitoring but not diagnostic tool

Excellent validity concerning the changes of CO (vs. PAC)

Probe displacement: usual source of errors

“EDM guided” fluid titration in high risk surgical pts: Evidence for
improved outcome (LOS, complications post- op)
Pulse contour Cardiac Output (PCCO):
Principles, equipment, advantages

Arterial waveform: interaction SV/mechanics of arterial tree

PCCO methods: estimation of SV by pressure waveform

PiCCO®, PulseCO®: Waveform analysis (various arterial models) &
indicator dilution technique for calibration

FloTrac, Vigileo™: Waveform analysis, no need for calibration

Minimally invasive, continuous, real time CO
Pulse contour Cardiac Output (PCCO):
Flaws & Limitations

Aortic Valve disease

Arrhythmias

Quality of the arterial waveform
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Frequent & rapid changes in arterial compliance

Need for frequent calibrations - every 4h or before important acquisitions
Minimally invasive???
Cardiac Output Evaluation
The absolute value of C.O. is meaningless.(Hypo, Hyperthermia, Drugs)
ICU patients
Frequent modifications of Mechanical Ventilation and PEEP, TR, Sedation,
General Anesthesia, Surgery, Variations of body temperature in the O.R.,
Substantial blood losses.
SvO2, ScvO2, (a-v)DO2, DO2, VO2.
Adequacy of C.O and oxygen transport, quality of tissue oxygenation.
Contractility Evaluation
Regional (Myocardial ischemia)
Correlative study (100 patients) comparing PAC, ECG (12 lead), TEE
M. van Daele et al. Circulation.1990.
TEE = gold standard in detecting RWMA
ECG = Sensitivity = 69% Specificity = 99%
PAC = Sensitivity = 25% Specificity = 96%
Global
PAC Ventricular Work – PCWP (Ventricular Compliance)
TEE By Eye, Ejection Fraction, Fract. Shortening.
Contractility Evaluation
(global systolic function) with PAC
17 y/o male admitted to the ICU with the diagnosis of ARDS due to bilateral
pneumonia, fever 39 °C for a week.
Upon admission, Bilateral Infiltrates in the CXRay, Temp= 39.4
WBC= 12000, 85%Neutrophils, HR=120 b/min, ECG=NL, MAP=110/55
under 1.2 mcg/kg/min of Noradrenaline.
Acute Renal Failure due to Rabdomyolysis(CPK=35000).
PAC findings
C.O. =10 lit/min, PAOP =18mmHg, (a-v)DO2 = 4.8ml%
1. Do you consider the systolic function normal?
2. Do you consider the systolic function abnormal?
3. You will ask for an ECHO study to assess LV systolic function
Contractility Evaluation
(global systolic function) with PAC
Contractility Evaluation
(global systolic function) with PAC
-Sepsis
-Myocarditis
-Dialated Cardiomyopathy
Contractility Evaluation
(regional systolic function) with PAC
Regional systolic function
M. Van Daele et al. Circulation 1990
ECHO, ECG 12 leads, PAC
ECHO
ECG
PAC
Gold standard
Sensitivity. Specificity.
69%
99%
25%
96%
TEE transversal axis (T)
Diastolic dysfunction
Diastolic dysfunction
Decrease of the inflow and outflow of blood
into the cardiac chambers
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Pulmonary Embolism
Tamponade
Valvular stenosis
Tumors
HOCM
Πλεονεκτήματα της Υπερηχοκαρδιογραφίας στήν
Οξεία Πνευμονική Εμβολή

Ευαισθησια 80%

Εξειδικευση 92-100%
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Οξεια-υποξεια Π.E
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Μαζικη-υπομαζικη Π.E
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Καθοδηγηση της Θεραπειας
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Ανταποκριση στη Θεραπεια

Βαθμονομηση του
κινδυνου
Wood K. CHEST 2002;121:877
Αμεσα ευρήματα
Εμμεσα Ευρήματα

Διαταση RV/RA

Σχεση RV/LV

Μετατοπιση του ΜΚΔ

Ανεπαρκεια Τριγλωχινος

Ταχυτητα ροης του
ανεπαρκουντος jet της
τριγλωχινας < 3m/sec
Case history
A 73 –year-old lady admitted to the hospital for surgical repair of hip
fracture.
Preoperative assessment revealed exertional dyspnea attributed to
moderate obesity and reduced physical activity
Chest X-Ray: moderate cardiomegaly
ECG showed atypical ST segment and T wave abnormalities.
In the immediate post- operative period while recovering from regional
anaesthesia she developed pulmonary oedema and acute respiratory
failure.
She was intubated and mechanically ventilated and a PAC was inserted for
hemodynamic management.
PAC data
C.I = 1,9 lit/min/m2, PAP=55/30-42 mmHg, PAOP=28 mmHg.
HR =125 b/min, ABP=120/90 mmHg
Initial treatment consisted of diuretics (intra-operative fluid
balance was 1.5 lit positive), dobutamine, and nitroglycerine,
considering that this lady was suffering from congestive heart failure
Despite the above treatment, leading to a negative fluid balance of 2,5 lit,
the patient did not improve
I.C.U
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ICU PAC data
under:
sedation (Remifentanyl –Propofol)
Dobutamine=8 mcg/kg/min, Nitroglycerine = 1 mcg/kg/min
Furosemide 20 mg/hr

ABP= 110/85 mmHg, HR = 135 beats /min
C.I =1.8 lit/min/m2, PAP = 60/35-45 mmHg, PAOP = 30

Suggestions for therapy changes?

mmHg
Hypertrophic Cardiomyopathies (HCM)

Prevalence 0,2%, 1/500

Inherited autosomal dominant trait

Primary sarcomere disorder

LVH and Clinical symptoms during
any phase of life

Elderly patients > 75 years compose
as much as 25%.

Clinical course
– Sudden death
– Congestive heart failure
Hypertrophic Cardiomyopathies (HCM)
Non Obstructive (75%)
Hypertrophic Cardiomyopathies (HCM)
Obstructive (25%)
Ejection
Eject
Venturi effect - SAM
Obstruct
Abnormal MV closure
Leak
MR+++
Tumors
Tamponade
ECHO
unique tool to
Diagnose
Guide the therapy
Quantity (loculated)
Quality clear fluid,
Thrombi.
P.A.C
Little diagnostic specificity
Equalization of pressures
CVP = PCWP
Tamponade
Conclusion

PAC invasive technique but necessary for selected patients (need
for SvO2)

Echocardiography (TT &TEE) non invasive non expensive in
every day practice but special training is necessary

Esophageal Doppler non invasive , training is necessary, in
the OR

Pulse contour analysis: non invasive no special training in
every day