huidige en toekomstige
hemodynamische bewaking
© 2010 Universitair Ziekenhuis Gent
Stefan De Hert
Department of Anesthesiology
Ghent University Hospital
Ghent University
Belgium
disclosures ?
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hemodynamic monitoring ?
~ adequacy of organ perfusion
 blood pressure
 cardiac output
 tissue oxygen saturation
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hemodynamic monitoring ?
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blood pressure
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clinically available non-invasive
continuous blood pressure measurement devices
~ Peňaz technique
(vascular unloading technique)
 uses a volume-clamp technique, which employs
the technique of “vascular unloading”
 basic device consists of a small finger cuff with a photoplethysmograph,
able to estimate blood volume of the finger via infrared light absorbance
 this plethysmographic signal is used in a feedback loop for
adjustment of the cuff to keep the blood volume constant and the vessels
in a constant state of “vascular unloading”
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Finapress
(FINger Arterial PRESSure)
 assumption that the cuff pressure is equal to the arterial pressure
and then use a formula (algorithm) to reconstruct the
brachial arterial pressure
 this signal is displayed showing a similar waveform as obtained with
invasive pressure monitoring
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CNAP™
(Continuous Noninvasive Pressure)
 a mathematical calibration to upper arm values is performed
using a transfer function.
 immediately after a non-invasive measurement,the
CNAP® computer puts systolic and diastolic finger BP
on the same level as NBP values.
The computer memorizes this transfer function and
retains it until next NBP is performed.
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clinically available non-invasive
continuous blood pressure measurement devices
~ arterial tonometry
(pulse pressure method)
 provides a waveform similar to the Penaz technique but
the principle of operation is very different
 tonometer is placed over a superficial artery with sufficient bony support
 tonometer compresses the vessel until it is flattened but
NOT occluded (applanation)
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clinically available non-invasive
continuous blood pressure measurement devices
~ arterial tonometry
(pulse pressure method)
 a pressure transducer on the skin surface then should be able
to measure arterial blood pressure via contact pressure
 the amount of pressure needed to flatten (but not occlude) the vessel
(proper hold-down pressure) is calculated by an algorithm which
reports the data as systolic/diastolic/mean pressures
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cardiac output
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different techniques as the basis for arterial waveform analysis
FloTrac
 samples data points from the arterial waveform
 pulse pressure is assessed by calculating the SD of the data points
arterial
waveform
CO = HR *  AP * C,R
data
sampling
C,R = M (PR, AP, C(P), BSA, MAP, µ3AP, ...)
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different techniques as the basis for arterial waveform analysis
PiCCO
 area under the systolic portion of the arterial waveform
arterial
waveform
data
sampling
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different techniques as the basis for arterial waveform analysis
LiDCO
 converts the arterial pressure waveform into a standardized
volume waveform which is analysed as a sine wave
arterial
waveform
 multiplication of the waveform values
with themselves gives a
double wave pattern with
positive deflections only
data
sampling
which are
further processed to volume data
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NICOM
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validation of techniques
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Bland Altman analysis
biais + 2 SD
A-B
95 % CI
biais - 2 SD
A+B/2
Y axis
X axis
=
=
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difference between measurement A and B
mean of measurement A and B
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gold standard ?
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tissue oxygen saturation
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hemodynamic strategies
protocol for perioperative hemodynamic optimization
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protocol for hemodynamic optimization in sepsis
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conclusions
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