Hemodynamic Calculations II – M. L. Cheatham, MD, FACS, FCCM
HEMODYNAMIC MONITORING: PART II
CONTINUOUS CARDIAC OUTPUT
IN THE LAST LECTURE…
• We monitor patients to
– Guide therapeutic interventions
– Allow early detection of organ dysfunction in order
to avoid organ failure
– Identify
y the need for changes
g in treatment strategy
gy
• Cardiac performance can be assessed and therapeutic
interventions directed using simple physiologic
equations
Michael L. Cheatham, MD, FACS, FCCM
Director, Surgical Intensive Care Units
Orlando Regional Medical Center
POTENTIAL SOURCES OF ERROR IN
THE PAOP ASSUMPTION
Is ventricular
geometry
unchanged?
Is ventricular
compliance
unchanged?
Is there
mitral valve
disease?
IS catheter
properly
positioned?
Preload = LVEDV = LVEDP = LAP = PAOP
PAOP and CVP are accurate
ONLY when these potential
sources of error have been
eliminated
Are intrathoracic or
intra-abdominal
pressures elevated?
INTERMITTENT CO TECHNOLOGY
• Cardiac output (CO) is traditionally determined by the
“thermodilution technique”
– Iced saline is injected into the right atrium
– The temperature of the blood flowing past a
thermistor on the tip of the PAC is measured
– A “thermodilution
“thermodilution curve” is created
• If CO is high, the cold saline flows through the heart
quickly and blood temperature returns to normal as
the saline bolus rapidly moves through the heart
• If CO is low, blood flow is slower and blood
temperature remains lower longer
Revised 01/13/2009
• Traditional intracardiac filling pressures ((ie
ie.,
., PAOP
and CVP) are inaccurate in the critically ill surgical
patient
VOLUMETRIC VARIABLES
• Volumetric technology allows measurement of
– Right ventricular ejection fraction (RVEF)
– Right ventricular end
end--diastolic volume index
(RVEDV)
• RVEDVI can b
be used
d as an estimate
ti t off iintravascular
t
l
volume or “preload” status
• RVEDVI is independent of zerozero-pressure references
and changing ventricular compliance
– It is unaffected by the majority of potential
sources of error which plague PAOP and CVP
THERMODILUTION CURVE
• As the iced saline bolus flows
through the right atrium and
ventricle, the intracardiac blood
temperature decreases and then
returns to normal
• The area under the curve
determines the CO
• Accuracy is dependent upon
multiple factors
– Respiratory cycle
– Injection technique
– Regular heart rate / stable CO
1
Hemodynamic Calculations II – M. L. Cheatham, MD, FACS, FCCM
INTERMITTENT VOLUMETRIC TECHNOLOGY
• In the early 1990’s, volumetric PAC’s were introduced
capable of measuring beat
beat--to
to--beat temperature changes
• Required a modified PAC
– Rapid response thermistor
¾To
T detect
d
changes
h
in
i temperature rapidly
idl
– Intracardiac electrodes
¾To determine heart rate using the R
R--R interval
– Multi
Multi--hole injectate port
¾To ensure more thorough mixing of the injected
saline in the right atrium
CONTINUOUS CO TECHNOLOGY
INTERMITTENT VOLUMETRIC TECHNOLOGY
Two problems remained
1. RVEF varies with the
respiratory cycle and
timing of injection
2. Intermittent
measurements
provide only a
“snapshot” of the
cardiac function when
a “moving picture” is
needed
• BeatBeat-to
to--beat temperature changes
allow determination of stroke
volume (SV), RVEDVI, and RVEF
as well as CO
Revised 01/13/2009
Peak-Inspiration
Mid-Expiration
RVEF .39
RVEF .29
• Energy to the coil is turned on
and off in a pseudopseudo-random
pattern
• Pulmonary artery blood
temperature is measured
continuously
• Promotes improved resuscitation by providing a
constantly updated CO assessment not previously
available
• These curves are combined
mathematically to construct a
traditional thermodilution curve
RVEF .46
• A wire coil on the surface of the
PAC heats (rather than cools)
the blood in the right atrium
• Reduces measurement variability
– Averages respiratory cycle variation
– Standardizes “injection” technique
– Eliminates inconsistency associated with irregular
heart rates
• By correlating the changes in
blood temperature with when the
thermal coil was heated, a series
of thermal curves are generated
Mid-Inspiration
RVEF .51
CONTINUOUS CO TECHNOLOGY
• In the early 2000’s, continuous CO measurements
became available
– Utilizes continuous pulsed thermal energy instead
of intermittent iced saline
CONTINUOUS CO TECHNOLOGY
End-Expiration
CASE PRESENTATION
• 76 year old male with claudication
– Past medical history
• Hypertension
• Coronary artery disease
• Congestive heart failure
• Diabetes mellitus
• Arteriogram
Aortoiliac occlusive disease
• Procedure
Preoperative optimization
Aortobifemoral bypass graft
2
Hemodynamic Calculations II – M. L. Cheatham, MD, FACS, FCCM
PREOPERATIVE OPTIMIZATION
INTERMITTENT METHODOLOGY
• A volumetric PAC is placed the day prior to
operation in high risk patients
5
4
Cardiacc Index
• Patient response to fluids and vasoactive
medications is assessed
• Cardiopulmonary function is optimized in an
attempt to reduce morbidity and mortality
3
2
1
• Patient resuscitation is continued postoperatively
Preoperative Optimization Operation Postoperative Resuscitation
0
10/16
14:24
10/16
19:12
10/17
0:00
10/17
4:48
10/17
9:36
10/17
14:24
10/17
19:12
10/18
0:00
10/18
4:48
Hours
PREOPERATIVE OPTIMZATION
5
5
4
4
1
0
3
2
1
Preoperative Optimization Operation Postoperative Resuscitation
10/16
14:24
10/16
19:12
10/17
0:00
10/17
4:48
10/17
9:36
10/17
14:24
10/17
19:12
10/18
0:00
10/18
4:48
Dobutamine
2
IVF
3
IVF
Cardiac index
Cardiacc Index
CONTINUOUS VOLUMETRIC TECHNOLOGY
0
10/16 14:24
10/16 19:12
10/17 0:00
10/17 4:48
Hours
Hours
PREOPERATIVE OPTIMZATION
150
0.6
125
0.5
75
0.4
0
10/16 14:24
IVF
25
10/16 19:12
IVF
50
Dobutamine
CED
DVI
100
10/17 0:00
0.3
0.2
10/17 4:48
Hours
Revised 01/13/2009
3
Hemodynamic Calculations II – M. L. Cheatham, MD, FACS, FCCM
2
0.5
0.4
75
50
0.3
1
25
0
0.2
0
10/17 12:00
10/17 7:12
10/17 14:24
10/17 9:36
POSTOPERATIVE RESUSCITATION
0.6
IVF
NTG
IVF
IVF
125
IVF
150
IVF
NTG
IVF
IVF
Dobutamine
POSTOPERATIVE RESUSCITATION
4
10/17 14:24
Hours
Hours
5
10/17 12:00
IVF
10/17 9:36
Dobutamine
10/17 7:12
0.5
100
2
0.4
75
.
3
CEDV
VI
Cardiac Index
0.6
.
100
Release RLE
125
Release LLE
Cross clamp
Induction
150
CEDV
VI
3
INTRAOPERATIVE COURSE
Release RLE
Cardiac Index
4
Release LLE
Induction
5
Cross clamp
INTRAOPERATIVE COURSE
50
0.3
1
25
0
10/17 14:24
10/18 0:00
Hours
BENEFITS OF VOLUMETRIC TECHNOLOGY
• The previous graphs demonstrate that significant
physiologic changes go undetected by
conventional intermittent monitoring technologies
• Patient response to interventions is immediately
apparent using continuous CO monitoring
• Patient resuscitation is much more efficient and
goal--directed
goal
Revised 01/13/2009
0.2
0
10/17 19:12
10/17 14:24
10/17 19:12
10/18 0:00
Hours
THE VALUE OF RVEF AND RVEDVI
• Numerous studies have demonstrated the value of
volumetric measurements in resuscitation of the
critically ill
– Diebel et al. 1992, 1994, 1997
– Eddy et al. 1994
– Chang et al. 1995, 1996, 1998
– Cheatham et al. 1994, 1998, 1999
4
Hemodynamic Calculations II – M. L. Cheatham, MD, FACS, FCCM
THE VALUE OF RVEF AND RVEDVI
RVEF TECHNOLOGY
• RVEDVI is a valuable indicator of resuscitation
adequacy in the following patient populations
– General / vascular surgery
– Trauma
– Burns
– Sepsis
– Acute respiratory distress syndrome (ARDS)
– Intra
Intra--abdominal hypertension (IAH)
– Abdominal compartment syndrome (ACS)
• RVEF was originally intended to estimate the
contractility of the right ventricle
– RVEF is too dependent upon afterload and the
right ventricle too weak to maintain contractility
¾Increased afterload decreases RVEF
• RVEF, however, allows calculation of the right
ventricular endend-diastolic volume index (RVEDVI)
¾A volumetric as opposed to pressurepressure-based
assessment of preload
SVI
RVEF
RVEDVI =
• RVEDVI is independent of pressure references and
is not confounded by
– Changing compliance
– Elevated intraintra-thoracic pressure
– Elevated intraintra-abdominal pressure
p
• Positive end
end--expiratory pressure
(PEEP) has a number of effects on
the heart and lung
– Decreases venous return
– Decreases CO
– Increases SVR
– Decreases pulmonary compliance
– Increases intrathoracic pressure
• RVEDVI can be confounded by
– Irregular heart rate and/or rhythm
– Mitral valve disease
– Incorrect catheter placement
• ARDS and IAH / ACS also result in
increases in intrathoracic pressure
that can affect cardiac function
RVEDVI IN ARDS
r= 0.24
p=0.01
20
100
PEEP 15-29 cm H2O
0
30
100
20
50
10
1
2
3
4
5
6
0
0
7
1
CARDIAC INDEX
200
3
4
5
30
r= 0.82
p<0.001
150
2
6
7
PEEP 30-50 cm H2O
2
3
4
5
6
CARDIAC INDEX
7
8
4
5
6
1
2
3
4
5
6
CARDIAC INDEX
7
8
2
3
4
60
r= 0.72
p<0.001
100
1
5
6
7
CARDIAC INDEX
r= -0.30
p=ns
40
20
0
0
0
7
50
0
1
3
150
10
0
2
200
r= 0.04
p=ns
20
50
1
CARDIAC INDEX
100
0
0
0
CARDIAC INDEX
PAOP
0
Revised 01/13/2009
r= -0.36
p=0.003
40
150
10
0
PEEP 6-14 cm H2O
r= 0.52
p<0.001
200
PAOP
RVEDVI
PEEP 5 cm H2O
RVEDVI IN ARDS
r= 0.08
p=ns
30
200
CI
HR x RVEF
INTRATHORACIC PRESSURE
VOLUMETRIC VARIABLES
300
=
0
0
1
2
3
4
CARDIAC INDEX
5
6
0
1
2
3
4
5
6
CARDIAC INDEX
5
Hemodynamic Calculations II – M. L. Cheatham, MD, FACS, FCCM
HEMODYNAMIC EFFECTS OF ARDS
450
RVEDVI AND ARDS
40
400
• PAOP provides erroneous information that may lead
to inappropriate patient interventions
CI
350
30
• RVEDVI is a superior predictor of preload status in
patients on PEEP
300
250
20
200
PAOP
• Volumetric PA catheters are indicated in any patient
with ARDS and those who require PEEP > 15 cm H2O
150
10
100
RVEDVI
50
0
• Each patient requires resuscitation to optimize CO
and tissue perfusion rather than to an arbitrary PAOP
value
0
5
6-14
15-29
30-50
cm H2O
• PAOP provides contradictory information concerning preload status
• The negative effects of PEEP are typically not seen until > 15 m H2O
ABDOMINAL COMPARTMENT SYNDROME
• Characterized by the presence of IAH and one or more
of the following signs:
Oliguria
Abdominal distention
Refractory oliguria
Elevated airway pressures
Hypercarbia
Hypoxemia
Refractory metabolic acidosis
Elevated intracranial pressure
RVEDVI IN INTRA-ABDOMINAL HYPERTENSION
70
• Use of PAOP and CVP in patients with IAH may lead
to inappropriate therapy
• RVEDVI is a more accurate estimate of intravascular
volume status than PAOP in patients with IAH / ACS
RVEDVI IN INTRA-ABDOMINAL HYPERTENSION
70
45
r = - 0.33
35
40
30
30
25
20
10
1
2
3
4
5
6
7
8
30
5
0
9
30
25
20
15
10
10
0
0
35
40
10
0
40
20
15
20
r = - 0.33
45
50
PAOP
50
50
r = - 0.33
60
r = - 0.33
40
CVP
PAOP
• Increased intraintra-abdominal or intrathoracic pressure
elevates intracardiac pressures by an amount that is
unpredictable
50
60
5
0
0
0
1
2
CARDIAC INDEX
3
4
5
6
7
8
9
1
2
3
4
5
6
7
8
0
9
1
2
CARDIAC INDEX
3
4
5
6
7
8
9
CARDIAC INDEX
r = 0.68
CARDIAC INDEX
70
40
30
20
10
0
r = 0.69
200
80
60
40
10
20
PAOP
Revised 01/13/2009
30
40
50
150
100
50
20
0
0
250
100
RVEDVI
50
PEAK AIR WAYPR ESSU RE
120
r = 0.44
60
IAP
HEMODYNAMIC MONITORING IN IAH/ACS
CVP
–
–
–
–
–
–
–
–
Cheatham et al. Crit Care Med 1998
0
0
10
20
PAOP
30
40
50
0
1
2
3
4
5
6
7
8
9
CARDIAC INDEX
6
Hemodynamic Calculations II – M. L. Cheatham, MD, FACS, FCCM
CORRELATION WITH CI
HEMODYNAMIC MONITORING IN IAH / ACS
Variable
r
p
RVEDVI
0.69
<0.0001
PAOP
- 0.33
<0.0001
CVP
- 0.32
<0.0001
PIP
- 0.30
<0.0001
Paw
- 0.16
0.02
IAP
- 0.05
0.40
PEEP
- 0.04
0.53
• CI correlates significantly better with RVEDVI than
with PAOP or CVP
• PAOP and CVP provide erroneous information and
may lead to inappropriate therapy
• RVEDVI is a superior predictor of patient response
to fluid challenge
• Right ventricular function PAC’s are the catheter of
choice in patients with IAH / ACS
Cheatham et al. J Trauma 1998
RVEDVI AS A PREDICTOR OF SURVIVAL
• Several studies have demonstrated improved
patient outcome with the use of volumetric PAC’s
– RVEDVI > 110 mL
mL/m2
/m2 (RVEF 0.39) (Miller)
• Decreased MSOF and death
– RVEDVI > 120 mL
mL/m2
/m2 ((RVEF 0.34)) ((Chang)
g)
• Improved visceral perfusion
• Decreased organ dysfunction and failure
– RVEDVI > 130 mL
mL/m2
/m2 (RVEF 0.37) (Cheatham)
• Improved survival from IAH / ACS
KEY POINTS TO INTERPRETING RVEF &
RVEDVI VALUES
“OPTIMAL” RVEDVI
• Initial studies suggested that an RVEDVI of 130130-140
mL/m2 was optimal
– This oversimplifies what is actually a complex
and dynamic relationship
• RVEDVI and RVEF are “mathematically
mathematically coupled”
coupled
– RVEF must be taken into consideration when
assessing the adequacy of RVEDVI
RVEDVI = SVI / RVEF ≅ 1 / RVEF
KEY POINTS TO INTERPRETING RVEF &
RVEDVI VALUES
1) RVEDVI reflects preload status
2) RVEF reflects contractility and afterload
3) Ventricular contractility and compliance are
constantly changing (Eddy 1995)
4) For a given preload status, as RVEF changes,
RVEDVI must also change
Revised 01/13/2009
RVEDVI must
ust be interpreted
te p eted
in conjunction with RVEF
7
Hemodynamic Calculations II – M. L. Cheatham, MD, FACS, FCCM
“FAMILIES” OF STARLING CURVES
RVEF
• 20-29%
• 30-39%
• > 40%
6
CARDIAC INDEX
5
“FAMILIES” OF STARLING CURVES
• As RV contractility changes, patients move to a new
Starling curve and the target RVEDVI must change
RVEF 0.20
4
RVEF 0.30
3
RVEDVI
RVEF 0.40
2
1
0
50
100
RVEDVI
150
200
CARDIAC INDEX
“RVEF CORRECTED” RVEDVI
CONCLUSIONS
“Optimal” RVEDVI
RVEF
Normal
Critically ill
200
mL/m2
240
.30
150
mL/m2
180 mL/m2
.35
125 mL/m2
150 mL/m2
.40
100 mL/m2
120 mL/m2
.50
50 mL/m2
60 mL/m2
.20
mL/m2
• Critically ill patients can have widely disparate
levels of ventricular function
• Optimal RVEDVI, PAOP, or CVP values must be
determined for each individual patient
• RVEDVI is superior to PAOP or CVP in determining
preload recruitable increases in CI
– Especially true when cardiac filling pressure
interpretation is confounded by conditions such
as shock, ARDS, and ACS
HEMODYNAMIC VARIABLES
CASE STUDIES
The following are a series of patient
scenarios that illustrate the key points from
the Hemodynamic Monitoring lectures
Preload
Contractility
Afterload
PAOP
CI
SVRI
CVP
LVSWI*
PVRI
RVEDVI
RVSWI*
SVI
RVEF
RVEF
* Assumes preload and afterload optimized
Revised 01/13/2009
8
Hemodynamic Calculations II – M. L. Cheatham, MD, FACS, FCCM
PATIENT 1
PREOPERATIVE OPTIMIZATION GOALS
• 74 yo male 2 weeks S/P ABF bypass
– PMH: CAD, MI x 2, NIDDM
CI
> 2.5 L/min/m2
LVSWI
> 40 (g
(g--m/m2)
• Initially seen at an outside hospital with hypotension,
abdominal pain, low UOP
Ca--vO2
Ca
< 5.5 mL O2/ dL blood
• Transferred to ICU via helicopter on dopamine
DO2I
> 600 mL
L O2/m
/ 2
VO2I
> 170 mL O2/m2
RVEDVI
> 100 mL/m
mL/m2
RVEF
> 0.40
• Surgeon diagnoses ischemic left colon and plans
exploratory laparotomy; requests preop evaluation
• Indications for PA catheter:
– Pre
Pre--operative optimization
PATIENT 1
PATIENT 1
Parameter
09:51
CI (L/min/m2)
2.6
HR (beats/min)
109
LVSWI (g(g-M/m2)
15
RVEF (fraction)
0.28
RVEDVI (mL
(mL/m
/m2)
83
PAOP (mmHg)
Parameter
Q: What therapeutic
changes should be
implemented?
A: The patient’s UOP
and RVEDVI both
suggest hypovolemia.
The patient’s CI, RVEF,
and LVSWI suggest
decreased contractility.
This should always be
corrected first by
ensuring adequate
preload.
15
SVRI (dyne.sec.cm-5/m2)
1683
SvO2 (fraction)
0.69
DO2I (mL
(mL O2/m2)
423
VO2I (mL
(mL O2/m2)
125
Urine output (mL
(mL/hr)
/hr)
10
PATIENT 1
Parameter
10:49
17:15
4.3
2.6
HR
102
92
LVSWI
40
18
RVEF
0.42
0.37
RVEDVI
130
76
SVRI
2900 mL
L IVF
10 500 mL EBL
1083 250 mL UOP
1764
SvO2
0.73
0.61
The patient goes to the
operating room and
returns with the
parameters listed.
Q: What therapeutic
changes should be
implemented now?
23
DO2I
710
458
VO2I
217
139
Urine output
40
110
Revised 01/13/2009
09:51
10:49
CI
2.6
4.3
HR
109
102
LVSWI
15
40
RVEF
0.28
0.42
83
130
RVEDVI
PAOP
15
SVRI
1683
SvO2
0.69
1000 mL
IVF
1000 mL of IVF is
administered and the
patient’s UOP and
RVEDVI respond.
Q: What therapeutic
changes should be
implemented now?
10
1083
0.73
DO2I
423
710
VO2I
125
217
Urine output
10
40
A: The patient’s preload
is adequate, but
afterload (SVRI) has
fallen. The patient
meets the preoperative
optimization goals and
is allowed to go to the
operating room.
PATIENT 2
CI
PAOP
These parameters are
discussed in the
“Oxygenation
Parameters” lecture.
You may want to
come back and
review these cases
again after reviewing
that lecture.
A: The patient’s preload
is inadequate and the
SVRI has increased to
compensate given the
hypovolemia. Further
fluid resuscitation is
indicated as the patient
has responded well to
this previously.
• 18 yo male with bilateral femur fractures following a
MVC
• Admitted to ICU for acute respiratory failure 12
hours following intramedullary nailing of his femurs
– Progressive ARDS requiring PEEP / FiO2
• “Pulmonary fat emboli syndrome”
– Blood loss requiring fluid resuscitation
• Indications for PA catheter
– Refractory shock
– Progressive ARDS
9
Hemodynamic Calculations II – M. L. Cheatham, MD, FACS, FCCM
PATIENT 2
PATIENT 2
Parameter
#1
CI (L/min/m2)
2.1
HR (beats/min)
140
RVEF (fraction)
.43
43
RVEDVI (mL
(mL/m
/m2)
60
PAOP (mmHg)
12
PEEP (cm H2O)
10
FiO2 (fraction)
.40
UOP (mL
(mL/hr)
/hr)
10
Q: What therapeutic
changes should be
implemented?
A: The patient’s preload
is inadequate as
evidenced by the
tachycardia and low UOP
and RVEDVI. Fluid
resuscitation is
indicated.
PATIENT 2
#1
#2
CI
2.1
2.9
HR
140
110
RVEF
.43
43
.38
38
RVEDVI
97
PAOP
60 2000 mL
IVF
12
PEEP
10
10
FiO2
.40
.40
UOP
10
50
15
The patient is given 2000
mL of normal saline.
Q: What therapeutic
changes should be
implemented now?
A: Although the
patient’s UOP has
improved, his CI, RVEF,
and RVEDVI remain low.
His PAOP is 15, but he
is on PEEP of 10 cm
H2O making his
transmural “true” PAOP
less than that. As is
common for such
patients, he still needs
more fluid.
PATIENT 2
Parameter #1
#2
#3
CI
2.1
2.9
3.5
HR
140
110
90
RVEF
.43
43
.38
38
.42
42
RVEDVI
60
PAOP
12
97 1000 mL 122
IVF
15
15
PEEP
10
10
10
FiO2
.40
.40
.40
UOP
10
50
60
Parameter
#3
#4
CI
3.5
2.4
HR
90
120
RVEF
.42
42
A: The patient’s CI, HR,
RVEF, RVEDVI, and UOP
are improving. You elect
to monitor his progress.
RVEDVI
122
PAOP
15
Six hours later, his
SaO2 slowly drops to
0.90. What intervention
is appropriate at this
time?
PEEP
10
18
FiO2
.40
.60
UOP
60
5
The patient is given
another 1000 mL of IVF.
Q: What therapeutic
changes should be
implemented now?
PATIENT 2
.28
28
PEEP
87
25
You increase the PEEP
serially to 18 cmH2O
and FiO2 to 0.60. His
ARDS is worsening with
a chest x-ray showing
bilateral patchy
infiltrates His UOP has
infiltrates.
fallen.
Q: What therapeutic
changes should be
implemented now?
A: The increased
intrathoracic pressure is
impeding venous return
to the heart. Further IVF
is warranted.
PATIENT 3
Parameter
#3
CI
3.5
2.4
3.1
HR
90
120
105
RVEF
.42
42
.28
28
.30
30
RVEDVI
122 PEEP 87
PAOP
15
25
27
PEEP
10
18
18
FiO2
.40
.60
.50
UOP
60
5
35
Revised 01/13/2009
Parameter
#4
• 25 yo male S/P GSW to inferior vena cava
#5
IVF
115
• Transferred to ICU following “damage control
laparotomy” for ongoing hemorrhage
– “Bogota bag” in place covering the open abdomen
With IVF administration,
his CI, HR, RVEDVI, and
UOP all improve. RVEF
remains decreased due
to the increased right
ventricular afterload
from ARDS and PEEP.
• Patient remains hypotensive with elevated arterial
lactate and low urinary output
• Indications for PA catheter
– Refractory shock
– Oliguria
10
Hemodynamic Calculations II – M. L. Cheatham, MD, FACS, FCCM
PATIENT 3
PATIENT 3
Parameter
#1
(L/min/m2)
2.3
HR (beats/min)
150
RVEF (fraction)
.38
38
RVEDVI (mL
(mL/m
/m2)
43
PAOP (mmHg)
5
CI
IAP (mmHg)
15
PIP (cm H2O)
36
UOP (mL
(mL/hr)
/hr)
2
Parameter
Q: What therapeutic
changes should be
implemented?
A: The patient’s preload
is inadequate as noted
by the low CI, RVEDVI,
PAOP, and UOP. His IAP
is moderately high and
will needed to be
watched closely. Fluid
resuscitation is needed.
PATIENT 3
#1
#2
#3
CI
2.3
2.5
1.8
HR
150
120
160
RVEF
.38
38
.31
31
.25
25
RVEDVI
43
IVF
53
IVF
You give additional
saline to try and
improve visceral
perfusion. IAP and PIP
continue to rise. You call
the surgeon back and
inform him of the
patient’s recurrent ACS
49
PAOP
5
18
30
IAP
15
22
35
PIP
36
52
87
UOP
2
10
0
Q: What therapeutic
changes should be
implemented now?
A: The patient needs
immediate abdominal
decompression for his
severe ACS.
PATIENT 3
CI
2.3
2.5
HR
150
120
RVEF
.38
38
.31
31
RVEDVI
43 1000 mL
IVF
5
53
PAOP
IAP
15
22
PIP
36
52
UOP
2
10
18
1000 mL of saline is
given, but minimal
response is seen.
Q: What therapeutic
changes should be
implemented now?
A: The patient’s preload
remains inadequate. His
PAOP, IAP, and PIP are
all rising rapidly. You
recommend revision of
the patient’s Bogota
bag, but the surgeon
says he doesn’t believe
abdominal compartment
syndrome is present.
Parameter
#3
#4
CI
1.8
2.9
105
HR
160
RVEF
.25
25
.42
42
RVEDVI
49 Exp Lap
108
PAOP
30
16
IAP
35
14
PIP
87
48
UOP
0
50
The surgeon reluctantly
reopens the abdomen
and finds ongoing
bleeding. This is
controlled and a larger
Bogota bag is placed.
Q: What therapeutic
changes should be
implemented now?
A: The patient is still
hypovolemic (low CI and
RVEDVI. Further IVF
administration is
warranted as is serial
monitoring of the
patient’s IAP.
PATIENT 4
#3
#4
#5
CI
1.8
2.9
3.4
HR
160
105
88
RVEF
.25
25
.42
42
.40
40
RVEDVI
49
PAOP
30
16
22
IAP
35
14
13
PIP
87
48
46
UOP
0
50
45
Revised 01/13/2009
#2
PATIENT 3
Parameter
Parameter
#1
Exp Lap
108
IVF
130
• 56 yo female admitted to ICU with acute cholecystitis
– PMH: unremarkable
• Blood cultures demonstrate Enterococcus faecalis
The patient responds
appropriately to the
additional IVF. He
demonstrates
evidence of good
organ perfusion and
his IAP remains at an
acceptable level
yp
, oliguric,
oliguric
g
, tachycardic
y
• Patient is hypotensive,
hypotensive
• Indications for PA catheter
– Refractory shock
– Oliguria
11
Hemodynamic Calculations II – M. L. Cheatham, MD, FACS, FCCM
PATIENT 4
PATIENT 4
Parameter
#1
Parameter
(L/min/m2)
1.3
HR (beats/min)
160
RVEF (fraction)
.42
42
RVEDVI (mL
(mL/m
/m2)
38
PAOP (mmHg)
3
CI
SVRI (dyne.sec.cm-5/m2)
4500
UOP (mL
(mL/hr)
/hr)
0
SvO2 (fraction)
Q: What therapeutic
changes should be
implemented?
A: The patient is in
severe septic shock. She
is markedly
hypovolemic. Immediate
fluid resuscitation is
warranted.
.41
PATIENT 4
3 liters of IVF are
administered with some
response. Appropriate
broad-spectrum
antibiotics are started.
#2
CI
1.3
2.2
HR
160
120
RVEF
.42
42
.40
40
RVEDVI
38
PAOP
3
3000 mL 118
IVF
15
SVRI
4500
2100
UOP
0
10
SvO2
.41
.68
Q: What therapeutic
changes should be
implemented now?
A: Further fluid
resuscitation is
warranted as the
patient’s systemic
perfusion remains
inadequate.
PATIENT 4
Parameter
#1
#2
#3
CI
1.3
2.2
2.3
HR
160
120
110
RVEF
.42
42
.40
40
.30
30
RVEDVI
38
PAOP
3
15
17
SVRI
4500
2100
1900
UOP
0
10
22
SvO2
.41
.68
.67
IVF
118
IVF
150
Additional IVF is given
with a decrease in RVEF
and rise in RVEDVI. CI
and UOP remain low and
SVRI is dropping. You
recognize that increased
contractility and
afterload is needed.
Q: What therapeutic
changes should be
implemented now?
A: You initiate a
norepinephrine infusion
to raise the patient’s
afterload and improve
contractility.
CONCLUSIONS
• Volumetric pulmonary artery catheter monitoring is
a valuable tool in the care of the critically ill
• RVEDVI is superior to PAOP and CVP in predicting
response to resuscitation
• RVEDVI must be interpreted in conjunction with the
RVEF
• Continuous hemodynamic monitoring provides time
critical information that is useful for guiding
resuscitation
Revised 01/13/2009
#1
Parameter
#3
#4
#5
CI
2.3
0.9
2.6
HR
110
110
130
RVEF
.30
30
.13
13
0.22
0 22
RVEDVI
150
PAOP
17
26
22
SVRI
1900
540
1100
NE
220
NE
IVF
170
UOP
22
0
25
SvO2
.67
.44
.62
The
e pat
patient
e t de
develops
e ops
severe septic shock, but
with time, additional IVF,
norepinephrine, and
antibiotics, her shock
state improves.
CONTINUOUS CO MONITORING
• Continuously updated
– Preload (RVEDVI)
– Contractility (CI)
– RV afterload (RVEF)
– Oxygen transport balance
(SvO2)
• Provides a comprehensive assessment of
cardiopulmonary function
12