This document discusses hemodynamic monitoring in critically ill patients. It notes that while hemodynamic monitoring is a cornerstone of management, the utility of most methods is unproven. Physicians have become psychologically dependent on feedback from monitors independent of their effectiveness. The effectiveness of monitoring is limited to specific patient groups and diseases where proven effective treatments exist. The document discusses various hemodynamic monitoring methods including invasive and non-invasive options like arterial catheters, central venous pressure, and echocardiography. It notes that no individual parameter necessarily defines hemodynamic stability and thresholds vary between patients and clinical contexts.

2. 
Hemodynamic monitoring -cornerstone in
the management of the critically ill patient

Identify impending cardiovascular
insufficiency, its probable cause, and
response to therapy.

Despite the many options available, utility
of most hemodynamic monitoring is
unproven

3. Physicians have developed a
psychological dependence on
feedback from continuous
hemodynamic monitoring tools,
independent of their utility
 Effectiveness of hemodynamic
monitoring to improve outcome limited
to specific patient groups and disease
processes for which proven effective
treatments exist


4. “To help direct management in medical
patients in whom hemodynamics will alter
treatment and clinical estimates are unreliable”
 “To assist management of surgical patients”
 “To establish or assist in establishing specific
diagnoses”
– Cardiac vs. non-cardiac pulmonary edema
– VSD vs. MR in acute MI
– Pericardial tamponade
– RV MI


5. Monitoring device will improve patientcentered outcomes when coupled to a
treatment which, itself, improves
outcome
 Time -crucial for early diagnosis of
hemodynamic catastrophe -earlier
therapy improves outcome in this
situation

N Engl J Med 2001; 345:1368–1377

6. Non Invasive
Clinical variables
 BP
 ECG
 Echocardiography

 O2
saturation

7. Invasive
 CVP
 SvO2, Mixed venous oxygen saturation
(from the central venous line
 Arterial
 Cardiac
catheter
output
 PA Catheter

8. Blood pressure
 Heart rate and rhythm
 Rate of capillary refill of skin after
blanching
 Urine output
 Mental status


9.  Proper
 Width
 Lower
Fit of a Blood Pressure Cuff
of bladder = 2/3 of upper arm
edge of cuff approximately 2.5
cm above the antecubital space

10.  Too
small
 Too
LARGE causes false-low
reading
causes false-high reading

11. 
Normal blood pressure ≠hemodynamic
stability

Hypotension (MAP < 65 mmHg) is always
pathological.

12. 
Errors in measurement :
› Long stethoscope tubing
› Poor hearing in observer
› Calibration errors of
sphygmomanometer
› Decreased blood flow in the extremity
› Severe atherosclerosis (unable to
occlude)
› Inappropriate cuff size
› Too rapid deflation

13. Intra-arterial catheters ("art lines") are a
reliable method to continuously monitor
systemic blood pressure.
 A NORMAL WAVE form will be:
- Within the normal parameter of blood
pressure
- Present a characteristic shape
- Synchronous with the EKG waveform


16. The normal peripheral arterial waveform
will display the peak systolic pressure
after the QRS.
 This phenomenon reflects the time it
takes the cardiac systolic pressure wave
to reach the peripheral catheter and
sensor.
 The dicrotic notch reflects the closure of
the aortic valve.


17. Overdamping: seen as a smooth
waveform that loses the dicrotic notch.
 It can be caused by air bubbles in the
system, too many stopcocks, kink in the
catheter or tubing, blood on the
transducer, a clot in the catheter, an
empty flush bag, aortic stenosis,
vasodilation or a low cardiac output

18. Underdamping: seen as a sharp
exaggerated waveform with overshoot
of the systolic pressure and undershoot
of the diastolic.
 It can be caused by excessive
tubing, excessive catheter
movement, atherosclerosis, vasoconstrict
ion, aortic regurgitation, hyperdynamic
states and hypertension.

19. 
Arterial Catheter

Pressure Tubing

Pressure Cable

Flush – 500cc NS
19

20.  Hemorrhage
 Air
Emboli
 Infection
 Altered
Skin Integrity
 Impaired
Circulation

21. 

Improper set-up and equipment malfunction
are the primary causes for hemodynamic
monitoring problems
Retracing the set-up process or tubing
(patient to monitor) may identify the problem
and solution quickly
21

22. Damped Waveforms
 Pressure bag inflated to 300 mmHg
 Reposition extremity or patient
 Verify appropriate scale
 Flush or aspirate line
 Check or replace module or cable
22

23. Inability to obtain/zero waveform
 Connections between cable & monitor
 Position of stopcocks
 Retry zeroing after above adjustments
23

24.  What
is the target BP ?
No threshold BP that defines adequate organ
perfusion among organs, between patients, or
in same patient over time
 Based mainly on anecdotal experience, a
systolic pressure of 100mmHg usual target, with
HR < 120 /min-Controversial

Curr Opin Crit Care.2001; 7:422–430

MAP ≥ 65 mmHg -Initial target in septic
shock,>40 mmHg in hemorrhagic shock and
> 90 mmHg in Traumatic brain injury –Level 1 B
Intensive Care Med. 2007; 33:575–590
International Consensus Conference
Surviving sepsis Campaign 2008

25. Arrhythmia Monitoring –Up to 95% of AMI
have arrhythmia within 1st48 hrs
 Up to 1/3 have VT. Early diagnosis and
prompt treatment may improve survival
 Heart rate variability may reflect
prognosis


Ischemia Monitoring –Significant
uncertainty to reliably detect myocardial
ischemia and diagnose MI in critically ill
patients

26. Evidence
 Ischemia in ICU related to pain, fluid
balance, fever, catecholamine levels, or
other physical stresses
 Hurford et al -worsening of ischemia (cont
ECG ) in patients rapidly weaned from
positive pressure to spontaneous ventilation
 Continuous ECG monitoring in ICU detected
a 6.4% incidence of ischemia during
weaning
 Patients with ischemia fail to wean more
commonly

27. 
Sole imaging modality that provides realtime information on cardiac anatomy and
function at bedside

Ideally suited to early hemodynamic
evaluation of patients with persistent shock
despite aggressive goal-directed therapy

28. Hemodynamic instability
–Ventricular failure
–Hypovolemia
–Pulmonary embolism
–Acute valvular dysfunction
–Cardiac tamponade






-Complications after cardiothoracic surgery
-Infective endocarditis
-Aortic dissection and rupture
-Unexplained hypoxemia
-Source of embolus

29. 
High image quality vital–Aortic
dissection -Intracardiac thrombus
–Assessment of endocarditis

Inadequately seen by TTE
–Thoracic aorta
-Left atrial appendage
–Prosthetic valves

30. 
Inadequate image clarity with TTE
–Severe obesity
–Emphysema
Mechanical ventilation with high-level PEEP
 Presence of surgical drains, surgical
incisions, dressings
 Acute perioperative hemodynamic
derangements


31. Myocardial or coronary perforation
secondary to catheter-based
interventions (pacemaker lead insertion,
central catheter placement, or
percutaneous coronary interventions)
 Uremic or infectious pericarditis
 Compressive hematoma after cardiac
surgery
 Proximal ascending aortic dissection


32. Blunt or penetrating chest trauma
 Complication of myocardial infarction
(e.g., ventricular rupture)
 Pericardial involvement by metastatic
disease or other systemic processes


33. 
Changes in management after TEE in 30–
60% of patients leading to surgical
interventions in 7–30%
Crit Care Med 2007; 35[Suppl.]:S235-4

Critically ill patients with unexplained
hypotension, new diagnoses were made
in 28% -leading to surgical intervention in
20%
J Am Coll Cardiol 1995; 26:152–2

34. 
ECHO for diagnosis in patients with
clinical evidence of ventricular failure
and persistent shock despite adequate
fluid resuscitation -Level 2 B
Intensive Care Med. 2007; 33:575–590 International
Consensus Conference

35. All physicians in charge of critically ill patients
should be trained in goal directed
echocardiography
 Far from being competitive or conflicting, use
of echocardiography by intensivists and
cardiologists is complementary
 German Society of Anesthesiology and
Intensive Care Medicine-already developed
their own certification
 Brief (10 hrs) formal training in using a
handheld ECHO system, intensivists able to
successfully perform limited TTE in 94% of
patients and interpreted correctly in 84% changed management in 37% of patients.

Intensive Care Med .2008.34:243–249

37. Describes the pressure of blood in the thoracic
vena cava, near the right atrium of the heart.
 Normal Value: 2-6 mmHg (7-12 cm H2O)
 Reflects blood volume, RV performance, and
venous tone.

May reflect LV filling pressures in patients with
normal LV function (EF > 40%), valves, and
pulmonary status.

38. Leveling
 Standard reference level for assessment
sternal angle, 5 cm vertically above the
mid-point of the right atrium -even when
the person sits up at a 60ºangle
 In supine patient, reference level intersection of the fourth intercostal space
with midaxillary line (3 mm Hg / 4.2 cm >
sternal angle measurement )

39. CVP, should be made at end expiration pleural pressure is closest to atmospheric
pressure
 intrinsic or extrinsic PEEP, pericardial fluid, or
increased abdominal pressure can
increase CVP
 PEEP of 10 cmH2O, increases the
measured CVP by less than 3 mmHg in
normal lung and even less in deceased
lung


40. 
4th intercostal space, mid-axillary line

Level of the atria
(Edwards Lifesciences,
n.d.)
40

41. 
CVP only elevated( > 10 mm Hg ) in
disease, but clinical utility of CVP as a
guide to diagnosis or therapy has not
been demonstrated

If CVP is ≤ 10 mmHg then CO decrease
when 10 cm H2O PEEP applied whereas
a CVP above 10 mmHg -no predictive
value

42. 
Fluid resuscitation initially target a CVP of
at least 8 mm Hg (12 mm Hg in
mechanically ventilated patients)-Level
1C

43. 
However no threshold value of CVP that
identifies patients whose CO will increase
in response to fluid resuscitation.

44.  Provides
global estimation of adequacy
of oxygen delivery (DO2 ) relative to
tissue needs.
 SvO2 = SaO2 - (VO2/(CO x 1.34 x Hb))
 If O2 sat, VO2 & Hb remain constant,
SvO2 is indirect indicator of CO
 Can be measured using from blood gas
from distal lumen of PA catheter
 Normal SvO2 ~ 65% [60-75]

45. ↑
SvO2 [> 75%]
› Wedged PAC: reflects LAP saturation
› Low VO2: hypothermia, general anesthesia,
NMB
› Unable to extract O2: CO poisoning
› High Cardiac output: sepsis, burns, L→ R
shunt, AV fistulas

46. ↓
SvO2 [< 60%]
› Low CO: MI, CHF, hypovolemia
› Low Hb : bleeding, shock
› ↓ SaO2 : hypoxia, resp distress
› ↑ VO2: fever, agitation, thyrotoxic, shivering

48. 
SvO2 is a balance between oxygen
consumption and oxygen delivery
› Normal: 60-80%

ScvO2 (Pre-Sep) catheter is placed in
superior vena cava or right atrium
› ScvO2 is always 5-18%
>SvO2 in septic shock
› Goal: ScvO2>70%
› Use just like any other
central line

51. The Nobel Prize in Physiology or Medicine 1956
“…develop a technique for
the catheterization of the
heart. This he did by
inserting a canula into his
own antecubital vein,
through which he passed a
catheter for 65 cm and
then walked to the X-ray
department, where a
photograph was taken of
the catheter lying in his right
auricle.” -The Nobel
Foundation 1956

54. The purpose of this catheter is to :






Evaluate the hemodynamic treatments and
measure the patient’s hemodynamic status
Indirectly measures the LAP by wedging a
catheter into a small pulmonary artery tightly
enough to block flow from behind and thus to
sample the pressure beyond. (PCWP : 5-12mm
Hg)
Draw mixed venous blood samples
Obtain central vascular pressures
measurements
Evaluation of cardiac output in complex
medical situations
Prophylactic insertion for high-risk surgeries

57. 
Fick Method (ADOLF FICK in 1870)
› Amount of oxygen picked up by
the blood as it passes through the
lungs must be equal to the amount
of oxygen taken up by the patients
lungs during respiration
› Concept that oxygen consumption
= oxygen extraction by the tissues
per unit time from the circulation
› O2 Extracted (VO2) = (CaO2 CvO2) x CO
› CO = VO2/(CaO2-CvO2)

58. 
Indicator Dilution
› Dye Dilution
› Thermodilution
 Current Method Of Choice
 inert indicator without drawing of
blood
 cold injectate into RA with resulting
temp change detected at PA
thermistor
 modified Stewart-Hamilton equation
solved by computer (area under temp
versus time curve)
 CO is inversely proportional to area

59. Absolute
 Tricuspid or Pulmonary valve
stenosis
 RA or RV masses
 Tetralogy of Fallot
Relative
 Severe arrhythmias
 Coagulopathy
 Newly inserted pacemaker wires

60. Arrhythmias, complete heart block
 Valvular damage
 Catheter knotting and entrapment
 Endobronchial hemorrhage
 Pulmonary infarction
 Thrombocytopenia, thrombus formation
 Incorrect placement, balloon rupture


61. Clinical management involving the early use of
PAC in patients with shock, ARDS or both
did not significantly affect
morbidity and mortality.
JAMA 2003; 290:2717-2720

64. 
PAC is a classical tool for hemodynamic
assessment since it enables continuous
monitoring of numerous hemodynamic
parameters such as tissue oxygenation
variables and estimates of cardiac filling
pressures that are not provided by other
monitoring devices.

65. 
A large recently published metaanalysis
of RCT demonstrated that its use does
not cause harm to critically ill patients.
(Shah et al JAMA. 2005;294: 1664-1670)

The heterogeneous results should be
interpreted in light of the specific
interventions tested, the delay for
inclusion and the case mixed of the
patients, and not of the choice of PAC
per se as a monitoring tool

66. TEE produced a change in therapy in at
least one third of ICU patients, independent
of the presence of a PAC
 Study by Benjamin et al. TEE was performed
in 12 ±7 mins vs. ≥ 30 mins for PAC insertion
 Bedside echocardiography has a better
safety profile
 PAC continuous monitoring technique to
assess the response to a therapeutic
intervention


67. Advantages
Less-Invasive Than Thermodilution
 Real Time/ Repetitive Monitoring

Disadvantages
Needs Recalibration
 Dependent on Compliance of Arterial Tree
 Little Validation in Patients with Shock


68. The PiCCO Technology is a combination of 2
techniques for advanced hemodynamic and volumetric
management without the necessity of a pulmonary artery
-∆T
-∆T
catheter in most patients:

t
a. Transpulmonary thermodilution
t
b. Arterial pulse contour analysis

70. Transpulmonary thermodilution
measurement simply requires the
central venous injection of a cold
(<8°C) or room-tempered (<24°C) saline
bolus…
 After which, the thermistor in the tip of
the arterial catheter measures the
temperature changes
 The cardiac output is calculated by
analysis of the thermodilution curve
using a modified Stewart-Hamilton
algorithm


71. -Tb Injection
CV Bolus
Injection
t
PiCCO Catheter
e.g. in femoral artery

72. via intermittent transpulmonary
thermodilution
 Transpulmonary cardiac output (C.O.)
 Intrathoracic blood volume (ITBV)
 Global end diastolic volume (GEDV)
 Extravascular lung water (EVLW)
 Cardiac function index (CFI)

73. Global Enddiastolic Volume (GEDV) is the
volume of blood contained in the 4
chambers of the heart.
 Global End diastolic Blood Volume GEDV:
680 – 800 ml/m2


74. Intrathoracic Blood Volume (ITBV) is the
volume of the 4 chambers of the heart +
the blood volume in the pulmonary
vessels.
 Intrathoracic Blood Volume Index
ITBI:
850 – 1000 ml/m2


75. Extravascular Lung Water (EVLW) is the
amount of water content in the lungs. (
Normal : 3 – 7 ml/kg)
 It allows bedside quantification of the
degree of pulmonary edema.
EVLW has shown to have a clear correlation
to severity of ARDS, length of ventilation
days, ICU-stay and mortality and shown to
be superior to assessment of lung edema
by CXR.


76. Intrathoracic Blood Volume (ITBV) and
Global End diastolic Volume (GEDV) have
shown to be far more sensitive and specific
to cardiac preload than the standard
cardiac filling pressures CVP + PCWP but
also than right ventricular end diastolic
volume.
 The striking advantage of ITBV and GEDV is
that they are not wrongly influenced by
mechanical ventilation and give correct
information on the preload status under
any condition.


77. via continuous pulse contour analysis
 Continuous pulse contour cardiac
analysis (PCCO)
 Arterial blood pressure (AP)
 Heart rate (HR)
 Stroke volume (SV)
 Stroke volume variation (SVV)
 Systemic vascular resistance (SVR)
calculated as (MAP- CVP) / CO

78. 







Principle - Lithium hemodilution cardiac output
Lithium dilution curve with arterial wave form
analysis calibrated with lithium dilution
Injectate is an isotonic solution of lithium
chloride 0.15 -0.30 mmol for an average adult
Arterial pulse power analysis which estimates
stroke volume & flow
Invasive
Continuous CO data
Peripheral or Central venous line for injectate
(No PA catheter needed)
Peripheral arterial line needed to attach
sampling probe

79. Cardiac Output = (Lithium Dose x
60)/(Area x (1-PCV))

80. Patients on lithium therapy
 Patients on muscle relaxants (atracurium)
 Weight < 40 kgs
 First trimester of pregnancy period
 Renal dysfunction or dialysis


81. Principle : Indirect FICK calculation with
partial CO2 rebreathing technique
 Uses CO2 production and difference in
CO2 tension from normal respiration and
re-breathing to calculate CO
 No intravascular access needed


82. Requires endotracheal intubation
 Most accurate with stable respiratory
and metabolic rate
 Completely non invasive
 Placement of NICO sensor between
endotracheal tube & breathing circuit Y
piece


84. 







CO/CI
SV
Pulm capill blood
flow
ETCO2
Inspired CO2
RR
SpO2
HR






PEEP
Mean airway
pressure
PIP
Minute volume
Dynamic
compliance
Airway resistance

85. Non invasive
 No risks of infection
 Automated & continuous
 Not technique dependent
 Proven accuracy
 Extremely simple to set up & use
 Cost effective


86. Sepsis is accompanied by
hypermetabolic state, with enhanced
glycolysis and hyperlactataemia -not due
to hypoxia
 Marker of tissue perfusion and adequacy
of resuscitation
 Blood lactate concentration in excess of
4 mmol /L: is associated with a high risk of
mortality


87.  Appropriate
to use elevated lactate
trigger to initiate aggressive care-Level
1C
› In the event of hypotension and/or lactate >
4 mmol/l (36 mg/dl):–initial minimum of 20
ml/kg of crystalloid (or colloid equivalent)
› Apply vasopressors for hypotension not
responding to initial fluid resuscitation to
maintain MAP >65 mmHg

88. A knowledge deficit disorder continues to
exist in ICU regarding ideal hemodynamic
monitoring
 Major problem is the user not the device
of monitoring

Not everything that counts
can be counted;
And not everything that
can be counted

89. Thank You