El documento describe diferentes métodos de monitoreo cardiovascular para pacientes, incluyendo el uso del fonendoscopio para monitorear la frecuencia cardíaca, la técnica manual para medir la presión arterial, y el monitoreo arterial directo e invasivo mediante el uso de catéteres. También describe cómo medir la presión venosa central de forma no invasiva y mediante el uso de catéteres, así como las complicaciones asociadas con estos métodos.

1. ¿QUÉ AYUDAS
TENEMOS PARA EL
MONITOREO
CARDIOVASCULAR DE
NUESTROS PACIENTES?

2. MONITORIA
CARDIOVASCULAR
Marcelino Murillo Deluquez
Residente Anestesia y Reanimación
Universidad de Cartagena

3. MONITOREO CIRCULATORIO

4. USO DEL FONENDOSCOPIO
 LAENNEC 1.818
 Harvey Cushing
1908

5. MONITOREO DE LA FRECUENCIA
CARDIACA

6. DIFERENCIAS ENTRE FC Y PULSO
 Disociación electromecánica.
 Actividad eléctrica sin pulso.
 Fibrilación auricular.
 Taponamiento cardiaco.
 Hipovolemia marcada.

7. TÉCNICA MANUAL DE TOMA DE TENSIÓN
ARTERIAL
 Riva-Rocci
 Korotkoff 1.905

8. PSEUDO HIPERTENSIÓN
 TEMBLOR
 CALCIFICACIONES “signo de Osler”
 TAMAÑO INAPROPIADO

9. PSEUDO HIPOTENSIÓN
 Shock cardiogénico
 Vasopresores a altas dosis.

10. TOMA DE LA TA AUTOMATIZADA

11. COMPLICACIONES EN LA MEDICIÓN DE LA T.A.
NO INVASIVA
COMPLICACIONES
DOLOR
PETEQUIAS Y EQUIMOSIS
EDEMA DE LA EXTREMIDAD
ESTASIS VENOSO Y TROMBOFLEBITIS
NEUROPATÍA PERIFERICA
SINDROME COMPARTIMENTAL

12. MONITORÍA ARTERIAL
INDICACIONES PARA LINEA ARTERIAL INVASIVA
Monitoría de TA en tiempo real, continua.
Manipulación cardiovascular mecánica, farmacológica.
Toma de muestras continuas.
Falla en la toma de TA indirecta.
Información diagnostica suplementaria de onda arterial.
Determinación de la respuesta volumétrica de la presión sistólica y variación en la
presión de pulso.

13. MONITORIA ARTERIAL DIRECTA
 Arteria Radial.
 Slogoff et al.
 Test Allen Mod.
 Procedimiento.

14. COMPLICACIONES DE LA CANALIZACIÓN DE LA
ARTERIA RADIAL
 < 0.1 %  Vasoespasmo Arterial.
 Lesion Arterial.
 Trombocitosis
 Shock
 POCO COMUN  Altas dosis de
vasopresores.
 Canulación prolongada.
 Infección.

15. COMPLICACIONES DEL MONITOREO DE TA
DIRECTA.
COMPLICACIONES
Isquemia distal, pseudoaneurisma, fistula AV
Hematoma, Hemorragia.
Embolización Arterial.
Infección local y sepsis
Neuropatía periférica.
Mala interpretación de datos
Mal uso de los equipos.

16. PRESION ARTERIAL INVASIVA

17. ONDA DE PRESIÓN ARTERIAL NORMAL

18. ONDAS DE PRESIÓN ARTERIAL Y DE PULSO A NIVEL
PERIFERICO

19. ONDAS DE PRESIÓN ARTERIAL JOVEN Y ADULTO

20. VARIABILIDAD SISTÓLICA DE LA PRESIÓN ARTERIAL

21. VARIABILIDAD DE PRESIÓN DE PULSO

22. MONITORIZACIÓN DE LA PRESIÓN VENOSA
CENTRAL

23. TECNICA DE CANALIZACIÓN VENOSA CENTRAL
DERECHA

24. CATETERIZACIÓN YUGULAR INTERNA IZQUIERDA
 Riesgo de Pneumotórax.
 Lesión del conducto toráxico.
 Lesión de la pared lateral derecha de la cava
superior.
 La vena Yugular interna izquierda es más
pequeña.
 Requiere confirmación radiográfica.

25. CANALIZACIÓN DE LA SUBCLAVIA
 Menor riesgo de infección.
 Terapia IV por largo tiempo.
 Hiperalimentación.
 Quimioterapia.
 En Trauma cervical.
 Máximo 2 – 3 intentos.
 VIDEO

26. CANALIZACIÓN YUGULAR EXTERNA
 Menos riesgo de pneumotórax.
 Se pueden realizar más intentos.
 Venas más tortuosas.
 Abducción del hombro 90 grados.
 No hacer fuerza al pasarlo por la subclavia.

27. CANALIZACIÓN DE LA VENA FEMORAL
 ALTERNATIVA EN LESIONES DE CUELLO,
TÓRAX, CRANEO.
 LESION ARTERIA O NERVIO FEMORAL.
 RIESGO DE TROMBOEMBOLISMO
 RIESGO DE INFECCIÓN

28. IMAGEN ULTRASONOGRAFICA EN LA CANALIZACIÓN DE LA
YUGULAR INTERNA

29. CANALIZACIÓN VENOSA CENTRAL BAJO
ULTRASONIDO
 Beneficio comprobado en UCI y QX.
 Solo es usa en un 15 %
 Se puede usar con Doppler
 Bidimensional 10 Hz
 Operador dependiente.
 Confirmar posición realizada sin ultrasonido.
 Accesos Yugular, Subclavio, Femoral.

31. PRESIÓN VENOSA CENTRAL
 PRESIÓN CAVA-AURICULA
 FUERZA DE LLENADO AURICULAR
 DEPENDE DEL VOLUMEN SANGUINEO
INTRAVASCULAR.
 REFLEJA LA CAPACIDAD FUNCIONAL V.D,
 VALORA: FUNCIÓN V.D Y VOLUMEN
SANGUINEO

32. ONDAS NORMALES DE PRESIÓN VENOSA
CENTRAL

33. ONDAS DE PRESIÓN VENOSA CENTRAL

34. ONDAS DE PRESIÓN VENOSA CENTRAL

35. ANORMALIDADES EN LA ONDA DE PVC

36. CAMBIOS EN LA PVC

37. INFLUENCIA DEL
CICLO
RESPIRATORIO
EN L,A PVC

39. PRESSURE WAVEFORM AND DISPLAYS A, C, AND V WAVES. RIGHT VENTRICULAR PRESSURE
SHOWS HIGHER SYSTOLIC PRESSURE THAN SEEN IN THE RIGHT ATRIUM, ALTHOUGH THE END-
DIASTOLIC PRESSURES ARE EQUAL IN THESE TWO CHAMBERS. PULMONARY ARTERY PRESSURE
SHOWS A DIASTOLIC STEP-UP WHEN COMPARED WITH VENTRICULAR PRESSURE. NOTE ALSO
THAT RIGHT VENTRICULAR PRESSURE INCREASES DURING DIASTOLE WHEREAS PULMONARY
ARTERY PRESSURE DECREASES DURING DIASTOLE (SHADED BOXES). PULMONARY ARTERY
WEDGE PRESSURE HAS A SIMILAR MORPHOLOGY TO RIGHT ATRIAL PRESSURE, ALTHOUGH THE
A-C AND V WAVES APPEAR LATER IN THE CARDIAC CYCLE RELATIVE TO THE
ELECTROCARDIOGRAM

41. FIGURE 40-28 THE TIP OF THE PULMONARY ARTERY CATHETER MUST BE WEDGED IN LUNG
ZONE 3 TO PROVIDE AN ACCURATE MEASURE OF PULMONARY VENOUS (PV) OR LEFT ATRIAL (LA)
PRESSURE. WHEN ALVEOLAR PRESSURE (PA) RISES ABOVE PV IN LUNG ZONE 2 OR ABOVE
PULMONARY ARTERIAL PRESSURE (PA) IN LUNG ZONE 1, WEDGE PRESSURE WILL REFLECT
ALVEOLAR PRESSURE RATHER THAN INTRAVASCULAR PRESSURE. LV, LEFT VENTRICLE; PA,
PULMONARY ARTERY; RA, RIGHT ATRIUM; RV, RIGHT VENTRICLE

42. FIGURE 40-29 TEMPORAL RELATIONSHIPS BETWEEN NORMAL SYSTEMIC ARTERIAL
PRESSURE (ART), PULMONARY ARTERY PRESSURE (PAP), CENTRAL VENOUS
PRESSURE (CVP), AND PULMONARY ARTERY WEDGE PRESSURE (PAWP). NOTE THAT
THE PAWP A-C AND V WAVES APPEAR TO OCCUR LATER IN THE CARDIAC CYCLE THAN
THEIR COUNTERPARTS ON THE RIGHT SIDE OF THE HEART SEEN IN THE CVP TRACE.
THE ART SCALE IS ON THE LEFT; THE PAP, CVP, AND PAWP PRESSURE SCALES ARE ON
THE RIGHT.

43. FIGURE 40-30 TALL LEFT ATRIAL PRESSURE (LAP) A AND V WAVES TRANSMITTED IN
A RETROGRADE DIRECTION THROUGH THE PULMONARY VASCULATURE DISTORT THE
ANTEGRADE PULMONARY ARTERY PRESSURE (PAP) WAVEFORM. THE LAP A WAVE
DISTORTS THE SYSTOLIC UPSTROKE, AND THE V WAVE DISTORTS THE DICROTIC
NOTCH

44. FIGURE 40-31 NORMAL TEMPORAL RELATIONSHIPS BETWEEN THE
ELECTROCARDIOGRAPHIC, CENTRAL VENOUS PRESSURE (CVP), AND LEFT ATRIAL
PRESSURE (LAP) TRACES. THE LAP AND CVP WAVEFORMS HAVE NEARLY IDENTICAL
MORPHOLOGIES, ALTHOUGH THE CVP A WAVE SLIGHTLY PRECEDES THE LAP A WAVE

45. FIGURE 40-32 ARTIFACTUAL PRESSURE PEAKS AND TROUGHS IN THE PULMONARY ARTERY PRESSURE (PAP)
WAVEFORM CAUSED BY CATHETER MOTION. THE CORRECT VALUE FOR PULMONARY ARTERY END-DIASTOLIC
PRESSURE IS 8 MM HG (A), ALTHOUGH THE MONITOR DIGITAL DISPLAY ERRONEOUSLY REPORTS THE PAP AS
28/0 MM HG (B).

46. ARTIFACTUAL WAVEFORM RECORDINGS. THE FIRST TWO ATTEMPTS TO INFLATE THE
PA CATHETER BALLOON (FIRST TWO ARROWS) PRODUCE A NONPULSATILE
INCREASING PRESSURE CAUSED BY AN OCCLUDED CATHETER TIP. AFTER THE
CATHETER IS WITHDRAWN SLIGHTLY, BALLOON INFLATION ALLOWS PROPER WEDGE
PRESSURE MEASUREMENT (THIRD ARROW). BEFORE THE THIRD ATTEMPT AT
BALLOON INFLATION, THE PA PRESSURE LUMEN IS FLUSHED, WHICH RESTORES THE
APPROPRIATE PULSATILE PRESSURE DETAILED TO THE PA AND WEDGE PRESSURE
WAVEFORMS ON THE RIGHT SIDE OF THE TRACE.

47. FIGURE 40-34 SEVERE MITRAL REGURGITATION. A TALL SYSTOLIC V WAVE IS
INSCRIBED IN THE PULMONARY ARTERY WEDGE PRESSURE (PAWP) TRACE AND ALSO
DISTORTS THE PULMONARY ARTERY PRESSURE (PAP) TRACE, THEREBY GIVING IT A
BIFID APPEARANCE. THE ELECTROCARDIOGRAM (ECG) IS ABNORMAL BECAUSE OF
VENTRICULAR PACING. LEFT VENTRICULAR END-DIASTOLIC PRESSURE IS ESTIMATED
BEST BY MEASURING PAWP AT THE TIME OF THE ELECTROCARDIOGRAPHIC R WAVE,
BEFORE ONSET OF THE REGURGITANT V WAVE. NOTE THAT MEAN PAWP EXCEEDS
LEFT VENTRICULAR END-DIASTOLIC PRESSURE IN THIS CONDITION

48. LEFT ATRIAL PRESSURE-VOLUME CURVES DESCRIBE THE THREE FACTORS THAT DETERMINE V
WAVE HEIGHT. A, INFLUENCE OF LEFT ATRIAL VOLUME. FOR THE SAME REGURGITANT VOLUME
(X), THE LEFT ATRIAL V WAVE WILL BE TALLER IF BASELINE ATRIAL VOLUME IS GREATER (POINT B
VERSUS POINT A). B, INFLUENCE OF LEFT ATRIAL COMPLIANCE. FOR THE SAME REGURGITANT
VOLUME (X), THE LEFT ATRIAL V WAVE WILL BE TALLER IF BASELINE ATRIAL COMPLIANCE IS
REDUCED (POINT B VERSUS POINT A). C, INFLUENCE OF REGURGITANT VOLUME. BEGINNING AT
THE SAME BASELINE LEFT ATRIAL VOLUME (POINTS A AND B), IF REGURGITANT VOLUME
INCREASES (X VERSUS X), THE LEFT ATRIAL PRESSURE V WAVE WILL INCREASE (V VERSUS V).

49. Figure 40-36 Mitral stenosis.
Mean pulmonary artery wedge
pressure (PAWP) is increased
(35 mm Hg) and the diastolic y
descent is markedly attenuated.
Compare the slope of the y
descent in the PAWP trace with
the y descent in the central
venous pressure (CVP) trace. In
addition, compare this PAWP y
descent with the PAWP y descent
in mitral regurgitation (see Fig
40-34 ). A waves are not seen in
the PAWP or CVP traces because
of atrial fibrillation. ART, arterial
blood pressure

50. FIGURE 40-37 MYOCARDIAL ISCHEMIA. PULMONARY ARTERY PRESSURE (PAP) IS
RELATIVELY NORMAL AND MEAN PULMONARY ARTERY WEDGE PRESSURE (PAWP) IS
ONLY SLIGHTLY ELEVATED (15 MM HG). HOWEVER, PAWP MORPHOLOGY IS MARKEDLY
ABNORMAL, WITH TALL A WAVES (21 MM HG) RESULTING FROM THE DIASTOLIC
DYSFUNCTION SEEN IN THIS CONDITION.

51. Figure 40-38 Pericardial
constriction. This condition
causes elevation and
equalization of diastolic filling
pressure in the pulmonary artery
pressure (PAP), pulmonary artery
wedge pressure (PAWP), and
central venous pressure (CVP)
traces. The CVP waveform
reveals tall a and v waves with
steep x and y descents and a
mid-diastolic plateau wave (*) or
h wave

52. FIGURE 40-39 CARDIAC TAMPONADE. THE CENTRAL VENOUS PRESSURE WAVEFORM SHOWS
INCREASED MEAN PRESSURE (16 MM HG) AND ATTENUATION OF THE Y DESCENT. COMPARE
WITH FIGURE 40-38 .

53. FIGURE 40-40 INFLUENCE OF POSITIVE-PRESSURE MECHANICAL VENTILATION ON
PULMONARY ARTERY PRESSURE. PULMONARY ARTERY PRESSURE SHOULD BE
MEASURED AT END-EXPIRATION #1, 15 MM HG) TO OBVIATE THE ARTIFACT CAUSED
BY POSITIVE PRESSURE INSPIRATION (#2, 22 MM HG). COMPARE WITH FIGURE 40-26

54. LEFT VENTRICULAR (LV) PRELOAD. THERE ARE THREE INTERPRETATIONS OF INCREASED
TRANSDUCED PULMONARY ARTERY WEDGE PRESSURE (PAWP, 20 MM HG). A, JUXTACARDIAC
PRESSURE (-5 MM HG) AND LV COMPLIANCE ARE NORMAL, TRANSMURAL PAWP IS INCREASED
(25 MM HG), AND LV VOLUME IS INCREASED. B, JUXTACARDIAC PRESSURE IS INCREASED
(+10 MM HG), LV COMPLIANCE IS NORMAL, TRANSMURAL PAWP IS DECREASED (10 MM HG),
AND LV VOLUME IS NORMAL OR DECREASED. C, JUXTACARDIAC PRESSURE IS NORMAL, LV
COMPLIANCE IS DECREASED, TRANSMURAL PAWP IS INCREASED (25 MM HG), AND LV VOLUME
IS NORMAL OR DECREASED.

55. FIGURE 40-42 ANATOMIC AND PHYSIOLOGIC FACTORS THAT INFLUENCE THE RELATIONSHIPS
BETWEEN VARIOUS MEASURES OF LEFT VENTRICULAR (LV) FILLING AND TRUE LV PRELOAD. THE
FURTHER UPSTREAM FILLING PRESSURE IS MEASURED, THE MORE CONFOUNDING FACTORS
MAY INFLUENCE THE RELATIONSHIP BETWEEN THIS MEASUREMENT AND LV PRELOAD. CVP,
CENTRAL VENOUS PRESSURE; LA, LEFT ATRIUM; LAP, LEFT ATRIAL PRESSURE; LVEDP, LEFT
VENTRICULAR END-DIASTOLIC PRESSURE; PA, PULMONARY ARTERY; PADP, PULMONARY ARTERY
DIASTOLIC PRESSURE; PAWP, PULMONARY ARTERY WEDGE PRESSURE; P-V, PRESSURE-VOLUME;
RA, RIGHT ATRIUM, RV, RIGHT VENTRICLE

56. Figure 40-43 Relationship
between left atrial pressure (LAP)
and left ventricular end-diastolic
pressure (LVEDP). LVEDP is
measured at the Z-point on the
left ventricular pressure (LVP)
trace at the time of the
electrocardiographic R wave.
Mean LAP (9 mm Hg)
underestimates LVEDP (15 mm
Hg), but the LAP a wave pressure
peak closely estimates LVEDP.

57. MODIFIED FROM MARK JB: PREDICTING LEFT VENTRICULAR END-DIASTOLIC
PRESSURE. IN MARK JB (ED): ATLAS OF CARDIOVASCULAR MONITORING. NEW YORK,
CHURCHILL LIVINGSTONE, 1998, P 59.
LAP, LEFT ATRIAL PRESSURE; LVEDP, LEFT VENTRICULAR END-DIASTOLIC PRESSURE;
PADP, PULMONARY ARTERY DIASTOLIC PRESSURE; PAWP, PULMONARY ARTERY
WEDGE PRESSURE

58. MODIFIED FROM MARK JB: PREDICTING LEFT VENTRICULAR END-DIASTOLIC
PRESSURE. IN MARK JB (ED): ATLAS OF CARDIOVASCULAR MONITORING. NEW YORK,
CHURCHILL LIVINGSTONE, 1998, P 59.
LAP, LEFT ATRIAL PRESSURE; LVEDP, LEFT VENTRICULAR END-DIASTOLIC PRESSURE;
PADP, PULMONARY ARTERY DIASTOLIC PRESSURE; PAWP, PULMONARY ARTERY
WEDGE PRESSURE

61. FORMULAS DE LA LAMINA ANTERIOR

63. PULMONARY ARTERY CATHETER–DERIVED HEMODYNAMIC VARIABLES
THE CARDIOVASCULAR SYSTEM IS OFTEN MODELED AS AN ELECTRICAL CIRCUIT, WITH
THE RELATIONSHIP BETWEEN CARDIAC OUTPUT, BLOOD PRESSURE, AND RESISTANCE
TO FLOW RELATED IN A

64. FIGURE 40-44 PULMONARY HYPERTENSION. THE INCREASED GRADIENT ACROSS THE
PULMONARY VASCULATURE CAUSES PULMONARY ARTERY DIASTOLIC PRESSURE TO
EXCEED PULMONARY ARTERY WEDGE PRESSURE (PAWP). PAP, PULMONARY ARTERY
PRESSURE.

66. FIGURE 40-45 SPECTRAL DOPPLER TRACINGS OF AORTIC BLOOD FLOW RECORDED WITH
ESOPHAGEAL DOPPLER CARDIAC OUTPUT MONITORING. THE VELOCITY-TIME WAVEFORM SHAPE
REFLECTS ALTERATIONS IN CONTRACTILITY (MAINLY AFFECTING PEAK VELOCITY AND MEAN
ACCELERATION), PRELOAD (MAINLY AFFECTING SYSTOLIC FLOW TIME CORRECTED FOR HEART
RATE [FTC]), AND AFTERLOAD (WHICH AFFECTS FTC, MEAN ACCELERATION, AND PEAK FLOW
VELOCITY).

69. FUE MONITORIZADO ?