Cardiac Monitoring

Presentation by Dr Deepti Tiwari

Moderator Dr Upasana Goswami
 Stethoscopy

• Laennec introduced in 1818

• During surgery by Harvey Cushing
• Precordial and Esophageal stethoscopy
• Now a days not used for continuous monitoring because for introduction of
other methods.{ except for peads and remote location].
 Heart Rate monitoring
• “Finger on pulse” is the easiest and quickest method to assess heart rate.
• ECG is most common method to detect heart rate in ot, by measurement of
r-r interval.
• ECG can get confounded by electrosurgical instruments, power line noises,
twitchings and fasciculations, lithotripsy machine, cardiopul bypass, and fluid
warmers.
• Direct ECG monitoring is better than monitoring of derived heart rate.
Picture shows HR of 49 but direct observation shows dangerous bradyarrythmia
it may be a asystole that cannot be assessed by digitally displayed HR.
Arrow shows correction of baseline by ECG filters.
 Pulse Rate monitoring
• Difference between pulse rate and heart rate is the difference between
electrical depolarization and mechanical contraction of heart.
• Pulse deficit arises in conditions such as AF , PEA( in Cardiac tamponade,
extreme hypovolemia, and conditions where electrical activity is present but
not capable of producing pulse).
• Pulse oxymetery gives PR. Although it seems redundant to measure both HR
and PR but its important to avoid error.
 Arteial blood pressure monitoring
• Sphygmomanometer use for systolic blood pressure first described by Riva and
Rocci in 1896(palpatory method). Korotkoff in 1905 described measurement of
diastolic as well.(auscultatory method).
• Any condition causing decrease in blood flow below the level of detection, or
conditions needing excessive pressure to occlude artery.
• Size of cuff 40% and 80%of circumference and length of arm. Too large can still
be accepted but too small will give spuriously high reading. Pressure should be
released slowly to assess korotkofs sounds properly. Rapid deflation results in
falsely low readings.
 Automated NIBP
• Intermittent based on oscillometery method, first described by marey 1876.
• Assess MAP most accurately and SBP and DBP are derived. DBP is least reliable by this
method.
• This method is although highly unrelialable, its still most used in critical care settings but its
use other than upper arm is not validated.
• Complications may occur due to continuous use and use in patients with coagulopathies,
arterial and venous insufficiency, thrombolytic therapy and peripheral neuropathies.
• Automated continuous techniqes(eg:finger BP by arterial volume clamp method) are also
available but with several disadvantages.
Complications of Noninvasive Blood Pressure Measurement

• Pain
• Petechiae and ecchymoses
• Limb edema
• Venous stasis and thrombophlebitis
• Peripheral neuropathy
• Compartment syndrome
 IBP/ Direct blood pressure monitoring
• Despite various complications and need of expertise IBP monitoring is ideal
reference standard for BP monitoring ,which provide timely and crucial
information.
• Arterial cannulation can be done in radial, ulnar, brachial, axillary or femoral artery.
• More central the artery is more are the chances of embolism. Axillary and femoral
arterial cannulation results waveforms that resembles change in pressure in aortic
arch more closely.
• In radial artery cannulation hyperextension is avoided to prevent median nerve
injury and in femoral artery cannulation must be done below the inguinal ligament.
 MODIFIED ALLENS TEST

odified Allen’s Test

Indications for Arterial Cannulation

• Continuous, real-time blood pressure

monitoring
• Planned pharmacologic or mechanical
cardiovascular manipulation
• Repeated blood sampling
• Failure of indirect arterial blood pressure
measurement
• Supplementary diagnostic information from
the arterial waveform
• Determination of volume responsiveness
from systolic pressure or pulse pressure
variation
 Complications of Direct Arterial Pressure
Monitoring

• Distal ischemia, pseudoaneurysm,

arteriovenous fistula.
• Hemorrhage, hematoma
• Arterial embolization
• Local infection, sepsis
• Peripheral neuropathy
• Misinterpretation of data
• Misuse of equipment
 NORMAL ARTERIAL PRESSURE TRACING
1, Systolic upstroke; 2, systolic peak pressure; 3, systolic decline; 4, dicrotic notch; 5,
diastolic runoff; 6, end-diastolic pressure.
 Arterial Blood Pressure Waveform Abnormalities
• Condition Characteristics
• Aortic stenosis Pulsus parvus (narrow pulse pressure)
• Pulsus tardus (delayed upstroke)
• Aortic regurgitation Bisferiens pulse (double peak)
• Wide pulse pressure
• Hypertrophic cardiomyopathy Spike-and-dome pattern (midsystolic
obstruction)
• Systolic left ventricular failure Pulsus alternans (alternating pulse
pressure amplitude)
• Cardiac tamponade Pulsus paradoxus (exaggerated decrease in systolic
blood pressure during spontaneous inspiration
A, Normal ART and pulmonary artery pressure (PAP) wave, B, In aortic stenosis, the ART waveform is distorted and demonstrates a
slurred upstroke and delayed systolic peak.. See text for greater detail. C, Aortic regurgitation produces a bisferiens pulse and a wide
pulse pressure. D, The arterial pressure waveform in hypertrophic cardiomyopathy shows a peculiar “spike-and-dome” configuration.
The pressure waveform assumes a more normal morphology after surgical correction of this condition
 Central venous Pressure monitoring
• Central vein is catheterized for various purposes.
• Measurement of CVP is often necessary in heamodynamically unstable and
patietns undergoing major surgeries.
• Rt IJV is most commonly catheterised central vein. Others are left IJV , right
and left subclavian, femoral, external jugulars and axillary.
• Most commonly used size is 7 French , 20 cm catheter with a 18 g introducer
needle and guide wire.
Indications for Central Venous Cannulation
• Central venous pressure monitoring
• Pulmonary artery catheterization and monitoring
• Transvenous cardiac pacing
• Temporary hemodialysis
• Drug administration -Concentrated vasoactive drugs
• Hyperalimentation
• Chemotherapy
• Agents irritating to peripheral veins
• Prolonged antibiotic therapy (e.g., endocarditis)
• Rapid infusion of fluids (via large cannulas) Trauma
• Major surgery
• Aspiration of air emboli
• Inadequate peripheral intravenous access
• Sampling site for repeated blood testing
 Complications of CVP:

• Mechanical Vascular injury Arterial • Thromboembolic

Venous Venous thrombosis
Hemothorax Pulmonary embolism
Cardiac tamponade Arterial thrombosis and embolism (air, clot)
Catheter or guidewire embolism
• Respiratory compromise
Airway compression from hematoma • Infectious Insertion site infection
Tracheal, laryngeal injury Catheter infection
Pneumothorax Bloodstream infection
Endocarditis
• Nerve injury
• Arrhythmias • Misinterpretation of data
• Subcutaneous/mediastinal emphysema • Misuse of equipment
Central Venous Pressure Waveform Components

• a wave End diastole Atrial contraction

• c wave Early systole Isovolumic ventricular contraction,
tricuspid motion toward the right atrium
• v wave Late systole Systolic filling of the atrium
• h wave Mid to late diastole Diastolic plateau
• x descent Mid systole Atrial relaxation, descent of the base,
systolic collapse
• y descent Early diastole Early ventricular filling, diastolic
collapse
 JVP's - Appearance and Interpretation
Introduction
The JVP (jugular venous pressure) is a manometer of pressure in the right atrium; when pressure in the
atrium is high the JVP will be raised and when right atrial pressure is low the JVP will drop.

Features of the JVP

A venous pulse is not usually palpable.
Pressing at the base of the vein will make the vein visible as it continues to fill and distend above the
point of pressure NB do not do this in exams.
Hepatojugular reflex aids identfication of JVP - probably by forcing blood out of liver into IVC and
therefore into right atrium increasing its pressure.
JVP alters with changes in posture.
 How to find the JVP
Sit patient at 45° and turn head slightly away from you.
• Look for JVP in internal jugular vein (not external jugular vein)
medial to the clavicular head of sternocleidomastoid; the vein
passes behind the angle of the jaw in direction of earlobe.
• Measure JVP in cm above the sternal notch - a vertical not
diagonal distance - if larger than 3cm the JVP is raised.

Abnormalities of the JVP

1) Raised JVP with normal waveform
•right heart failure
•fluid overload
•bradycardia
The JVP Waveform
Abnormalities of the JVP
1) Raised JVP with normal waveform
•right heart failure
•fluid overload
•bradycardia
2) Raised JVP with absent pulsation
•SVC obstruction - full dilated jugular veins, no pulsation,
oedematous face and neck
3) Large a wave
•tricuspid stenosis - atria contracts against stiff tricuspid and so
pressure in atria rises higher than normal
•pulmonary hypertension - there are generally higher pressures on
the right side of the heart
•pulmonary stenosis
4) Extra-large a wave = Cannon wave
5) Absent a wave
•atrial fibrillation
6) Systolic waves = combined c-v waves = big v waves
•tricuspid regurgitation (c-v wave because the pressure in the right atrium is raised
throughout ventricular systole - tip is to watch for earlobe movement!)
7) The slow y descent occurs in tricuspid stenosis (if the HR is so low as to allow the
length of descent to be appreciated!)8) Paradoxical JVP = Kussmaul's sign
Normally the JVP should rise on expiration and fall on inspiration.
When the JVP rises on inspiration it indicates
•pericardial effusion
•constrictive pericarditis
•pericardial tamponade
Pulmonary Artery Catheter
 Introduction
• Pulmonary artery catheters (also called as Swan-Ganz catheter) are used for
evaluation of a range of condition

Although their routine use is not common, they are still occasionally placed
for management of critically ill patients
 Physiological Measurements
• Direct measurements of the following can be obtained from an accurately placed
pulmonary artery catheter(PAC)

• Central Venous Pressure(CVP)

• Right sided intracardiac pressures(RA/V)
• Pulmonary artery pressure(Pap)
• Pulmonary artery occlusion pressure (PAOP)
• Cardiac Output
• Mixed Venous Oxygen Saturation(SvO2)
• Indirect measurements that are possible:
• Systemic Vascular Resistance
• Pulmonary Vascular Resistance
• Cardiac Index
• Stroke volume index
• Oxygen delivery
• Oxygen uptake
 Indications
• Diagnostic:
• Differentiation among causes of shock
• Differentiation between mechanisms of pulmonary edema
• Evaluation of pulmonary hypertension
• Diagnosis of pericardial tamponade
• Diagnosis of right to left intracardiac shunts
• Unexplained dyspnea
• Therapeutic:
• Management of perioperative patients with unstable cardiac status
• Management of complicated myocardial infarction
• Management of patients following cardiac surgery/high risk surgery
• Management of severe preecclampsia
• Guide to pharmacologic therapy
• Burns/ Renal Failure/ Heart failure/Sepsis/ Decompensated cirrhosis
• Assess response to pulmonary hypertension specific therapy
 Contraindications
• Absolute: • Relative:

• Infection at insertion site • Coagulopathy

• Presence of RV assist device • Thrombocytopenia
• Insertion during CPB • Electrolyte disturbances
• Lack of consent (K/Mg/Na/Ca)
• Severe Pulmonary HTN
Making decision to place pulmonary artery
catheter

In critically ill or perioperative patients

decision to place a pulmonary artery catheter should be based

on patient’s hemodynamic status or diagnosis

that cannot be answered satisfactory by clinical or non-invasive

assessment
 Preparation
• Patient has to be monitored with continuous ECG throughout the
procedure, in supine position regardless of the approach

• Aseptic precautions must be employed

• Cautions should be taken while cannulating via IJV/ Subclavian vein

• Equipments:
• 2% chlorhexidine skin preparation solution
• Sterile gown, gloves, face shield and cap
• Sterile gauze pads
• 1% lidocaine -5 cc
• Seeker needle 23G
• Introducer needle  18G
• J-tip guidewire
• Transduction tubing
• Sterile catheter flush solution
• Sheath
• Pulonary catheter
• Sterile sleeve for catheter
• 2-0 silk suture
• Sterile dressing
Technique:
1. Aseptic precautions undertaken
2. Local infiltration done
3. Check balloon integrity by inflating with 1.5ml of air
4. Check lumens patency by flushing with saline 0.9%
5. Cover catheter with sterile sleeve provided
6. Cannulate vein with Seldinger technique
7. Place sheath
8. Pass catheter through sheath with tip curved towards the heart
9. Once tip of catheter passed through introducer sheath inflate balloon at
level of right ventricle
10. The progress of the catheter through right atrium and ventricle into
pulmonary artery and wedge position can be monitored by changes in
pressure trace
11. After acquiring wedge pressure  deflate balloon
• Important tip:
• When advancing catheter- always inflate tip
• When withdrawing catheter- always deflate
• Once in pulmonary artery - NEVER INFLATE AGAINST RESISTANCE - RISK
OF PULMONARY ARTERY RUPTURE.
 Interpretation of hemodynamic values and
waveforms

• Ensuring accurate measurements:

• Zeroing and Referencing
• Correct placement
• Fast flush test
• Zeroing and Referencing:
• PAC must be appropriately zeroed and referenced to obtain accurate readings  in
supine position/30 degrees semi-recumbent position

• Correct placement :
• By either pressure waveform/ fluoroscopic guidance
• Rapid flush test:
 Catheter waveforms and pressures

• Pressure waveforms can be obtained from

• Right atrium
• Right ventricle
• Pulmonary artery
• Right atrium:
• In presence of a competent tricuspid valve, RA pressure waveform reflect both
• Venous return to RA during ventricular systole
• RV End Diastolic Pressure
• Normal RA pressure: 0-7 mmHg
• Elevated RA pressure:
• Diseases of RV( infarction/ cardiomyopathy)
• Pulmonary hypertension
• Pulmonic stenosis
• Left to right shunts
• Pericardial diseases
• LV systolic failure
• Hypervolemia
• Differentiating among etiologies depends on
• Clinical
• Radiographical
• Echocardiographic features
+
PAC findings
Eg: Increased RA Pressure and Mean pulmonary Pressure  PAH
Increased RAP and Normal Pa pressures  RV disease/ Pulmonary stenosis
• Abnormal RA waveforms:
• Tall v waves: Tricuspid Regurgitation
• Giant/ cannon a waves:
• Ventricular tachycardia
• Ventricular pacing
• Complete heart block
• Tricuspid stenosis
• Loss of a waves:
• Atrial fibrillation/ Atrial flutter
• Right Ventricle:
• Transitioning from SVC or RA to RV:
• Once balloon is inflated in the SVC/RA  the catheter is slowly advanced

When catheter tip is across tricuspid valve pressure waveform changes and systolic
pressure increases
• 2 pressures are typically measured in right ventricular pressure waveform
• Peak RV systolic pressure  15-25mmHg
• Peak RV diastolic pressure  3-12 mmHg
• As a general rule  elevations in RV pressure:
• Diseases increasing pulmonary artery pressure
• Pulmonic valve disorders
• Diseases affecting right ventricle

• Pulmonary vascular and pulmonary valve disorders a/w increased RV systolic pressures

• RV disorders – ischemia/infarction/failure – a/w increased RV End diastolic pressure

• Pulmonary artery:
• The risk of arrhythmias is greatest while catheter tip is in RV

Thus, catheter should be advanced from RV to PA without delay

• When catheter tip passes pulmonary valve Diastolic pressure increases and
characteristic dichrotic notch appears in waveform
• Normal pulmonary artery pressures:
• Systolic  15-25mmHg
• Diastolic  8-15 mmHg
• Mean  16 (10-22mmHg)

• Main components of PA tracing:

• Systolic and Diastolic pressure
• Dichrotic notch(due to closure of pulmonic valve)
• Increase in mean pulmonary pressure:
• Acute:
• Venous Thromboembolism
• Hypoxemia induced Pulmonary Vasoconstriction

• Acute on Chronic:
• Hypoxemia induced pulm VC in patient with chronic cardiopulmonary disease

• Chronic:
• Pulmonary hypertension
• Types of PHT:
• Primary
• Due to Heart Disease
• Due to Lung Disease
• Due to chronic venous thromboembolism
• Miscellaneous ( Sickle Cell Anemia)
 Pulmonary arterial occlusion pressure
• Once catheter tip has reached PA, it should be advanced until PAOP is
identified by decrease in pressure and change in waveform

The balloon should then be deflated and PA tracing should reappear

If PCOP tracing persists catheter should be withdrawn with definitive PA

tracing obtained
• Final position of the catheter within PA must be such that PCOP
tracing is obtained whenever 75-100% of 1.5ml maximum
volume of balloon is insufflated
• If < 1ml of air is injected and PAOP is seen then it is overwedged 
needs to be withdrawn

• If after maximal inflation fails to result in PCOP tracing or after 2-3

seconds delay  too proximal – advanced with balloon inflated
• PCWP/PAOP  interprets Left atrial pressures

more importantly – LVEDP

• Best measured in
• Supine position
• At end of expiration
• Zone 3 (most dependent region)

• Normal PCWP- 6-15 mmHg ; Mean :9mmHg

• Abnormal PAOP:
• Increased LVEDP  Increased PAOP
• LV systolic HF
• LV Distolic HF
• Mitral and Aortic valve disease
• Hypertrophic cardiomyopathy
• Hypervolemia
• Large R-L shunts
• Pericardial disease
• Decreased PCWP:
• Hypovolemia
• Obstructive shock due to large pulmonary embolus

• Abnormal waveforms
• Large a waves:
• MS
• LV systolic /diastolic function
• LV volume overload
• MI

• Large v waves - MR
• Calculation of cardiac output:
• 2 methods
• Thermodilution method
• Fick’s Method

• Better measurement with Cardiac index

• Normal – 2.8- 4.2 l/min/m2
• Decreased CO: • Increased CO:

• Systolic HF
• Systemic A-V fistulas
• Diastolic HF
• Anemia
• MR
• Beriberi
• Hypovolemia
• Renal Disease
• Pulmonary HT
• RVF • Sepsis
• Other uses of pulmonary artery catheter:
• Detection of Left to right shunts
• Estimation of systemic and pulmonary vascular resistance
 Complications
• General:
• Immediate:
• Bleeding
• Arterial Puncture
• Air embolism
• Thoracic duct injury ( L side)
• Pneumothorax/hemothorax

• Delayed:
• Infections
• Thrombosis
• Related to insertion of PAC:
• Arrhythmias (most common- Ventricular/ RBBB)
• Misplacement
• Knotting
• Myocardial/valve/vessel rupture

• Related to maintenance and use of PAC:

• Pulmonary artery perforation
• Thromboembolism
• Infection
 ECHO/ DOPPLER
CARDIOGRAPHY
• A diagnostic Study that reveals information about:
• The structure and function of the heart

• Cardiac hemodynamics of the heart

THEORY AND TECHNIQUE OF THE STUDY

• Utilizes the Application of Ultasonic waves being reflected back on hitting a

structure
• This is done utilizing a transducer that both sends out the beam and then receives
it back
• The transducer can have one crystal or multiple crystals
• Utilizing the technique of doppler with ultrasound allows the ability to quantitate
the direction and velocity of objects
APPLICATION OF THE TECHNIQUE:
• M mode echo
• 2 DIMENSIONAL ECHO:
• Tran thoracic Echo- transducer directly on the chest wall
• Transesophageal Echo- probe placed into the esophagus and stomach
• Stress echocardiography- Tran thoracic echo at rest and post stress or
exercise
APPLICATION OF THE TECHNIQUE:

• Doppler can be viewed as:

• Continuous wave- continuous transmission of signal with 2nd transducer available to
receive the signal
• Pulsed Doppler- same probe transmits, waits an the receives
• Color flow- vectors directions given colors, usually blue if flow is away from transducer
and red if goes toward the transducer.
THIS TECHNIQUE ALLOWS THE EVALUATION OF:

• Cardiac Chambers- size and motion or function

• The thickness of the walls of the heart
• Abnormal Objects in the heart: tumors or masses
• Valvular structure (size and shape)
• Valvular function (thickness, stenosis, or leakage)
• Blood flow- hemodynamics
• Other pathologies- fluid: pericardial effusionOther objects- vegetations etc.
• Mechanical valves
• Pacemaker wires
 ABNORMAL IMAGES

• LEFT VENTRICULAR FUNCTION

 VALVULAR DISEASE

AORTIC VALVE
MITRAL VALVE
CARDIOMYOPATHY
PACEMAKER WIRE
STRESS ECHOCARDIOGRAPHY