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Cardiovascular Monitoring II

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Invasive CVS monitoring Overview

a. Arterial line b. Central venous pressure c. Pulmonary artery catheter d. Transoesophageal echocardiography
Indications What is being measured Technique- Positioning, sites Complications

Arterial Line
Direct measurement of blood pressure most accurate technique continuous haemodynamic information blood gas measurement

How accurate?
Depend on the setup
Use correct tubing Bubbles free (tips) Tight connections Zero calibration Level of transducer

Heparin or not?

Patient factors
Patient with severe sepsis or shock Cardiac diseases such as unstable angina, recent AMI, current congestive heart failure or cardiac arrhythmias or on pacemaker

Surgical considerations
Cardiac surgery Major surgery on aorta or carotid artery Neurosurgery such as craniotomy or aneurysm clipping Major surgery with expected blood loss more than 1 blood volume

Indications (Contd)
Anaesthetic considerations
Controlled hypotensive techniques Inability to measure blood pressure noninvasively Frequent blood sampling required during and after operation

Setting up an arterial line

Pressure bag Collapsible 0.9% 500cc Normal saline bag with air expelled Pressure transducer and infusion set Cannula + heparin (1-2 units /ml)

1. Set up the pressure measurement system and pressurized the bag to 300 mmHg 2. Cannulate an artery 3. Connect to the pressure measurement system 4. Fix the cannula securely 5. Zeroing the transducer 6. Fix the transducer at the heart level 7. Start measurement

1. 2. 3. 4. 5. 6. Blood loss due to disconnection Arterial thrombosis Infection Haematoma formation True and false aneurysm formation Distal and central embolisation

Central venous pressure monitoring

Introduction Monitoring of intracardiac pressures ventricular dysfunction due to ischaemia, valvular abnormalities or primary myocardial disease allow differentiation between hypovolaemia and myocardial depression

1. Assessment of preload in patients with hypovolaemia / septic shock / valvular problems / congestive heart failure 2. Assessment of right ventricular dysfunction associated with severe lung disease, pulmonary hypertension, cardiac tamponade 3. Craniotomy in the sitting position 4. Major surgery with expected blood loss >1 blood volume 5. Difficult intravenous access

Setting up the CVP manometer

Normal Saline or Dextrose 5% solution Simple IV set Prime the CVP manometer tubing Run at least 10 cm of water into the manometer Remove all bubbles in the water column

Type of CVP cannula

Single lumen
long angiocath (16G,14G), catafix (375mm, 475mm), percutaneous sheath (7F, 8.5F) Swan sheath (8.5F)

Multiple lumens
2-,3-,4- lumen

Steps in setting up CVP monitoring line

1. Prime the CVP manometer or set up the pressure transducer 2. Choose the site of central vein insertion 3. Position the patient- shoulder support and head down and turn to opposite side for IJV and SCV cannulation, 4. Sterilise the area with aseptic solution and create a sterile field 5. Local the vein with seeker needle 6. Use Seldinger technique to canulate the vein 7. Connect to the CVP manometer or transducer 8. Fix the cannula securely 9. Back flow of blood

Vein or artery ?
Colour of blood Pressure Artery Bright red Vein Dark red

High Low Plunger push back Rapid back flow of blood High PaO2

Blood gas

Complications of CVP
1. Carotid artery puncture 2. Pneumothorax 3. Air embolism 4. Arrhythmia 5. Perforation of SVC or R atrium/ventricle -> cardiac tamponade 6. Brachial plexus, vagus nerve, phrenic nerve injury 7. Thoracic duct perforation (usually left side) -> chylothorax 8. Retroperitoneal haematoma

Complications of CVP (Contd)

9. Infection 10. Pleural effusion 11. Airway obstruction- extravasation of infusate or bleeding from puncture artery 12. Allergic reaction to substance impregnated on the catheter

Pulmonary artery pressure monitoring

Allow measurement of pressures close to the left ventricle LVEDV LVEDP LAV LAP PCWP RVEDV RVEDP RAV - RAP CVP

1. Ischaemic heart disease with recent myocardial infarction 2. Symptomatic valvular heart disease 3. Cardiomyopathy 4. Congestive heart failure and low ejection faction 5. Shock- septic or hypovolaemic 6. Pulmonary hypertension 7. Cardiac surgery with poor ventricular function

What is being measured by PAFC?

1. Central venous pressure 2. Pulmonary artery systolic and diastolic pressure 3. Pulmonary capillary wedge pressure 4. Cardiac output 5. Mixed venous oxygen saturation 6. Derived values such as stroke volume, cardiac index, ventricular stroke work, systemic and pulmonary vascular resistance

Technique of insertion
1. Choose the site of line insertion 2. Position the patient- should support and head down and turn to opposite side for IJV and SCV cannulation, 3. Sterilise the area with aseptic solution and create a sterile field 4. Local the vein with seeker needle 5. Use Seldinger technique to cannulate the vein with the swan sheath 6. Fix the swan sheath securely by stitches 7. The PAFC is flushed with saline through each of its ports and the balloon at the tip tested

Technique of insertion


8. The transducers are zeroed and calibrated 9. The PAFC is introduced into the sheath and advanced to the 20cm mark. 10.The balloon at the tip is inflated with 1.5 ml of air and kept inflated. 11.The catheter is slowly advanced to obtain right ventricular tracing. Further advance the catheter into the pulmonary artery which occurs when the diastolic pressure increases. At this point the catheter is slowly advanced to a wedge position with the waveform changed to that similar to the atrial tracing. The balloon is then deflated and a PA tracing will appear.

Technique of insertion


12. The transducers are placed at the right atrial level. Haemodynamic measurements and thermodilution cardiac outputs are performed and derived variables calculated.
13. CXR should be obtained if complication is suspected or after surgery

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Measurement of cardiac output using PAFC

1. Ensure correct positioning of the PAFC in the heartproximal opening in R ventricle and distal thermister in pulmonary artery 2. Measure the PCWP 3. Press the CO measurement button and observe that the temperature baseline is stable 4. Withdraw 10 ml of normal saline or dextrose at room temperature into syringe 5. Press the start button and inject the 10 ml of fluid as fast as possible 6. A temperature change curve will be observed 7. Repeat the measurement 3-4 times 8. Select the 3 best temperature curve and press calculate

Similar to that of CVP insertion Additional complications are:
1. 2. 3. 4. 5. 6. Arrhythmogenesis, Thrombosis and embolism, Pulmonary infarction or haemorrhage, Endocarditis, Perforation of atrium, ventricle and pulmonary artery, Intracardiac knotting

Transoesophageal echocardiography
Indications American Society of Anaesthesiologists practice guidelines for perioperative TEE Category I indications - supported by strongest evidence or expert opinion Category II indications - supported by weaker evidence or expert consensus Category III indications Little current scientific or expert support

Patient with oesophageal stricture Patient with history of oesophageal tumour Patient with oesophageal varices Patient with severe coagulalopathy preop

What is being measured?

Ischaemic state via measurement of regional wall motion and wall thickening changes Ventricular function via measurement of ejection fraction, wall shortening and ventricular volumes Valvular function Intracardiac air and masses (eg. thrombus, tumour, etc)

Turn on the TEE machine Put in a suitable month gag between patients teeth Lubricate the first 20-30 cm of the TEE probe with lubricant jelly Insert the TEE probe through the month gag into the patients month and then gently into the appropriate position in the oesophagus Connect the TEE probe to the TEE machine and select the appropriate probe setting

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Oesophageal perforation GI bleeding Oesophageal burn Transient vocal cord oedema

Any Questions?

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