CVS Monitoring in Shock

CVS Monitoring in ShockCVS Monitoring in Shock

CVS MonitoringCVS Monitoring Non-invasive techniques: Non-invasive techniques: • Clinical assessment of tissue perfusion Clinical assessment of tissue perfusion • ECG, NiBP, pulseECG, NiBP, pulse oximetry; oximetry; • Non-invasive CO studies – Echo, NiCO methodNon-invasive CO studies – Echo, NiCO method

Invasive Monitoring:Invasive Monitoring:• Central venous pressure monitoring; Central venous pressure monitoring; • Direct arterial line pressure monitoring;Direct arterial line pressure monitoring;• Cardiac Output studies (Pulmonary Artery Catheter)Cardiac Output studies (Pulmonary Artery Catheter)

Central Venous CatheterisationCentral Venous Catheterisation

Internal jugular veinInternal jugular vein Subclavian veinSubclavian vein Axillary veinAxillary vein Femoral veinFemoral vein

TThe he absolute valueabsolute value is often unhelpful, except in extreme is often unhelpful, except in extreme cases of severe hypovolaemia, significant fluid overload, or cases of severe hypovolaemia, significant fluid overload, or heart failure.heart failure.

Correct interpretation requires assessment of the Correct interpretation requires assessment of the change in change in central venous pressurecentral venous pressure in response to a in response to a fluid challengefluid challenge in conjunction with alterations in other monitored variables.in conjunction with alterations in other monitored variables.

Other Indications for CVC: Drug delivery (Adrenaline, Other Indications for CVC: Drug delivery (Adrenaline, Noradrenaline, Potassium, other hypertonic solutions),Noradrenaline, Potassium, other hypertonic solutions),Total Parenteral Nutrition (TPN), etc.Total Parenteral Nutrition (TPN), etc.

Complications of central cathetersComplications of central catheters

• On insertionOn insertion Cardiac arrythmiasCardiac arrythmias Pneumothorax / haemothoraxPneumothorax / haemothorax Air embolismAir embolism Surrounding tissue injuries Surrounding tissue injuries Cardiac tamponadeCardiac tamponade

• Post insertionPost insertion Infection (consider removal after 7 days)Infection (consider removal after 7 days) Cardiac arrhythmiasCardiac arrhythmias Displacement of catheterDisplacement of catheter Blockage of lumen(s)Blockage of lumen(s) Air / material embolismAir / material embolism Thrombus formationThrombus formation

Direct arterial pressure monitoringDirect arterial pressure monitoring

Invasive cannulation of an artery for continuousInvasive cannulation of an artery for continuous monitoring of direct BP; used in:monitoring of direct BP; used in:

-Haemodynamically unstable patient, patient in shockHaemodynamically unstable patient, patient in shock-Patient receiving inotropic Patient receiving inotropic / vasoactive / vasoactive agentsagents-For blood sampling (ABGFor blood sampling (ABG’’s, U&Es, U&E’’S, glucose etc)S, glucose etc)-Patient with physiological difficulties for NIBP (obesity, AF)Patient with physiological difficulties for NIBP (obesity, AF)

Stroke volume variationStroke volume variation (SVV) : difference between the largest and the

smallest arterial wave traces during respiratory cycle

SPV and PVISPV and PVI

Techniques Techniques toto assess cardiac assess cardiac output output (Flow-based techniques)(Flow-based techniques)

Oesophageal DopplerOesophageal Doppler• based on determination of RBC velocity/flowbased on determination of RBC velocity/flow

TTrans-oesophageal Echocardiography (TOE)rans-oesophageal Echocardiography (TOE)• Gold standard Gold standard inin USA USA

Arterial pulse/pressure Arterial pulse/pressure wave wave analysis (PPWA)analysis (PPWA)• eg Pieg PiCCO, Vigileo, LiDCOCCO, Vigileo, LiDCO

Combination of Combination of pulse/pressure pulse/pressure wave wave analysis (PPAW) with analysis (PPAW) with oesophageal Dopler flow measurement (oesophageal Dopler flow measurement (for re calibration)for re calibration)

Bioimpedance / BioreactanceBioimpedance / Bioreactance• Change in amplitude / frequency of a transmitted electrical signalChange in amplitude / frequency of a transmitted electrical signal

Oesophageal DopplerOesophageal Doppler

Pulse contour analysisPulse contour analysisPPWAPPWA

If an arterial pressure waveform is calibrated to a known cardiac output then tracking the changed in the shape and size of arterial waveform can give information to the changes in cardiac output.

Pulmonary artery catheterisationPulmonary artery catheterisation

Dr. Jeremy Dr. Jeremy SwanSwan and Dr. William and Dr. William GanzGanz Developed 1971 Developed 1971 Catheterisation of the pulmonary artery with a balloon flotation Catheterisation of the pulmonary artery with a balloon flotation

catheter allows to measure:catheter allows to measure:

• PPreload - indirect assessment of the filling pressure of the left reload - indirect assessment of the filling pressure of the left ventricle (pulmonary artery occlusion or wedge pressure)ventricle (pulmonary artery occlusion or wedge pressure)

• Contractility – by using Contractility – by using ‘‘thermodilutionthermodilution’’ technique technique

• Afterload or SVR - by calculating from the formulaAfterload or SVR - by calculating from the formulaSVR = CO / MAPSVR = CO / MAP

(PAC; PAFC; PAOP; PAWP)(PAC; PAFC; PAOP; PAWP)