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Clinical monitoring in the ICU By: ABRAHA HAILU(MD)
Hemodynamic Monitoring
Overview ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Why monitor BP? ,[object Object],[object Object],[object Object]
Noninvasive Hemodynamic Monitoring ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Indications for  Arterial Blood Pressure ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Supplies to Gather ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Potential Complications  Associated With Arterial Lines ,[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object]
[object Object],[object Object],[object Object],[object Object]
CVP BLOOD VOLUME (INCREASED VENOUS RETURN RAISES CVP CARDIAC COMPETENCE  (REDUCED VENTRICULAR FUNCTION RAISES CVP) INTRATHORACIC AND INTRAPERITONEAL PRESSURE  (RAISES CVP) SYSTEMIC VASCULAR RESISTENCE  (INCREASED TONE RAISES CVP)
 
NORMAL CVP MEASUREMENTS ,[object Object],[object Object],[object Object],[object Object]
Indications for central venous catheter placement ,[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Contraindications ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Central Venous Catheter Placement  ,[object Object],[object Object],[object Object],[object Object]
sites ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Equipment ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Techniques: ,[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
 
 
 
[object Object],[object Object],[object Object],[object Object],[object Object]
WATER MANOMETER : ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
EQUIPMENT ,[object Object],[object Object],[object Object],[object Object],[object Object],a. b. c. d. e.
EQUIPMENT IV extension  set to entry port  of patients  central line. IV giving set to fluid bag. Stopcock (Three way tap)
DIRECTION OF FLOW The white arrows indicate the direction of fluid flow.  (a).   Initially the white knob is turned straight up,  allowing fluid to flow from the fluid bag to the patient's catheter  to assure the catheter is patent.. If fluid does not flow freely into the patient's catheter a valid CVP reading  will not be obtained.  (b)  Then the knob is turned toward the patient and fluid will fill the manometer. The manometer  should not contain any air bubbles . If air is present in the manometer or fluid line, let the fluids run, overfilling the  manometer until all air is purged from the system.  (c)  Then turn the knob toward the fluids. The level of fluid in the manometer will fall (the fluid is running into the patient's catheter) until the height of the  fluid column exerts a pressure equivalent to the patient's  CVP The top of the fluid column will slightly oscillate up and down as the pt’s  heart beats and as the  pt breathes. a. c. b.
POSITION OF PATIENT 3-way tap manometer Fluid Bag Patient in supine position Central Venous Access
 
PRESSURE TRANSDUCER: ,[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object]
FACTORS AFFECTING THE MEASUREMENT OF CVP ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
INFORMATION FROM THE  CVP  WAVEFORM ,[object Object]
WAVEFORMS IN  CVP ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
THE CVP WAVEFORM ,[object Object]
INFORMATION OBTAINED FROM CVP WAVEFORMS ,[object Object],[object Object],[object Object],[object Object]
The a and v waves ,[object Object],[object Object],[object Object],[object Object]
M marks the appropriate place for measurement. The bottom tracing shows the overlap tracing with pulmonary artery pressure (PAP). This also can be used for timing the end of diastole and the place to make the measurement.  shows a tracing from a young woman who had a major bleed following a hysterectomy
Tricuspid regurgitation ,[object Object],[object Object]
This indicates severe TR.  It must be appreciated that the peak of the v wave, which is 35 mmHg, will still have an important impact on upstream structures such as the liver and kidney
Rhythm disorders ,[object Object],[object Object],[object Object]
 
 
Cannon A waves
“ M sign” from Pericardial Constriction
The y descent ,[object Object],[object Object],[object Object]
 
Tamponade ,[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object]
 
Respiratory variation in  CVP ,[object Object],[object Object],[object Object]
Complications of central venous catheterization ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
MANAGEMENT OF A PATIENT WITH A CVP LINE ,[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object]
REMOVAL OF CENTRAL LINE ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
PULMONARY ARTERY AND PULMONARY CAPILLARY WEDGE PRESSURE MONITORING ,[object Object],[object Object],[object Object],[object Object],[object Object]
Why PCWP? ,[object Object],[object Object]
[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object]
 
Indications For PAP & PCWP Monitoring ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
PA (Swan-Ganz) Catheter description ,[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
PULMONARY ARTERY CATHETER
Components of a Pulmonary Artery  Catheter
Components of Swan-Ganz  ,[object Object],[object Object],[object Object],[object Object],[object Object]
 
[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Insertion procedure   : ,[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object]
 
 
 
 
INVASIVE HEMODYNAMIC    MONITORING
PA Insertion Waves
Components of the Monitoring System ,[object Object],[object Object],[object Object]
Phlebostatic Axis
Pulmonary Artery Pressure Monitoring ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Complications of Swan-Ganz ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
mmHg
 
 
Cardiac Output ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Cardiac Index ,[object Object],[object Object],[object Object]
Low Cardiac Output ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Low Cardiac Output ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
High Cardiac Output ,[object Object],[object Object],[object Object],[object Object],[object Object]
Determinants of  Cardiac Output & Stroke Volume ,[object Object],[object Object],[object Object]
Clinical Measurement of Preload ,[object Object],[object Object],[object Object],[object Object],[object Object]
Clinical Measurement of Preload ,[object Object],[object Object]
Factors that Affect Preload ,[object Object],[object Object],[object Object],[object Object]
Factors that Decrease Preload ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Factors that Increase Preload ,[object Object],[object Object],[object Object],[object Object],[object Object]
Afterload ,[object Object],[object Object],[object Object],[object Object],[object Object]
Factors that Affect Afterload ,[object Object],[object Object],[object Object],[object Object]
Decreased Afterload ( ↓ SVR) ,[object Object],[object Object],[object Object]
Increased Afterload ( ↑SVR) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Increased Afterload ( ↑ PVR) ,[object Object],[object Object],[object Object],[object Object],[object Object]
Contractility = Inotropy ,[object Object],[object Object],[object Object]
Factors/M eds Increasing Contractility ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Factors Decreasing Contractility ,[object Object],[object Object],[object Object],[object Object],[object Object]
Conditions Resulting in PCWP and LVEDP Discrepancies ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
ASA Guidelines for PAC Use
Thermodilution Cardiac Output ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Mixed venous oxygen saturation ,[object Object],[object Object],[object Object]
[object Object]

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Clinical monitoring in ICU

  • 1. Clinical monitoring in the ICU By: ABRAHA HAILU(MD)
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  • 11. CVP BLOOD VOLUME (INCREASED VENOUS RETURN RAISES CVP CARDIAC COMPETENCE (REDUCED VENTRICULAR FUNCTION RAISES CVP) INTRATHORACIC AND INTRAPERITONEAL PRESSURE (RAISES CVP) SYSTEMIC VASCULAR RESISTENCE (INCREASED TONE RAISES CVP)
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  • 31. EQUIPMENT IV extension set to entry port of patients central line. IV giving set to fluid bag. Stopcock (Three way tap)
  • 32. DIRECTION OF FLOW The white arrows indicate the direction of fluid flow. (a). Initially the white knob is turned straight up, allowing fluid to flow from the fluid bag to the patient's catheter to assure the catheter is patent.. If fluid does not flow freely into the patient's catheter a valid CVP reading will not be obtained. (b) Then the knob is turned toward the patient and fluid will fill the manometer. The manometer should not contain any air bubbles . If air is present in the manometer or fluid line, let the fluids run, overfilling the manometer until all air is purged from the system. (c) Then turn the knob toward the fluids. The level of fluid in the manometer will fall (the fluid is running into the patient's catheter) until the height of the fluid column exerts a pressure equivalent to the patient's CVP The top of the fluid column will slightly oscillate up and down as the pt’s heart beats and as the pt breathes. a. c. b.
  • 33. POSITION OF PATIENT 3-way tap manometer Fluid Bag Patient in supine position Central Venous Access
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  • 45. M marks the appropriate place for measurement. The bottom tracing shows the overlap tracing with pulmonary artery pressure (PAP). This also can be used for timing the end of diastole and the place to make the measurement. shows a tracing from a young woman who had a major bleed following a hysterectomy
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  • 47. This indicates severe TR. It must be appreciated that the peak of the v wave, which is 35 mmHg, will still have an important impact on upstream structures such as the liver and kidney
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  • 52. “ M sign” from Pericardial Constriction
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  • 74. Components of a Pulmonary Artery Catheter
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  • 91. INVASIVE HEMODYNAMIC MONITORING
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  • 120. ASA Guidelines for PAC Use
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Hinweis der Redaktion

  1. A wave: right atrial contraction (P wave on the ECG) If the A wave is elevated the patient may have right ventricular failure or tricuspid stenosis. C wave: tricuspid valve closure (follows QRS complex on the ECG). V wave: pressure generated to the right atrium during ventricular contraction, despite the tricuspid valve being closed (latter part of the T wave on the ECG)
  2. Transparent dressings should be used to permit continuous monitoring of the site. If infection of the CVP line is suspected blood cultures should be taken following removal of the line. The catheter tip should be sent for M C & S.