Cardiac monitoring

1. Cardiac Monitoring
Presentation by Dr Deepti Tiwari
Moderator Dr Upasana Goswami

2. 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].

3. 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.

4. 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.

5. 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.

6. 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.

7. 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.

9. Complications of Noninvasive Blood Pressure Measurement
• Pain
• Petechiae and ecchymoses
• Limb edema
• Venous stasis and thrombophlebitis
• Peripheral neuropathy
• Compartment syndrome

10. 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.

11. odified Allen’s Test
MODIFIED ALLENS TEST

12. 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

13. 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

14. NORMAL ARTERIAL PRESSURE TRACING
1, Systolic upstroke; 2, systolic peak pressure; 3, systolic decline; 4, dicrotic notch; 5,
diastolic runoff; 6, end-diastolic pressure.

16. 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

17. 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

18. 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.

19. 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

20. Complications of CVP:
• Mechanical Vascular injury Arterial
Venous
Hemothorax
Cardiac tamponade
• Respiratory compromise
Airway compression from hematoma
Tracheal, laryngeal injury
Pneumothorax
• Nerve injury
• Arrhythmias
• Subcutaneous/mediastinal emphysema
• Thromboembolic
Venous thrombosis
Pulmonary embolism
Arterial thrombosis and embolism (air, clot)
Catheter or guidewire embolism
• Infectious Insertion site infection
Catheter infection
Bloodstream infection
Endocarditis
• Misinterpretation of data
• Misuse of equipment

21. 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

23. 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.

24. 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

25. The JVP Waveform

26. 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

27. 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

28. Pulmonary Artery Catheter

29. 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

30. 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)

31. • Indirect measurements that are possible:
• Systemic Vascular Resistance
• Pulmonary Vascular Resistance
• Cardiac Index
• Stroke volume index
• Oxygen delivery
• Oxygen uptake

32. 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

33. • 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

34. Contraindications
• Absolute:
• Infection at insertion site
• Presence of RV assist device
• Insertion during CPB
• Lack of consent
• Relative:
• Coagulopathy
• Thrombocytopenia
• Electrolyte disturbances
(K/Mg/Na/Ca)
• Severe Pulmonary HTN

35. 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

36. 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

37. • 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

40. 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
Technique:

41. 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

44. • 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.

45. Interpretation of hemodynamic values and
waveforms
• Ensuring accurate measurements:
• Zeroing and Referencing
• Correct placement
• Fast flush test

46. • 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

47. • Rapid flush test:

48. Catheter waveforms and pressures
• Pressure waveforms can be obtained from
• Right atrium
• Right ventricle
• Pulmonary artery

49. • 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

51. • Elevated RA pressure:
• Diseases of RV( infarction/ cardiomyopathy)
• Pulmonary hypertension
• Pulmonic stenosis
• Left to right shunts
• Pericardial diseases
• LV systolic failure
• Hypervolemia

52. • 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

53. • 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

56. • 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

57. • 2 pressures are typically measured in right ventricular pressure waveform
• Peak RV systolic pressure  15-25mmHg
• Peak RV diastolic pressure  3-12 mmHg

59. • 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

60. • 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

61. • 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)

63. • 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

64. • Types of PHT:
• Primary
• Due to Heart Disease
• Due to Lung Disease
• Due to chronic venous thromboembolism
• Miscellaneous ( Sickle Cell Anemia)

65. 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

66. • 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

67. • 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

70. • 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

71. • 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

72. • Calculation of cardiac output:
• 2 methods
• Thermodilution method
• Fick’s Method
• Better measurement with Cardiac index
• Normal – 2.8- 4.2 l/min/m2

73. • Decreased CO:
• Systolic HF
• Diastolic HF
• MR
• Hypovolemia
• Pulmonary HT
• RVF
• Increased CO:
• Systemic A-V fistulas
• Anemia
• Beriberi
• Renal Disease
• Sepsis

74. • Other uses of pulmonary artery catheter:
• Detection of Left to right shunts
• Estimation of systemic and pulmonary vascular resistance

75. Complications
• General:
• Immediate:
• Bleeding
• Arterial Puncture
• Air embolism
• Thoracic duct injury ( L side)
• Pneumothorax/hemothorax
• Delayed:
• Infections
• Thrombosis

76. • 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

77. ECHO/ DOPPLER
CARDIOGRAPHY
• A diagnostic Study that reveals information about:
• The structure and function of the heart
• Cardiac hemodynamics of the heart

78. 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

81. 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

82. 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.

88. 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

99. ABNORMAL IMAGES
• LEFT VENTRICULAR FUNCTION

102. VALVULAR DISEASE
AORTIC VALVE

107. MITRAL VALVE

114. CARDIOMYOPATHY

115. PACEMAKER WIRE

116. STRESS ECHOCARDIOGRAPHY