nemodynam|c Mon|tor|ng

and Shock
!ohn (!ack) 8uckley, Mu, lCC
AugusL 2013
D|sc|osure
ln Lhe pasL 10 years, l have noL knowlngly recelved any
gls, lncome, fees, expenses pald by a pharmaceuucal
company or manufacLurer of medlcal devlces
l llkely own some form of equlLy ln such companles as
parL of professlonally managed reuremenL accounLs
Medlcal malpracuce consulung for several MldwesL Law
rms (<$10,000/year)
Lmployee of lndlana unlverslLy and lndlana unlverslLy
PealLh hyslclans
More D|sc|osure
MosL medlcauons uo nC1 have luA lndlcauons for
whaL l dlscuss
ersonal:
l don'L haLe ulmonary ArLery CaLheLers and sull
place Lhem(seemlngly fewer, each year).
AlLhough, Lhey are an excellenL Leachlng lnsLrumenL
Lo learn hemodynamlc paLhophyslology.
Cb[ecnves
8evlew ulmonary ArLery CaLheLerlzauon funcuon,
daLa lnLerpreLauon and common plualls
Apply hemodynamlc lnformauon Lo asslsL ln cllnlcal
managemenL
LlsL Lechnlques of esumaung cardlac ouLpuL
CuLllne Lypes, hemodynamlc pauerns and
managemenL of shock

u|monary Artery Catheters (ACs)
Cllnlcal use of Lhese devlces conunues Lo evolve:
Less use ln Lhe lCu's
More use ln evaluauon and managemenL of
ulmonary PyperLenslon
rlnclples never go away
locus of Loday's presenLauon:
uaLa lnLerpreLauon
Waveforms
1roubleshooung
Pemodynamlc proles of shock
AC's: 8efore you make a s|ng|e read|ng..
Check Lhe posluon of Lhe Lransducer
Zero and callbraLe Lhe sysLem
lrequency 8esponse, naLural Parmonlcs of Lhe
sysLem, Slgnal uampenlng and CaLheLer Whlp
naLural Parmonlcs of Lhe sysLem:
1ublng ls su Lo allow accuraLe Lransmlsslon of pressures
Su Lublng ls more prone Lo vlbrauon and dependenL on
Lublng lengLh
1herefore, kLL 1u8lnC LLnC1P SPC81
erform|ng a I|ush 1est
8un graphlc recorder
8apldly acuvaLed and
release Lhe ush
8ecord Lhe square
wave
Norma| Square Wave 1est
Square wave qulckly
reLurns Lo basellne
1-2 bounces follow
8ounce <40ms
2
nd
bounce < 1/3 of1sL
AC Ca||branon
key Interpretanon o|nts
Measure aL Lnd-
explrauon
vlsual
assessmenL of
Lraclng requlred
Change ln venL
parameLers noL
recommended
AC Norma| Va|ues
8A 2-8 mmPg
8v 20-30 / 2-8 mmPg
A 20-30 / 3-13mmPg
AC 3-12 mmPg
CC 4-8 L/mln
SvC2 63-73
CourLesy of !. Zlmmerman
1. What |s the most
accurate CV?
A) 26 mmPg
8) 23 mmPg
C) 19 mmPg
u) 13 mmPg

What about CV |n atr|a| hbr|||anon?
CourLesy of !. Zlmmerman
CV Measurement: CAU1ICN w|th k|ght
S|de re-|oad Determ|nanons
varlables lnuenclng measuremenL
8v funcuon -- lnLra-Lhoraclc pressure
valvular ulsease -- lnLra-abdomlnal pressure
ulmonary ulsease
venous Lone
oor correlauon beLween Cv and sLroke volume
ConLexL ls essenual
1rends ln Cv probably more useful Lhan slngle
measuremenL
CourLesy of !. Zlmmerman
CourLesy of !. Zlmmerman
2. Cn ass|st contro| venn|anon, what |s
the pu|monary artery (A) pressure?
30-
20-
10-
0-
A) 30/20
8) 38/20
C) 34/20
u) 38/30
L) Can'L Lell
CourLesy of !. Zlmmerman
kesp|ratory Lects
SponLaneous breaLhlng ln a non-lnLubaLed pauenL
does whaL Lo A caLheLer waveforms?
Mechanlcal venulauon does whaL Lo A caLheLer
waveforms?
AuvlCL: 8ead Lhe lasL clear wave leasL aecLed by
breaLhlng
3. What |s the AC |n th|s
spontaneous|y breath|ng panent?
CourLesy of !. Zlmmerman
4. What |s the most accurate AC?
A) 34 mmPg
8) 30 mmPg
C) 20 mmPg
u) 13 mmPg
CourLesy of !. Zlmmerman
More troub|eshoonng: Lung 2ones
When Lo suspecL you are ln
Zone 1 or 2:
AC > A-dlasLole
Pypovolemla, Plgh LL
venous blood on perlpheral
porL sample
1lp above le aLrlum
8esplraLory varlauon of AC
ls > dlerence ln A sysL-dlas
Cther AC L|m|tanons:
Ovk-LS1IMA1LS LVLD
ALrlal myxoma
ulmonary Lmbollsm
ulmonary venous
obsLrucuon
lnLra-cardlac shunL
Lung zone 1 or 2
1achycardla
MlLral valve lnsumclency
uNuk-LS1IMA1LS LVLD
Aoruc valve regurg
uecreased Lv compllance
Card|ac Cutput v|a 1hermod||unon
rocess:
ln[ecL vla proxlmal AC porL lnLo rlghL aLrlum
need accuraLe LemperaLure & volume of ln[ecLaLe
1hree measuremenLs, ldeally one mlnuLe aparL
ln[ecL over 2 seconds aL end-explrauon
lalsely Low:
1rlcuspld 8egurglLauon
lalsely LlevaLed:
lnLracardlac shunLs
ulsLal CaLheLer posluon
Cther Means of Mon|tor|ng Card|ac
Cutput
ArLerlal waveform analysls
CallbraLed
uncallbraLed
ulsed uoppler Lechnology
Applled llck prlnclple
8lo-lmpedance
1ransesophageal doppler
Comments on Less-Invas|ve
nemodynam|c Mon|tor|ng
no clear, rellable correlauon wlLh A caLheLer
SlgnlcanL markeung of producLs
value may be ln Lrendlng hemodynamlcs raLher Lhan
slngle, polnL-ln-ume assessmenLs
unllkely Lo appear on A8lM examlnauon
I|u|d kespons|veness |n
Non-Venn|ated anents
volume expanslon (300mL crysLallold or collold)
CC or Sv lncrease by 10-13

asslve leg ralslng
llaL posluon wlLh feeL elevaLed 43 degrees for
10mln
CC or Sv lncrease by > 12
CourLesy of !. Zlmmerman
Genera| r|nc|p|es
Cxygen ConLenL (CaC2 or CvC2) ln an allquoL of blood:
Pgb, C2 saL, dlssolved oxygen
C2 uellvery (uC2) = CaC2 x Cardlac CuLpuL (CC)
C2 LxLracuon (vC2) = (CaC2-CvC2) x CC
CxlmeLry:
ArLerlal: measure anywhere
venous (SvC2): depends on local ussue exLracuon
Mlxed, CenLral venous, eLc.
Norma| SvC2: 6S-7S
Low SvC2
Low CC
Anemla
Low aC2
lncreased C2
consumpuon
n|gh SvC2
PypoLhermla
Sedauon / paralysls
PypoLhyroldlsm
Cyanlde polsonlng
Av shunLs (eg. clrrhosls)
Sepsls
CourLesy of !. Zlmmerman
Shock
uenluon: [noun] Syndrome of lmpalred ussue
oxygenauon and perfuslon
Causes:
AbsoluLe / 8elauve decrease ln C2 dellvery
lneecuve ussue perfuslon
lneecuve exLracuon of dellvered C2
PypoLenslon does noL dene shock
1ypes of Shock
Card|ogen|c:
conLracullLy, arrhyLhmla,
obsLrucuve

D|str|bunve:
sepsls, neurogenlc,
adrenal lnsumclency,
anaphylaxls


nypovo|em|c:
hemorrhaglc, non-
hemorrhaglc

Cbstrucnve:
ulmonary embollsm,
cardlac Lamponade
perlcardlus, Lenslon
pneumoLhorax
S. Wh|ch of the fo||ow|ng proh|es |s most
cons|stent w|th sepnc shock?
8 CV A AC CI SvC2
A) 90/68 18 36/24 22 1.8 69
8) 90/46 3 22/8 6 4.7 70
C) 88/40 20 22/16 12 2.2 33
u) 84/60 3 18/6 3 1.8 62
L) 90/68 18 32/18 17 1.8 33
nemodynam|c auerns |n Shock:
..a s|mp||snc v|ew
Card|ac
Cutput
I||||ng
ressures
Vascu|ar
kes|stance
SvC2
Cardlogenlc
Pypovolemlc
ulsLrlbuuve n or n or n or
CbsLrucuve
Cxygen De||very DC2
Ma|nta|n 8 to keep anents A||ve
Ma|nta|n 8|ood I|ow to keep Crgans A||ve
Determ|nants
Cardlac CuLpuL
Cxygen ConLenL
Pgb
Pgb saLurauon
aC2
urlvlng pressure (8)
Intervennons
llulds (preload)
vasoacuve agenLs
1ransfuslons
SupplemenLal C2
CourLesy of !. Zlmmerman
I|u|d Adm|n|stranon
|n Shock
Opnons:
CrysLallold
Collold
8lood
6enero/ Princip/es:
CrysLallold and collold
are equlvalenL
CrysLallold bolus:
300-1000mL
Collold bolus:
230-300mL
8eassess and monlLor
physlologlc endpolnLs
Selecuve blood
producLs
Vasopressors
Drug A|pha 8eta 8 Lect
uopamlne ++ ln hlgh
doses
++ ln medlum
doses
lncrease
noreplnephrlne ++++ + lncrease
henylephrlne ++++ 0 lncrease
Lplnephrlne ++++ ++++ lncrease
uobuLamlne + +++ ?
vaspressln nA nA usually
ad[uncL
6. Wh|ch of the fo||ow|ng |s the best
|nd|cator of overa|| nssue oxygenanon
and perfus|on |n a panent w|th shock?
A) LacLaLe
8) urlne CuLpuL
C) Caplllary rell (hands)
u) 8lood ressure
L) ulse oxlmeLry
l) SvC2
Seps|s kesusc|tanon
lnluaLe when 8 ls low or LacLaLe > 4 mmol/L
Coals:
Cv 8-12 mmPg
Mean ArLerlal ressure > 63 mmPg
urlne CuLpuL > 0.3 mL/kg/hr
SvC2 > 70
Conslder uobuLamlne and 88C's when
approprlaLe
7. A panent w|th sepnc shock rece|ved 4L 0.9
sa||ne over 2 hours, annb|oncs adm|n|stered and now
|ntubated. 1here |s a|most no ur|ne output, 8 |s
80]44 mmng, and nk |s 124bpm. At th|s nme, wh|ch
of the fo||ow|ng vasoacnve med|canons |s most
appropr|ate?
A) vasopressln
8) lurosemlde
C) uopamlne
u) Lplnephrlne

Summary
AC use requlres a sLrong undersLandlng of:
Pemodynamlcs
Waveform lnLerpreLauon
1roubleshooung
Shock can come ln dlerenL forms
locus on cllnlcal endpolnLs of resusclLauon
Cllnlcal conLexL ls essenual