Hemodynamic monitoring

All about the Swan

Indications for pulmonary artery catheterization in the ICU:

Establish diagnosis of shock and/or respiratory failure Guide therapy of shock and/or respiratory failure

By improving oxygen delivery

Oxygen delivery = CaO2 x CO

Cardiac output = HR x SV SV is determined by:
Preload (end-diastolic volume) Cardiac contractility Afterload

Information derived from PA catheter

Directly measured

Calculated

CVP PAOP Pulmonary artery pressure SvO2 Cardiac output

Systemic vascular resistance Pulmonary vascular resistance Stroke volume Oxygen delivery

Normal values
Directly measured CVP 2-4 mm Hg PA 25/10 PAOP 8-12 SvO2 60-75% Cardiac output 4-8 L/m Cardiac index 2.5-4.0 L/min/M2 Calculated SVR 900-1200 dynes sec/cm5 PVR 50-140 SV = 50-100mL SV index 25-45

Insertion of Swan Ganz

Ask why? Then immediately ask why not:

Coagulopathy Ventricular ectopy LBBB Pacemaker? Defibrillator? Large pulmonary embolism Severe pulmonary arterial hypertension

Swan complications

Associated with cordis placement Ventricular arrhythmias requiring treatment 1.3 1.5% Right bundle branch block ~0.5 -5% Pulmonary artery rupture ~0.06 to 0.2% Pulmonary artery pseudoaneurysm formation Pulmonary infarction ~ 1.4% Thromboembolic events ~1.6% Mural thrombi Sterile cardiac valve vegetation Endocarditis esp of the pulmonic valve

So much information, why dont we Swan more often?

1996 observational study

Swan within the first 24 hours of ICU admission associated with increased 30d hospital mortality (OR 1.24) Association with poor outcome highest in the least sick pts

Meta-analysis of RCTs: no benefit but no harm ESCAPE trial in patients with heart failure: no mortality benefit RCT of peri-operative use in high risk pts undergoing cardiac, vascular or orthopedic surgery: no benefit FACCT study of ARDS pts: no benefit of Swan v. CVP monitoring in managing vasoactive agents and fluid status

Nevertheless

PAC can be occasionally useful in the carefully selected patient

Insertion sites
Insertion site RA IJ 1520 1520 4045 RV 30 PA 40 PAOP 45-50
Easy to float especially from right. Carotid puncture/PTX Easy to float esp from left. Highest risk PTX Most difficult to float Highest risk of infection and DVT

Comments

SC Fem
Rule of 10s

30 5055

40

45-50

60- 65-70 65

Musts

Full barrier precautions for maximal sterile technique Flush and zero catheter prior to insertion at the phlebostatis axis Remember catheter sheath Once catheter tip is in the right atrium, always advance the catheter with the balloon inflated. Always watch the waveforms transduced from the distal end of the catheter while advancing Always withdraw catheter with the balloon deflated Advance the catheter quickly while in the right ventricle Advance slowly once the distal tip is in the pulmonary artery

Tip of the catheter should be no more than 3-5 center fro midline. Daily CXRs to monitor for catheter migration

Waveforms

X descent: fall n right atrial pressure following atrial contraction Y descent: call in right atrial pressure following opening of the tricuspid valve and passive ventricular filling

ECG correlation is mandatory for correct identification of the right atrial wave forms

Elevations in RAP

Hypervolemia Right ventricular infacrtion Impaired RV contraction Pulmonary hypertension Pulmonic stenosis Left to right shunts Tricuspid valve disease Cardiac tamponade

Overwedging

Abnormal waveforms

Seen with non compliant ventricle Mitral or tricuspid stenosis

Seen with tricuspid valve regurgitation Ventricular ischemia Ventricular failure Hypervolemia

Right ventricular pressure

Peak systolic pressure RV end-diastolic pressure

Early rapid filling (~60% of filling) Slow phase (25% filling) Atrial systolic phase

Left to right shunts

Arterial sampling from RA, RV, and PA Detection og an oxygen saturation stepup allows confirmation and determination of its location Definition of step-up = >10% rise in oxygen saturation

Equalization of pressures

RAP = RVed= PCWP

Cardiac tamponade Constrictive pericardial disease Restrictive cardiomyopathies

Cardiac output

Thermodilution

Saline injected through the proximal port Thermistor at the distal end of catheter measures the change in blood temperature over time

Area under the curve is inversely proportional to the rate of blood flow past the pulmonary artery This rate is equivalent to cardiac output

Should not differ by more than 10%

Factors that decrease accuracy of thermodilution cardiac output

Tricuspid regurgitation Septal defects Technical issues

Sensor malfunction Improper injectate

Continuous thermodilution cardiac output

10 cm thermal filament located 15-25 cm from the catheter tip. It generates low-energy head pulses transmitted to surrounding blood

Interpretation of the data

Cases

Case 1

20M presents post-MVA with abdominal pain. T 97 BP 70/55 HR 130 RR 24 Exam: Alert, pale, diaphoretic. Extremities cool and clammy with poor capillary refill. Abdomen is distended and tender.

MAP = 60 CVP = 2 PA = 15/3 PAOP = 4 CO = 3 SvO2 50%

SVR? SV?

What kind of shock?

Case 2

30F with flank pain, dysuria, fever to 104. T 104 BP 70/35 HR 140 Exam: Flushed, warm, bounding pulses

MAP 47 CVP 2 PA 20/5 PAOP 5 CO 7 SvO2 75%

SV ? SVR ?

What kind of shock?

Case 3

55M intermittent chest pains for last 24 hours presents with progressive shortness of breath and weakness T 96 BP 80/60 HR 120 RR 28 SpO2 88% Exam: Dyspneic, diaphoretic. Poor capillary refill. He has JVD, a gallop, soft murmur. Very little edema

MAP 67 CVP 10 PA 42/28 PAOP 29 CO 2.5 SvO2 55%

SV? SVR?

What kind of shock?

Case 4

60M feeling bad and losing weight last 8 months. Hasnt seen an MD in 30 years. Present with progressive weakness, shortness of breath, and edema. T 96 BP 75/60 HR 120 RR 24 SpO2 92% Exam: Cachectic. JVD. Distant heart sounds. Generalized edema. Thready pulses, poor capillary refill

MAP = 70 CVP 24 PA 40/24 PAOP 24 CO 2.4 SvO2 45%

SV? SVR?

Case 5

46 F presents with worsening shortness of breath and chest pains over a 5 days period. T 98 BP 78/62 HR 130 RR 28 pulse ox 84% Exam: Tachypneic, dyspneic. JVD. Lungs clear. Heart sounds tacycardic with RV heave, pronounced S2, II/VI systolic murmur at LLSB.

MAP = 67 CVP 14 PA 60/28 PAOP 6 CO 3.5 SvO2 48%

SVR? PVR? SV?

What is going on?

Case 6

36M admitted to the ICU with lobar pneumonia, septic shock. Given 8 Liters of normal saline over 3 hours, but remains in refractory shock, requiring initiation of norephinephrine. Develops progressive hypoxemia and intubated. Post intubation CXR demonstrates bilateral pulmonary infiltrates Exam T 103 BP 95/50 HR 120 RR 28 on vent SpO2 98% Intubated, sedation. Warm and flushed with brisk capillary refill and bounding pulses.

MAP 65 CVP 9 PA 35/18 PAOP 16 CO 9.0 SvO2 80%

SVR? SV?

Clinical scenario?