224507278 Monitoring Hemodinamik

MONITORING HEMODINAMIK

Ezra Oktaliansyah

BAGIAN ANESTESIOLOGI & REANIMASI FAKULTAS

KEDOKTERAN UNPAD / RSHS

BANDUNG

Right

Atrium

Right

ventricle

Left

ventricle

Pulmonal

vein

Lung

Left

atrium

SVR =

organ

Systemic

Vascular

Resistance

WHY?

Untuk optimalisasi konsumsi oksigen & metabolisme

Dan ketersediaan energi

HOW?

Monitoring tekanan arterial A-line

Monitoring tekanan arteri pulmonalis PA catheter; “Swan Ganz”

Monitoring tekanan atrium kanan

RAP; CVP

Prinsip-prinsip

Tekanan = aliran x resistensi

> aliran = semakin tinggi tekanan

Semakin > resistensi = semakin

tinggi tekanan

FLOW =

PRESSURE

RESISTANCE

Normal

Vessel

FLOW

FLOW = PRESSURE

RESISTANCE

VASOCONSTRICTION:

Angiotensin II, ADH, Adrenaline,

NorEphinephrine, Metaraminol

OBSTRUCTION:

Trombus, sclerotic

FLOW

FLOW

VASODILATATION:

Nitroglyserine,

Nitroppruside,

milrinone, dobutamine

FLOW =

PRESSURE

RESISTANCE

Prisip-prinsip

Tekanan darah = aliran (cardiac output) x

resistensi (ukuran lumen)

Sistem sirkulasi adalah suatu sirkuit yg

kontinyu

Cairan mengalir dari daerah tekanan

tinggi ke tekanan rendah

Heart pressures

Pressures in Heart

Cardiac Output (curah jantung)

CO = HR X SV

SV = Preload, afterload, dan

contractility

Preload

Regangan serabut otot sebelum sistole (volume dalam ruang jantung pada ahir diastole)

Ditentukan oleh LVEDV/LVEDP

Hukum Starling’s Regangan ↑= volume ↑

(regangan berada dalam batas normal)

Preload/Afterload in Heart

Afterload

Tekanan atau tahanan yg harus dilawan

oleh ventrikel waktu ejection

Ditentukan oleh resistensi katup aorta, tek.

Arterial sistemik & viskositas

SVR & tek. Arterial → Left vent. afterload

PVR & tek. Arteri P → Right vent.

Afterload

Kontraktilitas

Kekuatan kontraksi ventrikel

Bagaimana jantung memompa dengan baik

No direct measure

Cardiac Output x SVR

Volume =

Blood

Hypovolemic

Shock

Cardiogenic

Shock Distributive

Shock

Inotropes Vasopressor

Fluids

Obstructive

Shock

Release

tamponade,etc Arterial pressure Pipe = Vascular

Ejection Fraction

Prosentase vol darah yg

diejeksikan saat sistole

Normal : 60% - 70%

Komponen Monitoring Hemodinamik

Transducer

• Merubah peristiwa2 fisiologis kedalam sinyal2 elektrik (e.g. tekanan, temperatur, cahaya)

Amplifier

• Menangkap sinyal elektrik dan mentransmisikan kelayar monitor

Components of Hemodynamic

Monitoring

Monitor Display

• Layar monitor (gambaran gelombang,

nilai pressure)

Catheter tubing / flush system

• Perawatan kateter

• Heparinized solution (protokol)

• Pressure bag

Reliable Measurements

Level = phlebostatic axis (4th intercostal

space, midaxillary line)

Balance = zero reference (negates

atmosphere pressure)

Calibration = numerical accuracy

How often to check?

Intraarterial Monitoring

Indikasi

Monitoring kontinyu tekanan darah

Blood sampling

p↑an tek. Intrakranial

Obat vasoaktive

Sites

Radial

Brachial

Femoral

Nursing interventions

Monitor waveform

Compare values with cuff

• A-line should be more accurate reading

Check connections in system

Check site and circulation to extremities

Set alarms

Complications

AIR Embolus: major complication

Hemorrhage: keep connections tight

Thrombosis

Right Atrial Pressure

RV preload/RVEDP

Right pressure changes usually occur

late

Catheters that Measure RAP

Pulmonary artery catheter (proximal port)

Central line (e.g. triple lumen catheter)

Peripherally inserted central catheter

(PICC) line

Measurement

Measured via pressure system

Normal value is 0 to 8 mm Hg

Recorded as MEAN value

Nursing implications

Zero/level/balance

• Positioning patient

• Respiratory cycle

Interpretation of Values

Low CVP

• Hypovolemia

• Vasodilation

High CVP

• Hypervolemia

• Vasoconstriction

• Right CHF

• Pulmonary

hypertension

Complications of Insertion

Pneumo/hemothorax

Heart perforation

Dysrhythmias

What assessments should be done during insertion and immediately after insertion?

What are important interventions to prevent complications?

Nursing Implications

Zero/balance

Waveform analysis

Respiratory variation

Monitor complications Infection

Correlate values obtained with nursing

assessment

Central Venous Pressure

TRIPPLE LUMEN CATHETER

18 Ga

16 Ga

18 Ga

INTERPRETATION

Pulmonary Artery Catheter

1970

Dr. Swan and Ganz (Swan-Ganz is a brand)

Reflects left heart pressures

Description

Balloon-tipped

Measures PA systolic, diastolic, mean, and wedge (PCWP; PAWP; PAOP)

Multi-lumen Proximal (RA)

Proximal injectate

Distal (PA)

Balloon

Insertion

Provide explanation and obtain

informed consent

Site: usually subclavian or internal

jugular

Incision: guide wire, introducer,

catheter, sheath

Flush lumens

Insertion

Inserted with balloon down, selected

inflation to get into PA

Waveform changes as catheter

progresses

Check for proper wedging

Secure and dress site

During insertion

Monitor pressures in each chamber

Record values

Assess for complications

• Dysrhythmias

• Pneumo/hemothorax

PA Values

Normal is 25 to 10 with mean is 15

Systolic 15 to 30 mm Hg

Diastolic 4 to 12 mm Hg

PCWP 6 to 12 mm Hg

Diastolic reflects PCWP unless pulmonary hypertension present (mitral valve open during end diastole; therefore, open circuit)

Interpretation

Increased PA pressures = volume

overload, CHF

Decreased PA pressures = volume

depletion

Complications

Infection

Dysrhythmias

Air embolus

Thromboembolism

PA rupture

Pulmonary infarction

Critical Thinking Challenge

What nursing interventions can assist in

preventing complications associated with

PA catheters?

Why is a chest x-ray done after the

insertion of a PA catheter?

What symptoms might indicate a

pulmonary infarction?

Cardiac Output vs. Index

Index is a better assessment; based on

body size

Uses body surface area

Calculated on the computer after entering

client’s height and weight

SvO2 monitoring

Measurement of oxygen saturation in PA

Fiberoptic technique

Reflects CO, SaO2, Hgb, and VO2

Reflects overall tissue oxygenation

Rate of greater than 60% is desirable

Can calculate oxygen delivery and consumption profiles

THANK YOU