Hemodinamik Periop CB2013

8/13/2019 Hemodinamik Periop CB2013

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Perioperative Hemodynamic

Monitoring

Cindy E. BoomRS.Pusat Jantung dan Pembuluh DarahHarapan Kita Jakarta


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- Seorang pria 70 tahun, datang dengan keluhan

tidak bisa BAB, perut kembung, tidak dapatmakan sudah 3 hari

- Pola napas terengah-engah, gelisah

- Posisi setengah duduk

- Kulit pucat, akral dingin

- Nadi: 130 x/menit. TD : 90/35 mmHg

- Respirasi : 35 40 x/mnt

- Auskultasi : rales +, wheezing


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Instability Hemodynamic

A clinical state

Systemic blood pressure

Cardiac output

Organ function


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Low Cardiac Output Syndrome ( LCOS)MAP < 65mmHg

Oliguria (


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Adequate Oxygen Delivery?

ConsumptionDemand


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+ Adequate Balance of Tissue Oxygenation

Preload

AfterloadHeart RateContractility

Demand

O2ExtractionDiastolic Time

Diastolic PressureCoronary Artery

Flow

Supply

Myocardial Oxygen Balance


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Oxygen Delivery

Arterial

Blood

Gas

Hb

PaO2

Oxygen

Content

Oxygen

Delivery

Cardiac

Output

Oxygen

Content= X

Hemodynamic

Monitors


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Low Cardiac Output SyndromeLCOSFirst Step Clinical Evaluation


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LCOS

MAP < 65mmHg

Oliguria (


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+Resuscitation

Goal Oriented Hemodynamic Therapy

Volume Medikamentosa Mechanical

How?


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Hemodynamic Management of LCOS

Second Step : CVP / Scv O2Myocardial and/ or Vascular Dysfunction


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Insert

CVP/ScvO2

ScvO2 >70% SvO2


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CVP

MAP

ScvO2

CRYSTALLOID

VASOACTIVE

AGENT

PRBC to Hct 30 %

INOTROPE(S)

< 8 mmHg

8-12 mmHg

< 65 mmHg

> 90 mmHg

> 65 mmHg

< 90 mmHg

< 70%

< 70%

GOAL

> 70%

GDT


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F R

MAP

ScvO2

CRYSTALLOID

VASOACTIVE AGENT

PRBC to Hct 30 %

INOTROPE(S)

positive

negative

< 75 -85mmHg

> 75-85 mmHg

< 70%

< 70%

P(cv-a)CO2

> 70%

GDT


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Indices of Fluid

ResponsivenessCrystalloid

MAP

ScvO2

P(cv-a)CO2

Goals

achieced

Vasopressor

Weaning trial

Decrease O2Consumption

Vasoactive

agent(s)

Packed red blood

Cells to Hct > 30%

Inotrope(s)

positive

< 75-85 mmHg

> 75-85 mmHg

< 70%

< 70% > 70%> 70%

> 6

Yes

No

No

Refining the Toolsfor Early Goal-directed

Therapy


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Third Step: Echocardiography


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Echocardiography

Predominent left

ventricular failure

Echocardiographic guided

pericardiocentesisor surgical

intervention

Massive mitral

regurgitation ?

Pulmonaryhypertension?

Pulmonary

vasodilators

RV ischaemia?

Reduce RV afterload, avoid

excess volume, use

inotropes if CO low

Mebazaa et al. I ntensive Care Med, 2004;30:185-96

LV dysfunction

No

Any CO

Monitoring,

ideally non

invasive

Optimise LV pre- and afterload,

Inotropes if required

Predominent right

ventricular failure

TAMPONADE ?

Yes

Globalheart

failure

PA catheter

No


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Fourth Step: Pulmonary Artery Catheter


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LCOS

MAP < 65mmHg

Oliguria (


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O2uptake O2transport O2extraction O2utilisation

Optimize Oxygenation

-

Oxygen Delivery Oxygen Comsumption

ScvO2Cardiac Output Arterial Oxygen

Content

Stroke

VolumeHeart

RateOxgenation

SaO2

Hemoglobin

Hb

Preload After Load Contractiliy

Volume Vasopressors Inotropes Red Blood Cells+- +- + - +


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+Pemantauan Kardiovaskuler

CO (cardiac output) = SV (stroke volume) x HR (heart rate)

MAP (mean arterial pressure) = (Sistolik + 2x Diastolik)/ 3

Atau MAP= Diast+ (Sist-Diast)/3

Besar MAP orang dewasa normal : 60-70 mmHg.

PP ( pulse pressure) adalah selisih antara tekanan sistolik dan

diastolik.

PP = Sist- Diast, atau PP= 3x ( MAP-Diast)

Fungsi utama sistem Kardiovaskuler: menjamin kecukupan pasokan

dan kebutuhan sel-sel tubuh akan O2 dan membawa sisa metabolismeuntuk diekskresikan.


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+Saturasi Oksigen dan Oksigenasi

Jaringan ( SaO2dan DO

2)

Delivery Oxygen (DO2) adalah jumlah oksigen yang harus

tersedia bagi jaringan tubuh per menit.

DO2= CO x CaO2( oxygen content)

CaO2= (1,34 x Hb x SaO2) + (0,0031x PaO2)

DO2 = CO x (( 1,34 x Hb x SaO2) + ( 0,0031 x PaO2))

DO2 = delivery oxygen

CO = cardiac output

CaO2 = arterial oxygen content

PaO2 = tekanan parsial oksigen di dalam darah arteri


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FLUID RESUSCITATION AND

ORGAN PERFUSION

A. GENERAL

B. URINE PRODUCTION

C. ACID BASE BALANCE


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RESPONSE TO EARLY FLUID

RESUSCITATION

A. IMMEDIATE RESPONSE

B. TEMPORARY RESPONSE

C. MINIMALLY / NO RESPONSE


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RESPON TERHADAP TERAPI CAIRAN AWAL

Tanda Vital RESPON RESPON TANPACEPAT SEMENTARA RESPON

Dugaan Minimal Sedang, masih ada BeratKehilangan Darah (10 - 20%) (20 - 40 % ) ( > 40 % )

Kebutuhan Sedikit Banyak BanyakKristaloid

Kebutuhan Darah Sedikit Sedang - Banyak Segera

Persiapan Darah Type Specific dan Type Specific Emergency

CrossmatchOperasi Mungkin Sangat Mungkin Hampir Pasti

Kehadiran Dini Ahli Perlu Perlu PerluBedah


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Pulmonary edema

Myocardium edema

Mesenteric effects

Central nervous system effects

Fluid Resuscitation Complication


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CVP : 15 mmHg

Wedge pressure : 10 -12 mm Hg

Cardiac index : > 3 L/min/m2

Oxygen uptake (V02) : > 100 mL/min/m2

Blood lactate : 4 mmol/L

Base deficit :3 mmol/L

Urine : 0.5 1ml/kgbb/hr


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HEMODYNAMIC MONITORING DEVICES

ECG monitoring

Arterial Catheter

Pulmonary Arterial Catheter

Central Venous Catheter

Urinary Catheter

Thermodilution Continuous Cardiac Output

Transesophageal echocardiography (TEE)

Transthorasic echocardiography (TTE)


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Blood Pressure

Cardiac Output / CO Systemic VascularResistance / SVR

Stroke Volume / SV Heart Rate

Preload

Contractility Afterload

HYPOVOLEMI SHO K


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Blood

Pressure

Cardiac Output / CO SystemicVascular

Resistance / SVRStroke Volume / SV Heart Rate

Preload

Contractility

Afterload

CARDIOGENIC SHOCK


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Cardiac Output / CO

Systemic Vascular

Resistance / SVR

Stroke Volume / SV HeartRate

PreloadContractility

Afterload

CIRCULATORY SHOCK

Blood Pressure


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+ CO = HR x SV

Preload Contractility fterload

Vasoconstriction

Tissue Perfusion


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Hemodynamic profiles

of the shock states

Physiologicvariable

PreloadPump

functionAfterload

Tissueperfusion

Clinicalmeasurement

Pulmonarycapillarywedge

pressure

Cardiac outputSystemicvascular

resistance

Mixed venousoxygen

saturation

Hypovolemic Decreased Decreased Increased Decreased

Cardiogenic Increased Decreased Increased Decreased

Distributive Decreased Increased Decreased Increased


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+Hemodynamic Monitoring Parameters

1. Non Invasive Blood Pressure (BP)

Mean Arterial Pressure (MAP)

Heart Rate (HR)

Peripheral Oxygen Saturation (SpO2)

2. Invasive CVP (central venous pressure) PCWP (pulmonary catheter wedge pressure)

RVEDVI (right ventricle end diastolic volume index) LVSVI (left ventricle stroke volume index) LVP (left ventricle pressure) SvO2 (mixed vein oxygen saturation)


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Why SvO2?

22


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+Transport Oksigen


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+Transport Oksigen

venaarteri

CO CO tetap

Hb Hb tetap

SaO2 SvO2 berubah

Konsumsi O2 = CO x Hb x (SaO2 - SvO2) x 1.34

Konsu

msi

Teta

p


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Berapa harga normal SvO2?

Harga normal SvO2 adalah 68 - 77%

Nilai < 50% sudah mengkhawatirkan

Nilai


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+Oxygen Delivery Optimalisation


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Monitor

HemodinamikYang Mana ?


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+ASA Basic Intraoperative Monitoring

1. Standard I : Qualified anesthesia personel

2. Standard II:

Oxygenation : inspired gas, blood oxygenation, pulse

oxymetri

Ventilation : end-tidal CO2- capnograph, alarmdetecting disconnect from ventilator.

Circulation : ECG, every 5 min (arterial blood pressure,heart rate), pulse palpation, auscultatio of heart sound,intraarterial pressure

Body Temprature


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Arterial Line

+


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+ ARTERIAL LINE PURPOSESContinue BP monitoring

Early detected of HD

HD controlled

Blood Gas Analysis

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+Arterial Line Inserting Techniques

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Arterial Line Waveform


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CENTRAL VENOUS PRESSURE

Tekanan Vena Sentral

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entral Venous Pressure Monitoring

Better than Regular Manometer :

Continue monitoring of venous pressure.

Give us more reliable data of CVP

Pressure vs Volume


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Central Venous Pressure Waveform

3 positive waveforms : a, c dan v

2 negative waveforms : x, y


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CVP Inserting Technique

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+VCS/ VCI

A. Pulmonalis

Trikuspid

V. Pulmonalis

Mitral

Aorta

Atrium Kanan

Ventrikel Kanan

Paru-paru

Atrium Kiri

Ventrikel Kiri


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PAC PURPOSES

Pulmonary Arterial Pressure : S/ D/ M

Wedge Pressure (PCWP)

Cardiac Output / Cardiac Index (CO/CI)

Systemic Vascular Resistance (SVR/I)

and Pulmonary Vascular Resistance (PVR/I)

+


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PAC Waveform


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- Seorang pria 70 tahun, datang dengan keluhan tidak

bisa BAB, perut kembung, tidak dapat makan

sudah 3 hari.

- Pola napas terengah-engah, gelisah.

- Posisi setengah duduk

- Kulit pucat, dingin, akral dingin.

- Nadi: 130 x/menit. TD : 90/35 mmHg.

- Respirasi : 3540 x/mnt.

- Auskultasi : rales +, wheezing -.


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Titik Akhir Terapeutik

Capillary refill time < 2 detik

Ekstremitas hangat, kering dan kemerahan

Produksi urine > 1 ml/kg/jam

Status mental normal

Laktat menurun

Saturasi vena sentral > 70%


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Masalah-masalahdalam

pelaksanaan


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Saya tidak punyamonitoring ScvO2!

Gunakan pemeriksaan AGD serial

dari darah kateter vena sentral

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+Saya Tidak Punya Monitor

CVP/ Kateter TVS

Anda Sedang Berhadapan Dengan Masalah Serius

Segera rujuk ke rumah sakit terdekat

Lakukan

RESUSITASI CAIRAN SEMAKSIMAL MUNGKIN

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With an Excellent Teamwork WeDo Our Best to

Save the Patients Life

Terima Kasih

Hemodinamik Periop CB2013

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