PAC and Hemodynamic Monitoring 2-4-08

8/6/2019 PAC and Hemodynamic Monitoring 2-4-08

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Pulmonary Artery CathetersPulmonary Artery Catheters

and Hemodynamic Monitoringand Hemodynamic Monitoring

byby

Joseph Esherick, M.D., FAAFPJoseph Esherick, M.D., FAAFP


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JAMA. 2005; 294: 1664JAMA. 2005; 294: 1664--70.70.

13 RCTs13 RCTs

5051 patients analyzed5051 patients analyzed

Surgical patients, ARDS, Sepsis and advanced CHFSurgical patients, ARDS, Sepsis and advanced CHF


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Shock EquationsShock Equations

Definition of shockDefinition of shock

A medical condition in which tissue perfusion andA medical condition in which tissue perfusion andoxygen delivery is insufficient for the metabolic demandsoxygen delivery is insufficient for the metabolic demandsof the body.of the body.

In shock, there is an imbalance between oxygenIn shock, there is an imbalance between oxygendelivery to tissues and oxygen consumption by tissuesdelivery to tissues and oxygen consumption by tissues

Oxygen delivery (DOOxygen delivery (DO22))

DODO22== cc (Hgb)(CO)(SaO(Hgb)(CO)(SaO22)) Oxygen consumption (VOOxygen consumption (VO22))

VO2= c (Hgb)(CO)(SaO2-SvO2)


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Hemodynamic PrinciplesHemodynamic Principles

CO is theholy grail ofhemodynamics


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Basic HemodynamicsBasic Hemodynamics

CO = HR XSV

RAP

Volume

CVP RVEDP

PAPPCWPPVP

LAP

LVEDP

LVEDV

RVEDVI


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Indications for PulmonaryIndications for Pulmonary

Artery Catheters (PACs)Artery Catheters (PACs) Assessment of shock statesAssessment of shock states

Assessment of pulmonary edema (cardiogenic vs ARDS)Assessment of pulmonary edema (cardiogenic vs ARDS)

Guidance of therapy with combined oliguria or hypotensionGuidance of therapy with combined oliguria or hypotensionand pulmonary edemaand pulmonary edema

Optimization of cardiac index in cardiogenic shockOptimization of cardiac index in cardiogenic shock

Evaluation and drug titration for severe pulmonaryEvaluation and drug titration for severe pulmonaryhypertensionhypertension

Diagnostic evaluation of leftDiagnostic evaluation of left--toto--right cardiac shuntsright cardiac shunts


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Relative ContraindicationsRelative Contraindications

of PACsof PACs

Severe coagulopathy or thrombocytenia (PLT < 50K)Severe coagulopathy or thrombocytenia (PLT < 50K)

Prosthetic right heart valveProsthetic right heart valve

Endocardial pacemaker/ defibrillatorEndocardial pacemaker/ defibrillator

Caution with LBBB (5% risk of complete heart block)Caution with LBBB (5% risk of complete heart block)

RightRight--sided Endocarditissided Endocarditis

Uncontrolled ventricular or atrial dysrhythmiasUncontrolled ventricular or atrial dysrhythmias

Right ventricular mural thrombusRight ventricular mural thrombus


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Complications of PACsComplications of PACs

Complications from cordis catheter placementComplications from cordis catheter placement PneumothoraxPneumothorax

Arterial punctureArterial puncture

Air embolusAir embolus

Atrial or ventricular dysrhythmiasAtrial or ventricular dysrhythmias RBBB (0.1RBBB (0.1-- 5% of insertions)5% of insertions)

Pulmonary infarctionPulmonary infarction

Pulmonary artery rupture (0.2% incidence, leave balloon inflated)Pulmonary artery rupture (0.2% incidence, leave balloon inflated)

CatheterCatheter--related blood stream infectionrelated blood stream infection Marantic or infectious endocarditisMarantic or infectious endocarditis

Mural thrombusMural thrombus

Knotting of catheterKnotting of catheter


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Normal Hemodynamic ValuesNormal Hemodynamic Values

CategoryCategory Normal rangeNormal range InterpretationInterpretation

Cardiac output (CO)Cardiac output (CO) 44--8L/min.8L/min. CI is more acc urateCI is more accurate

Cardiac index (CI)Cardiac index (CI) 2.52.5--4.0L/min.4.0L/min. C O adjusted for body surface areaCO adjusted for body surface area

Systemic vascularSystemic vascular

resistance (SVR)resistance (SVR)

900900--13001300

dynes/cmdynes/cm22Calculated value systemicSBP and COCalculated value systemicSBP and CO

SVRISVRI 19701970--23902390

dynes/cmdynes/cm22SVR adjusted for body surface areaSVR adjusted for body surface area

Pulmonary vascularPulmonary vascular

resistance (PVR)resistance (PVR)

100100--250250

dynes/cmdynes/cm22Elevated in pulmonary hypertension, acute PE,Elevated in pulmonary hypertension, acute PE,

hypercapnia and hypoxemiahypercapnia and hypoxemia


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Cardiac Index

(Thermodilution Technique)

Conditions causing a high Cardiac IndexConditions causing a high Cardiac Index

Cirrhosis, Thyrotoxicosis, AV fistula, Beriberi, PregnancyCirrhosis, Thyrotoxicosis, AV fistula, Beriberi, Pregnancy

Fever, activity and delirium tremensFever, activity and delirium tremens

Distributive shockDistributive shock

Conditions causing a low Cardiac IndexConditions causing a low Cardiac Index

Cardiogenic shock, tension pneumothorax, cardiac tamponade, andCardiogenic shock, tension pneumothorax, cardiac tamponade, and

massive PEmassive PE

High PEEPHigh PEEP

HypovolemiaHypovolemia

Falsely low: Severe TR/PI or VSDFalsely low: Severe TR/PI or VSD


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1111

Hemodynamic PrinciplesHemodynamic Principles

CVP = RAP = RV preloadCVP = RAP = RV preload

PCWP = pulmonary venous pressure = left atrial pressurePCWP = pulmonary venous pressure = left atrial pressureapproximatingapproximating LVEDP = LV preloadLVEDP = LV preload

Read the PCWP at the Z point at endRead the PCWP at the Z point at end--expirationexpiration Z point is 0.08seconds after the QRScomplexZ point is 0.08seconds after the QRScomplex

Cardiogenic pulmonary edema excluded if PCWP 18mmHgCardiogenic pulmonary edema excluded if PCWP 18mmHg

PAD = PCWP (in most circumstances)PAD = PCWP (in most circumstances)

PAD > PCWPPAD > PCWP with pulmonary hypertension, cor pulmonale, acutewith pulmonary hypertension, cor pulmonale, acutepulmonary embolus, pulmonary venoocclusive disease andpulmonary embolus, pulmonary venoocclusive disease andEisenmengers syndromeEisenmengers syndrome


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Systemic Vascular ResistanceSystemic Vascular Resistance

Conditions associated with high SVRIConditions associated with high SVRI

Cardiogenic shockCardiogenic shock


Obstructive shockObstructive shock

Conditions associated with a lowSVRIConditions associated with a lowSVRI

Distributive shockDistributive shock

CirrhosisCirrhosis

PregnancyPregnancy

ThyrotoxicosisThyrotoxicosis


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CVP and PCWPCVP and PCWP

Conditions that Increase CVPConditions that Increase CVP

RV infarctRV infarct

Severe tricuspid valve diseaseSevere tricuspid valve disease

Cardiac tamponadeCardiac tamponade Left/Right heart failureLeft/Right heart failure

PEEP > 10mmHgPEEP > 10mmHg

Pulmonary embolusPulmonary embolus

Conditions that Increase PCWPConditions that Increase PCWP

ARDSARDS

COPDCOPD

Pulmonary embolusPulmonary embolus PEEP > 10mmHgPEEP > 10mmHg

Mitral valve diseaseMitral valve disease

Aortic valve diseaseAortic valve disease

Diastolic dysfunctionDiastolic dysfunction

Tension pneumothoraxTension pneumothorax Vasopressor therapyVasopressor therapy

Severe abdominal distensionSevere abdominal distension

RV infarct with fluid overloadRV infarct with fluid overload


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PAC waveformsPAC waveforms


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PCWP WaveformPCWP Waveform


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PCWP MeasurementPCWP Measurement


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Placement of PulmonaryPlacement of Pulmonary

Artery CatheterArtery CatheterInsertion siteInsertion site RA distance (cm)RA distance (cm) RV distance (cm)RV distance (cm) PA distance (cm)PA distance (cm)

Right IJRight IJ 1515 25 25 40 40

Left IJLeft IJ 2020 30 30 45 45

RightSCVRightSCV 1010--1515 20 20--2525 35 35--4040

LeftSCVLeftSCV 1515 25 25 40 40

FemoralFemoral 4545--5050 55 55--6060 7070--7575

Direct catheter medially from Right IJ and LeftSCV locationsDirect catheter medially from Right IJ and LeftSCV locations

Direct catheter inferiorly from RightSCV location (may need to rotate catheter counterDirect catheter inferiorly from RightSCV location (may need to rotate catheter counter--clockwise once RV is reached)clockwise once RV is reached)

Direct catheter posteriorly from femoral vein locations and rotate catheter counterDirect catheter posteriorly from femoral vein locations and rotate catheter counter--

clockwise once RV is reachedclockwise once RV is reached


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West Zones of the LungWest Zones of the Lung


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PAC VideoPAC Video


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2020

Normal Hemodynamic ValuesNormal Hemodynamic Values

LocationLocation NormalNormal

(mmHg)(mmHg)

Conditions increasingConditions increasing ConditionsConditions

decreasingdecreasing

RARA 22--66 Pulmonary edema, Any valvular disease, cardiacPulmonary edema, Any valvular disease, cardiacischemia, pulmonary HTN, ARDS, sepsis, RVischemia, pulmonary HTN, ARDS, sepsis, RV

infarct, cardiac tamponade, restrictiveinfarct, cardiac tamponade, restrictive

cardiomyopathy (CMP), PEEP>10cardiomyopathy (CMP), PEEP>10


RVRV 1515--25/25/33--77

Everything that increases RAP (exceptEverything that increases RAP (excepttamponade) and ASD and VSDtamponade) and ASD and VSD Hypovolemia, TSHypovolemia, TSand tamponadeand tamponade

PAPA 2020--30/30/

55--1515

PE, COPD, ARDS, sepsis, pulmonary HTN,PE, COPD, ARDS, sepsis, pulmonary HTN,

restrictive CMP, ASD, VSD, pulmonary edema,restrictive CMP, ASD, VSD, pulmonary edema,

MV/AV disease, diastolic dysfunction, cardiacMV/AV disease, diastolic dysfunction, cardiac

tamponade, HR > 125tamponade, HR > 125

Hypovolemia, TSHypovolemia, TS

and PSand PS

PCWPPCWP 88--1212 ARDS, sepsis, pulmonary HTN, COPD, PE,ARDS, sepsis, pulmonary HTN, COPD, PE,restrictive CMP, cardiac ischemia, volumerestrictive CMP, cardiac ischemia, volume

overload, MV/AV disease, diastolic dysfunction,overload, MV/AV disease, diastolic dysfunction,

cardiac tamponade, HR > 125, PEEP> 10, Westcardiac tamponade, HR > 125, PEEP> 10, West

Zone I/II placementZone I/II placement

Hypovolemia, AI,Hypovolemia, AI,

PI andPI and

pneumonectomypneumonectomy


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Overwedged PACOverwedged PAC

Cant inflate the full balloon without resistanceCant inflate the full balloon without resistance

Rising PCWP baseline when balloon is inflatedRising PCWP baseline when balloon is inflated

Wedged waveform seen with the balloon downWedged waveform seen with the balloon down


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Evaluation of Shock StatesEvaluation of Shock StatesShock typeShock type PCWP PCWP Cardiac index Cardiac index

(CI)(CI)

Systemic vascularSystemic vascular

resistance index (SVRI)resistance index (SVRI)

CardiogenicCardiogenic

(CI < 2.0L/min.)(CI < 2.0L/min.) HypovolemicHypovolemic DistributiveDistributive (sepsis,(sepsis,

acute pancreatitis,acute pancreatitis,

anaphylactic oranaphylactic or

neurogenic)neurogenic)

NormalNormal

Elevated (unlessElevated (unless

SIRSSIRS--relatedrelated

myocardialmyocardial

dysfxn)dysfxn)

ObstructiveObstructive (tension(tension

PTX, massive PEPTX, massive PEoror

tamponade*tamponade* (tamponade)(tamponade)NL/NL/ (PE)(PE)

**-- tamponade will show equalization of RA, RV and PAD pressurestamponade will show equalization of RA, RV and PAD pressures

-- Massive PE associated with elevated PA, RA and CVP pressures, PAD>PCWP, profoundMassive PE associated with elevated PA, RA and CVP pressures, PAD>PCWP, profound

hypoxemia and right heart strain on EKGhypoxemia and right heart strain on EKG


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KumarA et al. Crit Care Med. 2004; 32: 691KumarA et al. Crit Care Med. 2004; 32: 691--9.9. 2323

Optimizing PreloadOptimizing Preload

Determine the optimal PCWP by calculating CI atDetermine the optimal PCWP by calculating CI atdifferent PCWPdifferent PCWP

Calculate the patients FrankCalculate the patients Frank--Starling CurveStarling Curve

Neither the initial CVP nor the initial PCWP valueNeither the initial CVP nor the initial PCWP valueaccurately predicts the CI response to fluidsaccurately predicts the CI response to fluids

Clues to hypovolemiaClues to hypovolemia

Drop in CVP when patient takes a spontaneous breathDrop in CVP when patient takes a spontaneous breath

Marked change in SaOMarked change in SaO22waveform during respirationwaveform during respiration

Fall in SBP during inspiration with positive pressureFall in SBP during inspiration with positive pressureventilationventilation


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Mixed Venous Oxygen SaturationMixed Venous Oxygen Saturation

SvOSvO22 is the oxygen saturation returning to the right heartis the oxygen saturation returning to the right heart

Determinants ofSvODeterminants ofSvO22 Oxygen deliveryOxygen delivery

Oxygen extractionOxygen extraction

High values indicate (70%):High values indicate (70%):

Adequate tissue perfusionAdequate tissue perfusion

Poor tissue extraction of oxygenPoor tissue extraction of oxygen

Desired values in shockDesired values in shock

SvOSvO2270%70%


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N Engl J Med. 2001; 345: 1368N Engl J Med. 2001; 345: 1368--7777 2525

EarlyEarly--Goal Directed TherapyGoal Directed Therapy

in Septic Shockin Septic Shock

Assure SaOAssure SaO22 92% or PaO26092% or PaO260

Crystalloiduntil CVP8Crystalloiduntil CVP8--12mmHg or PCWP1212mmHg or PCWP12--15mmHg15mmHg

If MAP


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Management of Shock StatesManagement of Shock States


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Crit Care Med. 2001; 29: 1081Crit Care Med. 2001; 29: 1081 2727

Right Ventricular EndRight Ventricular End--

Diastolic Volume IndexDiastolic Volume Index

Right ventricular endRight ventricular end--diastolic volume index (RVEDVI)diastolic volume index (RVEDVI)

Volumetric measurementVolumetric measurement

Calculated from SVICalculated from SVI

More reliable than CVP or PCWP as a predictor ofMore reliable than CVP or PCWP as a predictor ofpreload status in shock and response to fluidspreload status in shock and response to fluids

Linear improvement of CI when RVEDVILinear improvement of CI when RVEDVI 70to 10070to 100--140140

Unreliable with severe TRUnreliable with severe TR


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VasopressorsVasopressors

Pure Alpha P ure BetaBeta actionAlpha = Beta

High dose Dopamine Low dose


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MedicationMedication ReceptorsReceptors Inotropy Inotropy Chronotropy Chronotropy DoseDose

DopamineDopamine

Dopamine rr.Dopamine rr.

= =

> >

Vasodilation effectVasodilation effect

Yes YesYes Yes

Vasoconstriction effectVasoconstriction effect

5mcg/kg/min 5mcg/kg/min

55--10mcg/kg/min10mcg/kg/min

> 10mcg/kg/min> 10mcg/kg/min

DobutamineDobutamine 11 and and 22>> YesYes YesYes 2.52.5-- 20mcg/kg/min20mcg/kg/minNorepinephrineNorepinephrine

(Levophed)(Levophed) > > YesYes + / + /--

0.030.03 1.51.5

mcg/kg/min.mcg/kg/min.

VasopressinVasopressin

(adjunct)(adjunct)

V1 / V2V1 / V2

receptorsreceptors

VasoconstrictionVasoconstriction

Augments catecholaminesAugments catecholamines0.010.01-- 0.04units/min0.04units/min

PhenylephrinePhenylephrine(Neosynephrine)(Neosynephrine) VasoconstrictionVasoconstriction 0.50.5-- 8mcg/kg/min.8mcg/kg/min.

IsoproterenolIsoproterenol P ure agonistPure agonistYesYes YesYes

22--10mcg/min10mcg/minMild vasodilationMild vasodilation

InotropesInotropes


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Misc. Information for PACMisc. Information for PAC

WWW.PACEP.ORGWWW.PACEP.ORG

CodingCoding

9350393503 Insertion and placement of flowInsertion and placement of flow--directeddirected

catheter for monitoring purposescatheter for monitoring purposes


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PAC and Hemodynamic Monitoring 2-4-08

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