HEMODYNAMIC MONITORING

IN ICU
Dr Saibu George
Consultant –Critical Care.
NO CONFLICT OF INTEREST
 • Preload assessment and fluid
responsiveness
Learning Objectives
• Invasive Hemodynamic
• MICOM
• NICOM
• Pulse contour cardiac output
monitoring-Case Scenarios
 A Vascular tone
Status Assessment
1-Factors that directly
affect hemodynamic
monitoring are: B Cardiac contractility

C Venous return

D Cerebral perfusion pressure

 a-The ulnar artery is the dominant blood supply to the hand
Status Assessment
2. Arterial pressure b-Allen’s test should never be performed.
monitoring:

c-SBP measurement in the dorsalis pedis artery will be 10-20 mm

hg lower than in central circulation.

d-During spontaneous breathing of a normovolemic patient

,Intrathoracic pressure and lung volumes produce cyclical
variations in BP.

e-MAP[Mean arterial Pressure= {systolic BP- Diastolic BP} + 1/3

diastolic pressure.
Status Assessment
a-Start PLR from recumbent position to semi
3-Regarding Passive leg raising recumbent position.
test

b-Stroke volume variation >12% is consistent

with fluid responsiveness.

c-PLR with pulse pressure variation has more

sensitivity than PLR with PICCO monitoring

d-PLR is contraindicated in cardiac failure

patients
 a-Central Line is only needed.
b-Mean Transit Time {MTT} represents the time taken for all
4-In relation to PICCO the thermal tracer to pass thru the venous circulation, heart,
monitor, The following lungs to the arterial circulation.
are true c-Pulmonary thermal volume {PTV} can be calculated from
the downslope time {DST}.
d-EVLWI extra vascular lung water index is a poor marker for
mortality in ARDS

5-Electrical bioimpedance cardiac
output monitoring
• A. Performs well in critically ill patients
• B. Is invasive
• C. Measures variations in electrical
impedance caused by vascular blood
flow.
• D. Can estimate changes in cardiac
output with electrodes placed on thorax
SHOCK
Train of Shock
Hemodynamic
instability

Reduced organ perfusion

Altered tissue
microcirculation

Tissue hypoxia

Onset and maintenace of

MultiOrgan Dysfunction
Syndrome

Rivers E N Engl J Med 2001

INTRODUCTION

• HEMODYNAMIC MONITORING intermittent or continuous observation

of physiological parameters pertaining to the circulatory system with a
view to early detection of need for therapeutic interventions
 HEART RATE
AND
VENOUS CONTRACTILITY
RETURN
INTRAVASCULAR
VOLUME

VASCULAR
TONE
VASOACTIVITY
Circulatory Failure (Shock)
Pump Failure

Obstruction in the circuits

Volume Loss

Vasodilatory
Where are we now?
• The Move From Static to Dynamic Measurements.

• Transition to Minimally Invasive and Noninvasive-Hemodynamic Monitoring

techniques.

• Introduction of Artificial Intelligence to predict hemodynamic changes.

Initial steps

Clinical assessment

Basic monitoring and assessment of global perfusion

Preload monitoring and fluid responsiveness

Advanced monitoring measures

Cardiac output monitoring

Assessment of cardiac contractility

Assessment of tissue perfusion

Preload is the degree of
cardiac muscle tension at
the initiation of contraction
Fluid responsiveness is
the response to fluid
challenge by increase in
cardiac output or stroke
volume >10-15%
 Preload and fluid responsiveness

Frank – Starling Curve and Fluid Responsiveness

➢ The only reason to Fluid challenge → Increase stroke volume

➢ If no increase in stroke volume : Volume loading is of no benefit
and can even be harmful
Heart –Lung Interaction

Perel A, Pizov R, Cotev S Respiratory variations in the arterial pressure during mechanical ventilation reflect volume status and fluid responsiveness. Intensive Care Med 2014
ARTERIAL LINE –INVASIVE BP MONITORING
 • Arterial line
• Real time SBP, DBP, MAP
• Pulse pressure variation (PP)

• ΔPP (%) = 100 × (PPmax - PPmin)/([PPmax + PPmin]/2)

• >= 13% (in septic pts,) discriminate between fluid responder and non responder
(sensitivity 94%, specificity 96%)

Am J Respir Crit Care Med 2000, 162:134-138

 Pulse Pressure Variation

✓Prerequisites for the adequate use of PPV

1. Sinus rhythm
2. Absence of spontaneous ventilatory effort
(sedated)
3. Absence of right heart failure
4. Tidal volume ≥8 mL/kg.

Marik PE . Crit Care Med 2009

 Passive Leg Raise Test: 5 rules
5. Reassess CO in semi recumbent
3. Assess PLR Should return to baseline
affects with CO
2. Bed Adjustment (not with BP only)
Don’t touch patient

4. Use real time

measurement of CO
1. Check:
trunk at 45
degree
 • PLR-induced changes in CO very reliably predict the response of CO to volume expansion in
adults with acute circulatory failure.
• When PLR effects are assessed by changes in PP, the specificity of the PLR test remains
acceptable but its sensitivity is poor

• Passive leg raising predicts fluid responsiveness in the critically ill.Monnet X, Rienzo M, Osman D, Anguel N, Richard C, Pinsky MR, Teboul JL-Crit Care Med. 2006 May; 34(5):1402-7
• Bubenek-Turconi SI, Craciun M, Miclea I, Perel A. Noninvasive continuous cardiac output by the Nexfin before and after preload-modifying maneuvers: a comparison with intermittent
thermodilution cardiac output. Anesth Analg. 2013;117:366–372.
 Echocardiography

• Echocardiography can be a life-saving tool in critically

ill patients.

Diagnostic Tool Monitoring Tool

Hypotension
✓ Pericardial effusion ✓ Pre Load
✓ Severe LV dysfunction Assessment
✓ Acute RV dilatation ✓ Fluid
and Valvular pathologies Responsiveness
Basic Exam
ECHO:IVC Collapsibility
ADVANCED HEMODYNAMIC MONITORING
 Advanced Hemodynamic Monitoring
Cardiac Function Monitoring

• The three main reasons for monitoring cardiac function in shock are :
• Identifying the type of shock.
• Selecting the therapeutic intervention.
• Evaluating the patient’s response to therapy.
 Advanced Hemodynamic Monitoring

Cardiac Function Monitoring

• When?
✓Patient remains hypotensive despite adequate fluid
resuscitation
✓Ongoing evidence of global tissue hypo perfusion.

Vincent JL Clinical review: Update on hemodynamic monitoring- a consensus of Crit Care 2011
Indications for PAP monitoring

• Shock of all types

• Assessment of cardiovascular function and response to therapy
• Assessment of pulmonary status
• Assessment of fluid requirement
• Perioperative monitoring
 Clinical applications of PAC

PAC can generate large numbers of haemodynamic variables

• Central venous pressure (CVP)
• Pulmonary arterial occlusion pressure (PAOP)
• Cardiac output / cardiac index (CO / CI) =LAP = LVEDP
• Stroke volume (SV)  By thermodilution
• R ventricle ejection fraction/ end diatolic volume (RVEF / RVEDV)
• Systemic vascular resistance index (SVRI)
• Pulmonary vascular resistance index (PVRI)
• Oxygen delivery / uptake (DO2 / VO2)
 Clinical applications of PAC

• Advantages
• Provide lot of important haemodynamic parameters
• Sampling site for SvO2
• Disadvantages
• Costly
• Invasive
• Multiple complications (eg arrhythmia, catheter looping, balloon rupture, PA injury,
pulmonary infarction etc)
• Mortality not reduced and can be even higher

Crit Care Med 2003;31: 2734-2741

JAMA 1996;276 889-897
PICCO Monitoring
 Transpulmonary thermodilution: Volumetric parameters

After injection, the indicator passes the following intrathoracic

compartments:
ITTV
PTV
Thermodilution curve
CV Bolus Injection measured with arterial
catheter

RAEDV RVEDV Lungs LAEDV LVEDV

Right Heart Left

Heart
The intrathoracic compartments can be considered as a series of “mixing
chambers” for the distribution of the injected indicator (intrathoracic thermal
volume).
The largest mixing chamber in this series are the lungs, here the indicator (cold)
has its largest distribution volume (largest thermal volume).
 Transpulmonary
Transpulmonary thermodilution:
thermodilution: Volumetric
Volumetric parameters
parameters

All volumetric parameters are obtained by advanced analysis of the thermodilution curve:

For the calculations of volumes… Advanced Thermodilution Curve Analysis

Mtt: Mean Transit time Tb injection
time when half of the indicator has passed the point of recirculation
detection in the artery
ln Tb
e -1
DSt: Down Slope time t
exponential downslope time of the thermodilution MTt DSt
curve
Calculation of ITTV and PTV

By using the time parameters from the thermodilution curve

and the CO ITTV and PTV can be calculated

Tb
Injection
Recirculation

In Tb
e-1

MTt DSt t

Intrathoracic Thermal Volume Pulmonary Thermal Volume

ITTV = MTt x CO PTV = Dst x CO
 Transpulmonary thermodilution: Cardiac Output

Cardiac output is calculated by analysis of the thermodilution curve using a modified Stewart-Hamilton algorithm:

injection
CO Calculation:
➔ Area under the
Tb
Thermodilution Curve

Tb = Blood temperature
(Tb − Ti )  Vi  K Ti = Injectate temperature
CO TDa = Vi = Injectate volume
 Tb  dt ∫ ∆ Tb . dt = Area under the thermodilution curve
K = Correction constant, made up of specific weight and
specific heat of blood and injectate
 Pulse Contour Analysis - Principle

P [mm Hg]

t [s]

 P(t) dP
PCCO = cal • HR • ( + C(p) • ) dt
 SVR dt
Systole Shape of
Patient-specific calibration factor Heart Area under Aorticpressure curve
(determined by thermodilution) rate pressure curve compliance
 Parameters measured with the PiCCO-Technology

The PiCCO measures the following parameters:

Thermodilution Parameters
• Cardiac Output CO
• Global End-Diastolic Volume GEDV
• Intrathoracic Blood Volume ITBV
• Extravascular Lung Water EVLW*
• Pulmonary Vascular Permeability Index PVPI*
• Cardiac Function Index CFI
• Global Ejection Fraction GEF
Pulse Contour Parameters
• Pulse Contour Cardiac Output PCCO
• Arterial Blood Pressure AP
• Heart Rate HR
• Stroke Volume SV
• Stroke Volume Variation SVV
• Pulse Pressure Variation PPV
• Systemic Vascular Resistance SVR
• Index of Left Ventricular Contractility dPmx*
 Extravascular Lung Water, EVLW

Clear correlation to severity of ARDS, length of ventilation days, ICU-Stay and Mortality and is superior to
assessment of lung edema by chest x-ray and clearly indicates fluid overload

Mortality as function of ELWI* in 373 critically ill ICU patients Sakka et al , Chest 2002
 Clinical application

CO GEDV SVV SVR EVLW*

What is the current situation? Cardiac Output!

What is the preload? Global End-Diastolic Volume!
Will volume increase CO? Stroke Volume Variation!

Are the lungs still dry? Extravascular Lung Water!*

What is the afterload? Systemic Vascular Resistance
Picco Decision Tree
<3.0 >3.0
CFI (l/min/m2)

GEDI <700 >700 <700 >700

OR
ITBV <850 >850 <850 >850
(ml/m2)

EVLW
(ml/kg)
<10 >10 <10 >10 <10 >10 <10 >10

V+! Cat
Therapy V+ Cat V+ V+! V-
Cat V-

Target temporary temporary temporary temporary

GEDI >700 700

>700 700 >700 700 700
OR
ITBV >850 850
(ml/m2) >850 850 >850 850 850

Optimise to
<10 <10 <10 <10 <10 <10 <10 <10
SVV**

CFI >4.5 >5.5 >4.5 >5.5

OK!
Or
GEF >25 30 >25 >30
EVLW
(slowly <10 <10 <10 <10
responding)

V+ = Volume loading (!= cautiously); V- = Volume Contraction; Cat = Catecholamine /Cardiovascular agents
** SVV is only applicable in ventilated patients without cardiac arrhythmias.
PICCO CASE

• Blood flow High

• CI- 7.45 CFI-5.7 CPI-0.74 • Preload Low

• SVV-6 GEDI-532
• ELWI- 22 • Vascular resistance Low
• PVPI- 6.1
• SVRI- 856 dyn-sec/cm • Condition Distributive shock with ARDS
PICCO CASE

• CI- 1.9 CFI-4.3 CPI-0.64 • Blood flow Low

• SVV-24 GEDI-446
• ELWI- 6 • Preload Low

• PVPI- 2.1
• SVRI- 3407 dyn-sec/cm • Vascular resistance High

• Condition Hypovolemic shock

Noninvasive monitoring of CO
 )
Respiratory derived cardiac output monitoring system: partial CO2-rebreathing (NiCO®) (non-calibrated

• Using CO2instead of O2 as an indicator in the Fick principle

• NiCO® uses a partial rebreathing method to measure the CO.

• The system consists of a CO2 and airflow sensor combined with a pulse oximeter.
 Bioimpedance

• Amplitude of the voltage change across the thorax.

• Levels change as the left ventricular contracts and blood flows into the thoracic aorta.
 Bioreactance

Tracks the phase of the electrical currents traversing the chest.

Higher the cardiac stroke volume → more significant these phase shifts become.
Photoplethysmography

Near-infrared spectroscopy:
✓ Noninvasively illuminate the tissue below the skin
✓ Wavelengths of light scatter in the tissue and are absorbed differently, depending on the
amount of oxygen attached to Hb in the arterioles, venules, and capillaries
56 year old male – T2DM,HTN on Lisinopril, metformin admitted to A/E with

h/o productive cough, SOB and dizziness for 3 days .

HR-112

BP-90/48

SPo2-90%0N RA

Patient is awake but drowsy

Hemodynamic monitoring?
Lactate- 5

BP- 82/40

INTUBATED – Type 1respiratory failure

On VAC- rate-18,TV-450, PEEP-10, Fio2-80%

P/F RATIO < 200

PEEP OPTIMISATION AND RECURITEMENT DONE.

Hemodynamic Monitoring?
Now On VAC –rate 30,TV 350 ,PEEP- 12

MAP<65

LACTATE- 5.8

Hemodynamic Monitoring?
 Studies examining CO estimates by NICOM method show a
percentage error ranging from 24% to 58% (average 44%)
compared with TPTD.

In a recent meta-analysis, percentage errors for these CO

monitoring devices were 42% for bioimpedance and bioreactance,
40% for CO2-rebreathing, and 62% for pulse wave transit time.

Ameloot K, Palmers PJ, Malbrain ML. Curr Opin Crit Care 2015;21:232–9.
Joosten A. Br J Anaesth 2017;118:298–310.43
Fellahi JLJ Cardiothorac VascAnesth2014;28:755–60.44
Jaffe MB. J Clin Monit Comput 1999;15:387–401
T.W.L. Scheeren Journal of Cardiothoracic and Vascular Anesthesia 33 (2019) S67S72 S71
 • 1: No hemodynamic monitoring technique can
improve outcome by itself
In conclusion • 2: Monitoring requirements may vary over time
and can depend on local equipment availability
and training
• 3: There are no optimal hemodynamic values
that are applicable to all patients{Precision
Medicine}.
• 4: We need to combine and integrate variables
• 5: Cardiac output is estimated, not measured
• 6: Monitoring hemodynamic changes over short
periods of time is important
THANK YOU