Cardiovascular monitoring

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Dr Megha T
Assistant Professor
Department of Anaesthesiology
Invasive blood pressure (IBP)
• Intra-arterial blood pressure (IABP) measurement is often
considered to be the gold standard of blood pressure
measurement.

• It allows continuous beat-to-beat pressure measurement

• The waveforms produced may be analysed, allowing further

information about the patient’s cardiovascular status (pulse
contour analysis)
• It may also be useful where NIBP measurement is difficult e.g.
burns or obesity

• It reduces the risk of tissue injury and neuropraxias in patients

who will require prolonged blood pressure measurement

• It allows frequent arterial blood sampling

• It is more accurate than NIBP

BASIC PRINCIPLE
INDICATION:

• Current or anticipated hypotension or wide blood pressure

deviations

• Surgical procedures with anticipated blood loss or major fluid

shifts

• Patients with compromised cardiac condition

• Intentional pharmacological or mechanical cardiovascular

manipulation eg: CPB, vasoactive drugs
• End organ disease necessitating beat to beat blood pressure
regulation

• Failure of indirect BP measurement eg: obese, burns patient

• Need for multiple arterial blood gas measurements

CONTRAINDICATION

• Inadequate collateral blood flow

• Pre existing vascular insufficiency

• Local infection

• Coagulopathy
SELECTION OF ARTERY FOR CANNULATION

• Radial artery : Commonly cannulated

• Ulnar artery

• Brachial artery

• Femoral artery

• Dorsalis pedis and posterior tibial artery

• Axillary artery
MODIFIED ALLENS TEST
TECHNIQUE OF RADIAL ARTERY CANNULATION
COMPONENTS OF IBP MONITORING

• The measuring apparatus

• The transducer

• The monitor
THE MEASURING APPARATUS

• Arterial cannula- polyurethane or Teflon

• Tubing containing continuous column of saline

• Also connected to a flushing system. Plain or heparinized saline

at 1-3ml/hr through pressurized bag at 300mm of Hg.

THE TRANSDUCER

• Converts mechanical energy to electrical energy

• Flexible diaphragm

• Pressure applied to diaphragm >> stretches>> resistance

changes>> electrical output

• Zeroing and leveling of the transducer

ZEROING AND LEVELLING OF THE TRANSDUCER
THE MONITOR

• Amplify the input signal

• Filter the noise

• Display the arterial waveform

• Display digital values

• Alarms
• OSCILLATION: Tendency of the system to move either side
of set point

• DAMPING: How freely system oscillates following an input of

energy

“well damped”- donot oscillate freely

“poorly damped”- oscillated wildy

Damping coefficient (D) - optimal for IBP 0.6-0.7

Overdamped - slurred upstroke and loss of finer details
Underdamped- systolic pressure overshoot and additional artifacts
COMPLICATIONS

• Hematoma

• Bleeding (particularly with catheter tubing disconnections )

• Vasospasm

• Arterial thrombosis

• Embolization of air bubbles or thrombi

• Infection

• Pseudoaneurysm formation

• Nerve damage

• Necrosis of digits and unintentional drug injection

CLINICAL INTEPRETATION
• It represents ejection of blood from left ventricle to aorta

• Aortic valve opens blood is ejected and recorded as increase in

pressure

• Highest point is the systolic measurement

• Dicrotic notch represents aortic Valve closure and signifies start

of diastole

• Lowest point is the diastolic measurement

CENTRAL VENOUS PRESSURE
• The central venous pressure (CVP) measures the right atrial
pressure.

• It gives an estimate of the intravascular volume status and is an

interplay of the :

(1) circulating blood volume

(2) venous tone and

(3) right ventricular function.

INDICATION

• Major operative procedures involving large fluid shifts and / or blood loss
• Intravascular volume assessment when urine output is not reliable or
unavailable (e.g.: renal failure)

• Major trauma

• Surgical procedures with a high risk of air embolism, such as sitting

position craniotomies.

• Frequent venous blood sampling

• Venous access for vasoactive or irritating drugs

• Chronic drug administration

• Inadequate peripheral IV access

• Rapid infusion of IV fluids

• Special Uses:

• (i) insertion of PA catheters

• (ii) insertion of transvenous pacing wire

• (iii) haemodialysis/plasmapheresis
CONTRAINDICATION

• Absolute contraindication:

• i. SVC syndrome

• ii. Infection at the site of insertion

• Relative contraindication:

• i. Coagulopathies

• ii. Newly inserted pacemaker wires (4-6weeks)

• iii. Presence of carotid disease

• iv. Recent cannulation of the internal jugular vein

• v. Contra lateral diaphragmatic dysfunction

• vi. Thyromegaly or prior neck surgery

CENTRAL VENOUS CATHETER
CENTRAL VENOUS CATHETER
• Polyurethane

• Most commonly used 7 Fr , 20 cm triplelumen catheter with one port of 16

gauge and other two 18 gauge.

• Inserted using Seldinger technique

SITE

• Internal jugular vein ( IJV):

• Commonly used: (Right>>left)

• The reason for this popularity relates to its landmarks- it’s short, straight
(right IJV), valveless course to the superior vena cava (SVC) and right
atrium (RA) .

• Its position at the patient’s head, which provides easy access to

anesthetists in more intra operative settings.

• Further, the success rate is high.

• Other sites used:

• Subclavian vein

• Femoral vein

• Antecubital vein
CVP WAVEFORM
• The normal CVP waveform consists of three upwards
deflections (a, c, & v waves) and two downward defections (x
and y descents).

• These waves are produced as follows:

• 1. The ‘a’ wave is produced by right atrial contraction and

occurs just after the P wave on the ECG.

• 2. The ‘c’ wave occurs due to isovolumic ventricular

contraction forcing the tricuspid valve to bulge upward into the
right atrium. (RA)
• 3. The pressure within the RA then decreases as the tricuspid
valve is pulled away from the atrium during right ventricular
ejection, forming the ‘x’ descent.

• 4. The RA continues to fill during late ventricular systole,

forming the ‘v’ wave.
• 5. The ‘y’ descent occurs when the tricuspid valve opens and
blood from the RA empties rapidly into the RV during early
diastole.
• Normal CVP 5-10 cm of H2O in spontaneously breathing
patient.
• Increases by 3-5 cm of H2O during mechanical ventilation

• CVP increased in:

• Cardiac tamponade

• Forced exhalation

• Heart failure

• Hypervolemia
• Mechanical ventilation with PEEP

• Tension pneumothorax

• Pleural effusion

• Pulmonary hypertension

• Pulmonary embolism
• CVP decreased in:

• Shock

• Hypovolemia

• Deep inhalation
COMPLICATIONS

• Complications of central venous cannulation :

• i) Arterial puncture with hematoma

• ii) Arteriovenous fistula

• iii) Hemothorax

• iv) Chylothorax

• v) Pneumothorax
• vi) Nerve injury Brachial plexus Stellate ganglion (Horner’s
syndrome)

• vii) Air emboli

• viii) Catheter or wire shearing

• Complications of catheter presence :

• i) Thrombosis, thromboembolism

• ii) Infection, sepsis, endocarditis

• iii) Arrhythmias

• iv) Hydrothorax
THANK YOU