PhysiologicBasisforHemodynamicMonitoring.pptVIP

Physiologic Basis for Hemodynamic Monitoring 臺大醫院麻醉部 鄭雅蓉 Circulation to Perfusion Adequate Oxygen Delivery? Oxygen Delivery Oxygen Consumption Physiological Truth Physiological Truth There is no such thing as a “Normal Cardiac Output” Cardiac output is either Absolute values can only be used as minimal levels below which some tissue beds are probably under perfused History of Monitoring 1960s: golden age of vasopressors 1970s: golden age of inotropes 1980s: 1990s till now: Hemodynamic Monitoring Truth No monitoring device, no matter how simple or complex, invasive or non-invasive, inaccurate or precise will improve outcome Unless coupled to a treatment, which itself improves outcome Goals of Monitors To assure the adequacy of perfusion Early detection of inadequacy of perfusion To titrate therapy to specific hemodynamic end point To differentiate among various organ system dysfunctions Different Environments Demand Different Rules Emergency Department Trauma ICU Operation Room ICU RR Hemodynamic monitors (1) Traditional invasive monitors Arterial line CVP ScvO2 PA catheter, CCO, SvO2 Functional pressure variation Pulse pressure variation Stroke volume variation Hemodynamic monitors (2) Alternative to right-side heart catheterization PiCCO Echocardiography Transesophageal echocardiography (TEE) Esophageal doppler monitor Is Cardiac Output Adequate? Is Cardiac Output Adequate? Ventricular Function Left ventricular function Right ventricular function Depressed right ventricular function was further linked to more severely compromised left ventricular function. Respiration and RV function Spontaneous ventilation Mechanical positive pressure ventilation Use of Heart Lung Interactions to Diagnose Preload-Responsiveness ValSalva maneuver Ventilation-induced changes in: Right atrial pressure Systolic arterial pressure Arterial pulse pressure Inferior vena caval diameter Superior vena caval diameter Mechanical positive pressure ventilation Preload Preload Respon