Hemodynamics - Hemodynamic Assessment and Invasive...

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Hemodynamic Assessment and Invasive Monitoring Kevin M. Creamer M.D. Pediatric Critical Care Walter Reed AMC
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Overview Introduction Hemodynamic Determinants & Assessment Monitoring Considerations A Cautionary Tale Monitoring indications “Normal Values” Complications Hemodynamic scenarios
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Seven Alternatives to Evidence Based Medicine Eminence Based Medicine Vehemence Based Medicine Eloquence Based Medicine Providence Based Medicine Diffidence Based Medicine Nervousness Based Medicine Confidence Based Medicine
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Eminence Based Medicine Experience is worth any amount of evidence “making the same mistakes with increasing confidence over an impressive number of years” Fitzgerald, Br Med J, 1999
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Introduction Purpose of repeated hemodynamic assessment and continuous monitoring Gain an understanding of the patient’s physiologic status Make timely interventions Assess effectiveness of therapies Provide warning of hemodynamic changes that may be dangerous
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The heart is a lazy stupid organ, but it is strong like bull Its only algorithm: I must maintain CO!
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Hemodynamic Determinants Preload Afterload Contractility Heart Rate Rhythm
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Hemodynamic Determinants Ohm’s Law (V= I X R) BP = CO X SVR Important Physiologic principle manipulation of variables can alter hemodynamics Ex. BP can be normal in the face of low CO when….
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Hemodynamic Determinants Preload: volume indirectly generates a pressure based on compliance This is why normal CVP is not an absolute Afterload: any factor that resists ejection of blood from the heart Impedance, Inertia, Ejection pressure, Ventricular outflow tract obstruction, and wall stress SVR is a gross approximation of afterload
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DO 2 CaO 2 CO Sat % PaO 2 Hg HR SV Preload Contractility Afterload
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Starling’s Law Preload C a r d i c p e f o m n 1 2 3
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Hemodynamic Determinants CO = HR X SV Preload -Volume Afterload -Resistance to LV emptying Contractility -Squeeze Heart Rate - rate = SV Rhythm -Atrial kick 10% CO
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Hemodynamic Assessment
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Cardiac output I Pulse quality Central vs. Peripheral pulses Differential Temperatures Dipstick of SVR and indirectly CO Capillary refill time (CRT)
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Organ Perfusion CNS – Alert > Verbal > Pain > Unresponsive ? Renal - UOP only organ with easily measured output Foley catheter is a poor smart man’s PA catheter Acidosis? Cardiac output II
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Hemodynamic Assessment Stroke volume - pulse quality Preload - Liver size, CXR - heart size Relative liver size may be better than CVP for initial assessment of preload SVR - CRT, Pulse pressure, differential temperatures
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Inadequate Hemodynamics Common features Elevated HR - attempt to CO Elevated RR - beware Resp. alkalosis Decreased pulses - CO Depressed LOC - CO Acidosis - CO Falling UOP - CO
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Distinguishing Exam Scenario Signs WOB CRT Liver Skin Hypovolemic nl >2 nl Cool Cardiogenic +++ >2 +++ Cool Distributive +/++ +/- nl +/-
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This note was uploaded on 12/24/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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Hemodynamics - Hemodynamic Assessment and Invasive...

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