Seminar on hemodynamic monitoring

Presenter: Dr. Mulusew (IMR2)

Moderator: Dr. Wakjira (Consultant
Anesthesiologist & Critical care specialist)
Outline

 Introduction

 Non invasive monitoring

 Invasive monitoring

 Reference

09/22/2025 hemodynamic Monitoring 2

Objective

To understand the basic non invasive and invasive way of

monitoring patient in critical care medicine

To identify the indication ,contraindication and interpretation of

each monitoring technique

09/22/2025 hemodynamic Monitoring 3

 Introduction
• Critically ill patients require continuous assessment of
their CVS to diagnose and manage their complex medical
conditions achieved by hemodynamic monitoring.
• Provide quantitative information about vascular capacity,
blood volume, pump effectiveness and tissue perfusion by
using invasive and non invasive methods.

09/22/2025 hemodynamic Monitoring 4

 Purposes
• Early detection, identification and treatment of life
threating conditions
• Evaluate patient’s immediate response to treatment
• Evaluate the cardiovascular functions

09/22/2025 hemodynamic Monitoring 5

 Indications
• Any deficit or loss of cardiac function
• Shock
• Monitor and manage unstable patients
• Assess hemodynamic response to therapies
• Suspected anatomical lesions

09/22/2025 hemodynamic Monitoring 6

 Blood Pressure Monitoring

• BP is a fundamental cardiovascular vital sign

• Accomplished via either intermittent or continuous
and direct or indirect methods.

09/22/2025 hemodynamic Monitoring 7

Non invasive arterial Bp monitoring
 The peak pressure in systolic contraction
is the SBP
 The lowest pressure in diastolic
relaxation is the DBP
 PP =SBP-DBP.
 MAP=(SBP+2DBP)/3

09/22/2025 hemodynamic Monitoring 8

 Pluse pressure
 It is determined by mainly
 stroke volume output of the heart and the compliance
(total dispensability) of the arterial tree
 There is no widely accepted definition of "normal" pulse
pressure, however a reasonable definition for normal
pulse pressure 30-60 mmHg.

09/22/2025 hemodynamic Monitoring 9

 Wide pulse pressure cause:

09/22/2025 hemodynamic Monitoring 10

• BP should be recorded on bilateral extremities and a base line value taken in
both upper and lower extremities
• In severe peripheral vascular disease, there may be a significant difference in
the extremities.
• The higher value should be used in these patients.
• BP variation between rt and lt extrymities is < 10 mmhg under normal
condition
• popliteal systolic measurments are 10%- 20% higher than brachial
• Wrist BP measurment used in obese patients and in axilary LND,systolic BP
rises and diastolic record lowers

09/22/2025 hemodynamic Monitoring 11

 Patient position
 Supine values tend to be 2-3 mmhg higher systolic record and 2-3 mmhg
lower diastolic value than sitting measurements
 Orthostatic hypotension
• Assumption of upright position results in peripheral pooling of blood resulting
low BP
• This activates SNS and limits the decrement in systolic BP fall of 5-10 mmhg
 Patients with autonomic failure or volume depletion affected most by position
• Decrements in systolic BP >= 20mmg, diastolic >=10 mmhg
• These values were taken after 2-5 min quite standing from 5 minutes period
of supine rest

09/22/2025 hemodynamic Monitoring 12

 Noninvasive Arterial Blood Pressure
Monitoring
 Indications
 The use of any anesthetic is an indication for arterial blood pressure
measurement
 Contraindications
 vascular abnormalities (e.g., dialysis shunts)
 wound
 Amputation
 Paralysis
 IV lines
 recent axillary LN dissection.
 Burn
09/22/2025 hemodynamic Monitoring 13
Technique

A. Palpation
 Used to determine the systolic BP only
 Inflating pressure cuff till distal pulse dis appears and releasing slowly 2-3
mmhg per beat
 This method tends to underestimate systolic pressure
 Palpation does not provide a diastolic pressure or MAP.
 The equipment required is simple and inexpensive.

09/22/2025 hemodynamic Monitoring 14

B. Doppler Probe
 sensitive enough to be useful in obese
patients, pediatric patients, and
patients in shock
 Note that only systolic pressures can
be reliably determined with the
Doppler technique.
 This method is usually used to
estimate ABI

09/22/2025 hemodynamic Monitoring 15

 C. Automated Intermittent
 the most commonly used means of measuring blood pressure in the OR
 Small oscillations in pressure amplitude are measured in an air-filled cuff
 It slowly deflates from a pressure well in excess of that needed to collapse
the underlying artery.
 The point of maximal oscillation marks the mean arterial blood pressure
(MAP)
 systolic and diastolic calculated from the MAP
 systolic BP has the poorest agreement with invasive blood pressure values
when inappropriate cuff size is used

09/22/2025 hemodynamic Monitoring 16

• tend to underestimate MAP values during periods of hypertension
and
• overestimate during hypotension,
 the forearm may be a preferable site to upper arm in obese
patients,
• but such cuffs had overestimation of the systolic and
underestimation of the diastolic BP.

09/22/2025 hemodynamic Monitoring 17

 D. Manual Intermittent
• collapse an underlying artery, by inflating a pressure cuff .
• This causes a turbulent flow at level between diastolic and systolic pressure
• These sounds are termed as korotoff sounds
• Corresponding to systolic and diastolic pressure
• conditions that interfere with sound detection (e.g., severe edema, obesity, )
or
• blood flow (shock, intense vasoconstriction) will frustrate manual blood
pressure measurement

09/22/2025 hemodynamic Monitoring 18

 to get accurate result
• pressure cuff with a bladder that measures 40% of arm circumference,
• 80% of length of the upper arm, and centered over the artery is needed
• A cuff that is too large will often yield acceptable results
• but a small cuff will usually yield falsely high readings.
AHA Cuff size recommendation
Arm circ. Group cuff size
• 22- 26 small adult 12*22 cm
• 27-34 adult 16*30 cm
• 35-44 large adult 16*36 cm
• 45-52 adult high 16*42 cm

09/22/2025 hemodynamic Monitoring 19

 Complications of NIBP Measurement
• Pain
• Petechiae and ecchymoses
• Limb edema
• Venous stasis and thrombophlebitis
• Peripheral neuropathy
• Compartment syndrome

09/22/2025 hemodynamic Monitoring 20

Electrocardiography

 Is a fundamental part of cardiovascular assessment.

 It is an essential tool for investigating cardiac disorders.

 with the wide range of patterns seen in the ECG of normal subjects and an

understanding of the effects of non-cardiac disorders on the trace are

prerequisites to accurate interpretation.

09/22/2025 hemodynamic Monitoring 21

 ECG records electrical activity of the heart
 three primary reasons for ECG monitoring are
 continuous monitoring of HR
 identification of arrhythmias and
conduction abnormalities
 detection of myocardial ischemia.

09/22/2025 hemodynamic Monitoring 22

ECG leads

09/22/2025 hemodynamic Monitoring 23

09/22/2025 hemodynamic Monitoring 24
ECG analysis
1. Heart rate
2. Rhythm
3. Axis
4. P-wave: morphology, duration and amplitude
5. PR interval
6. QRS wave duration, voltage, morphology
7. ST segment morphology
8. T_ wave morphology
9. QT interval

09/22/2025 hemodynamic Monitoring 25

 INVESIVE HEMODYNAMIC
MONITORING

09/22/2025 hemodynamic Monitoring 26

 • Hemodynamic monitoring using invasive technique is the
mainstay of todays practice of critical care and allow
precise frequent determination of cardiorespiratory
variables.

09/22/2025 hemodynamic Monitoring 27

 There are different form of invasive monitoring

 Invasive Blood Pressure monitoring(Arterial line)

 CVP Monitoring(Central Venous Catheterization)

 Pulmonary Artery Catheterization

09/22/2025 hemodynamic Monitoring 28

 Invasive Blood Pressure monitoring(Arterial line)
 It is the standard for blood pressure monitoring despite its risk, cost, and need

for technical expertise for placement and management.

 Superior over noninvasive techniques for early detection of intraoperative

hypotension

09/22/2025 hemodynamic Monitoring 29

Indication

 Continuous monitoring of arterial BP

 Identification of abnormal arterial waveform patterns

 Frequent blood sampling – ABG-analysis

 Failure of indirect arterial blood pressure measurement

09/22/2025 hemodynamic Monitoring 30

Contraindication

 An abnormal modified Allen's test

 Local infection ,thrombus or distorted anatomy at the puncture site

 Severe peripheral vascular disease of the artery selected for sampling

 Active Raynaud syndrome (particularly at the radial site)

 Coagulopathy (plt < 30k)

09/22/2025 hemodynamic Monitoring 31

 Relative contraindication

Anticoagulation

Atherosclerosis

Inadequate collateral flow

Previous surgery in the area

09/22/2025 hemodynamic Monitoring 32

Site selection
 Common sites include
 Peripheral arteries -located more easily, and have a lower infection risk
 Radial [most common],
 Brachial
 Dorsalis pedis sites
 Central arteries
 Femoral [most common]
 Axillary sites

09/22/2025 hemodynamic Monitoring 33

Wave forms
1.Systolic upstroke
2. Systolic peak pressure
3. Systolic decline
4. Dichroitic notch
5. Diastolic runoff
6. End-diastolic pressure

09/22/2025 hemodynamic Monitoring 34

Complication

 Bleeding(particularly with catheter  Nerve damage,

tubing disconnections),  Infection,
 Vasospasm,  Necrosis of extremities or digits
 Arterial thrombosis,

 Embolization of air bubbles or

thrombi,
 Pseudoaneurysm formation
09/22/2025 hemodynamic Monitoring 35
CVP Monitoring

A central venous access device is defined as a catheter placed

into a thoracic central vein (eg, superior vena cava,
brachiocephalic vein, subclavian vein, internal jugular vein) or
the iliocaval venous system (eg, inferior vena cava, iliac vein,
common femoral vein).

09/22/2025 hemodynamic Monitoring 36

Indication

 For monitoring central venous pressure (CVP)

 Administration of fluid,drug and parenteral nutrition

 Aspiration of air emboli

 Insertion of transcutaneous pacing leads

 Gaining venous access in patients with poor peripheral veins

 For continuous monitoring of central venous oxygen saturation (scvo2)

09/22/2025 hemodynamic Monitoring 37

 Contraindication
 Coagulopathy and/or thrombocytopenia (relative)

 Anatomic distortion

 Indwelling intravascular hardware (pacemaker or hemodialysis catheter)

 Contaminated or potentially contaminated sites

 Vascular injury proximal to the insertion site

09/22/2025 hemodynamic Monitoring 38

 Site selection

 Deponds on

 Clinical setting skill and expertise

 Patient underlying medical condition
 Trauma patients(Hard neck collar) -----femoral or subclavian catheter
 Emergency volume resuscitation and long term IV therapy- subclavian vein

 Risks associated with placement (eg, coagulopathy, pulmonary disease

09/22/2025 hemodynamic Monitoring 39

 cont...

 The right internal jugular vein provides a combination of

accessibility and safety.

 Left-sided internal jugular vein catheterization has an

increased risk of pleural effusion and chylothorax.

09/22/2025 hemodynamic Monitoring 40

 placement of an internal jugular venous line
 Trendelenburg position to decrease the risk of air embolism
and to distend the vein
 Apply full aseptic technique
 The two heads of the sternocleidomastoid muscle and the
clavicle form the three sides of a triangleA 25-gauge needle is
used to infiltrate the apex of the triangle with local anesthetic.
 The internal jugular vein can be located using ultrasound,
 Aspiration of venous blood confirms the vein’s location.
09/22/2025 hemodynamic Monitoring 41
waves

09/22/2025 hemodynamic Monitoring 42

09/22/2025 hemodynamic Monitoring 43
complication
 infection
 air or thrombus embolism
 arrhythmias (indicating that the catheter tip is in the right atrium or ventricle)
 hematoma
 pneumothorax
 hemothorax
 hydrothorax
 chylothorax
 cardiac perforation
 cardiac tamponade
 trauma to nearby nerves and arteries
09/22/2025 hemodynamic Monitoring 44
pulmonary artery catheterization

 pulmonary artery (PA) catheter (or Swan-Ganz catheter) was introduced into routine
practice in operating rooms and in coronary and critical care units in the1970s.

09/22/2025 hemodynamic Monitoring 45

Indication
 Direct measurements obtained from PAC is;

 Central Venous Pressure(CVP)

 Right sided Intracardiac pressures(RA/V)

 Pulmonary artery pressure(Pap)

 Pulmonary capillary occlusion pressure (PCOP; PCWP)

 Cardiac Output(CO)

09/22/2025 hemodynamic Monitoring 46

 Indirect measurements that are possible:
 Systemic Vascular Resistance(SVR)

 Pulmonary Vascular Resistance(PVR)

 Cardiac Index(CI)

 Stroke volume index (SVI)

 Oxygen delivery(DO2)

 Rt ventricular stroke work index (RVSWI)

09/22/2025 hemodynamic Monitoring 47

contraindication

 Left bundle-branch block (because of the concern about complete heart block)
 Conditions associated with a greatly increased risk of arrhythmias
 Infection at insertion site
 Coagulopathy( INR<1.5) Thrombocytopenia(<50,000)
 Electrolyte disturbances and acid base disturbance

09/22/2025 hemodynamic Monitoring 48

Insertion
 Patient positioning in trendelenburg or supine

 Aseptic precautions undertaken and then Local infiltration or sedation done

 Insert the introducer with modified seldinger techniques and suture

 The balloon is then inflated with air (usually 1.5 mL)at SVC or RA soasto
 To protect the endocardium from the catheter tip and

 To allow flow through the right ventricle to direct the catheter forward

09/22/2025 hemodynamic Monitoring 49

 Advance the catheter either using pressure waveform or fluoroscopic guidance

 To know the location of the catheter we use

 Rule of 10 “ anatomic and hemodynamic changes occur at approximately 10 cm

interval”Int jugular or Subclavian vein RA entered after inserting 20cm, RV after 30cm,
PA after 40cm and PCWP after 50cm

 A sudden ↑ the systolic pressure on the distal tracing →right ventricular location

 Sudden ↑in diastolic pressure→entry into the pulmonary artery

09/22/2025 hemodynamic Monitoring 50

Complications

 Thrombogenesis,
 Pulmonary infarction
 PA rupture
 Hemorrhage (in patients taking anticoagulants, elderly or female)
 Catheter knotting
 Arrhythmias
 Conduction abnormalities
 Pulmonary valvular damage

09/22/2025 hemodynamic Monitoring 51

Reference

 Miller's Anesthesia 9th edition

 Morgan and Mikhail's Clinical Anesthesiology 7th Edition

 Up-to-date 2025

09/22/2025 hemodynamic Monitoring 52