MONITORING HEMODINAMIKMONITORING HEMODINAMIK

Ezra Oktaliansyah

BAGIAN ANESTESIOLOGI & REANIMASI FAKULTAS KEDOKTERAN UNPAD / RSHS

BANDUNG

Pendahuluan

Hemodinamik

Panduan Resusitasi

Memahami penyakit, Menentukan & Memantau Terapi

VARIABEL HEMODINAMIK

SIRKULASI

PULMONER

SISTEMIK

TAHANAN

POMPA

TEKANAN

KELUAR

MAP/ MPAP

KEDALAM

PAOP/ CVP

PULMONER/ PVRI

SISTEMIK/ SVRI

Right Atrium

Right ventricle

Pu

lmo

nal

art

ery

Left ventricle

Pulmonal vein

Lung

Left atrium

SVR =

Aorta

organ

Systemic Vascular Resistance

Komponen Hemodinamik

Blood Pressure (BP)/TD Central Venous Pressure (CVP) Right and Left Heart Pressures

WHY?WHY?

Untuk optimalisasi konsumsi oksigen & metabolisme Dan ketersediaan energi

HOW?HOW? Monitoring tekanan arterialMonitoring tekanan arterial

A-lineA-line Monitoring tekanan arteri pulmonalis Monitoring tekanan arteri pulmonalis

PA catheter; “Swan Ganz”PA catheter; “Swan Ganz” Monitoring tekanan atrium kananMonitoring tekanan atrium kanan

RAP; CVPRAP; CVP

KRITERIA HEMODINAMIK YG MEMERLUKAN MONITORING KETAT

MAP < 65 or > 120 mmHgCI < 2L/min/m2

PAWP > 15 or < 5 mmHg

Prinsip-prinsipPrinsip-prinsip

Tekanan = aliran Tekanan = aliran xx resistensi resistensi > aliran = semakin tinggi tekanan> aliran = semakin tinggi tekanan Semakin > resistensi = semakin tinggi Semakin > resistensi = semakin tinggi

tekanantekanan

Prisip-prinsipPrisip-prinsip

Tekanan darah = Tekanan darah = aliran aliran (cardiac output) (cardiac output) xx resistensiresistensi (ukuran lumen) (ukuran lumen)

Sistem sirkulasi adalah suatu sirkuit yg Sistem sirkulasi adalah suatu sirkuit yg kontinyukontinyu

Cairan mengalir dari daerah tekanan Cairan mengalir dari daerah tekanan tinggi ke tekanan rendahtinggi ke tekanan rendah Heart pressuresHeart pressures

Pressures in Heart

ALIRAN = TEKANAN

TAHANAN

Normal Vessel

ALIRAN

ALIRAN = TEKANAN

TAHANAN

VASOCONSTRICTION: Angiotensin II, ADH, Adrenaline,

NorEphinephrine, Metaraminol

OBSTRUCTION: Trombus, sclerotic

ALIRAN

ALIRAN

VASODILATATION: Nitroglyserine,

Nitroppruside, milrinone, dobutamine

ALIRAN = TEKANAN

TAHANAN

Cardiac Output (curah jantung)Cardiac Output (curah jantung)

CO = HR X SVCO = HR X SV SV = Preload, afterloadSV = Preload, afterload, dan , dan

contractilitycontractility

PreloadPreload

Regangan serabut otot sebelum sistole Regangan serabut otot sebelum sistole (volume dalam ruang jantung pada ahir (volume dalam ruang jantung pada ahir diastole)diastole)

Ditentukan oleh LVEDV/LVEDPDitentukan oleh LVEDV/LVEDP Hukum Starling’sHukum Starling’s

Regangan ↑= volume ↑Regangan ↑= volume ↑ (regangan berada dalam batas normal)(regangan berada dalam batas normal)

Preload/Afterload in Heart

AfterloadAfterload

Tekanan atau tahanan yg harus dilawan Tekanan atau tahanan yg harus dilawan oleh ventrikel waktu oleh ventrikel waktu ejectionejection

Ditentukan oleh resistensi katup aorta, Ditentukan oleh resistensi katup aorta, tek. Arterial sistemik & viskositastek. Arterial sistemik & viskositas

SVR & tek. Arterial → Left vent. afterloadSVR & tek. Arterial → Left vent. afterload PVR & tek. Arteri P → Right vent. PVR & tek. Arteri P → Right vent.

AfterloadAfterload

Kontraktilitas Kontraktilitas

Kekuatan kontraksi ventrikelKekuatan kontraksi ventrikel Bagaimana jantung memompa dengan baikBagaimana jantung memompa dengan baik No direct measure No direct measure

Ejection FractionEjection Fraction

Prosentase vol darah yg Prosentase vol darah yg diejeksikan saat sistolediejeksikan saat sistole

NormalNormal : : 60% - 70% 60% - 70%

Cardiac Output x SVR

Volume =Blood

Hypovolemic Shock

Cardiogenic Shock

Distributive Shock

Inotropes Vasopressor

Fluids

Obstructive Shock

Release tamponade,etc

Arterial pressurePipe = Vascular

Komponen Monitoring Hemodinamik Komponen Monitoring Hemodinamik

TransducerTransducer • Merubah peristiwa2 fisiologis kedalam Merubah peristiwa2 fisiologis kedalam

sinyal2 elektrik (e.g. tekanan, sinyal2 elektrik (e.g. tekanan, temperatur, cahaya)temperatur, cahaya)

AmplifierAmplifier• Menangkap sinyal elektrik dan Menangkap sinyal elektrik dan

mentransmisikan kelayar monitormentransmisikan kelayar monitor

Components of Hemodynamic Components of Hemodynamic MonitoringMonitoring

Monitor DisplayMonitor Display• Layar monitor (gambaran gelombang, Layar monitor (gambaran gelombang,

nilai pressure)nilai pressure) Catheter tubing / flush systemCatheter tubing / flush system

• Perawatan kateterPerawatan kateter• Heparinized solutionHeparinized solution ( (protokol)protokol)• Pressure bagPressure bag

Reliable MeasurementsReliable Measurements

Level = phlebostatic axis (4th intercostal Level = phlebostatic axis (4th intercostal space, midaxillary line)space, midaxillary line)

Balance = zero reference (negates Balance = zero reference (negates atmosphere pressure)atmosphere pressure)

Calibration = numerical accuracyCalibration = numerical accuracy How often to check?How often to check?

Bgm mengukur tekanan darah yg benar?

• Ukuran alat yg tepat

•Teknik pengukuran yg benar

Interval penilaian

• Manual : 15 menit

• NIBP : 3 menit

• Intra-arterial/invasive : real time/kontinyu

Intraarterial MonitoringIntraarterial Monitoring

IndikasiIndikasi Monitoring kontinyu tekanan darahMonitoring kontinyu tekanan darah Blood samplingBlood sampling p↑an tek. Intrakranialp↑an tek. Intrakranial Obat vasoaktiveObat vasoaktive

SitesSites RadialRadial BrachialBrachial FemoralFemoral

Allen Test

Nursing interventionsNursing interventions

Monitor bentuk gelombangMonitor bentuk gelombang Bandingkan dengan nilai ‘cuff’Bandingkan dengan nilai ‘cuff’

• A-line harus lebih akurateA-line harus lebih akurate Periksa sistem koneksiPeriksa sistem koneksi Periksa kateter arteri & sirkulasi pd Periksa kateter arteri & sirkulasi pd

ekstremitasekstremitas Set alarmsSet alarms

KomplikasiKomplikasi

Emboli udara: komplikasi mayorEmboli udara: komplikasi mayor PerdarahanPerdarahan TrombosisTrombosis

Tekanan Atrium KananTekanan Atrium Kanan

RV preload/RVEDPRV preload/RVEDP Right pressure changes usually occur Right pressure changes usually occur

latelate

Kateter untuk menilai RAPKateter untuk menilai RAP

Pulmonary artery catheter (proximal port)Pulmonary artery catheter (proximal port) Central line (e.g. triple lumen catheter)Central line (e.g. triple lumen catheter) Peripherally inserted central catheter Peripherally inserted central catheter

(PICC) line(PICC) line

MeasurementMeasurement

Measured via pressure systemMeasured via pressure system Normal value is 0 to 8 mm Hg Normal value is 0 to 8 mm Hg Recorded as MEAN valueRecorded as MEAN value

Nursing implicationsNursing implications

Zero/level/balanceZero/level/balance• Positioning patientPositioning patient• Respiratory cycleRespiratory cycle

Interpretasi Nilai CVPInterpretasi Nilai CVP

CVP RendahCVP Rendah• HypovolemiaHypovolemia• VasodilationVasodilation

CVP TinggiCVP Tinggi• HypervolemiaHypervolemia• VasoconstrictionVasoconstriction• Right CHFRight CHF• Pulmonary Pulmonary

hypertensionhypertension

KomplikasiKomplikasi

Pneumo/hemothoraxPneumo/hemothorax Perforasi jantungPerforasi jantung DisritmiaDisritmia

What assessments should be done during insertion What assessments should be done during insertion and immediately after insertion?and immediately after insertion?

What are important interventions to prevent complications?What are important interventions to prevent complications?

Implikasi PerawatanImplikasi Perawatan

Zero/balanceZero/balance Analisa gelombangAnalisa gelombang Variasi Respirasi Variasi Respirasi Monitor komplikasi InfeksiMonitor komplikasi Infeksi

Central Venous PressureCentral Venous Pressure

TRIPPLE LUMEN CATHETER

18 Ga

16 Ga

18 Ga

INTERPRETATION

Kateter Arteri PulmonalisKateter Arteri Pulmonalis

19701970 Dr. Swan and Ganz Dr. Swan and Ganz (Swan-Ganz is a brand)(Swan-Ganz is a brand)

Menggambarkan tekanan pada jantung Menggambarkan tekanan pada jantung kirikiri

DescriptionDescription

Balloon-tippedBalloon-tipped Measures PA systolic, diastolic, Measures PA systolic, diastolic,

mean, and wedge (PCWP; PAWP; mean, and wedge (PCWP; PAWP; PAOP)PAOP)

Multi-lumenMulti-lumen Proximal (RA)Proximal (RA) Proximal injectateProximal injectate Distal (PA)Distal (PA) BalloonBalloon

InsertionInsertion

Provide explanation and obtain Provide explanation and obtain informed consentinformed consent

Site: usually subclavian or internal Site: usually subclavian or internal jugularjugular

Incision: guide wire, introducer, Incision: guide wire, introducer, catheter, sheathcatheter, sheath

Flush lumensFlush lumens

InsertionInsertion

Inserted with balloon down, selected Inserted with balloon down, selected inflation to get into PAinflation to get into PA

Waveform changes as catheter Waveform changes as catheter progresses progresses

Check for proper wedgingCheck for proper wedging Secure and dress siteSecure and dress site

During insertionDuring insertion

Monitor pressures in each chamberMonitor pressures in each chamber Record valuesRecord values Assess for complicationsAssess for complications

• DysrhythmiasDysrhythmias• Pneumo/hemothoraxPneumo/hemothorax

PA ValuesPA Values

Normal is 25 to 10 with mean is 15Normal is 25 to 10 with mean is 15 Systolic 15 to 30 mm HgSystolic 15 to 30 mm Hg Diastolic 4 to 12 mm HgDiastolic 4 to 12 mm Hg PCWP 6 to 12 mm Hg PCWP 6 to 12 mm Hg

Diastolic reflects PCWP unless Diastolic reflects PCWP unless pulmonary hypertension present pulmonary hypertension present (mitral valve open during end (mitral valve open during end diastole; therefore, open circuit)diastole; therefore, open circuit)

CVP location

PA cath location

A. pulmonalisRight Atrium

InterpretationInterpretation

Increased PA pressures = volume Increased PA pressures = volume overload, CHFoverload, CHF

Decreased PA pressures = volume Decreased PA pressures = volume depletiondepletion

ComplicationsComplications

InfectionInfection DysrhythmiasDysrhythmias Air embolusAir embolus ThromboembolismThromboembolism PA rupturePA rupture Pulmonary infarctionPulmonary infarction

THANK YOU