Perioperative Hemodynamic Monitoring Cindy E. Boom RS.Pusat Jantung dan Pembuluh Darah Harapan Kita-Jakarta

Seorang pria 70 tahun, datang dengan keluhan tidak bisa BAB, perut kembung, tidak dapat makan sudah 3 hari Pola napas terengah-engah, gelisah Posisi setengah duduk Kulit pucat, akral dingin Nadi: 130 x/menit. TD : 90/35 mmHg Respirasi : 35 – 40 x/mnt Auskultasi : rales +, wheezing

Instability Hemodynamic A clinical state Systemic blood pressure Cardiac output Organ function

Low Cardiac Output Syndrome ( LCOS) MAP < 65mmHg Oliguria (<0.5ml/Kg/hour) Clinical signs of tissue Hypoperfusion Volemia Heart function Vessel tone

BP : blood pressure CO : cardiac output SVR : systemic vascular resistance BP = CO X SVR

Adequate Oxygen Delivery? Demand Consumption

Adequate Balance of Tissue Oxygenation Myocardial Oxygen Balance O2 Extraction Diastolic Time Diastolic Pressure Coronary Artery Flow Preload Afterload Heart Rate Contractility Demand Supply

= X Oxygen Delivery Hemodynamic Monitors Oxygen Delivery Cardiac Output Oxygen Content = X Arterial Blood Gas Hb PaO2 Oxygen Content

Low Cardiac Output Syndrome LCOS First Step – Clinical Evaluation

Oliguria (<0.5ml/Kg/hour) Clinical signs of tissue hypoperfusion LCOS MAP < 65mmHg Oliguria (<0.5ml/Kg/hour) Clinical signs of tissue hypoperfusion 1) Clinical approach HR/BP Peripheral perfusion Impact of volume loading Urine output

Goal Oriented Hemodynamic Therapy Resuscitation Goal Oriented Hemodynamic Therapy Volume Medikamentosa Mechanical How?

Hemodynamic Management of LCOS Second Step : CVP / Scv O2 Myocardial and/ or Vascular Dysfunction

Insert CVP/ScvO2 CVP low CVP high CVP N or low Sepsis? ScvO2 >70% SvO2 <70% CVP N or low CVP high CVP low Consider global/right ventricular failure Hypovolaemic/ Haemorrhagic/ cause? Sepsis? Repeat Fluid challenge 250ml/ 5mins Echocardiography that preceeds cardiac output monitoring Repeat fluid challenge (250ml/5mins) or transfusion if necessary. Continue until normal values obtained Haemodynamic improvement Yes Continue until normal values obtained Haemodynamic improvement ? No response No Vasopressors Echocardiography that preceeds CO monitoring

GDT CVP MAP ScvO2 CRYSTALLOID VASOACTIVE AGENT PRBC to Hct 30 % GOAL < 8 mmHg CRYSTALLOID 8-12 mmHg MAP < 65 mmHg VASOACTIVE AGENT > 90 mmHg > 65 mmHg < 90 mmHg ScvO2 Tahapan EGDT yaitu : Resusitasi cairan sampai mencapai target. Mempertahankan tekanan arteri rata2 (MAP) berkisar 65 – 90 mmHg dengan menggunakan obat vasoaktif. Mempertahankan saturasi vena sentral sekitar 70% dengan memberikan transfusi atau obat inotropik. < 70% PRBC to Hct 30 % < 70% > 70% GOAL INOTROPE(S)

GDT F R MAP ScvO2 CRYSTALLOID VASOACTIVE AGENT PRBC to Hct 30 % positive CRYSTALLOID negative MAP < 75 -85mmHg VASOACTIVE AGENT > 75-85 mmHg ScvO2 Tahapan EGDT yaitu : Resusitasi cairan sampai mencapai target. Mempertahankan tekanan arteri rata2 (MAP) berkisar 65 – 90 mmHg dengan menggunakan obat vasoaktif. Mempertahankan saturasi vena sentral sekitar 70% dengan memberikan transfusi atau obat inotropik. < 70% PRBC to Hct 30 % < 70% > 70% P(cv-a)CO2 INOTROPE(S)

Refining the Tools for Early Goal-directed Therapy Indices of Fluid Responsiveness positive Crystalloid Decrease O2 Consumption MAP < 75-85 mmHg Vasoactive agent(s) > 75-85 mmHg ScvO2 < 70% Packed red blood Cells to Hct > 30% > 70% < 70% > 70% Inotrope(s) P(cv-a)CO2 No > 6 Refining the Tools for Early Goal-directed Therapy Goals achieced No Yes Vasopressor Weaning trial

Hemodynamic Management of LCOS Third Step: Echocardiography

Mebazaa et al. Intensive Care Med, 2004;30:185-96 Echocardiography Global heart failure Predominent left ventricular failure Predominent right ventricular failure TAMPONADE ? Massive mitral regurgitation ? Yes No LV dysfunction No Echocardiographic guided pericardiocentesis or surgical intervention PA catheter Pulmonary hypertension? Pulmonary vasodilators RV ischaemia? Reduce RV afterload, avoid excess volume, use inotropes if CO low Any CO Monitoring, ideally non invasive Optimise LV pre- and afterload, Inotropes if required Mebazaa et al. Intensive Care Med, 2004;30:185-96

Hemodynamic Management of LCOS Fourth Step: Pulmonary Artery Catheter

Oliguria (<0.5ml/Kg/hour) Clinical signs of tissue hypoperfusion LCOS MAP < 65mmHg Oliguria (<0.5ml/Kg/hour) Clinical signs of tissue hypoperfusion 1) Clinical approach HR/BP Peripheral perfusion Impact of volume loading Urine output 2) CVP/SvcO2 3) Echocardiography should proceed any CO monitoring Predominant RVF or global F PAC catheter Predominant LVF any CO monitoring

Optimize Oxygenation ScvO2 Oxygen Delivery Oxygen Comsumption - - + - O2 uptake O2 transport O2 extraction O2 utilisation Oxygen Delivery Oxygen Comsumption ScvO2 Cardiac Output Arterial Oxygen Content Stroke Volume Heart Rate Oxgenation SaO2 Hemoglobin Hb Preload After Load Contractiliy - - + Volume - Inotropes + - Vasopressors + Red Blood Cells +

Pemantauan Kardiovaskuler Fungsi utama sistem Kardiovaskuler: menjamin kecukupan pasokan dan kebutuhan sel-sel tubuh akan O2 dan membawa sisa metabolisme untuk diekskresikan. CO (cardiac output) = SV (stroke volume) x HR (heart rate) MAP (mean arterial pressure) = (Sistolik + 2x Diastolik)/ 3 Atau MAP= Diast+ (Sist-Diast)/3 Besar MAP orang dewasa normal : 60-70 mmHg. PP ( pulse pressure) adalah selisih antara tekanan sistolik dan diastolik. PP = Sist- Diast, atau PP= 3x ( MAP-Diast)

Saturasi Oksigen dan Oksigenasi Jaringan ( SaO2 dan DO2) Delivery Oxygen (DO2) adalah jumlah oksigen yang harus tersedia bagi jaringan tubuh per menit. DO2 = CO x CaO2 ( oxygen content) CaO2= (1,34 x Hb x SaO2) + (0,0031x PaO2) DO2 = CO x (( 1,34 x Hb x SaO2) + ( 0,0031 x PaO2)) DO2 = delivery oxygen CO = cardiac output CaO2 = arterial oxygen content PaO2 = tekanan parsial oksigen di dalam darah arteri

FLUID RESUSCITATION AND ORGAN PERFUSION A. GENERAL B. URINE PRODUCTION C. ACID BASE BALANCE

RESPONSE TO EARLY FLUID RESUSCITATION A. IMMEDIATE RESPONSE B. TEMPORARY RESPONSE C. MINIMALLY / NO RESPONSE

RESPON TERHADAP TERAPI CAIRAN AWAL Tanda Vital RESPON RESPON TANPA CEPAT SEMENTARA RESPON Dugaan Minimal Sedang, masih ada Berat Kehilangan Darah (10 - 20%) (20 - 40 % ) ( > 40 % ) Kebutuhan Sedikit Banyak Banyak Kristaloid Kebutuhan Darah Sedikit Sedang - Banyak Segera Persiapan Darah Type Specific dan Type Specific Emergency Cross match Operasi Mungkin Sangat Mungkin Hampir Pasti Kehadiran Dini Ahli Perlu Perlu Perlu Bedah

Fluid Resuscitation Complication Pulmonary edema Myocardium edema Mesenteric effects Central nervous system effects

CVP : 15 mmHg Wedge pressure : 10 -12 mm Hg Cardiac index : > 3 L/min/m2 Oxygen uptake (V02) : > 100 mL/min/m2 Blood lactate : 4 mmol/L Base deficit : ± 3 mmol/L Urine : 0.5 – 1ml/kgbb/hr

HEMODYNAMIC MONITORING DEVICES ECG monitoring Arterial Catheter Pulmonary Arterial Catheter Central Venous Catheter Urinary Catheter Thermodilution Continuous Cardiac Output Transesophageal echocardiography (TEE) Transthorasic echocardiography (TTE)

Preload HYPOVOLEMIC SHOCK Cardiac Output / CO Blood Pressure Systemic Vascular Resistance / SVR Stroke Volume / SV Heart Rate Contractility Afterload Preload

CARDIOGENIC SHOCK Cardiac Output / CO Contractility Stroke Volume / SV Blood Pressure Systemic Vascular Resistance / SVR Cardiac Output / CO Stroke Volume / SV Heart Rate Preload Afterload Contractility

CIRCULATORY SHOCK Stroke Volume / SV Preload Contractility Blood Pressure Cardiac Output / CO Stroke Volume / SV Heart Rate Preload Afterload Systemic Vascular Resistance / SVR Contractility

CO ↓ = HR x SV Preload↓ Contractility Vasoconstriction Afterload Vasoconstriction Tissue Perfusion ↓

Hemodynamic profiles of the shock states Physiologic variable Preload Pump function Afterload Tissue perfusion Clinical measurement Pulmonary capillary wedge pressure Cardiac output Systemic vascular resistance Mixed venous oxygen saturation Hypovolemic Decreased Increased Cardiogenic Distributive

Hemodynamic Monitoring Parameters Non Invasive Blood Pressure (BP) Mean Arterial Pressure (MAP) Heart Rate (HR) Peripheral Oxygen Saturation (SpO2) Invasive CVP (central venous pressure) PCWP (pulmonary catheter wedge pressure) RVEDVI (right ventricle end diastolic volume index) LVSVI (left ventricle stroke volume index) LVP (left ventricle pressure) SvO2 (mixed vein oxygen saturation)

Why SvO2? 22

Transport Oksigen

Transport Oksigen vena arteri CO CO tetap Hb Hb tetap SaO2 SvO2 Konsumsi Tetap tetap Hb Hb tetap SaO2 SvO2 berubah Konsumsi O2 = CO x Hb x (SaO2 - SvO2) x 1.34

Pada umumnya penurunan SvO2 merupakan indikator dini adanya gangguan oksigenasi jaringan

Berapa harga normal SvO2? Harga normal SvO2 adalah 68 - 77% Nilai < 50% sudah mengkhawatirkan Nilai<30% menunjukkan adanya metabolisme anaerobik Lebih berguna mengikuti trend (sebagai respons terhadap perubahan terapi) dibanding hanya melihat nilai pada satu satuan waktu

Oxygen Delivery Optimalisation DO2 = CO x Hb x SaO2 x 1,34 Oxygenation/Ventilation HR x SV Preload Contractility Afterload

Oxygen Delivery Optimalisation DO2 = CO x Hb x SaO2 x 1,34 Oxygenation/Ventilation HR x SV 1 Mechanical Ventilation Preload Contractility Afterload

Oxygen Delivery Optimalisation DO2 = CO x Hb x SaO2 x 1,34 Oxygenation/Ventilation HR x SV 1 Mechanical Ventilation 2 Preload Contractility Afterload Terapi Cairan

Oxygen Delivery Optimalisation DO2 = CO x Hb x SaO2 x 1,34 Oxygenation/Ventilation HR x SV 1 Mechanical Ventilation 2 3 Preload Contractility Afterload Terapi Cairan Vasoaktif

Oxygen Delivery Optimalisation 5 Transfusi DO2 = CO x Hb x SaO2 x 1,34 Oxygenation/Ventilation HR x SV 1 Mechanical Ventilation 2 3 Preload Contractility Afterload Terapi Cairan Vasoaktif Inotropik 4

Monitor Hemodinamik Yang Mana ?

ASA Basic Intraoperative Monitoring Standard I : Qualified anesthesia personel Standard II: Oxygenation : inspired gas, blood oxygenation, pulse oxymetri Ventilation : end-tidal CO2- capnograph, alarm detecting disconnect from ventilator. Circulation : ECG, every 5 min (arterial blood pressure, heart rate), pulse palpation, auscultatio of heart sound, intraarterial pressure Body Temprature

Arterial Line

ARTERIAL LINE PURPOSES Continue BP monitoring Early detected of HD HD controlled Blood Gas Analysis

Arterial Line Inserting Techniques

Arterial Line Waveform

CENTRAL VENOUS PRESSURE Tekanan Vena Sentral

Central Venous Pressure Monitoring Better than Regular Manometer : Continue monitoring of venous pressure. Give us more reliable data of CVP Pressure vs Volume

Central Venous Pressure Waveform 3 positive waveforms : a, c dan v 2 negative waveforms : x, y

CVP Inserting Technique

A. Pulmonalis Trikuspid V. Pulmonalis Mitral Aorta Atrium Kanan Ventrikel Kanan Paru-paru Atrium Kiri Ventrikel Kiri VCS/ VCI

PULMONARY ARTERIAL CATHETER (PAC) SWANZ GANZ

PAC PURPOSES Pulmonary Arterial Pressure : S/ D/ M Wedge Pressure (PCWP) Cardiac Output / Cardiac Index (CO/CI) Systemic Vascular Resistance (SVR/I) and Pulmonary Vascular Resistance (PVR/I)

PAC Waveform

Seorang pria 70 tahun, datang dengan keluhan tidak bisa BAB, perut kembung, tidak dapat makan sudah 3 hari. Pola napas terengah-engah, gelisah. Posisi setengah duduk Kulit pucat, dingin, akral dingin. Nadi: 130 x/menit. TD : 90/35 mmHg. Respirasi : 35 – 40 x/mnt. Auskultasi : rales +, wheezing -.

Titik Akhir Terapeutik Capillary refill time < 2 detik Ekstremitas hangat, kering dan kemerahan Produksi urine > 1 ml/kg/jam Status mental normal Laktat menurun Saturasi vena sentral > 70%

Masalah-masalah dalam pelaksanaan

Gunakan pemeriksaan AGD serial dari darah kateter vena sentral Saya tidak punya monitoring ScvO2! Gunakan pemeriksaan AGD serial dari darah kateter vena sentral

Saya Tidak Punya Monitor CVP/ Kateter TVS Anda Sedang Berhadapan Dengan Masalah Serius Segera rujuk ke rumah sakit terdekat Lakukan RESUSITASI CAIRAN SEMAKSIMAL MUNGKIN

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