THE ROLE OF

NON INVASIVE MONITORING

IN CRITICAL CARE SETTING

Wahyu Bimantoro
bmantorowhy@yahoo.com
 WHAT IS THE HEMODYNAMIC

The primary function of the Cardiovascular System is to:

1. Deliver nutrients/O2 and
2. Remove wastes/CO2
Microcirculatory
Mitochondria
Dysfunction
Syndrome
MMDS
 MAP = CO X R R = ARTERIOLE RESISTANCE TO FLOW

More Cardiac Output = larger MAP

Less Cardiac Output = smaller MAP

More Resistance = smaller arteriole = greater MAP but slower flow

Less Resistance = larger arteriole = lower MAP but greater flow

 1
2
Hemorrhagic shock
ARDS

Vasodilatory shock
Severe
Bradycardia

Hypovolemic shock
4
Cardiogenic shock
5
Aortic disease
6
George 2015
THE TRADITIONAL HEMODYNAMIC
MONITORING;

USING BLOOD PRESURE AND CLINICAL SIGN

AS A GOAL
 Hubungan antara BP dan CO

Normal = Normal x Normal

Blood Pressure Cardiac Output SVR

Normal/high =  x 
Blood Pressure Cardiac Output SVR

Preload: Contractility: Compensatory

Hypovolemia Cardiac Failure response
Haemorrhage

Normal/high = High x Low

Blood Pressure Cardiac Output SVR

Compensatory Septic Shock

response Anaphilactic Shock
Spinal Shock
SHOEMAKER CONCLUDED
• The conventionally measured variables such as
blood pressure, heart rate, urine output

WERE OF LITTLE PROGNOSTIC VALUE

BEST PROGNOSTIC INDICATORS OF
OUTCOME IN THESE “HIGH RISK”
SURGICAL PATIENTS

1. Cardiac output
2. Oxygen delivery
3. Oxygen consumption
 SHOCK CLASSIFICATION
DRAMATICALLY CHANGED
MAP PAWP CO SVR

HYPODYNAMIC

- Hypovolemic: hemorrhage, dehydration ↓↔ ↓ ↓ ↑

- Cardiogenic: myocardial infarction ↓ ↑ ↓ ↑

- Obstructive: pulmonary embolism, pericardial tamponade, ↓ ↔↑ ↓ ↑

tension pneumotoraks

HYPERDYNAMIC

- Distributive sepsis, adrenal insuficiency, anaphylaxis ↓ ↔↓ ↔↑ ↓

11
METHODS OF MEASSURING CARDIAC
OUTPUT
HEMODYNAMIC MONITORING
CARDIAC OUTPUT MEASSUREMENT,
INTERPRETATION AND APPLICATION
HEMODYNAMIC MONITORING
THE TECHNIQUES

Continuous !
As the patient’s haemodynamic status may change
rapidly, continuous hemodynamic monitoring will
provide information allowing rapid adjustment of
therapy
THE GOAL
OF HEMODYNAMIC MONITORING

TO ASSESS AND
OPTIMIZE CARDIAC FUNCTION

TO ACHIEVE AND MAINTAIN ADEQUATE

TISSUE PERFUSION
HEMODYNAMIC MONITORING

• Definisi : Merupakan upaya untuk mengukur dan memonitor

faktor-faktor yang mempengaruhi kekuatan dan aliran darah,
Inotropik, resistensi dan cairan di tubuh
• Tujuan : Untuk membantu dalam diagnosis, diagnosis banding,
monitoring, pengobatan dan titrasi obat pasien dengan sakit kritis
• Jika hemodinamik diketahui, maka perubahan dan penyebab
masalah dalam sistem kardiovaskular dapat dideteksi lebih awal ,
sehingga memudahkan tata laksana pengobatan
 CARA PENILAIAN CARDIAC OUTPUT YANG
SERING DIGUNAKAN BERDASARKAN
METODA PENGUKURAN
Metoda

1. pengukuran
• Direct meassurement Fick’s Method
• Indicator Dilution Methods:
– Transcardiac Indicator Dilution
technique
• Swan Ganz
– Transpulmonary Indicator Dilution
technique
• PiCCO, EV1000, LiDCO
2. kalkulasi
 Ultrasound
• Echocardiography
• Doppler technology
– Pulse Countour Analysis (Vigileo,PiCCO)
– Bio-impedance (Bionz)
– Bio-reactance (NICOM)
– Cardiometry
• ICON

Courtessy of YWH George MD

 PENILAIAN CARDIAC OUTPUT
BERDASARKAN METODA
Method System Preload and Limitations
Additional variable
Transcardiac Thermodilution PA catheter PAOP, PAP, SvO2 Invasiveness,
Catheter Ccombo RVEF, RVEDV Training required

Transpulmonary Indicator PiCCO GEDV, EVLW, SVV, PPV Invasiveness,

Dilution LiDCO Need for dedicated catheter
(calibrated)
Arterial-pressure waveform Vigileo SVV, dP/dT, CCE, PPV, SVV Need for optimal arterial
derived MostCare signal
(not calibrated)
Doppler’s principle Esophageal CardiacQ Ftc, peakV Partial meassurement of CO
Suprasternal USCOM Estimation of AoCSA

Fick’s principle NiCO Shunt calculation Intubated patients

Less reliable in respiratory
failure

Bioimpedance Lifegard, TEBCO None Not applicable in

cardiothoracic surg

Cardiometry Opsyka FTc, SVV Applicable for

pediatric and
neonates
HEMODYNAMIC MONITORING YG IDEAL :
• AKURAT & TERPERCAYA
• MUDAH DIGUNAKAN
• BAHAN HABIS PAKAI MURAH
• BISA DIGUNAKAN DALAM KONDISI APAPUN
• UNTUK SEMUA UMUR
• NON INVASIVE
• BEAT BY BEAT
• DAPAT DIREKAM / DOKUMENTASI
• MUDAH DIINTERPRETASIKAN
Alhashemi et al. Critical Care 2011 15:214 doi:10.1186/cc9996
Kuster et al. World Journal of Emergency Surgery (2015) 10:11
EMERGENCY DEPARTEMENT NON-INVASIVE CARDIAC
OUTPUT IS ASSOCIATED WITH TRAUMA ACTIVATION
PATIENT INJURY SEVERITY AND HOST CONDITION
Thomas J. Chirichella, C. Michael Dunham, Brian S. Gruber, Jonathan P. Ferrari, Joseph A. Martin

V
S
 CONTOH NICOM DAN PERBANDINGANNYA

ICO
N

Cardiology Research and Practice

TED TCDU TE BR Volume 2012 (2012), Article ID 531908,
12 pages
 ELECTRICAL CARDIOMETRY
 4 sensor diletakkan di leher dan dada pada sisi yang sama

 Gelombang dipancarkan dari elektroda untuk mencari resistensi paling

rendah : pada saat darah mengisi aorta

 Baseline (resistensi dan aliran) diukur dengan menggunakan elektroda

dalam (selama fase diastol)

 Setiap detak jantung , alignment sel darah merah akan berubah , demikian
juga dengan volume darah, alran darah serta kecepatannya dalam aorta
berubah

 Perubahan konduktivitas yang terjadi diukur

 Perubahan baseline, alignment sel darah merah dan resistensi , digunakan

untuk mengukur dan menghitung parameter hemodinamik

 Alignment sel darah merah merupakan faktor utama terjadinya perubahan

konduktivitas 􏰆 akurasi yang tinggi pada semua usia
 MENILAI CARDIAC OUTPUT
MENGGUNAKAN CARDIOMETRY

Courtessy of YWH George

 PARAMETER YANG DAPAT DIUKUR DAN DIHITUNG DENGAN NON-
INVASIVE CARDIAC OUTPUT MONITORING ( ICON )

TFC
PEP
LVET

LCW FTC
SVR
STR SVV

HR SV

CO [1.39 x Hb x SaO2 + (0.003 x PaO2)]

Betts, J. Gordon (2013). Anatomy & physiology. pp. 787–
 PENGUKURAN
846. ISBN 1938168135. Retrieved 11 August 2014.

 PERHITUNGAN
 Supplemental oxygen ± endotracheal PCT/lactate
intubation and mechanical ventilation

Blood culture
Electric velocimetry ( ICON)

diagnostic
sedation,paralysis ( if intubated ) or both

FTC Low- Crystalloid

colloid
SVV high
normal

SVR Low Vasoactive agent

normal
Transfusion and or
Low inotropic
DO2

NO Goals achieved
ye
s
Hospital admission
71 thn, post hemoragik shock krn GI bleeding ec ulkus duodenum.
Hari ke 3 setelah gastroskopi, dilaporkan hipotensi, tanpa topangan
katekolamin.

Courtessy of YWH George MD

 Hypovolemia state

Very low cardiac

index
Overshoot SVRI  high blood
pressure
Low FTc/preload

Low Stroke Volume

Normal index of
contractility

Courtessy of YWH George

Courtessy of YWH George MD
 Normal cardiac
index

Very low SVRI

Vasopressor
Normal preload
No fluid loading

Low Stroke
Volume

Normal index of
contractility

Courtessy of YWH George MD

 SUMMARY
• Assessment of a patient's hemodynamic status is
essential to understanding their disease process and
implementing appropriate therapy.
• Tool-assisted patient monitoring greatly facilitates both
the diagnosis and treatment of shock states encountered
in the critically ill patient.
• A combination of measured and calculated hemodynamic
variables provides the clinician with vital information by
which to guide resuscitation. These variables should be
utilized to create a comprehensive assessment of the
patient's dynamic cardiac status.
• Therapy should never be guided by reliance on a single
variable alone.
THANK YOU