Академический Документы
Профессиональный Документы
Культура Документы
Suparto
Anesthesia Department FK UKRIDA
Objectives
Understands basic cardiopulmonary anatomy
and physiology
Determinates of cardiac output and their
relationships to each other
List indications for hemodynamic monitoring
Demonstrates monitor system and set up
Introduction
Hemodynamics, by definition, is the study of
the motion of blood through the body.
In simple clinical application this may include
the assessment of a patients heart rate,
pulse quality, blood pressure, capillary refill,
skin color, skin temperature, and other
parameters.
Introduction
Monitoring is never therapeutic
It must be integrated with patient assessment
and clinical judgement to determine optimal
care.
The goals are to recognize physiologic
abnormalities and to guide interventions to
ensure adequate blood flow and oxygen
utilization for maintenance of cellular and
organ function
Cardiopulmonary anatomy
and physiology
Respiration
3 processes for adequate oxygenation and
acid-base balance
Ventilation: Gas distribution into and out of the
pulmonary airways
Pulmonary perfusion: blood flow from the right
side of the heart, through the pulmonary
circulation, and into the left side of the heart
Diffusion: Gas movement from an area of
greater to lesser concentration through a
semipermeable membrane
Cardiac
system
Carries life
sustaining O2 and
nutrients in the
blood to all cells of
the body
Removes metabolic
waste products in
the blood from the
cells
Mnemonic:
Some Believe In
Acting Badly Before
Performing
Sinoatrial node
Bachmanns bundle
Internodal pathways
Atrioventricular
node
Bundle of His
Bundle branches
Purkinje fibers
Cardiac
output
myocardium to contract
Influenced by preload
Afterload
Normal CO: 4-8 L/min Pressure that the
ventricle muscles must
Normal Stroke
generate to overcome
Volume: 50-100
the higher pressure in
ml/beat
the aorta
Blood circulation
preload contractility - afterload
Systemic vascular
resistance
The resistance against
which the left ventricle
must pump to move
blood throughout
systemic circulation.
Normal SVR: 770
1,500 dynes/sec/cm-5
Affected by:
Tone and diameter
blood vessel
Viscosity of the blood
Resistance from the
inner lining of the blood
vessels
SVR include:
Hypothermia
Hypovolemia
Stress response
Syndrome of low CO
SVR include:
Anaphylactic and
neurogenic shock
Anemia
vasodilation
MAP- CVP X 80
CO
Factor
Decreased preload
Possible cause
Hypovolemia
Vasodilation
Effects on heart
stroke volume
vent work
myocardial O2 req
(in compensatory
range)
Factor
Increased afterload
Possible cause
Hypovolemia
Vasoconstriction
Effects on heart
strokevolume
vent work
myocardial O2
req
Factor
Decreased afterload
Possible cause
Vasodilation
Effects on heart
stroke volume
vent work
myocardial O2 req
Therapeutic Interventions
AtropineLow
Arterialdilator,
Inotropics inhibitors
Low
Contractility
ACE
Standard Monitoring
ASA standard: Oxygenation, ventilation,
circulation, and temperature
Standard for General Anesthesia:
ASA standard (Pulse Oximetry, Capnography,
minute ventilation, ECG, BP, temp if necessary
Standard for MAC and Regional Anesthesia:
Pulse Oximetry, RR, ECG, BP, temp if
necessary
Additional: Arterial line, CVP, NMBA monitor
Preparation before induction: Anesthesia
Mechine, ECG Monitor
Cardiovascular system
O2 delivery
CO = SV x HR
ECG
Determine HR
Detect and diagnose
dysrhytmia
Myocardial ischemia
Electrolyte imbalance
(hipo/hyperkalemia)
Manual Blood
Pressure
BP = CO x SVR
Measures systolic dan
diastolic BP by
auscultation of
korotkoff sound,
palpation
Cuff width should
cover 2/3 of upper
arm or thigh
Palpation:
A. radial (80mmHg)
A. femoral (60mmHg)
A. Carotid (50mmHg)
Mean Arterial
Pressure
MAP = sis + 2 Dias/ 3
Normal: 60-70mmHg
Arterial BP indication
Tight BP control
Unstable patient
Arterial blood
sampling
CVP Monitoring
The theory is that as
fluid volume in
chamber increases, so
too will the pressures
measured in the
chamber.
This correlation is true
only in a limited
sense
The key to remember
is that pressure is
not equal to volume.
The pressure is
trended as an
indicator of volume
status, but must be
correlated to
physical assessment
findings and the
patients history to
come to an accurate
clinical impression.
CVP Monitoring
Help us to
Pressure at end
learn a patients cardiac
diastole reflects back
function,
to the catheter
evaluate venous return,
When connected to a
indirectly gauge how
transducer or
well the heart is
manometer, the
pumping,
catheter measures
access to fluid
CVP, a direct
administration,
reflection of right
atrial pressure and an
obtain blood samples.
indirect measure of
preload of the right
ventricle.
CVP Monitoring
Signs of excess preload
Signs of inadequate with adequate cardiac
preload include
function:
Poor skin turgor
Distended neck veins
Dry mucous
Crackles in the lungs
membranes,
Bounding pulses
Low urine output
With poor cardiac function:
Tachycardia
Crackles in the lungs,
Thirst
an S3 heart sound,
Weak pulses
Low urine output,
Flat neck veins.
Tachycardia,
Cold clammy skin with
weak pulses,
Edema.
CV and PA catheter
insertion
Sterile procedure
Insertion site:
or insufficiency
Constrictive pericarditis
Pulmonary
hypertension
Cardiac tamponade
Right ventricular
infarction
Causes of
decreased pressure
Reduced circulating
blood volume
Cm H2O : 1.36 =
mmHg
Penumothorax, hemothorax
Sign & symptoms: decreased breath
sounds, abnormal chest X-ray
Causes: Repeated or long term use of same
vein, large blood vessel puncture
Interventions: set up and assist with chest
tube insertion, administer oxygen
Prevention: patients position during
insertion, immobilized patient, ultrasound
guided
Air embolism
Sign & symptoms: respiratory distress, loss
of consciousness, unequal breath sounds
Causes: intake of air into the CV system
during catheter insertion
Intervention: turn the patient on his left
side, head down, so that air can enter the
right atrium and maintain this position for
20-30 min, life support
Prevention: purge all air from the tubing
before hookup
Thrombosis
Sign & symptoms: ipsilateral swelling of arm, neck
and face, pain along vein, dyspnea, cyanosis
Causes: Sluggish flow rate, hypercoagulable state
of patient
Interventions: possibly remove the catheter, apply
warm, wet compresses locally, dont use the limb
on the affected side for venipuncture or blood
measurement, life support
Prevention: Maintain a steady flow rate with the
infusion pump, or flush the catheter at regular
intervals
PA catheter insertion
Swan-Ganz
catheter
PAP and PAWP
provide information
about LV function
Respiratory System
Pulse Oxymetri
Normal: 96%-99%
88% acceptable for
patient with lung
disease
High pulse ox
indicates:
O2 available in the lung,
taken up in the blood,
delivered to distal
tissues.
Low pulse ox
Problem along the above
pathway or due to error
Capnography
Ventilation
Assessment
Confirmation
endotracheal
intubation
Normal: PetCO2 is
2-5mmHg lower
than arterial PCO2,
so typical range 3040 mmHg under
General anesthesia
Suhu tubuh
normal 365-375 C
Suhu nasofaringeal mendekati suhu inti
Peningkatan menandakan meningkatnya
metabolisme sel
Suhu produksi CO2
Produksi Urine
Dewasa: 0.5-1cc/Kg/jam
Pediatrik: 1-2cc/Kg/jam
Pemantauan sistem
saraf
Bispectral Index, utk
mengetahui
kedalaman anesthesia
dari mendeteksi dan
rekaman gelombang
elektroensefalogram
(EEG)
Tingkat anestesi nilainya
40-60 (100 artinya
sadar penuh)
Train of Four
Mengukur tingkat
blokade oleh
pelumpuh otot
memberikan 4
stimulus
berturutan
dengan
frekwensi 2 Hz
selama 2 detik