MONITORING HEMODINAMIK

Ezra Oktaliansyah

BAGIAN ANESTESIOLOGI & REANIMASI FAKULTAS

KEDOKTERAN UNPAD / RSHS
BANDUNG
Pendahuluan

Panduan Resusitasi

Hemodinamik

Memahami penyakit, Menentukan & Memantau Terapi

VARIABEL HEMODINAMIK
POMPA

SISTEMIK
SISTEMIK/ SVRI
SIRKULASI TAHANAN
PULMONER/ PVRI
KELUAR
PULMONER
MAP/ MPAP

TEKANAN
KEDALAM
PAOP/ CVP
 Aorta

Lung

Pulmonal

Pulmonal artery
Left
atrium vein

SVR =
Right Systemic
Atrium Left
ventricle Vascular
Resistance

Right
ventricle

organ
Komponen Hemodinamik
 Blood Pressure (BP)/TD
 Central Venous Pressure (CVP)

 Right and Left Heart Pressures

 WHY?
Untuk optimalisasi konsumsi oksigen & metabolisme
Dan ketersediaan energi

HOW?
 Monitoring tekanan arterial
 A-line
 Monitoring tekanan arteri pulmonalis
 PA catheter; “Swan Ganz”
 Monitoring tekanan atrium kanan
 RAP; CVP
KRITERIA HEMODINAMIK YG
MEMERLUKAN MONITORING KETAT

 MAP < 65 or > 120 mmHg

 CI < 2L/min/m2

 PAWP > 15 or < 5 mmHg

Prinsip-prinsip
 Tekanan = aliran x resistensi
 > aliran = semakin tinggi tekanan
 Semakin > resistensi = semakin tinggi
tekanan
Prisip-prinsip
 Tekanan darah = aliran (cardiac output) x
resistensi (ukuran lumen)
 Sistem sirkulasi adalah suatu sirkuit yg
kontinyu
 Cairan mengalir dari daerah tekanan
tinggi ke tekanan rendah
 Heart pressures
Pressures in Heart
 Normal
Vessel

ALIRAN

TEKANAN
ALIRAN =
TAHANAN
 VASOCONSTRICTION:
 Angiotensin II, ADH, Adrenaline,
NorEphinephrine, Metaraminol

ALIRAN

TEKANAN
ALIRAN =

TAHANAN

ALIRAN

OBSTRUCTION: 
Trombus, sclerotic
 TEKANAN VASODILATATION:
Nitroglyserine,
ALIRAN = Nitroppruside,
TAHANAN milrinone, dobutamine
Cardiac Output (curah jantung)

 CO = HR X SV
 SV = Preload, afterload, dan
contractility
Preload
 Regangan serabut otot sebelum sistole
(volume dalam ruang jantung pada ahir
diastole)
 Ditentukan oleh LVEDV/LVEDP
 Hukum Starling’s
 Regangan ↑= volume ↑
(regangan berada dalam batas normal)
Preload/Afterload in Heart
Afterload

 Tekanan atau tahanan yg harus dilawan

oleh ventrikel waktu ejection
 Ditentukan oleh resistensi katup aorta,
tek. Arterial sistemik & viskositas
 SVR & tek. Arterial → Left vent. afterload

 PVR & tek. Arteri P → Right vent.

Afterload
Kontraktilitas

 Kekuatan kontraksi ventrikel

 Bagaimana jantung memompa dengan baik
 No direct measure
Ejection Fraction

 Prosentase vol darah yg

diejeksikan saat sistole
 Normal : 60% - 70%
 Cardiogenic Distributive
Shock Shock

Inotropes
Vasopressor

Release Pipe = Vascular Arterial pressure

tamponade,etc

Obstructive Cardiac Output x SVR

Shock

Volume =
Blood

Hypovolemic
Fluids Shock
Komponen Monitoring Hemodinamik
 Transducer
• Merubah peristiwa2 fisiologis kedalam
sinyal2 elektrik (e.g. tekanan,
temperatur, cahaya)
 Amplifier
• Menangkap sinyal elektrik dan
mentransmisikan kelayar monitor
Components of Hemodynamic
Monitoring
 Monitor Display
• Layar monitor (gambaran gelombang,
nilai pressure)
 Catheter tubing / flush system

• Perawatan kateter

• Heparinized solution ( protokol)

• Pressure bag
Reliable Measurements

 Level = phlebostatic axis (4th intercostal

space, midaxillary line)
 Balance = zero reference (negates
atmosphere pressure)
 Calibration = numerical accuracy

 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 Monitoring

 Indikasi
 Monitoring kontinyu tekanan darah
 Blood sampling
 p↑an tek. Intrakranial
 Obat vasoaktive
 Sites
 Radial
 Brachial
 Femoral
Allen Test
Nursing interventions

 Monitorbentuk gelombang
 Bandingkan dengan nilai ‘cuff’
• A-line harus lebih akurate
 Periksa sistem koneksi
 Periksa kateter arteri & sirkulasi pd
ekstremitas
 Set alarms
Komplikasi

 Emboli udara: komplikasi mayor

 Perdarahan

 Trombosis
Tekanan Atrium Kanan

 RV preload/RVEDP
 Right pressure changes usually occur
late
 Kateter untuk menilai RAP
 Pulmonary artery catheter (proximal port)
 Central line (e.g. triple lumen catheter)

 Peripherally inserted central catheter

(PICC) line
Measurement

 Measured via pressure system

 Normal value is 0 to 8 mm Hg

 Recorded as MEAN value

Nursing implications

 Zero/level/balance
• Positioning patient
• Respiratory cycle
Interpretasi Nilai CVP

CVP Rendah CVP Tinggi

• Hypovolemia • Hypervolemia
• Vasodilation • Vasoconstriction
• Right CHF
• Pulmonary
hypertension
Komplikasi

 Pneumo/hemothorax
 Perforasi jantung
 Disritmia

What assessments should be done during insertion

and immediately after insertion?

What are important interventions to prevent complications?

Implikasi Perawatan

 Zero/balance

 Analisa gelombang
 Variasi Respirasi

 Monitor komplikasi Infeksi

Central Venous Pressure
TRIPPLE LUMEN CATHETER

16 Ga

18 Ga 18 Ga
INTERPRETATION
Kateter Arteri Pulmonalis

 1970
 Dr. Swan and Ganz (Swan-Ganz is a brand)
 Menggambarkan tekanan pada jantung
kiri
Description

 Balloon-tipped
 Measures PA systolic, diastolic,
mean, and wedge (PCWP; PAWP;
PAOP)
 Multi-lumen
 Proximal (RA)
 Proximal injectate
 Distal (PA)
 Balloon
Insertion

 Provide explanation and obtain

informed consent
 Site: usually subclavian or internal
jugular
 Incision: guide wire, introducer,
catheter, sheath
 Flush lumens
Insertion

 Inserted with balloon down, selected

inflation to get into PA
 Waveform changes as catheter
progresses
 Check for proper wedging

 Secure and dress site

During insertion

 Monitorpressures in each chamber

 Record values

 Assess for complications

• Dysrhythmias
• Pneumo/hemothorax
PA Values
 Normal is 25 to 10 with mean is 15
 Systolic 15 to 30 mm Hg
 Diastolic 4 to 12 mm Hg
 PCWP 6 to 12 mm Hg
 Diastolicreflects PCWP unless
pulmonary hypertension present
(mitral valve open during end
diastole; therefore, open circuit)
 PA cath location
CVP location

Right A. pulmonalis
Atrium
Interpretation

 Increased PA pressures = volume

overload, CHF
 Decreased PA pressures = volume
depletion
Complications

 Infection

 Dysrhythmias

 Airembolus
 Thromboembolism

 PA rupture

 Pulmonary infarction
THANK YOU