Department of Ambulatory,

PHILIPPINE HEART CENTER Emergency and Critical Care

Division of Critical Care Medicine
 Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 LEARNING OUTCOMES
At the end of the discussion, the learners
shall be able to:
1. Latest guideline on hemodynamics and
clinical assessment
2. Define hemodynamic variables and
physiologic principles.
3. Monitoring arterial and central venous
pressure variations.
4. Advanced bedside techniques: PAC, TPT
and echocardiography.

Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 CONSENSUS ON CIRCULATORY SHOCK AND HEMODYNAMIC MONITORING
RECOMMENDATION GRADE TYPE OF
STATEMENT
We recommend further hemodynamic assessment (such as assessing cardiac Ungraded Best Practice
function) to determine the type of shock if the clinical examination does not lead to a
clear diagnosis
We suggest that, when further hemodynamic assessment is needed, Level 2; Recommendation
echocardiography is the preferred modality to initially evaluate the type of shock as QoE
opposed to more invasive technologies moderate
In complex patients, we suggest to additionally use pulmonary artery catheterization Level 2; Recommendation
or transpulmonary thermodilution to determine the type of Shock QoE low
In patients with a central venous catheter, we suggest measurements of ScvO2 Level 2; Recommendation
and V-ApCO2 to help assess the underlying pattern and the adequacy of cardiac QoE
output as well as to guide therapy moderate

Cecconi M, De Backer D, Antonelli M, Beale R, Bakker J, Hofer C, Jaeschke R, Mebazaa A, Pinsky MR, Teboul JL, Vincent JL. Consensus on circulatory shock and hemodynamic
monitoring. Task force of the European Society of Intensive Care Medicine. Intensive care medicine. 2014 Dec;40:1795-815.

Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 IMPACT OF HEMODYNAMIC OPTIMIZATION ON POSTOPERATIVE MORBIDITY:
RESULTS FROM FIVE META-ANALYSES IN HIGH RISK SURGICAL PATIENTS
REFERENCES Number of Studies Reduction in postop
(patients) morbidity (%)
Hamilton 29 (4,805) 57
Grocott 31 (5,292) 32
Pearse 22 (3,024) 23
Michard 19 (2,159) 54
Chong 95 (11,659) 34

Fellahi JL, Futier E, Vaisse C, Collange O, Huet O, Loriau J, Gayat E, Tavernier B, Biais M, Asehnoune K, Cholley B. Perioperative hemodynamic optimization: from
guidelines to implementation—an experts’ opinion paper. Annals of Intensive Care. 2021 Dec;11:1-0.

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PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 PERIOPERATIVE HEMODYNAMIC OPTIMIZATION: EXPERT’S OPINION
RECOMMENDATION
We propose to use fluids and vasoconstrictors in combination via a goal directed 100% agreement of consensus
therapy (GDT) algorithm to simultaneously achieve perioperative optimal blood flow panel
and perfusion pressure, avoid volume overload and improve outcome in high risk
surgery patients.

Fellahi JL, Futier E, Vaisse C, Collange O, Huet O, Loriau J, Gayat E, Tavernier B, Biais M, Asehnoune K, Cholley B. Perioperative hemodynamic optimization: from
guidelines to implementation—an experts’ opinion paper. Annals of Intensive Care. 2021 Dec;11:1-0.

Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 PHILIPPINE HEART CENTER
Department of Ambulatory,
Emergency and Critical Care
Division of Critical Care Medicine

Lobdell KW, Chatterjee S, Sander M. Goal-Directed Therapy for Cardiac Surgery.

Critical Care Clinics. 2020 Oct 1;36(4):653-62.
 GUIDELINES FOR PERIOPERATIVE CARE IN CARDIAC SURGERY
ENHANCED RECOVERY AFTER SURGERY SOCIETY RECOMMENDATIONS
RECOMMENDATION CLASS LOE
We recommend goal-directed fluid therapy to reduce postoperative complications CLASS I B
(class I, level B-R).

Engelman DT, Ali WB, Williams JB, Perrault LP, Reddy VS, Arora RC, Roselli EE, Khoynezhad A, Gerdisch M, Levy JH, Lobdell K. Guidelines for perioperative care in cardiac surgery:
enhanced recovery after surgery society recommendations. JAMA surgery. 2019 Aug 1;154(8):755-66.

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 1. High risk patients in
shock

2. High risk patients

undergoing non-
cardiac surgery

3. Patients undergoing
cardiac surgery

Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 “The goals of hemodynamic assessment and
manipulation in the critically-ill patient are to ensure
adequate organ blood flow and oxygen supply.”
Jeremias A, Brown DL. Cardiac intensive care. Elsevier Health Sciences; 2010 May 15.

Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 PRESSURE
BLOOD
PRESSURE / MAP

FLOW
STROKE
VOLUME / CARDIAC
OUTPUT

RESISTANCE SVR

Secomb TW. Hemodynamics. Comprehensive physiology. 2016;6(2):975.

/ PVR

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PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 MAP >65 mmHg

STROKE 60-100
VOLUME ml/min

CARDIAC 4-8 CARDIAC >2.2L/mi

BSA
OUTPUT L/min INDEX n/m2
700-1500
SVR dynes/sec/cm-5

100-200
PVR dynes/sec/cm-5
Secomb TW. Hemodynamics. Comprehensive physiology. 2016;6(2):975.

Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 Heart-Lung Interaction

Coupling

Grubler, M. R., Wigger, O., Berger, D., and Blochlinger, S. (2017). Basic concepts of heart-lung interactions during mechanical ventilation. Swiss Med.
Wkly. 147, w14491. doi:10.4414/smw.2017.14491

Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 Heart-Lung Interaction

Coupling

Grubler, M. R., Wigger, O., Berger, D., and Blochlinger, S. (2017). Basic concepts of heart-lung interactions during mechanical ventilation. Swiss Med.
Wkly. 147, w14491. doi:10.4414/smw.2017.14491

Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 Heart-Lung Interaction

Grubler, M. R., Wigger, O., Berger, D., and Blochlinger, S. (2017). Basic concepts of heart-lung interactions during mechanical ventilation. Swiss Med.
Wkly. 147, w14491. doi:10.4414/smw.2017.14491

Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
Grubler, M. R., Wigger, O., Berger, D., and
Blochlinger, S. (2017). Basic concepts of heart-lung
interactions during mechanical ventilation. Swiss
Med. Wkly. 147, w14491.
doi:10.4414/smw.2017.14491

Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
Grubler, M. R., Wigger, O., Berger, D., and
Blochlinger, S. (2017). Basic concepts of heart-lung
interactions during mechanical ventilation. Swiss
Med. Wkly. 147, w14491.
doi:10.4414/smw.2017.14491

Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
PULMONARY ARTERY
CATHETER
 • Obtained from the proximal
port of the central venous
catheter
• Provides information on right
atrial pressure & right
ventricular filling
• Normal Value: 2-6 mmHg
Jeremias A, Brown DL. Cardiac intensive care. Elsevier Health Sciences; 2010 May 15.
Bojar RM. Manual of perioperative care in adult cardiac surgery. John Wiley & Sons; 2020 Nov 17.

Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 • A phase-delayed, amplitude
damped version of LA
pressure that can represent
LV end diastolic pressure
• During diastole, the
pulmonary venous system,
LA, and LV are a continuous
circuit
• Normal value: 6-12 mmHg
Jeremias A, Brown DL. Cardiac intensive care. Elsevier Health Sciences; 2010 May 15.
Bojar RM. Manual of perioperative care in adult cardiac surgery. John Wiley & Sons; 2020 Nov 17.
Photo from: https://aneskey.com/invasive-hemodynamic-monitoring-in-the-cardiac-intensive-care-unit/

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 Volume Responsive

Volume Overload

Monnet, X., Marik, P. E., & Teboul, J. L. (2016). Prediction of fluid responsiveness: an update. Annals of intensive care, 6(1), 1-11.

Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 Venous O2 sat
Mixed
Arterial O2 sat Venous O2

Central Venous
O2

Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 “The total uptake or release of a substance by an organ is the
product of the blood flow to the organ and the arteriovenous
concentration difference of that substance.”

UPTAKE/RELEASE ARTERIO-VENOUS
BLOOD FLOW
OF A SUBSTANCE DIFFERENCE

Ragosta M. Textbook of Clinical Hemodynamics 2nd edition. Elsevier Health Sciences; 2018

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OXYGEN Emergency and Critical Care
Division of Critical Care Medicine
 OXYGEN ARTERIO-VENOUS
CARDIAC OUTPUT
CONSUMPTION DIFFERENCE

Ragosta M. Textbook of Clinical Hemodynamics 2nd edition. Elsevier Health Sciences; 2018

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PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 OXYGEN CONSUMPTION
CARDIAC
OUTPUT
ARTERIO-VENOUS
OXYGEN 1.36 HEMOGLOBIN 10
DIFFERENCE

Mann DL, Zipes DP, Libby P, Bonow RO. Braunwald's heart disease: a textbook of cardiovascular medicine. Elsevier Health Sciences; 2014 Jul 30.

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PHILIPPINE HEART CENTER Emergency and Critical Care
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 DIRECT FICK
OXYGEN MEASURED BY A COLLECTION
CONSUMPTION BAG OR HOOD
CARDIAC
OUTPUT
ARTERIO-VENOUS
OXYGEN 1.36 HEMOGLOBIN 10
DIFFERENCE

Mann DL, Zipes DP, Libby P, Bonow RO. Braunwald's heart disease: a textbook of cardiovascular medicine. Elsevier Health Sciences; 2014 Jul 30.

Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 DIRECT FICK
OXYGEN
DERIVED FROM A FORMULA
CONSUMPTION
CARDIAC
OUTPUT
ARTERIO-VENOUS
OXYGEN 1.36 HEMOGLOBIN 10
DIFFERENCE

Mann DL, Zipes DP, Libby P, Bonow RO. Braunwald's heart disease: a textbook of cardiovascular medicine. Elsevier Health Sciences; 2014 Jul 30.

Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
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 DIRECT FICK
125ml/m2 BSA (m2)
CARDIAC
OUTPUT
SaO2-SvO2 1.36 Hgb (g/dL) 10

Grafton G, Cascino TM, Perry D, Ashur C, Koelling TM. Resting oxygen consumption and heart failure: importance of measurement for determination of cardiac
output with the use of the Fick principle. Journal of cardiac failure. 2020 Aug 1;26(8):664-72.

Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 ADVANTAGES DISADVANTAGES
Independent of factors that affect Difficulty obtaining accurate oxygen
thermodilution curve shape consumption measurements
More accurate in patients with Wide range of variance among
significant TR different derived formulas for O2
consumption
Easier to do among invasive methods Requires frequent blood extractions
(only requires a CV access)

Ragosta M. Textbook of Clinical Hemodynamics 2nd edition. Elsevier Health Sciences; 2018

Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 Arterial Venous
pH 7.35-7.45 7.31-7.41
pO2 80-100 30-40
pCO2 35-45 41-51
HCO3 22-28 23-29
Mixed/Central
O2Sat >94% >65%-70%
Venous O2sat

Pinsky MR, Teboul JL, Vincent JL, editors. Hemodynamic monitoring. Springer; 2019 Feb 21.
Higgins C. Central venous blood gas analysis. From: https://acutecaretesting.org/en/articles/central-venous-blood-gas-analysis

Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 MIXED Oxygen Saturation
(SVO2): From the pulmonary
artery, >65%

CENTRAL Oxygen Saturation

(ScVO2): From the SVC-RA
junction; >70%
Bojar RM. Manual of perioperative care in adult
cardiac surgery. John Wiley & Sons; 2020 Nov 17.

Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
Crude Estimates of Cardiac Output SVO2
Measures the balance between
oxygen delivery and consumption
Low mixed/central venous O2
saturation = decreased O2
delivery or increased peripheral
O2 utilization = could suggest low
cardiac output ScVO2
Bojar RM. Manual of perioperative care in adult cardiac surgery. John
Wiley & Sons; 2020 Nov 17.

Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 125ml/m2 BSA (m2)
CARDIAC
OUTPUT
SaO2-SvO2 1.36 Hgb (g/dL) 10

Increased SvO2 = lower gradient = increased CO

Decreased SvO2 = higher gradient = decreased CO
Grafton G, Cascino TM, Perry D, Ashur C, Koelling TM. Resting oxygen consumption and heart failure: importance of measurement for determination of cardiac output with the
use of the Fick principle. Journal of cardiac failure. 2020 Aug 1;26(8):664-72.

Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 Arterial Venous
pH 7.35-7.45 7.31-7.41
pO2 80-100 30-40
pCO2 35-45 41-51 PCO2 Gap N=2-6
HCO3 22-28 23-29
O2Sat >94% >65%-70%
Pinsky MR, Teboul JL, Vincent JL, editors. Hemodynamic monitoring. Springer; 2019 Feb 21.
Higgins C. Central venous blood gas analysis. From: https://acutecaretesting.org/en/articles/central-venous-blood-gas-analysis

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PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 Al Duhailib Z, Hegazy
AF, Lalli R, Fiorini K,
Priestap F, Iansavichene
A, Slessarev M. The use
of central venous to
arterial carbon dioxide
tension gap for
outcome prediction in
critically ill patients: a
systematic review and
meta-analysis. Critical
Care Medicine. 2020
Dec 1;48(12):1855-61.

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Division of Critical Care Medicine
 The Role of Central Venous to
Arterial Carbon Dioxide
Tension Gap to Predict
Outcomes in Postoperative
Cardiac Patients: A Systematic
Review and Meta-Analysis

Armand Delo Tan, MD, Marion

Patricio MD, Christian Tortosa
MD, Chito Permejo MD, Luis
Martin I. Habana MD

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PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
PPV/SVV
 Hofer CK, Cannesson M. Monitoring fluid responsiveness. Acta Anaesthesiologica Taiwanica. 2011 Jun 1;49(2):59-65.

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PHILIPPINE HEART CENTER Emergency and Critical Care
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 Dynamic means of assessing volume responsiveness or the ability of
the stroke volume to increase in response to fluids.

Accurate only if 4 conditions are present:

1. Patient has normal sinus rhythm

2. Patient is intubated and mechanically ventilated,
making no spontaneous respiratory efforts Heart-Lung Interaction is
3. Patient is ventilated with at least 8mL/kg of tidal “standardized”
volume
4. Patient has no significant alterations to chest wall
compliance, such as an open chest
Delannoy B, Wallet F, Maucort-Boulch D, Page M, Kaaki M, Schoeffler M, Alexander B, Desebbe O. Applicability of pulse pressure variation during unstable
hemodynamic events in the intensive care unit: a five-day prospective multicenter study. Critical care research and practice. 2016 Jan 1;2016

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PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
FRANK-STARLING CURVE Plateau of the
curve; slight
decrease in stroke
volume with a
mechanical breath

Steep portion;
marked decrease
in stroke volume
with a mechanical
breath

Pinsky MR, Teboul JL, Vincent JL, editors.

Hemodynamic monitoring. Springer; 2019 Feb 21.

Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 PPmax – PPmin
PPV =
PPmean

>12%
Fluid responsive

Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 SVmax – SVmin
SVV =
SVmean

>12%
Fluid responsive

Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
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 • Injection of a bolus of liquid (normal saline)
with known temperature into the proximal
port of the PA catheter
• The liquid admixes with the blood in the
right side of the heart
• Change of blood temperature is measured
by a thermistor on the distal tip

Ragosta M. Textbook of clinical hemodynamics. Elsevier Health Sciences; 2008 Feb 25.

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Division of Critical Care Medicine
 CO = k x (Tblood – Tinjection) x Vinjectate
∫ ∆TB x dt

CO = volume of injectate x temperature difference

area under the temperature-time curve

Gilbert-Kawai, E. T., & Wittenberg, M. D. (2014). Essential Equations for Anaesthesia. Cambridge University Press.

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 • Transduced to a cardiac monitor
which plots the change in
temperature against time to produce
a thermodilution curve

Ragosta M. Textbook of clinical hemodynamics. Elsevier Health Sciences; 2008 Feb 25.

Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
Ragosta M. Textbook of clinical hemodynamics. Elsevier Health Sciences; 2008 Feb 25.

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PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 • Involves injection of a bolus of
liquid or saline through the
central venous access with
the change in temperature
detected by a peripheral
artery catheter (e.g. femoral
artery)

Fot EV, Kuzkov VV. Transpulmonary Thermodilution.

InAdvanced Hemodynamic Monitoring: Basics and New
Horizons 2021 Sep 1 (pp. 61-67). Cham: Springer
International Publishing.

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PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 ADVANTAGES DISADVANTAGES
Obviates the need for withdrawal of May have errors in patients with
blood severe TR or PR

Rapid display of results with Invasive (requires CVP/PAC in place)

computerized methods

Mann DL, Zipes DP, Libby P, Bonow RO. Braunwald's heart disease: a textbook of cardiovascular medicine. Elsevier Health Sciences; 2014 Jul 30.

Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
PULSE CONTOUR ANALYSIS
 PULSE CONTOUR ANALYSIS
• Main prerequisite is an arterial line with a good pressure waveform signal
• Monitors are able to estimate CO from the arterial pulse contour waveform
• Systolic portion of the arterial waveform is proportional to stroke volume

Dicrotic notch

Systolic length Diastolic length

Grensemann, J. (2018). Cardiac output monitoring by pulse contour analysis, the technical basics of less-invasive techniques. Frontiers in medicine, 5, 64.

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Division of Critical Care Medicine
 PULSE CONTOUR ANALYSIS

Huygh, J., Peeters, Y., Bernards, J. & Malbrain M.L. "Hemodynamic monitoring in the critically ill: an overview of current cardiac output monitoring methods." F1000Research 5 (2016).

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 Agreement of Continuous non- Conclusion: CNAP derived
invasive arterial blood pressure hemodynamic parameters had a
monitoring (CNAP) and Pulmonary high mean difference compared to
Artery Catheter Thermodilution the PACT suggesting a poor
method in estimating the agreement between the two
hemodynamic parameters of post methods. However, CNAP had
Coronary artery bypass graft positive correlation with the PACT in
surgery patients in the Surgical terms of trending capability, making
Intensive Care Unit it possible for the CNAP to track the
hemodynamic changes during the
Juxerez Maria B. Sulit, MD; post operative course.
Armand Delo A. Tan, MD;
Chito C. Permejo, MD

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PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
PULSE WAVE TRANSIT TIME
 Estimated Continuous Cardiac Output (esCCO)
• Pulse wave transit time (PWTT) =
time it takes for the pulse wave to
travel between 2 arterial sites
• PWTT is inversely correlated with
SV and CO
• CO and SV are computed through
a predetermined equation that
involves the PWTT value and
experimental constants
Feissel, M., Aho, L. S., Georgiev, S., Tapponnier, R., Badie, J., Bruyere, R., & Quenot, J. P. (2015). Pulse wave transit time measurements of cardiac output in septic shock patients:
a comparison of the estimated continuous cardiac output system with transthoracic echocardiography. PLoS One, 10(6), e0130489
Nihon Kohden. EsCCO Information. Vol 1. A Novel Technology to Non-Invasively Measure Continuous Cardiac Output from ECG and SpO2

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PHILIPPINE HEART CENTER Emergency and Critical Care
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 Conclusion: The absolute
values of hemodynamic
Concordance and correlation of a
parameters obtained from the
continuous non-invasive
non-invasive esCCO had a poor
hemodynamic monitor compared
agreement with the measured
to thermodilution method on
parameters from the gold
monitoring of hemodynamic
standard thermodilution.
parameters in post coronary
Variations in SVR, which are
artery bypass surgery
common in patients after
coronary artery bypass
Mary Rose Anne E. Lacanin, MD;
grafting, appear to influence
Christian John M. Tortosa, MD;
the accuracy of esCCO, as seen
Armand Delo A. Tan, MD;
by wide ranges of agreement
Marion D. Patricio, MD;
between esCCO and TD.
Bernard Benjamin P. Albano, MD
Further refinement of this
technology is warranted.

Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 PCA and PWTT
ADVANTAGES DISADVANTAGES
Minimally invasive or non-invasive Cannot be used in patient’s with
arrhythmias or in patients with poor
peripheral perfusion
Not significantly affected by the Less accurate than the gold standard
presence of regurgitant lesions or (thermodilution)
intracardiac shunts
Provide continuous monitoring which
is recommended for use in fluid
responsiveness tests

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PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
HANDHELD ULTRASOUND
 FOCUSED CARDIAC ULTRASOUND (FOCUS)
ØSafe, portable, and readily available
ØProvides information on cardiac
structure, function, and hemodynamics
ØGross examination of the heart can
reveal:
1. new wall motion abnormalities
2. pericardial effusion or tamponade
3. LV and RV size
Franchi F, Vetrugno L, Scolletta S. Echocardiography to guide fluid therapy in critically ill patients:
check the heart and take a quick look at the lungs. Journal of thoracic disease. 2017 Mar;9(3):477.

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PHILIPPINE HEART CENTER Emergency and Critical Care
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 FOCUSED CARDIAC ULTRASOUND (FOCUS)

Stroke Volume = LVOT area x LVOT VTI

= 𝛑 (LVOT diameter/2)2 x LVOT VTI

Beigel R, Cercek B, Siegel RJ, Hamilton MA. Echo-Doppler hemodynamics: an important management tool for today’s heart failure care. Circulation. 2015 Mar 17;131(11):1031-4.
Image from: Gaspar HA, Morhy SS. The role of focused echocardiography in pediatric intensive care: a critical appraisal. BioMed research international. 2015 Oct 28;2015.

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 POCUS LUNG ULTRASOUND
A profile B profile
Dry interlobular septa Alveolar-interstitial syndrome

Volpicelli G, Elbarbary M, Blaivas M, Lichtenstein DA, Mathis G, Kirkpatrick AW, Melniker L, Gargani L, Noble VE, Via G, Dean A. International evidence-based
recommendations for point-of-care lung ultrasound. Intensive care medicine. 2012 Apr 1;38(4):577-91.

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 • Measurements of IVC
collapsibility, distensibility, and
respiratory variation
• Measures the change in IVC
diameter throughout the
respiratory cycle Max Min
• Assesses the adequacy of
venous return
Lee CW, Kory PD, Arntfield RT. Development of a fluid resuscitation protocol using inferior vena cava and lung ultrasound. Journal of critical care. 2016 Feb
1;31(1):96-100.
Si X, Xu H, Liu Z, Wu J, Cao D, Chen J, Chen M, Liu Y, Guan X. Does respiratory variation in inferior vena cava diameter predict fluid responsiveness in
mechanically ventilated patients? A systematic review and meta-analysis. Anesthesia & Analgesia. 2018 Nov 1;127(5):1157-64.

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PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 • IVC Collapsibility index
(spontaneously breathing):
Maximum – minimum diameter x 100
Maximum diameter
Volume responsive if > 40%

• IVC Distensibility index Max Min

(mechanically ventilated):
Maximum – minimum diameter x 100
Minimum diameter Lee CW, Kory PD, Arntfield RT. Development of a fluid resuscitation protocol using inferior

Volume responsive if > 18%

vena cava and lung ultrasound. Journal of critical care. 2016 Feb 1;31(1):96-100.

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 POINT OF CARE ULTRASONOGRAPHY

ADVANTAGES DISADVANTAGES
Non-invasive Highly operator dependent

Provides quick bedside Device capability must be

assessment to guide considered (e.g. some devices do
management decisions not have doppler measurements)

Poor window in postop patients

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PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 SYSTEMIC VASCULAR RESISTANCE

SVR
[ MEAN ARTERIAL
PRESSURE
CENTRAL VENOUS
PRESSURE
] 80
CARDIAC OUTPUT

Bojar RM. Manual of perioperative care in adult cardiac surgery. John Wiley & Sons; 2020 Nov 17.

Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 PULMONARY VASCULAR RESISTANCE

PVR
[ MEAN PULMONARY
ARTERY PRESSURE
PULMONARY
CAPILLARY WEDGE
PRESSURE ] 80
CARDIAC OUTPUT

Bojar RM. Manual of perioperative care in adult cardiac surgery. John Wiley & Sons; 2020 Nov 17.

Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 PARAMETER FORMULA PURPOSE
Cardiac Power Output (MAP x CO)/451 Monitor inotropic
(CPO) interventions; Aids in
decision making for MCS
Pulmonary Artery (PASP - PADP)/RAP Low values suggestive of
Pulsatility Index (PAPI) Right Heart Failure

Right – Left discordance RAP:PCWP Increased values

of filling pressures suggestive of Right Heart
Failure
Dynamic Arterial PPV/SVV Predict the arterial
Elastance pressure response to
volume expansion
https://scai.org/mechanical-circulatory-support-cardiogenic-shock
Pinsky MR, Teboul JL, Vincent JL, editors. Hemodynamic monitoring. Springer; 2019 Feb 21.
Monge García MI, Gil Cano A, Gracia Romero M. Dynamic arterial elastance to predict arterial pressure response to volume loading in preload-dependent patients. Critical care. 2011 Feb;15:1-9.

Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 INVASIVE

INTERMITTENT CONTINUOUS

NON-INVASIVE
 Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 1. Hemodynamic monitoring techniques cannot improve outcome by
themselves
2. Monitoring requirements may vary over time and can depend on local
equipment availability and training
3. There are no optimal hemodynamic values that are applicable to all
patients
4. Hemodynamic variables need to be combined and integrated
5. Monitoring hemodynamic changes over short periods of time is
important
6. Continuous measurement of all hemodynamic variables is preferable
7. Non-invasiveness is not the only issue
Vincent JL, Rhodes A, Perel A, Martin GS, Della Rocca G, Vallet B, Pinsky MR, Hofer CK, Teboul JL, de Boode WP, Scolletta S. Clinical review: Update on hemodynamic
monitoring-a consensus of 16. Critical care. 2011 Aug 18;15(4):229.

Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine
 Department of Ambulatory,
PHILIPPINE HEART CENTER Emergency and Critical Care
Division of Critical Care Medicine