![Stethoscopy
• Laennec introduced in 1818
• During surgery by Harvey Cushing
• Precordial and Esophageal stethoscopy
• Now a days not used for continuous monitoring because for introduction of
other methods.{ except for peads and remote location].](https://image.slidesharecdn.com/cardiacmonitoringppt-170904022316/85/Cardiac-monitoring-ppt-2-320.jpg)
Cardiac monitoring ppt
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This document provides an overview of cardiac monitoring techniques including stethoscopy, electrocardiography, pulse rate monitoring, arterial blood pressure monitoring, central venous pressure monitoring, and pulmonary artery catheterization. Key points include: stethoscopy was introduced in 1818 but is not used for continuous monitoring; electrocardiography is the most common method to detect heart rate; differences exist between heart rate and pulse rate; noninvasive and invasive blood pressure monitoring methods are described along with their complications; central venous pressure monitoring provides information on right atrial pressure; and pulmonary artery catheters allow direct measurement of pressures and cardiac output in critically ill patients.
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Cardiac monitoring ppt
- 1. Cardiac Monitoring Presentation byDr Deepti Tiwari Moderator Dr Upasana Goswami
- 2. Stethoscopy • Laennec introducedin 1818 • During surgery by Harvey Cushing • Precordial and Esophageal stethoscopy • Now a days not used for continuous monitoring because for introduction of other methods.{ except for peads and remote location].
- 3. Heart Rate monitoring •“Finger on pulse” is the easiest and quickest method to assess heart rate. • ECG is most common method to detect heart rate in ot, by measurement of r-r interval. • ECG can get confounded by electrosurgical instruments, power line noises, twitchings and fasciculations, lithotripsy machine, cardiopul bypass, and fluid warmers. • Direct ECG monitoring is better than monitoring of derived heart rate.
- 4. Picture shows HRof 49 but direct observation shows dangerous bradyarrythmia it may be a asystole that cannot be assessed by digitally displayed HR. Arrow shows correction of baseline by ECG filters.
- 5. Pulse Rate monitoring •Difference between pulse rate and heart rate is the difference between electrical depolarization and mechanical contraction of heart. • Pulse deficit arises in conditions such as AF , PEA( in Cardiac tamponade, extreme hypovolemia, and conditions where electrical activity is present but not capable of producing pulse). • Pulse oxymetery gives PR. Although it seems redundant to measure both HR and PR but its important to avoid error.
- 6. Arteial blood pressuremonitoring • Sphygmomanometer use for systolic blood pressure first described by Riva and Rocci in 1896(palpatory method). Korotkoff in 1905 described measurement of diastolic as well.(auscultatory method). • Any condition causing decrease in blood flow below the level of detection, or conditions needing excessive pressure to occlude artery. • Size of cuff 40% and 80%of circumference and length of arm. Too large can still be accepted but too small will give spuriously high reading. Pressure should be released slowly to assess korotkofs sounds properly. Rapid deflation results in falsely low readings.
- 7. Automated NIBP • Intermittentbased on oscillometery method, first described by marey 1876. • Assess MAP most accurately and SBP and DBP are derived. DBP is least reliable by this method. • This method is although highly unrelialable, its still most used in critical care settings but its use other than upper arm is not validated. • Complications may occur due to continuous use and use in patients with coagulopathies, arterial and venous insufficiency, thrombolytic therapy and peripheral neuropathies. • Automated continuous techniqes(eg:finger BP by arterial volume clamp method) are also available but with several disadvantages.
- 9. Complications of NoninvasiveBlood Pressure Measurement • Pain • Petechiae and ecchymoses • Limb edema • Venous stasis and thrombophlebitis • Peripheral neuropathy • Compartment syndrome
- 10. IBP/ Direct bloodpressure monitoring • Despite various complications and need of expertise IBP monitoring is ideal reference standard for BP monitoring ,which provide timely and crucial information. • Arterial cannulation can be done in radial, ulnar, brachial, axillary or femoral artery. • More central the artery is more are the chances of embolism. Axillary and femoral arterial cannulation results waveforms that resembles change in pressure in aortic arch more closely. • In radial artery cannulation hyperextension is avoided to prevent median nerve injury and in femoral artery cannulation must be done below the inguinal ligament.
- 11. odified Allen’s Test MODIFIEDALLENS TEST
- 12. Indications for ArterialCannulation • Continuous, real-time blood pressure monitoring • Planned pharmacologic or mechanical cardiovascular manipulation • Repeated blood sampling • Failure of indirect arterial blood pressure measurement • Supplementary diagnostic information from the arterial waveform • Determination of volume responsiveness from systolic pressure or pulse pressure variation
- 13. Complications of DirectArterial Pressure Monitoring • Distal ischemia, pseudoaneurysm, arteriovenous fistula. • Hemorrhage, hematoma • Arterial embolization • Local infection, sepsis • Peripheral neuropathy • Misinterpretation of data • Misuse of equipment
- 14. NORMAL ARTERIAL PRESSURETRACING 1, Systolic upstroke; 2, systolic peak pressure; 3, systolic decline; 4, dicrotic notch; 5, diastolic runoff; 6, end-diastolic pressure.
- 16. Arterial Blood PressureWaveform Abnormalities • Condition Characteristics • Aortic stenosis Pulsus parvus (narrow pulse pressure) • Pulsus tardus (delayed upstroke) • Aortic regurgitation Bisferiens pulse (double peak) • Wide pulse pressure • Hypertrophic cardiomyopathy Spike-and-dome pattern (midsystolic obstruction) • Systolic left ventricular failure Pulsus alternans (alternating pulse pressure amplitude) • Cardiac tamponade Pulsus paradoxus (exaggerated decrease in systolic blood pressure during spontaneous inspiration
- 17. A, Normal ARTand pulmonary artery pressure (PAP) wave, B, In aortic stenosis, the ART waveform is distorted and demonstrates a slurred upstroke and delayed systolic peak.. See text for greater detail. C, Aortic regurgitation produces a bisferiens pulse and a wide pulse pressure. D, The arterial pressure waveform in hypertrophic cardiomyopathy shows a peculiar “spike-and-dome” configuration. The pressure waveform assumes a more normal morphology after surgical correction of this condition
- 18. Central venous Pressuremonitoring • Central vein is catheterized for various purposes. • Measurement of CVP is often necessary in heamodynamically unstable and patietns undergoing major surgeries. • Rt IJV is most commonly catheterised central vein. Others are left IJV , right and left subclavian, femoral, external jugulars and axillary. • Most commonly used size is 7 French , 20 cm catheter with a 18 g introducer needle and guide wire.
- 19. Indications for CentralVenous Cannulation • Central venous pressure monitoring • Pulmonary artery catheterization and monitoring • Transvenous cardiac pacing • Temporary hemodialysis • Drug administration -Concentrated vasoactive drugs • Hyperalimentation • Chemotherapy • Agents irritating to peripheral veins • Prolonged antibiotic therapy (e.g., endocarditis) • Rapid infusion of fluids (via large cannulas) Trauma • Major surgery • Aspiration of air emboli • Inadequate peripheral intravenous access • Sampling site for repeated blood testing
- 20. Complications of CVP: •Mechanical Vascular injury Arterial Venous Hemothorax Cardiac tamponade • Respiratory compromise Airway compression from hematoma Tracheal, laryngeal injury Pneumothorax • Nerve injury • Arrhythmias • Subcutaneous/mediastinal emphysema • Thromboembolic Venous thrombosis Pulmonary embolism Arterial thrombosis and embolism (air, clot) Catheter or guidewire embolism • Infectious Insertion site infection Catheter infection Bloodstream infection Endocarditis • Misinterpretation of data • Misuse of equipment
- 21. Central Venous PressureWaveform Components • a wave End diastole Atrial contraction • c wave Early systole Isovolumic ventricular contraction, tricuspid motion toward the right atrium • v wave Late systole Systolic filling of the atrium • h wave Mid to late diastole Diastolic plateau • x descent Mid systole Atrial relaxation, descent of the base, systolic collapse • y descent Early diastole Early ventricular filling, diastolic collapse
- 23. JVP's - Appearanceand Interpretation Introduction The JVP (jugular venous pressure) is a manometer of pressure in the right atrium; when pressure in the atrium is high the JVP will be raised and when right atrial pressure is low the JVP will drop. Features of the JVP A venous pulse is not usually palpable. Pressing at the base of the vein will make the vein visible as it continues to fill and distend above the point of pressure NB do not do this in exams. Hepatojugular reflex aids identfication of JVP - probably by forcing blood out of liver into IVC and therefore into right atrium increasing its pressure. JVP alters with changes in posture.
- 24. How to findthe JVP Sit patient at 45° and turn head slightly away from you. • Look for JVP in internal jugular vein (not external jugular vein) medial to the clavicular head of sternocleidomastoid; the vein passes behind the angle of the jaw in direction of earlobe. • Measure JVP in cm above the sternal notch - a vertical not diagonal distance - if larger than 3cm the JVP is raised. Abnormalities of the JVP 1) Raised JVP with normal waveform •right heart failure •fluid overload •bradycardia
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- 26. Abnormalities of theJVP 1) Raised JVP with normal waveform •right heart failure •fluid overload •bradycardia 2) Raised JVP with absent pulsation •SVC obstruction - full dilated jugular veins, no pulsation, oedematous face and neck 3) Large a wave •tricuspid stenosis - atria contracts against stiff tricuspid and so pressure in atria rises higher than normal •pulmonary hypertension - there are generally higher pressures on the right side of the heart •pulmonary stenosis 4) Extra-large a wave = Cannon wave
- 27. 5) Absent awave •atrial fibrillation 6) Systolic waves = combined c-v waves = big v waves •tricuspid regurgitation (c-v wave because the pressure in the right atrium is raised throughout ventricular systole - tip is to watch for earlobe movement!) 7) The slow y descent occurs in tricuspid stenosis (if the HR is so low as to allow the length of descent to be appreciated!)8) Paradoxical JVP = Kussmaul's sign Normally the JVP should rise on expiration and fall on inspiration. When the JVP rises on inspiration it indicates •pericardial effusion •constrictive pericarditis •pericardial tamponade
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- 29. Introduction • Pulmonary arterycatheters (also called as Swan-Ganz catheter) are used for evaluation of a range of condition Although their routine use is not common, they are still occasionally placed for management of critically ill patients
- 30. Physiological Measurements • Directmeasurements of the following can be obtained from an accurately placed pulmonary artery catheter(PAC) • Central Venous Pressure(CVP) • Right sided intracardiac pressures(RA/V) • Pulmonary artery pressure(Pap) • Pulmonary artery occlusion pressure (PAOP) • Cardiac Output • Mixed Venous Oxygen Saturation(SvO2)
- 31. • Indirect measurementsthat are possible: • Systemic Vascular Resistance • Pulmonary Vascular Resistance • Cardiac Index • Stroke volume index • Oxygen delivery • Oxygen uptake
- 32. Indications • Diagnostic: • Differentiationamong causes of shock • Differentiation between mechanisms of pulmonary edema • Evaluation of pulmonary hypertension • Diagnosis of pericardial tamponade • Diagnosis of right to left intracardiac shunts • Unexplained dyspnea
- 33. • Therapeutic: • Managementof perioperative patients with unstable cardiac status • Management of complicated myocardial infarction • Management of patients following cardiac surgery/high risk surgery • Management of severe preecclampsia • Guide to pharmacologic therapy • Burns/ Renal Failure/ Heart failure/Sepsis/ Decompensated cirrhosis • Assess response to pulmonary hypertension specific therapy
- 34. Contraindications • Absolute: • Infectionat insertion site • Presence of RV assist device • Insertion during CPB • Lack of consent • Relative: • Coagulopathy • Thrombocytopenia • Electrolyte disturbances (K/Mg/Na/Ca) • Severe Pulmonary HTN
- 35. Making decision toplace pulmonary artery catheter In critically ill or perioperative patients decision to place a pulmonary artery catheter should be based on patient’s hemodynamic status or diagnosis that cannot be answered satisfactory by clinical or non-invasive assessment
- 36. Preparation • Patient hasto be monitored with continuous ECG throughout the procedure, in supine position regardless of the approach • Aseptic precautions must be employed • Cautions should be taken while cannulating via IJV/ Subclavian vein
- 37. • Equipments: • 2%chlorhexidine skin preparation solution • Sterile gown, gloves, face shield and cap • Sterile gauze pads • 1% lidocaine -5 cc • Seeker needle 23G • Introducer needle 18G • J-tip guidewire • Transduction tubing • Sterile catheter flush solution • Sheath • Pulonary catheter • Sterile sleeve for catheter • 2-0 silk suture • Sterile dressing
- 40. 1. Aseptic precautionsundertaken 2. Local infiltration done 3. Check balloon integrity by inflating with 1.5ml of air 4. Check lumens patency by flushing with saline 0.9% 5. Cover catheter with sterile sleeve provided 6. Cannulate vein with Seldinger technique 7. Place sheath 8. Pass catheter through sheath with tip curved towards the heart Technique:
- 41. 9. Once tipof catheter passed through introducer sheath inflate balloon at level of right ventricle 10. The progress of the catheter through right atrium and ventricle into pulmonary artery and wedge position can be monitored by changes in pressure trace 11. After acquiring wedge pressure deflate balloon
- 44. • Important tip: •When advancing catheter- always inflate tip • When withdrawing catheter- always deflate • Once in pulmonary artery - NEVER INFLATE AGAINST RESISTANCE - RISK OF PULMONARY ARTERY RUPTURE.
- 45. Interpretation of hemodynamicvalues and waveforms • Ensuring accurate measurements: • Zeroing and Referencing • Correct placement • Fast flush test
- 46. • Zeroing andReferencing: • PAC must be appropriately zeroed and referenced to obtain accurate readings in supine position/30 degrees semi-recumbent position • Correct placement : • By either pressure waveform/ fluoroscopic guidance
- 47. • Rapid flushtest:
- 48. Catheter waveforms andpressures • Pressure waveforms can be obtained from • Right atrium • Right ventricle • Pulmonary artery
- 49. • Right atrium: •In presence of a competent tricuspid valve, RA pressure waveform reflect both • Venous return to RA during ventricular systole • RV End Diastolic Pressure • Normal RA pressure: 0-7 mmHg
- 51. • Elevated RApressure: • Diseases of RV( infarction/ cardiomyopathy) • Pulmonary hypertension • Pulmonic stenosis • Left to right shunts • Pericardial diseases • LV systolic failure • Hypervolemia
- 52. • Differentiating amongetiologies depends on • Clinical • Radiographical • Echocardiographic features + PAC findings Eg: Increased RA Pressure and Mean pulmonary Pressure PAH Increased RAP and Normal Pa pressures RV disease/ Pulmonary stenosis
- 53. • Abnormal RAwaveforms: • Tall v waves: Tricuspid Regurgitation • Giant/ cannon a waves: • Ventricular tachycardia • Ventricular pacing • Complete heart block • Tricuspid stenosis • Loss of a waves: • Atrial fibrillation/ Atrial flutter
- 56. • Right Ventricle: •Transitioning from SVC or RA to RV: • Once balloon is inflated in the SVC/RA the catheter is slowly advanced When catheter tip is across tricuspid valve pressure waveform changes and systolic pressure increases
- 57. • 2 pressuresare typically measured in right ventricular pressure waveform • Peak RV systolic pressure 15-25mmHg • Peak RV diastolic pressure 3-12 mmHg
- 59. • As ageneral rule elevations in RV pressure: • Diseases increasing pulmonary artery pressure • Pulmonic valve disorders • Diseases affecting right ventricle • Pulmonary vascular and pulmonary valve disorders a/w increased RV systolic pressures • RV disorders – ischemia/infarction/failure – a/w increased RV End diastolic pressure
- 60. • Pulmonary artery: •The risk of arrhythmias is greatest while catheter tip is in RV Thus, catheter should be advanced from RV to PA without delay • When catheter tip passes pulmonary valve Diastolic pressure increases and characteristic dichrotic notch appears in waveform
- 61. • Normal pulmonaryartery pressures: • Systolic 15-25mmHg • Diastolic 8-15 mmHg • Mean 16 (10-22mmHg) • Main components of PA tracing: • Systolic and Diastolic pressure • Dichrotic notch(due to closure of pulmonic valve)
- 63. • Increase inmean pulmonary pressure: • Acute: • Venous Thromboembolism • Hypoxemia induced Pulmonary Vasoconstriction • Acute on Chronic: • Hypoxemia induced pulm VC in patient with chronic cardiopulmonary disease • Chronic: • Pulmonary hypertension
- 64. • Types ofPHT: • Primary • Due to Heart Disease • Due to Lung Disease • Due to chronic venous thromboembolism • Miscellaneous ( Sickle Cell Anemia)
- 65. Pulmonary arterial occlusionpressure • Once catheter tip has reached PA, it should be advanced until PAOP is identified by decrease in pressure and change in waveform The balloon should then be deflated and PA tracing should reappear If PCOP tracing persists catheter should be withdrawn with definitive PA tracing obtained
- 66. • Final positionof the catheter within PA must be such that PCOP tracing is obtained whenever 75-100% of 1.5ml maximum volume of balloon is insufflated • If < 1ml of air is injected and PAOP is seen then it is overwedged needs to be withdrawn • If after maximal inflation fails to result in PCOP tracing or after 2-3 seconds delay too proximal – advanced with balloon inflated
- 67. • PCWP/PAOP interprets Left atrial pressures more importantly – LVEDP • Best measured in • Supine position • At end of expiration • Zone 3 (most dependent region) • Normal PCWP- 6-15 mmHg ; Mean :9mmHg
- 70. • Abnormal PAOP: •Increased LVEDP Increased PAOP • LV systolic HF • LV Distolic HF • Mitral and Aortic valve disease • Hypertrophic cardiomyopathy • Hypervolemia • Large R-L shunts • Pericardial disease
- 71. • Decreased PCWP: •Hypovolemia • Obstructive shock due to large pulmonary embolus • Abnormal waveforms • Large a waves: • MS • LV systolic /diastolic function • LV volume overload • MI • Large v waves - MR
- 72. • Calculation ofcardiac output: • 2 methods • Thermodilution method • Fick’s Method • Better measurement with Cardiac index • Normal – 2.8- 4.2 l/min/m2
- 73. • Decreased CO: •Systolic HF • Diastolic HF • MR • Hypovolemia • Pulmonary HT • RVF • Increased CO: • Systemic A-V fistulas • Anemia • Beriberi • Renal Disease • Sepsis
- 74. • Other usesof pulmonary artery catheter: • Detection of Left to right shunts • Estimation of systemic and pulmonary vascular resistance
- 75. Complications • General: • Immediate: •Bleeding • Arterial Puncture • Air embolism • Thoracic duct injury ( L side) • Pneumothorax/hemothorax • Delayed: • Infections • Thrombosis
- 76. • Related toinsertion of PAC: • Arrhythmias (most common- Ventricular/ RBBB) • Misplacement • Knotting • Myocardial/valve/vessel rupture • Related to maintenance and use of PAC: • Pulmonary artery perforation • Thromboembolism • Infection
- 77. ECHO/ DOPPLER CARDIOGRAPHY • Adiagnostic Study that reveals information about: • The structure and function of the heart • Cardiac hemodynamics of the heart
- 78. THEORY AND TECHNIQUEOF THE STUDY • Utilizes the Application of Ultasonic waves being reflected back on hitting a structure • This is done utilizing a transducer that both sends out the beam and then receives it back • The transducer can have one crystal or multiple crystals • Utilizing the technique of doppler with ultrasound allows the ability to quantitate the direction and velocity of objects
- 81. APPLICATION OF THETECHNIQUE: • M mode echo • 2 DIMENSIONAL ECHO: • Tran thoracic Echo- transducer directly on the chest wall • Transesophageal Echo- probe placed into the esophagus and stomach • Stress echocardiography- Tran thoracic echo at rest and post stress or exercise
- 82. APPLICATION OF THETECHNIQUE: • Doppler can be viewed as: • Continuous wave- continuous transmission of signal with 2nd transducer available to receive the signal • Pulsed Doppler- same probe transmits, waits an the receives • Color flow- vectors directions given colors, usually blue if flow is away from transducer and red if goes toward the transducer.
- 88. THIS TECHNIQUE ALLOWSTHE EVALUATION OF: • Cardiac Chambers- size and motion or function • The thickness of the walls of the heart • Abnormal Objects in the heart: tumors or masses • Valvular structure (size and shape) • Valvular function (thickness, stenosis, or leakage) • Blood flow- hemodynamics • Other pathologies- fluid: pericardial effusionOther objects- vegetations etc. • Mechanical valves • Pacemaker wires
- 99. ABNORMAL IMAGES • LEFTVENTRICULAR FUNCTION
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