monitoring hemodinamik
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MONITORING HEMODINAMIKMONITORING HEMODINAMIK
Ezra Oktaliansyah
BAGIAN ANESTESIOLOGI & REANIMASI FAKULTAS KEDOKTERAN UNPAD / RSHS
BANDUNG
Pendahuluan
Hemodinamik
Panduan Resusitasi
Memahami penyakit, Menentukan & Memantau Terapi
VARIABEL HEMODINAMIK
SIRKULASI
PULMONER
SISTEMIK
TAHANAN
POMPA
TEKANAN
KELUAR
MAP/ MPAP
KEDALAM
PAOP/ CVP
PULMONER/ PVRI
SISTEMIK/ SVRI
Right Atrium
Right ventricle
Pu
lmo
nal
art
ery
Left ventricle
Pulmonal vein
Lung
Left atrium
SVR =
Aorta
organ
Systemic Vascular Resistance
Komponen Hemodinamik
Blood Pressure (BP)/TD Central Venous Pressure (CVP) Right and Left Heart Pressures
WHY?WHY?
Untuk optimalisasi konsumsi oksigen & metabolisme Dan ketersediaan energi
HOW?HOW? Monitoring tekanan arterialMonitoring tekanan arterial
A-lineA-line Monitoring tekanan arteri pulmonalis Monitoring tekanan arteri pulmonalis
PA catheter; “Swan Ganz”PA catheter; “Swan Ganz” Monitoring tekanan atrium kananMonitoring tekanan atrium kanan
RAP; CVPRAP; CVP
KRITERIA HEMODINAMIK YG MEMERLUKAN MONITORING KETAT
MAP < 65 or > 120 mmHgCI < 2L/min/m2
PAWP > 15 or < 5 mmHg
Prinsip-prinsipPrinsip-prinsip
Tekanan = aliran Tekanan = aliran xx resistensi resistensi > aliran = semakin tinggi tekanan> aliran = semakin tinggi tekanan Semakin > resistensi = semakin tinggi Semakin > resistensi = semakin tinggi
tekanantekanan
Prisip-prinsipPrisip-prinsip
Tekanan darah = Tekanan darah = aliran aliran (cardiac output) (cardiac output) xx resistensiresistensi (ukuran lumen) (ukuran lumen)
Sistem sirkulasi adalah suatu sirkuit yg Sistem sirkulasi adalah suatu sirkuit yg kontinyukontinyu
Cairan mengalir dari daerah tekanan Cairan mengalir dari daerah tekanan tinggi ke tekanan rendahtinggi ke tekanan rendah Heart pressuresHeart pressures
Pressures in Heart
ALIRAN = TEKANAN
TAHANAN
Normal Vessel
ALIRAN
ALIRAN = TEKANAN
TAHANAN
VASOCONSTRICTION: Angiotensin II, ADH, Adrenaline,
NorEphinephrine, Metaraminol
OBSTRUCTION: Trombus, sclerotic
ALIRAN
ALIRAN
VASODILATATION: Nitroglyserine,
Nitroppruside, milrinone, dobutamine
ALIRAN = TEKANAN
TAHANAN
Cardiac Output (curah jantung)Cardiac Output (curah jantung)
CO = HR X SVCO = HR X SV SV = Preload, afterloadSV = Preload, afterload, dan , dan
contractilitycontractility
PreloadPreload
Regangan serabut otot sebelum sistole Regangan serabut otot sebelum sistole (volume dalam ruang jantung pada ahir (volume dalam ruang jantung pada ahir diastole)diastole)
Ditentukan oleh LVEDV/LVEDPDitentukan oleh LVEDV/LVEDP Hukum Starling’sHukum Starling’s
Regangan ↑= volume ↑Regangan ↑= volume ↑ (regangan berada dalam batas normal)(regangan berada dalam batas normal)
Preload/Afterload in Heart
AfterloadAfterload
Tekanan atau tahanan yg harus dilawan Tekanan atau tahanan yg harus dilawan oleh ventrikel waktu oleh ventrikel waktu ejectionejection
Ditentukan oleh resistensi katup aorta, Ditentukan oleh resistensi katup aorta, tek. Arterial sistemik & viskositastek. Arterial sistemik & viskositas
SVR & tek. Arterial → Left vent. afterloadSVR & tek. Arterial → Left vent. afterload PVR & tek. Arteri P → Right vent. PVR & tek. Arteri P → Right vent.
AfterloadAfterload
Kontraktilitas Kontraktilitas
Kekuatan kontraksi ventrikelKekuatan kontraksi ventrikel Bagaimana jantung memompa dengan baikBagaimana jantung memompa dengan baik No direct measure No direct measure
Ejection FractionEjection Fraction
Prosentase vol darah yg Prosentase vol darah yg diejeksikan saat sistolediejeksikan saat sistole
NormalNormal : : 60% - 70% 60% - 70%
Cardiac Output x SVR
Volume =Blood
Hypovolemic Shock
Cardiogenic Shock
Distributive Shock
Inotropes Vasopressor
Fluids
Obstructive Shock
Release tamponade,etc
Arterial pressurePipe = Vascular
Komponen Monitoring Hemodinamik Komponen Monitoring Hemodinamik
TransducerTransducer • Merubah peristiwa2 fisiologis kedalam Merubah peristiwa2 fisiologis kedalam
sinyal2 elektrik (e.g. tekanan, sinyal2 elektrik (e.g. tekanan, temperatur, cahaya)temperatur, cahaya)
AmplifierAmplifier• Menangkap sinyal elektrik dan Menangkap sinyal elektrik dan
mentransmisikan kelayar monitormentransmisikan kelayar monitor
Components of Hemodynamic Components of Hemodynamic MonitoringMonitoring
Monitor DisplayMonitor Display• Layar monitor (gambaran gelombang, Layar monitor (gambaran gelombang,
nilai pressure)nilai pressure) Catheter tubing / flush systemCatheter tubing / flush system
• Perawatan kateterPerawatan kateter• Heparinized solutionHeparinized solution ( (protokol)protokol)• Pressure bagPressure bag
Reliable MeasurementsReliable Measurements
Level = phlebostatic axis (4th intercostal Level = phlebostatic axis (4th intercostal space, midaxillary line)space, midaxillary line)
Balance = zero reference (negates Balance = zero reference (negates atmosphere pressure)atmosphere pressure)
Calibration = numerical accuracyCalibration = numerical accuracy How often to check?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 MonitoringIntraarterial Monitoring
IndikasiIndikasi Monitoring kontinyu tekanan darahMonitoring kontinyu tekanan darah Blood samplingBlood sampling p↑an tek. Intrakranialp↑an tek. Intrakranial Obat vasoaktiveObat vasoaktive
SitesSites RadialRadial BrachialBrachial FemoralFemoral
Allen Test
Nursing interventionsNursing interventions
Monitor bentuk gelombangMonitor bentuk gelombang Bandingkan dengan nilai ‘cuff’Bandingkan dengan nilai ‘cuff’
• A-line harus lebih akurateA-line harus lebih akurate Periksa sistem koneksiPeriksa sistem koneksi Periksa kateter arteri & sirkulasi pd Periksa kateter arteri & sirkulasi pd
ekstremitasekstremitas Set alarmsSet alarms
KomplikasiKomplikasi
Emboli udara: komplikasi mayorEmboli udara: komplikasi mayor PerdarahanPerdarahan TrombosisTrombosis
Tekanan Atrium KananTekanan Atrium Kanan
RV preload/RVEDPRV preload/RVEDP Right pressure changes usually occur Right pressure changes usually occur
latelate
Kateter untuk menilai RAPKateter untuk menilai RAP
Pulmonary artery catheter (proximal port)Pulmonary artery catheter (proximal port) Central line (e.g. triple lumen catheter)Central line (e.g. triple lumen catheter) Peripherally inserted central catheter Peripherally inserted central catheter
(PICC) line(PICC) line
MeasurementMeasurement
Measured via pressure systemMeasured via pressure system Normal value is 0 to 8 mm Hg Normal value is 0 to 8 mm Hg Recorded as MEAN valueRecorded as MEAN value
Nursing implicationsNursing implications
Zero/level/balanceZero/level/balance• Positioning patientPositioning patient• Respiratory cycleRespiratory cycle
Interpretasi Nilai CVPInterpretasi Nilai CVP
CVP RendahCVP Rendah• HypovolemiaHypovolemia• VasodilationVasodilation
CVP TinggiCVP Tinggi• HypervolemiaHypervolemia• VasoconstrictionVasoconstriction• Right CHFRight CHF• Pulmonary Pulmonary
hypertensionhypertension
KomplikasiKomplikasi
Pneumo/hemothoraxPneumo/hemothorax Perforasi jantungPerforasi jantung DisritmiaDisritmia
What assessments should be done during insertion What assessments should be done during insertion and immediately after insertion?and immediately after insertion?
What are important interventions to prevent complications?What are important interventions to prevent complications?
Implikasi PerawatanImplikasi Perawatan
Zero/balanceZero/balance Analisa gelombangAnalisa gelombang Variasi Respirasi Variasi Respirasi Monitor komplikasi InfeksiMonitor komplikasi Infeksi
Central Venous PressureCentral Venous Pressure
TRIPPLE LUMEN CATHETER
18 Ga
16 Ga
18 Ga
INTERPRETATION
Kateter Arteri PulmonalisKateter Arteri Pulmonalis
19701970 Dr. Swan and Ganz Dr. Swan and Ganz (Swan-Ganz is a brand)(Swan-Ganz is a brand)
Menggambarkan tekanan pada jantung Menggambarkan tekanan pada jantung kirikiri
DescriptionDescription
Balloon-tippedBalloon-tipped Measures PA systolic, diastolic, Measures PA systolic, diastolic,
mean, and wedge (PCWP; PAWP; mean, and wedge (PCWP; PAWP; PAOP)PAOP)
Multi-lumenMulti-lumen Proximal (RA)Proximal (RA) Proximal injectateProximal injectate Distal (PA)Distal (PA) BalloonBalloon
InsertionInsertion
Provide explanation and obtain Provide explanation and obtain informed consentinformed consent
Site: usually subclavian or internal Site: usually subclavian or internal jugularjugular
Incision: guide wire, introducer, Incision: guide wire, introducer, catheter, sheathcatheter, sheath
Flush lumensFlush lumens
InsertionInsertion
Inserted with balloon down, selected Inserted with balloon down, selected inflation to get into PAinflation to get into PA
Waveform changes as catheter Waveform changes as catheter progresses progresses
Check for proper wedgingCheck for proper wedging Secure and dress siteSecure and dress site
During insertionDuring insertion
Monitor pressures in each chamberMonitor pressures in each chamber Record valuesRecord values Assess for complicationsAssess for complications
• DysrhythmiasDysrhythmias• Pneumo/hemothoraxPneumo/hemothorax
PA ValuesPA Values
Normal is 25 to 10 with mean is 15Normal is 25 to 10 with mean is 15 Systolic 15 to 30 mm HgSystolic 15 to 30 mm Hg Diastolic 4 to 12 mm HgDiastolic 4 to 12 mm Hg PCWP 6 to 12 mm Hg PCWP 6 to 12 mm Hg
Diastolic reflects PCWP unless Diastolic reflects PCWP unless pulmonary hypertension present pulmonary hypertension present (mitral valve open during end (mitral valve open during end diastole; therefore, open circuit)diastole; therefore, open circuit)
CVP location
PA cath location
A. pulmonalisRight Atrium
InterpretationInterpretation
Increased PA pressures = volume Increased PA pressures = volume overload, CHFoverload, CHF
Decreased PA pressures = volume Decreased PA pressures = volume depletiondepletion
ComplicationsComplications
InfectionInfection DysrhythmiasDysrhythmias Air embolusAir embolus ThromboembolismThromboembolism PA rupturePA rupture Pulmonary infarctionPulmonary infarction
THANK YOU