hemodynamikkk ved hjertesvikt · effect on central venous oxygen saturation 0 12 24 36 48 60 72...
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Hemodynamikkk ved
hjertesvikt - invasiv og non-invasiv monitorering
Geir Øystein Andersen
Hjertemedisinsk intensiv og
overvåkning
Oslo universitetssykehus Ullevål
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Hemodynamikk –
• Pasienter med ulik grad av
– Dyspnoe
– Hypotensjon
– Sirkulatorisk påvirkning
• Ofte lignende symptombilde
• Helt ulik hemodynamikk
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Heart Rate = Cardiac Output
Slagvolumet er avhengig av fyllning,
kontraktilitet og afterload
Stroke
Volume
Preload Afterload Contractility
1. Bridges EJ. In: Woods SL, et al, eds. Cardiac Nursing. 5th ed. 2005. 2. Adams KL. AACN Clin Issues. 2004;15:534-545.
x
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BT= CO x TPR (Blodtrykk=hjerteminutt volum x total perifer motstand)
CO= SV x hjertefrekvens
• Blodtrykk er et surrogat for
vevsperfusjon
• Samme BT kan representere både god
og inadekvat vevsperfusjon
• Ulik grad av vasokonstriksjon
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SVRI
MAP
SV
PCWP
CI HR
Nitroprusside ved
hjertesvikt og
aortastenose
• 25 pasienter
• EF <0.35
• Areal <1.0 cm2
NEJM 2003;348:2756
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Monitorering - Vevsperfusjon
• Har pasienten adekvat vevsperfusjon ?
– Tilfredstillende minuttvolum ? – Godt nok fyllt ? Preload vurdering
– Høyre ventrikkelsvikt
– Myokardfunksjon/slagvolum
– Perifer motstand ? Afterload vurdering
• Er pasienten lungestuvet ?
– Overfyllt ?
– Redistribusjon av væske ?
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Monitorering - Hjerteovervåkningspasient
• Hjerterytme, hjertefrekvens, iskjemi overvåkning
– Kontinuerlig EKG
• Venstre-ventrikkelfunksjon
– Ekkokardiografi
• Vevsperfusjon
– hudtemperatur, bevissthetsgrad
– Diurese
– Blodtrykk (pulstrykk, MAP)
• Oksygenering
– Puls oksymeter
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Monitorering - Kardiogent sjokk
Alle bør ha:
• Arteriekran og CVK
– Arteriell blodgass (laktat, pH, Hb,elektrolytter)
– sentral venøs oksygenmetning (ScvO2)
• Måling av timediurese
• Ekko monitorering av minuttvolum/fyllning
• Evt. lungearteriekateter/Swan-Ganz
• Evt. pulsbølge/pulskontur analyse
– PiCCO kateter
– FloTrac (Vigileo)
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Blandet venøs oksygenmetning
• Fra vena cava superior (ScvO2) eller
fra lungearterien (SvO2)
• Reflekterer grad av ekstraksjon i
vevet og kroppens totale
oksygenreserve.
• Reflekterer organperfusjon og
dermed hjertets minuttvolum,
(forutsetter adekvat arteriell
oksygenering)
• SvO2 < 60 % eller ScvO2 < 65-70 %
indikerer hypoperfusjon
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Effect on central venous oxygen saturation
0 12 24 36 48 60 72 0.45
0.50
0.55
0.60
0.65
0.70
0.75
Time in hours
Effect on serum lactate
0 12 24 36 48 0
2
4
6
8
10
12
14
Time in hours
La
cta
te
Hypotensive patient with afib, low cardiac output, organ
hypoperfusion, renal failure and metabolic acidosis
Volume therapy, amiodarone and levosimendan
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Lungearteriekateter
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Lungearteriekateter
• Minuttvolum, grad av fyllning og perifer motstand
• Ikke vist effekt på overlevelse
• Obs arytmifare hos iskemiske pasienter
Feilkilder:
Minuttvolum (termodilusjon)
• Stor tricuspidal eller pulmonal insufficiens
• VSD, ASD
–Wedge/kiletrykk overestimerer LVEDP
• Mitralstenose, venstre atrium myksom
• Lungeemboli
• Stor mitralinsufficens
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Hemodynamic measurements in
a patient in cardiogenic
shock after PCI of LMS
HR
Levosimendan
infusjon
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CVP at admission and WRF in pts with ADHF
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Pulskonturanalyse
• Pulskonturanalyse brukes til å beregne
slagvolum (SV) (og cardiac output=SV x HR)
• Pulstrykk er proporsjonalt med slagvolum
• Med (PiCCO) eller uten (FloTrac/Vigileo)
transpulmonal termodilusjon (kalibrering)
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Pulskonturanalyse
• OBS – kan ikke brukes ved
(Endret/varierende pulskontur og vaskulær
compliance)
– IABP, Impella, ECMO
– arytmier (atrieflimmer)
Stor aortainsuffisiens
Aortaaneurisme
Betydelig vasodilatasjon eller vasokontriksjon
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Vigileo Kobles til arterikran i arteria radialis
Pulskonturanalyse har «ingen» korreksjon
Beregnede parametere
CO/CI
SV
SVR/SVRI
SVV
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PiCCO -Pulse contour cardiac output-dynamisk
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a. Transpulmonary Thermodilution –statisk måling
CVC Bolus Injection
Right Heart
Lungs
Left Heart
PiCCO Catheter e.g. in femoral artery
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30
32
34
36
38
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
Temp.
0
500
1000
1500
2000
2500
3000
1 3 5 7 9 11 13 15 17 19 21
SVRI
1
1.5
2
2.5
3
3.5
4
1 3 5 7 9 11 13 15 17 19 21
PCCI
PICCO measurements during MTH - out of hospital cardiac arrest survivors
60
65
70
75
80
85
1 3 5 7 9 11 13 15 17 19 21 23 25
ScvO2
20
30
40
50
60
70
80
1 3 5 7 9 11 13 15 17 19 21
HR
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Slagvolum variasjon (ved kontrollert overtrykksventilering)
>12-13% variasjon= sannsynlig volum responsiv
Normalt < 10-13 %
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Ekko • Vurdering av kontraktilitet, klaffefeil,
tamponade
• Minuttvolum beregning
• Fyllning – Visuellt
– Vena cava inferior,
– mitralflowsignal
• Estimere trykk i høyre ventrikkel og pulmonalkretsløpet – Tricuspidal gradient (systolisk trykk)
– Pulmonalgradient (diastolisk trykk)
• Vurdere endediatolisk trykk i venstre ventrikkel – E/E`, lungeveneflow, mitralflowsignal
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Beregning av minuttvolum
Slagvolum = LVOT areal x LVOT VTI
= Pi(LVOT diameter/2)^2 x LVOT VTI
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Likt slagvolum, doblet minuttvolum
pga frekvensøkning
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Beregning av systemisk
karmotstand- SVR
• SVR (dyn-s-cm-5): Utregning fra MAP,
mean RAP (=CVP) og CO
• BT=CO x SVR
• SVR= ((MAP-CVP)x80)/CO
• SVRI= ((MAP-CVP)x80)/CI
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Betydning av riktig LVOT diameter
LVOT
Diam.
2.0 2.3 2.5
SV 56 75 88
CO 3.4 4.5 5.3
CI 1.7 2.3 2.7
SVRI 2823 2133 1811
•HR 60
•LVOT VTI 18 cm
•BSA 2.0
•MAP75
•CVP 15
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Tegn til økt fyllningstrykk
• Venstre atrium: økt størrelse
• Mitralflowsignal:
– økt E/A ratio (>2)
– Kort DT (<150 ms)
• Lungeveneflow:
– svekket systolisk komponent (S/D <40 %)
– Lang varighet på Ar bølgen (> mitral A)
• E/E`>15
• Høy CVP –dilatert VCInf uten resp variasjon
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Mitralflow, lungeveneflow, mitral
annulus hastighet (vevs doppler)
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TH
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Vurdering av fyllning Vena cava inferior
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Trygkgradient (endediastole) over pulmonal+ CVP=
endediastolisk trykk i pulmonalkretsløpet
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E` (early diastolic velocity)
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Snittet av måling medialt og lateralt
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TR2
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TR4
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Troponin T
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NT-proBNP
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ALAT
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Kreatinin
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Multi-organsvikt –lavt
minuttvolum
Inotropi ->IABP -> Impella -> ECMO
Høyre kat:
SvO2 46 %, Cardiac index 1.4
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Monitorering ved akutt hjertesvikt • Hjerterytme, iskjemi overvåkning
– EKG
• Venstre-ventrikkelfunksjon
– Ekkokardiografi
• Vevsperfusjon
– hudtemperatur, bevissthetsgrad
– Diurese
– Blodtrykk (pulstrykk, MAP)
• Oksygenering
– Puls oksymeter
– Arteriell blodgass
Ved kardiogent sjokk:
– Arteriekran, CVK
– Sentral venøs oksygenmetning fra CVK eller lungearterien
– Vurder PiCCO/Vigileo evt Swan-Ganz kateter
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Forkortelser-Swan-Ganz katetermålinger
• Swan-Ganz kateter-lungearteriekateter-PA-kateter
• CVP -sentralt venetrykk
• RAP -høyre atrietrykk
• RVP -høyre ventrikkeltrykk
• PAP -lungearterietrykk
• PCWP/PAWP-innkilt lungearterietrykk-kiletrykk
• SV/SVI -slagvolum-indeksert slagvolum
• CO/CI -hjerteminuttvolum-indeksert minuttvolum
• SVR/SVRI -systemisk karmotstand-indeksert SVR
• PVR/PVRI -lungekarmotstand - indeksert PVR
• SvO2 -sentralvenøs oksygenmetning
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Normalverdier