¿QUÉ AYUDAS TENEMOS PARA EL MONITOREO CARDIOVASCULAR DE NUESTROS PACIENTES?

MONITORIA CARDIOVASCULAR

Marcelino Murillo DeluquezResidente Anestesia y Reanimación

Universidad de Cartagena

MONITOREO CIRCULATORIO

USO DEL FONENDOSCOPIO

LAENNEC 1.818

Harvey Cushing 1908

MONITOREO DE LA FRECUENCIA CARDIACA

DIFERENCIAS ENTRE FC Y PULSO

Disociación electromecánica. Actividad eléctrica sin pulso. Fibrilación auricular. Taponamiento cardiaco. Hipovolemia marcada.

TÉCNICA MANUAL DE TOMA DE TENSIÓN ARTERIAL

Riva-Rocci

Korotkoff 1.905

PSEUDO HIPERTENSIÓN

TEMBLOR

CALCIFICACIONES “signo de Osler”

TAMAÑO INAPROPIADO

PSEUDO HIPOTENSIÓN

Shock cardiogénico

Vasopresores a altas dosis.

TOMA DE LA TA AUTOMATIZADA

COMPLICACIONES EN LA MEDICIÓN DE LA T.A. NO INVASIVA

COMPLICACIONES

DOLOR

PETEQUIAS Y EQUIMOSIS

EDEMA DE LA EXTREMIDAD

ESTASIS VENOSO Y TROMBOFLEBITIS

NEUROPATÍA PERIFERICA

SINDROME COMPARTIMENTAL

MONITORÍA ARTERIAL

INDICACIONES PARA LINEA ARTERIAL INVASIVA

Monitoría de TA en tiempo real, continua.

Manipulación cardiovascular mecánica, farmacológica.

Toma de muestras continuas.

Falla en la toma de TA indirecta.

Información diagnostica suplementaria de onda arterial.

Determinación de la respuesta volumétrica de la presión sistólica y variación en la presión de pulso.

MONITORIA ARTERIAL DIRECTA

Arteria Radial.

Slogoff et al.

Test Allen Mod.

Procedimiento.

COMPLICACIONES DE LA CANALIZACIÓN DE LA ARTERIA RADIAL

< 0.1 %

POCO COMUN

Vasoespasmo Arterial.

Lesion Arterial. Trombocitosis Shock Altas dosis de

vasopresores. Canulación

prolongada. Infección.

COMPLICACIONES DEL MONITOREO DE TA DIRECTA.

COMPLICACIONES

Isquemia distal, pseudoaneurisma, fistula AV

Hematoma, Hemorragia.

Embolización Arterial.

Infección local y sepsis

Neuropatía periférica.

Mala interpretación de datos

Mal uso de los equipos.

PRESION ARTERIAL INVASIVA

ONDA DE PRESIÓN ARTERIAL NORMAL

ONDAS DE PRESIÓN ARTERIAL Y DE PULSO A NIVEL PERIFERICO

ONDAS DE PRESIÓN ARTERIAL JOVEN Y ADULTO

VARIABILIDAD SISTÓLICA DE LA PRESIÓN ARTERIAL

VARIABILIDAD DE PRESIÓN DE PULSO

MONITORIZACIÓN DE LA PRESIÓN VENOSA CENTRAL

TECNICA DE CANALIZACIÓN VENOSA CENTRAL DERECHA

CATETERIZACIÓN YUGULAR INTERNA IZQUIERDA

Riesgo de Pneumotórax. Lesión del conducto toráxico. Lesión de la pared lateral derecha de la

cava superior. La vena Yugular interna izquierda es

más pequeña. Requiere confirmación radiográfica.

CANALIZACIÓN DE LA SUBCLAVIA

Menor riesgo de infección. Terapia IV por largo tiempo. Hiperalimentación. Quimioterapia. En Trauma cervical. Máximo 2 – 3 intentos. VIDEO

CANALIZACIÓN YUGULAR EXTERNA

Menos riesgo de pneumotórax. Se pueden realizar más intentos. Venas más tortuosas. Abducción del hombro 90 grados. No hacer fuerza al pasarlo por la

subclavia.

CANALIZACIÓN DE LA VENA FEMORAL

ALTERNATIVA EN LESIONES DE CUELLO, TÓRAX, CRANEO.

LESION ARTERIA O NERVIO FEMORAL. RIESGO DE TROMBOEMBOLISMO RIESGO DE INFECCIÓN

IMAGEN ULTRASONOGRAFICA EN LA CANALIZACIÓN DE LA YUGULAR INTERNA

CANALIZACIÓN VENOSA CENTRAL BAJO ULTRASONIDO

Beneficio comprobado en UCI y QX. Solo es usa en un 15 % Se puede usar con Doppler Bidimensional 10 Hz Operador dependiente. Confirmar posición realizada sin

ultrasonido. Accesos Yugular, Subclavio, Femoral.

PRESIÓN VENOSA CENTRAL

PRESIÓN CAVA-AURICULA FUERZA DE LLENADO AURICULAR DEPENDE DEL VOLUMEN SANGUINEO

INTRAVASCULAR. REFLEJA LA CAPACIDAD FUNCIONAL

V.D, VALORA: FUNCIÓN V.D Y VOLUMEN

SANGUINEO

ONDAS NORMALES DE PRESIÓN VENOSA CENTRAL

ONDAS DE PRESIÓN VENOSA CENTRAL

ONDAS DE PRESIÓN VENOSA CENTRAL

ANORMALIDADES EN LA ONDA DE PVC

CAMBIOS EN LA PVC

INFLUENCIA DEL CICLO

RESPIRATORIO EN L,A PVC

GRACIAS

FIGURE 40-27  CHARACTERISTIC WAVEFORMS RECORDED DURING PASSAGE OF THE PULMONARY ARTERY CATHETER. RIGHT ATRIAL PRESSURE RESEMBLES A CENTRAL VENOUS PRESSURE WAVEFORM AND DISPLAYS A, C, AND V WAVES. RIGHT VENTRICULAR PRESSURE SHOWS HIGHER SYSTOLIC PRESSURE THAN SEEN IN THE RIGHT ATRIUM, ALTHOUGH THE END-DIASTOLIC PRESSURES ARE EQUAL IN THESE TWO CHAMBERS. PULMONARY ARTERY PRESSURE SHOWS A DIASTOLIC STEP-UP WHEN COMPARED WITH VENTRICULAR PRESSURE. NOTE ALSO THAT RIGHT VENTRICULAR PRESSURE INCREASES DURING DIASTOLE WHEREAS PULMONARY ARTERY PRESSURE DECREASES DURING DIASTOLE (SHADED BOXES). PULMONARY ARTERY WEDGE PRESSURE HAS A SIMILAR MORPHOLOGY TO RIGHT ATRIAL PRESSURE, ALTHOUGH THE A-C AND V WAVES APPEAR LATER IN THE CARDIAC CYCLE RELATIVE TO THE ELECTROCARDIOGRAM

FIGURE 40-28  THE TIP OF THE PULMONARY ARTERY CATHETER MUST BE WEDGED IN LUNG ZONE 3 TO PROVIDE AN ACCURATE MEASURE OF PULMONARY VENOUS (PV) OR LEFT ATRIAL (LA) PRESSURE. WHEN ALVEOLAR PRESSURE (PA) RISES ABOVE PV IN LUNG ZONE 2 OR ABOVE PULMONARY ARTERIAL PRESSURE (PA) IN LUNG ZONE 1, WEDGE PRESSURE WILL REFLECT ALVEOLAR PRESSURE RATHER THAN INTRAVASCULAR PRESSURE. LV, LEFT VENTRICLE; PA, PULMONARY ARTERY; RA, RIGHT ATRIUM; RV, RIGHT VENTRICLE

FIGURE 40-29  TEMPORAL RELATIONSHIPS BETWEEN NORMAL SYSTEMIC ARTERIAL PRESSURE (ART), PULMONARY ARTERY PRESSURE (PAP), CENTRAL VENOUS PRESSURE (CVP), AND PULMONARY ARTERY WEDGE PRESSURE (PAWP). NOTE THAT THE PAWP A-C AND V WAVES APPEAR TO OCCUR LATER IN THE CARDIAC CYCLE THAN THEIR COUNTERPARTS ON THE RIGHT SIDE OF THE HEART SEEN IN THE CVP TRACE. THE ART SCALE IS ON THE LEFT; THE PAP, CVP, AND PAWP PRESSURE SCALES ARE ON THE RIGHT.

FIGURE 40-30  TALL LEFT ATRIAL PRESSURE (LAP) A AND V WAVES TRANSMITTED IN A RETROGRADE DIRECTION THROUGH THE PULMONARY VASCULATURE DISTORT THE ANTEGRADE PULMONARY ARTERY PRESSURE (PAP) WAVEFORM. THE LAP A WAVE DISTORTS THE SYSTOLIC UPSTROKE, AND THE V WAVE DISTORTS THE DICROTIC NOTCH

FIGURE 40-31  NORMAL TEMPORAL RELATIONSHIPS BETWEEN THE ELECTROCARDIOGRAPHIC, CENTRAL VENOUS PRESSURE (CVP), AND LEFT ATRIAL PRESSURE (LAP) TRACES. THE LAP AND CVP WAVEFORMS HAVE NEARLY IDENTICAL MORPHOLOGIES, ALTHOUGH THE CVP A WAVE SLIGHTLY PRECEDES THE LAP A WAVE

FIGURE 40-32  ARTIFACTUAL PRESSURE PEAKS AND TROUGHS IN THE PULMONARY ARTERY PRESSURE (PAP) WAVEFORM CAUSED BY CATHETER MOTION. THE CORRECT VALUE FOR PULMONARY ARTERY END-DIASTOLIC PRESSURE IS 8 MM HG (A), ALTHOUGH THE MONITOR DIGITAL DISPLAY ERRONEOUSLY REPORTS THE PAP AS 28/0 MM HG (B).  

FIGURE 40-33  OVERWEDGING OF THE PULMONARY ARTERY (PA) CATHETER CAUSES ARTIFACTUAL WAVEFORM RECORDINGS. THE FIRST TWO ATTEMPTS TO INFLATE THE PA CATHETER BALLOON (FIRST TWO ARROWS) PRODUCE A NONPULSATILE INCREASING PRESSURE CAUSED BY AN OCCLUDED CATHETER TIP. AFTER THE CATHETER IS WITHDRAWN SLIGHTLY, BALLOON INFLATION ALLOWS PROPER WEDGE PRESSURE MEASUREMENT (THIRD ARROW). BEFORE THE THIRD ATTEMPT AT BALLOON INFLATION, THE PA PRESSURE LUMEN IS FLUSHED, WHICH RESTORES THE APPROPRIATE PULSATILE PRESSURE DETAILED TO THE PA AND WEDGE PRESSURE WAVEFORMS ON THE RIGHT SIDE OF THE TRACE.  

FIGURE 40-34  SEVERE MITRAL REGURGITATION. A TALL SYSTOLIC V WAVE IS INSCRIBED IN THE PULMONARY ARTERY WEDGE PRESSURE (PAWP) TRACE AND ALSO DISTORTS THE PULMONARY ARTERY PRESSURE (PAP) TRACE, THEREBY GIVING IT A BIFID APPEARANCE. THE ELECTROCARDIOGRAM (ECG) IS ABNORMAL BECAUSE OF VENTRICULAR PACING. LEFT VENTRICULAR END-DIASTOLIC PRESSURE IS ESTIMATED BEST BY MEASURING PAWP AT THE TIME OF THE ELECTROCARDIOGRAPHIC R WAVE, BEFORE ONSET OF THE REGURGITANT V WAVE. NOTE THAT MEAN PAWP EXCEEDS LEFT VENTRICULAR END-DIASTOLIC PRESSURE IN THIS CONDITION

FIGURE 40-35  V WAVE HEIGHT AS AN INDICATOR OF THE SEVERITY OF MITRAL REGURGITATION. LEFT ATRIAL PRESSURE-VOLUME CURVES DESCRIBE THE THREE FACTORS THAT DETERMINE V WAVE HEIGHT. A, INFLUENCE OF LEFT ATRIAL VOLUME. FOR THE SAME REGURGITANT VOLUME (X), THE LEFT ATRIAL V WAVE WILL BE TALLER IF BASELINE ATRIAL VOLUME IS GREATER (POINT B VERSUS POINT A). B, INFLUENCE OF LEFT ATRIAL COMPLIANCE. FOR THE SAME REGURGITANT VOLUME (X), THE LEFT ATRIAL V WAVE WILL BE TALLER IF BASELINE ATRIAL COMPLIANCE IS REDUCED (POINT B VERSUS POINT A). C, INFLUENCE OF REGURGITANT VOLUME. BEGINNING AT THE SAME BASELINE LEFT ATRIAL VOLUME (POINTS A AND B), IF REGURGITANT VOLUME INCREASES (X VERSUS X), THE LEFT ATRIAL PRESSURE V WAVE WILL INCREASE (V VERSUS V).  

Figure 40-36  Mitral stenosis. Mean pulmonary artery wedge pressure (PAWP) is increased (35 mm Hg) and the diastolic y descent is markedly attenuated. Compare the slope of the y descent in the PAWP trace with the y descent in the central venous pressure (CVP) trace. In addition, compare this PAWP y descent with the PAWP y descent in mitral regurgitation (see Fig 40-34 ). A waves are not seen in the PAWP or CVP traces because of atrial fibrillation. ART, arterial blood pressure

FIGURE 40-37  MYOCARDIAL ISCHEMIA. PULMONARY ARTERY PRESSURE (PAP) IS RELATIVELY NORMAL AND MEAN PULMONARY ARTERY WEDGE PRESSURE (PAWP) IS ONLY SLIGHTLY ELEVATED (15 MM HG). HOWEVER, PAWP MORPHOLOGY IS MARKEDLY ABNORMAL, WITH TALL A WAVES (21 MM HG) RESULTING FROM THE DIASTOLIC DYSFUNCTION SEEN IN THIS CONDITION.  

Figure 40-38  Pericardial constriction. This condition causes elevation and equalization of diastolic filling pressure in the pulmonary artery pressure (PAP), pulmonary artery wedge pressure (PAWP), and central venous pressure (CVP) traces. The CVP waveform reveals tall a and v waves with steep x and y descents and a mid-diastolic plateau wave (*) or h wave

FIGURE 40-39  CARDIAC TAMPONADE. THE CENTRAL VENOUS PRESSURE WAVEFORM SHOWS INCREASED MEAN PRESSURE (16 MM HG) AND ATTENUATION OF THE Y DESCENT. COMPARE WITH FIGURE 40-38 .

FIGURE 40-40  INFLUENCE OF POSITIVE-PRESSURE MECHANICAL VENTILATION ON PULMONARY ARTERY PRESSURE. PULMONARY ARTERY PRESSURE SHOULD BE MEASURED AT END-EXPIRATION #1, 15 MM HG) TO OBVIATE THE ARTIFACT CAUSED BY POSITIVE PRESSURE INSPIRATION (#2, 22 MM HG). COMPARE WITH FIGURE 40-26

FIGURE 40-41  INFLUENCE OF JUXTACARDIAC PRESSURE AND VENTRICULAR COMPLIANCE ON LEFT VENTRICULAR (LV) PRELOAD. THERE ARE THREE INTERPRETATIONS OF INCREASED TRANSDUCED PULMONARY ARTERY WEDGE PRESSURE (PAWP, 20 MM HG). A, JUXTACARDIAC PRESSURE (-5 MM HG) AND LV COMPLIANCE ARE NORMAL, TRANSMURAL PAWP IS INCREASED (25 MM HG), AND LV VOLUME IS INCREASED. B, JUXTACARDIAC PRESSURE IS INCREASED (+10 MM HG), LV COMPLIANCE IS NORMAL, TRANSMURAL PAWP IS DECREASED (10 MM HG), AND LV VOLUME IS NORMAL OR DECREASED. C, JUXTACARDIAC PRESSURE IS NORMAL, LV COMPLIANCE IS DECREASED, TRANSMURAL PAWP IS INCREASED (25 MM HG), AND LV VOLUME IS NORMAL OR DECREASED.

FIGURE 40-42  ANATOMIC AND PHYSIOLOGIC FACTORS THAT INFLUENCE THE RELATIONSHIPS BETWEEN VARIOUS MEASURES OF LEFT VENTRICULAR (LV) FILLING AND TRUE LV PRELOAD. THE FURTHER UPSTREAM FILLING PRESSURE IS MEASURED, THE MORE CONFOUNDING FACTORS MAY INFLUENCE THE RELATIONSHIP BETWEEN THIS MEASUREMENT AND LV PRELOAD. CVP, CENTRAL VENOUS PRESSURE; LA, LEFT ATRIUM; LAP, LEFT ATRIAL PRESSURE; LVEDP, LEFT VENTRICULAR END-DIASTOLIC PRESSURE; PA, PULMONARY ARTERY; PADP, PULMONARY ARTERY DIASTOLIC PRESSURE; PAWP, PULMONARY ARTERY WEDGE PRESSURE; P-V, PRESSURE-VOLUME; RA, RIGHT ATRIUM, RV, RIGHT VENTRICLE

Figure 40-43  Relationship between left atrial pressure (LAP) and left ventricular end-diastolic pressure (LVEDP). LVEDP is measured at the Z-point on the left ventricular pressure (LVP) trace at the time of the electrocardiographic R wave. Mean LAP (9 mm Hg) underestimates LVEDP (15 mm Hg), but the LAP a wave pressure peak closely estimates LVEDP.  

MODIFIED FROM MARK JB: PREDICTING LEFT VENTRICULAR END-DIASTOLIC PRESSURE. IN MARK JB (ED): ATLAS OF CARDIOVASCULAR MONITORING. NEW YORK, CHURCHILL LIVINGSTONE, 1998, P 59.LAP, LEFT ATRIAL PRESSURE; LVEDP, LEFT VENTRICULAR END-DIASTOLIC PRESSURE; PADP, PULMONARY ARTERY DIASTOLIC PRESSURE; PAWP, PULMONARY ARTERY WEDGE PRESSURE

MODIFIED FROM MARK JB: PREDICTING LEFT VENTRICULAR END-DIASTOLIC PRESSURE. IN MARK JB (ED): ATLAS OF CARDIOVASCULAR MONITORING. NEW YORK, CHURCHILL LIVINGSTONE, 1998, P 59.LAP, LEFT ATRIAL PRESSURE; LVEDP, LEFT VENTRICULAR END-DIASTOLIC PRESSURE; PADP, PULMONARY ARTERY DIASTOLIC PRESSURE; PAWP, PULMONARY ARTERY WEDGE PRESSURE

FORMULAS DE LA LAMINA ANTERIOR

PULMONARY ARTERY CATHETER–DERIVED HEMODYNAMIC VARIABLES THE CARDIOVASCULAR SYSTEM IS OFTEN MODELED AS AN ELECTRICAL CIRCUIT, WITH THE RELATIONSHIP BETWEEN CARDIAC OUTPUT, BLOOD PRESSURE, AND RESISTANCE TO FLOW RELATED IN A

FIGURE 40-44  PULMONARY HYPERTENSION. THE INCREASED GRADIENT ACROSS THE PULMONARY VASCULATURE CAUSES PULMONARY ARTERY DIASTOLIC PRESSURE TO EXCEED PULMONARY ARTERY WEDGE PRESSURE (PAWP). PAP, PULMONARY ARTERY PRESSURE.

FIGURE 40-45  SPECTRAL DOPPLER TRACINGS OF AORTIC BLOOD FLOW RECORDED WITH ESOPHAGEAL DOPPLER CARDIAC OUTPUT MONITORING. THE VELOCITY-TIME WAVEFORM SHAPE REFLECTS ALTERATIONS IN CONTRACTILITY (MAINLY AFFECTING PEAK VELOCITY AND MEAN ACCELERATION), PRELOAD (MAINLY AFFECTING SYSTOLIC FLOW TIME CORRECTED FOR HEART RATE [FTC]), AND AFTERLOAD (WHICH AFFECTS FTC, MEAN ACCELERATION, AND PEAK FLOW VELOCITY).

FUE MONITORIZADO ?

GRACIAS