Download - Monitorizarea Cardio Vasculara
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MONITORIZAREA HEMODINAMICA
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MONITORIZAREA HEMODINAMICA
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MONITORIZAREA HEMODINAMICA Sistemul cardio-circulator este
responsabil de transportul oxigenului si a substsntelor nutritive spre tesuturi si de indepartarea produsilor de catabolim rezultati din metabolismul celular
Exercitarea acestei functii implica un cord functional normal si un sistem circulator adecvat .
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MONITORIZAREA HEMODINAMICA
DEBITUL CARDIAC ADECVAT ?
INADECVAT?1. Volum- presarcina ?2. Contractilitate ?3. Frecventa cardiaca ?4. R.V.S –postsarcina ?
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MONITORIZAREA HEMODINAMICA
DEBITUL CARDIAC
VOLUMUL SISTOLICFRECVENTA CARDIACA
PRESARCINAPOSTSARCINA CONTRACTILITATEA
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MONITORIZAREA HEMODINAMICA
CLINICASEMNE DE DEBIT CARDIAC
SCAZUT
• S.N.C.• CARDIO-VASCULAR• RENAL• DIGESTIV• PERIFERIC
PARACLINICA
• E.K.G.• TENSIUNE ARTERIALA• PULSOXIMETRIE• P.V.C.• DEBIT CARDIAC• BIOMARKERI CARDIAC• ECOCARDIOGRAFIA
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MONITORIZAREA HEMODINAMICAPARMETRII CLINICI
S.N.C•alterarea starii de constienta•agitatie •somnolenta•deficite motorii
CARDIO-VASCULAR
•Durere precordiala•Dispnee•Polipnee•± Turgescenta jugujara•Modificari E.K.G
PERIFERIC
•Tegumente reci•Timp de umplere capilar prelungit•Scaderea amplitudinii undei de puls
RENAL•Scaderea fluxului urinar
DIGESTIV
•Dureri abdominale•Diminuarea zgomotelor intestinale•hematoke
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MONITORIZAREA HEMODINAMICAPARACLINIC
NONINVAZIVA
• E.K.G.• PULSOXIMETRIE• TENSIUNE ARTERIALA
INVAZIVA
• TENSIUNEA ARTERIALA• DEBIT CARDIAC• R.V.S.• P.V.C• P.C.W.P.• ECOCARDIOGRAFIA
TRANSESOFAGIANA
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MONITORTIZAREA E.K.G
• monitorizarea conducerii impulsului nervos de-a lungul cordului
SCOP -1. monitorizarea frecventei cardiace 2. detectarea tulburarilor de ritm 3. detectarea tulburarilor de conducere 4. detectarea ischemiei miocardice 5.aprecierea functionalitatii pacemaker 6.detectarea tulburarilor electrolitice
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MONITORTIZAREA E.K.G
AVANTAJE• metoda noninvaza• continua• permite detectarea in timp
real a modificarilor in activitatea electrica a cordului
DEZAVANTAJE• nu ofera informatii asupra
debitului cardiac• nu poate aprecia
contractilitatea miocardica
E.K.G normal nu implica o performanta cardiaca adecvata
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MONITORTIZAREA E.K.G.
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EKG NORMAL
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MONITORIZAREA EKG- DERIVATII
PRECORDIALE 6 electrozi V1-V6
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MONITORIZAREA EKG DERIVATII UNIPOLARE
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MONITORIZAREA EKG
• MONITORIZAREA IN T.I./S.O. utilizeaza 3/5 electroz permite detectarea1. tulburarilor de ritm –relatia dintre unda P si complexul QRS vizibila cel mai bine in derivatia DII 2. ischemiei miocardice vizibila cel mai bine in
derivatiile V5 siDII
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MONITORIZAREA EKG
UNDA P = CONTRACTIA ATRIALA
COMPLEXUL QRS = CONTRACTIAVENTRICULARA
UNDA T = REPOLARIZAREA VENTRICULARA
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MONITORIZAREA EKG- DERIVATII12 DERIVATII
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MONITORIZAREA EKG
• RITM regulat
neregulat
• FRECVENTA
• MORFOLOGIA
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MONITORTIZAREA E.K.G
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MONITORIZAREA CARDIO-VASCULARA
• Prima unda pozitiva a complexului• Prezenta ei defineste ritmul sinusal indiferent de aspectul complexului QRS• Durata• Forma rotunjita
UNDA P
UNDA P =CONTRACTIA ATRIILOR
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MONITORIZAREA E.K.G.
UNDA Q
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MONITORIZAREA E.K.G.UNDA R
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MONITORIZAREA E.K.G.UNDA S
CONTRACTIA VENTRICULARA
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MONITORIZAREA E.K.G.SEGMENTUL ST
Important in detectia ischemiei miocardice
Deplasarea de la nivelul liniei isoelectrice in sus sau in jos = ischemie miocardica
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MONITORIZAREA E.K.G.UNDA T REPOLARIZARE VENTRICULARA
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MONITORIZAREA EKG
• P-R interval = 0.12 - 0.20 sec (3 - 5 small squares)
• QRS width = 0.08 - 0.12 sec (2 - 3 small squares)
• Q-T interval 0.35 - 0.43 sec
* The PR interval should really be referred to as the PQ interval; however it is commonly referred as the PR interval
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MONITORIZAREA E.K.G.• RITMUL CARDIAC –prezenta undei P in faţa fiecarui complex
QPS defineste ritmul sinusal
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MONITORIZAREA EKG
• RITM regulat
neregulat
• FRECVENTA
• MORFOLOGIA
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EKG NORMAL
RITM SINUSAL
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MONITORIZAREA E.K.G.
RITM SINUSAL
ES . VENTRICULARA
I.M. ACUT
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MONITORIZAREA E.K.GES. ATRIALA
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MONITORIZAREA EKG ARITMII CARDIACE
• RITM SINUSAL NEREGULAT
EXTRASISTOLE VENTRICULARE
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MONITORIZAREA E.K.G
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MONITORIZAREA E.K.G - FRECVENTA CARDIACA
• FRECVENTA CARDIACA
F.C. = 60-80/min
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MONITORIZAREA E.K.G - FRECVENTA CARDIACA
DETERMINAREA RAPIDA A FRECVENTEI CARDIACE
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MONITORIZAREA EKG
TAHICARDIE SINUSALA
F.C.> 100
FRECVENTA CARDIACA
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MONITORIZAREA EKG
• durere • hipovolemie• hipoxie• hipercapnie• febra• exces de catecolamine• sedare inadecvata• normal
TAHICARDIA SINUSALA
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MONITORIZAREA EKG
F.C.< 50-60
BRADICARDIE SINUSALA
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MONITORIZAREA EKG• durere• infarctul miocardic• medicatie β blocante anticalcice digoxin succinilcolina anticolinesterazice opioide• hipoxemia severa • embolia pulmonara• sedare excesiva• hipertensiunea intracraniana• normal
BRADICARDIA SINUSALA
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MONITORIZAREA EKG
Absenta undei P si asegmentului izoelectric FIBRILATIA ATRIALA
FLUTTER ATRIAL
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MONITORIZAREA EKG• Ischemia miocardica• Stimulare simpatica excesiva• Toxicitate droguri• cardiomiopatia etanolica• Durerea• Infectii• Interventiile pe cord /mediastin• idiopatica
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MONITORIZAREA EKG ISCHEMIA MIOCARDICA
• MODIFICAREA SEGMENTULUI ST/ UNDA T
INFARCT MIOCARDIC ACUT
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MONITORIZAREA EKG ISCHEMIA MIOCARDICA
INFARCT MIOCARDIC ACUT
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MONITORIZAREA EKG ISCHEMIA MIOCARDICA
INFARCT MIOCARDIC ACUT
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MONITORIZAREA EKG ARITMII CARDIACE
• RITM SINUSAL NEREGULA[
EXTRASISTOLE VENTRICULARE TAHICARDIE VENTRICULARA
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MONITORIZAREA EKG
CONCLUZII indispensabila monitorizarii intraanestezice si a
pacientului critic ; da informatii asupra activitatii electrice cardiace (factor determinant al performantei cardiace) nu da informatii despre debitul cardiac sau despre
contractilitatea miocardica in mod direct→trebuie asociata cu alte metode de monitorizare pentru a avea un profil hemodinamic complet al bolnavului
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MONITORIZAREA HEMODINAMICA
Utilizata ca un surogat al fluxului sangviuncardiace T.A. SISTOLICA =presiunea createa in artre in timpul
contractiei
T.A. DIASTOLICA =presiunea in timpul relaxarii cardiace
T.A. MEDIE =presinnea din artere pe tot parcursul ciclului cardiac
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MONITORIZAREA HEMODINAMICA
Metode de determinare a tensiunii arteriale A. NONINVAZIV 1. manual – ascultator - palpator 2.automat B. INVAZIVA – implica canularea unei artere si utilizarea unui
transductor de presiune ce transforma semnalul presional in impuls electric cuplat la un monitor
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MONITORIZAREA HEMODINAMICA
METADA ASCULTATORIE Permite determinarea tensiuniisistolice si diastolice prin ascultareazgomotelor Korotkoff Umflarea unei manete ocluzivepeste tensiunea sistolica si dezumflarealenta cu 2-3 mmHg/sec in timp ce se ascultafluxul sangvin Primul zgomot ascultat corespundeT.A. sistolice ,in timp ce punctul de lacare zgomotele diminua corespundeT.A. diastolice
LIMITE Implica utilizarea unui stetoscop pot aparea valori eronate in
conditiile in care nu se utilizeaza o manseta adecvata ca marime
Implica participarea actica a personalului
Vasoconstrictia periferica si T.A.mici fac greu auzibile zgomotele cardiace
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MONITORIZAREA HEMODINAMICA
METODA PALPATORIE
Palpare undei de puls in timpuldezumflarii mansetei de presiune cecorespunde T.A.sistolice
Permite estimarea T.A. cind aceasta are valori foarte mici
LIMITE
nu permite aprecierea T.A.diastolice
pot aparea valori eronate
Implica participarea actica a personalului
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MONITORIZAREA HEMODINAMICADETERMINAREA AUTOMATA NONINVAZIVA
dermina tensiunea arteriala la intervale presetate de timp
dermina T.A.s /T.A.d /T.A.m
nu necesita participarea activa a unui cadru medical
Elimina eroarea in umana din determinare
LIMITE
artefactele de miscare pot determina valori eronate sau pot anula determinarea → intirzieri in determinare
poate apare congestie venoasa ischemie la nivelul membrului prin determinari repetate
tulburarile de ritm pot interfera cu determinarea
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DETERMINAREA INVAZIVA A TENSIUNII ARTERIALE
INDICATII Bolnavul instabil hemodinamic,aflat sub suport vasoactiv
Necesitatea recoltarii frecvente de gaze sangvine
Bolnavul ce necesita controlul strict al tensiunii arteriale - hipotensiune controlata - hipertensiune controlata - risc de ruptura anevrism
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DETERMINAREA INVAZIVA A TENSIUNII ARTERIALE
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DETERMINAREA INVAZIVA A TENSIUNII ARTERIALE
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DETERMINAREA INVAZIVA A TENSIUNII ARTERIALE
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DETERMINAREA INVAZIVA A TENSIUNII ARTERIALE
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DETERMINAREA INVAZIVA A TENSIUNII ARTERIALE - Sediul canularii
ELECTIE1. Artera radiala
2. Artera femurala
ALTERNATIVE1. Artera ulnara2. Artera Brahiala3. Artera Axilara4. Artera Dorsala
piciorului
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DETERMINAREA INVAZIVA A TENSIUNII ARTERIALE –CANULAREA ARTEREI RADIALE
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DETERMINAREA INVAZIVA A TENSIUNII ARTERIALE –CANULAREA ARTEREI RADIALE
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DETERMINAREA INVAZIVA A TENSIUNII ARTERIALE
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DETERMINAREA INVAZIVA A TENSIUNII ARTERIALE –CANULAREA ARTEREI RADIALE
• SEDIUL CANULARII Artera radiala
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DETERMINAREA INVAZIVA A TENSIUNII ARTERIALE –CANULAREA ARTEREI RADIALE
TESTUL ALLEN
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TESTUL ALLEN
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TESTUL ALLEN
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TESTUL ALLEN POZITIV
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COMPLICATII CATETERISM ARTERIAL
ISCHEMIA PERIFERICAembolie tromboza
INFECTIA
PSEUDOANEVRISM
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COMPLICATII CATETERISM ARTERIAL
ISCHEMIE PERIFERICA
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COMPLICATII CATETERISM ARTERIAL
INFECTIE DUPA CANULARE ARTERA RADIALA
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COMPLICATII CATETERISM ARTERIAL
PSEUDOANEVRISM ARTERA RADIALA
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DETERMINAREA INVAZIVA A TENSIUNII ARTERIALE
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MONITORIZAREA HEMODINAMICA P.V.C
1. P.V.C –cuplarea spatiului vascular la un senzor de presiune
2. P.V.C.- masurare la nivelul atriului drept / V.C.S
INDICATII
Masurarea presiunilor de umplere la nivelul cordului drept ptr. aprecierea volumului intravascular si a functiei cordului drept
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MONITORIZAREA HEMODINAMICA P.V.C
P.V.C=2-8mmHg.
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MONITORIZAREA HEMODINAMICA P.V.C
Masoara presiunea la nivelul venei cave intratoracic, in apropierea atriului drept;
Reflecta: 1. cantitatea de singe ce ajunge la nivelul A.D
2.capacitatea cordului de a pompa singele in sistemul arterial;
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MONITORIZAREA HEMODINAMICA P.V.C
P.V.C.
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MONITORIZAREA HEMODINAMICA P.V.C
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MONITORIZAREA HEMODINAMICA P.V.C
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MONITORIZAREA HEMODINAMICA P.V.C
MANUALA
AUTOMATA
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MONITORIZAREA HEMODINAMICA P.V.C
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MONITORIZAREA HEMODINAMICA P.V.C
METODA MANUALA
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MONITORIZAREA HEMODINAMICA P.V.C
METODA MANUALA
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MONITORIZAREA HEMODINAMICA P.V.C
METODA AUTOMATA
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MONITORIZAREA HEMODINAMICA P.V.C
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MONITORIZAREA HEMODINAMICA P.V.C
IMPLICATII CLINICE
Aprecierea presinilor de umplere ventriculare drepte →presarcina V.D.
Reprezinta balanta intrevolumul sangvin circulantsi complianta sistemului venos
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MONITORIZAREA HEMODINAMICA P.V.C
IMPLICATII CLINICE
In conditiile in care nu exista modificari intrinseci ca nivelul cordului sau plaminului P.V.C. poate aprecia presarcina ventriculara stinga
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MONITORIZAREA HEMODINAMICA P.V.C
CRESTEREA P.V.C.• Insuficienta ventriculara
dreapta• Insuficienta tricuspidiana• Stenoza tricuspidiana• Hipertensiunea pulmonara• Hypervolemia• Tamponada cardiaca• Pneumotorax• Pericardita• Constrictive pericarditis• Ventilatia mecanica
SCADEREA P.V.C.• Hipovolemia• Cresterea contractilitatii• Crestera compliantei
vasculare
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MONITORIZAREA HEMODINAMICA CATETERUL SWAN GANTZ
MASURAREAPresiuni intracardiace Presiuni in circulatia pulmonaraDebitul cardiacSaturatia in oxigen a singelui venos
amestecat
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MONITORIZAREA HEMODINAMICA CATETERUL SWAN GANTZ
INDICATII 1.Managementul bolnavului cu instabilitate hemodinamica
majora
2. .Managementul bolnavului cu infarct miocardic complicat
3. Managementul bolnavului cu soc si afectiuni cardiace sau pulmonare asociate
4. Managementul bolnavului cu interventii pe cord deschis
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MONITORIZAREA HEMODINAMICA CATETERUL SWAN GANTZ
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MONITORIZAREA HEMODINAMICA CATETERUL SWAN GANTZ
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MONITORIZAREA HEMODINAMICA CATETERUL SWAN GANTZ
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MONITORIZAREA HEMODINAMICA CATETERUL SWAN GANTZ
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Hemodynamic Parameters - Measured• Central Venous Pressure (CVP)
– recorded from proximal port of PAC in the superior vena cava or right atrium– CVP = RAP– CVP = right ventricular end diastolic pressure (RVEDP) when no obstruction exists between atrium
and ventricle
• Pulmonary Artery Pressure (PAP) – measured at the tip of the PAC with balloon deflated– reflects RV function, pulmonary vascular resistance and LA filling pressures
• Pulmonary Capillary Wedge Pressure (PCWP) – recorded from the tip of the PAC catheter with the balloon inflated– PCWP = LAP = LVEDP (when no obstruction exists between atrium and ventricle)
• Cardiac Output (CO) – Calculated using the thermodilution technique– thermistor at the distal end of PAC records change in temperature of blood flowing in the pulmonary
artery when the blood temperature is reduced by injecting a volume of cold fluid through PAC into the RA
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Hemodynamic Parameters - Derived• Cardiac Index (CI) = CO/BSA
• Stroke Volume Index (SVI) = CI/HR
• Systemic Vascular Resistance (SVR)– reflects impedance of the systemic vascular tree– SVR = 80 x (MAP – CVP) / CO
• Pulmonary Vascular Resistance (PVR)– reflects impedance of pulmonary circuit– PVR = 80 x (PAM – PCWP) / CO
• Left ventricular stroke work index (LVSWI)= (MAP – PCWP) x SVI x 0.136
• Right ventricular stroke work index (RVSWI)= (PAM – CVP) x SVI x 0.136
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MONITORIZAREA HEMODINAMICA CATETERUL SWAN GANTZ
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MONITORIZAREA HEMODINAMICA CATETERUL SWAN GANTZ
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MONITORIZAREA HEMODINAMICA CATETERUL SWAN GANTZ
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MONITORIZAREA HEMODINAMICAECOCARDIOGRAFIA
AVANTAJE
1.Usor de utilizat
2.Metoda rapida de diagnostic
3.Incidenta scazuta a complicatiilor
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MONITORIZAREA HEMODINAMICAECOCARDIOGRAFIA
METODE: 1.TRANSTORACICA
2.TRANSESOFAGIANA
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MONITORIZAREA HEMODINAMICAECOCARDIOGRAFIA
ECOCARDIOGRAFIA TRANSESOFAGIANAINDICATII DE ELECTIE
- Pacientul cu instabilitate hemodinamica majora inexplicabila;
- Afectiuni valvulare acute;
- Afectiuni tromboembolice
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MONITORIZAREA HEMODINAMICAECOCARDIOGRAFIA
• ECOCARDIOGRAFIA TRANSESOFAGIANA
1.Permite aprecierea grosimii peretilor cordului 2.Permite aprecierea dimensiunilor cavitatilor cardiace
3.Permite aprecierea
4.Permite vizualizarea pleurei si a pericardului
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MONITORIZAREA HEMODINAMICAECOCARDIOGRAFIA
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MONITORIZAREA HEMODINAMICAECOCARDIOGRAFIA
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MONITORIZAREA HEMODINAMICAECOCARDIOGRAFIA
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MONITORIZAREA HEMODINAMICAECOCARDIOGRAFIA
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MONITORIZAREA HEMODINAMICAECOCARDIOGRAFIA
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MONITORIZAREA HEMODINAMICA
•ADMINISTRAREA DE VOLUMPRESARCINA
• VASOPRESOARE• VASODILATATOAREPOSTSARCINA
• INOTROPECONTRACTILITATEAFRECVENTA ANTIARITMICE
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MONITORIZAREA HEMODINAMICA
1.Permite identificarea disfunctiilor hemodinamice
2.Permite introducerea unui tratament adecvat in functie de disfunctia identificata
3.Permite monitorizarea raspunsului la terapie