Basic

Principles in Hemodynamic
Monitoring
Dr.Irmalita SpJP
 a) systole and diastole of both the atria and ventricles related to time
Siklus jantung
b) pressures in the aorta, atria and ventricles

Aortic Pressure

80

60 Left Ventricular Pressure

40 Identify
Atrial Systole
20 ISV Contraction
Rapid Ejection
0
Reduced Ejection
Left Atrial Pressure
ISV Relaxation
Rapid Vent. Filling
Reduced Vent. Filling

dicate the following events on the figure above:

 Monitoring hemodinamik memainkan
peranan pen>ng dalam tatalaksana pasien2
kri>s
Bila masalahnya sudah diketahui, monitoring
dapat membantu untuk mengetahui
patosiologi yang mendasari sehingga terapi
bisa lebih tepat.
Dengan monitoring dapat dilakukan >ndakan
lebih dini sebelum masalah jadi berat.
 Echocardiography and echo-Doppler
Dapat dipakai >dak hanya untuk mengukur CO
tapi juga dengan tambahan fungsi kardiak.
Berguna untuk menegakkan diagnosis karena
dapat memvisualisasi ruang2 jantung, katup2
dan pericardium.
Ventrikel yang kecil Small (kissing ventricles)
perlu dipikirkan pemberian cairan sedangkan
bila kontraksi miokard buruk, pemberian infus
dobutamin adalah pilihan yang lebih baik.
 Echocardiography and echo-Doppler
Pada dilatasi ventrikel kanan harus dipikirkan
emboli paru massif atau miokard infark.
Adanya cairan perikard harus dipikirkan diagnosis
tamponade perikard.
Kelainan katup yang berat dapat segera dikenali.
Tetapi pelayanan ini >dak selalu tersedia dimana-
mana; di kebanyakan ins>tusi ini merupakan
domain cardiologist yang perlu dipanggil untuk
melakukan pemeriksaan ini.
Wakeling HG et al: Intraopera)ve oesophageal Doppler guided uid management
shortens postopera)ve hospital stay a7er major bowel surgery.
Br J Anaesth 2005, 95:634-642.
 Non-invasive saja bukanlah tujuan. Walaupun
lebih disukai non invasive tapi kadang2 itu
>dak mungkin dan >dak efek>f.
ll be higher in the pulmonary
le, special attention should be Figure 20
ssures during insertion. Right Normal Insertion Tracings

Typical Hemodynamic Pressure Values

nary artery systolic pressures
ring them during insertion,
Table 1.
ation between the right
y may be more difficult. By Typical Hemodynamic Pressure Values
es, a rise in pressure value Location Normal Values in mm Hg
nary artery has been reached.
Right Atrium

Right Atrial (RAP) -1 to +7

Mean (MRAP) 4

Right Ventricle

Systolic (RVSP) 15 to 25

Diastolic (RVDP) 0 to 8

Pulmonary Artery
re 18
tery Waveform Systolic (PASP) 15 to 25

Diastolic (PADP) 8 to 15
still inflated, is now advanced
in a central branch of the Mean (MPAP) 10 to 20
t, right heart pressures and Wedge (PAWP) 6 to 12
uded. The catheter tip is
Left Atrial (LAP) 6 to 12
es. The waveform reflected
The pressures recorded will
ht atrium (6 mm Hg to Once the wedge position has been identified, the balloon is
deflated by removing the syringe and allowing the back
 Arterial Pressure Monitoring
The intra-arterial pressure is a dynamic pressure that has volume
displacement and energy wave components
.
The arterial pressure wave is a result of the pressure and volume
changes produced by the cardiac cycle.

Pressure = Flow X Resistance

Perfusion is more closely related to the mean blood pressure

Systolic blood pressure is important clinically because it is an indicator
of myocardial work and oxygen demand.

 result of mechanical function. Arterial waveforms are
produced after electrical activation of the heart. When
ynamic status of the

Komponen kurva Arteri

evaluating arterial waveforms at the same time as electrical
e monitoring. Use of
waves, the electrical activity will be noted first followed by
toring system, and
the mechanical activity.
us observation of the
monitoring
te from the arterial
hich is a common
mic parameters.

essures include
ppler devices. If
reflect the patients
However, it is
ese methods may

er the transmission
sed to determine
. It is thought that
of the vibration of
w from the cuff that
nder optimal
underestimate the
iastolic pressure by

Figure 39
 Peak systolic pressure menggambarkan tekanan maksimum
sistolik ventrikel kiri. Dimulai dengan pembukaan katup
aorta. Peningkatan yang tajam dari kurva menggambarkan
aliran darah keluar dari ventrikel ke sis>m arteri.
Dicro8c notch pada kurva adalah tempat katup Aorta
menutup. Ini merupakan akhir sistole dan mulainya
diastole.
Diastolic pressure tergantung kepada vessel recoil atau
vasokonstriksi dari sis>m arteri. Juga ada hubungan antara
tekanan diastolic dan waktu diastolic dari siklus jantung.
Bila waktu diasolic pendek, tekanan diastolic akan lebih
>nggi.
 Anacro8c Notch terjadi sebelum pembukaan
katup Aorta. This wave typically will be seen only
in central aor>c pressure monitoring, an aor>c
root tracing, or in some pathological condi>ons.
Pulse Pressure adalah beda antara sistolik dan
diastolik. Faktor yang dapat mempengaruhinya
adalah stroke volume, as noted in the systolic
pressure, and also changes in vascular
compliance, as seen in the diastolic pressure.

difference between the two called electro-mechanical myocardium is
Electrical vs. Mechanical Cycle
coupling, or the excitation-contraction phase. When looking
The second ph
at a simultaneous recording of the electrocardiogram and
Once the pulm

pressure tracing, the ECG will show the appropriate wave
before the mechanical tracings will. shorten even m
volume out of
approximately
ECG correlati

As the pressur
ventricular sys
phase, begins.
less volume.

During this ph
increase in atr
inflow. This ri
resultant rise i
atrial wavefor

Figure 2
Electrical vs. Mechanical C ycle
diastolic pressure in the aortic root for both the coronary
arteries to be perfused.
Perfusi Arteri Koroner

Figure 10
C oronary Artery Perfusion
umption can be
Through hemodynamic monitoring, demand factors such as
. Since oxygen
preload, afterload, contractility, and heart rate can be altered
n the demand or
by various therapeutic interventions. These interventions
nsate is to
and their effects will be addressed in a later section.

icle occurs
entricular wall
such an extent
endocardium. The
erefore less wall
stance, there is
y artery and into
ust be adequate
h the coronary

Figure 11
 Pen>ng untuk diingat bahwa Tekanan Darah
>dak akan berubah karena ada respons
simpa>s sebagai kompensasi tubuh sampai
kekurangan darah yang cukup dari sirkulasi
yang menunjukkan tubuh sudah >dak dapat
mengkompensasi keadaan itu.
storing potential energy that is released with the springing back of the aorta to its
diastolic dimension. This energy ensures that blood flow is maintained in diastole.
As systolic run-off to the peripheries continues it eventually exceeds the input of
volume from the ventricle. As a result pressure falls in the aorta and the aortic valve
closes the washback of pressure against the closed aortic valve results in a small
pressure rise called the dicrotic notch. (refer to the figure below)

Volume displacement component

Dicrotic notch
Inotropic component

Reflection waves

As the pressure wave and volume displacement wave move peripherally the waveform
changes as a result reflection waves off the periphery. This causes the character of
the dicrotic notch to change. Its position and shape, when measured in a peripheral
 Haemodynamic Monitoring Learning Package

Kurva Arteri Radialis

Radial Artery Trace

Dicrotic notch

Dicrotic notch

Vasoconstricted Vasodilated

The electronic transducer is a device designed to respond to the frequency

components that make up the arterial pressure wave. However, the transducer
 Pengukuran Central Venous Pressure
Indikator tekanan pengisian Ventrikel Kanan
Bila dibuat asumsi, bahwa ada hubungan
linear antara volume ventrikel (preload) dan
ventricular pressure, (ie as volume increases
then pressure will increase) maka tekanan
ventrikel pada akhir diastol adalah end
diastolik volum ventrikel atau preload.

 on the ECG represents atrial contraction. Because the pressure waveform
elayed the next positive rise in pressure after the p wave will be the a wave
Kurva CVP
wing diagram). The C wave which is not always present in the CVP wave
s after the a wave and followed by the v wave.

P wave

A wave, occurring after the p wave

The effect of intra-thoracic pressure changes on the measurement of C

PAWP
 Clinical Use Of CVP Measurement

The primary use of the CVP measurement is to provide an
indica>on of Right Ventricular Filling.
In clinical situa>ons of inadequate >ssue perfusion the CVP can
be used as a guide for the administra>on of uid volume.
The aim of the uid volume is to increase ventricular preload and
thus increase SV or CO. An increased in CO indicated by improved
urine output, improved peripheral perfusion, improved menta>on
etc.
Clinically, uid is given and CVP used as a guide to determine the
degree of ventricular loading.,and to avoid overload.

If the ventricle has been judged to be op>mally preloaded and the

signs of poor perfusion remain, indica>ng inadequate cardiac
output, then medica>ons to increase contrac>lity may be used eg
adrenaline, dopamine, dobutamine etc)
Algoritme diagnos)k berdasarkan
pemeriksaan echocardiography.
Hemodynamic instability

arterial catheter
central venous catheter

Fluid responsiveness ?
(low CVP ?)

present absent

echocardiography

hypovolemia likely small chambers tamponade

large ventricles RV dilation
poor contractile state (obstructive)
fluid challenge valvulopathy
(cardiogenic)

Vincent et al. Cri8cal Care 2011 15:229

 Faktor2 yang mempengaruhi
interpretasi cardiac output
PAP
RAP PAOP
EKG
End-diastolic
Heart rate volumes
Arterial pressure
CO
Microcirculation
(OPS, NIRS, ) Urine output
Mental status
PgCO2 Cutaneous perfusion
Sublingual capnometry
Lactate
CO2 gap SvO2

Vincent et al. Cri8cal Care 2011 15:229

 Algoritme diagnos)k berdasarkan
SvO2 and cardiac output
CARDIAC OUTPUT

HIGH LOW

SvO2 SvO2

HIGH LOW HIGH LOW

INFLAMMATION
ANEMIA LOW VO2 LOW OUTPUT
(incl. SEPSIS)
HYPOXEMIA (anesthesia, SYNDROME
EXCESSIVE hypothermia,...)
HIGH VO2 (hypovolemia,
BLOOD FLOW heart failure,
(hypervolemia,
pulm. embolism...)
excessive vasoactive therapy)

Vincent et al. Cri8cal Care 2011 15:229

 Kunci sis)m monitoring hemodinamik
yang ideal

Pengukuran sesuatu yang relefan
Punya hasil akurat dan bisa diulang
Punya data yang bisa diinterpretasi
Mudah digunakan
Mudah didapat
Tidak tergantung operator
Punya response-8me cepat
Tidak menimbulkan rasa sakit
Cost-eec>ve
Memuat informasi yang dapat mengarahkan terapi

Vincent et al. Cri8cal Care 2011 15:229

 Thank You