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Advanced Hemodynamic Monitoring information. Aortic regurgitation, arrhythmias, intra-cardiac shunts and aortic aneurysm are other factors that influence the accuracy of the measurements. If PA catheterization is not possible, this technology provides an acceptable and less invasive alternative. Computer Algorithm Another method for pulse contour analysis uses a computer algorithm and a mathematical model to determine the vascular tone based on patient gender, height, weight and BSA. This technology provides every 20 seconds updated information about CO, SV, and Stroke Volume Variation (SVV), as long as the patient is being mechanically ventilated, and without significant arrhythmias. Arterial pulse pressure rises during spontaneous inspiration, and falls during expiration as a result of changing intra-thoracic pressures. During mechanical ventilation this phenomenon is reversed and is called reverse pulsus paradoxus, or paradoxical pulsus, or respiratory paradox. This variation can be measured and is called SVV. A normal SVV is less than 10 –15% on controlled mechanical ventilation. SVV is not an actual indicator of preload, but more of fluid responsiveness. The combination of SV and SVV can be used to guide fluid management and optimize the preload. In combination with a central venous catheter (CVC), it can also provide SVR, and ScvO 2 , depending on the catheter type. Current literature only supports the use of SVV on patients that are on controlled mechanical ventilation with tidal volumes greater than 8cc/kg and on a fixed respiratory rate. Arrhythmias negatively affect SVV measurement. If increased levels of PEEP are used, SVV values can be increased. Changes in vascular tone with the use of vasodilatation therapy may also increase SVV values. Copyright 2010 Orlando Health, Education & Development 31
Advanced Hemodynamic Monitoring SV max and SV min are measured over 30 seconds then the SV mean is calculated. The variation in stroke volume (SVV) = SVmax-SVmin/SVmean. Cold Saline Calibration In order to obtain measurements, a central venous catheter and an arterial pressure catheter is needed. An initial injection of cold saline is needed for calibration related to analysis of the arterial pulse contours. This transpulmonary thermodilution technique then calculates the CO, SV and SVV. Additional parameters that can be calculated intermittently are global end-diastolic volume (GEDV), intrathoracic blood volume (ITBV) and extravascular lung water (EVLW). The ITBV is the sum of the GEDV and the pulmonary blood volume. Limitations include the necessity to recalibrate after changes in patient position, therapy or condition, or at least every eight hours. The accuracy of this pulse contour analysis technique depends on the location of the arterial catheter. Axillary or femoral locations are more accurate compared to a radial arterial catheter. Aortic regurgitation, arrhythmias, intra-cardiac shunts and aortic aneurysm influence the accuracy of the measurements. This technology can only be accurately applied if the patient is on controlled mechanical ventilation and has a stable heart rhythm. The PiCCO monitor is currently the only device that utilizes this type of pulse contour analysis. RAEDV RVEDV ETV PBV LAEDV LVEDV Right Atrial End Diastolic Volume Right Ventricular End Diastolic Volume EVWL Extra Vascular Lung Water Pulmonary Blood Volume Left Atrial End Diastolic Volume Left Ventricular End Diastolic Volume Copyright 2010 Orlando Health, Education & Development 32
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