1. CVS Monitoring in Shock

2. CVS Monitoring Non-invasive techniques: Invasive Monitoring:
Clinical assessment of tissue perfusion
ECG, NiBP, pulse oximetry;
Non-invasive CO studies – Echo, NiCO method
Invasive Monitoring:
Central venous pressure monitoring;
Direct arterial line pressure monitoring;
Cardiac Output studies (Pulmonary Artery Catheter) 2

3. Central Venous Catheterisation
Internal jugular vein
Subclavian vein
Axillary vein
Femoral vein
The absolute value is often unhelpful, except in extreme cases of severe hypovolaemia, significant fluid overload, or heart failure.
Correct interpretation requires assessment of the change in central venous pressure in response to a fluid challenge in conjunction with alterations in other monitored variables.
Other Indications for CVC: Drug delivery (Adrenaline, Noradrenaline, Potassium, other hypertonic solutions),
Total Parenteral Nutrition (TPN), etc. 3

4. Complications of central catheters
On insertion
Cardiac arrythmias
Pneumothorax / haemothorax
Air embolism
Surrounding tissue injuries
Cardiac tamponade
Post insertion
Infection (consider removal after 7 days)
Cardiac arrhythmias
Displacement of catheter
Blockage of lumen(s)
Air / material embolism
Thrombus formation 4

5. Direct arterial pressure monitoring
Invasive cannulation of an artery for continuous monitoring of direct BP; used in:
Haemodynamically unstable patient, patient in shock
Patient receiving inotropic / vasoactive agents
For blood sampling (ABG’s, U&E’S, glucose etc)
Patient with physiological difficulties for NIBP (obesity, AF)
Stroke volume variation (SVV) : difference between the largest and the smallest arterial wave traces during respiratory cycle 5

6. SPV and PVI
In spontaneous (negative pressure) breaths, pulmonary vessels dilated and fill with blood, so less gets to left side of heart 6

7. Techniques to assess cardiac output (Flow-based techniques)
Oesophageal Doppler
based on determination of RBC velocity/flow
Trans-oesophageal Echocardiography (TOE)
Gold standard in USA
Arterial pulse/pressure wave analysis (PPWA)
eg PiCCO, Vigileo, LiDCO
Combination of pulse/pressure wave analysis (PPAW) with oesophageal Dopler flow measurement (for re calibration)
Bioimpedance / Bioreactance
Change in amplitude / frequency of a transmitted electrical signal 7

8. Oesophageal Doppler

9. Pulse contour analysis PPWA
If an arterial pressure waveform is calibrated to a known cardiac output then tracking the changed in the shape and size of arterial waveform can give information to the changes in cardiac output.

10. Pulmonary artery catheterisation
Dr. Jeremy Swan and Dr. William Ganz
Developed 1971
Catheterisation of the pulmonary artery with a balloon flotation catheter allows to measure:
Preload - indirect assessment of the filling pressure of the left ventricle (pulmonary artery occlusion or wedge pressure)
Contractility – by using ‘thermodilution’ technique
Afterload or SVR - by calculating from the formula
SVR = CO / MAP
(PAC; PAFC; PAOP; PAWP) 10

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