Pulmonary Artery Catheters

DIVISION OF CRITICAL CARE MEDICINE GWUMC

or perhaps not

Housestaff perception of PA catheters:

MAP=SBP+2DBP/3 CO=HRxSV/1000CI=CO/BSA SVR=80x(MAP-RAP)/COPVR=80x(MAP-PAWP)/CORVEF=SV/EDVCaO2=(.0138xHgbxSaO2)+.0031xPaO2VO2=(C(a-v)O2) x CO x 10

Some Equations...

• MAP = 1/3 SBP + 2/3DBP• CO = SV x HR• CI = CO/BSA• SVR = (MAP-CVP)/CO x 80• PVR = (MPAP - PAOP)/CO x 80• LVSWI = SVI x (MPAP-PAOP)/BSA x

0.0136

Normal Values

• Cardiac Output (CO) : 4 -8 L/min• Cardiac Index (CI) : 2.4 - 4.0 L/min/m2• MAP : 70-105 mm Hg• Systemic Vascular Resistance (SVR):

800 - 1200 dynes/sec/cm5• Pulmonary Vascular Resistance (PVR):

<250 dynes/sec/cm5 • Stroke Volume (SV): 60-100 ml/beat

1. Why is this patient hypotensive?

2. Why is this patient in shock?

3. Why is this patient in pulmonary edema?

4. How can I minimize fluid infusion while maintaining perfusion in my hypoxic patient?

4. Will this patient tolerate empiric resuscitation and diagnosis through therapeutic challenge?

“The patient’s dead, he just doesn’t know it yet”

Dennis Quinlan, MD 1995

Volume 345:1368-1377 November 8, 2001 Number 19

Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock

Emanuel Rivers, M.D., M.P.H., Bryant Nguyen, M.D., Suzanne Havstad, M.A., Julie Ressler, B.S., Alexandria Muzzin, B.S., Bernhard Knoblich, M.D., Edward Peterson, Ph.D., Michael Tomlanovich, M.D., for the Early Goal-Directed Therapy Collaborative Group

Central venous O2 saturation (SCVO2)

?Mixed venous O2 saturation (SMVO2)

SMVO2 is approximately 5% lower than SCVO2

40 50 60 70 80 90 100

(Sv cO2 + SvO2)/2 %

Zia et al Crit.Care Medicine 2003;30:A71

Bland-Altman Plot

BP = CO x SVR

LVEDV Contractility

The four (five) causes of hypotension

Hypovolemia Pump failure Hemorrhage Myocardial ischemia GI losses Cardiomyopathy Dehydration Valvular disease Insensible Arrhythmias Distribution Obstruction Sepsis Pulmonary Embolism Anaphylaxis Tension pneumothorax Neurogenic Cardiac tamponade Adrenal insufficiency Constrictive pericarditis

The four (five) causes of hypotension

Hypovolemia Pump failure Hemorrhage Myocardial ischemia GI losses Cardiomyopathy Dehydration Valvular disease Insensible Arrhythmias Distribution Obstruction Sepsis Pulmonary Embolism Anaphylaxis Tension pneumothorax Neurogenic Cardiac tamponade Adrenal insufficiency Constrictive pericarditis

DRUGS&

DOCTORS

HR/RHYTHM CVP/PCWP SVR CO DX RX

⇑ ⇓ ⇓ ⇑ ⇓ Hypovolemia Volume

⇓ or ? ⇑ ⇑ ⇓ Pump Pacer, antiarrhythmic

⇑ ⇑ ⇑ ⇑ ⇓ Pump Inotrope

nl, ⇑ ⇑ ⇑ ⇑⇑ ⇓ Pump Valve,

rate control

⇑ ⇓ ⇓ ⇓ ⇑ Distribution Pressors,

volume ⇑ ⇑ ⇓ ⇑ ⇓ Obstruction Chest tube TPA

The data obtained from pulmonaryartery catheters should aid, not replace, clinical judgement.Treat the patient, not the numbers.

Remember

And of course…

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