Post on 06-Apr-2018
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MONI TOREO DEL PACI ENTE VENTI LADO MECANI CAMENTE
Monit oreo de las curvas del VM? Monit oreo hemodinmico?
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MONI TOREOMONI TOREO
HEMODI NAMI COHEMODI NAMI CO
GC
FC VSx
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MONI TOREOMONI TOREO
HEMODI NAMI COHEMODI NAMI CO
GC = FC x VSGC = FC x VS
GC = PAMGC = PAM PAD / RVSPAD / RVS
GC = PMAPGC = PMAP PEAP / RVPPEAP / RVP
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TRANSPORTE DE OXIGENOTRANSPORTE DE OXIGENO
Depende del GC y del contenido d e O2Depende del GC y del contenido de O2en la sangre:en la sangre:
DO2 = GC x CaO2 x 10DO2 = GC x CaO2 x 10 (DO2 = 900(DO2 = 900-- 1000 ml/ min)1000 ml/ min)
DO2: O2 delivery (transport)DO2: O2 delivery (transport) CaO2: contenido arterial de O2 (ml/ d l)CaO2: contenido arterial de O2 (ml/ d l)
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Ca02- CvO2: 5-6 ml
CaO2: (Hb x 1. 37 x sat O2) + (0.003 x PaO2)
CONTENI DO DE OXI GENO
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CONSUMO DE O2 (VO2)CONSUMO DE O2 (VO2)
VO2 = GC x (CaO2 CvO2) x 10
VO2: 250 ml/min
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APORTE DE OXIGENOAPORTE DE OXIGENO
DEBE EXISTIR UN EQUILIBRIO ENTRE
DO2 Y VO2 (750 ML/MIN)
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GCGC
PrecargaPrecarga PoscargaPoscarga ContractilidadContractilidad
FCFC
LlenadoLlenadoVentricularVentricular
CargaContraccin
VSVS PVIFDPVIFD PA
RVS
TAMAOVI
VSVS= X
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MONITOREOMONITOREO
HEMODINAMICOHEMODINAMICO
Monitoreo no invasivoMonitoreo no invasivo
Monitoreo invasivoMonitoreo invasivo
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MONITOREOMONITOREO
HEMODINAMICOHEMODINAMICO
Mon itoreo no invasivoMonitoreo no invasivo
Pulso (FC)Pulso (FC)
OximetrOximetra de pulsoa de pulso
PAPA (aparatos de registro automatizado)(aparatos de registro automatizado)
TT
DiuresisDiuresis
EXAMEN FISICOEXAMEN FISICO
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MONITOREOMONITOREO
HEMODINAMICOHEMODINAMICO
Monitoreo invasivoMonitoreo invasivo
LLnea arterialnea arterial
CCatatter venoso central (CVC)ter venoso central (CVC)
CatCatter de arteria pulmonar (Swanter de arteria pulmonar (Swan-- Ganz)Ganz)
PiCCOPiCCO
VigileoVigileo
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MONITOREO INVASIVOMONITOREO INVASIVO
Paciente crPaciente cr ticotico
Ambiente clAmbiente clnico y fisiolnico y fisiolgico cambiantegico cambiante
La interp retaciLa in terpretacin d e los parn d e los parmetros ametros a
mon itorizar son d e u tilidad cuando vanmon itorizar son de u tilidad cuando van
asociados a un razonamiento clasociados a un razonamiento cl niconico
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TRATAR ALTRATAR ALPACI ENTE Y NOPACI ENTE Y NO
AL MONI TORAL MONI TOR
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MONITORIZACIONMONITORIZACION
HEMODINAMICAHEMODINAMICA
ObjetivosObjetivos
AlertarAlertar
DiagnDiagnstico continuostico continuo
PronPronsticostico
GuGu a terapa terap uticautica
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IND ICACION ES DEIND ICACION ES DE
MO NITOREO HEMODINAMICOMON ITOREO HEMO DINAMICO
QuQu pacientes deben ser m onitorizadospacientes deben ser m onitorizadoshemodinamicamente?hemodinamicamente?
Los pacientes que desarrollan estados de bajoLos pacientes que desarrollan estados de bajodebito card iaco (gasto)debito card iaco (gasto)
Los pacientes en riesgo d e desarrollar bajo debitoLos pacientes en riesgo d e desarrollar bajo debito
La magnitud y la intensidad del monitoreoLa magnitud y la intensidad del monitoreo
dependerdepender de la patologde la patologa y cond icia y cond icin deln delpacientepaciente
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PACIENTES EN RIESGO DE DESARROLLARPACIENTES EN RIESGO DE DESARROLLAR
ESTADOS DE BAJO D EBITOESTADOS DE BAJO D EBITO
Pacientes con antecedentesPacientes con antecedentescard iopu lmonares que van a sercard iopu lmonares que van a sersometidos a cirugsometidos a ciruga mayora mayor
CirugCiruga de revascularizacia de revascularizacinnmiocmiocrd ica o cirugrd ica o ciruga card iacaa card iaca
CirugCiruga abdominal mayora abdominal mayor
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MONITOREO INVASIVOMONITOREO INVASIVO
LLnea arterialnea arterial
MonitorizaciMonitorizacin continu an continu a
Muestra de sangre arterialMuestra de sangre arterial
ComplicacionesComplicaciones
HematomasHematomas
Trombosis arterialTrombosis arterial
Isquemia distalIsquemia distal
InfecciInfeccinn
El GC es directamen te prop orcional alEl GC es directamen te prop orcional al rea bajorea bajola curva de p resila curva de p resinn
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MONITOREO INVASIVOMONITOREO INVASIVO
CatCatter venoso cen tral (CVC)ter venoso cen tral (CVC) IndicacionesIndicaciones
Aportar volum enAportar volum en
Medida de la PVCMedida de la PVC
AdministraciAdministracin de drogas irritativasn de drogas irritativas AlimentaciAlimentacin parenteraln parenteral
HemodiHemodilisislisis
InserciInsercin d e otros catn d e otros catteres como el SG o sondasteres como el SG o sondasmarcapaso transitoriasmarcapaso transitorias
La punta d el CVC debe quedar alojada enLa punta d el CVC debe quedar alojada enla vena cava superior (Rx)la vena cava superior (Rx)
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MONITOREO INVASIVOMONITOREO INVASIVO
InserciInsercinn Yugular int ernaYugular int erna
SubclaviaSubclavia
FemoralFemoral
Yugular externaYugular externa
Complicaciones CVCComplicaciones CVC
HematomaHematoma
Hematom a con obstrucciHematom a con obstruccin vn va aa a rearea
NeumotNeumotraxrax InfecciInfeccinn
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CVC
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MONITOREO INVASIVOMONITOREO INVASIVO
CatCatter de arteria pu lmonar (CAP)ter de arteria pu lmonar (CAP)
(Cat(Catter de Swanter de Swan Ganz)Ganz)
Analizar:Analizar:
Perfil hem odinPerfil hem odinmicomico
Clasificar la etiologClasificar la etiolog a de la hipotensia de la hipotensin y/ on y/ o
hipoperfusihipoperfusinn
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CATETER DE ARTERIACATETER D E ARTERIA
PULMONARPULMONAR
El catEl catter comter com n es de 110 cm de largon es de 110 cm de largo
y de 5y de 5 7 French (F) de di7 French (F) de d imetrometro
externoexterno
Esta marcado a intervalos de 10 cmEsta marcado a intervalos de 10 cm
(se(seal circular negra)al circular negra)
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El mEl m s coms com n tiene 4 vn tiene 4 vasas DistalDistal : en la pu nta d el cat: en la pu nta d el catter para medir later para m edir la
presipresin d e la arteria pulmonar y cuand o estn d e la arteria pulmonar y cuando estinflado el balinflado el baln la presin la presin en cun en cu a pu lmonara pu lmonar
ProximalProximal
: treinta cent: treinta cent
metros proximal a la pu nta,metros proximal a la pu nta,
debe localizarse en la au rdebe localizarse en la aur cula derecha y mide lacula derecha y mide lapresipresin venosa central. Tambin venosa central. Tambin se usa paran se usa parainyectar el linyectar el lquido frqu ido fr o para medir el gastoo para medir el gastocardcard acoaco
BalBalnn : para inflar el bal: para inflar el baln qu e estn qu e est localizado alocalizado a1cm de la pu nta1cm de la pu nta
TermistorTermistor : para m edir el GC: para m edir el GC
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MONITOREO INVASIVOMONITOREO INVASIVO
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MONITOREO INVASIVOMONITOREO INVASIVO
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VARIABLESVARIABLES
HEMODINAMICASHEMODINAMICAS
Volumen sistVolumen sistlico de eyeccilico de eyeccin (VS) o Stroken (VS) o StrokeVolume eVolume e ndice sistndice sistlico de eyeccilico de eyeccin (IS)n (IS)
VS = GC/ FCVS = GC/ FC
VS: VTDVS: VTD -- VTSVTS
IS = VS/ SCIS = VS/ SC
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VARIABLESVARIABLES
HEMODINAMICASHEMODINAMICAS
50-150 dinas/s/cm
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PICCOPICCO
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PICCOPICCO
El sistema PiCCOEl sistema PiCCO (Pulse Contour Cardiac(Pulse Contour Cardiac
Output),Output), ((Pulsion Medical SystemsPulsion Medical Systems,,
Munich, Alemania) es un mMunich, Alemania) es un m todo detodo de
monitoreo hemodinmonitoreo hemodinmico capaz demico capaz demedir el GC por termodilucimedir el GC por termodilucinn
transpulmonar (TDTP) y estimar latranspulmonar (TDTP) y estimar la
precarga por med io del volumenprecarga por med io del volumen
sangusangu neo intratorneo intratorcico (ITBV)cico (ITBV)
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ITTV: ITBV + EVLW
ITTV: volumen trmico intratorcico
ITBV: volumen sanguneo intratorcico
EVLW : agua pulmonar extravascular
ITBV = GEDV + PBVGEDV: volumen telediastlico global
PBV: volumen sanguneo pulmonar
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VIGILEOVIGILEO
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VIGILEOVIGILEO
Consta de un m onitor Vigileo y un sensor FloConsta de un m onitor Vigileo y un sensor FloTrac, conectado a u nTrac, conectado a u n catcatter radial o femoralter radial o femoral ..
El sensor flo trac valora y calcula la presiEl sensor flo trac valora y calcula la presin deln delpulso arterial, siend o esta directamentepulso arterial, siend o esta directamente
proporcional al volum en sistproporcional al volumen sistlicolico Con los parCon los parmetros especmetros especficos del paciente:ficos del paciente:
edad, sexo, altura y peso: se determina laedad, sexo, altura y peso: se determina lacompliance del lecho vascularcompliance del lecho vascular
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