Another part of the monitoring is carried out continuously. These complex devices and the need to service training and experience are required. Most of these devices are equipped with alarm settings that are active beyond certain limits. In each unit Intensive standardized procedures should be made in dealing with alarms.

Part of the monitoring is done without equipment (such as in direct clinical inspection and physical examination) and is performed repeatedly in accordance with the clinical picture of the patient. This form of monitoring typically include measurements of vital signs (temperature, blood pressure, pulse, respiratory rate), the determination of fluid intake and excretion and frequently also the daily determination of body weight. Blood pressure is determined using automated sphygmomanometer. A transcutaneous sensor for pulse oximetry is also used. Another part of the monitoring is carried out continuously. These complex devices and the need to service training and experience are required. Most of these devices are equipped with alarm settings that are active beyond certain limits. In each unit Intensive standardized procedures should be made in dealing with alarms. Although blood tests to commonly performed blood draws for the destruction of the vein lead, are painful and also can induce anemia, a daily blood collection is in intensive care patients still often necessary to control the treatment accordingly in a timely manner. The placement of a central venous catheter (Vascular Access: central venous catheterization) or an arterial catheter (vascular accesses: Arterial catheterization) can simplify the blood, since no repeated peripheral pinpricks are necessary. The risk of complications, however, has to be considered. Basically, the daily monitoring of electrolytes and full blood count is required. Arrhythmia magnesium, phosphate and calcium levels should be determined in addition. Patients receiving parenteral nutrition, need a weekly monitoring of liver enzymes and coagulation tests. Other tests (eg., Blood culture for fever, blood status after a bleeding) can be performed if necessary. Miniaturized rapid tests make it possible to carry out using automated small appliances certain blood tests directly at the bedside or at least in the ward (v. A. On such stations as intensive care, emergency room unit or operating area). Among the commercially available test procedures include tests for serum chemistry, glucose, arterial blood gases, complete blood count, cardiac enzymes and other cardiac parameters and coagulation tests. Most of them can be carried out within <2 min and with a required sample volume of <0.5 mL of whole blood. Cardiac Monitoring In most intensive care patients is performed a three-pole ECG lead. Often, the corresponding signals are transmitted to a central station monitor. This is done for example by a small transmitter that is worn by the patient. In the case of abnormal rhythms or frequencies monitoring device alarms generated, the corresponding curves are recorded for subsequent more detailed analysis. Specialized Kardiomonitore record ischemia. However, the real benefits of such devices can not be estimated. Among the data recorded here include the monitoring of ST segment and heart rate variability. The loss of the normal beat-to-beat variability indicates a reduction of the autonomous activity of the heart and may indicate a life-threatening coronary ischemia. Monitoring with pulmonary artery catheter, the use of a pulmonary artery catheter (PAC) is increasingly less common in ICU patients. A PAC has at the catheter tip via a balloon. The catheter is then washed in the blood stream via a central vein into the right ventricle and from there into the pulmonary artery. Such a catheter typically has a plurality of apertures which serve to pressure monitoring or the drug application. Some PACs also have a sensor for determining the mixed venous O2 saturation. The data collected with the PAC are mainly used for the determination of cardiac output and cardiac preload. The preload is thereby usually estimated using the pulmonary artery wedge pressure (pulmonary arterial occlusion pressure (pulmonary capillary wedge pressure, PCWP, and pulmonary artery occlusion pressure, PAOP)). Nevertheless, the initial load seems to be determined more on the right ventricular end-diastolic filling volume. Fast-response thermistors, which are controlled by the heart rate, make the determination of this size possible. Although the pulmonary artery catheter is clinically for a long time in use, there is no clear evidence that its use for the reduction of morbidity or mortality contributes. Rather, the use of a PAC itself may in turn lead to a rise in mortality. This is explained in part by the complications of dealing with such a catheter, but also by misinterpretation of the data thus obtained. Nevertheless, some doctors believe that PACs, when combined with other objective and clinical data represent an aid in the treatment of certain ICU patients. As with many other physiological measurement maneuvers the change of a data trend is also given greater weight than a singular divergent reading. Possible indications for a pulmonary artery catheter are shown in potential indications for pulmonary artery catheterization. Possible indications for pulmonary artery catheterization Cardiac disorders Acute valvular insufficiency pericardial tamponade heart failure with complications of myocardial infarction with complications Ventrikelseptumruptur Hemodynamic instability * Determining the volume status shock hemodynamic monitoring cardiac surgery Postoperative treatment in intensive care patients surgery and postoperative therapy in patients with significant heart disease Pulmonary disorders pulmonary embolism complications Pulmonary hypertension * Especially in need of inotropic agents. Procedure The PAC is introduced by a special catheter into a jugular vein or the subclavian vein with an empty balloon. Once the catheter tip reaches the superior vena cava, the balloon is filled with air 1-1.5 ml, to be then forwarded to the blood stream. The position of the catheter tip is usually about the pressure values ??determined (see Table: Normal values ??and intracardiac in the large vessels for intracardiac pressures and pressure conditions in the large vessels) determined or occasionally on fluoroscopy. The diastolic pressure remains unchanged compared to the right atrium or the pressure in the vena cava. The entry into the right ventricle is characterized by a sudden increase of the systolic pressure of about 30 mmHg. If the catheter is inserted into the pulmonary artery, there is no change in systolic pressure; However, the diastolic pressure rises to values ??above the right-ventricular end-diastolic pressure level or the central venous pressure (CVP). This means that the pulse pressure (the difference between systolic and diastolic pressure) is reduced. This means that the pulse amplitude decreases. Further movement of the catheter with the balloon seals from a distal Pulmonalarterienast. A radiograph can verify correct catheter position. Introduction of the pulmonary artery catheter Video created by Hospital Procedures Consultants, var model = {videoId: '3904295507001', playerId 'SyAEZ6ptl_default', imageUrl '' title: 'introduction of the pulmonary artery catheter' description: '' credits 'video created by Hospital Procedures Consultants,' hideCredits: true hideTitle: false, hideDescription: true loadImageUrlWithAjax: true};. var panel = $ (MManual.utils.getCurrentScript ()) Closest ( 'video element panel..'); ko.applyBindings (model, panel.get (0)); Normal values ??and intracardiac in the large vessels average pressure (mmHg) fluctuation range (mmHg) Right atrium 3 0-8 Right Ventricle peak systolic pressure diastolic pressure 25 15-30 4 0-8 pulmonary artery mean pressure 15 9-16 peak systolic pressure diastolic pressure 25 15-30 9 4-14 Pulmonary arterial occlusion Pressure means 9 2-12 Left atrial pressure medium 8 2-12 4-16 10 A-wave V-shaft 13 6-12 Left ventricular peak systolic pressure diastolic pressure 130 90-140 9 5-12 brachial artery mean pressure 85 70-150 systolic peak pressure 130 90-140 diastolic pressure 70 60-90 Adapted from Fowler NO: Cardiac Diagnosis and Treatment, ed 3. Philadelphia, JB Lippincott, 1980, p. 11. The systolic pressure (normal value 15-30 mmHg) and diastolic pressure (normal value 5-13 mmHg) are recorded with unfilled balloon catheter. The diastolic pressure correlates well with the occlusion, although at elevated pulmonary vascular resistance due to a primary pulmonary disorder, the diastolic pressure may exceed the occlusion (z. B. pulmonary fibrosis, pulmonary hypertension) .Pulmonalarterieller closure pressure (pulmonary capillary wedge pressure, PCWP, pulmonary or artery occlusion pressure, PAOP): With the balloon inflated, the pressure at the catheter tip is the static reverse-directional pressure of the pulmonary veins again. To reduce the risk of pulmonary infarction are allowed to spend the balloon no longer than 30 seconds to be ventilated. Under normal conditions the PAOP corresponds approximately to the left atrial pressure which is approximated, in turn, the left ventricular end diastolic pressure (LVEDP). The LVEDP in turn reflects the left ventricular end-diastolic volume (LVEDV). The LVEDV represents the preload, making it the current target parameters. There are numerous factors that prevent the PAOP provides a good illustration of LVEDV. These causes include mitral stenosis, high PEEP levels (> 10 cm H2O), and changes in left ventricular compliance (z. B. due to myocardial infarction, pericardial effusion or increased afterload). Technical difficulties may result from the excessive expansion of the balloon from the catheter incorrect position or the fact that the alveolar pressure exceeds the pulmonary venous pressure and by a marked pulmonary hypertension (which may be more difficult the introduction of the balloon). An increased PAOP arises in left ventricular failure. A reduction of the PAOP resulting in hypovolemia or reduced Vorlast.Gemischtvenöse oxygen saturation Gemischtvenöses blood comprising the blood of Vv. Cava superior and inferior after passing through the right heart and its entry into the pulmonary arteries. a blood sample can be taken to at the distal opening of the PAC. However, some catheters have integrated fiber optic sensors with which the O2 saturation can be measured directly. Among the causes of a reduced gemischtvenösenO2 content (SmvO2) include anemia, pulmonary disease, carboxyhemoglobin, a low cardiac output and an increased metabolic tissue requirements. whether the O2 supply is adequate to the ratio of SaO2 (SaO2 SmvO2) decides. An ideal ratio is 4: 1. A ratio of 2: 1, however, is the smallest possible acceptable quotient, wherein the metabolic needs wird.Herzminutenvolumen just covered sufficient (Cardiac Output): The cardiac output (CO) is intermittent bolus injections of ice water or – established through continuous warm thermodilution – for new catheters. For the determination of cardiac index, the value of HMV is divided by the body surface in order to adjust the ratio so that the body size of the patient (s. Standard values ??of the cardiac index and related measurements). Other parameters can be calculated from the HMV. These include the systemic and pulmonary vascular resistance as well as the right and left ventricular stroke work ( “right / left ventricular stroke work”, RVSW / LVSW). Standard values ??of the cardiac index and related measurements Parameter Units ± SD O2 uptake 143 ± 14.3 ml / min / m2 Arteriovenous difference O2 4.1 ± 0.6 dl cardiac index 3.5 ± 0.7 l / min / m2 stroke volume index 46 ± 8.1 ml / beat / m2 Systemic vascular resistor 1130 ± 178 dynes s cm-5 pulmonary vascular resistance 205 ± 51 dynes s cm-5 pulmonary arteriolar resistance 67 ± 23 dynes s cm-5 SD = standard deviation. Adapted from Barratt-Boyes BG, Wood EH: Cardiac output and related measurements and pressure values ??in the right heart and associated vessels, together with analysis of of the hemodynamic response to the inhalation of high oxygen Mixtures in healthy subjects. Journal of Laboratory and Clinical Medicine 51: 72-90, 1958. complications and precautions A pulmonary artery catheter may be difficult to introduce. Cardiac arrhythmias, especially ventricular arrhythmias are the most common complication. A pulmonary infarction at excessively and long term inflated balloon, perforation of the pulmonary artery, an intracardiac perforation, valve damage or endocarditis are possible consequences of the PAC system. The knotting of the catheter in the right ventricle, however, is a fairly rare event (then usually in patients with heart failure, cardiomyopathy or elevated pulmonary artery pressure). In less than 0.1% of the pulmonary artery catheter systems, there is a rupture of the pulmonary artery. This worst complication is often fatal, and usually in the “wedge position” (that is, either immediately and directly after the first measurement of the occlusion pressure) occurs immediately after the introduction of the catheter. Therefore, many intensivists prefer the monitor display of pulmonary artery diastolic pressure of Okklusionsdruckmessung. Non-invasive measurement of cardiac output (HMV) To the complications of a PAC to avoid, other methods have been developed for the determination of cardiac output such. As the thoracic bioimpedance and transesophageal echocardiography. Although these methods are potentially useful, but none has the reliability of the pulmonary artery catheter. Thoracic bioimpedance These systems with topical electrodes on front chest wall and neck measure the electrical impedance of the thorax. This value shows beat-to-beat changes in the thoracic blood volume and is therefore suitable for the estimation of HMV. Nevertheless, this technique is very susceptible to interference with respect to the contact of the electrodes on the body surface of the patient. The system is safe, and provides the desired levels in a short time (within 2-5 min). Therefore, the main benefit of the thoracic bioimpedance is less in the precise measurement of the HMV as in the detection of changes in these Größe.Transösophageale echocardiography (TEE), this technique uses a soft 6 mm catheter nasopharyngeal raised into the esophagus and then dorsal of the heart is positioned. A Doppler probe at the tip of the catheter allows for the continuous monitoring of the HMV and the stroke volume. In contrast to the invasiveness of the PAC, it does not come to complications such as pneumothorax, arrhythmias or infections in the TEE. In addition, the TEA may be even more accurate than the pulmonary artery catheter. This applies to patients with valvular, septal defects or pulmonary hypertension. However, it may, at the TEA already kommen.Tragbare by slight positional changes to a damped curve with inaccurate readings echocardiography Assessment of left ventricular function is particularly important because a decreased cardiac contractility is a common cause of hemodynamic instability in critically ill patients, including those with sepsis, represents. A study conducted at the bedside transthoracic echocardiography (TTE) allows rapid and non-invasive assessment of cardiac function in critically ill patients, but it may be delayed if an experienced Sonographist or cardiologist is not immediately available. Intensivists, which have a short briefing on the use of portable ultrasound devices that are available now completed, a point-of-care TTE can make at the bedside when a formal TTE is not immediately possible. Unlike a formal TTE, the limited investigation mainly focused on the review of hemodynamically relevant pericardial effusion and impaired global left ventricular function, which can affect the treatment. The results of such restricted TTE at the bedside by intensivists have a high correlation with the results of formal TTE. Intracranial pressure and its monitoring of intracranial A monitoring intracranial pressure (ICP) is performed by default in patients with severe closed head injury, and is used occasionally in other brain disorders, such. B. in selected cases of hydrocephalus and pseudotumor cerebri or in post-operative or postembolischen treating arteriovenous malformation. This measurement is used to optimize the cerebral perfusion pressure (mean arterial pressure minus intracranial pressure). Typically, cerebral perfusion pressure above 60 mmHg should be kept. Clinical Calculator: Mean vessel pressure (systemic or pulmonary) Various ICP monitoring systems available. The most favorable method places a catheter through the skull into the ventricle (ventriculostomy catheters). The advantage here is the additional possibility of ventricular drainage to thus lower the intracranial pressure. However, the ventriculostomy is also the most invasive and technically elaborate method with the highest infection rate at the same time. Occasionally the ventriculostomy is moved by an extensive edema. Among the other equipment required the ICP measurement include an intraparenchymal monitor and epidural seal. Of the two, the intraparenchymal monitor is more widespread. It applies to all ICP monitoring devices that they need to be replaced usually after a period of 5-7 days due to the risk of infection or removed. Other forms of monitoring the sublingual Kapnometrie makes a similar connection between an increased Pco2 sublingual and systemic hypoperfusion advantage. Thus can be monitored shock, using a noninvasive sensor is placed under the tongue. This measurement method is much simpler than the gastric tonometry and also reacts quickly to changes in the course of resuscitation. In tissue spectroscopy, a non-invasive sensor which operates in the near infrared (NIR), is located on the skin surface above the target tissue so as to determine the mitochondrial cytochrome redox state, which reflects the tissue perfusion. This method seems to be particularly useful for diagnosis in acute compartment syndrome (eg in trauma) or ischemia after free tissue transplantation. Also for post-operative monitoring a vascular bypass the lower extremity of this method can be used. A monitoring of the small intestinal pH may possibly be useful to determine the efficacy of resuscitation.

Health Life Media Team

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