เวชบำบัดวิกฤตพื้นฐาน Fundamental in Critical Care

146 rrrnilininqnfiugru

5. Richet H. Hubert B. Nitemberg G. et al. Prosp€etive multicenter study of vascular-catheter-related complications

and risk factors for positi\e central-catheter cultures in intensive care unit patients. J Clin Microbiol 1990:28:

2520-5.

6. Centers for Disease Control and Prevention. Guidelines for the Pre\ention of Intravascular Catheter-Related Infections.

[4MWB 2002:5'1:1 32.

7. Hind D, CaJvert N. Mcwilliams R, et.al. Ultrasonic locating devices for central venous cannulation: meta-analysis.

BMJ 2003:327:361-7.

8. Bain DS. Percuianeous appmach. including transeptal and apical puncture. In: Bain DS. ed. Grossman s cardiac

catheterization. angiography and intervention. Lippincptt Williams & Wilkins. USA 2000:

L IMilling J. Rose J. Briggs W M. et al. Randomized. conlrolled clinical trial of poant-of-care limited ultrasonography

assistance of central venous cannulation; The Third Sonography OLtcomes Assessment Program (SOAP-3) Trial.
Crit Care [,1ed 2005:33:1764-9.

'10. u:tr6o utnrrna. qfori vra,:oi. Bole of ultrasonography guided central venous cannulation. lanr:a rn rmdtfo
inqourir r:urnhr 2oosl3(g):14.

11. Sznajder Jl. Zveibil FR- Bitterman H. C€ntral vein catheterization. Failure and complic€tion rates by three p€rculaneous
appraches. Arch Intern Med 1986:146:259-61.

'12. Seneff MG. Cenlral venous catheterization: a comDrehensive review, Dart 2. J Intensive Care Med 1987:2218-23.
'13. Merrer J, De Jonghe B. Golliot F. et al. Complications ol femoral and subclavian venous catheterization in critically

ill patients: a randomized controlled trial. JAMA 2001!86:700-7.

14. Ruesch S, Walder B, Tramer lvlFi. Complications of central venous catheters: Internal jugular versus subclavian
access - a systemic review. Crit Care Med 2002:30:454-60.

15. Trautner B, Darouiche RO. Catheter-associaied infections. Pathogenesis affects prevention. Arch Intern Med 2004;
'164:842-50.

16. Worthington T, Elliott TSJ. Diagnosis of central venous catheter related infection in adult patieflts. Journal of

Infection 2005t51:267-80.

17. i,,lermel LA, Farr BM, Sherertz BJ, et al. Guidelines for the management of intravascular catheter related infections.
CID 2001t32:1249 72.

18. Timsit JF, furkas JC. Boyer JM, et al. Centralvein catheter-relaled thrombosis in intensive care patienls: incidence,
risk faslors, and relationship with catheter related s€psis. Chest 1998:'1'14:207-13.

19. Charyakunapruk N. Veenstra DL, Lipsky BA, Saint S. Chlorhexidine compared with povidone-iodine solution for
vascular catheter-site carer a meta-analysis. Ann Intern [.4ed 20021 36:792-80', .

20. Maki DG, Stolz SM. Wheeler S, Mermel LA, Prevention of central venous catheter-reiated bloodstream infection by
use of an antiseptic-impregnatEd catheter. A randomized, controlled trial. Ann Intern Med 1 997:127:257-66.

21 . Rupp ME, Lisco SJ. Lipsett PA, et al. Etfect of a second-generation venous catheter impr€nated with chlorhexidine
and silver sulladiazine on central catheter related infeclions. A randomized. controlled tnal. Ann Intern Med 2005:

143:570-80.

22. Darouiche RO. Raad ll. Heard SO, et al. A comparison of tr4,o antirnicrobial-impregnated central venous catheters.
Catheter Study Group. N Engl J Med 1999:340:1-8.

23. Deborah C, Adrienne F. Phillip K, et al. Central venous catheter replacement strategies: A systematic review of the
literature. Crit Care Med 1997:251417-24.

24. Fandolph AG, Cook DJ, Gonzales CA, Andrew i,4. Benefit of heparin in c€ntral venous and pulmonary artery
catheters: a meta-analysis ot randomized controlled trials. Chest 1998:113165-71.

25. van de Wetering. van Woensel, Kremer LCM, Caron HN. Prophylactic antibiotics for preventing early Gram-positive
central venous catheter infections in oncology patients. a Cochrane systematic revi8vv. Cancer Trealment Review
2005t31:186-96.

Vascula. .{ccess qiaf nan$ 147

fl"tfiotil?n

iofrrnnuro :ynrlun1?'ld central vascular catheter
rfi altdufir:snld centrat venous catheter

,lilfirirsro:Jd
lril'i'o'iro:6rJ'l6i centrar venous catheter rrdotrxor:rir}i udrrlirurruMrlor

u5ordolfi vasoactrve orug }JufirTuuuroMrlo uur r,l'lunl:riqr:ruljrar:611si centrar venous
catheter rfiatoriu orofiqr:ru'rlrnirdarynvrr.rn6findtdrlnnrrn:rqir.{nrufinrrrruriutiryiafi

n,lruhuolunrrnunfirJruiioqjtunrr:6anr?olri r,rrnriauahjfi nlluriudruionrtrhua nr:

ficr:ilr16i central venous catheler
franr::srllunrt1dflruorut-n central venous pressure

ldo{qrnaru centrar venous catheter rdanr:r-er cvp riu rflurtnnn'r:iiriurrirniulrn
rfio'lqrndrl6'irfl a:arn unvt#rrar'hjurulu{frrirurry orjr,:'l:fimrrfif.rrfionrr:ur:ndouldori

rola lourarr:'lu::oilunvrri'tdr,1uun; uvimJ:j:rr'rrj.ru i,rfifiouuyrjrurrrj:rnrrn-rd
1. riout6i central venous catheter en:q-ovirtoifi:JrslfirytJr;d mr n'nunjymrintfl

inro'lunrr'ldoruoru Tot raur:tu{rhufrdru riodr,lnruod'tunn;lrnrir (hypovotemia) n1:16i
central venous catheter ?o{ internal iugular vein uoy subclavian vein nr:lfiliilraoqjlurir
6:u:n'r ecrirlliorrr:nlrioruoruldirudu

2. aLirflurur td centratvenous catheter lutru:fifl.rJuuol rfjarornlonronrtrfio tension

hpneumothorax [[ny systemic air embolism ntrrn vrndrtflu6ot'lei central venous catheter

rru:fr ddrtlraulrnfio,rdr'hifirjrln,rlriau ort'ld sedation dr<irlflu

tpli uaat air embolism E.r,mvt cr scan rJonnnnln d,tnuitfr air bubbte ogfi right venticle

s. nrrtfl centrar venous cartreter riudo.rl' EKG monitoring rouo nia{q1nflruvfrninr:5oEJ
wire tiu nru wlre fi5ofla'rl i'lrlrfio avial anhythmia fiia ventricutar anhythmia d.rarcrfru

0l.ltlllUn\:t?n tO

148 rrtdrforinqadug'ru

+. rir-lT ufio{lunr?: acidosis ?u[r:n fiiofi electrolytes imbalance filutt:l niu hyper-

kalemia, hypokalemia, hypocalcemia. hypophosphatemia, hypomagnesemia fi1ultr'':6'tr;fi
a--uqrru rnlnrcdiou wire ]oflta 1cfir5ou wire ttfirlnu rignt ventricle o'11tfi9 ventricular

arrhyrhmia \d iu{ilrun{uiorq.ir rflufiotrrfiltln'l'lv electrolytes imbalance rvrirdrioudqc
ld central venous catheter vSod, l'rriufio,ltd central venous catheter oeirSou wire dntfio

nin16srntiun:rafi lfi ario right ventricle

s. lu{rhufifi severe hyperkalemia via severe metabolic acidosis orldo,:'lfinr:fnur

lnunr:v,lonrfioqriou (renal replacement therapy. RRT) riou'tri central venous catheter lsu'ld

fl1u dialysis catheter d lemoral vein rrnlhrfludan'ldd1ufi internal jugular vein lio subclavian

vein arjrviurur iou wire frntfiul euTounri.:lo.: right ventricle

6. fl1r'ldf,lu central venous catheter tt fldn1:ficr:rut9l dilator nlulln"':n111u1ufinu

16ooudti'r rflu}Jn1 fiFr1.r1o'tfifloordaofrnr:qvrflurialri niu nrrtd cenlral venous catheter
yt.l0 right subctavian vein rdadrnr:flE'nrfinoor6aerufir dilator n?rq;1fi'tfl.J0rr*tfio t.ttotttnont6ao
firn dilator fififiYrrflfi.tdu aretflu'hldfi central venous cattreter lnr}Jo{'lu brachiocephalic

vein nior{rl dt left inlernal jugular vein

z. nr:'ldoru central venous catheter ttdoio cvp rfu nr:Ganarufirioutdaolrndo,l
'ldcrur$unaruru nrn'l$c, uiirflu po* druiunr:'ld pulmonary artery catheter tlio transvenous

pacemaker doriuarufi u6.ruavn:r orl tfinntiun:rudoraootfian superior vena cava ld d.r

rir'h{rfio tremotrorax ntu'tR'tuvfl-.i tta:a'un:ruqcii.itfio}rrnn*uvrntdnrflsfiodtrtvnoo 16on

o'rdrufiru lilirqllflu left internal jugular vein ttio left subclavian vein tfiotctnfl'lu central

venous catheter d'atgjrutdu16oa brachiocephalic vein defrnllT6': tutruvfr central venous
catneter sfiodtt{.rtta:n:,r drtfilfinnrTun:ruoio brachiocephalic vein d,:nhtfirfin hemothorax

nlrrrld

Hemodynamic Monitoring

nniunt 4ftfttxg

{:Jruurinn"nfi:lqnrrn,:drunaercninrrhnriuurfion (hemodynamic) d.rrhrfludo,rld
funr:guoatirdnd0o nrrftornlrilrryr",r6,:riud.rdirrflu'luumrudfuronoirrfi.rndnnr:lunrt
r ilrr: i,,r$ d'rdE rfr arJ:rlurnSlunr:g un {rJr ud o}J

il:;umor hemodynamic monitoring

1. Invasiv€ hemodynamic monitoring fidrfrruldrrri arterial tine (A-line), central venous

pressure (CVP), pulmonary capillary w€dgE pre*sure (PGWP)

2. Non-invasive hemodynamic monitoring fi drfruldrrri echocardiography
luunnrudtvtonshrflc invasive hemodynamic monitoring ronrcludtum{ macro-
circutation wiliu Inriilldndtrfi,l cEntrat venous pressure d.:i:Lnnrrndnrirrfioudr drunr:
:l:vriuludrum,: microcirculation'hlilnrrlrnulRrurial tissue oerfusion

Arterial line
n"nu ciJnfito': arterial pressure waveform nnn'rlufld t
'lunrlrrJnan artorial pressure u/avetorm riu uvrnrlfiolfinrruftdot damping system

lfia':crnfiflnrioFir systolic blood pressur€ !!fls diastolic blood pressure Tnuot r damping system

nat arterial line dnrruru ldud

150 rrtdrrioinqaCugru

.J

tat} -

*

o-

7li t uaallnnvuvrlat artetial prcssure waveform Tau1a{nqn4o systolic blood pressure Taahqado

diastotic blood Fessurc gnf, ufran dicrotic notch dlfiutttumi,ti aoaic vatve f,o

1. Underdamped arterial waveform aYv{!'j1 systolic blood pressure q{du diastolic

blood pressure flan,: lrrud mean arterial blood pressure ntfi ar lv4 rfinlrnn15dof,lufiul,

rfiuIil fl5fl nlrfirlo{o1n1d?Ju1e 0.05-0.25 xfl.

2. Overdamped arterial waveform ey u'i'l systolic blood pressure 0l'1n,t diastolic
btood pressure 4.tdu Inud r""n arterial blood pressure n.lfi fl1r q finelnvloto'rnrnfi'tndnir
0.25 rnluoru fifiour6aormrra{ orllr:nufillldTnunl? flush flru

ll m:l ^^
Normal Overdamped underdamped

zflJi uaatmtufiatlnfl',at arterht waveform ttlJu overdamp ua: undetdamp

erfllfio n6lo': arterial pressure waveform finr:r:ru

1, Pulsus alternan Q;fl!fl-nurutl0{ arterial waveform fi amplitude ufrnrrn*ndnn'u

u\. l:l vrulettolu L---V systolic failure Ydal olnlllullln

nu

Hemod.vnamic \{oniroring $n?uni gfrfitIS l5l

2. Pulsus bisferiens eyfl:JR'nu :to\t arterial waveform fifi Oicrotic notch fl\,[fiou

[ ln-tl systolic blood pressure TnunJfi putse pressure ntr.r vulfflu aortic regurgitation

3. Pulsus parvus et tardus ?rvt:ln'nu itlo'r arteriar waveform fifiturntfinn,jr n6 dicrotic
notcn lridoreurfio\rfln aortic vatve finrjnfi loufifi putse pressure unl nuld'lu aortic stenosis

4. Spike and dome pattern Qivr n'nuu;flo{ arterial waveform dfi systolic pressure

arn'ir nfi ttny ! dicrotic odnhn.ir systolic btood pressure lrn uuldlu hypertrophic

cardiomyopathy

5. Pulsus paradoxus o;vtldnBfuygo.J arterial waveform dfinr:anawa,t systolic blood
pressure rrnn'lrrJn6lurir'rnr:nrutcr'fir rirtrfi systotic btood pressure 'ludrrnruterfi.rooa,:
rdaujiu!rfiillriu systotic btood pressure lutixurahaanrrnni.i 10 ul.t:oyr luid'lu cardiac

tamponade. severe pulmonary embolism

A !3s B F-..rl!g<

_so r60 I
FtE
a5
0

D zoo -

F

aTlii uan,snalafiatlnfigan araiat pressure waveform A. putsus alternant B. pudus bisferiens.

pulsus paNus et tardus, D. spike and dome pattern, E. pulsus paradoxus

n'nfinnuorrrnfi rafi'lni arterial line uono1nfi6n1 6 arterial pressure waveform rratci,t
systolic BP, diastolic BP llfly mean arlerlal pressure ttdl nl:n:rqyrorfl.tlrtflv01fl,]1t16[n.J10{

arterial occlusion lrriu rJnrad'lrfiu':noYrtiorfiunir nnl !!as arterial catheter infection (niu ld
fi discharge aan lqtn puncture site)

152 rrtrirrjai n q nfrugru

Pulmonary artery catheter
f,1u swan-Ganz catheter v30 pulmonary (PA) catheter turirn'!sia1ild1u:J$n?1111:

rSuntia'jr pec riJunrueruduruuuvti Jereny swan rl*6ufdu1ui n.rr 1970 onuruvro,to'ttl
d11.lu1x 110 ail, rdul'hgutinalnno{d1u6l,)u 2.3 tJ. (7 French)

nrrldfiru pulmonary artery catheter ilr1:iuldilnruriu non{ tfio':ernfinrrfinur
finlunrtdnulvrj, nr:tdaru pulmonary artery catheter lrjldtjrflooo'fi:roru ttnvfiiidufr

vrnruulddnir ati, .,rl:froru1u{r1':u shock dt'lldorr nr:'ldaru pulmonary artery catheter u"{

:n,rrfl unr:ificdurrnqrurdotflunT :;tfiuortuqttn:nr:eloufluots{ont:fnrr

fl1fl pulmonary artery catheter fildiuno{ilruvrinorcriuorutfio 3 fl'1,0 (3-tail), 4 fi'l\:

vt(4-rait) fiio 5 fi1,0 (s-tail) uddldrjouFotrisr 3 ur,tt?o q ii.1fidruil:;nalfirirfi'rg d":d

1. Proximal port figriJod 30 ttufilrn:ern nruora ri'rnfirdl n1lio central venous

pressure rtn:tflu port frhiar:ri, rrovur
2. Distal port fi;rflofrrJnruoru rirvrirfiin pulmonary artery catheter
B. Batloon port louo;fi oattoon oqjfr nruoru do?irnrr blow balloon cstflunr:i'n

pressure to.lr't''t'lqfi a.rfin'blfi o left atrium
4. Thermister port 1nr-r'lu +-tait1 fi;rilndrloruoralouo{ proximal da arstilmo': distal

lumen ti udrfi'tun t:iq core temperarure

Waveform filfittn putmonary adery catheter

1. H,A pressure waveform fin*nuru;tufiou CVP wave{orm:Jt;no rlfirg wave a, c, x.
v.y

2. RV pressure waveform rl:;nau'l dru systolic RV pressure rrn: diastolic RV pressure
fi.: systolic PA pressure o:g':n'ir RA wave{orm !'olQu

3. PA pressure waveform !:;no!'bjdxu syslolic PA pressure rtfl: diastolic PA pressure

it'r systolic PA pressure l:firdtrvirdl RV systolic pressure d1! diastolic PA pressure l;fi

ci1fl.rn'jl diastolic RV pressure ttovrmfidnnru:loi dicrotic notch
4. PcwP wavelorm fidnuru:tufiou CVP waveform rl::ngr-rlJdru wave a. c. x, v, y fi

File{'rn'j'r diastolic PA pressure vrnul'jr ecWP firir4ln'ir diastolic PA pressure lficlfrali

riauirfinmc overwedge rniahj d,r lfioqrnnr:dtciolu PA catheter finqurfiu}l tun:rfilo\: cardiac
tamponade ?lvtujl PCWP |1i'ttiLt diastolic PA pressure tYirnju CVP 6un'jl diastolic equalization

West's lung zone

West's lung zone tflu physiologic tung zonell1d anatomical lung zone tfiu lung zone
rflu tung zone dfinr:rildfluu:Ja,t}Jfir ur6ai:ivturlot{rJru

Hemodlrramic Monitoring on-zun{ nfrfimg I53

Inrrrod uaoldariodrolnr:trifl.tu pA catheter

1. Diagnosis

Differentiation among caus$ of shock

. Cardiogenic
. Hypovolemic
. Distributive (sepsis)
. Obstructive (massive pulmonary embolism)

Differentiation between mechanisms of pulmonary edema

o Cardiogenic
. Noncardiogenic

Evaluation of pulmonary hypertension

Diagnosis of pericardlal tamponade

Diagnosis o{ left{o-right intracardiac shunt

Diagnosis o{ lymphangitic spread of tumor and fat embolism (case reports based on
blood aspirated from wedge position)

Z Therapy

Management of perioperative patient with unstable cardiac status
Management of complicated myocardial infarction
Management ol patients following cardiac surgery
Management ol severe preeclampsia
Guide to pharmacologic therapy

. vasopressors
. Inotropes
. Vasodilators ({or patients with pulmonary hypertension)

Guide to nonpharmacologic therapy

. Fluid management
. Gastrointestinalbleed
. Traumatic exsanguination

Bums

Renal failure

Sepsis

Heart failure

Decompensated cirrhosis
Ventilator management (assessment of besl pEEp for O, delivery)

154 rrtrirrininqndlg,u

FIoxim.l port a1

. Locatcd :]0 cm from tip o
. CVP monitoring
. Fluidand drug adminislratioa

Dist.l port

. Atcath.tertip
. PAP, PC:WP monitoring

lhsrmirtar

. Pmximalto balloon
. M€surc PA blood tcinperature

EIsllAotocnathetcrtip

.l.5mLinflatablc

Ig-ld umvhutJeJnouranfll putmonary aftery catheter

gli s uaatn#n pulmonary capillary wedge pressur. Ioann blow balloon SJwfiunltia

oressu.e ?u left at um

Ilemodln.unic Lloni[oring nn?uni nfrfiLug 155

Ylbdo.d

Flight ventricle

25
20
15
10 Right atrium

5
0

gli a umt pressure waveform $ia?dau purmonary artery catheter fittJtnaudtu ght atriat

pressure waveform, ight ventricular waveform, pulmonary artery waveform LLaJ pulmonary
capilary wedge pressure waveform nun\rilL

Zone I tflu zone d alveolar pressure > pulmonary artery pressure > pulmonary capillary
pressure

Zone ll lilu zone fi putmonary artery pressure > alveolar pressure > pulmonary

capillary pressure

Zone lll liu zone fi putmonary artery pressure > pulmonary capi ary pressure >

alveolar pressure

tnr'lsi pulmonary artery catheter a.tltd'lfiaglu zone rfio,rernvrrn'tsi putmonary arrery

catneter tria{lu zone I r5o zane ll v,rlj'jr atveclar pressure asfiri.lflrnn'jr true pcwp lirifirir

rlPCWP ri'tnnj'tnlu riluoi.orfi omrnfi alnaar alveotar pressure addtu

156 rrtrir:ininqorfilSru

znr:r,rd ttoor,:sl'rLtv ,lto':oru PA catheter rfi8fi,: Rn. RV ttat PA qltJbild':l

Internal jugular '15-20 30 Easy to float, esp. Puncture of carotid
from right relatively common
Subclavian 15-20 30 Easy to cannulate Risk oJ pneumothorax
Higher risk of pneumothorax
45 Easy to float. esp than with lJ approach
ftom left
Easy to cannulate More difflcuh to float catheter
{may require fluoroscopy)
Easy to cannulate
Fewer major compli-
cations
Higher risk ol infection
Risk of DVT

40 50 60 Few major complications N,lore time-consuming

50 60 70 Safer if bleeding Difficult to float catheter

diathesis or coagulopathy

May be easiest in morbidly

Lower rate of success{ul Limited to 72 hour duration due

cannulation to phlebitis and infection risk

nTlrilfi fl a hemodynamic profi les
rdarorn hemodynamic profiles d'ldtrn pn catneter fin'trirdioldaln PA catheter ei{

luncfilfludra'rurru

t. rirfi'ldcrn PA catheterToustt$ rdu Cvp (RAP), systolic PAP. diastolic PAP, (d'rlJ1:n

rjT.rrrirurnrdr mean PAP 1d), PCWP. cardiac output

z. rdrdrflurdrn'rurolernrtru PA catheter r?iu svR. svRl. PVR. PVRI. RVSWI, LVSWI

uanerndu'.rdaolr nataiunll HR, systolic BP, diastolic BP (fl1tJ'll0 1tJ'ln"lu?n:rit mean
arterial pressure 1d), svoke volume (d1 't:of1rJ'lfi'lu,)tuFi'l stroke volume inoex ld)

orrur:n rt:.1 a Ha hemodynamic proti t e ldnrltl'rd':-rd'td

1. dotn0l systolic blood pressure, diastolic blood pressure vln uirfi hypotension'lt4

y.ru'ru1 ttufl6t1rt1Esiolrt'jrrflu shock fitfioqrn cardiac output n't v5o shock dtfiocrn cardiac
output q,i lnuqlrneit cardiac output friddo.rrrrJadod?tJfiun'u"l{ vasoactive drug dru

Hemod],namic Monitoring Laniuni nfrfiMS lS7

,//n(n) I\

/OR >rr >e.

16;:;;;;;l

6i;.;;;;q-l

Upright

19

\7":-\

zttii z unnflmtohtl nneudutr.liaurfiuurnittntttfiuta.r/nontfranuan (anenat pressure, pa)
attxauta,tvaantdanCau (pulmonary capillary pressure, pc) ua' n2wdura,tqna (atwolar

pressure, PA)

nr:r# g uan.srnrurflunr:liedu.j'r pA oatheter ad'lu West,s tung zone l

Zon€ lll

PCWP conlour cardiac ripple (a, v wave) unnatually smooth
Diastolic PA with PCWP diaslolic PA > PCWP
PEEP rrial aPCWP < 'j/, PEEP diastolic PA < PCWP
Respiratory variation
Catheter tip location < '/, Aplateau pressure aPCWP > 'i, PEEP

LA level or below el"-l> '/, Aplateau pressure ] I
ryou: l

2, tfilirn'r:n:rqoa!ri0!.j1dl pcwp niin.jl pA diastolic pressure riakj

. fl"rn PcWp firirg,on'lr pA diastotic pressure 'lfiR,rfru1lriau.irrflu overwedge 'lfi

drnr 6ouaru PA catheter rJlr't-l proximal oun:cf'rld pCWp n'tn.ir pA diastotic pressure

e y1n PCWp fidt rvirn"l pA diastolic pressure 'lfillruttrrdouflrsaonrr,,t proximal

158 rrttirrinrinqnfrugru

fi1nri,3lrjfin1:u.l6uuu:Ja'tr'trta{ffuiromfiritriurjotrdorir.rfi':h gericardial effusion) fi.'tvufi diastolic

equalization ld

3, lfiriliu!!fiuilnltrffrrfiufrrfiifi cvP ua: PcwPlnurfx'hJ PcwP etfid'r{''rn'j'r cvP

rinriarfirrrru 3-4 rtJ. :oYt

. y1n cvP qnn'j, PcwP tfifior:nrli'rfiilraa{iun{r lalse high cvP
r 1n cVP oirn'ir pcwp lfifier:ruTjr{ilruaqjlun4 false low cvP

4, 'lfid,'! rnn'j1 pulmonary artery pressure g,,:nio'lri urnrll'i'l mean PA pressure d.t
rrnn'ir 25 rr.il:or fioir{r.huoqjtunrr: pulmonary artery hypertension do'tdrnr:ttundo'l
'irarruqtfioornarr ofi n6lo,rfi''1'lqvrtdrutrruiarr'rdrufi'rI

. urntflu pulmonary artery hypertension fitfinernnm ftg:-lnfi1o{n1'lodrudru c;

rrru'ir CVP fi{rrn: PCWP 4't triu early left sided heart failure, mitral stenosis

. vrntiu pulmonary artery hypertension fitfiqqrnnrrtJfio nfitolv"r'hdrumr lv

vi!'jr CVP {,r rt{d PCWP ilnfin?asl'r rriu tricuspid regurgitation. pulmonary embolism

+nr:r.rii rtf,o': err r lLFl noito: J ll.il': CVP waveiorm t[RY PCWP waveform

a wave fl{n?1 v wave . Peak a wave St'D.tfifi"'t P wave =240 m/sec og

. Peak a wave q1 fin"'l P wave - n:')fl-! QFiS complex

80 m/sec aeilu PR interval . Peak 10,0 v wave tfinstlttdt': T wave

. Peak v wave tfioflurir'::Jnruiros T wave

qr':rod s usq.rnlr;ddrlfi pcwp Rfl; LVEDp lildrrfluifniu

PCWP > LVEDP

. Positive pressure ventilation

o PEEP

. Increased intrathoracic pressure
. Non-west Lung Zone lll PAC placement
. Chronic obstructive pulmonary disease
. Increased pulmonary vascular resistance
. Left atrial myxoma
. Mitral valve disease (stenosis. regurgilation)

PCWP < LVEDP

. Noncompliant LV (ischemia, hypertrophied LV)
. Aortic regurgitation (premature closure of the mitral valve)

llenxrdvnamic f!.tonirodn{i @ntuni qfrfifiT 159

6n1r1{fi rLf,Ft,tFil nfifr'tda1n pA catheier

Central venous CVP inlerunr.r i-6 rr. Tort pressure firrn 'trildr-iod.ir votume rfil
pressure oItfl lLn: pressure frriotL lrjldrjl

'it volume t'tstfltt01:J

Pulmonary capillary inlounr.J 6-12 ,lrar

wedge pressure

Cardiac output inloam:,r 4.5-5.5 Vmin

Cardiac index Cl = COi BSA 2.4-4 IJminJm' Estimate BSA =[Ht(cm) + Wt(kg) -

601/100

Stroke volume SV = COl HR 60-110 mubeat

Stroke volume index SVI SVt = SV/BSA 40-70 mU Estimate BSA o'rndrr,fi rrdu

=Left ventricular stroke LVSWI LVSWI beaV m" 0,01 36 6ai1fil.filiusrnFxr d'uun:
40-60 g m/m'z :.Jirrn:rfluuriru,:ru

work index (MAP-PCWP) x

Right ventricular SVI x 0.0136 4-B g-m/m' Hi1lrdurrfu{r,:fi1l
stroke volume index
=RVSWI BVSWT

(mPAP-CVP) x

Right ventricular SVI x 0.0'136 'ldorsmrufirsr
iqTnun:o

ejection fraction

Right ventricular end RVEDV =RVEDV 80-150 mUmr n'rurrulfi ravnrnruarufi rru

diastolic volume SVi RVEF

Systemic vascular SVR SVR = 800-1,300
resistance
(MAP -CVP) x dyne-sec/cmi
Systemic vascular
80 ico

SVRI SVRI= 1,600-2.400 dynes-

resistance index (MAP-RAP) x sec-cmt/mt

Pulmonary vascular 80/ cl
resistance
PVR PVR = < 250 dynes
Pulmonary vascular
resistance index (mPAP-PCWP) x -^^ -*5

80 /co

PVRI PVRI= 250-400 dynes

(PAP-PCWP)x -sec-cmu/m'

80/ cl

160 rrrdtioinqndug'ru

nr:r# o Lrf,a{ir n6filfie1n PA catheter (4b)

r108 CadiovdBcular

frm9

Orygen transport parameters

Mixed venous SvO, inleruot'r 7D-75%
oxygen saturation
Oxygen delivery DO'= q1 * 520-570 mumin/m'? cl fl xB Umin/m'

Oxygen uptake '13.4 xHb x Hb mjlu g/dl t3.4 crn,:fira,r

SaOa nl1 ri"llm 'lu

VO, VO,= Cl x13,4 xHb 110-160 mumin/m'

x (SaO, - SvO,)

Oxygen extraction orER orER =
ralio VO,/DO: (x100)

5. tfifiqliru1'i1 vascular resistance riluodr.r'l: fiianr:::dn'itrir vascular resistance

fi'ldriurflurirn"rurru'trildrirdinldri'r lourfl nficr:ru{dn".rd

. syslemic vascular resistance (SVR) flun?lildlullulolvaaotfi oqfiaaneln left

ventricb aufi,Jtloocrrdandrdr right atrium ii.rra'ru:ruldern (MAP -CVP) x 80 /CO fi'::lo{uiifi

0rflriodr SVR 'rnfiflnaa cardiac output lo{an 160 mean arterial pressure llflv CVP n1 tl"16i!

rir svn iioirrj.rron'jr{rhuoqj'lunr?y vasodilatation rir svn iiqtrJ'rlon'irf,r-huoqjtunrt:

vasoconstriction odrtl:fimrrnr:u flHnFi'r SVR dotdrnr:u:Jn'.ra jxilfi'un1:lfi vasoactive drug

firl tu{lruddru ln ;a or 'rn n'l:ldcir svRt lunrturJnnrn rdo,:qrnrvfinrr LLriudl rnn'jr

nr:lddr svR

. Pulmonary vascular resistance (PVR) tflua?lilfilunruno,tvoootdaofioonorn right

venhicte cun',luaao ldaofi 6r teft atrium d'rriu'rru't6orn (mPAP-PcwP) x 80 /co fi.rrlodufr

firundonir PVR il1nfiqo6o cardiac output :o':n,:lr6a mean pulmonary artery pressure ltflv
PCWP Fi'r pvR doitj,rron'jr{rhuoglunm: pulmonary vasodilatation rir evn frg.trj.rran'jr{

r-huoglunrr: putmonary vasoconstric'tion orjrtl:fisrr or:tr nruncir pvR do,tvthnrrttrJarunirl
rirnr:lfi vasoactive drug fiTu lu{ilrrfrdrurrnu?an.ro:.rrtn nxildril PVRt lunr:u ar.ra
rfio,rernr:fi arr uriutr"rnrnn'irnr:'ldFi1 pvF

rurirleefue;fiuurlfl lornrrtsorulo.t PA catheter riounr ua:nr:finstroranr:6nur

firujrnr:td pA catheterlilldrd6fluu a,rzunnl::'nur *oid,:drfiryfrar:rfrfi,:6a n1{fi PA catheter

fi11ifi{0il'rd'il1c:li'rtfirfinnrflur:ndourrindrl un:Hdnrrinr*rto,r{ilrilrj16ifiurfi'irfinr:l"fi pn

rflr:;itcatheter v6o"[ri 6 nr.i',: rdo.:q r n PA catheter rflurriu.l raiotfiofi'lff1un'r:6nnrrv5o sY,r

Hcmodlnamic Il( lnii( )rinB Lon.:uni rffififtg L6I

riuuvrrrifio.:yirnr:u:Jnl.rafldcrn pA catheter drunrr :crYrt:;.1-'.l rfradabtlfia$rnrj::lfluido
nTinuld\tfl0

n1?1'td 7 ttf,o{niflldr.lo hemodynamic profile c1n pulmonary artery catheter

c.o svR Comflent

Cardiogenic shock ^ t Usually extensive intarction

myocardial dysfunction t (> 40% of LV). severe
cardiomyopathy or myocarditis

Cardiogenic shock due

to mechanical detect l
acute vSD I f
t .t t Oxygen step up at RV level

t
INormal or

Hypovolemic shock tPCWP in late phase.
Obstructive shock
Pulmonary embolism diastolic equalization
Cardiac tamponade Bradycardia in neurogenic shock

Vasodilatory shock

In1?1nii uflq.rdod.rrnatl1n' tyml'hnrrrr afln hemodynamic profites eln putmonary artery

catheter

Pulmonary edema CO. SVR. PCWP, SvO,
Shock Oliguric renal lailure CO, PCWP
Lactic acidosis CO, SvO,
Pulmonary hypertension PA pressure, PVR. PADP compare with PCWP
VSD RV inlarction
Cardiac tamponade step up in oxygen saturation (RA to PA)
TF BAP > PCWP
Constrictive pericarditis
Narrow complex tachycardia FAP = PADP =PCWP. deep X descent
Wide QRS complex tachycardia board CV complex. deep Y descent
RAP = PADP = PCWP. deep Y descent
Flutter waveform (FIAP waveform)
Cannon a wave (AV dissociation)

162 remirrinlnqnfrugrl

SvO: mreal( > ?0%)
I|
-+ [| D"*tbl"-cll
low

{< ?095)

I

Sao2 -----+ low (hyporaia)

I l-o"vc*tb"*ev I

| | inaeaseernP
I

qaormal P 95t6)

Ctacrcas€ €rtractior ratio)

I

+
Csrdiacider

1\_. / \

Ltgh low
(>2.5 llariad)
(<2.5 llnind)

I a
H@gbbi'r
*

PAOP

,/\ ,/\ ,/\

>E/d <Egd >(m18yroacltagrdial < 16 mHg
{Stets, anxietY, (rtttsa}
(hlpovotmia)

paio; tuEF Or bloodtrostrrsin dyrfudioa) f,uid c.balleage

s!3urytio1) Dobutdnine

wu4ifr I uoauuznxmllrtf,agailn pulmonary artery catheter rznauntt resuscihtion (rio

mean arterial pressure tnnnil 65 uu.tJTon)

Hcmodvnamic l.Ionir()ring nn?utl; rffifilll1 163

Fluid responsive test
lnurlnn^ riia uvrvrfhiu'ile'iriliilrrunrrri'rluvaaor6an uiEJ.,rilafiialriiutrurfi nsraej

nr:lna risur6oolrin':fi ififrarlr:orirulfi'ldtuvrr.,rrjfrl-fi6o nr:rir frujd charenge test fj*rfi
:tun;16gostr nt:t.:fi 9 rrn; to

nr:r.rfi 9 urseo'n:rFrr?rduro.rnrr'hior:rlr urifirJrudatilunrr:6on !runntJrrrl-! cvp ttflr pcwp

(pulmonary capillary wedge pressure)

CVP (cmH,O) PCWP (mmHgl Fluid thelapy
< 10
<8 200 mL in 10 min
10-.14 100 mL in 10 min
a-12 50 mL in 10 min
>12 > 14

nr:rsfi to

l. z 1.g 11Uu
z< t<c
3 <I <7 1fior:riroio}.1
urfindrcrn:o 10 f ttT,rn,r z U\tff\t l> 3
:o 1o urfi
| <z t^<,t
rnqn}icr:rir fi orrrur vasoactive

drug
hiarru*r oi o}J

odr' :ffnrlt nr:lfiornhntri{ruuvrir'lunr:dr rtuid chattenge resr orqLi'ldrj'trron votume

starus drfi?3{ niu cvp rdrdu'L{ z rl.rir rfiolfior:rih zoo ra. lu ro urfi ic cvp ld 13 ail.dl

d.rfird'nfiu'lqerr mlr'r\r ruid charenge test filrrrlo'hior:rir uavticr:rurlfi vasopressor oial:J
runlunrr!rfluei,rufir fiilrulun{uifihirioufrno!auarrdoorlihlurrnrsiarr 6.,:-l6finr:6nfiui6
nr:fiq:n:rqaatlirir.rnrrflrxr:nnaucuo.rrdoor:rirfi"lfiv5olri 6an'ir fluid responsive test r'.l

otrT :o rrunldo-.ld

t. d'rurlrdriufi'lnr:rJfiEJuu o,Jn1:nrro.rulro\r pretoao d, rjrsun'rnr:'lfirnia,lrirtru.ru'lo

e. d'r urri:ddurirnr:r!fisuu:ln,rnr:nt;R.rufla{ pretoao {i.,rasurTl lnia.rrirunrute

;t m"rrrrJ:dn*unTlnr:t fi uuttrJo.,rto.,t stroke volume derived parameter

z; ra''r ruJrfiduril r fifluuln{ro,l parameter filritd stroke votume derived parameter

60fi fiorrdrtorfurlt:nr:utnrfi urfiunr:'[f parameter fi uaqlfio fluid (votume) responsive

test oir,r1 6o nr:vrtfi rslrriuofllunr'r: fruid responsive test hilduno,:.j.rfirjrli:rflfuadh

164 rrttiliorinqnfrugru

n11:fl10f'r (hypovolemia) tfl 01 wr:'rtnlriic{#flT rd'ildnialri rvdotqirfi lunrr'lfi

or:rirldrialri }raar-urrddo{xirrrficr:ru'r6o rjan rir'h da,tfial ualnla'l "pace

f,rurJ#iuriunrlr]duuu:la.rn'uni:e-'lston pretoaa dolridurTun, tlirn4o.,rrieEffioft

i6ftarui nr:rit passive leg raising Teru'ldno'ntotnrrt duunr:n:verultonr:r]r1u
ir,:nlucrndrulnru (peripheral part) tfi'l ldxunn'h1 (central part) nt.revliltfi venous retum
nr'du ririfi stroke volume rfiutu fifunaunr:rirdird

1. r*rduernriruaufiru:4,t 45 4,i61

z. nn'rornriutfi{ ruuou:rr un;un1l{.t 45 o,trl't lntnr:l duuurln.:vlnarnrrfnr:
'lvnriuu16oorq; tfinrrnfronfr t urfr

3, r'qnr:r fii,utt fl.!?o.J cardiac output i0 stroke votume fiflrlr:ninnl:trlduurr no

ldotirroiorfio.,: ttiu aortic blood flow

?lf I ufln,tnttrtt passive ieg raising

ntidr passive teg raising nrnfinr:rfildutrai stroke volume rrnn'jr 15% uiofinr:

rfiHeruto,r cardiac outprrt rnn'j1 t ox niuruld'ir{:Jra:rariurirovoglun4tr'?lo,J fluid responsive

1oufi sensitivity 83% ttns specificity 91%

nr:dr passive teg raising lrinr:ridun:rfld{rtrufi:0il:niil?lrrun;hn uian:nid{rtru
fin:vqntitmrin

i'ruilrddufrurnrddsuurJa,lnrtntstluioo preload doiunu,aia.r;T anrule tnuq*tnnrr

t 6auurJa.tla.r stroke volume derived parameter

nn-nnr:ra,ri6d6o {:Jrudotlfirnia.rritutttu'lq control mode ltactd tidal volume tv{0

:irurruhodr.:fiou I un-/nn,

nl1fl{lnfl arterial oressure waveform ti.lourrn'ld ::rfiu fluid responsiveness n{o

::rfi unr:noufluo,lrionr:lfigr:rirlfi lnunr:r-o pulse pressure variation

Ilemodlnamic \.tonirodnli nn?unf nfrfilltg L65

1u{ilravr"finr:ldrnia.rri?u''ru'lc c:'nr:r duulr n{to{ arteriar pressure waveform d.rd
t. rir'rnruterfir 'lurir'rdr:fi intrathoracic pressure rfirdu lurjr{u:nsa.rnr:firu"hrd.r
nr1r]ou'lul:rronii rfrr'rluo;drlifinr:laiu6aooone'rn left ventricre lirifi stroke vorume u'r'ndu

ci,rrlfl'hi systotic btood pressure q,rtru oialrludrlyd''{10,:nr: ru"[e rf,r nrrld.utuu:rtonfi
rfiilduc:drtfi venous return or^o v'hifi stroke volume onn.: si,ro.rnht systoric brood pressure

fl0fl{

e. rirorrrhoon'lutir,rd intratnoracic pressure nnnt tudr*ru:nrarnr:vrfl"lcoon arr

or"u'lur:'r,ronoon,r rirtfi venous return rfitdu si,lnn'h} systctic blood pressure dtdu

3. ::u;rVn i:',r riiutir,rfiruto,rnr:yru'lqoan rflutir.':dlrifiarnrutcrfiraan nii,fihiflnrr

t!fiuutt a.rra'r intrarhoracic pressure rir'hihjfinr:r:Jduuu n.:ro{ venous return vr:rtri svstoric

blood pressure a'rfi (baseline)

ql, iinr:iflaiowirunrulordofl:rqo srroke votume derived parameter fil fituu n,r nrrr:n
Yl't
Lofifl'tflaldf\i' torrn.

1. A up, A down, systolic pressure variation
2. Pulse pressure variation

3- Stroke volume variation

4. Peak aortic flow velocity variation

5. Aortic blood flow variation

lufrdevtoniirrra 'lJ purse pressure variation rfly stroke vorume variation fi.:ldLias
nir oarameter fi'l6u

Pulse pressure variation (PPVI

Putse pressure rflunraoirrlo,:nruer''uTafindrt systolic fitJ diastolic Influ tgfufir,ln-

lirtu stroke vorume tra;rrr.l:zunaiun"rdrnrrlr6orduro,:vnon r6on rrnr tiu6ofir stroke vorume

lrn rir pulse pressure o:rtnfirirnrufioudutorrnonrfionrdrufi.r purse pressure orrur:oior

rr'lfi crn:tl n:rv.lg a,J n G"ulnfi sr un yriruru p pv mlrJ d:.J nlt

I tt"tI' =gmax 2)- PPmin) x 100/ ((PPmax + PPmin)/ ,

nr:6nurtu{rlrunrrvfiard'oiu1a6g:1l.t,tllFi,t ppv fin0lnua,sn{aar:fraffitrnn.ir .t3%

n1l'r"o PPV 6rfl rnio'rdnlurifin"!nr:iodrufiafinrruLLnnfi'r,lniu16nriou (r 0% d1fif!n1?ieli'nTu:in^

ttRZ 1 2o/o drrfi nt:r"odr a fi oy

166 rrtrirriai n q nfrugru

uT sllttr

pld s uaa,rylrntvlanxffu[aftnum. Axludulutlnan6s6cfllhuna1nualn71un11ifr Lup' Ldown

lInv systolic pressu/E vanation (sPv) Iauii Lrp tflunlfl dauutla,nJan systolic btood pres'
sure rhgttiatfluun'u basetine. Ldown tflunnuJdwu awa't systolic blood pressure rhof't
daffi uriu baseline uflt SPv tf,uesshffia,t systo/ic b/ood pres sure rhg.tuat systolic blood
Dressure n,1efl'l

r.nohrh

ttlfi to ttgotnlzia pube pressure va(iation

Stroke volume variation (SW)

Stroke volume variation (SW) tflunr:r-n stroke volume (SU druj:aiuenrlnlrmut?
rdroondrsrn6o.rdxufllulq T6u'ldvdnnlri [nt']vtil:Jnllr4nerr.rri'ulafiot (pulse contour analysis)

udnnr:60 tu arterial wave{orm rfu duf,1fin:rflur;'t{ systolic time 60 stroke volume tnia,:
e v n'ru'r n-fl oudr nrt i ntegrate dufitfi n:rliludr.: systote

qrJn:nifi'ldnd'nnr:d lduri picco' io FloTrac vigileo riludu

Hemodl'rramic !{oniroring ffin?unf nfrfi$tg 167

P {rntn }bl

Sr*PCCo=car. HR. JtdS*q01.
qt.ob

-r' -r--, 1*_r,.+' 1*_!*". !*-

Fd.nlq.r$6 |hsr An.unfu Aortlc Strp. ot
Fgtl.m3m prr.$n
€lbr|tio0 frs.to. nb co|lrp{anor
{ima
(d.bnttl.d by

hrrrmd&rlio!)

tttrtJfi uaa,tna'nn1in1d1 stroke wrume6,tn'ifrclnntxituzaflui?,frmryt uazatutmitutruri't car-

diac output 16 Inana$trh strcke wrume aru u ho,n , te ii,tcz,i.t\#g.tutnfn cardiac

output lfiaitfiiauia,l (continuous cardiac output monitoring)

SW d1 'trodru?nrldnrrrolnr: d,rd

-rt.=SW (o/o) (SVmax - Svmin)

(SVmax + Svmin)/2

I

ra'r sw fildrrnn'j'l 9.50/o [f,o{fi.J fruid responsiveloufi sensitivity 81o/o !!flv specificity

82o/o

lun:nifrorur:nel'rurrudr cardiac output ldadlnsiorda,r lcontinuous cardiac output
monitoring) riiorhn'r:'lsicrur-a cvp fi3:d'r 'ri0i'ru'rfu9il systemic vascurar resistance (svR)
'ld rtiu 16 ur n'lnr:1ni pA carheter Ie unhurrulder n en:

SVR={MAP-CVP)x80

rirrjn6to,l svR 6o 8oo-1.g00 dyne-sec/cm5 rirfig,l uno.rn'.:nrrr vasoconstriction ritd
o'l LtdFr{n{n11 J vasodilatation

168 rrnirrioinqordugru
nrurl#dunTlnrt:l6auu alnr:nrue,tullo{t pretoaA dot}uniurnia.nirs}1ulc loaldldg
ernnrttfjdgulr f,{1o\t stroke volume derived parameter

il1rJ1:0li',r'ldun1ua6

1. Plethysmography (AVPV) drldlorunr:oil putse oximetry lfidutfiu waveform {i.:o;

fllfiri'nuru:nfirUril afterial waveform 15nfi1uxlu Venlilation-induced plethysmographic variation

(vPU 1de1n46:

l- utu = max amplilude - min amPlitude
/, (max amplitude + min amplitude)
rdr vpv dr-rnnir ts"z rrco.:'Jr{:-hu:T ariurilu volume responsive
2. Inferior vena cava collapsibility index (lVc-Cl) arduvn"nnr:Tount:'ld ultrasound

probe rrt'fi inferior vena cava (lVC) Joald w-mooe fit1nuiln6 lvc dimension a:finl?
r 6fluulJo,:$r n'r:vlulc

epld uant infeior vena cava fifintsttJduuu atalunttnlu'lc

nrrur:neirurrupir inferior vena cava collapsibility index alnflnl

IVC-CI = {Dmax-Dmin} x 100%

rir tvc-ct dlrnnir +ox {rlru:rtnYutilu volume responsivelaufi sensitivity 70% uflt

specificity 80olo

finr:i'fi tvc dimension tuntrqirriJu volume responsive fiiolri nril'l6o filn tvc

dimension tJlnn'jl 3 ttt. rovriu volume unresponsive tLn; lvc dimension oan'jr t tlr' rjr

ov!flu volume responsive

Hemodvnamic lvtonirorinla nn?unf qfrfrl1lg 169

n1rl{fi 11 [tfl6{ IVC dimension [tRy respiratory collapse 'hri.l.'urulct{r [nrn']: :: t fi1 CVp

<LC > 5oo/o 0-5
> 5oo/o 5-10
1.5 -2.5 < 50vo 10-15
1.5- 2.5 Little inspiralory variation 15-20

> 2.5

3. Inferior vena cava distensibitity index (DIVC) fi,ttJ.t?nf|"luxru'ldalnf,n:

DIVC= (Dmax-Dmin) x100

Dmin

cir ovc d rnnir tex drJr-uf,n'! votume responsivelnrfi sensitivity 90yo ufl; specificity

io'frriola.rnrr'lf,q'r urJ#ri.ruanntl v votume responsiveness

t. {rhudaotdrniolrixumula controt mode

8z. fia':td tidat votume orjl,:dofl n./nfl. (predicted body weight, pBW

e. f,ilrudo.ilfiiu'n sedate eu'hifi spontaneous movement fi t! nrunr:iqfiroir,Jr
+. loadruhqifir-hudaildr"ln1?td arreriat tine unrlln?nifl a\:nrtfo AvpV. tvc

collapsibility index, IVC distensibility index

r:fiilrafia.ilrifi n"T'lordufiq{,,r (carcriac arrhythmia)

b- lrjotn:orirhtfii open chest surgery 1fi

z. fiilrudfiI:nmlrdoiloolurrx (severe lung parenchymat disease) rfiawrn pressure
frtdt'flilil ay"[rjri0ufihin0io1n:.rofr,rdaqj'lunri.,:vr:rron d,::ufi.r superior vena cava
uA; inferior vena cava d'tg

170 rrrnjljoinqnfrugrl

nrdtqnfild parameter rfiInriu luio responsive test luntrJffi

Hemodynamic sbble ?

vascuEr

umtffi z uaontt tzun li panmeter tdutiu fluid responsive test lunnJfitfr

roflglTolilo\:

1. Brian Casserly. MD. Richard Read- MD. Mitchell M. Levy, MD. Hemodynamic Monitoring in Sepsis- Critical Care

Clinics - Volume 25, lssue 4 (October 2009).

2. Wa ey KR. Wood LDH. Shock. In: Hall JB. Schmidt GA, Wood LDH. edilorc. Principles ot critical care.2" edition.

New York: lvlcGraw Hill. Health Professions Division; 1998,

3. Casserly B. Hemodynamic Monitoring in Sepsis. Critical Care Clinics.01'OCT-2009:25(4):803-23. ix.

4. Invasive Intravascular Hemodynamic l!4onitoring: Technical lssues. Critical Care Cliaics. 01-JUL 2007;23(3):401-14.

lttin5. ronluni 4fifio3. Practical hemodynamic management. tu , ra niunf 4ifi nl. tfiltiqn. u::rurBnr: critical

Care :The Model of Holistic Approach 2008-200s. nlnlg r :r-r.iuoud r5uL1rafln:d ildo; 2551. 1'11i1 115-59

6. ryrfin::ni r:fidnarn:. Hemodynamic monitoring.lu : ltuinf rfilfiqn, ran?un5 nifio3. qfin on-n:. r::rur6nr:
Best Practice in critical care, np$ r : r.fiuaud rEurnoflfl:d c'rnin; 2549. v'i1 2w-226

t. flnr!6 fu:rqn. Determining fluid responsiveness. lu : roniuri 4fifir13,ltuiarri rfirrirln, l::rurinll critical care I

Towards optimal Perfection, nl,ttfl '1 : :t.iuaud r6u$roflriTi q'r o; zssz. vfir +3-66

e. nifln6'6flnierufnf wedge Precsure vs central venous Pressure.lu : raniunS gfifin5,ltufrrri rfilftqa, l::rurfinr:
Citical care: Towards Optimal Perfection. nprlxr 'l.iuol6 rEurnaflt:d '1"rfr'o; 2s52. 111i1 95-120

10

Central Venous Pressure

qin$ naoagi

nrtrir bedside central venous pressure (CVp) monitoring darfludrulrfioloonrz
rvtiunr:riroruaolr-r'huo:nr:inrlimruorahluirlnrmar{rJru:;u$nqn rirldlounr:1d

flrucrunooorfioarfrflnrdr-Ifiasq"rdrurjnruuia oaorfiansi'ldrunnr,rcu:Jaruorurdtilagludru
dutatyaanrdaa superior vena cava (SVC) mvrfja.,lmnflnoqrfian SVC rilordr{n-rtlrfiauu

mrlnunrl d.rriunrrfonrun'urfioolunaoqrfionn"r superior vena cava i,lfiun.uian'nlnTu

?o,0rfdcfia,:uurrrTprunro {il'lualrJn6l:firirnrudua{lu:ir,,r o-a finhrlsndroyl
'lu:rnnrudr;lfineirrfi{nrrldnruoruuoonr6oonhdrunar unr:in cvp uayn11d1ri1

cvphJlfl:ylwrilunr:gnn{:huTnuovuunndrrlumunv16uoqrllilrc1!flirmnrr'lfi,0rusru cvp
drniui6nrrtdqruoruunaerrfionn'rd?ufln1\:lrncRlr;u,:ndousir,rt dororfinaruldndmuunll
'luumnru#ol vascular access

nr:rJ:ssndl#1ffirfi efinsa,r central venous catheter

1. nr::Jzvrfiucrrrfi'luttsoo!6oq (Assessment and managemerfi of intra\,/ascular r,/olume

status)

1. nraltfiunrrrir'rruto.ofr'h (Assessment cardiac function)
3. ldriunrl'lfiurntocrrfrlrsriin (Ftuid and drugs administration)

4. icrfiuriffiJoonirouhdaosl"rdtrond'urdr{rfrr1o (Asstrsment of tissue oxygenation)

172 rrrnilia1nqnfrunrl

1. Assessment and management of intravascular volume status

:rarunmldu'luuoontf,onsird'lunor',: l6rrd nnoorfian superior vena cava (SVc) uoY
inferior vena cava (tVC) riurnJ:ri-unruj3mrurfiono'rdlnand'lrilt{ri'r1o dlrJilrrurfionfi'lrnn
nairlrdr{n'rhfidalrrirn-r-nJi rrutfioqdqnquiooonlrnri'rtoriurar tu{:hudfinr, vvrio,:ar:ri"r1u

irrn'rrqufi:lirrcur6ondgrLiooonornr,r'r'tqono,t l;lttitfi cvP m'rn'jr n6 'luvtr,:n:,:drr{:Jru

iifior:rirtunnoor6ofir'rntfiurad r;fi cvp d4on'lr:-Jnfi orJrtl:frrltr{rJrufifinmctrncr:lidu
flaaorfianrfi!.irfinflou rirour:nin cvP ld'dldogludr.rrJn6 1z-e finfiwnr:l:or)' ld rYod

rda':qrn:;!:Jfinoor6oahir.rnrulourarrcfinoot6onr{lfinrunrrr:ntunr::Jildrtdanolauoo
ria nr:tr n ar:rirlfi'lu:: d'rluii{ Tauriiofinr:troor:rirtu:;u;u:no:finr:noawa.: ilrrut6oaal'r
filunnniurdr{rhhfio,tuumr rir'lfi cvp oon.rtSnrlouoiolrtvtfionr:non"ua,tmontdann'r lnu
rour;uoont6oon'rnru'ludo\lfia., (splanchnic venous system) ua;vaaotaaouit?rund ldalon
ruruun:rr ri'rlfi ilrru16oorirfilvnnniu{r'rlorfi#uru cve firira1jturjuJnfild vrnnr:mnar:utr
f,ia'.rne, uiudaLi :Jirrnl6onlvnnniu{u'r'lol:aoa,radr,tsiorfiotcu cvP n'rn.: drun"larr:.tri'ulnfisl
docrn.radr,rd'urcurutfio hypovolemic shock tutt':nrodu rrnfi:JrufirJi rruor:fr'lurnafrrfioo
rfiutsumaoo rdaoq'rcvlurud'r rdoi:l:lSrrru16oodrfildu cvp e'.tri..rn..:o{lurir,rrJn61fi:ctlvfifj'l

o-.rriunr:rvld cvp rdatfluuu':nrs'lunr:'lfior:rirrrri{:Jru 6rnr:fior:nnt)o{adr'':1 lou

rorr: :rihra.rnr':riu ru ornrrunrarnr:uoar dqrprruirrrdr''ll Tnuront;a'qzrnr:tdumtfino:
run:rirnrrrduTnfin itililfiunr:fionuerut duuu n.ma{ cvP nd.rn,rtfior:rir lun:nifr

:J:;i6unrnrrn:rqir{nruil'#sdr,Jdnrtu'lr{irafin'n:rT do,lar:u?rcur:nfiqr:rur'hlorrfrnorrvu

ldadrr:ror5r drnir{:Jrrfr*rvrStrjurih'irc;fi:Jirrlucr:rirtfiutraniolri n6ofinrr:rdu'rfie:
rfierd'unmuernnr:lfiiuor:rirrurn rfiura6orrur:nrirnr:tfinr:#r6':tri6 fluid challenge test

Fluid challenge test
rijamrnnruour:nlunr:pialofiono.,rri'rloniolfirfiuwarionlrdornr:ldra$T ,':nru

riu rrua{rfuflr{uudn g :l:vnrt' lfiuri
1. Preload viorJ3r.nnlfi oorfi'lnand'lrdr{r{rhriuro,'r
2. contracti l ity 6onru ornr:ntunr:fi :.roYr1 o.ofl'rtq
3. Afterload tl?o tt:'ldrutrutotunaa t6oodtu:Jnlu (systemic vascular resistance, SVR)

tdrflodavd'ndevrflun'rrirtuor:d'wrrrun*uTnfisr i,tl.tn-r:-l3r'rnrt6aofrlnaaanqrnfi'rtc'lu urfi

(cardiac oulpul. CO)

Tna Blood pressure = co x sVR

lunrrvfionriudr,rnruo:'ldiraaninurlanr:ormrirjrfiu.,)flarYuol dornr:dlnir{

rhgfifint:6onornnr:i'lq6['T rf1fiiot6oo ftypovolemic shock) rra;{rtrud6onrdoternnr:fin
rdo (septic shoctl riu n'nflgo{fls{ SvR rfio,ternfinrrflu'tuto,:vaao16oo6iru nrs dr ni:J vascular

Cenfral \tenouii PressrLrc ginti ltan\ti L73

permeabitity rfjr.m*u 6,r ul3rr rafiorfinr:rrorcr:rirtuvnoorfion iitrflunr ruqrri'nro{n1r!nrl
nrr:60n6',rneirr n-r#unr:inu{nunr:irfiar:rh6.l rflui6fi rrrr;cl'lunrrr*n!.1n1?: septic shock3

dryfinr:ni ftuid chalengea riu 6onr:1fiar:rirr*rifirhrdfinrrynrrrfio n6lom:lu

lya ritrulnfi n louriryirtfi

lt . aur:nrfi Srr u6aolrooonornri'rl0Ifr atirt:ror rf r

z. atrr:nufi.lrnrrrn',:rroa.,tti.to,:ir.rnrdd

l3. rfiena rfrucrnnr:Id:h-,or:rir irrrurrnorir,r:rn r5r1 rioufioa

rrndtlr:oo:'toio::oir..t central venous pressure (CVp)lde:dxut!nt:dr fluid challenge
tfluodrrrrn fi.rfrdrd'ru-tunr:rir ftuid chalenge 6ocn:tfinrni.rnjruyt.:nnoo16ooo"rlu.rflhqiilrJ
n&.,r catheter fi1drflumrrrlfior:rirnr:firuro'ludnofl R?l uflynt:e;rflunuoyrfiuriufitirirnr:
monitor GVP5 dryiro"st:r rSrro.tnr:binrrutrorelfiorrrurnrru::nil cvp y5o pcwp rioulil fluid
challenge q"',rqr:r{fi 1

nrrfifi 1 uso,:o-0r:rrSrrilduro,:nr:}io.r:riruri{rJrerfiagllnrry6an urannrr:;cr''r cvp *n; pcwp

<8 < 10 200 mL in 10 min
a-12 100 mL in 10 min
10-14 50 mL in 10 min
212
> 15

'lutru:rirnr:'hiar:rirodr,,r:'ln rStiunl:6nnrrnrur duuu nt?o.r cvp fi;a pcwp'li
praoa rrnrTorardutrn"n 2-s dlyiu cvp uor e-z 6frritl pCwC dlfi:rtnvrdaoro'ruan.:'luuzuu4fi

fr1

r. rrwlf,*ral,l

t.t uru:rirnrr'hfrRr:rirdrua-rr:T rfrnrnrlr:r,rfr 1 yrnrldr cvp uirs*u > s cmH"o

mio pcwp rdrri*u r z mmHg 'hilrqonr:'lfiar:rihliriou ua: ::rfiu cvp x5o pcwp r.rdrnor

s'iru}"] t o urfr rd,r{o s)

1.2 dr:yn''r.r cvp y5o pcwp rfirdurfiurrfinriauorrr:o'hiflrrdldfll au6: n1
rirvuo udrrirnr: :yrfiu cVp yio pcwp ttr

e. nrfi.:triar:rhna.rnrrnhnuoturear t o urfi ninr::J:yrfiu6nni.:

2.i fil cvP niilntuq'ln rdurfiu 5 cmH,o yia pcwp rfilrsuqrnrdrrfiu z mmHg tfr

nqnnr:hiar:rfrlh;rrrx i0 tl'rfi LLdiilT:rfitt cvp fi50 pcwp dl

z-e fi"r cvp rfijmriulrnrfitriounir 2 cmH"o r?a pcwp rfilduornrfir'hirfiu e mmHg
aln:n}iar:rirsio'[il]fidruo'sr:rr5r rvirrdr uiarrndun.irrFurs,rddlrTrnr:no:.Lnro,rro,rfi:Jru

urnri,ter'rfia,rnr: cardiac output rfilduunyyrl'jrnr:tfior:frorlr:nrfirnrtlfi'uTnfioto.,:frlra
rirlinrrufdnd'rddumiaflnor, ylrndun.ntfior:u"rs{a}J lol"rurarjr n tu:rJii r1

174 retrirrin in qndunru

fluil .h. en;e

{n on, ecae + ln6adll

biarrrir6'ludprnlir q,'r nrsr,rd t

* r.lrn t:r I lrqne1:
l'|aT5ill
d;;>
ccrip r*ridu tt
r-r€r n€elri ".,

}iar:rl oionrJ

P,:!grrflT'rHUS

fr5q c,'p, pcrp

c.,,'P tfid,ri!fix 2 cmt! c.:e Gls:uir'r 2-s cnr.o :,o ifia€u:nn n'ii s..'",o
p:ric rfttdulrnrir 7 *"rg
pcrrp will:jfir a .*"g Pc,4P L'.l_l.isrFitn 3 7 nmHc

}larsrir pio urn{ ruoaraua.:6du 50 10 lrli
lud'c:rtfir
lbiarr *r pialuil''nrr frnr" rd

3e $iaorn!fiur:ounir c.;e tirlrnnirrflIifiu 5 c'n,r.c
p:.-rl tnnnittilerflu 7 nnxg
s cnr,o rcwp tdlrnifin zqem:ftim:frua:fi rrse,lhi
iau.ir 7 rr"rug
vascpressor uEa inotmpe
fi arsrurlriar :irluoiqr:r
mn(rJrrlrinouauarrio rira,: nir rfi r",r n{Ur t-r

nr:hlarstr f,arsoirlfi oa"Jauo00au
v:soDr€s:o' hrrr -orope

utugfri 1 uf,nnn1flJfirnn\fif,lsti'tuifriln"luntrr6on (Huid challenge: finwJarr.tnrlnated.,u t

atlJfr 4 un' 5t

2.3 d1 cvp ninr'uqrnrfi :vra'j1{ 2-5 cmHro fi6o PcwP utudu::niT,: 3-7 mmHg

*fiqrrcurtfiorti'rria'l:ituri'n:rddrnrn'lrr6rrrn{rJrufinr?srolrduot'hr'r{dds*urn',ilfif!or:fr

ttU 9ll'l?1{llnl'llJn lnfi9lg\:1u tirhufierr t"cfidriu rlnam:oanrrnrau uioern:rfir'ro:firirrru

rJorufi orjnrurfirlddoroudu lfludu

e. lurnnifindoduqanr:trTarnirude cvp nia pcwp g.rdur,rnlarxrn (cvp diildu

r.J'rnni'l 5 cmH,o vio PCwp rfiu;urrnn'il 7 mmHg n"t'luda t.t vio z.t 'lfivqnnr:'lfior:

1

tLtjtru.* 10 u1fi unilisrfiu cvp fi50 pcwP d1

3.1 fi1n cVP u"\ro{{\rn'j'rlqL+ildurfiu 5 cmH2o ua'qn'j'rrvljrlltn16uuTafiorlo'r{ilru
fior:rlurnrfiuvroufir nr:lfirgr:utrrf,r'hflu:;rr.rarrrio'lfirfion'r:rfirdura{ cvp }r5o pcwplos

lrisrrr:nnir co tfi{r]ruld 1n'trnlir e enilgild 1)

(lcntral Vcnous lJrcssute ttiati na'tati 775

n-M t Uflnnn2le f,Bultl \r?r\, stroke votume (SV)

lifl LVEDz nia pcwp tfiuiu 1ru1 uanatu

fxfruinat LVEDq iu LVEDv irhunri,t e $a
.l)n' f,n Y1L;n f*ruolulttuyrtit,tntu
{tntasttit ny

i1 sv ffiNdust|tntn nu lut ayfr sttitfftdiu
$utu'-t{y6.fi 1 t't.i-fi n1i; :
B L\€DP ti5o 0n LvEDp ath,s{a nu
PCWP fiuzt

ieq"'tun i B wyit LVEDp tiudua t,ntn1a
nLnN4if-al.t\fxei P1tnU, ffl i1u1 wU!'7tatUTtf;tr3unZnna1'f1i\nt nttl larNt-sf, t'1 t1iut.Vu1 Liy.-rJttJ J n I

uonttnqyligtu'tsntfru sv tLfr! Co za,tffilaa

ldufrt ti'tatqria'lyftfio votume oveaoad Ifr

3.2 n1n cvp ndldurrnla rilr{ulrirfiu 5 cmH,o uia pcwp niiliiuhjrfiu 7 mmHg
udo.:'irrvrus"torofflrJ'r:or"!rjilJrrudr:rirrfirrfilld urinr:hior:rirdrudn:r:eorSrorodr'hi rett
ventricle hidrrr:nrjflln"rrdoir votume ldn-u lnaranr;lu{rJ, ud'n1.r: diastotic dysfunction
d.,rvsi,ss.ral#fi putmonary eoema ld r.i',:rYunrnq;fier:rurlfinrrrirriahnr:'lfid-:uo-n:rrirfioun.,r

n'irrd uancrndnr:fior:rurnrrqorouaroionr:ldilcr:frrordrhudru

2. Assessment of cardiac function

nr:r"narrrd'ura'runoo l6anq"r SVC rfllnr:r"anrr n-uernfirlefia.Jtlunxl (right atrial
pressure, nnel fittunurJnfifiLifinr:o'llor6'uri'.:101e:nkflo nir cvp e:orrJr:n'tdrflusr-ruyru
1a{nrr n"u'lur,r''rterlatairrtrrd':.:duqotarnrtnnruor-r16 (right ventricutar end diastolic pressure,
RVEDP) HiaAnu"flyfi,:6onr: :: lfiunrtdr,lrutar ''rlefio.rair.rlrru&urot uanerndlunulnfifi

Lin'T:q1o.r!oouo:fi"ur,r''rtoftq!n6 nirnruoiuqo,rnooarfioonlutti.,rfinrrilffilrfi'u6fi'urcFriil teft
ventricular end diastotic pressure rfluoe-ir,rd 6,rarrrrn'ldrl:zrfiunr:rirmuro,rfirlefia.J6jr',rfrfl
1d'ur,rdar

2.1 Assessment of right ventricular tunction
rir'lorio.:lugrru50 right atrium riufinrri,rrr,: un:ri.rrrirfril ldooq"rfinfl-tlulcrniilm-r

176 rrmirfninqmdugru

drulurirUynonrfion SVC rrnvelna['td'rdruEirtl.jrulnon 16oet inferior vena cava (lVC) rioud
e:d{l.jrudufir'lqln:doflan.r{l'rlofio.rsir.ltrrrsislilrcar'uarr niutaor'r'lcfio,llua':rtunu:Jn6oqi'lu
rir.r z-e fio6r r5rj:anfi.,r rfru:;drrdrrrir-rnrud'uqorfi'tu'lutir.:rir'haorud'rto',rri"t'lofia',:drttrr
ii,rnrtro'urj',rnrirrtu nv o: lvirrYr'lu nn rfioocrnlutru;vrofuln:n"dilod.tLlflo n"lr.rYurfiaoda$lu
Rn d,rfioriofi'u16ooflu Rv itrofiouoflurjo'r'lr,r16urn-u nrnrtrtqlio,ldratlfinrruorur:n'iunrr

aorunirn,td (constant compliance) nr:di1rdulo.l cvp q:rj'l:Jon'jrfir'lefia{6ir.r1'lrd tfinr ia
nr:finrrvrir'lutaoqt6on!'tnfiu o6

2.2 Assessment of l6ft Yentriculal function
'lunu nGrdrnruo'uqnfiruttrir.:v''dcnnrufi'rrla.1fi'x'lofio{sir.ldrtrq;finlldl.rn'uf

niunr r iler''t-t1uri'r'lctioooir.rtr r o-o ol nr:

[2xCVP]+2=LVEDP

rrn{ilrufi cVP 4 finfirrn:rl:ar {rJrtilro;fi LVEDP ilY 1ru 10 fiRAt n: ravl

rflufiu nr:rJ:rrrrudr Lveop druiBdidldlu{ilruo'rqrioufi'trjfiT:ntoonfitrrdorir'le Ttndu
rirlqftoiln6rial:naoo oer 6tf,'trr:ntd cvp tl:vtfiunr:vt:roruts,rrirlqtio.IFir-tdru rtnvtdtiru
'lunr:ilir-rrlivrruor:rirfi t ;lfi uri {rh uld

riio.rqrn cvP tar{ rurrrnrirc:lrjinlrflr{uf fi'udr lvrop i.ilriaur:n'lf1u

nrr:clfiunr:d'r.:rula,rndlrrdsrirlclia'r6jr{druld {r-Jran{10",:ndrrldrrri f,:-hudfinlr.rfin
rJn6ro,rndrrrdau''rtoniadun-rhdrurrr {tJrufrfinrufin!nfua,:ndrrrdorir'loniod'urirtodru

firl Tsu railrvduri'rlehminunv{:-hudfinrrvnrudutuvnaa 16oq*or'mo'trJaog.:hjiro;rfiotrn

ctnq'lnfinlr

2.2.1 {Lhudfi n?11ft o:Jnfi talndrlrdori?'lqdrumrfiiafi nmtfi oiln6lo,,:durir'h

liuri {:-hudfinrufiorlnfita.:6'uv-rlqlmra-dilrr 6'ur''dorla1lfio n3afi'uv''r1q1ilrin rra:{rhufrfi

nfiurdor.r''rhdrutrrdr,:rufiar:Jnfi rdu firl:sdfintr:nfirrrdori'r'lodrutrltlfit6oo (right ventricular
myocardiat infarction) {drrrtdrdorfr RVEDP g,in'j1ilnA Tertlii rveop lrildq,rotul:ldru o-triu
i',rri.oilalfi cve firirq.r loulilfi nr, ufrlriud'riu weop

2.2.2 {il?uiifin1'rlfio nfito,rndurf,ori'r'lrdrurirtdra lduri {rhudfint;ndr*rrdo
rirhrro 16onrf,ulrrd'u (acute myocardial infarction) {r-hufifinfirrdorirted'r.:rufio nd ldilateo

cardiomyopathy) firtefio.rsir,rdruta,:{rJrunoildo:nru'r:ngl6n rfionoonb{rdur6oottottooofd'r

ldrioun'jrtlnfi (decrease stroke volume) un;fi Lvrop do.,:a*u d':no'hinrtrli'uluv'r'lqfio,rlu

firuq.r{uunvrir'hiri'rtlfia.':dr.n'nda.cniaruvrindu rdal;gu6ordacrrtnnaan 6anrto.ttloondlt

r{r{ri'rluio,ruudrutfild n:rulqfifi'rlqfio.rcirorrrd'Jrimu1fi6 nrtrriu Rvrop q;titntilnfiunv

cvp c;rirfieirilnG vr'*r1 fi LVEDP gtduufir qun::f,uiio1nfi9'r'lqrta,:rir.:tT rlriarrr:n:JilpTr

Cenhal \'enous t'ressure flinti trars€i 177

oio{rirnr:rflldula\: LVEDp llas LA pressure ld q; lfinnll:rir'lefio,:6ir*tlrrfirrrun? (right

ventricular faiture) st'lrJ 1 ni,:zunhl Rveop lcvey qJfiuorril:ldrrL lunrrsd'.rn6j1.tc;6t1 110
or:reflr'jrfi rufinrrcuYryiti ao (putmonary edema) rda.rornfinr:rdrdurarnlrrra"'uturirlq

fia'rrir.odru (LA pressure)'[droreu

2.2.3 fiil?r,riifi n?lrdruynurorunon6aouo{firJaqo,rdu lduri 4fi uiifi nrr:n.:udu
lurnaot6oouorsa.,.:rJoogtfr,ltfior{ai.,: rdu {rJrul:n primary putmonary artery hypertension,
{ilrul:nq'radr-hto.r (chronic obstructive putmonary disease. COPD) rroyrfiordulvrri'u nju

{rJrufirrfionoon"uh?naot1606 [[F]{ 0a (pulmonary embotism; firJrudfinrry ond'n rnladr,r:urrr,r
(severe pneumonial dr{:-hun{ura',:lyfinrryrnoot16onun,rlorrloorori'r rdo,:c'tnnr:?rnoon6rqu

(hypoxic pulmonary vasoconstriction; rirhiorud'uluunon rfian untra,lrlaoq,ldu "[utnr:iinrrl
ri'ulurirhdru$T uh'ldrfrrt*u rfiay-r'lodrueir.,rtrrfio.rnisrunrindu rdorartu: u:rdrurrusoo
uoanrfionuor.r'lu oo orqrtrtrifinnm;n"':'lodrurr, firurunruo;finr:rdrduro\r RvEDp ttay cvp
1d r{ftrn4udfulrinrrr:n'ld cvp riJunr'rurulunrr:J:;rfiunr:rirmura{rirlqdru6ir.idruld

iuf,rJrun{l rudriioroelriu6o,lordu putmonary artery catheter tunr: :: rfi unr:
ni{lura,rr.r'rlqdru$ru1nafl:.lrJ'rnnirnlro''tduuoirliu{ cvp L1fiu{od1{16flr otirtl:finrrn*r:;6n
ltnra'irrrnfi:Jr ulrifi nlrl fi nilnfirro,lfxteInrl0o o,rfr nairrlrour:nrdanld cvp'lunr:

ftj:vffiunr:rirtruaalti'r'lqrmynr: nr:1finr:rirurifir-hu1d

3. Administration of fluids and drugs

nr:'toinranrunnaol6aoairdrunnr,:flrlr:nlduflurrrtrlflrrnraluysoBldfiarrnrdr{ua,r
donrnlfiyrr,r rdurdoerohdrularflartria'lfirflanr:d'nrollorynonrr6os d ldu f,r:nsnrffio.rl tte]o-
l6ur.rnno-l:d fifinrrrrt:.rdusarl unor6urrfiu 40 mEq/L uncor:orfir:d'hirrlyaanrfionn"r

{(parenteral nutritionl drfineurftr{udnndr 9oo mosm/L (5%D sotution fiRtlx$ 253 mosm/

Llu uonmnriururrtfinlouron, :urfioonrlrdm!{iln1rirn-rsotunao16oo rliu norepinephrine

r!n; epineDhrine nrnlfiyrouoaqr6aon'td?u:Jalu!rdrrfinnr::"rfloonuontnan rdanlyd'rlfi

ufio rdoriiotfifiryu-'rsro r6onrurflrflld (subcutaneous tissue necrosis) o1':nyarfl rrd1drfiatfir.jru
fitudruvnonrfiono"'rdrunnrr e:pn 16oorrdru 16aoo"r:Jirrrulrrni*rlririotfilfinirpurn".rnairr

4. Assessment of tissue oxygenation

nr:n:rl::rY:.rRlrr nirduraraonf rqu'lufioon 16onrl'rd'lrnnno"u{rirhia{fll1 (mixed

venousoxygen) 6t'rtJ'ltntj.JrBn'jlrdorEjoriroflaoir.:nrul6fuaonfirqulfiflonocionrtrda,rnr:rt5ohj

lou!n6drnrtJrdrdusooooninu'lurfioqohesfirirliln'rn'jrtora: zo lu{:Jrufrfi::d'rarrr:rdrfiu
to{aanSreuturfiaon'rdbnna-r{ri':lqdrurrrn''tn'iriauny 6s udFr{'j1dr.:nruldi aonireul
tl'lU{ JOn0nll nUAi ,in1't t\:8']1tflOAln

178 rrtrirrininqmfiugru

t. rdardaoirrl fin':rrdo.rnrddoonfitcu rndu niu lunrr;fiardofild4.r nr:rirmutal

sieillYr:oerdrflufiu

z. rJ?lnruoonitqudo{lulfioorro':fitgngldooonarnfirto'hjrfiu.tro (hypoxemia)

e. rfi nornrlrtlqr6olnfi nldoirnirlfl 6 (low cardiac output)
'lumrn:.,:du{r-hadfin'n rdldulla {?tn"uoan€ta turfioqdrtfiuiaaa; zo ore'lrild
nr.nunlu'irrdariiodrrr ldfioanfirauniu',tt,loodrtttfitir rfia,,:orn'luurul?: ltiu septic shock
rdordoq;lrio'rrr:ndroanEnuqrnrfianun.,:lr'li:J:rTmritd rfinnrr;rf,ord0trqoonirau (tissue
hypoxemia) luqnr:firfioer!ro{e.jrurdr{maootfianrirTnulillilnnrjrufiaafit6ooilou 6trfionrrl
microvascutar shunt rdanrirdlnnnnir{rtrttfirutl6.:ri'rntfi:;ri'laoniroud4,r rflurJnfild

nfi ie R?l ilnwra o c dan nhci,runf, 1{

ihiudrA'qiinrrrior:mrfro1finr;r"ernlr.rn'urflullatirrqndo': 6a vi, uautot{rJruun:
al'r urrj':dldrfl uXnquri lzero reference)

Patients position

rfir rfru}Idarrlrt{:Jluuoutl.I'ru lrjvrluvlou Xn zero reference 6ooiruv .tfitnar.:la.:
rdugrlGfiarncrnnri,,tv:rrondtuurircirutia,,: intercostals space d 4 doornnluur:vu"l! ru 1n

dfiarflu1niifi::afunruo'utrirrit-rnruer'ul::mnrn dun{ooorgnrirruohiriruri'rnruo'urf uquti
r1rirrflufio,r'hi6:u;gtn'irn'rn"rnT :rirnr:rirm.rolod'lfirnSo,reirudra':r er"urfluqurilrritrn;io cve

'luyir16urriumnaorrnr drtfinraj:; rfiunrtrirldnr:firl:rurnr:t dfluttlntrot cvP vn'lnr:

bior:rirniourrilflRom:tfluua-n uvrunr:tdei'r Cvp dT"lerFirvfi.t rfia{crnio cvP tuyilli{ esld

rir cvp a{rn'irnr:{qtuviruou rfiooqrnfinr:tlduuu:Jo,tnrr uudfitd'l,oto':Tnn t{tn rdardo,:
'lun:nifilria, m'in'ldqrJmnidrfinlvr:fin1unr:iodr cvp arjr.:riorda.o or r:nordunr:td

:;o'rrir'luars extension tube fioiomornarunrutnootdaaoiiirloracruogtunoon tfiaoo"rsiru
nar,rl6 lqurfiadatnr:inrdr cvP erfia{rio oludlu extension iube tfidtJel'dnuxrru1n16 un
d'ltJ extension tuoe tfin',:arnnilrru?t'tu llslu three way tfiwr:rirtuaru €xtension tube fioda

n-:.ror:drtuorsoruvnoordaaTqun:.J unsfio{uil10'irlilir,lo,tarnrattn:nod'lu:vrr lilnr:iq:;d'

rirtuuurfu louordulnntonnr',ln:r.:on{i.,rfio'jlfludunr:riufionar.,rlo,rrirtlfioo!usertfluoqnud
(zero point) ::d'rrirdgduornXoqud6r Mrdunrr d'ura.:nnoqt6aneirdrunnr.:riuto.t tiiotern

rirdforldl;finriru lflurrufi un:rir d.raln:nurjn.r'lfioEflutdrafiniriln'nJ'ion'ldd',,rarnr:

["u"**ru- dl cvP (cmH,o) fi?o

I CVP (mmHg; = e11 CVP (cmH,O)/ 1.36

Central \,'enous Pressure flfoti lrawi 179

fi o*rn"sto.,tnrtia cvp tn uorfiurcq-ulh

l{t, kiRrlrrnl"ufin rfluldun:rriro,r cvp nilrfilila.t 1tnx-nri'lFrx.r o'ufi a *"u" Id

o rir,: urlqi.I

2. fi arrtrtrnn'rlrntunr:indt cvp yrnfi:Jruyrutcrdroonorir,t:rnrfr
s. fn'hiarrr:nfnrir cvp atir,:sia rdo,:ldrflurrnruru nirdior'lri'c y riiu rir ru rrnrtnrrn.r

vu{
q. r'o':lr rduao'anr:o'erdogdu rd o.lq r n nrrdds.,r rilnrlficr:ririr extension tube dl.rnrio

ri'r:.r::urnrrr oredrtfi:JnrEJoruilurfrou rdaortirlynlrf -or.lnruarulliurufirlurflou

u n y'ly n f, ou n nir rdr {n"r {rt r u drlfi rfi o nr :6o rdold

uonerndnr:fifi16oobnflouriur{6l.tu extension tuoe tru:firyo cvp vrnl ldilnr:

6oor:rir}j16ood'{noirrnnilrfirqid'r{:-h! 16oo?r'dr{odlufi1u ex'tension tube q; rfluuy6j,r lvtr:rda
ryvu6oiuilrdal:nfio'rtrjuriaucrn, nrudlu extension tuoe rdrlilId

finr*nrsn:ry{nr1x s"u Cvp

lun:rfifi1fqr.ln:nio'16nTn:finlunr:r"orir cvp odrrsiariio,: rdun:rv{errurTulor cve lria
o'vrro"u'lunaoorn'rtndriaude :rdr{rirhlduri nrrro'uro,r superior vena cava nfl: inferior vena

cava) 1:fidnuru: lfifiaun:'rv'lnruo"u'lurir'lofio,ruutnr (right atrium. R4 louo;rJ::nar_rdrunai
tornr:r:ifiuuudn.tnrun'udfirdro.,r (peak) ogj g sir uyri.,r ldud a wave. v wave ttR: c wave o,l
?ilfi 2. (RA pressure)

c wave

//

x descend

,y fle9cgnd

-,wilf,t

fi2x uflnnfrnvtuffia,1nnylaetuh'u Cvp

180 rlnirfninqndugru

a-nuru;ntruouro': cvp finrrlnjiturnJn':ogludr.:rrnl1lou a wave tfiac'lnnr:findl'rrdo
rirlora.:rormiurmnn'r rirlfiermlsulurirtefiatuurfilg':du ri'{riurfrorrJiurrfiu:rfi'!ndu'[v'lfirlirh

a wave iufindunrlvn,: P waue lu EcG (a wave fla{ RA tl'ltJllfl'.t P wave TJtJlfu 80

millisecond)

c wave tfluaduLfinl drrmrltri"r a wave !fi4?1nn'l:rel6oudrduto.l atriovenlricular
vatve ring ld,}lvrrornirrt'lu:vv'jrtnr:rnd'rtot9'r'lqlia.:eir'i Tela::fl;::vir,i a wave fi,: c
wave ?J lvhffr:ru:vir.:::v'jrt P wave n:.t B wave lotndu]{fl,l1i'r1o (pn interval) ri'.'ttiuo:

af,oilnn{ nrfri foi{uet"nnrr":uFr"nlrdod6'nrltor.u:n'ldur{rruhurdfaiftrutPaRrnpriotllongalion ra':otn c wave nmruotulutarniulq:

v wave tfl untr tfi axl lJn''ufl o,0 to tn?fl tudrt duoonr:Host''r?oo lruni tF a tfi oqrn l6aet

1r.rnnn-rrdr{rirlorfrotru16r.rd rioudduri'rle::r'jr,!il-x'lcfia.tluttn:eir.:q;riotfiotrunitFnnnrlnr
ri':t rrordrnrirrnm d'u'lutotsliu r;ana':tiou1 rfindnuru: y descent t*u 1utru:frnlr.roiulo.:
nuqir6nr;rfir.rdudr"l r6ondrutvqjrj:;rrruioao: 75-80 to\r stroke volume e;luoao{rru-
nirGolurirrd 16ooriruriatL :;u1tu 2Q-25 flon stroke votume e:ltlontqitrunitfialnaordunr:

fillm-rro': rorsriutJ

rir cvp fiqr rflum-r uvrllton preload dlrriqion'::tfiri, arrud'u a wave tfio,terntflud'1.1
uro'.,r ;d duln :doilor ris ril n o qj rirbinrr uoTulu ne tvir nb Rve op

nrmad z fl11

a wave fl\tn'll v wave v wave 'lnrln'irunvfl$nit a wave

peak a wave nrrruld't P wave = 80 m/sec peak a wave qutdl P wave =24O m/sec oli
au'lu PR interval
nvtJl\nJrfI,lJ! Q\.tRnJS complex
peak v wave tfioturirl nrglot T wave
peak flan v wave tfiqq1l11d,: T wave __ I

l

fl aso{n1?[rj6siluila{r?o\rRz1ildutuiltr{ on n1ild?.'t{{ilxsn1?fi 1s'le

rfio,,rornrirlcua:fiaoo!6oorl"16i?unar.:rfluaiur;fioti'luriasn:l,oon nrrut dsutttJo.tro,,:

nx1:Jri''utudo{vnx,:onsr'r dl,:q-,rvrcn1rfi'rflta {i{0lefiarrr.runnrir':ldrl:;r.r1 3-5 finAI ol:hoyr

6.rd,:anTauer:.rrio:so'tlor'r dulufi'r'hloutav,Jr;nl d'utuvaootfioon'rdrlnnl{ttflv cvP 6{
rln6finiro{ludrr o-12 fifl6urerr:har ri''ru"urfiahipir cvp fiin'l6rflueirdlnfi16u'rrf!nrrilrflucio
rrniiqn rrn:orrr:nt6tunr:nJiuulfisrn':'u.:r!6uu* n{nru a"{qtnnt:ri1 ftuid chaltenge tesl

il'[d irnrrrirnrdndl cVP yrfinluri'u1utlo.orr:r',ranairflasiodr cvP riaufion {imnd',rndrr

" : 'nT\:n!tX{61ilq010{n1:fi 1U 1400n doudfiil':aovriilvrulo rfl11na1ufir-huiivru'hra.i n11 oiu cvP

Cc-ntrrl \cnous Prcssure dind nadafl l8l

fixoduqonr:urrte0on?!fiFiT q\rn'jl'lurir,:vrirtcrdrluill{nfidrilfiilx!fiilrulei.jrurnioldrEr ru'lq

nir cvr fi1nfi'uqonr:firulcaonerfi Firm'rn.jrludr,ryrutcrd'r

fsrhrinlaonr:lf rir cvp luntrJtsriuardrgalfi .rnra

1. nlrtaa'r cvP rfiu.teir16u'ilrirfiltrodqvidron'itdrrnrufiornhrrnrfiulilnioriourfiulj
unliu'jrrir cve iiol{firirqln'jtian'rnirn'r:Jn6orjr,rrt.tn nr:'lsnr:r-o6norrrorur:Jfiuuur.ln,l

ro,J cvp ro"rlrnnr:lrtror:rir'lun'r: ::rfiu ?rrruo'r:frra,:ir,rnruun:ldtiru'lunr:o-o6ulet1i

or:rihuri4r-trr

z. {r-Jrudlfi fiurn::dunrryoro'.1:ro,:ynoqr6oo rtiu dopamtne, norepinephrine [[n:
epinephrtne e;finr:ynn'riarynaor6aoo'r rirlfi cvp finirag1ud.r.,r:Jnfir.riaa.rvi,rlddrrnrufi

nm:r,rdo,:ar:ri{d n-.,:riu{rJrrfr1df:Luro-,rneim{.,rnr:1dilln.lrn'1 ,,u,0 charrenge tesr rfiorun
nm:nr:srnor:frrorir.rnrarfi ra

e. {ilrgdfinrrl.t6ordllo,,,:rir'lofia,rdrwlrnno.: ldecreased right ventricutar comptiance}
lliu {dfinrr;nfitrrdorirldorrir.raruro6an (RV infarction) lirj'ltr restricrive cardiomyopathy.
constrictive pericarditis. cardiac tamponade. severe acidosis {rhatndrdl:fi::nt cve g,,rnir
rlnfi rirbin-r:rj:: lfi urlilrruor:rirna.rir{n.ru1nulddr cvp A6 nrq

4, nr:fi urGcnr rorunao16oonh yr"rornnru'lufinoqrdaorfiioqrnnr:nnr,rrlrnnruuon

ai.rnalfifinr:fi!ueua.,,:noaor6onni rirlfinr.:'liri-r cvp 'tlrnr::l::riuar:rirsa$r,rnrufinmr
fiq nroldleu rnr:'rn, rio cvp nd.rornoirunr.irdfinr:qnri'ue:ldrirdoirn.jrall.rrfuei.rturru:ii
'rnl"c ru qi uuri.rriounr:ao6'u rd.r cvp lvglfioilnfi

s. {rJrudfi enuft flJnfiro.,rdufr'lelo.ro'oiln
5.1 Tricuspid stenogs rdofi6u#r'lelnra'aila6,u rir cvp d{o'tdr:csn.j.rrir nveop
6,,r'[riarri, :nldlunr: ::rfi unr:drrruga.:r{rlcfi o.rdr,Irl.]rId

5.2 Tricuspid regurgiration nr:fidul''?lclm:n'diJodr e:d.t'lfidrn?r niuradula,r cvp
c,trsu uoycyyudr V wave 6t,rn.it a wave ri.r'lfinr:u aruR CVp rir'lfiri.urnuay
orelriolJr:n .r!anlirrruor.lfrto,:ir{nruld

o. {rJTufifirfionornrtrlodrudrulxnrfir{r''rlodrutrrTnun?{ (eft ro right shunt) lot

!a 'rt acute ventricular septal defect ntlfio tflunrrl llyt:ndaulo{nncndr tdortt'lqrro r6ao
riullrl n"u o ;drlfi cvp fi cir radr qrduruarorirtfi nr: uila

7. Frfl cvp fin'lrrftnun.rarrdo,:qrnfi v wave g,rdun.lrrJn6

a. {rhuiirfiaridradowjruyrulc crdrifiarrrd'uluro,ryr:rron4,rdr.rrdo.:orn fi'r'lqrnsfinon
16onq"rdrunorrrfluar"urvdagludo,rr:r,:an {,,rld:*lr.rnnrvfl!crnnrr d'ulurJon4,ldurtiun'u rir
cvp fir"prturru;firtriruldi!nr:drflvruhdru ln{o':tirurrriof,ofinirq,rn.jrr.lnfi nY,:1 dnr:nii*rdu

182 rrtr.irrioinqmfir.rgru

larnrtrnututio.ronrirlfrrdoori'rhnnnl rdrqirir'hldriouo..rd.lnro'ht preload 1o',114'{?onfl{ nov

li'rtiri'rlo4r.16orfionoanairnao16ootro'rlnr!noao (decrease cardiac output)

nr:q;r-erFir cvp tfi'lddldil1rdofro un;arrr:nldtunr: :stfiuar:rirto{dr,lnru'tufilril

d'ldrndofiirunra'ls nr:rfianr-nturir.olo.,:nr:firulofrnrr n'ulutiatu:r.:ondozuarunrusio:vo-:-t cvP

rioudqn {imir.,,:rrnrn'rndmon,trirtit.ffia.,,:nr: ra'lqoonrirff'ro:duqont riouii{rhul: rir.rqnar.r

ilru'hrfid{ecuilunrrn::fiuhirn{o'nhufiruttt? t rnrrdrrJoetl''rfirnficr:rurn:rlho';nr:t:Jdau

rur1or:;n''rro.l cvp q; rfiu'jrtjrrtrnrn-tnajrr tflutirtdfirir cvp non,rol'r riauiie: t+rrfirg.rltulu
rru:drnio,:tjruu-lrnHvrulqldr'htrrri{:.J'u rdolnia,rdrtrvrutotrhn td'rnrtrn'ulu:Jonrfil4tdu
tutru:rdurriufidtnnlfinrud'ulun'rlorio.,,:ttutmrrn;uaaotfioorirdrunar',,:g'ln*u nruldriio{fiu

r,rru'lcoonnrr d'uluria{:Jonnon{cufi,r1orn'rqotdanr:nruhaonduqoo.t ru d'xtrarn',:ndm n':ru
d'ututiatilooi,:de ora:!n':usionrltJfi'u'lurirtcrrav'luvnon r6aoohdrunnr.:rioufrqofuta'l

n'r llilrfu il ars e1 sf,xuilao o [5i o nrhdeun ardd lilil1gdil

vn-rnrt'ldRrucruvnaa lfloon'rnirunatl nmr4rnr:n:lqnrnriru:".ldr:r'':onrfraqnhrrnri,r

r.lnruorutfiuulniraqj'lunir urrJ,r#rrur;or 6o oglu svc tvfio:arda Svc tYlfir'lofio,rrutl

rfinriau losr'i:hlnlirnr:'tdnrfloruuaoor6onrd'rtd,qilfiutdoo subclavian vein vio intemal
jugutar vein drunlnrrleiorsfi n :;mru 1 3-1 7 tsu6 uln: rJnrlclm;a{tun"rulrjlfi trrrvol

ynn'lsiorsarumnfioon tdaqrdr rtdrud,u o:do.rloioruur':unttu6ontl ul?fivxl 15-20

ItuFt*rn:

nrn:Jnrunruogdnrdrl:Iurirtqfro.rul?ir orqriolfirfiqnrr;rirtcrduftodrflrvlnu la r;

atriat fibrittation tu{rhudd'r rfinlrn :lnruaruorcdrurfir}Jluri'rhfia,rair.rarr rfluctnqlfirfio

ventricutar arrhythmia ld uonornriurJnrafitaflluvoootfiaodnrririiogturirlofia.:uulrrd.lfi

ari.:!rtorqyrtr'lfirfionr:Y]vnno,,tntri,'tfia{f'r'lq tfietnlr; cardiac tamponade 1d

fi1f,aoufl1uf,?ulrfl ooliioodld, una,r{ (Central venous catheter removal}

nrlnouf,1ufl?ufioao16oon'rdrunar.rlouralrr;nT EJfild'luriruuri'tvnaaGann'1 subclavian

llffY internal ljuugguullaarr vveeinrnfinn?lu1ldlnr1nFr][yu r!lrd-jlo-d,,{r?e-r]nllua'leria, 9ht irf-ronm: ttr:ndouniu air embolism \v[d

rdafl o-rfiunrrvo-tneirrnr:ilfr ri6mrrurYuorousiol:Jd

1. v4-!n ArU?UUAUd 6:j:n1dn't',tR1n?

?O tfi

2. fln o1ufllu catheter 4n a1u bilfifinr:fiada:;r'jr',,trtnont6oaoittnlururmcnluuan
3. rirnrtuc:ornfiruftl?rrru:ouarfl f,ruvnontfiogtdl! povidone-iodine v?o antiseptic
du :oqu$fi,r i.rrirnr:n''oltrdXnvoonr6onrirfi rnfolt

4. d'rnr:nouf,ludruuaoordanlu{rnr:d{rlT unru'ltaanr?oarotobi{:Jrundunrln, u'lo
run;ni,r lvatsatva maneuver) urnf,,rJru1finmr.rdufiolfitru:noumflnruflaantfiaaoan ri, uir-r

Cenral \''enous Press!rc f,ifiii nanoti I83

{ilrufitdlolo':tirufi1sla nlr hnlroaufllufl?ul,ufl ;dlado,::irunrulorflrlfiuri{r-rru drovlfiu

rir,rfi nrtr d'uhiyr:rr o n rfll q,,rr'u

5. trn lfiott:ofiruyt'tunfutnoufl,tufl?uoon aitllug!racgtqdo,tnouf,taerunruld,nr:
fluoroscopy rfio{ernorclfinnr:n"n.osro,rorufiiotrrorhnrullra"'.rfi:Jru nrnvrurur er',,r0'rcr"llfi
rliluriudunoru a o n arnfi ioo,rumndroa g1uni,l {rhuld

o. fin'.rernnougruudr 'tdfionodu?rrru[lrorj:;lrzu s-ts urfi drrfinruarururorrfin
dldlllu::!vr?nrfu vioorolhriudornourufir zo-go urfi drrfr-rsrururntrqifilddrrliriu
rto'ruru rdu d"tu doubte tumen drmfirir hemodialysis riudu

z. rr"o u tcitfi ormun nhn.:r ccoro uan uayiJndlu gauze nn:nnrorn ofl f,

10ndl?d1t6\t

1. Leatherman JW, Maini JJ. Clinical use of the pulmona/y artery catheter. In: Hall JB. ed. Principles of critical care.

Mc craw-Hill. USA 2005:139-64.

2. Walley KR. Shock. In: Hall JB. ed. Principles of criticat ca€. Mc craw-Hi . USA 2005:249_65.
3. Russell JA Management oI Sepsis. N Engl J Med 2006:355:1699-713.

4. Vincent JL, Weil MH. Fluid chattenge revisited. Crit Care Med 20061393-7.

5. The Thai society ol critical care medicine Guideline for the management of adult patients 'with seDtic shock lu

ods: rur: u::rurinr:. olrnlrtrirl'oinqatrioJ::rnebl ::qliflnr:rj.r:cili ls+o:t-t.

6. l\4arino PL Farenteral nulrition. In: The ICU book 3'd edition. Uppincott W iams & Wtkins. phibdelphh USA 2007;

859-70.

184 rrt rfninqnfiugru

R1nflil?n

nldn central venous pressure (CVP)

nri'n nrlir'h
t. dotnituolofr lflunmlrri'uquri (zero point) fi'ln:':n'l right atrium vlrunrrl'jrfi't
nruri'u'luunaqt6ooohoqjgtn'ir zero point rvi,to frerrfludr cvt ta't{:-helr, uriu lour'dilnr:

drvun zero point rir'ld z i6
t1 ri'ruuod intercostal space fi 4 oYoriu midaxittary line tlo,Jrnl'l.0and1un?1 lfl

zero point

z) rilrund intercostal space fi 4 lullursl"oarn fnntrufiuuo,:lm,:on'lutturoY,:arn
'(dnru4,:nitnd.rzo{n'r1}n1rl'rfl o,ivl:rtondia'ldrfl u zero point

nr:riuun zero point m'.: z i6ii Fil cvP dtnldfidrlndrdulriu hinrddnr:rirnuo

zero poini ftrunr:ionlrtJn,'r 10 ttufitln:lrndurn'ut tuoa.:ornft:Jru rldn::rufinrrrJ ur1o'1
rfl.r o n'lriuvirriu

z, lurr,rrJ$rj6nr:hl{r-huuau:ru rtrihl.irrflurfiattrfi4 ruuou:rlToutanr:turirhadlri

orm:nuoul 6 triu lunrtv congestive heart tailure rdomrnrrfi{ rulri16uau:ru zero point

fiq:finr:rndaunr 'l dru tda,,rqrnnrrio cvp rflunrtiener s"u'lufioont6oon'r'hq,,:n'ir rignt

atrium rvi'r'lo un :nt :in cvp rfl un1 rtq n rrlr d'u'lu rrur 6t

s, Ljfia-rilanroio.:riruvru'lcfi?o nn PEEP (positive end expiratory pressure) dounrrisl

cvc rdo,,rlrn{rlruur,,r:rulrjortlr:onrutolfilo,r uiofia,rti':uflrEflcToutd rio, rlia PEEP 1u'lo
a.r nr:rjonrn{a.rrirsurutcaantru:rirnr:ia cvp orlrfiud'un:rufi,,tttriiisl

+. rfja,rqrnnr:io cve o;toiilnduqotto.:nr:trttooon end of expiration) tlttnrrt.lo"u
'lur:r,:sn (intrathoracic pressure) o:firir'lndrfiu,rqutifirfiruartlrir cvP riaudqo ttnctunr:

inurftrJrudoglunre:6an hjnrrrrnld cvp drnd{rfitr.rdrrdurtunr:sr'nfiu'jrfiilruo$'lunrr;
r,'rro'rrtir (hypovolemia) lianrt:rirtfiu (hypovolemia) nrnrraifia'tqnr:t fiuurr:lalloldr cvp

adr.rsiordo,,l (seriat change) tunr:dnfiu'jr{ilruaqjtunrtrtrnor:rirnionm;rir rfiu
r 1 iu{r;rufi1il1d"1'firn{o.:tirurruto 1fl:Jruuru'hra.r1 rfiorirnrrlhrfir nrrrsu'lu rr'ran

(intrathoracic pressure) qvfiFirtflun! tl:rvnr:firflletunrrl:ln6 {:Jruovfio.rnir':nmloiurflu

audulur:r,ran r$iolfiornrflcrnnruuonlnnr{rtfluvr:r.ronld'tutru;nr:nrrLtet{1d nrrrn-u'lu

uoaotdon superior vena cava fiq;aoo{d'ttt urldlfionr;rdrlrtil superior vena cava tJlndu

'turru:nrs'lar{rfintr tfio,rlrnnmuo'u'luvr:r.ronfitfiunrdor.rnr:ora'l:Jti.:r1n1n:itdil.inonrt?{0n
'lfifinrrro.-urflunl:ufi.:vnon t6on superior vena cava dtu d',oriu cvp tutrulfr{rhalruto
rd{qul}iti rniorlir ufi rs'lqiofi ai'r aqa.l

Central \''cnous l>rcssurc dilri nafat 185

ali t uaa,t Frank-stating cr*e Toatmuuau o LVEDV (teft ventticular end diastotic votumd fr,t

ti,nonfi,t preload mu;nudnndn cardiac outout

vsJ'tutfly 1 ufiqndn preload fiohfonu d,tfi cardiac output oh 'lfine{nwhaanit Inu'\fi

uuu fluid toading

2nv1flrfla ufranfrr pretoad fin\frfirtnvruznt,ta finl y'qnu tfruntfrinoanit 'hins

inwdzaanituuu fluid chaltenge test

nNl rai s ufin,,tfrn prctoad fra,tfifi#nsayntnifrnl franu altfia,tnasoudzzntflfianit

uuu ftuid cha enge test riaud,rsyificdtjli nlnu ?qha-lzi.ttfiudtfiottcut1ti

vasoactive drug

nt!1 rfr! 4 uantfu pretoad ia,tnu dtil cardiac output n"1 'lrtnninwdza vasoactive drug

rfi o ritnratooon nxl ti'uturl?{o ne: rfl uo:Jrioao, nddfl ud ornroorn t.t{ana:nn

rlaiou urfl".iu::urfl'tfin1ulon nrun"'u'lurnootfioo superior vena cava niiltsu rrfi,irrfiaoev

tfltltu".r superior vena cava aoo':lurruvrrslqoanfinrr tdo.rorncrrrro*u'luy?x.ranfi rflt,n!

riaun.,rlndqjgutitioilflrierulilf.,rylnIRtlrflSl{no{yri.t{anhifin'ltroiu rijuarLrioun,,,:1,ndqiqu6:rll

fittroootdao superior vena caua d,lr o-,rriu cvp'lufl ru:fi fiil1urru'hoonToulritdreia,rriru
lU.t1?-q{a,n1fi{1I u

rfionr:{o cvp fio,ri'osfucyrsloaonon (end of expiration; a-,:usu?'.,t$t:{n- cvp Fir

gr luvrruJS'rifi6oinl ru; n o a"ririr g.: Ren.t'u ro,:

z1 lufrilrufildreio.rr|luffiu'h rfioGlr.rruhrilr a,tluet'uluili1{afl (inrrathoracic pressure)
qcfiFirrflu!rn m:r:nr:vrulqlnutsrnSo,rtiruvruh tdrdnnr:tunr:o-onrrurilfirflurrnrfir}l

luurrtan (positive pressure venriration) tuaru;dflru'lerirloutdrn5ardruflrulc nrrrd'ulu

nnootfion superior vena cava q;rfllt:Jrn rtd'irrFaoqclvard1 'r superior vena cava fiauflt

frnr ldo{crnnrrrd'uluvrm'ronn'lfluurnr.io n:rcrubrirlnla:.roirrro.rn:rrantrtfiarruniu

186 r'rurirrjainqndugru

Intrathoracic pressure (lTP)

Central venous pressure (CVP)

-gli Z uanontzin CVP fiflsrttnr41u'lon,t (spontaneous breathing). latJ.tvduax usawitun ,t

7nft'uqntotnl'rn1a'lcaan (end ot expirution) d,tcznz iu cotumn itgt*a 6a cvp A'tst. t

nxnaf,n inspintory time. E n naf,n expiratory time

lflulrn:ufi.:vnoat6on superior vena cava dru ot*trfu cvp '1u1ru:frnrulo dr'lulru;iildln€a.:

drurrrto6'rfinir4'r

lfiori nruteoon n'lrro"utuv:rtonq: tiiutlrnfioua,lcutnfi{gud o1n1fla1n :l\rona:

gnrJriauurdrr elastic recoil r.nritfiunru'leoon (expiratory valve) 1a ':lnia{'druvruto nrr nu

iurnaorfiao superior vena cava flon't rrfiirrfionevlvnrfi superior vena cava rdln*ulutru;

x'rst?oonfinl:r rdo{ernnmtr6'u1un::.:onfiriulrnrioun'rlndqiqutidarnr:arul d':InTa:,tdi1't

ram:'r.ron'hifinrrl.tnYutflurrnriasa.rlnfi{quti:rrfitlnoo 16oo superior vena cava dru ri'.lrfu

cvp tul ruyii f, d? ufl 1 r'le o o ntufl ;fild rni otdr ru r uhit fi d r n'r o'r

rfionr:tn CVP fiotiolruvr,trrjteoonqo (end of expirationl o-triul-.rn:triu cvp nirpir
rt I
f; n o 6-l'
r"nr f"lurr,r:Jfr l'fr 6 a 'r er"'r 4 ntiu ta.J

fio#t molunrtt-n central venous pressure

fir{rJ'runrahnorrrn nlrrd'uto'tvt:r,ton'tr-ttru:rirflaaanqtr (end of expiration) o'11
firirtilulrnrrnn'irilnfi tfio'rlrnfl:Jru01{'ff$rilunrrrluhoon$t1n (forced expiration) rit}leir
cvP ea'rerLnfiouarnnrutfluos.t rvi:r:e;lrilfiiofi column tirfl'tflovio column rfrri,qod'.:rir

o i!r ci{r.l d'u l.rr{ni.rorc dattfi sedat ion rfi orir'Ifi fl,r-h urr utefi r a.l ri ounlli'o cvP

Central \renous Pressure qiwd nl,ta$ 187

Intrathoracic pressure (lTP)

of expiration of expiration

Etfr s uoanrla cw xuz{rl7s'lfrnia,tdunluloatladuuln (positive prcssure ventiration), 1n
dantliltltzdun:.u taa,tdluni4niuqata,,tntn ta?caan (end of expiration)
caumn ti,t

thqn 6a cvc rhd1, t nart6,r inspintory time, E nnafio exptntory time

n1:utJefl nfil central venous pressure
Tourieb ;r cvp dofr ri.rron.jrdrrnruogtun.."o.^ri. (hypovotemic state) ri1 cvp fi

g{ il,tuon'i1d1nn1uoflunm;rirrfiu (hypervotemic state) uoirdo.rorneh CVp dfo riuntir-a

nrrrn'u'lurooordann'rdrunnro drri,,,:ranflonrrrirrruro.ori,l'hfia.rtrr d'.,rriunr:do:td cvp

rh;fiu ilrruar:rirlurirbrlodru d{o:ri,:utunr:ifirdu.ir{r-huo{lunrr:rirlromiorhrfiuu'u

rrnurio"rda'lrdrlodairriortar cvp lun1:u onorjSlrruatrrirludr,lnru rfl:rcnrrrJ6'u1o\r cvp
lrildrjwonfiujllrruo'r:fr (votume staius) rf, rJa}J

t. nrr:d cvp a.,r ud LVEDv lri{,r riunrr Jslrruar:rirludrrnrorro riiunm:fi cvp

g.ta?n {false high CVP)

t.t ilm"ufirfinorn{iltu

1) putmonary artery firorud'ulu putmonary artery c,,rdu ocril'b1n?rild'u1u

right ventricte un; right atrium gldu d.tnro'hi Cvp gdu nilu{r-tru putmonary embolism rio

{rJrudfi primary putmonary artery hypertension l'1urr:.1 rdanlcl,iliilri'dofia.rdronna.r

188 r'rtrilioinqnfiugru

2) Pericardium firnruri'u'lu pericardial cavity {tlsu e;na right ventricle loun:t

riioomn right ventricte finriru'r,: uacogjfirufifiTqntdo{rhuo{tuviruourcru tfiao':ruot'u'lu rigtrt

ventrrcte f,,rLn.urvn{zunrfinrr fi'ulu right atrium rro; cvP 4ttsunuritd'u r6aoov-llhiiri'r'lqfio.i
drunant uulff1u{ilru cardiac tamponade ttn J constrictive pericarditis

3) putmonic vatve nt:iifi pulmonic valve 6lvioi't d.rHa'lfinrrrnull] right ventricle

rufls right atrium g.:l8u drlfi cvp qldu r6ooo:}ltitrir'lqlio.1drunoa,i

4) Right ventricte ntr:dfi right ventricle litruoon,t d'tHn'hiaT*rn"u'lu right ventricte

ruoc righr atrium q,,ldu rirbi cve q,,rntu rdanlJlildrrhlofio',rfiruaoco vruld"lu{il']u.right ventricular

fiurr;infarction, cardiomyopathy, myocarditis firv"T n'rpfionT: metabolic acidosis fi1utt:.'

16oo'lud'r,:nrud tflunrotiu otnonrrdt.trulo.t right ventricle uflv left ventricle

5) Left to right shunt tliu atrial septal defect (ASD), ventricular septal defect
(VSD), patent ductus arteriosus (poA llrrirdrirtrlnrluo'ulu right ventricle !ra: right atrium
pdu si.,,:nra'hi cvP q.ldu

6) Tricuspid vatve nrrydfi tricuspid valve firvSoir ri'rhln'lud'ulu right atrium g.1
r*u drlfi cvp 4,rdu r6ono;I:lti.:ri':"lefio.idrunono

Z) Right atrium vuldlu{:Jrlfrrflu chronic atrial fibrillation 6lcrdr'Ifi right atrium
ufl: left atrium fiturnlnrgdu rirlfinrtro'ulu right atrium {ldu

8) Superior vena cava nilfilu{r-hufirfl superior vena cava obsiruction t6ool;

.[rl
s*rrirhrla'rdrs a oa':

9) Intraabdominal pressure r rildtur$:Jrudfinr'lY intraabdominal hypertension 6,:

nmlo'u'ludo.tfialiiq.ldu eld,rdrubtitn::f,:or d.rflnltinrrilfiuludo.tll??iton (intraabdominal

pressure) grdu r{rli cve qtt*u mrldlu{rlrudfi ascites, ileus, hollow viscous perforation,

pancreatitis rt6 o flrJr rdld:-r nrl resuscitation dr u nr:ril?'ruru r n

1.2 l-llAoUvdtaLnOA'rnn1:ifll'l

t) nr:tdrnio',rriru ru'h (mechanical ventilator) niatornnr:'tdrnia.,rriruvru'hrflu

positive pressure ventilation ndrrfiotflunr:lfinruo'ulrnrdr'b-fluvr:r,lan rirtinrud'u'luu:r.con
(intrathoracic pressure) rfildu ai.rnradrlfi cve qtdu

z) n'r:'ifi PEEP (positive end expiratory pressure) rdo{qrnn'r:'1fi peep rflunr:rvrtl
nrun'urrn'lun:a',ronturir,,rrru'hoonqo fiod,lfinrud'u'h :tnon (intrathoracic pressure) tfi*t
du unvnr:io cvp rflunrriqnrunTu# eno of expiration Teufi:.t d.tnndlG cve qll*u

31 nr:t$ vasoactive drug tfio,:crnnt:td vasoactive drug uonorne;n"rbitnon tf,on

4ru.'o:r'i:,vtnnhdl'frifrin.rornflrudnarnldoriv"nftn"rrl(ov"ednodcrolfninst,ricritlino'nu)lndfi,s:trlrlfrifeit.vrdnuo*ndtrfionor':s1ffridvruasnonarc.:tdivreu drug turlro

{orirl'fi cvp

Central Venous Pressure tfrti pana{i 189

g'nau o'rriuiuvnur?ltltd6e',iiluldrflla'jr {r-rrudaglun11;60nfi cvp 6r{ lrnflrie:rirnr:rfir

vasoactive drug rfiorfir vasoactive drug rrdurdrnr:io cvp fr filcrdr'lc.irfirhu cvp ao

frocdrnr:rfirJ vasoactive orug dol:16n louli6n.jrnrrcd cvp o,rriurflunm;fi cvr g,rnr,r

(talse high Cvel firfiocrnnr:td vasoactive drug ruroqwiorfieltnntr;6u

1,3 iqe"ue'lnn'?fl'tl CVp

fl1u cvp orofifiourfiaaqodu (ctot) tuf,.iu arari'nnjl (kink) fiiaflru cvp fi
tun:arfouoan rf,oo (touch vascutar watty rirlfirdaolnnrdroonmnflru cvp ldbifirnrn d{}i
cvp 0.,t6'u d.rnrilrrnificdEifiirulotrnr:q.jr cotumn rir'lulru;din cvp finr:n:; rfiarduo,r
(fluctuation) nrlnr:firu'lqfiialri rirdornr:rnrouoru cvp lfiailfiJorhurirdru durrnrfiouaan
1d'o rirr rd u r ryiru'u lrietn:nrfiourdid

2. nttzfi cvp c'r utdrlStrruar:rirtu.dr,0nru rfiu rflunn;d cvp el".ld?.r (fatse low cvp)
nm;dyuldriau orovr,uld'lufi d:a left ventricutar faiture'hr; u: u:n To ufr {ft ufi

pulmonary edema ufil upir6oorT,rlrifiunalurti.ry'rtofiorarr 6triu6.,:rl,rlrivuL cvp a.lr*u {i.l

n.t?:dfia'nrrirdqrijoilrLfirhliifinrflirdr:r.:anugora'nu6u: diffuse atveotar infiltration rdororn

dolrrsn'irtflu cardiogenic pulmonary edema nia noncardiogenic pulmonary edema Lllt,t:
nr:inurdrlfi'u ri',rriu6rhinrrr:otfidr cvp ulutdr rdflrtunr:ifiqduld fia,rdurira'nunrvnr.r

n6findu1 :l:ynordru

uanqrndtr-.:yril6'1u{fiudfi oncotic pressure vl'r rriu atbumin n'r rdo{qrnnr: le"k
to.oor:rir1il1ddun-!ri't hydrostatic pressure oti,r.ordur yrnu'.,:tiuriudr oncotic Dressure di,tu
d'rrfuufirir cVP:Jnfiyionrr uoifirJru:rariufirir oncotic pressure dn"r fulrfionr.l teak ra{ fluid

Ifiun 6rdta.ro'lfi oxygenation lrrin,r

nrnirrir central venous pressure lrtlilufi.rlesnrin

rir cvp fiiaild etfi :yluu:tunr:a uninurfirhflsio'tild
r. {ilrtrfraqjtunt;fan d,,rdru'lunr:ciofiulo'jro:1ficr:rh niotfi vasoaclive drug

z. {rhudriunm;fanudr ursi tissue perfusion rhl*jd rriu flnorryri,raonriatn.i.r o.s
n./nn./n . o,rtd cvp rfiurfi'lri'nfiuiro;lfiorrutrdaLjniobturduiloalr; rdobi

flacrryaanrrndu

odr.:l:ffnrr rir cvp rfitLrrirrduT lriorlr:ndoRulfi.irfidrlrluoqjlunrr:frararir 6,ypo-
volemic state) nianmy{irirrfiu (hypervolemic state) fia.rldflnuilylNnnfindul ilrcnou flia
orrrir fl uid ch attenge test uiiotirfllunr:ifi qo"u

Fluid Therapy

mniuni pfrfttrg

nrrlfiarahlunirs shock

n'r:lfi srrrhluntcf an iil:vlutfluf; ondohd

1. Hypovolemic shock
2. Right sid€ cardiogenic shock
3. Obstructivo shock
4. Distributive 6hock (high cardiac output shock)

ir urnfu rosnnon fi lan'lurn:biarnlr

nr:rdonrdurfionrirdlfiu peripheral vein urnn'jrnrr'lfiarrrirnirurnl central venous

catheter rdo\tl'ln

t. nrrlfiorrhrnr peripherat vun rirldovn?nn'j'rnr:1fiqrfl.r*T1{ cernral venous c€theter

z. nrr'lficrrrirnr\t pedpheral vein rdoftflrlrvurns'rud.: nnaor6oon'rd':thlfi vasocon-
stricrion ecdou.l rurun-r rdo.rcrnnoootfionerhfiqruqilffilun,:iuar:frniot6on lvenous
capacitance) 1dd d':qrunuififtrifilu central venous cath€ter

s, srrfrdlfur.r peripherat vein lddrrorurundrldfur'r'le rirlfisrnhdbd,ntrlrtnd
rfifl.lfiu cor6 temoerature luruciinr:'ltinr?rl1ilru 'l't central venous catheter orl.hdlfir:n'

qrun4$ln{r6uufuqunqfifro,:ftn'in'il core temperatun-. rdoftfsrnhc'nralrnrfrrn':fir'lolaunr.l

ii':artrfin cardiac arrfiythmia ld

Flrrid -Iherapv $n:runi nfrfisJS l9l

nr:}ior:rirtunrrz6on ar:tdruror{ffitrinr:rh No. t6 n?o No. 1B rfia.relndi r:n
ri'r ftuid toading rnio ftuid chalenge ld rnnldr6r.rdfiru.ror6nn.jrd rrju No. 22 io No. 24 e;
lrinr:.rrrnfr ftuid toading Nio fluio cha enge ld

neTrrialunr:tf;rrnh

2or c Luj.r nlrr rSrr o.rnr :lfi nrtirlunr r :6 o n'ld riiu r r rnyr

1. Ftuid toading ldtun:rf,iifinrr: rdur6onrfilriratir.rfonu rtiu fi ':uori6rynfifinr:

rfiurdoodnreu {rhadfinrr;fi0'r rfrl1uur.,r {r-huiiogtunrr; sepric shock fi1rifiI:nrirloog'riau
orrr:o'hiaT :rirl6'ho'm:rfir5rn'ir fluid cha enge test n'arrnn'jr 1.200 r.Jfl./rrJ. rflo{qrna'n:r

nr:tfior:rirtu fluid chattenge tesr rror:grudr5rfiando zoo ra. tu to urfi r".:flrildfialos

rni.rn:"n'jrnrairfir5rn'jr t.zoo uo./sr. rfu ftuid toading roua "luurlil$i6orlfia'ir1firfluar:
rirfr riJod'm:{nnarjr,:rfr lfree ftow) Lilu ftuid toading adr.l'l:finufio,il:yufiuiror:rhfiifiLl
riue:r'rn rfiu'hly5olrj lnurovi, vlufirhrir^hlfi concurrent toss ufir rfl:rvorcdrhhfin votume
overload ld

2. Fluid chattenge testtdlun:nifiuyrnd{inur'hjriulilr{rJtuo$tunlwrirrrnyiorirrfiu
fnnhtun { #i rflu ratse high cvp nnjm6o urrdlrifuto'jrrir cve fi4,rriur.lwanfi{nmcu*rrfiu

niorirtrniiurlcS.rriolri 6lfi lr:rurdl fl uid chattenoe test

Fluid challenge test':
Ftuid chattenge test rflunrr'hiorrrirlurJirrrudfiaan'jl ftuid toading rfiafic: nna!'jr

rirlofia,:rrrTnulq 'ry right ventricte fi1rr:niror:rirlfilfirr'lot lorn"toru116g1u'j1flr right venrricte

iror:rhdr{ilild tu{:LrufikifiT:nrlaanial:nro,rrir'lqfiorfrrliifiilqnr teft ventricte frrire:iL

ar:rirldd':u Tntinr:dr ttuid chattenge test fiiorqrJ::o.:6 6o

t. orlr:n niir:Jilrrufionlfloooncrnri'r't{dodr.::rorfr Bt rrflunr:na':.r oretoac

2- orrr:n ufiltnr-,rn'rroarn',rri',or.r:'r,rnru'ld
g. rflr:yr-.re{nrfiufirfioduo'rnnr:tfiRr:rirrl3l'rruu',n Tourirtfirfinq.rarduriaflfrno

iinrrdr fluid chattenge o'.: [aq.r'tunr:r.:

Inr:rud uaoto-orrrl5?ri duso,Jnrr'irlortrsr uri{r-hufiaqjlunrrrdon uunqrr:roir cvp L!o: pcwp

(pulmonary capillary wedge pressure)

200 mL in 10 min
100 mL in 10 min
50 mL in 10 min

192 rrtrirrininqmdlgru

) 2 [[fln{n1: ,:-ljnlltflf,'llu1itnu4Ur\1sn1?:t04n
n1?l\ni

?ni.lern:a 10 urfi I | <z ^ <3 j rqolfiorrdr fior:ur
2 < l<5 I
L I sI 'u".rn.r
u-rar I r z l uq9999!ve llgs
I
I hinr:rir ria'[rl
l<3
:o to urfr

nqohior:rir fiorrrur

I

vasoactive drug

lfior:rirsie}j

fi'rotirrnr:'hiorti'r1unr:rir f I uid chal len ge test

t. i6 cvP tlilu:n16 z tr.r.rh lfrarfionril fluid challenge test fic'ti l'hia"r:ri zoo rlo.

lu to urfi nri"ilriartroulnfinti.r.lillfjrdu in cvpld a ot,.ti. cvp rfirduornrfir r sl.rir (riau
n'ir z rr,rirl d,rtfior:rirdaLldrro"n:r rdn6o zoo ro. 'lu t o u'rfi

2. ?-n cvp rdlu:n'ld z tr.rir lfiolfionril fluid challenge test fior:u't'lfiar:rir zoo la.
lu to urfi va-r}inrrr.rri'u1nfin'trirfirdu ?-n cvP ld ta m.,.th cvp nTHnumnrer-u 6 tll.u*t lLnn
n'jr 5 mr,rtrl i.ruqalfinrtirun;fiqr:rurlfi vasoactive orug udnetflrilfit*rruaru'jrtiiotfi
vasoactive drug udr qvlfiar:rirniolil lfi vrnrialr cvP noatviofito-ngluno{ fluid leakage

fi fi nrruir rfl udadriar:Jlsiolt

g. ?-n cvp 6rlurn'Ifi z tr.rir rfiardanri'r fluid challenge test fic'rrru1'hifl'r:rir zoo la.

lu to urfi vfi'.r1finru6'uTafiohirfjildu io cvpld tt ou.ti. cvp rfilrrsucrnrdil 4 ttr,d1 (od

'ludr,,r z-s sl.rir) l-.:rirnr::a 10 urfi rrn'r-a cvP ld I tr.ri, ovrfiu'jr cvp rfjl t tr.r.rir 1rdr.r
z tl.rfr ia1:iu e tr.riry {i.rrfirriaun'jr z tl.ri'r a'crfudJria'r:rhsio'bldrua-m:r tdrfio 2oo ra.
tu to urfi

4. r-o cvp rSru:n1d z r:.r.dr rfiardanrir ftuid chattenge test ficr:m'hior:fr eoo la.
lu to urfi rdohicrrruo''uTafinlrinidu in cvP16 rt mr.ri'r cvp niirdurrnrfir + tr.r.rh 1og1u
tjr.r z-s rr.rir) i,rrirnr::o 10 urfi rrn'r-o cvP ld 10 til.rir q;rfiu'jr cvp ntir e tr.r.rtr 116r
z tl.rir il1:iu t o trr.rh) dtrfill, nn'jr z tr.rir ei'rfu{.,rvqobior:rirun:fior:rurtfi vasoactive

orug

5. 'r-o cvp rdru:nlfi ro nr.rir rijarfionrir ftuid chattenge test rfier:rul'lfiortfr too
ra.lu to urfi mo's'hinruri'uTnfioridilrdililgu tn cvplfi r t tr.th cvp nildurrnrdu t ou.i.

(riaun'ir z gil.rht 6rtfiar:frsio'hldruo"n:r16160 100 trfl. lu to urfi

Fluid 'l-herapt' Lan?uni nNfrftS 193

6. in cvp rilu:nld 10 mJ.d1 rfiarfiandr ftuid chalenge test fior:rurh{ar:rir 1oo
xa. 'lu 10 urfi rii'tlfinrufi'uTnfiolilryridu x-a cvp ld tq ou.tir cvp rfirduornrd' 4 rr.rir

1o{iutirr z-s zr.rirl 6edrnr::o 10 urfi yrnr-n cvp.[ri rr ril.rjr cvrfiu.j1 cvp rfijr t rr.ri.r

lrdl 10 ttr.urr rhlrTu tt nr.rh1 t'rrfrlriounjr z tt.rir d'.,rriui.r}isr:rir6sl:ldruon:1drr6o

100 rJd. 'lu 10 urfi

7. 5n cvp riru:nld ts rrJ.ih rfiorfionrir ftuid chalenge test ficr:nn'lfiar:rih so ra.

lu to urfi vrri'rbinrtrd'ulnftnriolrirfildu ?-n cvp ld 14 ru.u"r cvp diilduqrnrfiu r rr.ri.t

lrioun'Jr z tr,u*r; 6t'lrtrn'r:rirsiol:Jfiruri'n:r ro'ilfi0 so rn.'lu ro urfi

rl.frs. in cvp rir.ru.inld ts rfrorFanrir ftuid chalenge test rior:cm1fior:u:r so ln.

iu to u'rfi nn'rtfiarrlldulnfinlrlrfidu io cvp ld rz ur.rir cvp rvr'ilduqrnrfir + m.ri,r 1og

luri'r.r z-s tr.rirl 6.rvirnr::a 10 urfi yrnr'o cvpld ro rr,rir r;rfiu.ir cvp rfir o tr.rir tr6:r
13 tx.ril ih1lr to nr.riry drrfrrurnnjr z rr.rir d.nful'.ruqn}iar:riruovfior:rur1fi vasoactive

orug

fiadlmnernnrrr''rnr:nh fluid challenge test

t, a'n:'rn'r:'hior:riro".rd:rlJ{luorr:r.r rflulfiu,r uur rr rvirriu uumdfiinurorr:r:n:lil

t:Jduuldnrrnr:srarouo'rtotfldru dror:frrrnfsrrquoreirtrar:rjrluilivrrufimnn.jrr,rio rSrn.jr

zoo lo. 'lu to urfifild Rfi'j't cvp n"lfiut:trnn.jr tz n.rir r?o1u{r-trudfinr::rrorirr *sifiFir

ejection fraction sl"r d{ilr:ran'jr contractitity lri6 orttfia'r:rir so ta. 'lu to urfifi16ufiir cvp

d.,rduq;fiaunir a mr.rir n?olu{rj.ru ABDS ddottfi nq m; pEEp tuturnfigr o.rodarl,fi
a.flih so rn.'lu to lnfi fildrulir cvp ne,:dueytioun.ir I r:.r.rir un:ri't ejection fraciion d,:

ogj'lurnnrd'6finrr d',rriurlirrruor:riridldvri Ruio chalenge tesr 6alrildriryuornlrld'r.jrq:fia,r

rflr"r zoo ro.lu ro urfi.nio zoo lo.'lu rs urfi rsro\l

2. nrtd'r ftuid cha enge test lrie'rrfludorl:;rfiuqrn cvp rcla}J orq :yrfiucrn JVp
(jugular venous pressure) Iofllddrilr;ilrnlir cvp lyi.rnil Jvp lrn6n s mufiurfi:fr ttqlu

:rufrlriour:oo JVp ld rdu {rJrudrutrn firJrufiur rnculrirfiu venous putsarion n.t?

fiqr:rurnrflu cvp LLylu

3. a'ar:rnr:triar:rirlunr:rir ftuid chauenge test ldfirS.rriodr dua{ri:t

1) Left ventricutar ejection fraction (LVEF) fir lVer sir ar:trlor:rit'lua-sr:rfrdr siru

firrir lver r.lnn'oro'hicr:rirfirfrnirlumr:r,rld urifia,,::c{ttufiilrE ?r'fi Lver grn.jrrJnfi lltiu

LVEF > 8o%) uio.:lrnorefi diastotic dysfunction drlldru dr{:Jrlneirdfilonranr:lfio putmonary
edema l6i1un'i1iln6 unrtrrntrinr:rirrioun'ir:JnF qyfi}ifrtcrfiurfrdurfrord*r cardiac ourour
rdorirTrrdursrn*uc:drtfirfio LV outfrow tract obstruction urndu drtfirfionrtrra"ulnfinoir

n".rriu'lu n ajl diastotic dysfunction orl'hinr:rir rSurnlrjld

194 retritloinqnfrugru

2) Disease 110{ lung parenchyma louom rf u:auT:er"tu atveol i nio:au'l:n'lu
interstitium dr firroufrnnr:erfl li'rilaeYi,J z ir.j (diffuse parenchymal lesion) q:rirlfinr:unn

r:JfisuffrsIEjn.totir,nrrn n-'trfufir{:Jrutdrnda.:tiruuru'lo rrrlvdfio-rrJfurnda.:drur'tru'llfrolfi

r]ooturul6illndu nr:ifior:rirtu{rJrun{rdfio'rififrn'irrlnfi fiavr.rsucr:rirvr'irlrdr}iq;irrfl1'h
iirdolon rirlfi nT :unn u.Jfi uuff rtrrdotl6

s) nrura'ulurjo':r1o,i{'i (intraabdominal hypertension; lrnn'r:'hiar:rlr ilrruun
tun{#ifinr:lfiortiht]?u.*urn or:rire:finrr*rfirrirl:Iuria,rfio.: vrnor:ri'rrdrLi'lutio,orio,r
rJ3lrul'rno:rir'lfinrrunu'luda.rfio.tg$rsu d.triolfirfioHot6lu aru ::nr: tdu dT1fi60olJ[du.l

lnaon.,r nhlfi venous retum nnm riirlftJilrn::looonn'lfi,ldr1firfin hypoxemia ntllrtt
+1 o'rl.rdulun:1nnn6:r*;g,l (increase intracranial pressure) lunojldn, :trtcr:rir

arqr"{fi nrrrn'u'lun:Irnnfi :u;qrduld"lun{rdfi nrrrurdu.r

a. nr:tficr:rird'.rsr1:r.Ifir,rfiu lflunr:lfior:rirdru crystalloids nrnfinrtrthrflufio'rld
co oids orctfluluron?rvfi,rror crysralloids d4:Lrunr:'Lfi

s. nr:vri ftuid chattenge lnut$ cvp rflulflrtrrutunr:fnur fio{rdrlo'ir cVP tflunrr

rh; rfiunrrritrluvnon rdaolorunr:ia hydrostatic pressure rfluvri'n usinrrtn6outoror:drdunir.r
hydrostatic pressure r!fly oncotic pressure louder:riro: rndouoontrnnnoo t6ondorfi a

hydrostatic pressure {oria oncotic pressure o{r ua:ar:riruonnnontfiantadautirnoonrfiao

rdatdo hydrostatic pressure ct'ru5o oncotic pressure g.,r d'.rriunrn{drudfi oncotic pressure oi1

rrju serum albumin n't rflrn rffio,i cvp 'tunr:fnarf anarer duul niu lu septic shock fi
rflrvrr'rrtunrrinurlnutri cvp oqjfi s-t z l.lrr. :or orrdo,tao::o"r. unrr:"nurTquli cvp oir

n'j'rrnrulfl u:rfl fr albumin fr 116r

6. h shock !1'11::rnr firflrfi ruta,:nliins' rirvfiaunirnr:rtra'r fluid challenge test
loflrovlr;tu septic shock toofirflrflr.nmo,inrrinurTnrinur:;n"! cvP fr g-tz sr.tJrovr tu

{:]rudlilfirloder cve g,rarrnia cvp ri'rflln ftiliti a-re nr.rirl firMrrfi to-ts rr.rh lu

firJrafirJoeunvfi'rluJnfi rfio.rorn septic shock rsunm;fonfido.'rnr:cr:rirrrnn'j'trJnGriia.rorn

dr.,rnruo{lual: vasoditatation rl:;naun-unr:finr:frtorgr:riroonuonvaaotfioo (capillary
teakage) rirdo.:r"o cvp Tofli6o::uorfi'l*j'ldrior{rn'! pressure manomete.'lfiqrufritnt'iunr:r.:
d"rfl t.so lun:dro,i seotic shocK

z, nr:hior:rirTofli6 fluid challenge test u0nq'rna:onlflr.l6rjuu:Ja,rlor CVp lrdr lrvrv{
fioost:rqir'rn'rufirnn'ng'ru'jrfin'nrrirrfiuourilu{ofirlltunrrtfiar:rirriobdnlillfi'irfiulohj rdu

!nl:flr']lv{l1 SS gallop :-i.ruonil systolic function 1o{v"r'hun do.: fi?anr:n:rq fine crepitalion

rjrron'jror:rirfr'lfibu'urio'hirfiq hydrostatic pressure fig.rrfiuluuaaor6an fudrtfior:rirdir

rfiul:Joglurdor.ton ri.rdunnrida.,ruun'fi iine crepitation dfi.rldutufiarnrqiuniahj niu pneumonia,
nRoS nio alveolar hemonhage

Flrrid Therap.v eniuni nfifinJS 195

8. ru'o',rflnnrr?i'l {ruid chaflenge rest rflunrflriornirrdr}Jnr,rrir"lcfiotfl1r fi1dil1ui
finr:vrirrurar righl ventricre hjd rir'lfinr:ilsYrro.J right ventricre lnudo-r vrilfi cvp rfirrju
ttsifir 6jafl:;u; nor'litjr.rnfi,:rl::lrru t o urfi flr right ventricre a',rn',rfi!fl"'r'l6jor:frlilEi.,r!.lon

un;rirlqfio,rdruld 6,: uao,r.irf,,:errr:otfior:riild6n urifir:o :ylru 1o urfiufir cvp Ei,,n,:

g.roti uano'fi right venrricre firf id'l*jd fi':nr:nqnirior:riruocfior:rurnr:'1fi vasoacrive drug
g. 'lunr:dr ftuid cha enge test riu dasfianurfir::ilrir cvp adr.r'lnfifianooqrror

tufiirrT .:tiro cve oroq.rdurrouunvrffia,:1fi vasoactive drug ufir 116' cvp oroe:srio,rrn6n
fi'lrfi s''roreruldtufirJrudfi teat<age tora'r:rirviofirfronoonsia rfiot (concurrent ross) yiao-]o
rrtu{rhufifi capirarv reakage 'lu septic shock d'rriu{rJrudr-orir cvp ld'fl{ lilldyilrflnrr i.l

cvP ?Y60,rd,lodniur?unnonlil

t o.tru:firir ftuid cha enge test d.t.t-q CVp ld6irn.'j orlrfio'tdernorrilndalild

t 1 fi rJruarnr: rrrin.l To sfi concunent toss ra.ror:rirniofi rfi aoaansio rdo.,r

z1 firhuornr: dn{ rfio,rernorofi capi ary teakage'iu septic shock
s1 firJruornrrfidu rfio,:orn16 ft:Jruadtun'; hypovotemic shock fiarcrfietd.r n':J
n'r'r: false high cvP {itdr,rnrumarauo,rdrunr:roa'rra.rvnon 16oo (vasoconstriction) rda'fui
or:rirrdr}Jm,,rnoooGaooh rfio{qrnnaonrfioorirfinruo ffiarrr:nsurud? (venous capacitance)
fi16oorraror:rir'ldilrn r'rlfirfiuisfitorvnonrfiaorfrrdu 6rrir1fi uasoconstriction naar 6rrir'1fi
cvp naa,rld rrinr:fi c;if,cdunrr:ftd ornr:rrrnRfinloEr:rrrzarfiilrrrdo^r6du

i1.nr:rir ftuid chalenge tesr lilIddlraul:noufr{ rtrdonrrirueu ufitru:{ilril1'Ifio$
'lunrrsfanfiomfio'rrir fluid cha|enge test tun:nifr tissue perfusion 1ri6 niu flfldrryaon
foun'jr o.s rro-/nn./?tlJ, niaiodr ScvO rioun.jr 70Zo 'lurru:iir"o CVp'ld'sr'l

Grystalloids/ colloids

nr:bicr:rih (ftuid therapy) lu{rJrafiou'lunm:6an firl::lstrjlunr:inurfanrn:J:;rnvr

rntiu teft-sided cardiogenic snoct fil orrr:n'lfiar:rjrld nr:lfia'r:rjr rflrnr:fnurfirirtrfrfirl.:a

:onrfiisr'lun1: ::6':.J :vnotvranrcmin.r:-lynriuurfioq (hemodynamics) nrnn.jrnr:'lfi vasoactive

drug

rhyrnuta.lnr:ri, fr'lfi

'1. Crystalloids

2. Colloids

Aralril*rnn crystalloids

or:u*r :;mr crysraloids dfisddtunrr:fonfi g sfio