17/2/2017

MEASUREMENT OF
CARDIOVASCULAR SYSTEM
1. UNDERSTAND ECG
2. UNDESTAND BLOOD PRESSURE
MEASUREMENT
3. UNDERSTAND BLOOD FLOW
MEASUREMENT AND CARDIAC
OUTPUT
4. UNDERSTAND HEARTSOUND

CARDIOVASCULAR SYSTEM
The cardiovascular system incorporates the
heart blood vessels and lymphatic vessels
The main purpose is to maintain adequate
blood circulation and hence the distribution of
nutrients to tissues and the delivery of
metabolic wastes to excretory/urinary organs
Systemic and pulmonary

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CARDIAC ACTION POTENTIAL

The cardiac action potential is a specialized
action potential in the heart, necessary for the
electrical conduction system of the heart
The cardiac action potential differs
significantly in different portions of the heart.
the specialized conduction tissue of the heart
has the special property of depolarizing
without any external influence. This is known
as cardiac muscle automaticity

ECG wave generation

ECG Leads: Lead I: Right arm (RA) () to Left
arm (LA) (+), displays lateral
Bipolar Leads: wall activity

Lead II: RA () to left leg (LL) (+),

displays Inferior wall activity

Lead III: LA (-) to LL (+) displays

a different angulation of
inferior wall activity

The right leg (RL) acts as the

ground or common

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1) AVR: displays the cardiac

impulse detected from the right
ECG Leads: arm.
Unipolar:  In the normal heart, AVR displays
as a negative waveform because the
cardiac impulse is traveling away
from the right arm.
 It doesnt display the electrical
activity of any single cardiac wall.
Therefore, it is called the orphan
lead.

2) AVL: displays the cardiac

impulse viewed from the left arm.
 AVL displays the electrical activity
of the lateral wall.

3) AVF:displays the cardiac impulse

as viewed from the left foot.
 It displays the electrical activity in
the inferior wall.

ECG Leads:
Chest Leads:

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P-wave:

 Represents the depolarization of the atria = Atrial

contraction
 Best visualized in LII
 Duration: 0.08 seconds (2 small squares)

P-R Interval:

 The PR Interval measures conduction time from the SA

Node through the AV Node.
 It measures 0.12 0.16 seconds (3-4 small squares)

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QRS Complex:

 QRS Complex: Represents the depolarization of the

ventricles (ventricular contraction)
 Normal QRS Duration: 0.06 - 0.08 sec (2 small squares)

T-Wave:

 T-wave represents repolarization of the ventricles

 Upright in Rt precordial leads in newborns for the first
week of life then becomes inverted and persists till
adolescence (14-16 years)
 If it is upright beyond neonatal period, think of
ventricular pathology
 T wave in V6 is always upright

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ST Segment:

 The ST segment, measured from J Point to end of the T

Wave
 It represents repolarization of the ventricles

ECG Graph
Paper
Y- Axis Amplitude in mill volts

X- Axis time in seconds

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ECG Graph Paper

 X-Axis represents time - Scale X-Axis 1 mm = 0.04 sec

 Y-Axis represents voltage - Scale Y-Axis 1 mm = 0.1 mV
 One big square on X-Axis = 0.2 sec (big box)
 Two big squares on Y-Axis = 1 milli volt (mV)
 Each small square is 0.04 sec (1 mm in size)
 Each big square on the ECG represents 5 small squares
= 0.04 x 5 = 0.2 seconds
 5 such big squares = 0.2 x 5 = 1sec = 25 mm
 One second is 25 mm or 5 big squares
 One minute is 5 x 60 = 300 big squares

13

ECG
Complex
P wave
PR Interval
QRS complex
ST segment
T Wave
QT Interval
RR Interval

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ECG
Complex
P Wave is Atrial contraction Normal 0.12 sec
PR interval is from the beginning of P wave to
the beginning of QRS Normal up to 0.2 sec
QRS is Ventricular contraction Normal 0.08 sec
ST segment Normal Isoelectic (electric silence)
QT Interval From the beginning of QRS to the
end of T wave Normal 0.40 sec
RR Interval One Cardiac cycle 0.80 sec

Identify the ECG

Complex
3

4
5
1
8
2

16

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Identify the ECG Complex

The Wave or Interval Duration # of Boxes

P wave : Atrial contraction 0.12 sec (3)
PR interval P to begin. of QRS 0.20 sec (5)
QRS complex - Ventricular 0.08 sec (2)
ST segment - Electrical silence Isoelectric
T wave - repolarization 0.12 sec (3)
QRS interval Ventricular cont. 0.08 sec (2)
QT interval - From Q to T end 0.40 sec (10)
TP segment - Electrical silence 0.20 sec (5)

Let us Identify the

waves
4

1 7
6 8

2
3
5

18

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Let us Identify
the waves
P wave Atrial contraction = 0.12 sec (3 small boxes)
PR Interval P + AV delay = 0.20 sec (5 small boxes)
Q wave Septal = < 3 mm, < 0.04 sec (1 small box)
R wave Ventricular contraction < 15 mm
S wave complimentary to R < 15 mm
ST segment Isoelectric decides our fate
T wave ventricular repolarization friend of ST
TP segment ventricular relaxation shortened in
tachycardia

Important
Precautions
Correct Lead placement and good contact
Proper earth connection, avoid other gadgets
Deep inspiration record of L3, aVF
Compare serial ECGs if available
Relate the changes to Age, Sex, Clinical
history
Consider the co-morbidities that may effect
ECG
Make a xerox copy of the record for future
use
Interpret systematically to avoid errors

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Normal
ECG

21

Normal
ECG
Standardization 10 mm (2 boxes) = 1 mV
Double and half standardization if required
Sinus Rhythm Each P followed by QRS, R-R constant
P waves always examine for in L2, V1, L1
QRS positive in L1, L2, L3, aVF and aVL. Neg in aVR
QRS is < 0.08 narrow, Q in V5, V6 < 0.04, < 3 mm
R wave progression from V1 to V6, QT interval < 0.4
Axis normal L1, L3, and aVF all will be positive
ST Isoelectric, T waves , Normal T in aVR,V1, V2

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Rate
Determination
No. of Big Boxes R R Interval Rate Cal. Rate T
A
One 0.2 sec 60 0.2 300 C
H
Two 0.4 sec 60 0.4 150 Y

Three 0.6 sec 60 0.6 100 N

O
R
Four 0.8 sec 60 0.8 75
M
A
Five 1.0 sec 60 1.0 60 L

Six 1.2 sec 60 1.2 50 B

R
Seven 1.4 sec 60 1.4 43 A
D
Eight 1.6 sec 60 1.6 37 Y

What is the Heart

Rate ?

Answer on next slide

24

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What is the
Heart Rate ?
To find out the heart rate we need to know
The R-R interval in terms of # of big squares
If the R-R intervals are constant
In this ECG the R-R intervals are constant
R-R are approximately 3 big squares apart
So the heart rate is 300 3 = 100

What is the Heart

Rate ?

Answer on next slide

26

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What is the
Heart Rate ?
 To find out the heart rate we need to know
 The R-R interval in terms of # of big squares
 If the R-R intervals are constant
 In this ECG the R-R intervals are constant
 R-R are approximately 4.5 big squares apart
 So the heart rate is 300 4.5 = 67

What is the Heart

Rate ?

Answer on next slide

28

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What is the
Heart Rate ?
 To find out the heart rate we need to know
 The R-R interval in terms of # of Big Squares
 If the R-R intervals are constant
 In this ECG the R-R intervals are not constant
 R-R are varying from 2 boxes to 3 boxes
 It is an irregular rhythm Sinus arrhythmia
 Heart rate is 300 2 to 3 = 150 to 100 approx

ECG Bipolar Limb Leads

- + - -
R L R L

F
+ +
F

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ECG Bipolar Limb Leads

Standard ECG is recorded in 12 leads

Six Limb leads L1, L2, L3, aVR, aVL,
aVF
Six Chest Leads V1 V2 V3 V4 V5
and V6
L1, L2 and L3 are called bipolar leads
L1 between LA and RA
L2 between LF and RA
L3 between LF and LA

ECG Unipolar Limb Leads

+ +
R L

+ F

Lead aVR Lead aVL Lead aVF

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ECG Unipolar Limb Leads

Standard ECG is recorded in 12 leads

Six Limb leads L1, L2, L3, aVR, aVL, aVF
Six Chest Leads V1 V2 V3 V4 V5 and V6
aVR, aVL, aVF are called unipolar leads
aVR from Right Arm Positive
aVL from Left Arm Positive
aVF from Left Foot Positive

ECG Chest
Leads

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ECG Chest
Leads
Precardial (chest) Lead Position
V1 Fourth ICS, right sternal border
V2 Fourth ICS, left sternal border
V3 Equidistant between V2 and V4
V4 Fifth ICS, left Mid clavicular
Line
V5 Fifth ICS Left anterior axillary
line
V6 Fifth ICS Left mid axillary line

The Six Limb

Leads FRONTAL PLANE

RIGHT

LEFT

INFERIOR
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The 12 Camera
Photography
There SIX cameras photographing frontal plane
Lead 1 and aVL are horizontal left sided cameras
Lead 2, aVF, Lead 3 are vertical inferior cameras
aVR is horizontal Rt. sided camera (cavitary lead)
Lateral Leads L1, aVL, V5 and V6
Inferior Leads L2, aVF, and L3 leads
Septal Leads V1 and V2
Anterior Leads V3 and V4
Anterio-lateral leads V3, V4, V5, V6, L1 and aVL

The Six Chest

Leads

TRANSVERSE PLANE

38

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The 12 Camera
Photography
There SIX cameras photographing in
transverse or anterio-posterior plane
V1 and V2 record events of septum
V3 and V4 record events of the anterior
wall
V5 and V6 record events of left lateral wall
To record right side events V2R to V6R
are needed In dextrocardia, in RV
infarction

Cardiac
Impulse

40

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Cardiac
Impulse
Cardiac impulse originates in the SA node
Traverses the atria simultaneously no special
conduction wires in atria so the delay
Reaches AV node the check post so delay
Enters bundle of His and branches through
specialized conducting wires called Purkinje
network - activates both ventricles quick QRS
First the septum from L to R, then right
ventricle and then the left ventricle and finally
the apex
Then the ventricles recover for next impulse

PRESSURE MEASUREMENT

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TYPES OF PHYSIOLOGICAL PRESSURE

MEASUREMENT
1. Non-invasive blood pressure (NIBP)-
measure from palpation on the radial artery
2. Invasive blood pressure (IBP)- measure by
inserting catheters into body

NIBP
SPHYGMOMANOMETER

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NIBP
Using sphygmomanometer and stetoscope
Stetoscope is placed over the bracial artery
under the cuff for characteristic Korotkoff
sounds(turbulent).
Also known as sphymomanometry or
auscultatory method

Systolic pressure = pressure at which korotkoff

sounds start
Diastolic pressure = pressure at which
korotkoff sounds stop

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IBP

Advantages and Disadvantages

NIBP IBP

Accurate Most accurate

Painless Painful

Normal patient Critically ill

convenient Discomfort

Not risky risky

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Mean Arterial Pressure

MAP = DAP + (1/3 X Pulse Pressure)
Systolic pressure is taken when the first
oscillations are detected
Mean pressure is taken when the oscillations
are maximal-most accurate
Pulse pressure (systolic-diastolic)

Blood pressure

Vital signs

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Measuring and
Recording Blood Pressure
Measurement of the pressure the blood exerts
on the walls of the arteries during the various
stages of heart activity
Measured in millimeters of mercury on an
instrument called a sphygmomanometer
Measurements read at two points

Copyright 2004 by Thomson

Delmar Learning. ALL RIGHTS 51
RESERVED.

Measuring and Recording

Blood Pressure (continued)
1. The first sound is called the systolic blood
pressure it measures the pressure in an
artery when the heart is contracting
2. The change in sound/or last sound heard is
the diastolic blood pressure - it measure the
pressure in an artery
when the heart relaxes between contractions.

Copyright 2004 by Thomson

Delmar Learning. ALL RIGHTS 52
RESERVED.

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Preparation for measurement

Patient should abstain
from eating, drinking,
smoking and taking
drugs that affect the
blood pressure one
hour before
measurement.

Remember the following for accuracy of

your readings
Instruct your patients to
avoid coffee, smoking
or any other
unprescribed drug with
sympathomimetic
activity on the day of
the measurement

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Preparation for measurement

Because a full bladder

affects the blood
pressure it should have
been emptied.

Preparation for measurement

Painful procedures and
exercise should not
have occurred within
one hour.
Patient should have
been sitting quietly for
about 5 minutes.

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Position of the Patient

Sitting position
Arm and back are
supported.
Feet should be resting
firmly on the floor
Feet not dangling.

Position of the arm

The measurements should be made on the right arm

whenever possible.
Patient arm should be resting on the desk and raised

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Position of the arm

Palm is facing up.

The arm should remain somewhat bent and
completely relaxed

In order to measure the Blood Pressure

(equipment)
Pediatric Cuff size
Minimum Cuff Width:
2/3 length of upper arm
Minimum Cuff length:
Bladder nearly encircles
arm

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In order to measure the Blood Pressure

(equipment)

Adult Cuff size

Cuff Width: 40% of
limb's circumference

Blood Pressure
If it is too small, the
readings will be
artificially elevated. The
opposite occurs if the
cuff is too large. Clinics
should have at least 2
cuff sizes available,
normal and large.

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In order to measure the Blood

Pressure (Cuff Position)
Patient's arm slightly
flexed at elbow
Push the sleeve up,
wrap the cuff around
the bare arm

In order to measure the Blood

Pressure (Cuff Position)
Cuff applied directly
over skin (Clothes
artificially raises blood
pressure )
Position lower cuff
border 2.5 cm above
antecubital
Center inflatable
bladder over brachial
artery

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Technique of BP measurement

In order to measure the BP

Wrap the cuff around
the patient's upper arm
Close the thumb-screw.

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In order to measure the BP

With your left hand
place the stethoscope
head directly over the
braquial artery . Press
in firmly but not so hard
that you block the
artery.

Technique of BP measurement
Use your right hand to
pump the squeeze bulb
several times and
Inflate the cuff until you
can no longer feel the
pulse to level above
suspected SBP

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Technique of BP measurement

If you immediately hear

sound, pump up an
additional 20 mmHg
and repeat

Technique of BP measurement
Listen for auditory
vibrations from artery
"bump, bump, bump"
(Korotkoff)

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In order to measure the BP

Systolic blood pressure
is the pressure at which
you can first hear the
pulse.

In order to measure the BP

Diastolic blood pressure is the last pressure at which

you can still hear the pulse

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In order to measure the BP

Avoid moving your
hands or the head of
the stethescope while
you are taking readings
as this may produce
noise that can obscure
the Sounds of Korotkoff.

In order to measure the BP

If you wish to repeat
the BP measurement
you should allow the
cuff to completely
deflate, permit any
venous congestion in
the arm to resolve and
then repeat a minute or
so later.

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Remember the following for accuracy of

your readings
If the BP is surprisingly
high or low, repeat the
measurement towards
the end of your exam
(Repeated blood
pressure
measurement can be
uncomfortable).

What Abnormal Results Mean

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In order to measure the BP

Diastolic blood pressure
allow free flow of blood
without turbulence and
thus no audible sound.
These are known as the
Sounds of Korotkoff.

Blood pressure
The minimal SBP
required to maintain
perfusion varies with
the individual.
Interpretation of low
values must take into
account the clinical
situation.

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Blood pressure for adult

Physician will want to
see multiple blood
pressure measurements
over several days or
weeks before making a
diagnosis of
hypertension and
initiating treatment.

What Abnormal Results Mean

Pre-high blood Stage 1 high blood

pressure: systolic pressure: systolic
pressure consistently pressure consistently
120 to 139, or diastolic 140 to 159, or diastolic
80 to 89 90 to 99

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What Abnormal Results Mean

Hypotension (blood
pressure below
normal): may be
indicated by a systolic
pressure lower than 90,
or a pressure 25 mmHg
lower than usual

Hypertension

High blood pressure greater than

139-89..

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Blood pressure (mm Hg)

Normal blood pressure
100/60 and 139/89.
Prehypertension
120,139-80,89

Blood pressure may be affected

by many different conditions

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Blood pressure may be affected by many

different conditions
Cardiovascular
disorders
Neurological conditions
Kidney and urological
disorders

Blood pressure may be affected by many

different conditions
Pre eclampsia in
pregnant women
Psychological factors
such as stress, anger, or
fear

Eclampsia

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Blood pressure may be affected by many

different conditions

Various medications
"White coat hypertension" may occur if the medical
visit itself produces extreme anxiety

Fluid and blood flow

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Introduction
A fluid in any liquid or gas can flow from one
place to another.
Some basic principles of fluid movement (fluid
dynamics) are therefore important to
understand.
Fluid dynamics are governed by two main
variables: pressure (which can cause a fluid to
flow) and resistance (which opposes flow)

IDA MARIA BINTI MOHD YUSOFF E4181-

PHYSIOLOGICAL MEASUREMENT

Measurement of pressure
Pressure is often measured by observing how high it
can push a column of mercury up in evacuated tube
called a manometer
Mercury is used because it is very dense liquid and
enables us to measure pressure with shorter columns
than we would need with a less dense liquid such as
water
Because pressure are compared to the force generated
by a column of mercury, they are expressed in terms of
millimeters of mercury (mmHg)
Blood pressure is usually measured with a
sphygmomanometer (a calibrated tube filled with
mercury and attached to an inflatable pressure cuff
wrapped around the arm
IDA MARIA BINTI MOHD YUSOFF E4181-
PHYSIOLOGICAL MEASUREMENT

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Pressure gradients and flow

For any fixed quantity of fluid, its pressure
depends on the volume of space it occupies.
The greater the volume, the lower the
pressure, and vice versa
In blood circulation, we are most concerned
with flow- and it is a pressure difference
between two points, or pressure gradient,
that makes a fluid flow

IDA MARIA BINTI MOHD YUSOFF E4181-

PHYSIOLOGICAL MEASUREMENT

Consider 2 hypothetical points in space, A and B,

where the pressure at point A is higher than the
pressure at point B.
Assuming nothing blocks its way, a fluid will flow
from A to B, down the pressure gradient.
As it does, the pressure at point A will fall and the
pressure gradient at point B will rise, until the
two are equal.
At that time, there will be no pressure gradient
between A and B, and flow will cease.
Flow will also cease if something blocks its way- a
point of obvious relevance where the opening
and closing of heart valves are concerned.
IDA MARIA BINTI MOHD YUSOFF E4181-
PHYSIOLOGICAL MEASUREMENT

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By analogy, suppose you pull back the plunger

of a syringe.
The volume in the syringe barrel increases and
its pressure falls
Since pressure outside the syringe is greater
than the pressure inside, air flows into it until
the pressure inside and outside are equal
If you then push the plunger in, pressure
inside rises above the pressure outside, and
air flows out

IDA MARIA BINTI MOHD YUSOFF E4181-

PHYSIOLOGICAL MEASUREMENT

The syringe barrel is analogous to a heart

chamber such as left ventricle
When the ventricle expanding, its internal
pressure falls.
If the AV valve is open, blood flow into the
ventricles from the atrium above.
When the ventricle contracts, its internal
pressure rises
When the aortic valve opens, blood is ejected
from the ventricle into the aorta

IDA MARIA BINTI MOHD YUSOFF E4181-

PHYSIOLOGICAL MEASUREMENT

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Overview of volume changes

An additional perspective on the cardiac cycle
can be gained if we review the volume
changes that occur.
Below balanced sheet is from the standpoint
of one ventricle; both ventricles have equal
volumes.
the volume vary from one person to another
and depend on a persons state of activity.

IDA MARIA BINTI MOHD YUSOFF E4181-

PHYSIOLOGICAL MEASUREMENT

End-systolic volume 60 mL
(ESV, left from previous heartbeat)
Passively added to the ventricle
during atrial diastole +30 mL
Added by atrial systole +40 mL
_______________________________________
Total: End-diastolic volume (EDV) 130 mL
Stroke volume (SV) ejected by -70 mL
ventricular systole
Leaves: End-systolic volume (ESV) 60 mL
IDA MARIA BINTI MOHD YUSOFF E4181-
PHYSIOLOGICAL MEASUREMENT

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Notice that the ventricle pumps as much blood as

it received during diastole: 70 mL in this example
Both ventricles eject the same amount of blood
even though pressure in the right ventricle is only
about one fifth the pressure in the left.
Blood pressure in the pulmonary trunk is
relatively low, so the ventricle does not need to
generate very much pressure to overcome it.
It is essential that both ventricles have the same
output to maintain homeostasis
If right ventricle pumps more-pulmonary
hypertension and edema
If left ventricle pumps more- systemic circuit
hypertension and edema
IDA MARIA BINTI MOHD YUSOFF E4181-
PHYSIOLOGICAL MEASUREMENT

Cardiac output
The amount ejected by each ventricle in 1
minute is called the cardiac output.
CO=HR x SV
Where HR (beats/min) and SV (mL/beat)
At typical resting values,
CO = 75 beats/min x 70 mL/beat = 5250 mL/min
Thus, the bodys total volume of blood (4-6 L)
passes through the heart every minute
CO= oxygen consumption/arterial difference
IDA MARIA BINTI MOHD YUSOFF E4181-
PHYSIOLOGICAL MEASUREMENT

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Heart rate
Radial artery/common carotid artery
Heart rate can be obtained by counting
number of pulses in 15 seconds and
multiplying by 4 to get the beats per minute.
In newborn infants, the resting heart rate is
commonly 120 bpm or greater.
Average 72 to 80 bpm in young adult females
64 to 72 bpm in young adult males
IDA MARIA BINTI MOHD YUSOFF E4181-
PHYSIOLOGICAL MEASUREMENT

Tachycardia above 100 bpm

Bradycardia below 60 bpm
A sustained program of exercise causes
hypertrophy of the ventricles, which increase
their stroke volume.
This allow the heart to beat more slowly and
still maintain a normal cardiac output
Endurance athletes,low HR 40 to 60 bpm, but
higher SV, their CO same like normal people.

IDA MARIA BINTI MOHD YUSOFF E4181-

PHYSIOLOGICAL MEASUREMENT

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Question
1. If the normal stroke volume is about 70 mL/beat and
normal heart rate is 72 bpm, calculate the cardiac
output
2. A patients oxygen consumption is found to be 275
mL/min. a physicain measure both the arterial and
venous pulmonary oxygen concentrations and finds
them to be 0.2 mL O2/ml blood and 0.3 ml O2/ml
blood respectively. Based on this information, what is
this patients cardiac output? If the physician finds
that the patients heart rate is 80 beats/min. what is
the patients stroke volume?

IDA MARIA BINTI MOHD YUSOFF E4181-

PHYSIOLOGICAL MEASUREMENT

Measuring Cardiac Output

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The Fick Principle

The Fick principle was first described by Adolf Eugen
Fick in 1870 and assumes that the rate at which
oxygen is consumed is a function of the rate of blood
flows and the rate of oxygen picked up by the red
blood cells
The Fick principle involves calculating the oxygen
consumed over a given period of time from
measurement of the oxygen concentration of the
venous blood and the arterial blood

IDA MARIA BINTI MOHD YUSOFF

E4181-PHYSIOLOGICAL MEASUREMENT

Q can be calculated from these measurements:

VO2 consumption per minute using a spirometer
(with the subject re-breathing air) and a CO2
absorber
the oxygen content of blood taken from the
pulmonary artery (representing mixed venous blood)
the oxygen content of blood from a cannula in a
peripheral artery (representing arterial blood)
From these values, we know that:
VO2 = (QCA) - (QCV)
where
CA = Oxygen content of arterial blood
CV = Oxygen content of venous blood.
IDA MARIA BINTI MOHD YUSOFF
E4181-PHYSIOLOGICAL MEASUREMENT

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This allows us to say Q = (VO2/[CA - CV])*100 and

therefore calculate Q. While considered to be the
most accurate method for Q measurement, Fick is
invasive, requires time for the sample analysis, and
accurate oxygen consumption samples are difficult to
acquire.
There have also been modifications to the Fick
method where respiratory oxygen content is
measured as part of a closed system and the
consumed Oxygen calculated using an assumed
oxygen consumption index which is then used to
calculate Q. Other modifications use inert gas as
tracers and measure the change in inspired and
expired gas concentrations to calculate Q
IDA MARIA BINTI MOHD YUSOFF
E4181-PHYSIOLOGICAL MEASUREMENT

Dilution methods
This method was initially described using an indicator
dye and assumes that the rate at which the indicator
is diluted reflects the Q. The method measures the
concentration of a dye at different points in the
circulation, usually from an intravenous injection and
then at a downstream sampling site, usually in a
systemic artery
More specifically, the Q is equal to the quantity of
indicator dye injected divided by the area under the
dilution curve measured downstream (the Stewart
(1897)-Hamilton (1932) equation):

IDA MARIA BINTI MOHD YUSOFF

E4181-PHYSIOLOGICAL MEASUREMENT

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The trapezoid rule is often used as an

approximation of this integral.

IDA MARIA BINTI MOHD YUSOFF

E4181-PHYSIOLOGICAL MEASUREMENT

Ultrasound Dilution method

Ultrasound Dilution method was firstly introduced in
1995.[7], and it was used extensively to measure flow
and volumes with extracorporeal circuits condition
such as ECMO[8][9] and Hemodialysis[10][11], leading
more than 150 peer reviewed publications, and now
it has adapted to Intensive Care Units (ICU) settings
as COstatus (Transonic System Inc. Ithaca, NY).

IDA MARIA BINTI MOHD YUSOFF

E4181-PHYSIOLOGICAL MEASUREMENT

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COstatus uses body temperature normal saline (NS)

as an indicator to measure cardiac output, plus a
group of important hemodynamic Blood Volumes
(BV) variables, such as total end-diastole volume
(TEDV), central blood volume (CBV) and active
circulation volume (ACVI).
COstatus technology is based on ultrasound indicator
dilution[12]. Blood ultrasound velocity (15601585
m/s) is a function of total blood protein
concentration (sums of proteins in plasma and in red
blood red cells), temperature etc. Injection of body
temperature normal saline (ultrasound velocity of
saline is 1533m/sec) into a unique AV loop decreases
blood ultrasound velocity, and produce dilution
curves.
IDA MARIA BINTI MOHD YUSOFF
E4181-PHYSIOLOGICAL MEASUREMENT

COstatus establishes an extracorporeal circulation through

its unique AV loop with two preexisting arterial and central
venous lines in ICU patients. When the saline indicator is
injected into the A-V loop, it is detected by the venous
clamp-on sensor on the AV loop before it enters the
patients right heart atrium. After the indicator traverses
the heart and lung, the concentration curve in the arterial
line is recorded and displayed on the COstatus HCM101
Monitor. Cardiac output is calculated from the area of the
concentration curve by the classic Stewart-Hamilton
equation. It is a non-invasive procedure only by connection
the AV loop and two lines of a patient. There lacks general
methods to measure cardiac output in pediatric ICU
patients, COstatus has been demonstrated to be a safe and
reproducible tool

IDA MARIA BINTI MOHD YUSOFF

E4181-PHYSIOLOGICAL MEASUREMENT

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Thermodilution
The indicator method was further developed with
replacement of the indicator dye by heated or cooled
fluid and temperature change measured at different
sites in the circulation rather than dye concentration;
this method is known as thermodilution. The
pulmonary artery catheter (PAC), also known as the
Swan-Ganz catheter, was introduced to clinical
practice in 1970 and provides direct access to the
right heart for thermodilution measurements.

IDA MARIA BINTI MOHD YUSOFF

E4181-PHYSIOLOGICAL MEASUREMENT

IDA MARIA BINTI MOHD YUSOFF

E4181-PHYSIOLOGICAL MEASUREMENT

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The PAC is balloon tipped and is inflated, which helps "sail"

the catheter balloon through the right ventricle to occlude
a smaller branch of the pulmonary artery system. The
balloon is deflated. The PAC thermodilution method
involves injection of a small amount (10ml) of cold glucose
at a known temperature into the pulmonary artery and
measuring the temperature a known distance away (6
10 cm) using the same catheter
The Q can be calculated from the measured temperature
curve (The thermodilution curve). High Q will change the
temperature rapidly, and low Q will change the
temperature slowly. Usually three or four repeated
measures are averaged to improve accuracy.

IDA MARIA BINTI MOHD YUSOFF

E4181-PHYSIOLOGICAL MEASUREMENT

However it is complex to perform and there are many

sources of inaccuracy in the method.[13][14] Modern
catheters are fitted with a heating filament which
intermittently heats and measures the thermodilution
curve providing serial Q measurement. However, these take
an average of measurements made over 29 minutes,
depending on the stability of the circulation, and thus do
not provide continuous monitoring.
PAC use is complicated by arrhythmias, infection,
pulmonary artery rupture, and right heart valve damage.
Recent studies in patients with critical illness, sepsis, acute
respiratory failure and heart failure suggest use of the PAC
does not improve patient outcomes.[4][5][6] PAC use is in
decline as clinicians move to less invasive technologies for
monitoring hemodynamics.
IDA MARIA BINTI MOHD YUSOFF
E4181-PHYSIOLOGICAL MEASUREMENT

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Doppler ultrasound method

This method uses ultrasound and the Doppler effect
to measure Q. The blood velocity through the heart
causes a 'Doppler shift' in the frequency of the
returning ultrasound waves. This Doppler shift can
then be used to calculate flow velocity and volume
and effectively Q using the following equations:
Q = SV HR
SV = vti CSA

IDA MARIA BINTI MOHD YUSOFF

E4181-PHYSIOLOGICAL MEASUREMENT

IDA MARIA BINTI MOHD YUSOFF

E4181-PHYSIOLOGICAL MEASUREMENT

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where:
CSA = valve orifice cross sectional area; use pr
r = valve radius
vti = the velocity time integral of the trace of the
Doppler flow profile
Doppler ultrasound is non-invasive, accurate and
inexpensive and is a routine part of clinical
ultrasound with high levels of reliability and
reproducibility having been in clinical use since the
1960s.

IDA MARIA BINTI MOHD YUSOFF

E4181-PHYSIOLOGICAL MEASUREMENT

Electromagnetic Flow Meter

IDA MARIA BINTI MOHD YUSOFF

E4181-PHYSIOLOGICAL MEASUREMENT

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Question
1. If the normal stroke volume is about 70 mL/beat and
normal heart rate is 72 bpm, calculate the cardiac
output
2. A patients oxygen consumption is found to be 275
mL/min. a physician measure both the arterial and
venous pulmonary oxygen concentrations and finds
them to be 0.2 mL O2/ml blood and 0.3 ml O2/ml
blood respectively. Based on this information, what is
this patients cardiac output? If the physician finds
that the patients heart rate is 80 beats/min. what is
the patients stroke volume?

IDA MARIA BINTI MOHD YUSOFF E4181-

PHYSIOLOGICAL MEASUREMENT

Pressure measurement

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Oscillometric technique

The oscillometric (wave) method to measure blood pressure using
an automated device gave patients a way to check their blood
pressure at home

Before this, the mercury-type method was too expensive for
widespread home use and the aneroid system was cumbersome.

Oscillometric devices use the pressure signal generated from the
cuff to determine blood pressure.

The pressure signal is caused by the interaction between the cuff
and blood flow through the brachial artery. Even when the
Korotkoff sounds are hardly detected due to hypotension, the
oscillometric method is capable to determine the BP because the
cuff oscillates as long as the artery pulsation exists.

When the pressure in the cuff is decreasing

slowly, the magnitude of the pressure
oscillation in the cuff gradually increases
and eventually reaches a peak.

Further decrease of the cuff pressure causes
the oscillation to decrease

The relationship between the changes of
cuff pressure and its oscillation is stored in
memory and used to determine BP
 The systolic value is taken when the oscillation
increses rapidly
 The diastollic value is taken when the oscillation
decreases rapidly and the MAP when the
oscillation reaches a peak

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IBP measurement setup - transducer

Invasive blood pressure measurement may be done by
inserting a sterile, saline filled catheter into the blood
stream

The pressure a the tip of the catheter is the transmitted
through the catheter fluid to an external pressure
transducer

To transmit the pressure with fidelity, the catheter should
be as short as it is practical, stiff and noncompliant

It should also have a large diameter as possible that will
allow to be threaded through the vein

To prevent clotting, the catheter may be continously
infused with an anticoagulant solution.

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The central venous pressure (CVP)

The catheter is threaded into the brachial vein so that the
diaphragm at the tip reaches the superior vena cava, then,
the CVP is measured.

The position of the catheter is determined by means of an
x-ray fluoroscope and by monitoring the blood pressure
pulse.

The tip of the catheter of the catheter is usually made of a
radio opaque material that gives clear x-ray images.

The catheter may be further inserted into the right atrium
to record the right atrial pressure (RAP)

Further insertion of the catheter will drive it through the
tricuspid valve into the right ventrical pressure (RVP)

Pulmonary artery wedge pressure

(PAWP)
In seriously ill patient, there is need in
knowing pulmonary artery pressure (PAP)
1970-Swn and Ganz invented a balloon guide
catheter for this purpose
A hazard in the procedure is that if the ballon
breaks, an air bubble will get into the
bloodstream.
Harmful side effect,blood clotting

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Balloon is inflated, the blood flow created a force

that drags the catheter forward

After the balloon passes through the pulmonary
valve of the heart into the pulmonary artery, it is
deflated and the PAP is measured

With the catheter is in the pulmonary artery, it is
possible to measure the pressure in the left
atrium, which is done by stopping the blood flow
in the artery momentarily by inflating the
balloon.

Swan ganz catheter with latex

balloon at the tip

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