Non-Invasive Monitoring 209 that increased atrial distension in pre - eclampsia triggered a diuretic response. These data have been contested. The most detailed study, to date, by Borghi et al. [15] described detailed cardiac fi ndings among 40 women with mild pre - eclampsia compared to a control cohort of pregnant women and non - pregnant controls. This study showed a progressive rise in left ventricular mass between non - pregnant women compared to normal pregnancy with a further increase in mass among women with pre - eclampsia. Ejection fraction and fractional shortening decreased in normal pregnancy while not reaching statistical signifi cance. However, women with pre - eclampsia had a signifi cant reduction in both these parameters in comparison to non - pregnant women. In addition, left ventricular end - diastolic volume rose signifi cantly in pre - eclampsia. Together with a fall in cardiac output in the pre - eclamptic group, these fi ndings suggest a compensatory increase in ventricular size to maintain cardiac output against an elevated systemic vascular resistance. The latter study also showed changes in the peak fi lling veloci- ties of the left ventricle during diastole. The E/A ratio fell signifi - cantly during pregnancy, partly refl ecting increased preload. In pre - eclamspsia further augmentation of the A - wave peak velocity resulted in further signifi cant reduction in the ratio. Collectively these data support the notion of changes in both cardiac systolic and diastolic function. The authors also measured ANP levels. In keeping with previous studies elevated levels of ANP were found in pregnancy with further increments occurring in pre - eclampsia. These could not be accounted for by differences in atrial size although a signifi cant correlation was found between left ven- tricular mass and volume in women with pre - eclampsia [15] . Doppler ultrasound and cardiomyopathy Doppler ultrasound has an important role in the management and evaluation of women with impaired ventricular function. Echocardiography is used to delineate impaired left ventricular systolic function in women with suspected peripartum cardiomy- opathy. It plays a further role in the ongoing evaluation of women once this diagnosis has been made. Specifi cally the prognosis has been related to the normalization of left ventricular size and func- tion within 6 months of delivery [16] . Currently accepted opinion is that approximately 50% of affected women will recover normal function. Those who have persistently impaired function face a signifi cant risk of mortality [16] . Subsequent pregnancies in women with a prior diagnosis of cardiomyopathy demand careful echocardiographic assessment. Although no clear agreement exists regarding risk, those with persistently abnormal left ventricular function have been advised against pregnancy. Confl icting reports have been made concern- ing those who become pregnant. De Souza et al. report on the evaluation of seven women who became pregnant after develop- ing peripartum cardiomyopathy in a previous pregnancy. All pregnancies were well tolerated without signifi cant change in patients. The fi ndings of this study showed a high correlation between invasive and non - invasive techniques in the measure- ment of stroke volume and cardiac output. Ventricular fi lling pressures and pulmonary artery pressures also showed a similar signifi cant correlation with invasive techniques [11] . The specifi c choice of echocardiographic technique for esti- mating stroke volume and ejection fraction was explored in the same group of patients. Comparisons between M - mode and two - dimensional Doppler techniques revealed similar fi ndings, although M - mode echocardiography was not possible in 2 out of 11 subjects secondary to body habitus and paradoxical motion of the intraventricular septum. This study also allowed calculation of the ejection fraction by dividing the stroke volume by the end - diastolic volume. Using this equation, similar results were obtained by all the methods employed for estimating left ven- tricular function in pregnant women [12] . Belfort et al. have reported a series of 14 patients with an indi- cation for invasive hemodynamic monitoring in whom Doppler ultrasound was used as a guide to clinical management. These 14 women had a spectrum of pathologies ranging from intractable hypertension to complex cardiac lesions and included women with oliguria and pulmonary edema. This pilot study concluded that the non - invasive monitoring had facilitated management and only two patients went on to have invasive monitoring in order to allow continuous monitoring. Large volumes of fl uid were administered to some of these patients (up to 8 L of crystal- loid) without the development of fl uid overload or pulmonary edema. To date this is the only study that has indicated the poten- tial utility of routine rapid echocardiographic assessment of left ventricular function in critically ill obstetric patients [13] . Doppler ultrasound and pre - eclampsia Doppler echocardiography has provided a ready means of study- ing women at risk for developing hypertensive complications during pregnancy. Longitudinal studies have demonstrated that women with non - proteinuric or gestational hypertension main- tain a hyperdynamic circulation with a high cardiac output throughout pregnancy. By contrast women destined to develop pre - eclampsia have signifi cantly elevated cardiac output without any change in systemic resistance in the preclinical phase of the disease. This is followed by a fall in cardiac output and increasing resistance coincident with the onset of clinical disease [14] . More recently, studies have focused on echocardiographically described cardiac structure and function in pre - eclampsia, espe- cially in relation to levels of atrial and brain natriuretic peptide (ANP, BNP). Initial work had related elevated ANP levels to increased left atrial dimensions following delivery in normal pregnancies. These increased ANP levels did not lead to any demonstrable diuresis in normal postpartum women. Women with pre - eclampsia had bigger atria and higher ANP levels in the early puerperium and these changes were associated with natri- uresis and diuresis. The hypothesis related by these fi ndings was Chapter 15 210 abosorbs the infrared light more strongly (Figure 15.1 ). This allows the simultaneous acquisition of peripheral signals from which the ratio of oxy - to deoxyhemoglobin can be calculated and expressed as a percentage of oxyhemoglobin saturation. Oximetry may be based on transcutaneous measurements or can be derived from mixed venous blood via a probe located in a pulmonary artery catheter. The peripheral pulse oximetry devices rely on detection of pulsed alterations in light transmitted between transmitter and a photodetector. This fi ltered signal is necessary to eliminate the signal arising from venous blood that would contain more deoxyhemoglobin. Although oximetry is regarded as an effective method of moni- toring oxygenation, some limitations are recognized. They include the assumptions that methemoglobin and carboxyhemo- globin are not present in signifi cant concentrations. Mixed venous oxygen saturation monitoring is less frequently used than peripheral oxygen saturation monitoring. It also shows greater spontaneous variation than peripheral monitors but has a clinical role to play in determining the balance between peripheral oxygen delivery and peripheral oxygen consumption. This is a robust measurement that will refl ect changes in cardiac output, hemo- globin concentration, arterial and venous hemoglobin oxygen saturation. This provides useful clinical information in many clinical circumstances. A number of the determinants of the ulti- mate mixed venous oxygen saturation value have the potential to change at any given moment (hemoglobin, oxygen saturation, and cardiac output). It is therefore important to understand that it is only when all other parameters remain stable that changes in the mixed venous oxygen saturation refl ect changes in cardiac output. Capnometery Exhaled gas can be evaluated using an infrared probe and a pho- todetector set to detect carbon dioxide. This is usually found in symptomatology. Echocardiographic studies showed no change in left ventricular end - diastolic diameters, with an increase occur- ring in left ventricular fractional shortening [17] . Other studies have reported similarly successful pregnancies [18] . However, there are papers suggesting a risk of recurrent cardiomyopathy and impaired contractile reserve, even in those with apparently normal left ventricular function before pregnancy [19,20] . Doppler ultrasound and other medical disorders Echocardiocardiography is an essential investigation in women with structural heart disease due to valvular damage or congenital malformation [21 – 27] . Echocardiography will also contribute to the diagnosis of Libman – Sacks endocarditis, which occurs, though not frequently, among women suffering from systemic lupus erythematosus, with or without antiphospholipid anti- bodies [28,29] . The management of Marfan ’ s syndrome also requires echocar- diographic assessment because of the risk of catastrophic aortic dissection. Transesophageal echocardiography is the preferred method for evaluating the ascending aorta. The risk of dissection correlates with an aortic root diameter greater than 4 cm [30] . Aortic dissection may also occur under other circumstances and may follow the use of crack cocaine [31,32] . The role of transesophageal D oppler Esophageal Doppler monitoring of hemodynamic data has been carried out in adult intensive care units and found to be equiva- lent to data derived from pulmonary artery catheter measure- ments [33] . Pregnancy data are few, and to date only one study has reported the use of transesophageal Doppler monitoring in pregnancy compared to pulmonary artery catheters. This study showed that the Doppler consistently underestimated cardiac output by 40% in women under the age of 35 years [34] . This error may be due to the assumptions implicit in the algorithm used to calculate output. These assumptions include a fi xed aortic diameter during systole and a fi xed percentage of blood perfusing upper and lower parts of the body. Pregnancy physiological changes probably invalidate these assumptions. The authors nev- ertheless conclude that esophageal Doppler may contribute to the estimation of trends in cardiac output over time in pregnancy. Oximetry in the intensive care environment Spectrophotometry is the detection of specifi c light frequencies refl ected by a range of molecules. Specifi c molecules refl ect spe- cifi c frequencies and their refl ective properties differ with changes in molecular conformation. Oximetry is the detection of oxygen- ated and deoxygenated blood. Deoxygenated hemoglobin absorbs more light at 660 nm whereas at 940 nm oxygenated hemoglobin 600 700 (RED) 660 nm (INFRARED) 910 nm 800 900 1000 WAVELENGTH (nm) Absorbance Hb HbO 2 0.1 10 Figure 15.1 Oximetry in the intensive care environment. The oxygenated hemoglobin refl ects more light at 660 nm whereas at 940 nm deoxyhemoglobin refl ects infrared light more strongly . Non-Invasive Monitoring 211 dinally (at 4 - week intervals) during normal gestation. The resis- tance index (RI), pulsatility index (PI), and cerebral perfusion pressure (CPP) were calculated using the velocity and blood pres- sure data. The mean value, and the 5% and 95% percentiles, were defi ned and it was noted that the middle cerebral artery (MCA) velocities and the resistance and pulsatility indices decrease, while the CPP increases, during normal pregnancy. Figure 15.2 shows the CPP change during normal pregnancy. This study defi ned the normative ranges for middle cerebral artery velocity, resistance indices, and cerebral perfusion pressure during normal human pregnancy using longitudinally collected data. Women with pre - eclampsia and hypertensive women with superimposed pre - eclampsia have been studied using TCD ultrasound. Findings among these subjects include globally elevated cerebral perfusion pressures and lower cerebral vascular resistance compared to normotensive controls [38,39] . The increased pressures were not directly related to blood pressure alone [39] . Doppler ultrasound, bias and confounders There are a number of confounding infl uences that can affect the interpretation of Doppler cerebral velocity data. These include any factors that may: (i) increase the CO 2 or H + tension in the cerebral circulation; (ii) decrease or increase the hemoglobin con- centration; (iii) independently alter the diameter of the vessel being studied at the point of insonation; and (iv) introduce error, such as cigarette smoking and changes in posture. In pregnant women (v) gestational age is another important factor that requires consideration, since as the pregnancy progresses there are signifi cant hemodynamic changes. Increased CO 2 tension leads to cerebral vasodilation, as does acidosis. Patients undergoing cerebral Doppler studies should, ideally, be studied in a steady state or should have their end - tidal CO 2 tension measured in order to control for fl uctuations. Even the expiratory limb of a ventilator circuit. Expired gas shows a pattern of increasing carbon dioxide concentration related to the sequential expiration of air in the upper airway followed by air from the alveoli. The end - expiratory (or end - tidal) carbon dioxide concentration should approximate the partial pressure of carbon dioxide in arterial blood. The development of a gradient between these measurements refl ects an increase in anatomical or physiological dead space. In the latter event, low cardiac output and pulmonary embolism may both affect the measurement. Changes in end - tidal partial pressure of carbon dioxide have been correlated to changes in cardiac output and may be used as a means of monitoring the effi cacy of resuscitation. Transcranial D oppler ultrasound Compared to the physiologic alterations in other vascular beds during gestation the normal cerebral blood fl ow changes of preg- nancy are poorly documented. This is due, partly, to technical diffi culties associated with in vivo studies of blood fl ow in the human brain. Angiography, the gold standard in the evaluation of the cerebral vasculature, is an invasive test and presents obvious ethical concerns for its use in normal pregnant women. Very little data exist on the physiologic adaptations of the brain to preg- nancy in the current literature and most texts dealing with the changes of pregnancy do not address this issue at all. There are also ethical problems with using angiography and other method- ologies involving radiation, as well as magnetic resonance imaging during pregnancy. The advent of Doppler ultrasound, and in particular transcranial Doppler (TCD) ultrasound, has changed this. It is now possible to acquire Doppler - derived velocity infor- mation from most of the basal brain arteries (including almost all of the circle of Willis branches) using a non - invasive tech- nique. Using these data, it is possible to diagnose arterial malfor- mations, functional abnormalities, and physiological changes in brain blood velocity. One can detect direction and velocity of blood fl ow, and from this infer the presence of distal or proximal arterial constriction or dilatation. In addition, TCD can be used to determine real - time changes over very short time intervals and to continuously monitor cerebral blood velocity during surgical procedures, or experimental drug protocols. TCD has been extensively used in the clinical scenario by neurologists and neu- rosurgeons to detect and follow cerebral vasospasm in patients with subarachnoid hemorrhage [35] . TCD has also been used for neurological monitoring during cardiopulmonary bypass in pediatric cardiac surgeries [36] . Investigators are beginning to use TCD to defi ne pregnancy - induced/associated changes in the cerebral circulation. Belfort et al. [37] have recently defi ned the hemodynamic changes, specifi cally velocity, resistance indices, and cerebral per- fusion pressure, in the middle cerebral artery distribution of the brain during normal pregnancy. TCD ultrasound was used to determine the systolic, diastolic, and mean blood velocities in the middle cerebral arteries in non - laboring women studied longitu- Figure 15.2 Cerebral perfusion pressure (CPP) changes during a normal pregnancy as detected by middle cerebral artery (MCA) velocity. Chapter 15 212 tone also tends to close the arterioles when pressure falls during the pulse cycle. Under conditions of low vascular resistance, the arterioles remain open throughout the pulse cycle and the active smooth muscle tone never causes them to close completely. However, even a slight increase in arteriolar tone will narrow the diameter of open arterioles and, in some cases, cause them to close completely when the pressure within them falls at the end of the pulse cycle. The pressure at which an arteriole closes is called its “ critical closing pressure ” [35,42] . Critical closing pres- sure explains why arterioles close as pressure falls during the pulse cycle and why fewer arterioles are open at the end of the pulse cycle than earlier, when pressure is at its systolic maximum. Thus, pressure at the end of a pulse cycle is less effective in perfusing the capillary bed than that early in the cycle. In the brain, CPP is reduced as arteriolar resistance rises abruptly due to more and more arterioles reaching their critical closing pressure. Another feature of arteriolar tone is its effect in delaying the fl ow of blood from arteries to capillaries. When arteriolar tone is high it reduces the rate of blood fl ow from arteries to capillaries. This maintains the arterial blood pressure at a higher level for a longer portion of the pulse cycle than if the arteriolar tone was low and there was a rapid run - off of blood. Blood pressure distends the arterial segments and blood is effectively stored in the arteries while the pressure decays during the pulse cycle. The amount stored in each segment depends on the compliance of the artery and the pres- sure gradient between the lumen and the region outside the artery. The result of storing blood in the arteries and reducing the rate of fl ow through arterioles is to slow the deceleration of blood fl ow during the pulse cycle. The more compliant the arterial segment, the slower the deceleration during the pulse cycle. This feature of arteriolar tone interacting with arterial pressure and arterial compliance affects the shape of the velocity profi le during the pulse cycle. When arteriolar tone is low, blood velocity rapidly rises to a maximum and falls quickly to a minimum. In contrast, when arteriolar tone is high, the blood fl ow velocity falls more slowly. The area under the pulsatile amplitude of the velocity waveform, and the height of the pulse velocity wave, may be used to estimate the proportion of blood fl ow stored in arterial seg- ments during the peak of the pulse cycle and released when pres- sure falls during the cycle. One of the major problems with the currently used Doppler indices is that they were initially developed for use in peripheral vascular examination of large - diameter arteries such as the femoral, dorsalis pedis, and brachial arteries. Indices such as the PI and RI focus on the systolic component of the velocity profi le. The traditional Doppler indices of hemodynamics (i.e. the RI and PI) provide limited data regarding arteriolar tone when applied to the cerebral circulation. Both the RI, defi ned as: velocity velocity velocity systolic diastolic systolic − ()() and the PI, defi ned as: velocity velocity velocity systolic diastolic mean − () () the minimal increases in tidal volume and respiratory rate associ- ated with labor contractions may be of importance. Labor itself has been shown to be associated with decreases in mean middle cerebral artery fl ow velocity. Hemoconcentration and hemodilution are also important and attention should be paid to the hematocrit level in studies where blood loss or volume infusion may have altered the hemoglobin content of the blood during the study period. The segmental nature of the vasospasm seen in some condi- tions, notably pre - eclampsia, is of concern as well, since the same segment of artery can show completely different velocity profi les depending on its state of contraction. Thus, if the region of vessel being insonated is apt to change, its diameter velocity readings may be inaccurate, particularly if some indication of downstream vascular condition is being extrapolated. In this regard, the M1 portion of the middle cerebral artery has been shown to be unlikely to change diameter [40] , since it is well supported by alveolar tissue in its bony canal. The angle of insonation is critical since the velocity is related to the cos of the angle of insonation ( q ). If q is less than 10 ° the error involved is almost negligible and quite acceptable for most purposes. Because of the anatomy of the bony canal through which the M1 portion of the MCA runs, the angle of insonation very rarely exceeds 10 ° . This ensures that, in almost all cases, once the optimum signal is obtained the angle of insonation is less than 10 ° . The effect of maternal cigarette smoking on middle cerebral artery blood fl ow velocities during normal pregnancy was described by Irion et al. [41] . They found that the systolic, dia- stolic, and mean velocities of the middle cerebral artery, detected in both the left lateral decubitus and sitting positions, were sig- nifi cantly higher at 18 and 26 weeks gestation in women who smoked cigarettes. They determined that the number of cigarettes smoked positively correlated with increased middle cerebral artery velocities. This factor must be taken into account when studying women known to smoke, and is an important con- founding factor in some of the earlier studies published. Posture should be taken into account when studying pregnant, and in particular, pre - eclamptic pregnant women. A change from lying to sitting has been shown to signifi cantly increase both systolic and diastolic velocities in the middle cerebral artery in such patients. Another important variable that must be taken into account when studying pregnant women is the gestational age. As preg- nancy advances there is a reduction in middle cerebral artery velocity which should be controlled for when comparing women of different gestational ages. Cerebral perfusion pressure Under normal conditions, the arterioles in the cerebrovascular system are responsible for about 80% of the vascular resistance. Because arterioles have active smooth muscle tone, they do not behave simply like tubes of variable dimension. Smooth muscle tone in the arterioles reduces their diameter when systolic pres- sure is transmitted into them via the arteries. In addition, this Non-Invasive Monitoring 213 eclamptics routine use of this modality is not recommended until further research has confi rmed the fi ndings. However, in those cases of refractory seizure activity unresponsive to conventional therapy, TCD may offer another diagnostic option. In those cases where CPP is shown to be signifi cantly elevated, drug therapy can be tailored to lowering the CPP (i.e. with labetalol) versus those rare cases where there is a low CPP and presumably cerebral ischemia from underperfusion, a cerebral vasodilator such as nimodipine can be used. Conclusion Non - invasive techniques of monitoring will become increasingly utilized as an alternative to the invasive techniques currently practiced in most intensive care units. This technology, however, requires expertise in the application and interpretation of data. Even correctly interpreted data are of unknown utility and strin- gent evaluation is necessary before this (often) expensive technol- ogy is incorporated into routine clinical practice. References 1 Flachskampf FA , Hoffmann R , Verlande M , Schneider W , Ameling W , Hanrath P . Initial experience with a multiplane transoesophageal echo - transducer: assessment of diagnostic potential . Eur Heart J 1992 ; 13 ( 9 ): 120 – 126 . 2 Krebs W , Klues HG , Steinert S et al. Left ventricular volume calcula- tions using a multiplanar transoesophageal echoprobe; in vitro vali- dation and comparison with biplane angiography . Eur Heart J 1996 ; 17 ( 8 ): 1279 – 1288 . 3 Flachskampf FA . The standard TEE examination: procedure, safety, typical cross - sections and anatomic correlations, and statistical analy- sis . Semin Cardiothorac Vasc Anesth 2006 ; 10 ( 1 ): 49 – 56 . 4 Lee LC , Black IW , Hopkins A , Walsh WF . Transoesophageal echocar- diography in heart disease – old technologies, new tricks . Aust N Z J Med 1992 ; 22 ( 5 Suppl ): 527 – 531 . 5 Mesa A , Jessurun C , Hernandez A et al. Left ventricular diastolic function in normal human pregnancy . Circulation 1999 ; 99 ( 4 ): 511 – 517 . 6 Valensise H , Novelli GP , Vasapollo B et al. Maternal cardiac systolic and diastolic function: relationship with uteroplacental resistances. A Doppler and echocardiographic longitudinal study . Ultrasound Obstet Gynecol 2000 ; 15 ( 6 ): 487 – 497 . 7 Mone SM , Sanders SP , Colan SD . Control mechanisms for physio- logical hypertrophy of pregnancy . Circulation 1996 ; 94 ( 4 ): 667 – 672 . 8 Geva T , Mauer MB , Striker L , Kirshon B , Pivarnik JM . Effects of physiologic load of pregnancy on left ventricular contractility and remodelling . Am Heart J 1997 ; 133 : 53 – 59 . 9 Poppas A , Shroff SG , Korcarz CE et al. Serial assessment of the car- diovascular system in normal pregnancy. Role of arterial compliance and pulsatile arterial load . Circulation 1997 ; 95 ( 10 ): 2407 – 2415 . 10 Robson SC , Hunter S , Boys RJ , Dunlop W . Serial changes in pulmo- nary haemodynamics during human pregnancy: a non - invasive study using Doppler echocardiography . Clin Sci (Colch) 1991 : 80 ( 2 ): 113 – 117 . are signifi cantly infl uenced by the systolic velocity which refl ects large - caliber arterial constriction. These indices were originally developed using older technology and larger diameter arteries (femoral artery and aorta). The typical waveform shape from such arteries has a tall peaked systolic component, a steep dia- stolic slope, and a low/non - existent diastolic component. The smaller diameter arteries that are now easily visualized with modern equipment provide completely different waveforms from those seen in the larger diameter, higher velocity, and higher resistance vessels. Using indices that focus on the systolic velocity tends to ignore aspects of waveform shape peculiar to lower resis- tance vascular beds. Specifi cally, the typical waveform seen in low resistance, low velocity, smaller diameter arteries has a low sys- tolic velocity, fl atter diastolic downslope, and a proportionately higher diastolic velocity, than that seen in high - resistance, high - velocity arteries. A further defi ciency of the current cerebral Doppler assessment techniques is that they fail to take into account the systemic arte- rial pressure, a vital component of the cerebral perfusion pres- sure. In 1986 Aaslid et al. [43] validated a Doppler method of estimating CPP. They measured velocity in the middle cerebral artery (Doppler ultrasound), and intraventricular pressure and radial arterial blood pressure (direct strain gauge transducers) in 10 patients undergoing a supratentorial shunt procedure. They estimated CPP using the following ratio: (mean fl ow velocity)/ (pulsatile amplitude of fl ow velocity) multiplied by the arterial blood pressure. To increase the accuracy, Fourier analysis was used and only the amplitude of the fi rst harmonic of the pulsatil- ity in both fl ow - velocity and arterial blood pressure recordings were used. They expressed their calculations as: CPP ABP=× V V 0 1 1 where V 0 is the mean and V 1 is the amplitude of the fi rst harmonic of the velocity waveform, and ABP 1 is the fi rst harmonic of the arterial pressure wave. Their experimental results confi rmed the validity of the method. The standard deviation between estimated CPP (CPP e ) and measured CPP (CPP m ) was 8.2 mmHg at a CPP of 40 mmHg, and the mean deviation was only 1 mmHg. Belfort et al. [44] have adapted the method of Aaslid et al. [43] by altering the formula to refl ect the area under the pulsatile amplitude of the fl ow velocity and arterial blood pressure wave- forms rather than the fi rst harmonic. Their equation, using areas under pulsatile amplitudes, is as follows [44] : CPP Velocity Velocity Velocity BP BP mean mean diastolic mean di = − ×− aastolic () Recently Belfort et al. [45] have suggested that elevated CPP, rather than decreased CBF, is the key determinant of cerebral injury in pre - eclampsia/eclampsia. 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Contractile reserve in patients with peripartum cardiomyopathy and recovered left ventricular function . Am J Obstet Gynecol 1997 ; 176 ( 1 Pt 1 ): 189 – 195 . 21 Gultekin F , Baskin E , Gokalp A , Dogan K . A pregnant woman with Ebstein ’ s anomaly. A case report . Mater Med Pol 1994 ; 26 ( 4 ): 149 – 151 . 22 Ben Farhat M , Gamra H , Betbout F et al. Percutaneous balloon mitral commissurotomy during pregnancy . Heart 1997 ; 77 ( 6 ): 564 – 567 . 23 Martinez Reding J , Cordero A , Kuri J , Martinez Rios MA , Salazar E . Treatment of severe mitral stenosis with percutaneous balloon val- votomy in pregnant patients . Clin Cardiol 1998 ; 21 ( 9 ): 659 – 663 . 24 Niwa K , Perloff JK , Kaplan S , Child JS , Miner PD . Eisenmenger syn- drome in adults: ventricular septal defect, truncus arteriosus, univen- tricular heart . J Am Coll Cardiol 1999 ; 34 ( 1 ): 223 – 232 . 25 Wilansky S , Phan B , Adam K . Doppler echocardiography as a predic- tor of pregnancy outcome in the presence of aortic stenosis: A case report . J Am Soc Echocardiogr 1999 ; 12 : 324 – 325 . 26 Barbosa PJ , Lopes AA , Feitosa GS et al. Prognostic factors of reheu- matic mitral stenosis during pregnancy and puerperium . Arq Bras Cardiol 2000 ; 75 ( 3 ): 215 – 224 . 27 Mangione JA , Lourenco RM , dos Santos ES et al. Long - term follow - up of pregnant women after percutaneous mitral valvuloplasty . Catheter Cardiovasc Interv 2000 ; 50 ( 4 ): 413 – 417 . 28 Gleason CB , Stoddard MF , Wagner SG , Longaker RA , Pierangeli S , Harris EN . A comparison of cardiac valvular involvement in the primary antiphospholipid syndrome versus anticardiolipin - negative systemic lupus erythematosus . Am Heart J 1993 ; 125 ( 4 ): 1123 – 1129 . 215 Critical Care Obstetrics, 5th edition. Edited by M. Belfort, G. Saade, M. Foley, J. Phelan and G. Dildy. © 2010 Blackwell Publishing Ltd. 16 Pulmonary Artery Catheterization Steven L. Clark 1 & Gary A. Dildy III 2 1 Women ’ s and Children ’ s Clinical Services, Hospital Corporation of America, Nashville, TN, USA 2 Maternal - Fetal Medicine, Mountain Star Division, Hospital Corporation of America, Salt Lake City, UT and Department of Obstetrics and Gynecology, LSU Health Sciences Center, School of Medicine in New Orleans, New Orleans, LA, USA Introduction Following its introduction into clinical medicine three decades ago, the pulmonary artery catheter was shown to play an impor- tant role in the management of critically ill patients in a number of specialties, including obstetrics [1 – 6] . Several early prospective trials demonstrated the benefi ts of pulmonary artery catheteriza- tion in select critically ill patients. Such benefi ts include a reduc- tion in operative morbidity and mortality in certain complicated surgical patients and a signifi cant mortality reduction in patients in shock in whom catheter - obtained parameters led to changes in therapy [7,8] . In one study, management recommendations changed as a direct result of knowledge obtained by pulmonary artery catheter placement in 56% of patients admitted to an intensive care unit [9] . In patients with major burn injuries, survival is predicted by early response to pulmonary artery catheter - guided resuscitation [10] . This technique, however, was not without its critics [11] . In a non - randomized observational study, Califf and colleagues [12] demonstrated increased mortal- ity and cost associated with pulmonary artery catheterization, and suggested that a randomized trial aimed at better patient selection was needed. An subsequent randomized controlled trial (n = 201) of the pulmonary artery catheter in critically ill patients concluded that its use is not associated with increased mortality [13] . In response to concerns of increased morbidity and mortality associated with the pulmonary catheter in observational studies, the National Heart, Lung, and Blood Institute (NHLBI) and the US Food and Drug Administration (FDA) conducted the Pulmonary Artery Catheterization and Clinical Outcomes work- shop in 1997 to develop recommendations to improve pulmo- nary artery catheter utility and safety [14] . They concluded that a “ need exists for collaborative education of physicians and nurses in performing, obtaining, and interpreting information from the use of pulmonary artery catheters. This effort should be led by professional societies, in collaboration with federal agen- cies, with the purpose of developing and disseminating standard- ized educational programs. ” Areas given high priority for clinical trials were pulmonary artery catheter use in persistent/refractory congestive heart failure, acute respiratory distress syndrome, severe sepsis and septic shock, and low - risk coronary artery bypass graft surgery. Since this conference, several investigators have attempted to better defi ne benefi ts and risks of pulmonary artery catheteriza- tion both in general categories of critical illness, and in specifi c subsets of critically ill patients. Most studies that used broad and non - specifi c patient inclusion criteria (such as “ critically ill patients ” or “ high - risk surgical patients ” ) have, not surprisingly, generally detected neither benefi cial nor detrimental effects of pulmonary artery catheterization on mortality rates [15 – 17] and the use of pulmonary artery catheterization has decreased in the United States over the past decade [18] . On the other hand, studies directed at specifi c subsets of critically ill patients have proven much more informative. It would appear, for example, that such monitoring techniques are not typically associated with improved survival in patients with acute lung injury and acute respiratory distress syndrome [19,20] . On the other hand survival benefi t has been demonstrated in patients with severe trauma or illness, those admitted in severe shock and in older trauma patients [21,22] . Another study demonstrating lack of benefi t of pulmonary artery catheterization in patients with severe septic shock does not address the question of whether patients so managed before late or end - stage disease may benefi t from the information provided by these techniques [23] . Interpretation of such data is further compounded by the general lack of uniform, evidence - based management protocols for most patients in whom pulmonary artery catheters are utilized. No diagnostic testing modality can improve outcomes in any disease in the absence of effective therapy [15,24] . Thus, at present, the pulmo- nary artery catheter should be viewed neither as a panacea for all seriously ill patients, nor as a technique lacking diagnostic value Chapter 16 216 punctured at the junction of the two clavicular heads, and the needle is directed with constant aspiration toward the ipsilateral nipple at an angle approximately 30 ° superior to the plane of the skin. Free fl ow of venous blood confi rms the position of the internal jugular vein. Next, the needle is withdrawn and the vein once again entered with a 16 - gauge needle and syringe. Then a guidewire is placed through the needle and into the jugular vein. This placement is perhaps the most crucial part of the entire procedure, and it is vital that the guidewire passes freely without any resistance whatsoever. Free passage confi rms entrance into the vein. Next, the needle is removed with the guidewire left in place. The incision is widened with a scalpel, and the introducer sheath/ vein dilator apparatus is introduced over the guidewire. During introduction of the introducer sheath/vein dilator, it is crucial that the proximal tip of the guidewire be visible at all times, to avoid inadvertent loss of the guidewire into the central venous system. The introducer sheath/vein dilator apparatus is advanced with a slight turning motion along the guidewire. In general, the point of entry into the vein is felt clearly by a sudden decrease in resistance. The sheath apparatus then is advanced to the hilt. The conscious patient is instructed to hold her breath to prevent nega- tive intrathoracic pressure and air embolism, and the guidewire and trocar are quickly removed with the sheath left in place. Occasionally, portable real - time sonography may be helpful in guiding central venous cannulation [28,29] . Most current introducer systems contain an accessory port, which attaches to the proximal end of the introducer sheath and includes a one - way valve that prevents air introduction into the central venous system during removal of the guidewire and trocar. To keep the line open, the sheath then is infused with a crystalloid solution containing 1 unit of heparin per milliliter and secured in place with suture. Insertion of the c atheter Phase two involves the actual placement of the pulmonary artery catheter (Figure 16.1 ). Careful attention must be paid to main- taining sterile technique as the catheter is removed from the package. The distal and proximal ports are fl ushed to assure patency. The balloon then is tested with 1 mL of air. When the catheter has been attached to the physiologic monitor and the air in any patient. In a recent review article focusing on the use of this technique in pregnant patients, Fujitani and Baldisseri [25] concluded “ Invasive monitoring remains useful when the patho- physiology of critically ill obstetric patients cannot be explained by non - invasive monitoring, and the patient fails to respond to conservative medical management; invasive hemodynamic monitoring may be helpul to guide management. ” As emphasized by Harvey et al, future studies will need to be adequately powered and focus on specifi c patient subsets receiving targeted therapies in order to better defi ne the proper role of this technique in the management of critically ill patients [26] . This chapter provides an overview of placement techniques and complications; indications for the use of this diagnostic tool in the obstetric patient are examined in more detail in the ensuing chapters. Catheter p lacement The procedure for catheter placement involves two phases. The initial phase of pulmonary artery catheterization is establishing venous access with a large - bore sheath. Access is most commonly obtained via the internal jugular or subclavian veins; however, under certain circumstances (e.g. where access to the neck or thoracic region is diffi cult or in a patient with a coagulopathy where bleeding from a major artery could be hazardous), peri- pheral veins – including cephalic or femoral – can be used [27] . Insertion of the introducer sheath via the right internal jugular vein is described here. Insertion of the s heath To catheterize the internal jugular vein, the patient is placed supine in a mild Trendelenburg position with the head turned to the left. The landmark for insertion is the junction of the clavicu- lar and sternal heads of the sternocleidomastoid muscle. When this junction is indistinct, its identifi cation can be facilitated by having the patient raise her head slightly. When the landmark has been identifi ed, 1% lidocaine is infi ltrated into the skin and superfi cial subcutaneous tissue. The internal jugular vein is entered fi rst with a fi nder needle, consisting of a 21 - gauge needle on a 10 - mL syringe. The skin is RV-paceport lumen hub (facing infusion) PA distal lumen hub Proximal injectate hub Thermistor connector Balloon inflation valve RV port @ 19 cm Thermistor Balloon PA distal lumen Proximal injectate port @ 30 cm Edwards Figure 16.1 Pulmonary artery catheter. (Reproduced by permission from American Edwards Laboratories.) Pulmonary Artery Catheterization 217 the pulmonary vasculature where the balloon diameter exceeds that of the corresponding pulmonary arterial branch. At this point, a wedge tracing is observed. If the balloon is defl ated, the tracing should return to a pulmonary artery pattern. Following catheter placement, it is essential that healthcare personnel skilled in the interpretation of these waveforms con- tinuously monitor the waveforms for evidence of catheter migra- tion (spontaneous advancement), which may lead to pulmonary infarction. This may be manifest by the appearance of a spontane- ous “ wedge ” tracing at the distal port, rather than the pulmonary artery waveform, which should be continuously manifest on the display monitor. Alternately, the appearance of a pulmonary artery waveform in the central venous pressure port will alert the attendant to distal catheter migration and the need for adjust- ment [30] . Komadina et al. described disturbingly high interob- server variability in the interpretation of waveform tracings, although agreement on numerical wedge pressure readings was high [31] . In a similar manner, Iberti et al. reported a wide varia- tion in the understanding of pulmonary artery catheter wave- forms and techniques among critical care nurses using this device [32] . It would appear that graphic recording at end - expiration is the most reliable means of measuring hemodynamic pressures [33] . Clearly, continuous training and credentialing programs are essential for healthcare providers utilizing these techniques. Recently described digital output volumetric pulmonary artery catheters have been shown to reduce interoperator interpretation variability and to improve consistency of treatment decisions. [34] Normal ranges for hemodynamic parameters in term pregnancy have been described, and are useful in assessing and managing the pregnant woman requiring invasive monitoring techniques [35,36] . completely fl ushed from the system, minute movements in the catheter tip should produce corresponding oscillations on the monitor. The catheter tip is introduced through the sheath and advanced approximately 20 cm. At this point, the balloon is infl ated and the catheter advanced through the introducer sheath into the central venous system. Occasionally, portable real - time sonography may be helpful in guiding central venous cannulation [29] . Waveforms and c atheter p lacement Once within the superior vena cava, the balloon on the tip of the catheter will advance with the fl ow of blood into the heart. Characteristic waveforms and pressures are observed (Figure 16.2 ). Entrance into the right ventricle is signaled by a high spiking waveform with diastolic pressures near zero. This is the time of maximum potential complications during catheter place- ment, because most arrhythmias occur as the catheter tip impinges on the interventricular septum. For this reason, the catheter must be advanced rapidly through the right ventricle and into the pulmonary artery. If premature ventricular contractions occur during this process and the catheter does not advance promptly out of the right ventricle, the balloon should be defl ated and the catheter withdrawn to the right atrium. As soon as the catheter enters the pulmonary artery, the wave- form has two notable characteristics. First, and most important, is the rise in diastolic pressure from that seen in the right ven- tricle. Second, a notching of the peak systolic waveform often is seen and represents closure of the pulmonic valve. After entrance into the pulmonary artery has been confi rmed (in most pregnant women, this occurs between 40 and 45 cm of catheter length), the catheter is advanced farther until the tip reaches a point within 30 20 10 0 RA RV 30 20 10 0 R A PA PAO P Figure 16.2 Pulmonary artery catheter placement. Catheter tip position, corresponding waveforms, and normal pressure ranges are demonstrated. (Reproduced by permission from American Edwards Laboratories.) Chapter 16 218 access. Such events include pneumothorax and insertion site infection and occur in 1 – 5% of patients undergoing this proce- dure [50 – 52] . Potential complications of pulmonary artery cath- eterization per se include air embolism, thromboembolism, pulmonary infarction, catheter - related sepsis, direct trauma to the heart or pulmonary artery, postganglionic Horner ’ s syn- drome, and catheter entrapment [53 – 58] . Such complications occur in 1% or less of patients. More recently, a pressure release balloon has been described to limit overinfl ation and potentially reduce the risk of vessel rupture [59] . Arrhythmias, consisting of transient premature ventricular contractions, occur during catheter insertion in 30 – 50% of patients and are generally of no clinical consequence. The remaining complications can be minimized or eliminated by careful attention to proper insertion maintenance and removal techniques [37] ). In patients with right - to - left shunts, the use of this catheter is hazardous; when its placement is deemed manda- tory, the use of carbon dioxide instead of air for balloon infl ation may minimize the risk of systemic air embolism [60] . A Food and Drug Administration task force has summarized recommenda- tions regarding methods to minimize complications of central venous catheterization procedures [61] . A recent study suggested that with proper attention to aseptic technique of placement and catheter maintainance, a pulmonary artery catheter may be left in place for up to 7 days before replacement becomes mandatory [62] . Numerous studies have documented the frequent discrepancy between measurements of pulmonary capillary wedge pressure and central venous pressure during pregnancy [4,63 – 65] . In such circumstances, clinical use of the central venous pressure would be misleading. Both techniques entail the risks of obtaining central venous access, the principal source of complication for either procedure. For these reasons, in a modern perinatal inten- sive care unit, central venous monitoring is uncommonly utilized. Where proper equipment and personnel exist, the vast amount of additional information obtainable by pulmonary artery catheterization often outweighs the slight potential increase in risk attributable to catheter placement itself. When the hemo- dynamic status of the critically ill pregnant woman is unclear, pulmonary artery catheterization is nearly always preferable. Non - i nvasive t echniques Despite the small risks associated with properly managed pulmo- nary artery catheterization, the search continues for non - invasive methods of central hemodynamic assessment of the critically ill patient. Such techniques generally focus on sonographic or bio- impedance techniques to estimate cardiac output, and have been described in both pregnant and non - pregnant patients [66 – 70] . In addition, investigation continues into techniques to allow non - invasive central pressure determination [71] . These techniques appear to be useful in a research setting or in patients requiring only a single evaluation of hemodynamics in order to classify Caution also is advised during pulmonary artery catheter removal; techniques to avoid complications have been described [37] . Cardiac o utput d etermination Once in place, cardiac output is obtained with the use of a cardiac output computer connected to a terminal on the pulmonary artery catheter. This instrument derives cardiac output from thermodi- lution curves created by the injection of cold or room - temperature saline into the proximal central venous port of the catheter. The resultant fl ow - related temperature changes detected at the distal thermistor are converted into cardiac output by the computer and correlate well in pregnant women with those obtained by the more precise, but clinically cumbersome, oxygen extraction (Fick) tech- nique [35] . Nevertheless, it should be emphasized that cardiac output determinations are of most value in following trends in individual patients; caution is advised in relying on absolute cardiac output values, and sound clinical judgment is essential in data interpretation [38] . One study suggests that the thermodilu- tion technique may overestimate cardiac output, especially with very low values [39] . In addition, meticulous attention must be paid to technique if reliable information regarding cardiac output is to be obtained. The exact injectate temperature must be known, the proximal injectate port must have advanced beyond the intro- ducer sheath, and the introducer sheath sidearm must be closed [40] . If the central venous port line becomes non - functional, room - temperature thermodilution cardiac outputs can be used with saline injection into the sideport, with the understanding that a slight overestimation of cardiac output will occur [41] . Additional issues that affect the validity of cardiac output measurements include the rate of injection, the timing of injection during the respiratory cycle, the position of the patient, and the presence of other, concurrent infusions [42] . More recently, techniques have been evaluated for continuous cardiac output measurement, both by thermodilution and with the use of a special fl ow - directed Doppler pulmonary artery catheter [43,44] . Penny et al. [45] demonstrated that esophageal Doppler monitoring consistently underestimates cardiac output in patients with pre - eclampsia by approximately 40%, compared to direct measurements with pulmonary artery catheters. With appropriate modifi cation of technique, right ventricular ejection fraction measurements also may be obtained with the pulmonary artery catheter [46,47] . Specially designed fi beroptic catheters allow continuous assessment of mixed venous oxygen saturation in critically ill patients. Newer techniques for continu- ous thermodilution measurement compare well with conven- tional methods [48,49] . Complications Most complications encountered in patients undergoing pulmo- nary artery catheterization are a result of obtaining central venous . anticardiolipin - negative systemic lupus erythematosus . Am Heart J 1993 ; 125 ( 4 ): 1 123 – 1129 . 215 Critical Care Obstetrics, 5th edition. Edited by M. Belfort, G. Saade, M. Foley, J. Phelan and. general categories of critical illness, and in specifi c subsets of critically ill patients. Most studies that used broad and non - specifi c patient inclusion criteria (such as “ critically ill patients. ventricular function in peripartum car- diomyopathy . Am Heart J 1991 ; 121 ( 6 Pt 1 ): 1776 – 1778 . 19 Demakis JG , Rahimtoola SH , Sutton GC et al. Natural course of peripartum cardiomyopathy