HEMODYNAMIC MONITORING
DEFINITION
Measuring and
monitoring the
factors that
influence the
force and flow
of blood.
PURPOSE
To aid in diagnosing, monitoring and
managing critically ill patients.
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To diagnose shock states
To determine fluid volume status
To measure cardiac output
To monitor and manage unstable patients
To assess hemodynamic response to therapies
To diagnose primary pulmonary hypertension,
valvular disease, intracardiac shunts, cardiac
tamponade, and pulmonary embolus
Tricuspid or pulmonary valve mechanical prosthesis
Right heart mass (thrombus and/or tumor)
Tricuspid or pulmonary valve endocarditis
Management of complicated MI
Assessment of respiratory distress
Severe LVF/RMI (precise management of heart failure)
Cardiogenic vs non-cardiogenic pulmonary edema
Assessment/Diagnosis of shock/ cardiac dysfunction
Cardiogenic/hypovolemic/septic
Tamponade
Pulmonary embolism
Severe dilated cardiomyopathy
Management of Pulmonary Hypertension
Management of high-risk surgical patients
CABG, vascular, valvular, aneurysm repair
Management of volume requirements in the critically ill
ARF, GI bleed, trauma, sepsis (precise management)
CO / CI
SV / SVI or SI
SVO2
RVEDVI or EDVI
SVR / SVRI
PVR / PVRI
RVEF
VO2 / VO2I
DO2 / DO2I
PAOP
CVP
PAP
Cardiac Output/Cardiac Index
Stroke Volume/Stroke Volume Index
Mixed Venous Saturation
RV End-Diastolic Volume
Systemic Vascular Resistance
Pulmonary Vascular Resistance
RV Ejection Fraction
Oxygen Consumption
Oxygen Delivery
Pulmonary Artery Occlusive Pressure
Central Venous Pressure
Pulmonary Artery Pressure
Values normalized for body size (BSA)
CI is 2.5 4.5 L/min/m2
SVRI is 1970 2390 dynes/sec/cm5/m2
SVI or SI is 35 60 mL/beat/m2
EDVI is 60 100 mL/m2
Mr. Smith
47
y/o male
60 kg
CO = 4.5
6 ft tall (72 inches)
BSA = 1.8
CI = 2.5 L/min/m2
Mr. Jones
47
y/o male
120 kg
CO = 4.5
6 ft tall (72 inches)
BSA = 2.4
CI = 1.9 L/min/m2
Cardiac Output - amount of blood pumped out
of the ventricles each minute
Stroke Volume - amount of blood ejected by
the ventricle with each contraction
CO = HR x SV
Decreased SV usually produces compensatory
tachycardia..
So. . .changes in HR can signal changes in CO
Systemic Vascular Resistance
Measurement
of the resistance (afterload) of blood
flow through systemic vasculature
*Increased SVR/narrowing PP = vasoconstriction
*Decreased SVR/widening PP = vasodilation
Blood Pressure
BP = CO x SVR
** SVR can increase to maintain BP despite
inadequate CO
Remember CO = HR x SV
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BP = CO x SVR
CO and SVR are inversely related
CO and SVR will change before BP changes
* Changes in BP are a late sign of hemodynamic
alterations
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Stroke Volume
Components Stroke Volume
Preload: the volume of blood in the
ventricles at end diastole and the
stretch placed on the muscle fibers
Afterload: the resistance the ventricles
must overcome to eject its volume of
blood
Contractility: the force with which the
heart muscle contracts (myocardial
compliance)
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Stroke Volume
Preload
Afterload
Contractilit
y
Filling Pressures
& Volumes
CVP
PAOP (PAD may
be used to
estimate PAOP)
Resistance to
Outflow
PVR, MPAP
SVR, MAP
Strength of
Contraction
RVSV
LVSV
Fluids, Volume
Expanders
Diuretics
Vasoconstrictor
s
Vasodilators
Inotropic
Medications
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Right Side: CVP/RAP * filling pressures
Left Side: PAOP/LAP
PAD may be used to estimate PAOP in the
absence of pulmonary disease/HTN
The pulmonary vasculature is a low pressure
system in the absence of pulmonary disease
These pressures are accurate estimations of
preload only with perfect compliance of heart
and lungs
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RV Afterload
MPAP
PVR
= 150-250 dynes/sec/cm-5
PVRI = 255-285 dynes/sec/cm-5/m2
LV Afterload
MAP
SVR
= 8001300 dynes/sec/cm-5
SVRI = 1970-2390 dynes/sec/cm-5/m2
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Cardiac Output
* flow
Normal = 4-8 L/min
Cardiac Index
Normal = 2.5-4.5 L/min/m2
Stroke Volume
Stroke volume Index
*pump performance
Normal = 50-100 ml/beat
Normal = 30-50 ml/beat/m2
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Ability of the ventricle to stretch
Decreased with LV hypertrophy, MI, fibrosis,
HOCM
*If compliance is decreased, small changes in
volume produce large changes in
pressure
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Large Markers = 50cm
Small Markers = 10cm
10 cm between small black markers on
catheter
Several types
Thermodilutional
CCO
Precep
NICCO
CO
Multiple lumens
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Bleeding
Infection
Dysrhythmias
Pulmonary Artery Rupture
Pneumothorax
Hemothorax
Valvular Damage
Embolization
Balloon Rupture
Catheter Migration
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Right
Atrium
Pulmonary
Pulmonary
Right
Artery
Ventricle Artery
Occlusion
Pressure
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Assess ECG for dysrhythmias.
Assess for signs and symptoms of respiratory distress.
Ascertain sterile dressing is in place.
Obtain PCXR to check placement.
Zero and level transducer(s) at the phlebostatic axis.
Assess quality of waveforms (i.e., proper configuration, dampening,
catheter whip).
Obtain opening pressures and wave form tracings for each waveform.
Assess length at insertion site.
Ensure that all open ends of stopcocks are covered with sterile deadend caps (red dead-end caps, injection caps, or male Luer lock caps).
Update physician of abnormalities.
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Measure all pressures at End-Expiration
Patient Peak
Vent Valley
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4th ICS Mid-chest, regardless of head elevation
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4th ICS Mid-chest, regardless of head elevation
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Measure all pressures at end-expiration
At top curve with spontaneous respiration
patient-peak
Intrathoracic pressure decreases during
spontaneous inspiration
Negative deflection on waveforms
Intrathoracic pressure increases during
spontaneous expiration
Positive deflection on waveforms
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Measure all pressures at end-expiration
At bottom curve with mechanical ventilator
vent-valley
Intrathoracic pressure increases during positive
pressure ventilations (inspiration)
Positive deflection on waveforms
Intrathoracic pressure decreases during
positive pressure expiration
Negative deflection on waveforms
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Measure all pressures with the HOB at a
consistent level of elevation
Level the transducer at the phlebostatic axis
4th intercostal space, mid-chest
Print strips with one ECG and one pressure channel
adequate
scale
allows accurate waveform analysis
Confirm monitor pressures with pressures obtained
by waveform analysis
**
correct waveform analysis is more accurate than pressures from
the monitor
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RAP (CVP)
0-8 mmHg
RVP
PAP
15-30/0-8
mmHg
PAOP
15-30/6-12
mmHg
8 - 12 mmHg
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A=
B=
C=
D=
RA (CVP) Waveform
RV Waveform
PA Waveform
PAWP Waveform
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Normal Value 0-8 mmHg
RAP = CVP
Wave Fluctuations Due To
Contractions
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a-wave
atrial
contraction (systole)
begins in the PR interval and QRS on the ECG
correct location for measurement of CVP/RAP
* average the peak & trough of the a-wave
* (a-Peak + a-trough)/2 = CVP
May
not see if no atrial contractions as with. . .
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Absent a waves
Atrial
fibrillation
Paced
rhythm
Junctional
rhythm
Measure at the end of the QRS
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* Measure at end of QRS!
*PACEP.ORG 2007
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c-wave
tricuspid
valve closure
Between ST segment
Between a and v waves
*may or may not be present
v-wave
Atrial
filling
begins at the end of the QRS to the beginning of the T
wave (QT interval)
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Reading the RA CVP) Waveform
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Vented Patient
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a wave
Vented Patient Vent Valley
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Normal Value 15-25/0-8 mmHg
Catheter In RV May Cause Ectopy
Swan Tip May Drift From PA to RV
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Usually only seen with insertion
Systole
measured at the peak
peak occurs after the QRS
Diastole
measured
just prior to the the onset of systole
No dicrotic notch
Dicrotic notch indicates valve closure
*** Aids in differentiation from the PA tracing
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After PA catheter is correctly placed, RV
waveform should not be seen. If it is, then
interventions are necessary:
Check
for specific unit protocol first
Inflate balloon with patient lying on their left side
(catheter may float back into PA)
With deflated balloon, pull catheter into RA
placement or remove completely
Document your actions and notify physician
** An RN should NEVER advance the
catheter!
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Normal Value 15-25/8-15 mmHg
Dicrotic Notch Represents PV Closure
PAD Approximates PAWP (LVEDP)
(in absence of58 lung or MV
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Systole
measured
at the peak of the wave
Diastole
measured
just prior to the upstroke of systole (end of
QRS)
Higher
than RV diastolic pressure
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Dicrotic notch
indicates
pulmonic valve closure
aids in differentiation from RV waveform
aids in determining waveform quality
Anachrotic Notch
Before
upsweep to systole
Opening of pulmonic valve
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Dicrotic notch
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10/20/30
Identify that it is the PA tracing
Look at the scale
What is the PAP?
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Look for dichrotic notch
Look at scale
What is the PAP?
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Normal Value 8-12 mmHg
Balloon Floats and Wedges in Pulmonary
Artery
PAWP = LAP = LVEDP
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a-wave
atrial
contraction
correct
location for measurement of PAOP
average the peak & trough of the a-wave
begins
near the end of QRS or the QT
segment
* Delayed ECG correlation from CVP since PA
catheter is further away from left atrium
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c-wave
rarely
present
represents mitral valve closure
v-wave
represents
left atrial filling
begins at about the end of the T wave
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Begins within
the QRS or the
QT segment
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Wedging Can Cause
Pulmonary Artery Rupture
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Assess ECG for dysrythmias
Assess for S/S of respiratory distress
Be sure sterile dressing is applied
Order CXR for placement
Get MD order before infusing through ports
Zero and level all transducers
Assess quality of waveforms
Dampening, proper configuration, scale
Obtain opening pressures and waveform tracings for each
waveform
Note length at insertion site
Place proper luer-lock connectors to lumens and cap all ports
Notify MD of any abnormalities
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Always set alarms on monitor
20mmHg
above and below pt baseline
If in PAOP with balloon down, have pt cough,
deep breath, change position
If unable to dislodge from PAOP, notify MD
immediately to reposition catheter
CXR
to reconfirm placement
If pt coughs up blood or it is suctioned via ETT,
suspect PA rupture and notify MD immediately
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Based on measuring blood temperature changes
Must know the following:
Computation
Volume
of injectate
Temperature
constant
of injectate
Iced or room temperature
Inject rapidly and smoothly over 4 seconds max
Thermister at end of PA catheter detects change
in temperature and creates CO curve
At least 3 measurements and average results
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*PACEP.ORG 2007
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*PACEP.ORG 2007
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A heat signal is produced by the thermal
filament of the PA catheter
The signal is detected by the thermistor on the
PA catheter and is converted into a
time/temperature curve
The CCO computer produces a time-averaged
calculation
Over
3 minutes
Updates
every 30-60 seconds
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Mixed Venous Oxygen Saturation
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Measures the amount of O2 in the blood (on the Hgb
molecule) returned to the heart
Helps to demonstrate the balance between O2
supply & demand in the body (tissue oxygenation)
Helps to interpret hemodynamic dysfunction when
used with other measurements
Normal: 70% (60-80)
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Mixed Venous Oxygen Saturation
End result of O2 delivery and
consumption
Measured in the pulmonary artery
An average estimate of venous
saturation for the whole body.
**Does not reflect separate tissue
perfusion or oxygenation
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Mixed Venous Oxygen Saturation
Continuous measurement
Early warning signal to detect
oxygen transport imbalances
Evaluates the effect of the
therapeutic interventions
Identify potential patient care
consequences (turning, suctioning)
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There are four factors that affect SVO2:
1. Hemoglobin
2. Cardiac output
3. Arterial oxygen saturation (SaO2)
4. Oxygen consumption (VO2)
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SvO2 Application
In a case of increased SVR with decreased CO. Nitroprusside was
started. The increase in SvO2 and increase in CO reflects the
appropriateness of therapy.
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Ways To Increase O2 Delivery
Increase CO
increase HR, optimize preload, decrease
afterload, add positive inotropes
Increase Hgb, increase SaO2
Improve pulmonary function
pulmonary toilet, prevent atelectasis
ventilation strategies
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Ways To Decrease O2 Demand
Decrease muscle activity
sedatives, (paralytics)
prevent/control seizures
prevent/control shivering
space care activities
Decrease temperature
prevent/control fever
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Usually performed by the nurse with
an MD order
Place patient supine with HOB flat
(reduces chance of air embolus)
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Make sure balloon is down, have
patient inhale and hold breath, pull
PA catheter out smoothly
monitor
for ventricular ectopy
stop immediately & notify MD if resistance is met
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If patient is unable to perform breath
hold:
Pull
PA catheter during period of positive intrathoracic
pressure to minimize chance of venous air embolus
Mechanically
ventilated patient
pull PA catheter during delivery of vent breath
Spontaneously
pull
breathing patient
PA catheter during exhalation
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If introducer sheath (cordis) is to remain in
place, it must be capped.
If introducer sheath (cordis) is to be removed,
repeat the steps used for PA catheter removal.
Hold pressure on the site (5-10 min.), keep
patient flat until hemostasis is achieved.
Apply sterile dressing or band-aid.
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The PA diastolic pressure is
measured at which part of the
waveform?
Just prior to the
upstroke of systole
108
Which part of the CVP and
PAOP waveforms is used to
calculate pressures?
The a wave
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The RV waveform can be
distinguished from the PA
waveform by:
RV has lower
diastolic pressure
and no dicrotic notch
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The v wave of the CVP & PAOP
waveforms represents:
Atrial filling
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The a wave of the CVP
waveform correlates with
which electrical event?
The PR interval on the ECG
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The a wave of the PAOP
waveform correlates with which
electrical event?
The QRS on the ECG
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