Transcript Hemodynamic Monitoring for the Respiratory Therapist

Hemodynamic
Monitoring
for the
Respiratory Therapist
Jane Reynolds, MS, RN, RRT
Definition of terms
Preload – amount of blood in the ventricle
before contraction – End diastolic volume
– EDV determines the amount of ‘stretch’ that is
placed on the myocardial muscle
– That ‘stretch’ determines the strength of the
next contraction
– The strength of the contraction determines how
much blood is pumped out of the ventricle
during the next systole ‘stroke volume’
– The stroke volume determines the blood
pressure and perfusing pressures
Definition of terms
Afterload - resistance to blood flow from
the ventricle; work that must be done to
pump blood from the ventricle to the
circulation
Resistance determined by size of valve
opening, blood viscosity and blood
pressure in pulmonary or systemic
circulation
Work – is the oxygen consumed by the
myocardium to overcome the resistance to
flow
C
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Normal Circulatory Pressures
1. Preload to RV
2. Afterload to RV
5
3
3. Preload to LV
4. Preload to LV
2
1
3
5. Afterload to LV
Circulation
Alveolar
Capillary
Membrane
Normal Alveolar Capillary Membrane
Begin Pulmonary Edema
Interstitial Edema
Pulmonary Edema - Late
Pulmonary Artery Catheter
Pulmonary Artery Catheter
Arterial Blood Gas Interpretation
1%
HBO2
Saturation
PO2
99%
Oxygenation
Saturation
PO2
27 mmHg
50%
40 mmHg
75%
60 mmHg
90%
95 mmHg
97%
150 mmHg
100%
Oxyhemoglobin Dissociation Curve
Case Study 1
An 18 year old white male was brought to the
ED by CFD after being rescued from his car
following a high speed collision with a parked
truck. He is conscious, c/o of chest pain and
is anxious. He was wearing his seat belt but
still hit his chest on the steering wheel. His
vital signs are: T 37, P 113, RR 23, B/P 100/
70. CT scan of chest was unremarkable and
he was brought to SICU for observation. He
continued to have fluctuations in his blood
pressure. A pulmonary artery catheter was
placed.
Case Study 1
Area
CVP
Normal
0 to 8
8 am
10
10:30
4
11:00
8
PAP
10 to 22
28
6
22
PWP
5 to 12
15
7
10
MAP
70 to 105
85
40
70
CO
4 to 8 LPM
5.9
2.5
5.7
HR
60 to 100
110
160
95
pH
7.35 to 45
7.37
7.22
7.39
PCO2
35 to 45
45
52
41
PaO2
80 to 100
65
50
88
PvO2
39 to 42
39
21
38
Cardiac Tamponade
Case Study 2
A 72 year old white female was admitted to
the MICU with an exacerbation of COPD.
She has emphysema and chronic
bronchitis and a 40 pack year history of
cigarette smoking. Breath sounds are
bilaterally diminished, crackles and
rhonchi.
She has JVD and pedal edema. A
pulmonary artery catheter was placed as
she had sustained hypotension and SOB.
Her VS are: T 37, P118, RR 32, B/P
150/90, FiO2 .28, HB 22 Gm%.
Case Study 2
Normal
Noon
1600
1800
CVP
0 to 8
25
20
18
PAP
10 to 22
50
35
32
PWP
5 to 12
15
12
10
MAP
70 to 105
60
72
75
CO
4 to 8 LPM
3.9
4.5
4.7
HR
60 to 100
110
90
88
pH
7.35 to 45
7.35
7.39
7.38
PCO2
35 to 45
69
55
51
PaO2
80 to 100
46
85
78
PvO2
39 to 42
35
38
39
Case Study 3
A 25 year Hispanic male was admitted to
the SICU after a thoracotomy for repair of
his aorta following a gun shot wound to his
chest. He has bilateral chest tubes. He is
intubated and receiving full ventilatory
support. His chest tube drainage for the
last hour was 400 ml. He has bloody
sputum and urine. His last CaO2 was
10.4 volumes% with a PaO2 of 110 and
saturation of 95%. VS T 36, P148, RR 14,
B/P 65/44.
Case Study 3
Normal
3 am
5:30
11:00
CVP
0 to 8
2
4
8
PAP
10 to 22
10
8
15
PWP
5 to 12
6
5
10
MAP
70 to 105
48
40
60
CO
4 to 8 LPM
2.94
3.5
5.7
HR
60 to 100
150
160
140
pH
7.35 to 45
7.22
7.20
7.32
PCO2
35 to 45
55
55
49
PaO2
80 to 100
110
94
110
PvO2
39 to 42
29
27
39
Case Study 4
A 52 year old white male with shortness of breath and
chest pain was admitted to the ED. ECG showed ST
elevation in 4 leads and his cardiac enzymes were
markedly elevated. His vital signs were stable, SpO2
on NC at 2 LPM was 95%. He was taken to the
cardiac cath lab and a diagnostic cardiac angiogram
revealed 99% occlusion of his LAD. A coronary stent
was placed and 15 minutes post intervention he began
complaining again of severe SOB and chest pain. He
was taken back to the cath lab. A pulmonary artery
catheter was placed. A left heart catheterization
revealed progression of the MI. His LVEDP is 32 and
an intra aortic balloon was placed and counter
pulsation started at 1:1.
Case Study 4
Normal
9 am
10:30
1600
CVP
0 to 8
10
8
PAP
10 to 22
28
20
PWP
5 to 12
35
15
MAP
70 to 105
72
47
65
CO
4 to 8 LPM
4.9
2.5
4.4
HR
60 to 100
110
80
65
pH
7.35 to 45
7.39
7.26
7.32
PCO2
35 to 45
40
50
38
PaO2
80 to 100
65
48
75
PvO2
39 to 42
28
36
Intra Aortic Balloon Counter Pulsation
Case Study 5
A 55 year old AA male was admitted to the
MICU with acute SOB, cough, HTN and
hypoxemia. He is oliguric and has required
hemodialysis for the past 2 years. He is
depressed and has not been following his
dietary and fluid restrictions and has
skipped his last 2 dialysis appointments.
His VS are now T 37, P118, RR 35, B/P
200/135. He is receiving oxygen via venturi
mask, FiO2 50%. He has a pulmonary
artery catheter in place to monitor his
cardiac status.
Case Study 5
Normal
8 am
10:30
11:00
CVP
0 to 8
25
19
12
PAP
10 to 22
40
32
28
PWP
5 to 12
22
18
15
MAP
70 to 105
150
110
100
CO
4 to 8 LPM
3.4
4.1
5.7
HR
60 to 100
110
95
86
pH
7.35 to 45
7.32
7.39
PCO2
35 to 45
49
38
PaO2
80 to 100
60
79
PvO2
39 to 42
34
38
Case Study 6
A 36 year old female was admitted to the ED with a
CC of SOB and chest pain. She has no
significant PMH, she does not smoke. She says
that she hurt her ankle about two weeks ago and
never went to the doctor about it. It is very
painful and she has been almost immobilized for
the past two weeks because it is just too painful
to walk on. She has a cough and says her SOB
came on rather suddenly after she went down to
her basement to put some clothes in the laundry
this morning. She is tachypneic, her MV is 12
LPM.
Case Study 6
Normal
5 am
24 hours later
CVP
0 to 8
25
12
PAP
10 to 22
40
29
PWP
5 to 12
10
9
MAP
70 to 105
65
75
CO
4 to 8 LPM
6.4
5.1
HR
60 to 100
110
84
pH
7.35 to 45
7.36
7.39
PCO2
35 to 45
45
38
PaO2
80 to 100
65
85
PvO2
39 to 42
38
41
Saddle Pulmonary Embolism
Questions??
Thank you!
You were great!!
Thoraco-abdominal
Pump Mechanism
Small Vessels
Venous return
Oxygen carried in the blood
Chest x-ray of ARDS
Normal Chest x-ray
CT Scan of ARDS
Left-Sided Heart Failure
Pulmonary congestion occurs
when left ventricle cannot pump
well
Dyspnea upon exertion,
orthopnea, and paroxysmal
nocturnal dyspnea
Oliguria
Right-Sided Heart Failure
Congestion of viscera and peripheral
tissues when right ventricle fails
Jugular vein distention
Dependent edema
Hepatomegaly
Ascites
Weakness, anorexia, and nausea
Weight gain
Sphincters Open
Sphincters Closed
Path
of
Blood
Major Blood Vessels