Transcript Slide 1

Understanding Adult
Hemodynamics
Theory, Monitoring,
Waveforms and
Medications
Vicki Clavir RN
Purpose
 The
primary purpose of invasive
hemodynamic monitoring is the early
detection, identification, and treatment of
life-threatening conditions such as heart
failure and cardiac tamponade. By using
invasive hemodynamic monitoring the
nurse is able to evaluate the patient's
immediate response to treatment such as
drugs and mechanical support. The nurse
can evaluate the effectiveness of
cardiovascular function such as cardiac
output, and cardiac index.
Objectives
Understands basic cardiac anatomy
Verbalizes determinates of Cardiac Output and their
relationships to each other
List indications for hemodynamic monitoring
Demonstrates monitor system and set up
Describe pharmacologic strategies that manipulate
the determinates of cardiac output
Indications for Hemodynamic
Monitoring:
One of the obvious indications for
hemodynamic monitoring is decreased
cardiac output. This could be from
dehydration, hemorrhage, G. I. bleed,
Burns, or surgery. All types of shock,
septic, cardiogenic, neurogenic, or
anaphylactic may require invasive
hemodynamic monitoring. Any deficit or
loss of cardiac function: such as acute
MI, cardiomyopathy and congestive
heart failure may require invasive
hemodynamic monitoring.
Coronary Arteries
Left Main
RCARA, RV&LV Inf,
Inf Septum
SA node 65%
AV node 80%
PDA 80-90%
CXLA,LV (side/back)
SA node 40%
AV node 20%
LAD –
LV (front/bottom)
Septum
Bundle branches
Cardiac Cycle
Diastole Phase
Early Diastole
Ventricles relax.
Semilunar valves close.
Atrioventricular valves
open.
Ventricles fill with blood.
Mid Diastole
Atria and Ventricles are
relaxed.
Semilunar valves are
closed.
Atrioventricular valves
are open.
Ventricles continue to fill
with blood.
Late Diastole
SA node contracts.
Atria contract.
Ventricles fill with more
blood.
Contraction reaches AV
node.
Cardiac Cycle
Systole Phase
Systole
Contraction
passes from AV
node to
Purkinje fibers
and ventricular
cells.
Ventricles
contract.
Atrioventricular
valves close.
Semilunar
valves open.
Blood is
pumped from
the ventricles
to the arteries.
Cardiac Cycle
Electrical Conduction system
SA node 
Atrial muscle
Internodal fibers
AV node 
AV bundle 
right and left
bundle branches
Ventricular muscle
Autonomic Nervous System
 The
autonomic nervous system
stimulates the heart through a
balance of sympathetic nervous
system and parasympathetic nervous
system innervations.
– The sympathetic nervous system plays
a role in speeding up impulse formation,
thus increasing the heart rate
– The parasympathetic nervous system
slows the heart rate.
The Cardiac Cycle
The Cardiac Cycle
•
Coronary Arteries Fill
The Cardiac Cycle
The Cardiac Cycle
Normal CO 4-8 liters
Normal Cardiac Index is 2.5 to 4.5 liters
Heart Rate
Works with Stroke Volume
Compensatory
Tachycardia
Bradycardia
Dysrhythmias
Factors Causing Low Cardiac
Output

Inadequate Left
Ventricular Filling
– Tachycardia
– Rhythm disturbance
– Hypovolemia
– Mitral or tricuspid
stenosis
– Pulmonic stenosis
– Constrictive
pericarditis or
tamponade
– Restrictive
cardiomyopathy

Inadequate Left
Ventricular Ejection
– Coronary artery
disease causing LV
ischemia or
infarction
– Myocarditis,
cardiomyopathy
– Hypertension
– Aortic stenosis
– Mitral regurgitation
– Drugs that are
negative inotropes
– Metabolic disorders
Hemodynamic terms
Preload-
Stretch of ventricular
wall. Usually related to
volume. (how full is the tank?)
– Frank Starling’s Law
Hemodynamic terms

Increased preload seen in
– Increased circulating volume (too much
volume)
– Mitral insufficiency
– Aortic insufficiency
– Heart Failure
– Vasoconstrictor use- (dopamine)

Decreased Preload seen in
– Decreased circulating volume (bleeding,3rd
spacing)
– Mitral stenosis
– Vasodilator use ( NTG)
– Asynchrony of atria and ventricles
Increased Preload
Decreased preload
Normal Value - 2-8 mm Hg
Or LVEDP
PAOP = 8-12 mm Hg
PAD = 10-15 mm Hg
Hemodynamic terms
 Contractility-
– How well does the ventricular walls
move? How good is the pump?
–  Decreased due to
Drugs – certain drugs will decrease
contractility
–Lido, Barbiturates, CCB, Betablockers
Infarction, Cardiomyopathy
Vagal stimulation
Hypoxia
Hemodynamic terms
 Contractility-
–  Increased
Positive inotropic drugs
–Dobutamine, Digoxin, Epinephrine
Sympathetic stimulation
–Fear, anxiety
Hypercalcemia ( high calcium)
CONTRACTILITY PRECAUTIONS
 Do
Not use Inotropes until
volume deficiency is corrected
 Correct
Hypoxemia and
electrolyte imbalance.
Hemodynamic terms
 Afterload
– resistance the blood in the
ventricle must overcome to
force the valves open and eject
contents to circulation.
X
Y
Hemodynamic terms
 Factors
that increase afterload are
– Systemic resistance or High Blood
pressure
– Aortic stenosis
– Myocardial Infarcts /
Cardiomyopathy
– Polycythemia – Increased blood
viscosity
Hemodynamic terms
 Factors
–
–
–
–
that  decrease Afterload
Decreased volume
Septic shock- warm phase
End stage cirrhosis
Vasodilators
Normal PVR is 120 to 200 dynes
Normal SVR - 800-1200 dynes
Mean Arterial Pressure
MAP is considered to be the perfusion
pressure seen by organs in the body.
 It is believed that a MAP of greater than
60 mmHg is enough to sustain the
organs of the average person under most
conditions.
 If the MAP falls significantly below this
number for an appreciable time, the end
organ will not get enough blood flow, and
will become ischemic.
 Calculated MAP = 2x diastolic + systolic
3

EKG
1.PRELOADvenous blood
return to the heart
Controlled by;
♥.Blood Volume
 PRBC’s
Albumin
Normal Saline
 Diureticslasix,bumex
Thiazides
 Ace inhibitors
♥. Venous Dilation
 Nitroglycerine
 Ca+ channel
blockers
clonidine
(Catapress)
methyldopa
trimethaphan
(arfonad)
↓ Dobutamine

Morphine
Drugs of Hemodynamics
2. CONTRACTILITYforcefulness of contractility
Ca+ channel blockers
Digoxin
Dopamine/Dobutamine
Milrinone/amrinone
3.AFTERLOAD – work
required to open
aortic valve and
eject blood –
resistance to flow
in arteries
° Dopamine (at
higher doses)
 Ace inhibitors
 Nipride/lesser
extent Nitro
 Calcium channel
blockers
 Labetalol
4. HEART RATE –
1. Beta blockers
2. Calcium
channel
blockers
3.  Atropine
4.  Dopamine
5.  Dobutamine
O2
O2
O2
•
Factors that make up SVO2 are
• Cardiac output
• SaO2
• VO 2 (oxygen consumption)
• Hemoglobin
Causative Factors

O2 Delivery
 Hb concentration
Oxygen saturation
(SaO2)
Clinical Conditions
- Anemia
- Hemorrhage
- Hypoxemia
-
 Cardiac Output
Lung disease
Low FIO2
- LV dysfunction (cardiac
disease, drugs)
- Shock – cardiac/septic (late)
-
 Oxygen consumption
Hypovolemia
Cardiac Dysrhythmias
Fever, infection
- Seizures, agitation
- Shivering
-  Work of Breathing
- Suctioning, bathing,
repositioning
-
Increased SVO2
 Most
common cause is - Sepsis
Or
 Wedged
PA catheter
 Functions

of PA Catheter
Allows for continuous bedside monitoring of the
following
– Vascular tone, myocardial contractility, and
fluid balance can be correctly assessed and
managed.
– Measures Pulmonary Artery Pressures, CVP, and
allows for hemodynamic calculated values.
– Measures Cardiac Output. (Thermodilution)
– SvO2 monitoring (Fiber optic).
– Transvenous pacing.
– Fluid administration.
PA Catheter
RED
KEEP
COVERED
KEEP LOCKED
BLUE
Clear
YELLOW
Markings on catheter.
1. Each thin line= 10 cm.
2. Each thick line= 50 cm.
Description of PA Catheter
Ports/lumens.
CVP Proximal (pressure line - injectate port
PA
for CO)-BLUE
Distal (Pressure line hook up)- Yellow
Extra port - usually- Clear
Thermistor – Red Cap
Continuous Cardiac Output and
SVO2 monitoring
Indications for PA catheter
 The
pulmonary artery catheter is indicated
in patients whose cardiopulmonary
pressures, flows, and circulating volume
require precise, intensive management.
MI
– cardiogenic shock - CHF
Shock - all types
Valvular dysfunction
Preoperative, Intraoperative, and Postoperative
Monitoring
ARDS, Burns, Trauma, Renal Failure
PRESSURE TRANSDUCER
SYSTEMS SET UP
500 ml Premixed Heparinized bag of NS
PHLEBOSTATIC REFERENCE
POINT
Angles 45°
30°
0°
♥ Re-level the transducer
with any change in the
patient’s position
♥Referencing the system 1
cm above the left atrium
decreases the pressure by
0.73 mm Hg
♥Referencing the system 1
cm below the left atrium
increases  the pressure by
0.73 mm Hg
Remove cap and
keep sterile
Turn stopcock
towards
pressure bag
Zero monitor
Replace cap
SQUARE WAVE TEST
- Determines the
ability of the
transducer to
correctly
reflect
pressures.
- Perform at the
beginning of
each shift
A
B
C
Thermodilution Cardiac
Outputs



Cardiac Outputs reading should be within .5 of
each other for averaging purposes.
Except in patients with atrial fibrillation- just
average 3 to 4 readings. (due to loss of atrial
kick output changes from minute to minute)
Cardiac Outputs should be obtained at the end
of respiration - at the same point each time
ARTERIAL WAVEFORM
RN magazine April, 2003 - PA
catheter refresher course.
ALL PA measurements are calculated at end expiration
because the lungs are at their most equal (negative vs. positive pressures)
a, c,& v Waves and their Timing to the ECG tracing
RA WAVEFORM
RV WAVEFORM
22
4
Ventricular
PAP DOCUMENTATION
Measure at end expiration
Measure pressures from a
graphic tracing
Measure pulmonary capillary
wedge pressure at end-expiration
using the mean of the a wave
a wave indicates atrial contraction and
falls within the P – QRS interval of the
corresponding ECG complex
PAW WAVEFORM WITH
MECHANICAL VENTILATION
PAOP/PAWP Pressure Safety
Points
 Watch
monitor during inflation and
stop when you see PAOP waveform
 Never inject more than 1.5 ml of air
or any fluid into PA port
 Don’t keep balloon inflated longer
than 15 seconds
 When completed - Allow air to
passively exit the balloon
OVERWEDGE
COMPLICATIONS OF PA
CATHETER
☹ Infection
☹ Electrocution (Microshock)
☹ Ventricular Arrhythmias
(Vtach.,Vfib., Cardiac Arrest)
☹ Atrial Dysrhythmias, RBBB
☹ Knotting and misplacement
☹ Hemo or Pneumothorax
☹ Cardiac valve trauma
COMPLICATIONS OF PA
CATHETER
☹ Catheter
thromboembolism or
air embolism
☹ Dissection or
Laceration of
subclavian artery or
vein
☹ Cardiac Tamponade
☹ Pulmonary
infarction
☹ Pulmonary artery
injury or rupture
☹ Balloon rupture
☹ Hematoma
Trouble Shooting
 Dampened
Waveform
– Flush catheter
– Check transducer system for air bubbles
 Blood
in Tubing
– Look for open Stopcock
– Put 300mgHg pressure in pressure bag
 Stuck
in Wedge /PWP
– Very slowly and gently pull back
catheter until you see PA waveform
References

Pulmonary Artery Catheter Education Project @
www.pacep.org sponsored by
–





American Association of Critical Care Nurses
American Association of Nurse Anesthetists
American College of Chest Physicians
American Society of Anesthesiologists
American Thoracic Society
National Heart Lung Blood Institute
Society of Cardiovascular Anesthesiologists
Society of Critical Care Medicine
Hemodynamics Made Incredibly Visual – LWW publishing
2007
AACN practice alert – Pulmonary Artery Pressure
Monitoring - Issued 5/2004
Handbook of Hemodynamic Monitoring – G Darovic 2nd ed.
TCHP Education Consortium 2005 – A Primer for
Cardiovascular Surgery and Hemodynamic Monitoring
Nursebob's MICU/CCU Survival Guide-Hemodynamics in
Critical Care -Hemodynamic Monitoring Overview
12/04/00