10/11/2016 1 Hemodynamic Monitoring Cardiac Boot Camp Cassia Yi, APRN, CNS, MSN, CCRN Objectives • Describe the location and function of the CVP, Pulmonary Artery and arterial line Catheters • Identify correct setup, positioning, leveling, measuring, and monitoring of hemodynamic waveforms • Review nursing role in line insertion • Review the purpose and process of CO and FICK calculation • State priorities of nursing care for turning, ambulation and ADLs • Verbalize chain of command and in indications for provider notification • Identify resources for assistance with invasive cardiac monitoring WHY?? A-line CVP Swan Indication minimally invasive way to measure continuous BP • pressure of blood near right atrium of heart • -Reflects amount of blood returning to heart Measures pulmonary artery pressures Examples
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10/11/2016
1
Hemodynamic Monitoring Cardiac Boot Camp
Cassia Yi, APRN, CNS, MSN, CCRN
Objectives
• Describe the location and function of the CVP, Pulmonary Artery and arterial
line Catheters
• Identify correct setup, positioning, leveling, measuring, and monitoring of
hemodynamic waveforms
• Review nursing role in line insertion
• Review the purpose and process of CO and FICK calculation
• State priorities of nursing care for turning, ambulation and ADLs
• Verbalize chain of command and in indications for provider notification
• Identify resources for assistance with invasive cardiac monitoring
WHY??
3
A-line CVP Swan
Indication minimally
invasive way to
measure
continuous BP
• pressure of
blood near
right atrium
of heart
• -Reflects
amount of
blood
returning to
heart
Measures
pulmonary artery
pressures
Examples
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Hemodynamics Quick Reference Sheet Last revised: 5/2016, KL, CY
Definition Normal range Elevated Depressed Significance
Central Venous Pressure
(CVP)
Reflects the amount of blood
returning to the RA and the
ability of the heart to pump the
blood into the arterial system.
2-6 mmHg Overhydration, HF, PA stenosis, Renal
failure, Pulm HTN, vasoconstriction,
Increased intrathoracic pressure
(PEEP)
Hypovolemic or septic shock,
third spacing, hyperthermia
Indicates right ventricular function
and systemic fluid status. Does not
measure volume but often used to
estimate preload
Pulmonary Artery Systolic
Pressure (PAS)
Represents rapid blood flow
from RV into PA. Occurs with
opening of pulmonic valve
15-30 mmHg Hypoxemia, Pulm HTN, LV
dysfunction
Hypovolemia Indicates fluid status and
pulmonary disorders
Pulmonary Artery Diastolic
Pressure (PAD)
Represents passive blood flow
from the RV into PA. Occurs
with closure of Pulmonic valve
5-15 mmHg PE, Tachycardia, Pulm HTN Hypovolemia Indicates fluid status and
pulmonary disorders. Mean PA
pressure should be between 7-16
mmHg
Pulmonary Artery Wedge
Pressure (PAWP, PCWP, PWP,
wedge)
Reflects left atrial and left
ventricular pressures.
4-12 mmHg Left sided heart failure, mitral stenosis,
Mean Arterial Pressure (MAP) Average arterial blood pressure
during a single cardiac cycle.
Considered to be the perfusion
pressure seen by organs in the
body
70-110 mmHg
*Typical drip parameters
in post-op CVC ICU pts
will be 65-85 but check
your orders to be sure
Exact causes unknown but associated
with factors such as: obesity, smoking,
race, gender, pulm HTN, stress,
anxiety, renal disorders, hypoxemia,
thyroid disorders
Hemorrhage,
Drugs/medication, shock,
stress, hypovolemia, acute
tamponade
A minimum of 60 mmHg is
necessary to perfuse the brain,
kidneys and coronary arteries
Mixed Venous Oxygen
Saturation (SVO2)
End result of both oxygen
delivery and consumption at the
tissue level. Determined by
SaO2, CO, Hgb, and O2
consumption. Drawn from PAD
port
60-80% Hypothermia, anesthesia,
pharmacologic paralysis, sepsis,
alkalosis, cirrhosis of liver
Hyperthermia, anemia,
hemorrhage, late sepsis,
acidosis, hypoxia,
shock,arrhythmias, pain,
shivering, seizures,
restlessness, agitation
Helps determine how much O2 the
body is utilizing. If body is
consuming large quantities of O2 a
higher fiO2 may be required even
with an adequate SaO2
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Pulmonary Artery Blood Pressure
PA pressure
PAS/PAD
Preload/Left Atrial Pressure
Wedge/PAWP/PCWP/PWP
Arterial Blood Pressure
(ABP, BP, A-line)
S/D
Preload/Right Atrial Pressure
CVP
Afterload/Systemic Vascular Resistance
SVR
800-1200
2-6 4-12
120/80
25/10
Pulmonary vascular resistance
PVR
50-250
Stroke Volume
60-100ml per beat!
Cardiac Output
4-8L/min
MVo2
O2 sat of blood right before it
goes to the lungs
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Pre-load
After-load
Rate= bpm
Contractility= squeeze
CO=SV x HR
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Transducing Lines
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Remember:
• The set up is the same for any transduced line-
the label on the monitor and where you zero may
be different
• If any portion touches the floor start over!
• Consider: Turkey foot? Vamp?
Supplies needed
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For the MD For the RN
Line insertion PPE kit
Sterile glove (extra pairs)
Bedside table(s)
Extra sterile gauze (just in case)
Extra masks/hats
Bag of 500cc NS
Transducer itself
• 3 way?
• Vamp?
IV pole with transducer holders
Pressure bag
Box(es) and cables for monitor
Central line dressing kit
Steps to transducer set-up
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1. Get your monitor set up: place the box and cable in the monitor and make
sure that it is labeled appropriately
2. Limit people in the room
3. Put a mask/hat on everyone in the room
4. Monitor MD to make sure that sterility is maintained
5. Take transducer out and tighten connections (compress vamp if there is one)
6. Spike and burp NS (label bag)
7. Prime transducer
8. Swap out caps for red caps
9. Label transducer with stickers
10.Hang NS in pressure bag and pump to 300mmHg (turn stopcock up)
11.Level (phlebostatic axis)
12.Zero (turn stopcock back to neutral and THEN replace cap)
13.You are ready to connect!
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There is an app for that!
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General Transducer Maintenance
Post strips of waveforms each shift and PRN changes
Square wave test and strip mounting done on each shift Keep pressure bag inflated to 300 mmHg. -prevents retrograde blood flow/ clotting -infuses saline @3-5 ml/hr -prevents damped waveform Flush bags of Normal Saline are changed every 96 hrs and PRN Never add extra stopcocks or tubing to system
Hands On!
• Let’s practice setting up pressure bags and
transducers
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Arterial Line Waveform
Allen’s Test
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Square Wave Test
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Arterial Line- Monitoring and Documentation
A-line must always be attached to the monitor
Once a shift, measure the a-line pressure along
with the cuff BP (do they correlate?)
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Troubleshooting Arterial Lines
Incorrect placement of
transducer
Uncalibrated system
Kinked cannula
Damped (under or over)
Level transducer
Re-zero
Remove kink
Remove air bubbles/clots
False Readings Interventions
Dressing changes
• Change per CVC dressing change policy
• On transduced lines, IV bag and IV tubing changed q 4 days (or when you run out
of fluid)
• Remember: Close the circle on the Biopatch!!!
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Arterial Line Cheat Sheet Set-up/equipment needed at bedside…(from the pole to the patient)
• Monitoring Equipment: Cable, Monitor
• Pressure Bag • 500 cc bag of NS or Heparinized Saline (according to order)
• Arterial Line Tubing • Pressure Transducer System with Vamp (when priming, observe flush of each port and then replace with
dead-end red caps) • Vamp, which allows for blood draws with needless syringe
• Sterile dressing with stat lock and biopatch
Documentation…
• To show arterial waveform at RN station: click on “sector set-up,” then “secondary wave” and select “ABP.”
• Run a strip and obtain arterial pressure measurements during end expiration.
• Place a strip in the chart at the start of every the shift and whenever there is a change in the waveform.
• Strip should also include square wave test
Pay extra attention to… • When blood pressure values don’t fit clinical picture
• Ensure transducer remains level (at phlebostatic axis) with position changes
• Assess extremity with the art line Q4h and PRN, observe insertion site for infection.
• Ensure pressure bag is inflated to 300mmHg and that there is fluid in flush bag at all times.
When to notify the MD…
When arterial BP’s don’t correlate with cuff pressures .
If BP is out of goal range (hypo or hypertensive)
Available resources: AACN Procedure Manual 6th Ed. Pages
534-547 UCSD Cardiovascular guidelines of Care
How and When to Zero the A-Line:
WHEN? at set-up, every shift, when troubleshooting waveforms,
and any time that disconnection occurs
How?
1. Level the transducer to
the phlebostatic axis
1. Turn the stopcock off to the patient,
open to air by removing the
red dead-end cap
1. Press zero on your monitor, waiting for the beep to indicate
that it was zeroed.
2. Return the stop cock to it’s neutral position and THEN
replace the red dead-end cap
3. Perform square wave test by flushing fast, and releasing
quickly. Monitor for over-dampened (slurred, blunted) or
under-dampened (Spikes) waveforms.
How to D/C an A-Line:
• Ensure you have an order from MD and check labs (PT, PTT, INR)
• Silence A-Line alarms • Have 4x4’s, tape, suture removal kit at bedside
• Deflate pressure bag and clamp tubing • Remove old dressing and cut suture
• Apply pressure 1-2 finger widths above insertion site. Remove the catheter and place sterile gauze over the site.
• Continue to hold pressure for approximately 5 minutes, if femoral press firmly for at least 10 minutes until bleeding has stopped.
• Once hemostasis has occurred, apply occlusive pressure dressing and monitor for any re-bleeding.
Over-damped Waveform Under-damped Waveform
Is the catheter kinked?
Are there air bubbles?
Is your line connected with no
leaks?
Is there fluid in your flush bag?
Is your pressure bag at 300mmHg?
ASPIRATE FIRST THEN FLUSH!
Are there air bubbles?
Is your tubing too long?
ASPIRATE THEN FLUSH
Trouble Shooting
Setting up the Transducer… http://www.youtube.com/watch?v=YeOmkqD3k6E&feature=youtu.be
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CVP placement in the heart
Central Venous Pressure
Pressure of blood in the thoracic vena cava, near the right atrium of the heart
Reflects the amount of blood returning to the heart and the ability of the heart to pump the blood into the arterial system
Good approximation of right atrial pressure which is a major determinant of right ventricular end diastolic volume (RVEDP)
CVP tubing should be connected to distal port on central line or blue RA port on swan
Also Referred to as Right Atrial Pressure
CVP Continued
• Measure and record CVP with patient supine, 0-
60 degrees, and leveled at Phlebostatic axis
• Measure CVP at end- expiration and end-
diastole
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CVP Waveform
A= atrial contraction
C= closure of the tricuspid valve
X descent= atrial relaxation
V= caused by continuous venous return
Y descent= end of ventricular systole
Example CVP Waveforms
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Steps to measure CVP: #1 Check your scale, Identify End-
• Pressure goes down during inhalation due to negative pressure as your
diaphragm pulls down.
• On pressure support (Vent or iPap): Mountain= Inhale, Valley= exhale
• Pressure goes up during inhalation due to positive pressure being
pushed in 31
Steps to measure CVP: #2 Draw a line from p-
wave down
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Steps to measure CVP: #3 Find you’re a-wave
(first peak after p-wave)
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Steps to measure CVP: #3 Draw a line through
the mean of the a-wave! That is your CVP
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Alterations in CVP Readings
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Remember!
• When transducing a CVP reading, you must make sure
the Stop Cock is OFF to any infusions or you will have
falsely ELEVATED readings
CVP Cheat Sheet Set-up/equipment needed at bedside…
• Monitoring Equipment: Cable, Monitor
• Pressure Transducer System (when priming flush each port and then replace with dead-end
red caps)
• Pressure Bag
• 500 cc bag of NS
Documentation…
Place a strip in the chart at the start of the shift and
whenever there is a change in waveform.
Document CVP in EPIC every time that you record
vital signs
Pay extra attention to…
• Connect CVP line to Distal Port of TLC (usually brown port)
• Check flush system Q4h (Ensure pressure bag is inflated to
300mmHg, and that you have enough fluid in the bag)
• Observe insertion site for infection, use central line sterile dressing kit
for dressing changes.
When to notify the MD…
When the CVP is out of goal range.
(Normal CVP is 2-6)
Available resources:
AACN Procedural Manual 6th Ed pages
606
UCSD Cardiovascular guidelines of care
Right atrium
CVP is elevated by:
• Over-hydration: which increases venous return
• Heart Failure or PA stenosis: which limits
venous outflow and leads to venous congestion
• Positive Pressure Breathing, straining
CVP is decreased by:
• Hypovolemia from hemorrhage, fluid shift,
dehydration
• Negative Pressure Breathing: mechanical
negative pressure or when pt demonstrates
retractions.
Level at phlebostatic axis
Connect CVP line to distal
port of TLC
How and When to Zero the CVP:
WHEN? at set-up, every shift, when troubleshooting waveforms,
and any time that disconnection occurs
How?
1. Level the transducer to
the phlebostatic axis
1. Turn the stopcock off to the patient,
open to air by removing the
red dead-end cap
1. Press zero on your monitor, waiting for the beep to indicate
that it was zeroed.
2. Return the stop cock to it’s neutral position and THEN
replace the red dead-end cap Distal Tip
Discontinuing TLC and CVP:
1. Place patient flat or in slight trendelenburg
2. Remove dressing and suture (clean glove)
3. Wash hands and place sterile gloves
4. Ask the patient to take a breath and HOLD IT!
5. Remove the catheter with a steady pull parallel
to the skin (if resistance met, stop and notify
MD).
6. Apply pressure with sterile gauze
7. The patient can now exhale
8. Hold pressure until bleeding stops and then
apply sterile occlusive dressing
9. Maintain bed rest for 20 min, observing for
bleeding
Measurement…
1. Position the patient flat in bed, HOB 0-45 degrees
2. Ensure that transducer is zeroed and level
3. To show arterial waveform at RN station: click on “sector set-up,” then “secondary wave” and select “CVP”
4. Run strip at end expiration
5. Identify the “a” waveform (right after the “p” wave)
6. The mean of your “a” wave is your CVP!
Setting up the Transducer… http://www.youtube.com/watch?v=YeOmkqD3k6E&feature=youtu.be
Break!
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PA Catheter in the Heart
Pulmonary Artery Pressure
Monitored with Swan Ganz catheter
Measures the BP in the PA
Consists of:
PAS (Peak systolic pressure) normal
15-30
PAD (Peak diastolic pressure) normal
8-15
Normal PAP: 15-30/8-15
Normal Mean : 9-18
Increased Pulmonary Artery
Pressures
May indicate
• Left to right cardiac shunt
• COPD
• Pulmonary HTN
• PE
• left or right sided heart failure
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Indications for PA Catheter
• Heart Failure
• Cardiogenic shock
• Cardiac tamponade
• Constrictive pericarditis
• Hypovolemic shock
• Pulmonary embolism
• Septic shock
Swan Infusion Ports
Swans come in different sizes
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How far in is my swan??
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Hands On!
• Let’s practice!
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Assisting with Swan Insertion
• Generally only occurs in ICU, PTU or Cath lab
• Prime and set-up the transducer
• Assist with sterile set-up (same as central line
insertion)
• Monitor during procedure
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PA Catheter (Swan Ganz) insertion
Documentation…
• PA catheter placement in cm. Dressing care. CXR placement
confirmation
• As long as there is an order in computer then the row and groups
should appear under Doc flow sheets, Point of care testing
Available resources:
• iShare PowerPoint presentation on hemodynamic monitoring
• http://www.youtube.com/watch?v=aLzI7DAkbjM
• Cardiovascular nursing standard of care
• AACN procedure Manuel Ed. 6 pg 626
1.Set up and flush pressure transducer system. After flushing line then apply bag pressure to 300mmhg
2.Assist MD/NP with patient positioning and sterile setup (utilize central line insertion kit), opening PA cath and introducer kit. Ensure only the insertion site is exposed. RN to wear, hair net, eye protection and sterile gloves and help ensure sterility is maintained.
3.Connect the pressure transducer system to the PA distal port of the PA catheter. Generally MD primes the entire PA catheter with sterile saline from insertion kit. Level at the phlebostatic axis and zero with bedside monitor by turning the stopcock of each system off to the pt, & open to air
4.The MD places the sterile plastic sleeve over the catheter before insertion, checks the balloon and ensures waveform on bedside monitor is working and has continuous ECG monitoring
5.Start running continuous PA and ECG waveform strip during insertion
6.After PA tip is in the RA, the balloon is inflated with no more than 1.5 ml of air to assist its forward flow to the PA
7.Observe for RA, RV PA and then PAO waveforms. Ventricular
dysrhythmias may occur from ventricular irritability.
8.Verify the PA cath placement. When it is in the PA the monitor should
show a PA tracing when the balloon is inflated it should show a PAO
tracing
9.Once in place. Open the stopcock and expel the air from the syringe.
Then reattach empty syringe to end of the balloon inflation valve (which
remains open).
10.Observe wave form and record performance of dynamic (square
wave) response test
11.Apply an occlusive dressing according to hospital policy
12.Document the external centimeter marking of the PA catheter at
introducer exit site
13.Set Alarms
14.Ensure CXR is done and read by MD/NP before infusing medications