Understanding Understanding Adult Adult Hemodynamics Hemodynamics Theory, Monitoring, Theory, Monitoring, Waveforms and Waveforms and Medications Medications Vicki Clavir RN
Understanding AdultUnderstanding AdultHemodynamicsHemodynamics
Theory, Monitoring, Theory, Monitoring, Waveforms and Waveforms and
MedicationsMedications
Vicki Clavir RN
PurposePurpose The primary purpose of invasive The primary purpose of invasive
hemodynamic monitoring is the early hemodynamic monitoring is the early detection, identification, and treatment of detection, identification, and treatment of life-threatening conditions such as heart life-threatening conditions such as heart failure and cardiac tamponade. By using failure and cardiac tamponade. By using invasive hemodynamic monitoring the invasive hemodynamic monitoring the nurse is able to evaluate the patient's nurse is able to evaluate the patient's immediate response to treatment such as immediate response to treatment such as drugs and mechanical support. The nurse drugs and mechanical support. The nurse can evaluate the effectiveness of can evaluate the effectiveness of cardiovascular function such as cardiac cardiovascular function such as cardiac output, and cardiac index. 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 Indications for Hemodynamic Monitoring:Monitoring:
One of the obvious indications for One of the obvious indications for hemodynamic monitoring is decreased hemodynamic monitoring is decreased cardiac output. This could be from cardiac output. This could be from dehydration, hemorrhage, G. I. bleed, dehydration, hemorrhage, G. I. bleed, Burns, or surgery. All types of shock, Burns, or surgery. All types of shock, septic, cardiogenic, neurogenic, or septic, cardiogenic, neurogenic, or anaphylactic may require invasive anaphylactic may require invasive hemodynamic monitoring. Any deficit or hemodynamic monitoring. Any deficit or loss of cardiac function: such as acute loss of cardiac function: such as acute MI, cardiomyopathy and congestive MI, cardiomyopathy and congestive heart failure may require invasive heart failure may require invasive hemodynamic monitoring. hemodynamic monitoring.
Coronary ArteriesCoronary Arteries
RCA-RA, RV&LV Inf,Inf SeptumSA node 65%AV node 80%PDA 80-90%
CX-LA,LV (side/back)
SA node 40%AV node 20%
LAD –LV (front/bottom)
SeptumBundle branches
Left Main
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 CycleCardiac Cycle
Electrical Conduction systemElectrical Conduction systemSA node SA node
Atrial muscleAtrial muscleInternodal fibersInternodal fibers
AV node AV node AV bundle AV bundle
right and leftright and left
bundle branchesbundle branches
Ventricular muscleVentricular muscle
Autonomic Nervous SystemAutonomic Nervous System The autonomic nervous system The autonomic nervous system
stimulates the heart through a stimulates the heart through a balance of sympathetic nervous balance of sympathetic nervous system and parasympathetic nervous system and parasympathetic nervous system innervations.system innervations.– The sympathetic nervous system plays a The sympathetic nervous system plays a
role in role in speedingspeeding up impulse formation, up impulse formation, thus increasing the heart ratethus increasing the heart rate
– The parasympathetic nervous system The parasympathetic nervous system slowsslows the heart rate. the heart rate.
The Cardiac Cycle
• Coronary Arteries Fill
The Cardiac Cycle
The Cardiac Cycle
The Cardiac Cycle
Normal CO 4-8 liters
Normal Cardiac Index is 2.5 to 4.5 liters
Heart Rate Heart Rate
Works with Stroke VolumeWorks with Stroke VolumeCompensatoryCompensatory
Tachycardia Tachycardia BradycardiaBradycardiaDysrhythmiasDysrhythmias
Factors Causing Low Cardiac Factors Causing Low Cardiac OutputOutput
Inadequate Left Inadequate Left Ventricular FillingVentricular Filling– TachycardiaTachycardia – Rhythm disturbanceRhythm disturbance– HypovolemiaHypovolemia– Mitral or tricuspid Mitral or tricuspid
stenosisstenosis– Pulmonic stenosisPulmonic stenosis– Constrictive Constrictive
pericarditis or pericarditis or tamponade tamponade
– Restrictive Restrictive cardiomyopathy cardiomyopathy
Inadequate Left Inadequate Left Ventricular EjectionVentricular Ejection– Coronary artery Coronary artery
disease causing LV disease causing LV ischemia or ischemia or infarctioninfarction
– Myocarditis, Myocarditis, cardiomyopathycardiomyopathy
– Hypertension Hypertension – Aortic stenosisAortic stenosis– Mitral regurgitation Mitral regurgitation – Drugs that are Drugs that are
negative inotropes negative inotropes – Metabolic disorders Metabolic disorders
Hemodynamic termsHemodynamic terms
PreloadPreload- Stretch of ventricular - Stretch of ventricular wall. Usually related to wall. Usually related to volume. (how full is the tank?)volume. (how full is the tank?)– Frank Starling’s LawFrank Starling’s Law
Hemodynamic termsHemodynamic terms Increased preload seen inIncreased preload seen in
– Increased circulating volume (too much Increased circulating volume (too much volume)volume)
– Mitral insufficiencyMitral insufficiency– Aortic insufficiencyAortic insufficiency– Heart FailureHeart Failure– Vasoconstrictor use- (dopamine)Vasoconstrictor use- (dopamine)
Decreased Preload seen inDecreased Preload seen in– Decreased circulating volume (bleeding,3Decreased circulating volume (bleeding,3rdrd
spacing)spacing)– Mitral stenosis Mitral stenosis – Vasodilator use ( NTG)Vasodilator use ( NTG)– Asynchrony of atria and ventriclesAsynchrony of atria and ventricles
Increased Preload
Decreased preload
Normal Value - 2-8 mm Hg
Or LVEDPPAOP = 8-12 mm Hg PAD = 10-15 mm Hg
Hemodynamic termsHemodynamic termsContractilityContractility--
– How well does the ventricular walls How well does the ventricular walls move? How good is the pump?move? How good is the pump?
Decreased due toDecreased due toDrugs – certain drugs will decrease Drugs – certain drugs will decrease
contractilitycontractility– Lido, Barbiturates, CCB, Beta-Lido, Barbiturates, CCB, Beta-
blockersblockersInfarction, CardiomyopathyInfarction, CardiomyopathyVagal stimulationVagal stimulationHypoxiaHypoxia
Hemodynamic termsHemodynamic terms
ContractilityContractility-- IncreasedIncreased
Positive inotropic drugsPositive inotropic drugs– Dobutamine, Digoxin, EpinephrineDobutamine, Digoxin, Epinephrine
Sympathetic stimulationSympathetic stimulation– Fear, anxietyFear, anxiety
Hypercalcemia ( high calcium)Hypercalcemia ( high calcium)
CONTRACTILITY - CONTRACTILITY - PRECAUTIONSPRECAUTIONS
Do Not use Inotropes until Do Not use Inotropes until volume deficiency is correctedvolume deficiency is corrected
Correct Hypoxemia and Correct Hypoxemia and electrolyte imbalance.electrolyte imbalance.
Hemodynamic termsHemodynamic terms
AfterloadAfterload – – resistance the blood in the resistance the blood in the ventricle must overcome to ventricle must overcome to force the valves open and force the valves open and eject contents to circulation.eject contents to circulation.
X
Y
Hemodynamic termsHemodynamic terms
Factors thatFactors that increaseincrease afterloadafterload are are– Systemic resistance or High Blood Systemic resistance or High Blood
pressurepressure– Aortic stenosisAortic stenosis– Myocardial Infarcts / Myocardial Infarcts /
CardiomyopathyCardiomyopathy– Polycythemia – Increased blood Polycythemia – Increased blood
viscosityviscosity
Hemodynamic termsHemodynamic terms
Factors that Factors that decrease Afterload decrease Afterload– Decreased volumeDecreased volume– Septic shock- warm phaseSeptic shock- warm phase– End stage cirrhosisEnd stage cirrhosis– VasodilatorsVasodilators
Normal PVR is 120 to 200 dynes
Normal SVR - 800-1200 dynes
Mean Arterial PressureMean Arterial Pressure MAPMAP is considered to be the perfusion is considered to be the perfusion
pressure seen by pressure seen by organs organs in the body.in the body. It is believed that a It is believed that a MAPMAP of greater than of greater than
60 mmHg60 mmHg is enough to sustain the organs is enough to sustain the organs of the average person under most of the average person under most conditions.conditions.
If the If the MAPMAP falls significantly below this falls significantly below this number for an appreciable time, the end number for an appreciable time, the end organ will not get enough blood flow, and organ will not get enough blood flow, and will become ischemic.will become ischemic.
Calculated MAP = Calculated MAP = 2x diastolic + systolic2x diastolic + systolic 33
EKG
1.PRELOAD-venous blood return to the heart Controlled by;♥.Blood Volume PRBC’s Albumin Normal Saline Diuretics-
lasix,bumex Thiazides
Ace inhibitors ♥. Venous Dilation Nitroglycerine Ca+ channel blockers clonidine (Catapress) methyldopa trimethaphan (arfonad) ↓ Dobutamine Morphine
2. CONTRACTILITY-forcefulness of contractilityCa+ channel blockersDigoxinDopamine/DobutamineMilrinone/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
Drugs of Hemodynamics
4. HEART RATE – Beta blockers Calcium
channel blockers
Atropine Dopamine Dobutamine
O2 O2 O2
O2
O2 O2O2
To BODY
From Body
O2O2O2
• Factors that make up SVO2 are • Cardiac output• SaO2
• VO 2 (oxygen consumption)
• Hemoglobin
Causative FactorsCausative Factors Clinical ConditionsClinical Conditions O2 DeliveryO2 Delivery
Hb concentrationHb concentration
- - AnemiaAnemia
- Hemorrhage- Hemorrhage
Oxygen saturationOxygen saturation
(SaO2)(SaO2)
- - HypoxemiaHypoxemia- Lung diseaseLung disease- Low FIO2Low FIO2
Cardiac OutputCardiac Output - - LV dysfunctionLV dysfunction (cardiac (cardiac disease, drugs)disease, drugs)
- - Shock Shock – – cardiac/septic (late)cardiac/septic (late)
- HypovolemiaHypovolemia- Cardiac DysrhythmiasCardiac Dysrhythmias
Oxygen consumptionOxygen consumption - Fever, infectionFever, infection- Seizures, agitationSeizures, agitation- ShiveringShivering- Work of BreathingWork of Breathing- Suctioning, bathing, Suctioning, bathing, repositioningrepositioning
Increased SVOIncreased SVO22
Most common cause is - SepsisMost common cause is - Sepsis
Or Or
Wedged PA catheterWedged 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 CatheterPA Catheter
KEEP COVERED KEEP LOCKED
YELLOW
Clear
BLUE
RED
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 for CO)-BLUE
PA Distal (Pressure line hook up)- Yellow
Extra port - usually- Clear
Thermistor – Red Cap
Continuous Cardiac Output and Continuous Cardiac Output and SVOSVO22 monitoring monitoring
Indications for PA catheterIndications for PA catheter The pulmonary artery catheter is The pulmonary artery catheter is
indicated in patients whose indicated in patients whose cardiopulmonary pressures, flows, and cardiopulmonary pressures, flows, and circulating volume require precise, circulating volume require precise, intensive management.intensive management.
MI – cardiogenic shock - CHFMI – cardiogenic shock - CHFShock - all typesShock - all typesValvular dysfunctionValvular dysfunctionPreoperative, Intraoperative, and Preoperative, Intraoperative, and
Postoperative MonitoringPostoperative MonitoringARDS, Burns, Trauma, Renal FailureARDS, Burns, Trauma, Renal Failure
PRESSURE TRANSDUCER PRESSURE TRANSDUCER SYSTEMSSYSTEMS SET UPSET UP
500 ml Premixed Heparinized bag of NS
PHLEBOSTATIC REFERENCE PHLEBOSTATIC REFERENCE POINTPOINT
♥ 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
Angles 45°
30°
0°
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 Thermodilution Cardiac OutputsOutputs
CCardiac ardiac OOutputs reading should be utputs reading should be withinwithin ..5 of 5 of each other for averaging purposes.each other for averaging purposes.
Except in patients with atrial fibrillation- just Except in patients with atrial fibrillation- just average 3 to 4 readings. (due to loss of atrial average 3 to 4 readings. (due to loss of atrial kick output changes from minute to minute)kick output changes from minute to minute)
CCardiac ardiac OOutputs should be obtained at the utputs should be obtained at the endend of respiration - at the same point each timeof respiration - at the same point each time
ARTERIAL WAVEFORMARTERIAL WAVEFORM
RN magazine April, 2003 - PA RN magazine April, 2003 - PA catheter refresher course.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 WAVEFORMRA WAVEFORM
RV WAVEFORMRV 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 PAW WAVEFORM WITH MECHANICAL VENTILATIONMECHANICAL VENTILATION
PAOP/PAWP Pressure Safety PAOP/PAWP Pressure Safety PointsPoints
Watch monitor during inflation and Watch monitor during inflation and stop when you see PAOP waveformstop when you see PAOP waveform
Never inject more than 1.5 ml of air Never inject more than 1.5 ml of air or any fluid into PA portor any fluid into PA port
Don’t keep balloon inflated longer Don’t keep balloon inflated longer than 15 secondsthan 15 seconds
When completed - Allow air to When completed - Allow air to passively exit the balloon passively exit the balloon
OVERWEDGEOVERWEDGE
COMPLICATIONS OF PA COMPLICATIONS OF PA CATHETER CATHETER
☹ InfectionInfection
☹ Electrocution (Microshock)Electrocution (Microshock)
☹ Ventricular Arrhythmias Ventricular Arrhythmias (Vtach.,Vfib., Cardiac Arrest)(Vtach.,Vfib., Cardiac Arrest)
☹ Atrial Dysrhythmias, RBBBAtrial Dysrhythmias, RBBB
☹ Knotting and misplacementKnotting and misplacement
☹ Hemo or Pneumothorax Hemo or Pneumothorax
☹ Cardiac valve traumaCardiac valve trauma
COMPLICATIONS OF PA COMPLICATIONS OF PA CATHETERCATHETER
☹ Catheter Catheter thromboembolism or thromboembolism or air embolism air embolism
☹ Dissection or Dissection or Laceration of Laceration of subclavian artery or subclavian artery or veinvein
☹ Cardiac TamponadeCardiac Tamponade
☹ Pulmonary Pulmonary infarction infarction
☹ Pulmonary artery Pulmonary artery injury or rupture injury or rupture
☹ Balloon rupture Balloon rupture
☹ HematomaHematoma
Trouble ShootingTrouble Shooting
Dampened Waveform Dampened Waveform – Flush catheterFlush catheter– Check transducer system for air bubblesCheck transducer system for air bubbles
Blood in TubingBlood in Tubing– Look for open StopcockLook for open Stopcock– Put 300mgHg pressure in pressure bagPut 300mgHg pressure in pressure bag
Stuck in Wedge /PWP Stuck in Wedge /PWP – VeryVery slowly and gently pull back slowly and gently pull back
catheter until you see PA waveformcatheter until you see PA waveform
ReferencesReferences Pulmonary Artery Catheter Education Project @ Pulmonary Artery Catheter Education Project @
www.pacep.org sponsored by www.pacep.org sponsored by – American Association of Critical Care NursesAmerican Association of Critical Care Nurses
American Association of Nurse Anesthetists American Association of Nurse Anesthetists American College of Chest Physicians American College of Chest Physicians American Society of Anesthesiologists American Society of Anesthesiologists American Thoracic Society American Thoracic Society National Heart Lung Blood Institute National Heart Lung Blood Institute Society of Cardiovascular Anesthesiologists Society of Cardiovascular Anesthesiologists Society of Critical Care Medicine Society of Critical Care Medicine
Hemodynamics Made Incredibly Visual – LWW publishing Hemodynamics Made Incredibly Visual – LWW publishing 2007 2007
AACN practice alert – Pulmonary Artery Pressure AACN practice alert – Pulmonary Artery Pressure
Monitoring - Issued 5/2004Monitoring - Issued 5/2004 Handbook of Hemodynamic Monitoring – G Darovic 2Handbook of Hemodynamic Monitoring – G Darovic 2ndnd ed. ed. TCHP Education Consortium 2005 – A Primer for TCHP Education Consortium 2005 – A Primer for
Cardiovascular Surgery and Hemodynamic Monitoring Cardiovascular Surgery and Hemodynamic Monitoring Nursebob's MICU/CCU Survival Guide-Hemodynamics in Nursebob's MICU/CCU Survival Guide-Hemodynamics in
Critical Care -Hemodynamic Monitoring OverviewCritical Care -Hemodynamic Monitoring Overview12/04/0012/04/00