hemodynamic monitoring

INVASIVE HEMODYNAMIC MONITORING : 

INVASIVE HEMODYNAMIC MONITORING Presentation by Karen Larson, MBA/TM, MSN, RN

Introduction : 

Introduction Swan-Ganz catheter has been in use for almost 30 years Initially developed for the management of acute myocardial infarction Now, widespread use in the management of a variety of critical illnesses and surgical procedures

Purposes of Invasive Hemodynamic Monitoring : 

Purposes of Invasive Hemodynamic Monitoring Early detection, identification, and treatment of life-threatening conditions such as heart failure and cardiac tampanade Evaluate the patient’s immediate response to treatment such as drugs and mechanical support Evaluate the effectiveness of cardiovascular function such as cardiac output and index

Indications for Hemodynamic Monitoring : 

Indications for Hemodynamic Monitoring Any deficit or loss of cardiac function: such as AMI,CHF,Cardiomyopathy All types of shock;cardiogenic,neurogenic,or anaphylactic, hypovolemic Decreased urine output from dehydration, hemorrhage,G.I. bleed,burns,or surgery

Components of a Pulmonary Artery Catheter : 

Components of a Pulmonary Artery Catheter

Components of Pulmonary Artery Catheter : 

Components of Pulmonary Artery Catheter

Components of the Monitoring System : 

Components of the Monitoring System Bedside monitor – amplifier is located inside. The amplifier increases the size of signal Transducer – changes the mechanical energy or pressures of pulse into electrical energy; should be level with the phlebostatic axis[ you can estimate this by intersecting lines from the 4th ICS,mid axillary line Recorder – please record information

Phlebostatic Axis : 

Phlebostatic Axis

Commonly used Terminology : 

Commonly used Terminology Preload Afterload Cardiac Output Cardiac Index Systemic Vascular Resistance [SVR] Pulmonary Vascular Resistance [PVR] Contractility

Preload : 

Preload Is the degree of muscle fiber stretching present in the ventricles right before systole Is the amount of blood in a ventricle before it contracts; also known as “filling pressures” Left ventricular preload is reflected by the PAWP Right ventricular preload is reflected by the CVP [RA]

Afterload : 

Afterload Any resistance against which the ventricles must pump in order to eject its volume How hard the heart [either side left or right] has to push to get the blood out Also thought of as the “ resistance to flow” or how “clamped” the blood vessels are

Drugs that affect Afterload : 

Drugs that affect Afterload Drugs that ↓ Afterload Vasodilators Nitroprusside, Nitroglycerin, Hydrazaline ACE inhibitors Captopril (Capoten), enalapril (Vasotec) Calcium Channel Blockers Drugs that ↑ Afterload Vasopressors Dopamine, Noreprinephrine, epinephrine

Contractility : 

Contractility Intrinsic ability of cardiac muscle (the force of the squeeze) Also called ‘inotropism’ or ‘inotropy’ Inotropic agents positive: increase contractility negative: decrease contractility

Drugs that affect contractility : 

Drugs that affect contractility Inotropes- is an agent that alters the force or energy of muscular contractions Postitive Inotropes Epinephrine (adrenalin) Norepinephrine (Levophed) Isoproteronol (Isuprel Dopamine Dobutamine Primacore Digoxin Negative inotropes Barbiturates Alcohol Calcium channel blockers

Cardiac Output/Index : 

Cardiac Output/Index Is the amount of blood ejected from the ventricle in one minute (4-8 L/min) Two components multiply to make the cardiac output: heart rate and stroke volume [amount of blood ejected with each contraction] Cardiac index is the cardiac output adjusted for body surface area (BSI) (2.5-4.2 L/min)

SVR / PVR : 

SVR / PVR Systemic Vascular Resistance – reflects left ventricular afterload Pulmonary Vascular Resistance – reflection of right ventricular afterload Many of the drugs we administer will affect Preload, Afterload, SVR/PVR, Cardiac Output and Contractility

Possible Complications : 

Possible Complications Increased risk of infections – same as with any central venous lines—use occlusive dressing and Biopatch to prevent Thrombosis and emboli-- air embolism may occur when the balloon ruptures, clot on end of catheter can result in pulmonary embolism Catheter wedges permanently—considered an emergency, notify MD immediately, can occur when balloon is left inflated or catheter migrates too far into pulmonary artery (flat PA waveform)…can cause pulmonary infarct after only a few minutes! Ventricular irritation – occurs when catheter migrates back into RV or is looped through the ventricle, notify MD immediately…can cause VT

Troubleshooting : 

Troubleshooting Dampened waveform –can occur with physical defects of the heart or catheter; can be caused by kinks, air bubbles in the system, or clots Solution: Check your line for kinks & air bubbles, aspirate (not flush) for clots, straighten out tubing or patient as much as possible No waveform – can occur with non-perfusing arrhythmias or line disconnection Solution: Check your line for disconnection, check your patient for pulse, could also be wet transducer or broken cable or box

Hemodynamic monitoring : 

Hemodynamic monitoring Central Venous Pressure Monitoring 0-8 mm Hg (CVP) Pulmonary artery pressure monitoring- 25/9 mm Hg (PAP) Pulmonary artery wedge pressure- 4.5 to 13 mm Hg (PAWP) Cardiac Output 4-8 L/min (CO)

Central Venous Pressure (CVP) : 

Central Venous Pressure (CVP) Zero transducer to the patient’s phlebostatic axis Always read CVP at end expiration CVP is a direct measurement of right ventricular end diastolic pressure

CVP : 

CVP Causes of Increased CVP pressures: Right-side heart failure Volume overload Right ventricular infarction Causes of Decreased CVP pressures: Hypovolemia

Pulmonary Artery Pressure Monitoring (PAP) : 

Pulmonary Artery Pressure Monitoring (PAP) Normal Pulmonary artery pressure is 25/9 with a mean pressure of 15 mm Hg Systolic range 15-30 mmHg Diastolic range 4-12 mmHg Measure at the end of expiration PAP is usually higher than the PAWP

Pulmonary artery wedge pressure (PAWP) 4.5 – 13 Hg : 

Pulmonary artery wedge pressure (PAWP) 4.5 – 13 Hg Measure the PAWP at end expiration PAWP should not be higher than PA diastolic PAWP is an indirect measurement of left ventricular end diastolic pressure. Zero the transducer to the patient’s phlebostatic axis.

Cardiac Output : 

Cardiac Output It is the amount of blood pumped by the heart in one minute. Calculated by multiplying heart rate times stroke volume. Cardiac Index is the cardiac output adjusted for body surface area.

WHAT IS AN ARTERIAL LINE? : 

WHAT IS AN ARTERIAL LINE? An arterial catheter over a needle which is inserted into an artery using a percutaneous method, usually the radial artery Radial artery is used as it is the most accessible The axillary, femoral, brachial and pedal arteries may also be used Once inserted the catheter is attached to a pressure transducer and attached to the monitor where a continuous waveform will be seen

Arterial Line : 

Arterial Line Indications Continuous blood pressure monitoring Freqeunt blood sampling Serial arterial blood gases

Allen Test : 

Allen Test is used to test blood supply to the hand Test done to prevent compromised arterial perfusion to the area distal to the arterial catheter insertion site If no collateral circulation existed and the cannulated artery became occluded, ischemia and infarction of the area distal to that artery could occur

How to perform an Allen Test : 

How to perform an Allen Test 1) The hand is elevated and the patient/person is asked to make a fist for about 30 seconds. 2) Pressure is applied over the ulnar and the radial arteries so as to occlude both of them. 3) Still elevated, the hand is then opened. It should appear blanched (pallor can be observed at the finger nails). 4) Ulnar pressure is released and the color should return in 7 seconds. Inference: Ulnar artery supply to the hand is sufficient and it is safe to cannulate/prick the radial If color does not return or returns after 7–10 seconds, then the ulnar artery supply to the hand is not sufficient and the radial artery therefore cannot be safely pricked/cannulated.

WAVEFORMS PRODUCED BY ARTERIAL PRESSURES! : 

WAVEFORMS PRODUCED BY ARTERIAL PRESSURES! A normal waveform on the monitor will have a sharp upstroke, a dicrotic notch and a clear end diastole Systolic Pressure Dicrotic Notch End Diastole Diastolic Pressure Sharp Upstroke

Arterial Pressure Monitoring System : 

Arterial Pressure Monitoring System