hemodynamic monitoring

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Chapter 26 : 

Chapter 26 Cardiac Hemodynamics

Hemodynamic monitoring : 

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

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 tamponade 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 **Cardiac output volume of blood being ejected by the heart in a minute. Normal 4-8 L per minute. Cardiac index= cardiac output/BSA body surface area. Normal cardiac index 2.2-4Lmin

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 Decreased urine output from dehydration, hemorrhage,G.I. bleed ,burns, or surgery

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 PCWP. Normal WEDGE 4.5-13 mm HG Right ventricular preload is reflected by the CVP [RA]. normal CVP 0-8 mm HG -preload can be increase by fluid administration and decreased by diuresis

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 **increase afterload often results in decreased cardiac output. When afterload decrease myocardial oxygen needs are decreased.

Components of Swan-Ganz [con’t] : 

Components of Swan-Ganz [con’t] Normally has four[4] ports Proximal port – [Blue] used to measure central venous pressure/ and injectate port for measurement of cardiac output Distal port – [Yellow] used to measure pulmonary artery pressure Balloon port – [Red] used to determine pulmonary wedge pressure;1.5 special syringe is connected Infusion port – [White] used for fluid infusion

Pulmonary Artery Catheter and Pressure Monitoring System : 

Pulmonary Artery Catheter and Pressure Monitoring System

Pulmonary Artery Pressure Monitoring : 

Pulmonary Artery Pressure Monitoring Normal Pulmonary artery pressure is 25/9 with a mean pressure of 15 mm Hg

Cardiac Output/Index : 

Cardiac Output/Index Is the amount of blood ejected from the ventricle in one minute 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)

Central Venous Pressure Monitoring : 

Central Venous Pressure Monitoring CVP- pressure in the vena cava or right atrium, used to assess right ventricular function and venous return to the right side of the heart Single lumen or multilumen catheter placed into the superior vena cava Chest x-ray done to confirm placement

Central Venous Pressure (CVP) 0-8MM HG : 

Central Venous Pressure (CVP) 0-8MM HG 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 Increase Hypervolemia Heart failure Decrease hypovolemia

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

Pulmonary artery wedge pressure (PAWP) 4.5 – 13 Hg An indirect measure of left arterial pressure

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 Pneumothorax

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

Drugs that affect contractility : 

Drugs that affect contractility Positive Inotropes- is an agent that alters the force or energy of muscular contractions Epinephrine (adrenalin) Norepinephrine (Levophed) Isoproteronol (Isuprel Dopamine Dobutamine Primacore Digoxin

Drugs that affect contractility : 

Drugs that affect contractility Negative inotropes Barbiturates Alcohol Calcium channel blockers

WHAT IS AN ARTERIAL LINE? : 

E.Doidge.june05 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 the Allen Test : 

How to perform the 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! : 

E.Doidge.june05 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 Sharp Upstroke Dicrotic Notch End Diastole Diastolic Pressure

Arterial Pressure Monitoring System : 

Arterial Pressure Monitoring System

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