ch09

Views:
 
Category: Education
     
 

Presentation Description

No description available.

Comments

Presentation Transcript

Chapter 9: Hemodynamic and Cardiac Monitoring : 

Chapter 9: Hemodynamic and Cardiac Monitoring Galveston College EMS Critical Care Paramedic 2009

Introduction : 

2/122 Introduction Hemodynamic monitoring important aspect of critical care medicine Subtle changes in hemodynamic parameters often earliest indications of patient deterioration Patients often transported with monitors and in-dwelling catheters

Value of Hemodynamic Monitoring : 

3/122 Value of Hemodynamic Monitoring Understand common critical care monitoring devices Interpret changes Allows the critical care paramedic to: Identify and appreciate trends Determine treatment effectiveness

Commonly Monitored Parameters : 

4/122 Commonly Monitored Parameters Electrocardiogram Arterial blood pressure Central venous pressure Cardiac output Pulmonary capillary wedge pressure Stroke volume Oxygen delivery

Electrocardiographic Monitoring(1 of 2) : 

5/122 Electrocardiographic Monitoring(1 of 2) 12-Lead ECG monitoring and interpretation now common in prehospital environment Principles of 12-lead monitoring similar to routine cardiac monitoring 12-Lead ECG designed to detect most common cardiac insults

Electrocardiographic Monitoring(2 of 2) : 

6/122 Electrocardiographic Monitoring(2 of 2) Anatomically specific to injury site Left ventricle Standard 12-lead ECG Left posterior and right ventricle not readily visible on standard 12-lead ECG 15 or 18-lead ECG used to monitor right side, posterior wall

15-Lead ECG : 

7/122 15-Lead ECG Adds three chest leads to standard 12-lead ECG V4R, V8, V9

18-Lead ECG : 

8/122 18-Lead ECG Adds three right-sided chest leads, three posterior leads V4R, V5R, V6R V7, V8, V9

Lead Placement: 18-Lead : 

9/122 Lead Placement: 18-Lead V4R electrode is placed in the fifth intercostal space at the right midclavicular line V5R is placed level with V4R at the right anterior axillary line V6R is placed level with V5R at the right midaxillary line V7 is placed lateral to V6 at the posterior axillary line V8 is placed at the level of V7 at the midscapular line V9 is placed at the level of V8 at the paravertebral line

Prehospital 12-Lead ECG Monitoring Procedure (1 of 3) : 

10/122 Prehospital 12-Lead ECG Monitoring Procedure (1 of 3) Explain procedure to patient Prepare all equipment Ensure leads and materials for skin prep are adequate Prep the skin If the patient is diaphoretic, dry the skin with a towel, and use tincture of Benzoin, if necessary It may sometimes be necessary to slightly abrade the skin to obtain a good interface Shave if needed to ensure good skin/electrode interface Place the four limb leads according to manufacturer’s recommendations

Prehospital 12-Lead ECG Monitoring Procedure (2 of 3) : 

11/122 Prehospital 12-Lead ECG Monitoring Procedure (2 of 3) Place lead V1 by attaching the positive electrode to the right of the sternum at the fourth intercostal space Place lead V2 by attaching the positive electrode to the left of the sternum at the fourth intercostal space Place lead V4 by attaching the positive electrode at the midclavicular line at the fifth intercostal space Place lead V3 by attaching the positive electrode in a line midway between lead V2 and lead V4

Prehospital 12-Lead ECG Monitoring Procedure (3 of 3) : 

12/122 Prehospital 12-Lead ECG Monitoring Procedure (3 of 3) Place lead V5 by attaching the positive electrode at the anterior axillary line at the same level as V4 Place V6 by attaching the positive electrode to the midaxillary line at the same level as V4 Ensure that all leads are attached to electrodes Turn on the machine Ensure that a good tracing is being received from each channel Record the tracing Interpret the tracing Provide the tracing to the receiving hospital

Arterial Blood Pressure : 

13/122 Arterial Blood Pressure One of the most important physiologic measurements in medicine Also one of the most unreliable Measurement with sphygmomanometer unreliable

Indirect (Noninvasive) Pressure Monitoring : 

14/122 Indirect (Noninvasive) Pressure Monitoring Sphygmomanometer Multiple sources of error Inappropriate size cuff User error Environmental distractions Usually adequate for most situations Critical care patient requires more accurate arterial blood pressure determination Arterial BP

Direct (Invasive) Pressure Monitoring : 

15/122 Direct (Invasive) Pressure Monitoring More involved than noninvasive pressure monitoring Invasive procedure Requires sophisticated equipment Catheter Transducer Oscilloscope or graph Arterial BP

Arterial Catheter : 

16/122 Arterial Catheter Filled with heparinized saline Serves as a fluid column between blood and transducer Transmits pressure from pulse Arterial BP

Transducer : 

17/122 Transducer Receives pressure from pulse and produces weak electrical signal Amplifier commonly used to strengthen signal Arterial BP

Oscilloscope or Graph : 

18/122 Oscilloscope or Graph Displays signal from transducer Electric monitor commonly used Arterial BP

Electronic Monitor Displays : 

19/122 Electronic Monitor Displays Pressure waveform Numerical values for: Systolic pressure Diastolic pressure Mean arterial pressure (MAP) Frequent calibration and maintenance required Arterial BP

Leveling and Zeroing of Transducer : 

20/122 Leveling and Zeroing of Transducer Zero reference point at phlebostatic axis Level of right and left atrium when patient supine Transducer is zeroed by exposing the pressure transducer to atmospheric air Open three-way stopcock so it is closed to patient and the transducer is open to atmospheric air Zeroing function on monitor activated System left untouched until flat line appears on monitor Three-way stopcock opened to patient and blood pressure measured System should be zeroed any time patient position changes Arterial BP

Arterial Waveform (1 of 2) : 

21/122 Arterial Waveform (1 of 2) Rapid upstroke Rapid ejection of blood from left ventricle into aorta Follows QRS complex on ECG Dicrotic notch Slight backflow of blood in aorta after closure of aortic valve End of ventricular systole Corresponds with end of ventricular repolarization T wave on ECG Value measured at peak of waveform is systolic pressure Value measured at trough is diastolic pressure Arterial BP

Arterial Waveform (2 of 2) : 

22/122 Arterial Waveform (2 of 2) Arterial BP

Mean Arterial Pressure (MAP) : 

23/122 Mean Arterial Pressure (MAP) Electronic determination preferred to calculated determination MAP preferred over systolic pressure Represents true peripheral blood flow driving pressure Arterial BP MAP  [(2  Pdiastolic)  Psystolic] 3

Art Line Indications : 

24/122 Art Line Indications Need for continuous monitoring if intra-arteria pressure Need for frequent arterial access Blood gas sampling Titration of vasoactive medications during transport Arterial BP

Insertion of Arterial Catheter(1 of 2) : 

25/122 Insertion of Arterial Catheter(1 of 2) Critical care paramedics not often responsible for placement Familiarity of placement sites and insertion technique helpful in management Common placement sites Radial artery Ulnar artery Rarely used Brachial artery Femoral artery Arterial BP

Insertion of Arterial Catheter(2 of 2) : 

26/122 Insertion of Arterial Catheter(2 of 2) Factors determining placement site Experience of practitioner Patient history of vascular disease Relative hemodynamic status of patient Evaluation of risks and benefits of each site Arterial BP

Allen’s Test(1 of 2) : 

27/122 Allen’s Test(1 of 2) Assures adequate collateral blood flow to palm Technique Have patient clench fist on arm to be used for catheterization Aids with venous flow from palm Digitally occlude radial and ulnar arteries Palmer region will blanch due to lack of arterial blood supply Arterial BP

Allen’s Test(2 of 2) : 

28/122 Allen’s Test(2 of 2) While occluding arteries, have patient open hand Release occlusion of ulnar artery that will not be cannulated If adequate perfusion supplied by unoccluded ulnar artery, blanching will subside in 3 seconds Positive Allen’s Test occurs when blushing of the palm indicates ulnar patency Arterial BP

Art Line Placement : 

29/122 Art Line Placement Sterile technique Catheter-over-needle Modified Seldinger technique Local anesthesia 1% Lidocaine at insertion site Any over-the-needle catheter may be used if anatomy allows For deeper vessels requiring longer catheters, commercial kits are available Guidewire used to increase success rate Arterial BP

Art Line Complications(1 of 4) : 

30/122 Art Line Complications(1 of 4) Pain Nerve fibers alongside arterial vessels Hemorrhage Higher pressure in arterial system compared to venous Significant hemorrhage can occur rapidly Direct pressure for at least 10 minutes Application of pressure dressing Monitor peripheral perfusion Assess for distal ischemia Use of blood thinners, fibrinolytics, 2b3a inhibitors Arterial BP

Art Line Complications(2 of 4) : 

31/122 Art Line Complications(2 of 4) Vasospasm Arteries more vasoactive than veins Waveform distortion Arterial line must be flushed often and rezeroed Ensures accurate readings Damping Suspected when reading does not improve with flushing and rezeroing Results from interaction of arterial pressure wave and arterial line setup Arterial BP

Art Line Complications(3 of 4) : 

32/122 Art Line Complications(3 of 4) Overdamping Causes Blood clots Air bubbles in tubing Kink in tubing Results in: Slurred upstroke Loss of dicrotic notch Loss of fine detail of tracing Erroneously low blood pressure readings Arterial BP

Art Line Complications(4 of 4) : 

33/122 Art Line Complications(4 of 4) Underdamping Causes Long connecting tubing Small tubing Catheter too large for vessel Occludes vessel lumen Results in: Exaggerations in peaks and troughs of waveform Erroneously high systolic pressures Erroneously low diastolic pressures Arterial BP

Troubleshooting Arterial Dampening (1 of 2) : 

34/122 Troubleshooting Arterial Dampening (1 of 2) Damping corrected by addressing underlying problem Ensure that all connections are tight Continuously reassess catheter insertion site Kinking of catheter can result in poor distal perfusion Distal ischemia Immobilization of extremity may help prevent catheter displacement, disconnection, and kinking Arterial BP

Troubleshooting Arterial Dampening(1 of 2) : 

35/122 Troubleshooting Arterial Dampening(1 of 2) Arterial BP

Arterial Catheter Waveform(1 of 2) : 

36/122 Arterial Catheter Waveform(1 of 2) After placement, arterial catheter attached to monitoring system Includes monitor Systolic blood pressure Indicated by systolic peak of waveform Peak begins to fall just after completion of QRS on ECG Normal range: 90–140 mmHg Arterial BP

Arterial Catheter Waveform(2 of 2) : 

37/122 Arterial Catheter Waveform(2 of 2) Diastolic blood pressure Indicated by trough in waveform Normal range: 60–90 mmHg Dicrotic notch Indicates closure of aortic valve Pressure measurement at dicrotic notch  MAP Normal values: 65–100 mmHg  60 mmHg  Hypoperfusion state  55 mmHg  Significant hypoperfusion state Arterial BP

Central Circulation Monitors : 

38/122 Central Circulation Monitors Provides important hemodynamic information Two frequently used methods Central venous pressure (CVP) monitor Pulmonary artery catheter monitor

Central Venous Pressure (CVP) Monitor : 

39/122 Central Venous Pressure (CVP) Monitor Central venous pressure Blood pressure in vena cava/right atrium Pressures equal as no valves exist between locations Provides information about right ventricular preload Helpful as a guide for fluid therapy Tip of catheter in vena cava near right atrium CVP

CVP Pressure Monitoring(1 of 2) : 

40/122 CVP Pressure Monitoring(1 of 2) Water manometer Placed in line between IV fluid and CVP catheter Three-way stopcock To measure, open stopcock between manometer and patient Column of water in manometer equilibrates with pressure in vena cava Level fluctuates with respiration cm H20 Divide by 1.36 to convert to mmHg CVP

CVP Pressure Monitoring(2 of 2) : 

41/122 CVP Pressure Monitoring(2 of 2) Electronic pressure transducer More common than manometry mmHg Must be leveled, calibrated, and zeroed CVP

CVP Pressure : 

42/122 CVP Pressure Normal CVP 5–8 cmH20 0–6 mmHg Trends important Isolated fluctuations of little importance CVP

Abnormal CVP : 

43/122 Abnormal CVP Low CVP secondary to: Hypovolemia Relative Venodilation Absolute Hypovolemia CVP

Increased CVP : 

44/122 Increased CVP Secondary to: Right ventricular failure Vasoconstriction Fluid volume overload Cardiac tamponade Chronic pulmonary disease Chronic left ventricular failure Tricuspid insufficiency Mechanical ventilation CVP

Indications : 

45/122 Indications Need for CVP monitoring Emergency venous access Large volume fluid administration Medication administration Routine venous access Peripheral sites unavailable Need for long-term venous access CVP

Central Venous Catheter Insertion : 

46/122 Central Venous Catheter Insertion Sterile conditions Seldinger technique Needle puncture site anesthetized with 1% lidocaine Needle placed in vein Guidewire passed through needle into vein Needle removed Small skin incision made at guidewire to facilitate catheter passage Catheter passed over guidewire into vein Guidewire removed Tubing attached to central line CVP

Seldinger Technique : 

47/122 Seldinger Technique CVP

Central Venous Catheter Insertion (1 of 2) : 

48/122 Central Venous Catheter Insertion (1 of 2) CVP

Central Venous Catheter Insertion (2 of 2) : 

49/122 Central Venous Catheter Insertion (2 of 2) Access routes Most frequently used Subclavian vein Internal jugular vein Infrequently used Femoral vein External jugular vein Antecubital vein If central route unobtainable Type of catheter used dictated by patient need Single lumen Double lumen Triple lumen CVP

Complications : 

50/122 Complications Hemorrhage Venous perforation Arterial puncture Cannula dislodgment Pulmonary complications Pneumothorax Hydrothorax Hemothorax Pneumomediastinum Hydromediastinum CVP Dysrhythmias Infection Extravasation of administered fluids, medications

Central Venous Catheter Waveform : 

51/122 Central Venous Catheter Waveform When electronic monitor is used, waveform and numerical display are produced Systolic and diastolic pressures are indistinguishable Low-pressure, venous system Mean pressure monitored CVP

Pulmonary Artery Pressure Monitoring (1 of 3) : 

52/122 Pulmonary Artery Pressure Monitoring (1 of 3) Central venous catheter passed through right atrium, right ventricle, past tricuspid valve, and into pulmonary artery Allows monitoring of: Right ventricular function Pulmonary vascular status Left ventricular function (indirectly) PAP

Pulmonary Artery Pressure Monitoring (2 of 3) : 

53/122 Pulmonary Artery Pressure Monitoring (2 of 3) Specific parameters measured CO Right arterial pressure Right ventricular pressure Pulmonary artery pressure Pulmonary artery wedge pressure (PAWP) PAP

Pulmonary Artery Pressure Monitoring (3 of 3) : 

54/122 Pulmonary Artery Pressure Monitoring (3 of 3) Catheter Flow-directed, balloon-tipped pulmonary artery catheter Swan-Ganz catheter Dual lumen Distal port Proximal port Balloon inflated to: “Float” catheter into position Measure pulmonary wedge pressures PAP

Waveform Interpretation : 

55/122 Waveform Interpretation Pressure changes during systole and diastole Waveforms classified as: Right atrial Right ventricular Pulmonary artery pressure Pulmonary artery wedge pressure Relationship between ECG and waveforms PAP

Right Atrial Pressure : 

56/122 Right Atrial Pressure Mean right atrial pressure 8 mmHg Right Atrial Pressure

Right Atrial Pressure Waveform (1 of 5) : 

57/122 Right Atrial Pressure Waveform (1 of 5) A wave First positive deflection Rise in pressure due to atrial contraction Follows P wave of ECG Right Atrial Pressure

Right Atrial Pressure Waveform (2 of 5) : 

58/122 Right Atrial Pressure Waveform (2 of 5) X descent Downslope following A wave Fall in pressure due to relaxation of atria Right Atrial Pressure

Right Atrial Pressure Waveform (3 of 5) : 

59/122 Right Atrial Pressure Waveform (3 of 5) C wave Small positive deflection on downslope of A wave (X descent) Bulging of tricuspid valve early in ventricular systole Right Atrial Pressure

Right Atrial Pressure Waveform (4 of 5) : 

60/122 Right Atrial Pressure Waveform (4 of 5) V wave First positive deflection following C wave Caused by atrial filling during ventricular systole Right Atrial Pressure

Right Atrial Pressure Waveform (5 of 5) : 

61/122 Right Atrial Pressure Waveform (5 of 5) Y descent Follows V wave Fall in pressure due to opening of tricuspid valve Ventricular filling Right Atrial Pressure

Right Ventricular Pressure(1 of 2) : 

62/122 Right Ventricular Pressure(1 of 2) Right-atrial end-diastolic pressure 0–8 mmHg Equal to right atrial pressure when tricuspid valve opens Right Ventricular Pressure

Right Ventricular Pressure(2 of 2) : 

63/122 Right Ventricular Pressure(2 of 2) Right-atrial systolic pressure 15–30 mmHg Opens pulmonic valve Propels blood into pulmonary artery Higher-pressure chamber Right Ventricular Pressure

Right Ventricular Pressure Waveform : 

64/122 Right Ventricular Pressure Waveform Early, steep upstroke Rapid, passive ventricular filling Right Ventricular Pressure Middle, gradual upstroke Slower filling period Late, steep upstroke Ventricular filling during atrial systole

Right Ventricular Pressure : 

65/122 Right Ventricular Pressure Right atrial and ventricular pressures equal during diastole Tricuspid valve open Pressures monitored Right ventricular systolic peak Right ventricular end-diastolic Right Ventricular Pressure

Pulmonary Artery Pressure (1 of 4) : 

66/122 Pulmonary Artery Pressure (1 of 4) Low-pressure system Pulmonary artery pressure PAP

Pulmonary Artery Pressure (2 of 4) : 

67/122 Pulmonary Artery Pressure (2 of 4) Systolic 15–30 mmHg Equal to right ventricular systolic pressure PAP

Pulmonary Artery Pressure (3 of 4) : 

68/122 Pulmonary Artery Pressure (3 of 4) Diastolic 8–15 mmHg Reflects resistance of pulmonary vascular bed Left-ventricular end-diastolic pressure also PA diastolic pressure is indirect measurement of left ventricular pressure PAP

Pulmonary Artery Pressure (4 of 4) : 

69/122 Pulmonary Artery Pressure (4 of 4) Mean pulmonary artery pressure 10–20 mmHg PAP

Pulmonary Artery Wedge Pressure (PAWP) : 

70/122 Pulmonary Artery Wedge Pressure (PAWP) Measures left-atrial and ventricular end-diastolic pressure More accurate than estimate from pulmonary artery diastolic pressure PAWP

PAWP : 

71/122 PAWP 8–12 mmHg Catheter tip placed in pulmonary artery In-place pulmonary artery catheter used Balloon on distal tip inflated PAWP Balloon advanced until it lodges in branch of pulmonary artery Forward blood flow stopped Static column of blood created Branch of artery Pulmonary capillaries Pulmonary vein Left atrium Open mitral valve During diastole Left ventricle Balloon deflated after measurements completed

PAWP Waveform : 

72/122 PAWP Waveform A wave Atrial contraction V wave Left ventricular contraction PAWP

Complications of PA Catheterization : 

73/122 Complications of PA Catheterization Pulmonary injury During needle puncture Dysrhythmias Infection Pulmonary artery rupture PAWP

Abnormalities in PA Catheter Pressures : 

74/122 Abnormalities in PA Catheter Pressures PAWP

PA Waveform Abnormalities : 

75/122 PA Waveform Abnormalities Increased size of A waves Impaired arterial emptying Tricuspid stenosis Right ventricular failure PAWP Increased size of V wave Tricuspid incompetence Regurgitation

Elevated PA Pressure : 

76/122 Elevated PA Pressure Left ventricular failure Mechanical ventilation Increased pulmonary vascular resistance Pulmonary hypertension Pulmonary embolism ARDS PAWP

PAWP Waveform Abnormalities : 

77/122 PAWP Waveform Abnormalities Increased size of V waves Seen with any resistance to ventricular filling Mitral regurgitation Increased size of A waves Seen with any pathology that increases pressure during atrial contraction Mitral stenosis PAWP

PAWP Elevation : 

78/122 PAWP Elevation Left ventricular dysfunction Increased circulating blood volume Increases in right and left ventricular diastolic pressures Constrictive pericarditis Pericardial tamponade PAWP

Cardiac Output Determination : 

79/122 Cardiac Output Determination Outputs of left and right ventricles are identical Methods of CO determination Fick method Standard technique Cold thermodilution technique CO  SV  HR

Fick Method : 

80/122 Fick Method Q (L/minute)  O2 Consumption (ml/minute) Arteriovenous Oxygen Difference (ml/minute) Q (L/minute)  O2 Consumption (ml/minute) Arteriovenous Oxygen Difference (ml/minute)

Standard Technique : 

81/122 Standard Technique Most dependable when CO low Arteriovenous oxygen difference large

Cold Thermodilution Technique : 

82/122 Cold Thermodilution Technique Principle When indicator is introduced to flow of blood, concentration of indicator at downstream site is inversely proportional to flow rate Higher the flow rate, lower the concentration Technique PA catheter proximal port used to introduce indicator fluid 5% dextrose solution Normal saline Mixes with blood in right ventricle Thermistor (temp probe) at distal tip of catheter measures temperature of fluid as it passes through pulmonary artery Most dependable when CO high

Hemodynamic Parameters : 

83/122 Hemodynamic Parameters

Body Surface Area (BSA) : 

84/122 Body Surface Area (BSA) Better indicator of body size than height and weight BSA (m2)  √ [Height (cm)  Weight (kg) 3,600

Central Venous Pressure (CVP) : 

85/122 Central Venous Pressure (CVP) Measured with pulmonary artery catheter CVP = Right Atrial Pressure = Right-Ventricular End-Diastolic Pressure

Pulmonary Capillary Wedge Pressure (PCWP) : 

86/122 Pulmonary Capillary Wedge Pressure (PCWP) PCWP = Left Atrial Pressure = Left-Ventricular End-Diastolic Pressure

Stroke Volume Index (SVI) : 

87/122 Stroke Volume Index (SVI) Amount of blood ejected by ventricles during one contraction SVI  Cardiac Index Heart Rate

Left Ventricular Stroke Work Index (LVSWI) (1 of 2) : 

88/122 Left Ventricular Stroke Work Index (LVSWI) (1 of 2) Amount of work involved in moving blood in the left ventricle during one contraction Assesses contractility 35–80 g/m2/beat LVSWI  (MAP  PAWP)  SVI  0.0136 [constant]

Left Ventricular Stroke Work Index (LVSWI) (2 of 2) : 

89/122 Left Ventricular Stroke Work Index (LVSWI) (2 of 2)

Systemic Vascular Resistance : 

90/122 Systemic Vascular Resistance Resistance to blood flow created by systemic vasculature Vasoconstriction increases SVR Changes in blood viscosity can also affect SVR Normal SVR  900–1,200 dyne/sec/cm-5 SVR  (MAP  CV) Å CO

Systemic Vascular Resistance Index (SVRI) : 

91/122 Systemic Vascular Resistance Index (SVRI) Measure of vascular resistance created by entire systemic circulation Depends on: Peripheral resistance Preload Cardiac output SVRI  MAP  Right Atrial Pressure  80 Cardiac Index

Pulmonary Vascular Resistance (PVR) : 

92/122 Pulmonary Vascular Resistance (PVR) Calculation of right-side afterload Resistance to blood flow created by pulmonary vasculature Pulmonary artery to left atrium Normal  100–200 dyne/sec/cm-5 PVR (dyne/sec/cm -5)  (Mean Pulmonary Artery Pressure  PCWP)  80

Pulmonary Vascular Resistance Index (PVRI) : 

93/122 Pulmonary Vascular Resistance Index (PVRI) PVRI  (PAP  PCWP)  80 Cardiac Index

Systemic Oxygen Transport (1 of 3) : 

94/122 Systemic Oxygen Transport (1 of 3) Oxygen content Amount of oxygen in blood available for offloading to cells Oxygen saturation Amount of blood bound to hemoglobin Oxyhemoglobin 95 to 97 Percent of oxygen present as oxyhemoglobin 3 to 5 Percent dissolved in plasma Blood gas sample Measures the oxygen dissolved in plasma

Systemic Oxygen Transport (2 of 3) : 

95/122 Systemic Oxygen Transport (2 of 3) Oxygen delivery Rate of oxygen transport DO2  Cardiac Index  13.4  Hb  SaO2 Mixed venous oxygen saturation Oxygen saturation in pulmonary artery (SVO2) Measured with pulmonary artery catheter SVO2 varies inversely with amount of oxygen offloaded in microcirculation (oxygen uptake) SVO2  1/O2 extraction

Systemic Oxygen Transport (3 of 3) : 

96/122 Systemic Oxygen Transport (3 of 3) Oxygen uptake (VO2) Amount of oxygen offloading in microcirculation VO2  Cardiac Index  13.4 X Hb  (SaO2  SVO2) Oxygen extraction ratio (O2ER) Ratio between O2 delivery and O2 uptake O2ER  (VO2/DO2)  100

Clinical Integration : 

97/122 Clinical Integration

Left Heart Failure : 

98/122 Left Heart Failure Decreased CI Elevated PCWP Elevated SVRI

Cardiogenic Shock : 

99/122 Cardiogenic Shock Decreased CI Elevated CVP Elevated SVRI Low DO2 Low VO2

Hypovolemic Shock : 

100/122 Hypovolemic Shock Decreased CI Decreased CVP Elevated SVRI Low VO2

Distributive Shock : 

101/122 Distributive Shock Increased CI Decreased CVP Decreased SVRI Low VO2

Pulmonary CatheterPlacement : 

102/122 Pulmonary CatheterPlacement

Indications of PA Catheter Placement (1 of 2) : 

103/122 Indications of PA Catheter Placement (1 of 2) Diagnosis of shock states and shock types Diagnosis of high-pressure versus low-pressure pulmonary edema Assessment of vascular tone Assessment of myocardial contractility, including determination of cardiac output Assessment of intravascular fluid balance

Indications of PA Catheter Placement (2 of 2) : 

104/122 Indications of PA Catheter Placement (2 of 2) Analysis of mixed venous oxygen saturation Monitoring and management of complicated AMI Assessment of hemodynamic response to therapies Management of MODS and/or severe burns Management of hemodynamic instability after cardiac surgery

Insertion of PA Catheter(1 of 2) : 

105/122 Insertion of PA Catheter(1 of 2) Catheter placed in vein Catheter fed into vein until distal tip in right atrium Distal balloon inflated with 1.5 cc of air Distal tip “floated” through tricuspid, into right ventricle, through pulmonic valve, and into pulmonary artery Balloon allowed to “wedge” itself in branch of pulmonary artery

Insertion of PA Catheter (2 of 2) : 

106/122 Insertion of PA Catheter (2 of 2)

Preparation for Hemodynamic Monitoring : 

107/122 Preparation for Hemodynamic Monitoring Prime the flush system Connect the transducer to the monitor Place the transducer Zero the pressure system to atmospheric pressure Calibrate the pressure system

Priming the Flush System(1 of 2) : 

108/122 Priming the Flush System(1 of 2) Necessary equipment 250–500 cc 0.9% normal saline or heparinized saline solution Flush administration setup Tighten all connections in the flush administration set Expel all air from flush bag 18g needle via medication administration port Spike flush bag, prime drip chamber, and administration set

Priming the Flush System(2 of 2) : 

109/122 Priming the Flush System(2 of 2) Inspect the flush system for air bubbles Connect flush administration set to catheter being monitored Flush administration set while connecting to catheter to eliminate air from the catheter Apply pressure infuser bag to flush solution Inflate to 300 mm Hg

Connecting the Transducer to the Monitor : 

110/122 Connecting the Transducer to the Monitor Pressure transducer in administration set Connects to monitor cable via connector Waveform visible Leveling and zeroing of transducer needed for pressure measurement

Transducer Leveling and Zeroing : 

111/122 Transducer Leveling and Zeroing Transducer placed at phlebostatic axis Level of right atrium, fourth intercostal space Patient supine Using three-way stopcock, close patient to transducer and open it to atmospheric air Activate zeroing function on monitor Close transducer to atmospheric air and open to patient

Transducer Waveform Calibration : 

112/122 Transducer Waveform Calibration Transducer internally calibrated by monitor Most monitors today have default settings Operator can rescale waveform

Complications of Invasive Catheters : 

113/122 Complications of Invasive Catheters Hemorrhage Dysrhythmias Pulmonary injury Cardiac injury Dislodgement

Intra-Aortic Balloon Pump (IABP)(1 of 3) : 

114/122 Intra-Aortic Balloon Pump (IABP)(1 of 3) Provides mechanical circulatory support for failing heart Catheter 30-cm polyurethane balloon on distal end Balloons sized according to height Placed in aorta distal to left of subclavian artery Inserted in femoral artery During operation, rapidly inflated and deflated with 35–40 ml of helium IABP

Intra-Aortic Balloon Pump (IABP) (2 of 3) : 

115/122 Intra-Aortic Balloon Pump (IABP) (2 of 3) IABP

Intra-Aortic Balloon Pump (IABP) (3 of 3) : 

116/122 Intra-Aortic Balloon Pump (IABP) (3 of 3) IABP pump Rate adjustable 1:1, 1:2, 1:8 Inflation volume adjustable IABP ©Craig Jackson/In the Dark Photography

Indications for IABP Therapy : 

117/122 Indications for IABP Therapy Cardiogenic shock Left ventricular failure Drug-induced cardiovascular failure Septic shock Stunned myocardium Cardiac surgery preparation IABP

IABP Operation : 

118/122 IABP Operation Balloon rapidly inflated at onset of ventricular diastolic period Increases peak diastolic pressure Displaces intravascular blood forward in circulation Coronary artery perfusion increases Rapidly deflates at beginning of ventricular systole Reduces end-diastolic pressure Reduces impedance to forward blood flow Decreases afterload Increases SV IABP Datascope, Fairfield, NJ

IABP Contraindications : 

119/122 IABP Contraindications Gross aortic insufficiency Peripheral vascular disease with poor femorals Irreversible brain damage Chronic end state heart disease Dissecting aortic or thoracic aneurysms Peripheral vascular disease IABP

Side Effects and Complications : 

120/122 Side Effects and Complications Limb ischemia Bleeding at insertion site Thrombocytopenia Immobility of balloon catheter Balloon leak or rupture Helium embolization Thrombus formation Infection Aortic dissection Compartment syndrome IABP

Mechanical Circulatory Support : 

121/122 Mechanical Circulatory Support Ventricular assist device (VAD) Used to increase CO in patients refractory to IABP therapy Commonly used post–cardiac bypass surgery Pumps placed in ventricle Right (RVAD) Left (LVAD) Both (BiVAD) External power source required Short-term device Bridge to cardiac transplantation

Summary : 

122/122 Summary Critical care paramedics will most likely not be required to establish/insert hemodynamic monitoring catheters Must be familiar with insertion technique, however Must be prepared to: Interpret data Use data in differential diagnosis and treatment decisions Manage complications of devices