By Nancy Jenkins RN,MSN What is Hemodynamic Monitoring an

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Hemodynamic Monitoring
By Nancy Jenkins RN,MSN
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What is Hemodynamic Monitoring and why do it?
It is measuring the pressures in the
heart It allows us to see inside the heart and
adjust volume as needed
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Comparing Hemodynamics to IV pump

• Fluid preload
• Pump CO or contractility (needs electricity)
• Tubing afterload

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Nursing ManagementHemodynamic Monitoring- You
are already doing

• General appearance
• Level of consciousness
• Skin color/temperature
• Vital signs
• Peripheral pulses
• Urine output
• Lung sounds

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Nursing ManagementHemodynamic Monitoring

• Single hemodynamic values are rarely
  significant.
• Monitor trends and evaluate whole clinical
  picture
• Goals
• Recognize early clues
• Intervene before problems develop or escalate

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Hemodynamic Monitoring Components We Will Look at
Today
Heart Rate Blood Pressure and MAP CVP Pulmonary
Artery Pressures Systemic Vascular Pressure
(SVR) Pulmonary Vascular Pressure (PVR) Cardiac
Output/ Cardiac Index Stroke Volume
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Important Equation
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Hemodynamic MonitoringGeneral Principles

• CO Volume of blood pumped by heart in 1 minute
• CI CO adjusted for body size
• SV Volume ejected with each heartbeat
• SVI SV adjusted for body size
• Easier to adjust HR than SV
• Preload, afterload, and contractility
  determine SV

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Hemodynamics Normal value
Mean Arterial Pressure (MAP) 70 -90 mm Hg Cardiac
Index (CI)- 2.2-4.0 L/min/m2 Cardiac Output
(CO)- 4-8 L/min Central Venous Pressure (CVP)
(also known as Right Atrial Pressure (RA)) 2-8
mmHg Pulmonary Artery Pressure (PA) Systolic
20-30 mmHg (PAS)Diastolic 4-12 mmHg (PAD)Mean
15-25 mmHg Pulmonary Capillary Wedge Pressure
(PWCP) 4-12 mmHg Systemic Vascular
Resistance(SVR) 800-1200  
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• Volume of blood within ventricle at end of
  diastole
• Measured by CVP and wedge pressure in ICU

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Preload

• Def- the volume that stretches the LV just before
  contraction
• Measured by CVP for RV and PAWP for LV
• Measures the preload of the LV or LVEDP wedge or
  PAW
• The greater the preload the greater the stroke
  volume and the greater the cardiac output

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Decreased Preload- leads to Dec. SV and venous
return

• Hypovolemia
• Tachycardia- why?
• Vasodilation/ dec. venous return
• Treatment- fluid
• A goal for heart failure

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Increased Preload

• Valvular disease
• Hypervolemia
• Heart failure
• Treatment- diuretics, vasodilators
• Vascular system holding tank- vasodilation,
  vasoconstriction depending on need

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• Measured by SVR and PVR in the ICU

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Afterload

• Resistance to ejection- arterial B/P
• Measured by PVR and SVR in the ER
• Decreased afterload
• Vasodilation (sepsis, hyperthermia)
• Hypotention
• Nitrates

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Afterload

• Increased afterload
• Vasoconstriction (hypovolemia, hypothermia)
• Aortic stenosis
• Hypertension
• Fight or flight
• Pulmonary hypertension
• The greater the afterload, the lower the
  cardiac output

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Cardiac Output

• COSVxHR CI CO/BSA
• Normal CO 4-8 L/min CI 2.2-4
• Urine output- indirect measurement
• To compensate for dec. CO get tachycardia
• Decreased CO
• Poor ventricular filling- hypovolemia or SVT
• Poor emptying, dec. contractility (infarct,
  ischemia, arrhythmias)
• Vasodilation- sepsis and drugs
• Increased afterload- hypertension,
  vasoconstriction

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Cardiac Output

• Increased
• Increased O2 demand- exercise
• SNS
• Drugs- positive inotropics (Continuous infusions
  Dobutamine, Dopamine, Primacor
• Digoxin- IVP

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Stroke Volume

• Def- amount of blood ejected with each heart beat
• Normal SV 60-130
• Exercise can increase SV
• Factors that determine SV
• Preload
• Afterload
• Contractility

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Contractility

• Starlings law
• Increased contractility
• SNS
• Drugs- positive inotropics, epinephrine, calcium
• Decreased contractility
• Loss of muscle (acute MI, cardiomyopathy)
• Hypoxemia
• Electrolyte imbalance
• Drugs- (lidocaine, calcium channel blockers, beta
  blockers

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Contractility

• Determined by the SV and the EF
• Important to know the EF of all heart failure
  patients
• Measured by echo
• EF- how much blood is ejected during systole
  compared to how much preload there is.
• Normal EF- 55-65
• Ex 90/140 64EF

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How and when do we measure afterload?Arterial
B/P and SVR

• Continuous arterial pressure monitoring
• Acute hypertension/hypotension
• Respiratory failure- frequent ABG sampling
• Shock
• Coronary interventional procedures
• Continuous infusion of vasoactive drugs

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Best indicator of tissue perfusion. Needs to be
at least 60-70 to perfuse organs
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Arterial Line
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Arterial Pressure Monitoring

• High- and low-pressure alarms based on patients
  status
• Risks
• Hemorrhage, infection, thrombus formation,
  neurovascular impairment, loss of limb
• Nursing- Check 5 Ps

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Arterial Pressure Waveform
Dicrotic notch signifies the closure of the
aortic valve.
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Pulmonary Artery Catheter
Fig. 66-7
PA Catheter Insertion
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PPA catheter tells you everything you want to
know about the heart (Snap, Crackle,
Pop) -         1) how well the pump is pumping
(cardiac output, cardiac index) (snap) -         
2)how full the right side of the heart is (CVP),
and how full the left side is (wedge pressure)
thats the volume(crackle)         3)  and how
well your patients arteries can squeeze thats
the SVR the systemic vascular
resistance (pop)
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PA Waveforms during Insertion
Fig. 66-9
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Important Measurements Obtained by PA Catheter

• Right Atrial Pressure (CVP)
• PAP
• Diastolic (PAD)
• PA Systolic (PAS)
• PA Wedge (Wedge, PAOP)
• Cardiac Output
• Cardiac Index

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Pulmonary Artery Pressure Monitoring- CVP

• Right atrium port- also know as proximal
• Measurement of CVP
• Injection of fluid for CO measurement
• Can you give meds through this port?
• Blood sampling

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Central Venous Pressure Waveforms
Fig. 66-11
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CVP valuesRight Heart Presssures

• Normal 2-8mmHg
• Dec.
• Hypovolemia
• Decreased venous return
• Inc.
• Hypervolemia
• Inc. venous return
• Right HF, pulmonary hypertension
• Tricuspid stenosis and regurgitation

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PA pressure

• PAD- should be close to wedge
• PAS- tells RV pressure
• PAW- LVEDP or preload of LV

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PA Pressures

• Normal 20-30 mmHg systolic, 4-12mmHg diastolic
• PAS RV pressure
• Inc PAS in pulmonary hypertension
• Inc. PAD in ventricular failure
• Dec. in hypovolemia
• Dec. in shock

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PAW

• Normal 6-12mmHg
• Equals LVEDP or preload of LV
• Dec.in hypovolemia or low stroke volume
• Inc. in LV failure, mitral valve disorders
• Inc. in hypervolemia
• Fluids for dec. wedge and diuretics for inc.
  wedge

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Measuring Cardiac Output
Fig. 66-12
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Cardiac Output
Cardiac Output Monitoring
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Measuring Cardiac Output and SVR

• SVR can be calculated when CO is measured
• SVR(MAP-CVP) x80/ CO
• ? SVR
• Vasoconstriction from shock
• Hypertension
• ? Release or administration of epinephrine or
  other vasoactive inotropes
• Left ventricular failure
• Dec. SVR
• Vasodilation
• sepsis

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Cardiac Output
http//www.lidco.com/docs/Brochure.pdf
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Complications with PA Catheters

• Infection and sepsis
• Asepsis for insertion and maintenance of catheter
  and tubing mandatory
• Change flush bag, pressure tubing, transducer,
  and stopcock every 96 hours
• Air embolus (e.g., disconnection)

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Complications with PA Catheters

• Ventricular dysrhythmias
• During PA catheter insertion or removal
• If tip migrates back from PA to right ventricle
• PA catheter cannot be wedged
• May need repositioning

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Complications with PA Catheters

• Pulmonary infarction or PA rupture
• Balloon rupture (e.g., overinflation)
• Prolonged inflation
• Spontaneous wedging
• Thrombus/embolus formation

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Noninvasive Hemodynamic Monitoring

• Impedance cardiography (ICG)
• Def-Continuous or intermittent, noninvasive
  method of obtaining CO and assessing thoracic
  fluid status
• Impedance-based hemodynamic parameters (e.g., CO,
  SV, SVR) are calculated from Zo, dZ/dt, MAP, CVP,
  and ECG

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Noninvasive Hemodynamic Monitoring

• Major indications
• Early signs and symptoms of pulmonary or cardiac
  dysfunction
• Differentiation of cardiac or pulmonary cause of
  shortness of breath
• Evaluation of etiology and management of
  hypotension

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Noninvasive Hemodynamic Monitoring

• Major indications (contd)
• Monitoring after discontinuing a PA catheter or
  justification for insertion of a PA catheter
• Evaluation of pharmacotherapy
• Diagnosis of rejection following cardiac
  transplantation

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hemodynamic cases (1 and 4)
Case Study
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Three main types of hypotension (shock states)
that youre going to see in the ICU

• 1. Pump- Cardiogenic shock
• 2. Volume- Hypovolemia
• 3. Squeeze - Sepsis

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-         Pump problems? Cardiogenic shock?
The cardiac output will be low, because the pump
isnt pumping. Blood pressure drops. The body
says to itself What to do? Got to keep the
blood pressure up somehow!, and starts to
tighten up the arterial bed. What number tells
how tight the arterial system is? SVR.
So in cardiogenic shock, the cardiac output
goes down, the SVR goes up the pattern is
usually plain as day. Ooh, look! The output is
only 2.2, and the SVR is 2400! What does the
wedge pressure do? (Remember, the LV is pumping
poorly, and cant empty itself)
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-         Volume problems? Hypovolemic shock?
Lost a lot of blood? Running too many marathons?
Cardiac output will probably be low, since there
isnt enough volume to pump with. CVP and wedge
pressures? Low, right? again, not enough
volume. SVR? Same as cardiogenic the arteries
clamp down, trying to maintain pressure.   Hypovo
lemic shock cardiac output low, central
pressures low, SVR high.  
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-         Squeeze problem? Any idea what makes
this happen? Anybody say, sepsis? All that
bacteremic endotoxin makes the arteries dilate
blood pressure drops. What to do? Now the body
uses the mirror reflex of what it did in the
cardiogenic setting instead of clamping down the
arteries, which it cant do, because thats where
the problem is now the heart picks up the
slack, pumping both faster and harder heart rate
goes up, and cardiac output does too.   Septic
shock cardiac output high, central pressures
low, SVR low.