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