Hemodynamics Basic Concepts

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  • 1.Understanding Adult Hemodynamics Theory, Monitoring, Waveforms and Medications Vicki Clavir RN

2. Purpose

  • The primary purpose of invasive hemodynamic monitoring is the early detection, identification, and treatment of life-threatening conditions such as heart failure and cardiac tamponade. By using invasive hemodynamic monitoring the nurse is able to evaluate the patient's immediate response to treatment such as drugs and mechanical support. The nurse can evaluate the effectiveness of cardiovascular function such as cardiac output, and cardiac index.

3. 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 4. Indications for Hemodynamic Monitoring:

  • One of the obvious indications for hemodynamic monitoring is decreased cardiac output. This could be from dehydration, hemorrhage, G. I. bleed, Burns, or surgery. All types of shock, septic, cardiogenic, neurogenic, or anaphylactic may require invasive hemodynamic monitoring. Any deficit or loss of cardiac function: such as acute MI, cardiomyopathy and congestive heart failure may require invasive hemodynamic monitoring.

5. 6. Coronary Arteries RCA- RA, RV&LV Inf, Inf Septum SA node 65% AV node 80% PDA 80-90% CX- LA,LV ( side/back) SA node 40% AV node 20% LAD LV(front/bottom) Septum Bundle branches Left Main 7. 8. Cardiac Cycle Diastole Phase SA nodecontracts.Atria contract.Ventricles fill with more blood.Contraction reachesAV node . Late Diastole Atria and Ventricles are relaxed.Semilunar valves are closed.Atrioventricular valves are open.Ventricles continue to fill with blood. Mid Diastole Ventricles relax.Semilunarvalvesclose.Atrioventricularvalvesopen.Ventricles fill with blood. Early Diastole Cardiac Cycle Systole Phase Contraction passes fromAV nodetoPurkinje fibersand ventricular cells.Ventricles contract.Atrioventricularvalvesclose.Semilunarvalvesopen.Blood is pumped from the ventriclesto the arteries. Systole 9. Cardiac Cycle 10. Electrical Conduction system

  • SA node
  • Atrial muscle
  • Internodal fibers
  • AV node
  • AV bundle
    • right and left
    • bundle branches
  • Ventricular muscle

11. Autonomic Nervous System

  • The autonomic nervous system stimulates the heart through a balance of sympathetic nervous system and parasympathetic nervous system innervations.
    • The sympathetic nervous system plays a role inspeedingup impulse formation, thus increasing the heart rate
    • The parasympathetic nervous systemslowsthe heart rate.

12. The Cardiac Cycle 13.

  • Coronary Arteries Fill

The Cardiac Cycle 14. The Cardiac Cycle 15. The Cardiac Cycle 16. Normal CO 4-8 liters Normal Cardiac Index is 2.5 to 4.5 liters 17. Heart Rate

    • Works with Stroke Volume
    • Compensatory
      • Tachycardia
      • Bradycardia
      • Dysrhythmias

18. 19. 20. Factors Causing Low Cardiac Output

  • Inadequate Left Ventricular Filling
    • Tachycardia
    • Rhythm disturbance
    • Hypovolemia
    • Mitral or tricuspid stenosis
    • Pulmonic stenosis
    • Constrictive pericarditis or tamponade
    • Restrictive cardiomyopathy
  • Inadequate Left Ventricular Ejection
    • Coronary artery disease causing LV ischemia or infarction
    • Myocarditis, cardiomyopathy
    • Hypertension
    • Aortic stenosis
    • Mitral regurgitation
    • Drugs that are negative inotropes
    • Metabolic disorders

21. 22. Hemodynamic terms

  • Preload - Stretch of ventricular wall. Usually related to volume. (how full is the tank?)
    • Frank Starlings Law

23. Hemodynamic terms

  • Increased preload seen in
    • Increased circulating volume (too much volume)
    • Mitral insufficiency
    • Aortic insufficiency
    • Heart Failure
    • Vasoconstrictor use- (dopamine)
  • Decreased Preload seen in
    • Decreased circulating volume (bleeding,3 rdspacing)
    • Mitral stenosis
    • Vasodilator use ( NTG)
    • Asynchronyof atria and ventricles

24. Increased Preload 25. Decreased preload 26. Normal Value - 2-8 mm Hg 27. Or LVEDP PAOP = 8-12 mm HgPAD = 10-15 mm Hg 28. 29. Hemodynamic terms

  • Contractility -
    • How well does the ventricular walls move? How good is the pump?
    • Decreased due to
      • Drugs certain drugs will decrease contractility
        • Lido, Barbiturates, CCB, Beta-blockers
      • Infarction, Cardiomyopathy
      • Vagal stimulation
      • Hypoxia

30. Hemodynamic terms

  • Contractility -
    • Increased
      • Positive inotropic drugs
        • Dobutamine, Digoxin, Epinephrine
      • Sympathetic stimulation
        • Fear, anxiety
      • Hypercalcemia ( high calcium)

31. CONTRACTILITY - PRECAUTIONS

  • Do Not use Inotropes until volume deficiency is corrected
  • Correct Hypoxemia and electrolyte imbalance.

32. 33. Hemodynamic terms

  • Afterload
    • resistance the blood in the ventricle must overcome to force the valves open and eject contents to circulation.

34. X Y 35. Hemodynamic terms

  • Factors that increase afterloadare
    • Systemic resistance or High Blood pressure
    • Aortic stenosis
    • Myocardial Infarcts / Cardiomyopathy
    • Polycythemia Increased blood viscosity

36. Hemodynamic terms

  • Factors thatdecrease Afterload
    • Decreased volume
    • Septic shock- warm phase
    • End stage cirrhosis
    • Vasodilators

37. Normal PVR is 120 to 200 dynes 38. Normal SVR - 800-1200 dynes 39. 40. 41. Mean Arterial Pressure

  • MAPis considered to be the perfusion pressure seen byorgansin the body.
  • It is believed that aMAPof greater than60 mmHgis enough to sustain the organs of the average person under most conditions.
  • If theMAPfalls significantly below this number for an appreciable time, the end organ will not get enough blood flow, and will become ischemic.
  • Calculated MAP =2x diastolic + systolic
  • 3

42. 43. 44. EKG 45. 46. 47. 48. 49. 50.

  • 1. PRELOAD- venous blood return to the heart
  • Controlled by;
  • .Blood Volume
  • PRBCs
  • Albumin
  • Normal Saline
  • Diuretics-
    • lasix,bumex
    • Thiazides
  • Ace inhibitors
  • . Venous Dilation
  • Nitroglycerine
  • Ca+ channelblockers
  • clonidine (Catapress)
  • methyldopa
  • trimethaphan (arfonad)
  • Dobutamine
  • Morphine

2.CONTRACTILITY - forcefulness of contractility Ca+ channel blockers Digoxin Dopamine/Dobutamine Milrinone/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 channelblockers Labetalol Drugs of Hemodynamics

  • 4.HEART RATE
  • Beta blockers
  • Calcium channel blockers
  • Atropine
  • Dopamine
  • Dobutamine

51. 52. 53. 54. 55. O2O2 O2 O2 O2 O2 O2 To BODY FromBody 56. O2 O2 O2 57.

  • Factor