Invasive Hemodynamic for Prep and Recovery
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Transcript of Invasive Hemodynamic for Prep and Recovery
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INVASIVEHEMODYNAMIC
MONITORING
Presentation by Donna Cohen, BSN, RN
Heart and Vascular CenterMedical University of South Carolina
February 2006
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INVASIVE HEMODYNAMIC
MONITORING
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Objectives Verbalizes purposes of Hemodynamic
Monitoring
Verbalize indications for HemodynamicMonitoring
Identify components of a Pulmonary Artery
Catheter[Swan-Gantz] Verbalize necessary equipment needed
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Objectives [cont] Identify the correct pressure waveforms
Identify the components of invasive
hemodynamic monitoring[RA,PA,PAM andPCWP]
Identify normal parameters for each
component of monitoring Verbalize how to troubleshoot abnormal
waveforms
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Objectives [cont] Verbalize definition of preload and afterload
Verbalize what and where to document data
collected Verbalize understanding of the Critical Care
Hemodynamic Monitoring Policy [C1]
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Introduction Swan-Ganz catheter has been in use for
almost 30 years
Initially developed for the management ofacute myocardial infarction
Now, widespread use in the management of a
variety of critical illnesses and surgicalprocedures
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Purposes of Invasive Hemodynamic
Monitoring Early detection, identification, and treatment
of life-threatening conditions such as heart
failure and cardiac tampanade Evaluate the patients immediate response to
treatment such as drugs and mechanical
support Evaluate the effectiveness of cardiovascular
function such as cardiac output and index
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Indications for Hemodynamic
Monitoring Any deficit or loss of cardiac function: such
as AMI,CHF,Cardiomyopathy
All types of shock;cardiogenic,neurogenic,oranaphylactic
Decreased urine output from dehydration,
hemorrhage,G.I. bleed,burns,or surgery
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Components of a Pulmonary Artery
Catheter
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Components of Swan-Ganz [cont]
Normally has four[4] ports
Proximal port[Blue] used to measure central
venous pressure/RAP and injectate port formeasurement of cardiac output
Distal port[Yellow] used to measure pulmonary
artery pressure
Balloon port[Red] used to determine pulmonarywedge pressure;1.5 special syringe is connected
Infusion port[White] used for fluid infusion
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Components of the Monitoring System
Bedside monitoramplifier is located inside.
The amplifier increases the size of signal
Transducerchanges the mechanical energyor pressures of pulse into electrical energy;
should be level with the phlebostatic axis[ you
can estimate this by intersecting lines fromthe 4th ICS,mid axillary line
Recorderplease record information
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Phlebostatic Axis
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Commonly used Terminology
Preload
Afterload
Cardiac Output Cardiac Index
Systemic Vascular
Resistance [SVR]
Pulmonary Vascular
Resistance [PVR]
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Preload
Is the degree of muscle fiber stretching
present in the ventricles right before systole
Is the amount of blood in a ventricle before itcontracts; also known as filling pressures
Left ventricular preload is reflected by the
PCWP Right ventricular preload is reflected by the
CVP [RA]
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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
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Cardiac Output/Index
Is the amount of blood ejected from the
ventricle in one minute
Two components multiply to make the cardiacoutput: heart rate and stroke volume [amount
of blood ejected with each contraction]
Cardiac index is the cardiac output adjustedfor body surface area (BSI)
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Computation Constant
Computation constant is based on the
1) type of catheter
2) temperature (iced or room temp) of theinjectate
3) the number of mLs (5mL vs 10mL) ---we
use 10 mL of room temperature injectate forour regular swanns, which requires a
computation constant of 0.592
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SVR / PVR
Systemic Vascular Resistancereflects left
ventricular afterload
Pulmonary Vascular Resistancereflectionof right ventricular afterload
Many of the drugs we administer will affect
Preload, Afterload, SVR/PVR, CardiacOutput
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Possible Complications Increased risk of infectionssame as with any central
venous linesuse occlusive dressing and Biopatch to prevent
Thrombosis and emboli-- air embolism may occur when the
balloon ruptures, clot on end of catheter can result inpulmonary embolism
Catheter wedges permanentlyconsidered an emergency,notify MD immediately, can occur when balloon is leftinflated or catheter migrates too far into pulmonary artery
(flat PA waveform)can cause pulmonary infarct after onlya few minutes!
Ventricular irritationoccurs when catheter migrates backinto RV or is looped through the ventricle, notify MDimmediatelycan cause VT
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Troubleshooting
Dampened waveformcan occur with physicaldefects of the heart or catheter; can be caused bykinks, air bubbles in the system, or clots
Solution: Check your line for kinks & airbubbles, aspirate (not flush) for clots, straightenout tubing or patient as much as possible
No waveformcan occur with non-perfusing
arrhythmias or line disconnection
Solution: Check your line for disconnection,check your patient for pulse, could also be wettransducer or broken cable or box
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Equipment NeededSET-UP FOR HEMODYNAMIC
PRESSURE MONITORING
1. Obtain Barrier Kit, sterile gloves, Cordis Kit and correct swan
catheter. Also need extra IV pole, transducer holder, boxes and cables.2. Check to make sure signed consent is in chart, and that patient and/or
family understand procedure.
3. Everyone in the room should be wearing a mask!
4. Position patient supine and flat if tolerated.
5. On the monitor, press Change Screen button, then select SwanGanz to allow physician to view catheter waveforms while inserting.
6. Assist physician (s) in sterile draping and sterile setup for cordis and
swan insertion.
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Equipment Needed
7. Set up pressure lines and transducers [see Critical Care Skills:
Clinical Handbook, Second Edition pages 293 -298]
Please level pressure flush monitoring system and transducers to the
phlebostastic axis. Zero the transducers. Also check to make sure
all connections are secure.8. Connect tubings to patient [PA port and CVP port] when physician
is ready to flush the swann. Flush all ports of swann before
inserting.
9. While floating the swann, observe for ventricular ectopy on the
monitor, and make physician aware of frequent PVCs or runs of
VT !
10. After swann is in place, assist with cleanup and let
patient know procedure is complete.
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Equipment Needed11. Obtain your RA [CVP], PAS/D, PAM, and wedge.
For Cardiac Outputs, inject 10 mLs of D5W after
pushing the start button, repeat X 3. Delete outputs
not within 1 point of the mean value. Can use .9NS
instead, but affects the accuracy of the output reading.12. Before obtaining the cardiac output, please check the
computation constant [should read 0.692 for regular
yellow swans; 0.692 for SVO2 or blue swanns]
13. Perform hemocalculations (enter todays height and weight).
14. Document findings on the ICU flowsheet.
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PA Insertion Waves
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Central Venous Pressure (CVP)
Zero transducer to the patients phlebostatic axis
Always read CVP at end expiration
CVP is a direct measurement of right ventricular enddiastolic pressure
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Right Ventricular Waveform If the swan falls or gets pulled back into the RV it is
considered a swan emergency.
If you see an RV waveform (looks like VT) pull the swanimmediately.
If the swan remains in the RV it may cause the patient to gointo VT.
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Pulmonary Capillary Wedge Pressure (PCWP)
Zero the transducer to the patients phlebostatic axis.
Measure the PCWP at end expiration
PCWP should not be higher than PA diastolic
PCWP is an indirect measurement of left ventricular enddiastolic pressure.
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Cardiac Output
It is the amount of blood pumped by the heart in one minute.
Calculated by multiplying heart rate times stroke volume.
Cardiac Index is the cardiac output adjusted for body surface
area.
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How to read a PA waveform
Measured at end expiration!
Dicrotic notch (closure of PulmonicValve) should always be on
Right side of wave (if notch on Left side find out if the tip in the RV)
Measure PAS at the top of the wave upslope (at end of QRS);
PAD is measured at the trough preceding the systolic peak(be careful not to measure whip in the wave)
How to read a PCWP (aka wedge) Measured at end expiration!
After balloon is inflated, compare waveform to respiratory waveform todetermine measurement at the end of expiration
(last clear wave before patient inspires)
Tip: if waveform is difficult to read, try resting hand on pts chest as youwedge; determine where the end of expiration occurs on the wedgewaveform, then measure across several waves for consistency
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Documentation
Document PAS, PAD, and PCWP on nursing flowsheet under
Hemodynamic Parameters
PCWP will rarely be > PAD (if so, means blood is flowing
backwards) If PCWP = PAD, look for tamponade Under circumstances where the catheter will not wedge (or
should not be), do not document any values in the PCWP
column on the flowsheet
If you use the PAD measurement for calculations, it isacceptable to write ONLY
PAD value used for calculations
at the top of your numbers
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