INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center...
-
Upload
benjamin-peters -
Category
Documents
-
view
220 -
download
0
Transcript of INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center...
![Page 1: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/1.jpg)
INVASIVE HEMODYNAMIC MONITORING
Presentation by Donna Cohen, BSN, RN
Heart and Vascular Center
Medical University of South Carolina
February 2006
![Page 2: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/2.jpg)
INVASIVE HEMODYNAMIC MONITORING
![Page 3: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/3.jpg)
Objectives Verbalizes purposes of Hemodynamic
Monitoring Verbalize indications for Hemodynamic
Monitoring Identify components of a Pulmonary Artery
Catheter[Swan-Gantz] Verbalize necessary equipment needed
![Page 4: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/4.jpg)
Objectives [con’t] Identify the correct pressure waveforms Identify the components of invasive
hemodynamic monitoring[RA,PA,PAM and PCWP]
Identify “normal” parameters for each component of monitoring
Verbalize how to troubleshoot abnormal waveforms
![Page 5: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/5.jpg)
Objectives [con’t] Verbalize definition of preload and afterload Verbalize what and where to document data
collected Verbalize understanding of the Critical Care
Hemodynamic Monitoring Policy [C1]
![Page 6: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/6.jpg)
Introduction Swan-Ganz catheter has been in use for
almost 30 years Initially developed for the management of
acute myocardial infarction Now, widespread use in the management of a
variety of critical illnesses and surgical procedures
![Page 7: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/7.jpg)
Purposes of Invasive Hemodynamic Monitoring Early detection, identification, and treatment
of life-threatening conditions such as heart failure and cardiac tampanade
Evaluate the patient’s immediate response to treatment such as drugs and mechanical support
Evaluate the effectiveness of cardiovascular function such as cardiac output and index
![Page 8: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/8.jpg)
Indications for Hemodynamic Monitoring Any deficit or loss of cardiac function: such
as AMI,CHF,Cardiomyopathy All types of shock;cardiogenic,neurogenic,or
anaphylactic Decreased urine output from dehydration,
hemorrhage,G.I. bleed,burns,or surgery
![Page 9: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/9.jpg)
Components of a Pulmonary Artery Catheter
![Page 10: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/10.jpg)
Components of Swan-Ganz [con’t] Normally has four[4] ports Proximal port – [Blue] used to measure central
venous pressure/RAP and injectate port for measurement of cardiac output
Distal port – [Yellow] used to measure pulmonary artery pressure
Balloon port – [Red] used to determine pulmonary wedge pressure;1.5 special syringe is connected
Infusion port – [White] used for fluid infusion
![Page 11: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/11.jpg)
![Page 12: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/12.jpg)
Components of the Monitoring System Bedside monitor – amplifier is located inside.
The amplifier increases the size of signal Transducer – changes the mechanical energy
or pressures of pulse into electrical energy; should be level with the phlebostatic axis[ you can estimate this by intersecting lines from the 4th ICS,mid axillary line
Recorder – please record information
![Page 13: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/13.jpg)
Phlebostatic Axis
![Page 14: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/14.jpg)
Commonly used Terminology Preload Afterload Cardiac Output Cardiac Index
Systemic Vascular Resistance [SVR]
Pulmonary Vascular Resistance [PVR]
![Page 15: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/15.jpg)
Preload Is the degree of muscle fiber stretching
present in the ventricles right before systole Is the amount of blood in a ventricle before it
contracts; also known as “filling pressures” Left ventricular preload is reflected by the
PCWP Right ventricular preload is reflected by the
CVP [RA]
![Page 16: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/16.jpg)
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
![Page 17: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/17.jpg)
Cardiac Output/Index Is the amount of blood ejected from the
ventricle in one minute Two components multiply to make the
cardiac output: heart rate and stroke volume [amount of blood ejected with each contraction]
Cardiac index is the cardiac output adjusted for body surface area (BSI)
![Page 18: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/18.jpg)
Computation Constant Computation constant is based on the
1) type of catheter
2) temperature (iced or room temp) of the injectate
3) the number of mL’s (5mL vs 10mL) ---we use 10 mL of room temperature injectate for our regular swanns, which requires a computation constant of 0.592
![Page 19: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/19.jpg)
SVR / PVR Systemic Vascular Resistance – reflects left
ventricular afterload Pulmonary Vascular Resistance – reflection
of right ventricular afterload Many of the drugs we administer will affect
Preload, Afterload, SVR/PVR, Cardiac Output
![Page 20: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/20.jpg)
Possible Complications Increased risk of infections – same as with any central
venous lines—use occlusive dressing and Biopatch to prevent Thrombosis and emboli-- air embolism may occur when the
balloon ruptures, clot on end of catheter can result in pulmonary embolism
Catheter wedges permanently—considered an emergency, notify MD immediately, can occur when balloon is left inflated or catheter migrates too far into pulmonary artery (flat PA waveform)…can cause pulmonary infarct after only a few minutes!
Ventricular irritation – occurs when catheter migrates back into RV or is looped through the ventricle, notify MD immediately…can cause VT
![Page 21: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/21.jpg)
Troubleshooting Dampened waveform –can occur with physical
defects of the heart or catheter; can be caused by kinks, air bubbles in the system, or clots Solution: Check your line for kinks & air bubbles, aspirate (not flush) for clots, straighten out tubing or patient as much as possible
No waveform – can occur with non-perfusing arrhythmias or line disconnection Solution: Check your line for disconnection, check your patient for pulse, could also be wet transducer or broken cable or box
![Page 22: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/22.jpg)
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 “Swan Ganz” to allow physician to view catheter waveforms while inserting.6. Assist physician (s) in sterile draping and sterile setup for cordis and swan insertion.
![Page 23: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/23.jpg)
Equipment Needed7. 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 PVC’s or runs of VT !10. After swann is in place, assist with cleanup and let patient know procedure is complete.
![Page 24: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/24.jpg)
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 today’s height and weight).14. Document findings on the ICU flowsheet.
![Page 25: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/25.jpg)
PA Insertion Waves
![Page 26: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/26.jpg)
![Page 27: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/27.jpg)
Central Venous Pressure (CVP) Zero transducer to the patient’s phlebostatic axis Always read CVP at end expiration CVP is a direct measurement of right ventricular end
diastolic pressure
![Page 28: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/28.jpg)
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 swan
immediately. If the swan remains in the RV it may cause the patient to go
into VT.
![Page 29: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/29.jpg)
Pulmonary Capillary Wedge Pressure (PCWP)
Zero the transducer to the patient’s phlebostatic axis. Measure the PCWP at end expiration PCWP should not be higher than PA diastolic PCWP is an indirect measurement of left ventricular end
diastolic pressure.
![Page 30: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/30.jpg)
![Page 31: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/31.jpg)
![Page 32: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/32.jpg)
![Page 33: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/33.jpg)
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.
![Page 34: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/34.jpg)
![Page 35: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/35.jpg)
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 to
determine measurement at the end of expiration (last clear wave before patient inspires) Tip: if waveform is difficult to read, try resting hand on pt’s chest as you
wedge; determine where the end of expiration occurs on the wedge waveform, then measure across several waves for consistency
![Page 36: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/36.jpg)
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 is acceptable to write ONLY
“PAD value used for calculations”
at the top of your numbers
![Page 37: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/37.jpg)
![Page 38: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/38.jpg)
![Page 39: INVASIVE HEMODYNAMIC MONITORING Presentation by Donna Cohen, BSN, RN Heart and Vascular Center Medical University of South Carolina February 2006.](https://reader036.fdocuments.in/reader036/viewer/2022062314/56649d1f5503460f949f27af/html5/thumbnails/39.jpg)