Hemodynamic Monitoring INTRODUCTION

Hemodynamic Monitoring
Presented by:
Zakaria Al Masri
BSC,MSN
King Saud University / King Khalid University Hospital
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INTRODUCTION
Critically ill patients require continuous
assessment of their cardiovascular
system to diagnose and manage their
complex medical conditions.
This is most commonly achieved by
using direct pressure monitoring
systems, often referred to as
hemodynamic monitoring.
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HEMODYNAMIC MONITORING
DEFINITION:
“ Using invasive technology to provide
quantitative information about vascular
capacity, blood volume; pump
effectiveness, and tissue perfusion.”
(Critical care nursing ,2005)
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Purpose of Hemodynamic
Monitoring
Evaluate cardiovascular system
Pressure, flow,
resistance
Establish baseline values and evaluate
trends
Determine presence and
degree of
dysfunction
Implement and guide interventions
early to prevent problems
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HEMODYNAMIC
MONITORING EQUIPMENT
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Hemodynamic Monitoring
Components
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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Parameter
Normal value
Blood Pressure
Systolic (SBP)
90-140 mmHg
Diastolic (DBP)
60-90mmHg
Mean Arterial Pressure (MAP)
70 - 100 mmHg
Cardiac Index (CI)
2.5-4 L/min/m2
Cardiac Output (CO)
4-8 L/min
Central Venous Pressure (CVP)
2-6 mmHg
Pulmonary Artery Pressure (PA)
Systolic 20-30 mmHg (PAS)
Diastolic 8-12 mmHg (PAD)
Mean 25 mmHg (PAM)
Pulmonary Capillary Wedge Pressure (PWCP)
4-12 mmHg
Pulmonary Vascular Resistance (PVR)
37-250 dynes/sec/cm5
Right Ventricular Pressure (RV)
Systolic-20-30 mmHg
Diastolic 0-5 mmHg
Stroke Index (SI)
25 - 45 ml/m2
Stroke Volume (SV)
50 - 100 ml
Systemic Vascular Resistance (SVR)
800-1200 dynes/sec/cm5
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PHLEBOSTATIC AXIS
The PHLEBOSTATIC AXIS : is the
reference point for zeroing the hemodynamic
monitoring device. This reference point is
important because it helps to ensure the
accuracy of the various pressure readings.
With the head of bed at 60 degrees or less,
the phlebostatic axis is located at the fourth
intercostal space at the mid-anterior-posterior
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diameter of the chest wall.
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Phlebostatic Axis
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PHLEBOSTATIC AXIS
NB: For every 1” discrepancy b/w heart &
transducer level  error of  2 mmHg
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ARTERIAL BLOOD PRESSURE MONITORING
This allows continuous monitoring of arterial pressures
and sampling of arterial blood for blood gases. This is a
more accurate means of pressure monitoring than the
use of a BP cuff.
Placement of catheter

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Radial
Brachial
Axillary
Femoral
Dorsalis pedis
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Palpation, Capillary
Refill and the Allen test
must be done prior to
arterial line insertion,
in order to reduce the
risk of ischemia due to
arterial occlusion.
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Indications for
Arterial Blood Pressure Monitoring
Frequent titration of vasoactive drips
Unstable blood pressures
Continuous real-time monitoring of blood
pressure.
Unable to obtain Non-invasive BP
(e.g. Morbid Obesity, Burned extremities)
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COMPLICATIONS
Peripheral ischemia and
gangrene
Spasm of the artery may
occur proximal to
cannulation site
Median nerve palsy
Carpal tunnel syndrome
Tendon damage
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Arterial Waveform
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Mean Arterial Pressure (MAP)

Best indicator of tissue perfusion
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CENTRAL VENOUS PRESSURE MONITORING
CVP is also known as
Right Atrial Pressure
is considered a direct
measurement of the
blood pressure in the
right atrium and vena
cava. CVP reflects the
amount of blood
returning to the heart
and the ability of the
heart to pump blood into
the arterial system.
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Catheter Types
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THE CVP WAVEFORM
The CVP waveform reflects changes in right
atrial pressure during the cardiac cycle
A wave: right atrial contraction (P wave on the ECG)If the A wave is
elevated the patient may have right ventricular failure or tricuspid
stenosis.
C wave: tricuspid valve closure (follows QRS complex on the ECG).
V wave: pressure generated to the right atrium during ventricular
contraction, despite the tricuspid valve being closed (latter part of the T
wave on the ECG)
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CVP is Elevated by :

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Overhydration which
increases venous
return
Heart failure
PA stenosis which
limit venous outflow
and lead to venous
congestion
Positive pressure
breathing, Straining
CVP Decreases with:

Hypovolemic shock
from Hemorrhage, Fluid
shift, Dehydration

Negative pressure
breathing which
occurs when the
patient demonstrates
retractions or
mechanical negative
pressure which is
sometimes used for
high spinal cord injuries
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Pulmonary Artery Pressures
Means to evaluate fluid status

Indicator of preload
LV function

PAOP, PCWP
CO measurement


Thermodilution technique
Intermittent or continuous
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PA catheters
Multi-lumen, polyvinylchloride catheters
with balloon at the tip

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Flow directed catheter
Inflation of balloon ensures that blood flow
will move the catheter forward in the
direction of blood flow
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PA catheters
Most commonly 4 lumens

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Balloon lumen for inflation
Distal lumen in PA
Proximal lumen in RA – drug infusion, CVP monitoring
Thermistor to measure blood temperature
Other lumens may be used for
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Temporary transvenous pacing
Measurement of RVEDV.
Continuous measurement of SvO2
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Prior to Insertion
Prior to insertion
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Flush all lumens with solution
Check integrity of balloon
Always deflate passively!
Prepare fluid filled system that has been leveled
and zeroed
Connect to appropriate lumens
 PA distal – PA pressures
 Proximal infusion – CVP
 Proximal injectate – CO device
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PA Catheters Insertion
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PA Catheter Insertion
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Contraindications to PA Catheter Insertion
•
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•
•
•
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Severe, uncorrectable coagulopathy
LBBB on ECG
Local infection at the skin insertion site
Pulmonary / tricuspid valve prosthesis
Pulmonary / tricuspid valve endocarditis
Right heart mass
Severe hypothermia
Inadequate monitoring equipments
Patient refusal
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Potential PA Catheter
Complications
1. Vintricular arrythmias
2. Infection
3. Pneumothorax
4. Pulmonary infarction
5. Balloon rupture and air embolism
6. Pulmonary artery rupture
7. Endocarditis
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Waveforms Used to Determine Location
of Catheter
Waveforms used to determine location
of catheter
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RA – a, c and v waves
RV – 25/0
PA – see change in diastolic pressure due
to closure of pulmonic valve
PAOP – wedge position
Hemodynamic Waveforms cont..
Right atrial waveform: 3 waves
“a” – Atrial pressure due to atrial
contraction (follows P wave)
“c” – Bulging of tricuspid valve (follows QRS)
“v” – Gradual  in atrial pressure with venous
return (occurs @ same time as T wave)
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Hemodynamic Waveforms cont..
Right Ventricle:
-Sharp upstroke due to ventricular systole
-High systolic pressures
-Low diastolic values (  mean atrial)
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Hemodynamic Waveforms, cont.
Pulmonary artery
- Systolic peak - due to RV ejection
- Dicrotic notch – pulmonary valve closure
- Diastolic trough – reflects LA & LV pressures in
diastole
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Hemodynamic Waveforms, cont.
PAOP should only be visualized when
balloon is inflated


Indicates blood flow obstructed in the vessel
Reflects LA pressure/volume
 High - LV failure
 Low - hypovolemia

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PA waveform should return when balloon deflated
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SAFE PRACTICE GUIDELINES
 Check balloon inflation prior to insertion
 Check position daily (CXR)
 Monitor volume required to inflate balloon
 Check waveform before balloon inflation
 Never use fluids to inflate balloon
 Keep wedge time to minimum
 Never flush line when balloon wedged
 Stop inflating immediately if a wedge waveform obtained
and allow balloon to deflate spontaneously
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SAFE PRACTICE GUIDELINES cont..
Calibrate and level the system at least once a shift.
Measure all pressures between breaths.
Maintain 300 mmHg of pressure on the flush solution
at all times.
Observe the patient for any abnormalities
Set alarm limits for monitored hemodynamic
variables.
Use aseptic technique during catheter insertion and
site care.
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SAFE PRACTICE GUIDELINES cont..
Label solution, tubing, and dressing with date and time of
change.
Thoroughly flush stopcock ports after drawing blood
samples from the pressure line.
Secure all connections and stopcocks.
Keep tubing free of kinks and tension.
Document and report.
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Removal of PA Catheter.
 Remove catheter with the patient flat in bed
in a quick smooth action, after having first
checked that the balloon is deflated.
 If resistance is felt DO NOT PULL!
 Observe for Ventricular arrhythmias.
 Tip of Catheter for C + S
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 Continuous or intermittent,
noninvasive method of obtaining
CO and assessing thoracic fluid
status
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Thank you
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