Download Hemodynamic Monitoring and Transthoracic

Hemodynamic Monitoring and
Transthoracic Lines
Deb Updegraff RN, CNS
Lucille Packard Children’s
Hospital
Pat Hock RN, Nurse Educator
Winnie Yung , CNS
 Infants and children undergoing open heart
surgery may require intracardiac monitoring.
 The hemodynamic data can assist in the
assessment of contractility, preload and
afterload.
 As the patient stabilizes post cardiac bypass, intracardiac catheters (RA) may be left
in place for vascular access reasons.
What’s the difference ??
“Percutaneous” vs “Transthoracic”
Percutaneous – Insertion site is through the skin.
Transthoracic- Insertion is done while the chest is open and directly through
the myocardium.
Examples of Percutaneous lines:
• PICCs
• Tunneled lines
• Non-tunneled lines
• Swan-Ganz thermodilutional catheters
• Dialysis/CRRT catheters
Examples of Transthoracic Lines
Percutaneous
Central
Venous
Catheter
PA
Pulmonary
Artery
Catheter
LA
Left Atrial
Transthoracic
Catheter
RA
Right Atrial
Transthoracic
Catheter
Roth, S. 1998
Hemodynamic Waveforms- Normal
Heart
(CVP)
Right Atrial Pressure Monitoring
Indications
• Measure right atrial pressure (RAP)
• Same as Central Venous Pressure (CVP)
• Assess blood volume; reflects preload to
the right side of the heart
• Assess right ventricular function
• Infusion site for large fluid volume
• Infusion site for hypertonic solutions
Reasons for elevated RA pressure:
• decreased right (or single) ventricle compliance
• tricuspid valve disease
• Intravascular volume overload
• cardiac tamponade
• tachyarrhythmia
Right Atrial Pressure
Mean: 1 to 7 mm Hg
Reasons for reduced RA pressure:
• low intravascular volume status
• inadequate preload
Right Atrial Pressure
Mean: 1 to 7 mm Hg
Right Atrial Pressure Monitoring
Complications
•
•
•
•
Pneumothorax
Hemothorax
Hemorrhage
Cardiac
tamponade
• Vessel, RA, or
RV perforation
• Arrhythmias
• Air embolism
• Pulmonary
embolism
• Thromboemboli
sm
• Infection
Right Atrial Pressure Monitoring
Waveform Analysis
•
•
•
•
•
a wave: rise in pressure due to atrial
contraction
x decent: fall in pressure due to atrial
relaxation
c wave: rise in pressure due to ventricular
contraction and closure of the tricuspid valve
v wave: rise in pressure during atrial filling
y decent: fall in pressure due to opening of
the tricuspid valve and onset of ventricular
filling
Right Atrial Pressure Monitoring
Waveform Analysis
 Elevated RAP
•
•
•
•
•
•
•
•
•
 Decreased RAP
RV failure
Tricuspid regurgitation
Tricuspid stenosis
Pulmonary hypertension
Hypervolemia
Cardiac tamponade
Chronic LV failure
Ventricular Septal Defect
Constrictive pericarditis
•
•
Hypovolemia
Increased contractility
Reasons for elevated LA pressure:
Elevated systemic ventricular end diastolic pressure
• mitral valve disease
• Large left-to-right shunt
• intravascular volume overload
• cardiac tamponade
• tachyarrhythmia
• Artifactual
Reasons for reduced LA pressure:
• low intravascular fluid status
• Inadequate preload
• Artifactual
Reasons for elevated PA pressure:
• mechanical obstruction of pul. circulation
• pul. arteriolar smooth muscle hypertrophy
• inflammatory response to CPB
• mechanical obstruction of the airways (for examples…)
• acidosis and hypoxia
• elevated LA pressure
• unrestrictive VSD or large PDA
• pul. hypertension
Nursing HOURLY assessment:
1.
2.
3.
4.
Air in line or stopcocks
Precipitates
Leaking at site
Increasing resistance
5. Condition of entrance sites
Dressing change policy at LPCH
Arterial line
prn (when seal is broken, wet, old blood, etc)
Non-tunneled CVC
Q 7 days & prn (Tegaderm & biopatch)
Tunneled CVC
Q7 days & prn (Tegaderm & biopatch)
Intracardiac catheter
Q 7 days & prn (Tegaderm & biopatch)
BEFORE REMOVAL
Transthoracic Line
• Check coagulation labs (pt, ptt, INR, platelets)
• Transfuse if Platelets < than 70 and INR > 1.5
• Ensure Packed Red Blood Cells in cooler at bedside
(Remember two RN check for PRBCs. Instructions
for blood in cooler, taped to cooler)
• Ensure good vascular access
• Ensure chest tube patency
• Evaluate need for sedation.
(if too active ↑ BP may → bleeding)
After Removal of Transthoracic Line
• Keep PRBCs for a minimum of 1 hour
• Continuous hemodynamic monitoring for a minimum of 1 hour
(assess for signs of tamponade-dampening arterial wave form
narrowing pulse pressure and bleeding- blood in chest tubes,
decrease blood pressure, pallor
altered LOC)
• Document vitial signs every 15 minutes
• Check HCT if bleeding suspected
• Ensure patency of chest tubes
• Do not transfer patient for at least 2 hours
Pressure Line Safety

What is air vigilance and why is it so important?

Why is it unsafe to draw back or flush fluid into a line infusing
vasoactive medications?

What precautions should be taken when discontinuing any
pressure line?

Is it safe to get a patient out of bed to be held or to sit in a
chair if they have a transthoracic pressure line?

What additional safety measures should be followed for
transthoracic pressure lines?
References








Alspach. AACN’s Core Curriculum for Critical Care Nursing.
Saunders.
Berne and Levy. Physiology. Mosby.
Hazinski. Manual of Pediatric Critical Care. Mosby.
Kinney, Packa, and Dunbar. AACN’s Clinical Reference for
Critical Care Nursing. Saunders.
Kumm. Hemodynamic Monitoring. University of Kansas
School of Nursing.
Kumm. Intra-arterial Pressure Monitoring. University of
Kansas School of Nursing.
Slota. AACN’s Core Curriculum for Pediatric Critical Care
Nursing. Saunders.
Taleghani, Fred. Invasive lines, hemodynamic monitoring,
and waveforms. LPCH, PICU.