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Hemodynamic Monitoring By Nancy Jenkins RN,MSN What is Hemodynamic Monitoring and why do it? It is measuring the pressures in the heart It allows us to see inside the heart and adjust volume as needed Comparing Hemodynamics to IV pump Fluid =preload Pump= CO or contractility (needs electricity) Tubing =afterload Nursing Management Hemodynamic Monitoring- You are already doing – – – – – – – General appearance Level of consciousness Skin color/temperature Vital signs Peripheral pulses Urine output Lung sounds Nursing Management Hemodynamic Monitoring **Single hemodynamic values are rarely significant. Monitor trends and evaluate whole clinical picture Goals – Recognize early clues – Intervene before problems develop or escalate Hemodynamic Monitoring Components We Will Look at Today Heart Rate Blood Pressure and MAP CVP Pulmonary Artery Pressures Systemic Vascular Pressure (SVR) Pulmonary Vascular Pressure (PVR) Cardiac Output/ Cardiac Index Stroke Volume Important Equation Hemodynamic Monitoring General Principles CO: Volume of blood pumped by heart in 1 minute CI: CO adjusted for body size SV: Volume ejected with each heartbeat SVI: SV adjusted for body size Easier to adjust HR than SV **Preload, afterload, and contractility determine SV Hemodynamics: Normal value Mean Arterial Pressure (MAP) 70 -90 mm Hg Cardiac Index (CI)- 2.2-4.0 L/min/m2 Cardiac Output (CO)- 4-8 L/min Central Venous Pressure (CVP) (also known as Right Atrial Pressure (RA)) 2-8 mmHg Pulmonary Artery Pressure (PA) Systolic 20-30 mmHg (PAS) Diastolic 4-12 mmHg (PAD) Mean 15-25 mmHg Pulmonary Capillary Wedge Pressure (PWCP) 4-12 mmHg Systemic Vascular Resistance(SVR) 800-1200 Volume of blood within ventricle at end of diastole –**Measured by CVP and wedge pressure in ICU Preload Def- the volume that stretches the LV just before contraction – Measured by CVP for RV and PAWP for LV – Measures the preload of the LV or LVEDP= wedge or PAW – **The greater the preload the greater the stroke volume and the greater the cardiac output Decreased Preload- leads to Dec. SV and venous return Hypovolemia Tachycardia- why? Vasodilation/ dec. venous return Treatment- fluid **A goal for heart failure Increased Preload Valvular disease Hypervolemia Heart failure Treatment- diuretics, vasodilators **Vascular system holding tankvasodilation, vasoconstriction depending on need –Measured by SVR and PVR in the ICU Afterload Resistance to ejection- arterial B/P Measured by PVR and SVR in the ER Decreased afterload – Vasodilation (sepsis, hyperthermia) – Hypotention – Nitrates Afterload Increased afterload – Vasoconstriction (hypovolemia, hypothermia) – Aortic stenosis – Hypertension – Fight or flight – Pulmonary hypertension – **The greater the afterload, the lower the cardiac output Cardiac Output CO=SVxHR; CI= CO/BSA Normal CO 4-8 L/min; CI 2.2-4 Urine output- indirect measurement To compensate for dec. CO get tachycardia Decreased CO – Poor ventricular filling- hypovolemia or SVT – Poor emptying, dec. contractility (infarct, ischemia, arrhythmias) – Vasodilation- sepsis and drugs – Increased afterload- hypertension, vasoconstriction Cardiac Output Increased – Increased O2 demand- exercise – SNS – Drugs- positive inotropics (Continuous infusions: Dobutamine, Dopamine, Primacor – Digoxin- IVP Stroke Volume Def- amount of blood ejected with each heart beat Normal SV= 60-130 Exercise can increase SV Factors that determine SV – Preload – Afterload – Contractility Contractility Starling’s law Increased contractility – SNS – Drugs- positive inotropics, epinephrine, calcium Decreased contractility – – – – Loss of muscle (acute MI, cardiomyopathy) Hypoxemia Electrolyte imbalance Drugs- (lidocaine, calcium channel blockers, beta blockers Contractility Determined by the SV and the EF% **Important to know the EF% of all heart failure patients Measured by echo EF- how much blood is ejected during systole compared to how much preload there is. **Normal EF%- 55-65% Ex 90/140= 64%EF How and when do we measure afterload? Arterial B/P and SVR – Continuous arterial pressure monitoring – Acute hypertension/hypotension – Respiratory failure- frequent ABG sampling – Shock – Coronary interventional procedures – Continuous infusion of vasoactive drugs Best indicator of tissue perfusion. Needs to be at least 60-70 to perfuse organs Arterial Line Arterial Pressure Monitoring High- and low-pressure alarms based on patient’s status Risks – Hemorrhage, infection, thrombus formation, neurovascular impairment, loss of limb Nursing- Check 5 P’s Arterial Pressure Waveform Dicrotic notch signifies the closure of the aortic valve. Pulmonary Artery Catheter Fig. 66-7 PA Catheter Insertion PPA catheter tells you everything you want to know about the heart: (Snap, Crackle, Pop) 1) how well the pump is pumping (cardiac output, cardiac index) (snap) 2)how full the right side of the heart is (CVP), and how full the left side is (wedge pressure) – that’s the volume…(crackle) 3) and how well your patient’s arteries can squeeze : that’s the SVR – the “systemic vascular resistance”… (pop) PA Waveforms during Insertion Fig. 66-9 Important Measurements Obtained by PA Catheter Right Atrial Pressure (CVP) PAP – Diastolic (PAD) – PA Systolic (PAS) – PA Wedge (Wedge, PAOP) Cardiac Output Cardiac Index Pulmonary Artery Pressure Monitoring- CVP Right atrium port- also know as proximal – Measurement of CVP – Injection of fluid for CO measurement – Can you give meds through this port? – Blood sampling Central Venous Pressure Waveforms Fig. 66-11 CVP values Right Heart Presssures Normal 2-8mmHg Dec. – Hypovolemia – Decreased venous return Inc. – Hypervolemia – Inc. venous return – Right HF, pulmonary hypertension – Tricuspid stenosis and regurgitation PA pressure PAD- should be close to wedge PAS- tells RV pressure PAW- LVEDP or preload of LV PA Pressures Normal 20-30 mmHg systolic, 4-12mmHg diastolic PAS= RV pressure Inc PAS in pulmonary hypertension Inc. PAD in ventricular failure Dec. in hypovolemia Dec. in shock PAW Normal 6-12mmHg Equals LVEDP or preload of LV Dec.in hypovolemia or low stroke volume Inc. in LV failure, mitral valve disorders Inc. in hypervolemia *** Fluids for dec. wedge and diuretics for inc. wedge Measuring Cardiac Output Fig. 66-12 Cardiac Output Cardiac Output Monitoring Measuring Cardiac Output and SVR SVR can be calculated when CO is measured SVR=(MAP-CVP) x80/ CO – ↑ SVR • Vasoconstriction from shock • Hypertension • ↑ Release or administration of epinephrine or other vasoactive inotropes • Left ventricular failure – Dec. SVR • Vasodilation • sepsis Cardiac Output http://www.lidco.com/docs/Brochure.pdf Complications with PA Catheters Infection and sepsis – Asepsis for insertion and maintenance of catheter and tubing mandatory – Change flush bag, pressure tubing, transducer, and stopcock every 96 hours Air embolus (e.g., disconnection) Complications with PA Catheters Ventricular dysrhythmias – During PA catheter insertion or removal – If tip migrates back from PA to right ventricle PA catheter cannot be wedged – May need repositioning Complications with PA Catheters Pulmonary infarction or PA rupture – Balloon rupture (e.g., overinflation) – Prolonged inflation – Spontaneous wedging – Thrombus/embolus formation Noninvasive Hemodynamic Monitoring Impedance cardiography (ICG) Def-Continuous or intermittent, noninvasive method of obtaining CO and assessing thoracic fluid status • Impedance-based hemodynamic parameters (e.g., CO, SV, SVR) are calculated from Zo, dZ/dt, MAP, CVP, and ECG Noninvasive Hemodynamic Monitoring Major indications – Early signs and symptoms of pulmonary or cardiac dysfunction – Differentiation of cardiac or pulmonary cause of shortness of breath – Evaluation of etiology and management of hypotension Noninvasive Hemodynamic Monitoring Major indications (cont’d) – Monitoring after discontinuing a PA catheter or justification for insertion of a PA catheter – Evaluation of pharmacotherapy – Diagnosis of rejection following cardiac transplantation hemodynamic cases (1 and 4) Case Study