Introduction to Introduction to

HEMODYNAMIC HEMODYNAMIC

MONITORINGMONITORING

22

DEFINITIONDEFINITION

PURPOSE

DEFINITION

HEMODYNAMIC MONITORING

Measuring and monitoring the factors that influence the force and flow of blood.

To aid in diagnosing, monitoring and managing critically ill patients.

33

INDICATIONSINDICATIONS To diagnose shock states To diagnose shock states

To determine fluid volume statusTo determine fluid volume status

To measure cardiac outputTo measure cardiac output

To monitor and manage unstable patients To monitor and manage unstable patients

To assess hemodynamic response to To assess hemodynamic response to therapies therapies

To diagnose primary pulmonary To diagnose primary pulmonary hypertension, valvular disease, intracardiac hypertension, valvular disease, intracardiac shunts, cardiac tamponade, and pulmonary shunts, cardiac tamponade, and pulmonary embolusembolus

44

CONTRAINDICATIONSCONTRAINDICATIONSfor an invasive PA Catheterfor an invasive PA Catheter

Tricuspid or pulmonary valve mechanical Tricuspid or pulmonary valve mechanical prosthesis prosthesis

Right heart mass (thrombus and/or tumor)Right heart mass (thrombus and/or tumor)

Tricuspid or pulmonary valve endocarditisTricuspid or pulmonary valve endocarditis

55

Clinical Scenario Use of PACClinical Scenario Use of PAC Management of complicated MIManagement of complicated MI

Severe LVF/RMI (precise management of heart failure)Severe LVF/RMI (precise management of heart failure) Assessment of respiratory distressAssessment of respiratory distress

Cardiogenic vs non-cardiogenic pulmonary edemaCardiogenic vs non-cardiogenic pulmonary edema Assessment/Diagnosis of shock/ cardiac Assessment/Diagnosis of shock/ cardiac

dysfunctiondysfunction Cardiogenic/hypovolemic/septicCardiogenic/hypovolemic/septic TamponadeTamponade Pulmonary embolismPulmonary embolism Severe dilated cardiomyopathySevere dilated cardiomyopathy

Management of Pulmonary HypertensionManagement of Pulmonary Hypertension Management of high-risk surgical patientsManagement of high-risk surgical patients

CABG, vascular, valvular, aneurysm repairCABG, vascular, valvular, aneurysm repair Management of volume requirements in the Management of volume requirements in the

critically ill critically ill ARF, GI bleed, trauma, sepsis (precise management)ARF, GI bleed, trauma, sepsis (precise management)

66

Hemodynamic ValuesHemodynamic Values CO / CICO / CI SV / SVI or SISV / SVI or SI SVOSVO22

RVEDVI or EDVIRVEDVI or EDVI SVR / SVRISVR / SVRI PVR / PVRIPVR / PVRI RVEFRVEF VOVO22 / VO / VO22II

DODO22 / DO / DO22II PAOPPAOP CVPCVP PAPPAP

Cardiac Output/Cardiac IndexCardiac Output/Cardiac Index Stroke Volume/Stroke Volume IndexStroke Volume/Stroke Volume Index Mixed Venous SaturationMixed Venous Saturation RV End-Diastolic VolumeRV End-Diastolic Volume Systemic Vascular ResistanceSystemic Vascular Resistance Pulmonary Vascular Resistance Pulmonary Vascular Resistance RV Ejection FractionRV Ejection Fraction Oxygen ConsumptionOxygen Consumption Oxygen DeliveryOxygen Delivery Pulmonary Artery Occlusive Pulmonary Artery Occlusive

PressurePressure Central Venous PressureCentral Venous Pressure Pulmonary Artery PressurePulmonary Artery Pressure

77

Index ValuesIndex Values

Values normalized for body size (BSA)Values normalized for body size (BSA)

CI CI is 2.5 – 4.5 L/min/mis 2.5 – 4.5 L/min/m22

SVRI SVRI is 1970 – 2390 dynes/sec/cm-is 1970 – 2390 dynes/sec/cm-5/m5/m22

SVI or SI SVI or SI is 35 – 60 mL/beat/mis 35 – 60 mL/beat/m22

EDVI EDVI is 60 – 100 mL/m2is 60 – 100 mL/m2

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Importance of Index ValuesImportance of Index Values

Mr. SmithMr. Smith 47 y/o male47 y/o male 60 kg60 kg CO = 4.5CO = 4.5 6 ft tall (72 inches)6 ft tall (72 inches) BSA = 1.8BSA = 1.8 CI = 2.5 L/min/mCI = 2.5 L/min/m22

Mr. JonesMr. Jones 47 y/o male47 y/o male 120 kg120 kg CO = 4.5CO = 4.5 6 ft tall (72 inches)6 ft tall (72 inches) BSA = 2.4BSA = 2.4 CI = 1.9 L/min/m2CI = 1.9 L/min/m2

99

BasicBasic ConceptsConcepts Cardiac Output Cardiac Output - - amount of blood pumped amount of blood pumped

out of the ventricles each minuteout of the ventricles each minute Stroke Volume Stroke Volume - - amount of blood ejected amount of blood ejected

by the ventricle with each contractionby the ventricle with each contraction CO = HR x SVCO = HR x SV

Decreased SV usually produces compensatory Decreased SV usually produces compensatory tachycardia.. tachycardia..

So. . .changes in HR can signal changes in So. . .changes in HR can signal changes in COCO

1010

BasicBasic ConceptsConcepts Systemic Vascular ResistanceSystemic Vascular Resistance

Measurement of the resistance (afterload) of Measurement of the resistance (afterload) of blood flow through systemic vasculatureblood flow through systemic vasculature

*Increased SVR/narrowing PP = vasoconstriction*Increased SVR/narrowing PP = vasoconstriction *Decreased SVR/widening PP = vasodilation*Decreased SVR/widening PP = vasodilation

Blood Pressure Blood Pressure BP = CO x SVRBP = CO x SVR

** ** SVR can increase to maintain BP SVR can increase to maintain BP despite inadequate COdespite inadequate CORememberRemember CO = HR x SV CO = HR x SV

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BasicBasic ConceptsConcepts

BP = CO x SVRBP = CO x SVR CO and SVR are inversely relatedCO and SVR are inversely related

CO and SVR will change before BP CO and SVR will change before BP changeschanges

* Changes in BP are a late sign of * Changes in BP are a late sign of hemodynamic alterationshemodynamic alterations

1212

StrokeStroke VolumeVolume Components Stroke VolumeComponents Stroke Volume

Preload: the volume of blood in the the volume of blood in the ventricles at end diastole and the ventricles at end diastole and the stretch placed on the muscle fibersstretch placed on the muscle fibers

Afterload: the resistance the ventricles the resistance the ventricles must overcome to eject it’s volume of must overcome to eject it’s volume of bloodblood

Contractility: the force with which the the force with which the heart muscle contracts (myocardial heart muscle contracts (myocardial compliance)compliance)

1313

StrokeStroke VolumeVolume PreloadPreload AfterloadAfterload ContractilitContractilit

yyFilling Pressures Filling Pressures & Volumes& Volumes

ResistanceResistance to to OutflowOutflow

Strength of Strength of ContractionContraction

CVPCVP

PAOP (PAD may PAOP (PAD may be used to be used to estimate PAOP)estimate PAOP)

PVR, MPAPPVR, MPAP

SVR, MAPSVR, MAPRVSVRVSV

LVSVLVSV

Fluids, Volume Fluids, Volume ExpandersExpanders

DiureticsDiuretics

VasoconstrictorVasoconstrictorss

VasodilatorsVasodilators

InotropicInotropic

MedicationsMedications

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ClinicalClinical MeasurementsMeasurements ofof PreloadPreload

Left Side: PAOP/LAP Left Side: PAOP/LAP PAD may be used to estimate PAOP in the PAD may be used to estimate PAOP in the

absence of pulmonary disease/HTNabsence of pulmonary disease/HTN

The pulmonary vasculature is a low pressure The pulmonary vasculature is a low pressure system in the absence of pulmonary diseasesystem in the absence of pulmonary disease

These pressures are “accurate” estimations These pressures are “accurate” estimations of preload only with of preload only with perfect complianceperfect compliance of of heart and lungsheart and lungs

Right Side: CVP/RAP Right Side: CVP/RAP ** filling pressures filling pressures

1515

ClinicalClinical MeasurementsMeasurements ofof AfterloadAfterload

RV AfterloadRV Afterload MPAPMPAP PVR = 150-250 dynes/sec/cmPVR = 150-250 dynes/sec/cm-5-5

PVRI = 255-285 dynes/sec/cmPVRI = 255-285 dynes/sec/cm-5/-5/mm22

LV AfterloadLV Afterload MAPMAP SVR = 800–1300 dynes/sec/cm-5SVR = 800–1300 dynes/sec/cm-5 SVRI = 1970-2390 dynes/sec/cm-5/m2SVRI = 1970-2390 dynes/sec/cm-5/m2

1616

ClinicalClinical EstimationEstimation ofof ContractilityContractility

Cardiac Output Cardiac Output * flow* flow

Normal = 4-8 L/minNormal = 4-8 L/min Cardiac IndexCardiac Index

Normal = 2.5-4.5 L/min/m2Normal = 2.5-4.5 L/min/m2

Stroke VolumeStroke Volume *pump performance*pump performance

Normal = 50-100 ml/beatNormal = 50-100 ml/beat Stroke volume IndexStroke volume Index

Normal = 30-50 ml/beat/m2Normal = 30-50 ml/beat/m2

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Ventricular ComplianceVentricular Compliance

Ability of the ventricle to stretchAbility of the ventricle to stretch

Decreased with LV hypertrophy, MI, Decreased with LV hypertrophy, MI, fibrosis, HOCMfibrosis, HOCM

*If compliance is decreased, *If compliance is decreased, smallsmall changes in changes in volumevolume produce produce large large changes in changes in pressurepressure

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The PA CatheterThe PA Catheter

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Pulmonary Artery CathetersPulmonary Artery Catheters

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The Pulmonary Artery The Pulmonary Artery CatheterCatheter

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““Swan-Ganz” PA CatheterSwan-Ganz” PA Catheter

Large Markers Large Markers = 50cm= 50cm Small Markers Small Markers = 10cm= 10cm 10 cm between small black markers on 10 cm between small black markers on

cathetercatheter Several typesSeveral types

Thermodilutional COThermodilutional CO CCOCCO PrecepPrecep NICCONICCO

Multiple lumensMultiple lumens

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BREAKBREAKTake 5 MINUTESTake 5 MINUTES

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Demonstration of PA catheterDemonstration of PA catheterand and

Hands-on practiceHands-on practice

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BleedingBleeding InfectionInfection DysrhythmiasDysrhythmias Pulmonary Artery Pulmonary Artery

RuptureRupture PneumothoraxPneumothorax HemothoraxHemothorax Valvular DamageValvular Damage EmbolizationEmbolization Balloon RuptureBalloon Rupture Catheter MigrationCatheter Migration

Risks With The PA CatheterRisks With The PA Catheter

2525

Hemodynamic Hemodynamic WaveformsWaveforms

2727

PA-Catheter PositioningPA-Catheter Positioning

RightRight AtriumAtrium

RightRight VentricleVentricle

PulmonaryPulmonary ArteryArtery

PulmonaryPulmonary ArteryArtery OcclusionOcclusion PressurePressure

2828

PAC Insertion SequencePAC Insertion Sequence

2929

Post PA Catheter InsertionPost PA Catheter Insertion Assess ECG for dysrhythmias.Assess ECG for dysrhythmias. Assess for signs and symptoms of respiratory distress.Assess for signs and symptoms of respiratory distress. Ascertain sterile dressing is in place.Ascertain sterile dressing is in place. Obtain PCXR to check placement.Obtain PCXR to check placement. Zero and level transducer(s) at the phlebostatic axis. Zero and level transducer(s) at the phlebostatic axis. Assess quality of waveforms (i.e., proper configuration, dampening, Assess quality of waveforms (i.e., proper configuration, dampening, catheter whip). catheter whip). Obtain opening pressures and wave form tracings for each Obtain opening pressures and wave form tracings for each waveform.waveform. Assess length at insertion site. Assess length at insertion site. Ensure that all open ends of stopcocks are covered with sterile dead-Ensure that all open ends of stopcocks are covered with sterile dead-end caps (red dead-end caps, injection caps, or male Luer lock caps). end caps (red dead-end caps, injection caps, or male Luer lock caps). Update physician of abnormalities.Update physician of abnormalities.

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General Rules for General Rules for Hemodynamic Hemodynamic MeasurementsMeasurements

Measure all pressures at End-ExpirationMeasure all pressures at End-Expiration

““Patient Peak”Patient Peak”

““Vent Valley”Vent Valley”

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Phlebostatic AxisPhlebostatic Axis

4th ICS Mid-chest, regardless of head elevation4th ICS Mid-chest, regardless of head elevation

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Phlebostatic AxisPhlebostatic Axis

4th ICS Mid-chest, regardless of head elevation4th ICS Mid-chest, regardless of head elevation

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Spontaneous RespirationsSpontaneous Respirations

Measure all pressures at Measure all pressures at end-expirationend-expiration At At top curve top curve with spontaneous with spontaneous

respirationrespiration

““patient-peak”patient-peak” Intrathoracic pressure Intrathoracic pressure decreasesdecreases

during spontaneous during spontaneous inspirationinspiration Negative deflection on waveformsNegative deflection on waveforms

Intrathoracic pressure Intrathoracic pressure increasesincreases during during spontaneous spontaneous expirationexpiration

Positive deflection on waveformsPositive deflection on waveforms

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Spontaneous RespirationsSpontaneous Respirations

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Mechanical VentilationMechanical Ventilation Measure all pressures at Measure all pressures at end-expirationend-expiration At At bottom curvebottom curve with mechanical with mechanical

ventilatorventilator

““vent-valley”vent-valley” Intrathoracic pressure Intrathoracic pressure increases increases during during

positive pressure ventilations positive pressure ventilations ((inspirationinspiration))

Positive deflection on waveformsPositive deflection on waveforms Intrathoracic pressure Intrathoracic pressure decreases decreases

during positive pressure during positive pressure expirationexpiration Negative deflection on waveformsNegative deflection on waveforms

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3737

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General Rules for General Rules for Hemodynamic MeasurementsHemodynamic Measurements

Measure all pressures with the HOB at a … Measure all pressures with the HOB at a … consistentconsistent level of elevationlevel of elevation

Level the transducer at the Level the transducer at the phlebostatic axisphlebostatic axis 4th intercostal space, mid-chest4th intercostal space, mid-chest

Print strips with one ECG and one pressure Print strips with one ECG and one pressure channelchannel adequate scaleadequate scale allows accurate waveform analysisallows accurate waveform analysis

Confirm monitor pressures with pressures Confirm monitor pressures with pressures obtained by waveform analysisobtained by waveform analysis ** correct waveform analysis is more accurate than ** correct waveform analysis is more accurate than

pressures from the monitorpressures from the monitor

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Review of Normal ValuesReview of Normal Values

RAP (CVP)RAP (CVP)

RVPRVP

PAPPAP

PAOPPAOP

0-8 mmHg0-8 mmHg

15-30/0-8 15-30/0-8 mmHgmmHg

15-30/6-12 15-30/6-12 mmHgmmHg

8 - 12 mmHg8 - 12 mmHg

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PA INSERTION WAVEFORMSPA INSERTION WAVEFORMS

A = A = RA (CVP) WaveformRA (CVP) Waveform B = RV WaveformB = RV Waveform C = PA WaveformC = PA Waveform D = PAWP WaveformD = PAWP Waveform

B

C D

A

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PAC Insertion SequencePAC Insertion Sequence

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Right Atrium (CVP)Right Atrium (CVP)

Normal Value 0-8 mmHgRAP = CVPWave Fluctuations Due To Contractions

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Components of the RA Components of the RA (CVP) Waveform(CVP) Waveform

a-wavea-wave atrial contraction (systole)atrial contraction (systole) begins in the PR interval and QRS on the begins in the PR interval and QRS on the

ECGECG correct location for measurement of correct location for measurement of

CVP/RAPCVP/RAP * average the peak & trough of the a-wave* average the peak & trough of the a-wave * (a-Peak + a-trough)/2 = CVP* (a-Peak + a-trough)/2 = CVP

May not see if no atrial contractions as with. May not see if no atrial contractions as with. . .. .

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Absent a wavesAbsent a waves

Atrial fibrillationAtrial fibrillation

Paced rhythmPaced rhythm

Junctional rhythmJunctional rhythm

Measure at the end of the QRSMeasure at the end of the QRS

Components of the RA Components of the RA (CVP) Waveform(CVP) Waveform

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Absent A WaveAbsent A Wave

*PACEP.ORG 2007

* Measure at end of QRS!

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c-wavec-wave tricuspid valve closuretricuspid valve closure Between ST segmentBetween ST segment Between a and v wavesBetween a and v waves *may or may not be present*may or may not be present

v-wavev-wave Atrial fillingAtrial filling begins at the end of the QRS to the begins at the end of the QRS to the

beginning of the T wave (QT interval)beginning of the T wave (QT interval)

Components of the RA Components of the RA (CVP) Waveform(CVP) Waveform

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Reading the RA CVP) Reading the RA CVP) WaveformWaveform

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CVP WaveformCVP Waveform

Vented Patient

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CVP WaveformCVP Waveform

Vented Patient – “Vent Valley”

a wave

5353

Right VentricleRight Ventricle

Normal Value 15-25/0-8 mmHgCatheter In RV May Cause EctopySwan Tip May Drift From PA to RV

5454

RV WaveformRV Waveform

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Components of the RV Components of the RV WaveformWaveform

Usually only seen with insertionUsually only seen with insertion Systole Systole

measured at the peakmeasured at the peak peak occurs after the QRSpeak occurs after the QRS

DiastoleDiastole measured just prior to the the onset of systolemeasured just prior to the the onset of systole

No dicrotic notchNo dicrotic notch Dicrotic notch indicates valve closureDicrotic notch indicates valve closure *** Aids in differentiation from the PA tracing*** Aids in differentiation from the PA tracing

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Reading the RV WaveformReading the RV Waveform

5757

RV Waveform InterventionsRV Waveform Interventions After PA catheter is correctly placed, RV After PA catheter is correctly placed, RV

waveform should not be seen. If it is, waveform should not be seen. If it is, then interventions are necessary:then interventions are necessary: Check for specific unit protocol firstCheck for specific unit protocol first Inflate balloon with patient lying on their left Inflate balloon with patient lying on their left

side (catheter may float back into PA)side (catheter may float back into PA) With deflated balloon, pull catheter into RA With deflated balloon, pull catheter into RA

placement or remove completelyplacement or remove completely Document your actions and notify physicianDocument your actions and notify physician

** An RN should NEVER advance the ** An RN should NEVER advance the catheter!catheter!

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Pulmonary ArteryPulmonary Artery

Normal Value 15-25/8-15 mmHgDicrotic Notch Represents PV ClosurePAD Approximates PAWP (LVEDP) (in absence of lung or MV disease)

5959

PA WaveformPA Waveform

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Components of the PA Components of the PA WaveformWaveform

SystoleSystole measured at the peak of the wavemeasured at the peak of the wave

DiastoleDiastole measured just prior to the upstroke of measured just prior to the upstroke of

systole (end of QRS)systole (end of QRS) Higher than RV diastolic pressureHigher than RV diastolic pressure

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Dicrotic notchDicrotic notch indicates pulmonic valve closureindicates pulmonic valve closure aids in differentiation from RV waveformaids in differentiation from RV waveform aids in determining waveform qualityaids in determining waveform quality

Anachrotic NotchAnachrotic Notch Before upsweep to systoleBefore upsweep to systole Opening of pulmonic valveOpening of pulmonic valve

Components of the PA Components of the PA WaveformWaveform

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Reading the PA WaveformReading the PA Waveform

Dicrotic notch

6363

PA WaveformPA Waveform

Identify that it is the PA tracing

Look at the scale

What is the PAP?

10/20/30

6464

PA WaveformPA Waveform

Look for dichrotic notch

Look at scale

What is the PAP?

6565

PAOP / WedgePAOP / Wedge

Normal Value 8-12 mmHgBalloon Floats and Wedges in Pulmonary Artery PAWP = LAP = LVEDP Wedging Can Cause Capillary Rupture

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a-wavea-wave atrial contractionatrial contraction correct location for measurement of correct location for measurement of

PAOPPAOP average the peak & trough of the a-waveaverage the peak & trough of the a-wave

begins near the end of QRS or the QT begins near the end of QRS or the QT segmentsegment

* Delayed ECG correlation from CVP since * Delayed ECG correlation from CVP since PA catheter is further away from left atriumPA catheter is further away from left atrium

Components of the PA Components of the PA WaveformWaveform

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c-wavec-wave rarely presentrarely present represents mitral valve closurerepresents mitral valve closure

v-wavev-wave represents left atrial fillingrepresents left atrial filling begins at about the end of the T begins at about the end of the T

wave wave

Components of the PA Components of the PA WaveformWaveform

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Reading the PAOP WaveformReading the PAOP Waveform

Begins within the QRS or the QT segment

6969

Wedging Can Cause Wedging Can Cause Pulmonary Artery Pulmonary Artery

RuptureRupture

7070

PA Tracing to PAOP Tracing to PA Tracing to PAOP Tracing to PA TracingPA Tracing

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Post PAC InsertionPost PAC Insertion Assess ECG for dysrythmiasAssess ECG for dysrythmias Assess for S/S of respiratory distressAssess for S/S of respiratory distress Be sure sterile dressing is appliedBe sure sterile dressing is applied Order CXR for placement Order CXR for placement

Get MD order before infusing through portsGet MD order before infusing through ports

Zero and level all transducersZero and level all transducers Assess quality of waveformsAssess quality of waveforms

Dampening, proper configuration, scaleDampening, proper configuration, scale

Obtain opening pressures and waveform tracings for Obtain opening pressures and waveform tracings for each waveformeach waveform

Note length at insertion siteNote length at insertion site Place proper luer-lock connectors to lumens and cap Place proper luer-lock connectors to lumens and cap

all portsall ports Notify MD of any abnormalitiesNotify MD of any abnormalities

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PrecautionsPrecautions Always set alarms on monitor Always set alarms on monitor

20mmHg above and below pt baseline20mmHg above and below pt baseline

If in PAOP with balloon down, have pt If in PAOP with balloon down, have pt cough, deep breath, change positioncough, deep breath, change position

If unable to dislodge from PAOP, notify MD If unable to dislodge from PAOP, notify MD immediately to reposition catheterimmediately to reposition catheter CXR to reconfirm placementCXR to reconfirm placement

If pt coughs up blood or it is suctioned via If pt coughs up blood or it is suctioned via ETT, suspect PA rupture and notify MD ETT, suspect PA rupture and notify MD immediatelyimmediately

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Intermittent Thermodilution Intermittent Thermodilution COCO

Based on measuring blood temperature Based on measuring blood temperature changeschanges

Must know the following:Must know the following: Computation constantComputation constant

Volume of injectateVolume of injectate

Temperature of injectate Temperature of injectate Iced or room temperatureIced or room temperature

Inject rapidly and smoothly over 4 seconds maxInject rapidly and smoothly over 4 seconds max Thermister at end of PA catheter detects Thermister at end of PA catheter detects

change in temperature and creates CO curvechange in temperature and creates CO curve At least 3 measurements and average resultsAt least 3 measurements and average results

7474

Cardiac Output via Cardiac Output via ThermodilutionThermodilution

*PACEP.ORG 2007

7575

Averaging CO Averaging CO MeasurementsMeasurements

*PACEP.ORG 2007

7676

Continuous Cardiac OutputContinuous Cardiac Output A heat signal is produced by the thermal A heat signal is produced by the thermal

filament of the PA catheterfilament of the PA catheter

The signal is detected by the thermistor on The signal is detected by the thermistor on the PA catheter and is converted into a the PA catheter and is converted into a time/temperature curvetime/temperature curve

The CCO computer produces a time-The CCO computer produces a time-averaged calculationaveraged calculation Over 3 minutesOver 3 minutes

Updates every 30-60 secondsUpdates every 30-60 seconds

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Mixed Venous Oxygen Mixed Venous Oxygen SaturationSaturation

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Mixed Venous Oxygenation Mixed Venous Oxygenation Monitoring Monitoring

(SvO2)(SvO2) Measures the amount of OMeasures the amount of O22 in the blood (on in the blood (on

the Hgb molecule) returned to the heartthe Hgb molecule) returned to the heart

Helps to demonstrate the balance between OHelps to demonstrate the balance between O2 2

supply & demand in the body supply & demand in the body (tissue (tissue oxygenation)oxygenation)

Helps to interpret hemodynamic dysfunction Helps to interpret hemodynamic dysfunction when used with other measurementswhen used with other measurements

Normal: 70% (60-80)Normal: 70% (60-80)

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Mixed Venous Oxygen Mixed Venous Oxygen SaturationSaturation

End result of OEnd result of O22 delivery and delivery and consumptionconsumption

Measured in the Measured in the pulmonary arterypulmonary artery An average estimate of venous An average estimate of venous

saturation for the whole body.saturation for the whole body.

**Does not reflect separate tissue **Does not reflect separate tissue perfusion or oxygenationperfusion or oxygenation

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Mixed Venous Oxygen Mixed Venous Oxygen SaturationSaturation

Continuous measurementContinuous measurement

““Early” warning signal to detect Early” warning signal to detect oxygen transport imbalancesoxygen transport imbalances

Evaluates the effect of the Evaluates the effect of the therapeutic interventionstherapeutic interventions

Identify potential patient care Identify potential patient care consequences (turning, suctioning)consequences (turning, suctioning)

8181

Mixed Venous Oxygen Mixed Venous Oxygen SaturationSaturation

There are four factors that affect SVOThere are four factors that affect SVO22::

1.1. HemoglobinHemoglobin

2.2. Cardiac outputCardiac output

3.3. Arterial oxygen saturation (SaOArterial oxygen saturation (SaO22))

4.4. Oxygen consumption (VOOxygen consumption (VO22))

8282

SvO2 ApplicationSvO2 Application

In a case of increased SVR with decreased CO. Nitroprusside was started. The increase in SvO2 and increase in CO reflects the appropriateness of therapy.

8383

Ways To Increase O2 Ways To Increase O2 DeliveryDelivery

Increase COIncrease CO increase HR, optimize preload, decrease increase HR, optimize preload, decrease

afterload, add positive inotropes afterload, add positive inotropes

Increase Hgb, increase SaO2Increase Hgb, increase SaO2

Improve pulmonary functionImprove pulmonary function pulmonary toilet, prevent atelectasispulmonary toilet, prevent atelectasis

ventilation strategiesventilation strategies

8484

Ways To Decrease O2 DemandWays To Decrease O2 Demand Decrease muscle activityDecrease muscle activity

sedatives, (paralytics)sedatives, (paralytics)

prevent/control seizuresprevent/control seizures

prevent/control shiveringprevent/control shivering

space care activitiesspace care activities

Decrease temperatureDecrease temperature prevent/control feverprevent/control fever

8585

Removal of the PA CatheterRemoval of the PA Catheter

Usually performed by the nurse Usually performed by the nurse withwith an MD order an MD order

Place patient supine with HOB flatPlace patient supine with HOB flat (reduces chance of air embolus)(reduces chance of air embolus)

8686

Removal of the PA CatheterRemoval of the PA Catheter

Make sure balloon is down, have Make sure balloon is down, have patient inhale and hold breath, patient inhale and hold breath, pull PA catheter out smoothlypull PA catheter out smoothly monitor for ventricular ectopymonitor for ventricular ectopy stop immediately & notify MD if stop immediately & notify MD if

resistance is metresistance is met

8787

Removal of the PA CatheterRemoval of the PA Catheter

8888

Removal of the PA CatheterRemoval of the PA Catheter

If patient is unable to perform breath If patient is unable to perform breath hold:hold: Pull PA catheter during period of positive Pull PA catheter during period of positive

intrathoracic pressure to minimize chance of intrathoracic pressure to minimize chance of venous air embolusvenous air embolus

Mechanically ventilated patientMechanically ventilated patient pull PA catheter during delivery of vent pull PA catheter during delivery of vent

breath breath Spontaneously breathing patientSpontaneously breathing patient pull PA catheter during exhalationpull PA catheter during exhalation

8989

Removal of the PA CatheterRemoval of the PA Catheter If introducer sheath (cordis) is to remain in If introducer sheath (cordis) is to remain in

place, it place, it must be cappedmust be capped..

If introducer sheath (cordis) is to be If introducer sheath (cordis) is to be removed, repeat the steps used for PA removed, repeat the steps used for PA catheter removal.catheter removal.

Hold pressure on the site (5-10 min.), keep Hold pressure on the site (5-10 min.), keep patient flat until hemostasis is achieved.patient flat until hemostasis is achieved.

Apply sterile dressing or band-aid.Apply sterile dressing or band-aid.

9090

BreakBreakTake 5 MinutesTake 5 Minutes

9191

Hemodynamic Hemodynamic Waveform PracticeWaveform Practice

9292

MEASUREMENTSMEASUREMENTS

9393

SAMPLE MEASUREMENTSSAMPLE MEASUREMENTS

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SAMPLE MEASUREMENTSSAMPLE MEASUREMENTS

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SAMPLE MEASUREMENTSSAMPLE MEASUREMENTS

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SAMPLE MEASUREMENTSSAMPLE MEASUREMENTS

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SAMPLE MEASUREMENTSSAMPLE MEASUREMENTS

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SAMPLE MEASUREMENTSSAMPLE MEASUREMENTS

9999

SAMPLE MEASUREMENTSSAMPLE MEASUREMENTS

100100

SAMPLE MEASUREMENTSSAMPLE MEASUREMENTS

101101

SAMPLE MEASUREMENTSSAMPLE MEASUREMENTS

102102

SAMPLE MEASUREMENTSSAMPLE MEASUREMENTS

103103

SAMPLE MEASUREMENTSSAMPLE MEASUREMENTS

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SAMPLE MEASUREMENTSSAMPLE MEASUREMENTS

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SAMPLE MEASUREMENTSSAMPLE MEASUREMENTS

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SAMPLE MEASUREMENTSSAMPLE MEASUREMENTS

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ReviewReview

108108

ReviewReview

The PA diastolic pressure is The PA diastolic pressure is measured at which part of measured at which part of the waveform?the waveform?

Just prior to the upstroke of

systole

109109

ReviewReview

Which part of the CVP and Which part of the CVP and PAOP waveforms is used to PAOP waveforms is used to calculate pressures?calculate pressures?

The a wave

110110

ReviewReview

The RV waveform can be The RV waveform can be distinguished from the PA distinguished from the PA waveform by:waveform by:

RV has lower diastolic pressure and no dicrotic

notch

111111

ReviewReview

The v wave of the CVP & The v wave of the CVP & PAOP waveforms represents:PAOP waveforms represents:

Atrial filling

112112

ReviewReview

The a wave of the CVP The a wave of the CVP waveform correlates with waveform correlates with which electrical event?which electrical event?

The PR interval on the ECG

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ReviewReview

The a wave of the PAOP The a wave of the PAOP waveform correlates with waveform correlates with which electrical event?which electrical event?

The QRS on the ECG

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Questions?Questions?