hemodynamic monitoring

Hemodynamic Hemodynamic MonitoringMonitoring

Hemodynamics?Hemodynamics?

Hemo: bloodHemo: blood

Dynamics: movementDynamics: movement Hemodynamics: movement of bloodHemodynamics: movement of blood

The measurement of the force (pressure) exerted The measurement of the force (pressure) exerted by the blood as it moves through blood vessels by the blood as it moves through blood vessels or heart chambers during systole and diastoleor heart chambers during systole and diastole

For many critically ill patients, hemodynamic For many critically ill patients, hemodynamic monitoring can add valuable information to the monitoring can add valuable information to the clinical management of the patient.clinical management of the patient.

Physiology of Blood PressurePhysiology of Blood Pressure

Without sufficient BP the tissues will not receive Without sufficient BP the tissues will not receive oxygen.oxygen.

High BP strains the heart and vessels.High BP strains the heart and vessels.

3 factors control BP3 factors control BP HeartHeart BloodBlood VesselsVessels

Review of Heart AnatomyReview of Heart Anatomy

4 chambers serving 4 circulatory branches4 chambers serving 4 circulatory branches

Each Chamber has its own BP.Each Chamber has its own BP.

Hemodynamics is measuring each of those Hemodynamics is measuring each of those pressures.pressures.

LV - Systemic arteriesLV - Systemic arteries RA – Systemic veinsRA – Systemic veins RV – Pulmonary ArteriesRV – Pulmonary Arteries LA – Pulmonary VeinsLA – Pulmonary Veins

The HeartThe Heart

Muscular 4 chambered organ.Muscular 4 chambered organ.

Pericardium – membranous sac covering heart.Pericardium – membranous sac covering heart.

Epicardium – visceral pericardiumEpicardium – visceral pericardium

Myocardium – heart muscleMyocardium – heart muscle

Endocardium – Lines the heart chambersEndocardium – Lines the heart chambers

Cardiac CycleCardiac Cycle

Refers to the pumping cycle consisting of Refers to the pumping cycle consisting of systole and diastole.systole and diastole.

Preload – stretch of ventricle muscle fibers Preload – stretch of ventricle muscle fibers before contraction, created by end-before contraction, created by end-diastolic volumediastolic volume

Afterload – Resistance to ejection of blood Afterload – Resistance to ejection of blood during systole.during systole.

PreloadPreload

Preload can be defined as the initial Preload can be defined as the initial stretching of the cardiac myocytes prior to stretching of the cardiac myocytes prior to contraction.contraction.

For example, when venous return is For example, when venous return is increased, the end-diastolic pressure and increased, the end-diastolic pressure and volume of the ventricle are increased,volume of the ventricle are increased,

IntroductionIntroduction

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Types of CathetersTypes of Catheters

1.1. Arterial CatheterArterial Catheter

2.2. Central Venous CatheterCentral Venous Catheter

3.3. Pulmonary Artery CatheterPulmonary Artery Catheter

Technical BackgroundTechnical Background

Liquids are noncompressibleLiquids are noncompressible

Pressures at any given point within a liquid are Pressures at any given point within a liquid are transmitted equally transmitted equally Pascal’s PrinciplePascal’s Principle

When a closed system is filled with liquid the When a closed system is filled with liquid the pressure exerted at one point can be measured pressure exerted at one point can be measured accurately at any other point on the same levelaccurately at any other point on the same level

Technical BackgroundTechnical Background

Hemodynamically Unstable Hemodynamically Unstable PatientsPatients

Receiving fluid infusionReceiving fluid infusion Receiving drugs toReceiving drugs to

Improve circulationImprove circulation Improve heart functionImprove heart function Improve blood vessel caliberImprove blood vessel caliber

Experiencing extremes in blood pressureExperiencing extremes in blood pressure Patients who require serial ABGsPatients who require serial ABGs

Arterial CatheterArterial Catheter Common UsesCommon Uses

Measure systemic Artery PressureMeasure systemic Artery Pressure Collect arterial blood gas samplesCollect arterial blood gas samples Indocyanine green C.O. measurementIndocyanine green C.O. measurement

Insertion SitesInsertion Sites RadialRadial, brachial, femoral, dorsalis pedis, umbilical , brachial, femoral, dorsalis pedis, umbilical

(neonates)(neonates) LocationLocation

Within systemic artery near insertion siteWithin systemic artery near insertion site Radial artery is the site of choice because of the Radial artery is the site of choice because of the

collateral circulation to the hand provided by the ulnar collateral circulation to the hand provided by the ulnar arteryartery

http://www.youtube.com/watch?http://www.youtube.com/watch?v=qv54USEYNzw&feature=relatedv=qv54USEYNzw&feature=related

Arterial Catheter: Arterial Catheter: Arterial WaveformArterial Waveform

3→1: increase of BP during systole3→1: increase of BP during systole 2: dicrotic notch2: dicrotic notch

closure of aortic valve during diastoleclosure of aortic valve during diastole 3: Arterial end-diastolic pressure3: Arterial end-diastolic pressure

1

2

3

A-lineA-line

An arterial waveform should have aAn arterial waveform should have a

• Clear upstroke on the left (ejection)Clear upstroke on the left (ejection)

• With a dicrotic notch (valve closure)With a dicrotic notch (valve closure)

• Down stroke on the right (diastolic runoff)Down stroke on the right (diastolic runoff)

• A pulmonary artery waveform will look A pulmonary artery waveform will look similar to this waveform, however the similar to this waveform, however the pressures will be lowerpressures will be lower

Arterial Catheter: Arterial Catheter: Normal Arterial PressureNormal Arterial Pressure

120/80 mmHg120/80 mmHg

Systolic (contraction): 100-140 mmHg; min acceptable 90Systolic (contraction): 100-140 mmHg; min acceptable 90

Diastolic (relaxation): 60-90 mmHgDiastolic (relaxation): 60-90 mmHg

Mean: 80-100 mmHgMean: 80-100 mmHgMAP = MAP = (Psystolic + 2 x Pdiastolic)(Psystolic + 2 x Pdiastolic)

33 The diastolic value receives greater weight in this formula The diastolic value receives greater weight in this formula

because the diastolic phase is about twice as long as the because the diastolic phase is about twice as long as the systolic phasesystolic phase

A MAP of 60 mmHg is considered the minimum pressure A MAP of 60 mmHg is considered the minimum pressure needed to maintain adequate tissue perfusionneeded to maintain adequate tissue perfusion

Arterial Catheter: Arterial Catheter: Decreased Arterial PressureDecreased Arterial Pressure

Absolute hypovolemiaAbsolute hypovolemia Blood lossBlood loss DehydrationDehydration

Relative hypovolemiaRelative hypovolemia ShockShock VasodilationVasodilation

Cardiac FailureCardiac Failure

Arterial Catheter: Arterial Catheter: Increased Arterial PressureIncreased Arterial Pressure

Improvement in circulatory volume and Improvement in circulatory volume and functionfunction

Sympathetic stimulationSympathetic stimulation

VasoconstrictionVasoconstriction

Administration of vasopressorsAdministration of vasopressors

StrokeVolume

Vascular Resistance

ArterialPressure

Since arterial pressure is the product of stroke volume and vascular Since arterial pressure is the product of stroke volume and vascular resistance, changes in either parameter can affect arterial pressureresistance, changes in either parameter can affect arterial pressure

Opposing changes of these two parameters (e.g. increase in stroke Opposing changes of these two parameters (e.g. increase in stroke volume and a decrease in vascular resistance) may present volume and a decrease in vascular resistance) may present

an unchanged arterial pressurean unchanged arterial pressure

Arterial Catheter:Arterial Catheter:Pulse PressurePulse Pressure

Arterial Catheter:Arterial Catheter:Pulse PressurePulse Pressure

The difference between arterial systolic and The difference between arterial systolic and diastolic pressure.diastolic pressure.

Pulse pressure = systolic pressure – diastolic Pulse pressure = systolic pressure – diastolic pressure.pressure.

Bradycardia: low rate allows the blood volume Bradycardia: low rate allows the blood volume more time for diastolic runoff and causes a lower more time for diastolic runoff and causes a lower diastolic pressurediastolic pressure

Tachycardia: high rate allows the blood volume Tachycardia: high rate allows the blood volume less time for diastolic runoff and causes a higher less time for diastolic runoff and causes a higher diastolic pressurediastolic pressure

Decrease Pulse PressureDecrease Pulse Pressure

↓ ↓ pulse pressure = early sign of pulse pressure = early sign of hypovolemiahypovolemia

↓ ↓ stroke volume (hypovolemia)stroke volume (hypovolemia)

↑↑blood vessel compliance (shock)blood vessel compliance (shock)

TachycardiaTachycardia

Increase Pulse PressureIncrease Pulse Pressure

↑ ↑ pulse pressure = early sign of vol. pulse pressure = early sign of vol. restorationrestoration ↑ ↑ stroke volume (hypervolemia)stroke volume (hypervolemia)

↓ ↓ blood vessel compliance (arteriosclerosis)blood vessel compliance (arteriosclerosis)

bradycardiabradycardia

Cardiac OutputCardiac Output

QT or CO = the amount of blood pumped out the QT or CO = the amount of blood pumped out the left ventricle and into the systemic circulation.left ventricle and into the systemic circulation.

CO = HR x SVCO = HR x SV

CO = (130 x BSA) / (CaO2 – CvO2)CO = (130 x BSA) / (CaO2 – CvO2)

Normal is 4 – 8 lpm and depends on body size.Normal is 4 – 8 lpm and depends on body size. Measured by thermal dilution technique.Measured by thermal dilution technique.

Factors Affecting Cardiac Factors Affecting Cardiac OutputOutput

Factors affecting cardiac output in a healthy but Factors affecting cardiac output in a healthy but untrained individual could be: untrained individual could be:

Increase/ decreased in heart rateIncrease/ decreased in heart rateChange of postureChange of postureSympathetic nervous system activitySympathetic nervous system activityParasympathetic nervous system activity can also affect Parasympathetic nervous system activity can also affect cardiac output.cardiac output.Heart rate can vary by a factor of approximately 3, Heart rate can vary by a factor of approximately 3, between 60 and 180 beats per minute, whilst stroke volume between 60 and 180 beats per minute, whilst stroke volume can vary between 70 and 120 ml, a factor of only 1.5.can vary between 70 and 120 ml, a factor of only 1.5.

Cardiac Index (CI)Cardiac Index (CI)

Used to normalize CO measurements among Used to normalize CO measurements among patients of varying body size.patients of varying body size.

CI = CO/BSA - 2.5 – 3.5 L/min/mCI = CO/BSA - 2.5 – 3.5 L/min/m22..

CI values between 1.8 and 2.5 L/min/mCI values between 1.8 and 2.5 L/min/m22 indicate indicate hypoperfusion.hypoperfusion.

CI < 1.8 L/min/mCI < 1.8 L/min/m22 may be indicative of may be indicative of cardiogenic shock.cardiogenic shock.

Stroke Volume (SV)Stroke Volume (SV)

Measures the average CO per one heartbeat.Measures the average CO per one heartbeat. ↑ ↑ by drugs that raise cardiac contractility and by drugs that raise cardiac contractility and

during early stages of compensated septic during early stages of compensated septic shock.shock.

↓ ↓ by drugs that lower cardiac contractility and by drugs that lower cardiac contractility and during late stages of decompensated shock.during late stages of decompensated shock.

SV = CO / HRSV = CO / HR NV: 40 to 80 mLNV: 40 to 80 mL

Stroke Volume Index (SVI)Stroke Volume Index (SVI)

Used to normalize stroke volume Used to normalize stroke volume measurements among patients of varying measurements among patients of varying body size.body size.

SVI = SV / BSASVI = SV / BSA

NV: 33 to 47 mL/mNV: 33 to 47 mL/m22

Factors Factors ↑ SV, SVI, CO, CI↑ SV, SVI, CO, CI

Positive Inotropic Drugs (Positive Inotropic Drugs (↑ contractility)↑ contractility) Digoxin (Lanoxin), Dobutamine (Dobutrex), Digoxin (Lanoxin), Dobutamine (Dobutrex),

Epinephrine (Adrenalin), Dopamine (Intropin), Epinephrine (Adrenalin), Dopamine (Intropin), Isoproterenol (Isuprel), Digitalis, Amrinone Isoproterenol (Isuprel), Digitalis, Amrinone (Inocor)(Inocor)

Abnormal ConditionsAbnormal Conditions Septic shock (early stages), Hyperthermia, Septic shock (early stages), Hyperthermia,

Hypervolemia, ↓ vascular resistanceHypervolemia, ↓ vascular resistance

Factors Factors ↓ SV, SVI, CO, CI↓ SV, SVI, CO, CI

Negative Inotropic Drugs (Negative Inotropic Drugs (↓ contractility)↓ contractility) Propanolol (Inderal), Metoprolol (Lopressor), Propanolol (Inderal), Metoprolol (Lopressor),

Atenolol (Tenormin)Atenolol (Tenormin) Abnormal ConditionsAbnormal Conditions

Septic shock (late stages), CHF, Septic shock (late stages), CHF, Hypovolemia, Pulmonary emboli, ↑ vascular Hypovolemia, Pulmonary emboli, ↑ vascular resistance, MIresistance, MI

Hyperinflation of the LungsHyperinflation of the Lungs MV, CPAP, PEEPMV, CPAP, PEEP

Ejection FractionEjection FractionThe ejection fraction is a measurement of the heart's efficiency and can be The ejection fraction is a measurement of the heart's efficiency and can be used to estimate the function of the left ventricle, which pumps blood to the used to estimate the function of the left ventricle, which pumps blood to the rest of the body. The left ventricle pumps only a fraction of the blood it rest of the body. The left ventricle pumps only a fraction of the blood it contains. The ejection fraction is the amount of blood pumped divided by contains. The ejection fraction is the amount of blood pumped divided by the amount of blood the ventricle contains. A normal ejection fraction is the amount of blood the ventricle contains. A normal ejection fraction is more than 55% of the blood volume. If the heart becomes enlarged, even if more than 55% of the blood volume. If the heart becomes enlarged, even if the amount of blood being pumped by the left ventricle remains the same, the amount of blood being pumped by the left ventricle remains the same, the relative fraction of blood being ejected decreases. the relative fraction of blood being ejected decreases.

For example: For example: A healthy heart with a total blood volume of 100 mL that pumps 60 mL to A healthy heart with a total blood volume of 100 mL that pumps 60 mL to the aorta has an ejection fraction of 60%.the aorta has an ejection fraction of 60%.A heart with an enlarged left ventricle that has a total blood volume of 140 A heart with an enlarged left ventricle that has a total blood volume of 140 mL and pumps the same amount (60 mL) to the aorta has an ejection mL and pumps the same amount (60 mL) to the aorta has an ejection fraction of 43%.fraction of 43%.A reduced ejection fraction indicates that cardiomyopathy is present.A reduced ejection fraction indicates that cardiomyopathy is present.

Arterial Catheter:Arterial Catheter:Transducer PositionTransducer Position

To ensure accurate measurements, the To ensure accurate measurements, the transducer, catheter, and measurement transducer, catheter, and measurement site should all be at the same levelsite should all be at the same level

Transducer or catheter higher than site: Transducer or catheter higher than site: false false ↓ pressure reading↓ pressure reading

Transducer or catheter lower than site: Transducer or catheter lower than site: false ↑ pressure readingfalse ↑ pressure reading

Arterial Catheter:Arterial Catheter:ComplicationsComplications

IschemiaIschemia HemorrhageHemorrhage InfectionInfection• Ischemia secondary to embolism, thrombus, or arterial spasm Ischemia secondary to embolism, thrombus, or arterial spasm

evidenced by pallor distal to the insertion site and usually evidenced by pallor distal to the insertion site and usually accompanies by pain and paresthesisaccompanies by pain and paresthesis

• Hemorrhage if disconnect or open stop cockHemorrhage if disconnect or open stop cock

• Infection as with all invasive lines, risk increases dramatically after 4 Infection as with all invasive lines, risk increases dramatically after 4 daysdays

• Fever in any patient with a line in place must trigger questions about Fever in any patient with a line in place must trigger questions about the necessity of the lines and their role in the infection processthe necessity of the lines and their role in the infection process

Central Venous CatheterCentral Venous Catheter

A multiple lumen catheter like this one •Allows the infusion of blood and various medications through different ports•Permits aspiration of blood samples•Or injections for cardiac output measurements without the interruption of medications

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eded

Central Venous Catheter:Central Venous Catheter:Central Venous Pressure (CVP)Central Venous Pressure (CVP)

CVP is pressure of the blood in the CVP is pressure of the blood in the Vena cavaVena cava Right atriumRight atrium Right ventricleRight ventricle

CVP is also referred to asCVP is also referred to as Right atrial pressure (RAP)Right atrial pressure (RAP) right side preloadright side preload Right ventricular end-diastolic pressure (RVEDP)Right ventricular end-diastolic pressure (RVEDP)

Central Venous Catheter:Central Venous Catheter:Central Venous Pressure (CVP)Central Venous Pressure (CVP)

CVP measures right heart function and CVP measures right heart function and fluid levelsfluid levels

Transducer is placed at level of RATransducer is placed at level of RA

NormalNormal 2-6 mmHg by transducer2-6 mmHg by transducer 4-12 cmH4-12 cmH220 by water manometer0 by water manometer

Central Venous Catheter:Central Venous Catheter:IndicationsIndications

Assessment of right ventricular function Assessment of right ventricular function and intravascular volume statusand intravascular volume status

Administration of fluids, parenteral Administration of fluids, parenteral nutrition, blood, or drugsnutrition, blood, or drugs

Emergency route for temporary Emergency route for temporary pacemaker insertionpacemaker insertion

Central Venous CatheterCentral Venous Catheter

Common UsesCommon Uses Measure central venous pressureMeasure central venous pressure Administer fluid, blood, or medicationsAdminister fluid, blood, or medications Aspiration of blood samplesAspiration of blood samples

Insertion SitesInsertion Sites Subclavian or internal jugular veinSubclavian or internal jugular vein

LocationLocation Superior vena cava near right atrium or within Superior vena cava near right atrium or within

right atriumright atrium

Central Venous Catheter:Central Venous Catheter:Decrease in CVPDecrease in CVP

Decreased venous return (VOLUME!)Decreased venous return (VOLUME!) Absolute hypovolemiaAbsolute hypovolemia

Blood loss - HemorrhageBlood loss - Hemorrhage DehydrationDehydration

Relative hypovolemiaRelative hypovolemia ShockShock VasodilationVasodilation

Decrease in CVPDecrease in CVP

Decreased intrathoracic pressureDecreased intrathoracic pressure Spontaneous inspirationSpontaneous inspiration

Increased ability of the right heart to move Increased ability of the right heart to move bloodblood

Central Venous Catheter:Central Venous Catheter:Increase in CVPIncrease in CVP

Increased venous returnIncreased venous return HypervolemiaHypervolemia

Volume overloadVolume overload Fluids being given faster than the heart can Fluids being given faster than the heart can

toleratetolerate

Increased intrathoracic pressureIncreased intrathoracic pressure Positive pressure ventilationPositive pressure ventilation PneumothoraxPneumothorax


Decreased ability of the right heart to Decreased ability of the right heart to move blood – Right heart failuremove blood – Right heart failure

Increased pulmonary vascular resistanceIncreased pulmonary vascular resistance Pulmonary hypertensionPulmonary hypertension Pulmonary embolismPulmonary embolism

Compression around the heartCompression around the heart Constrictive pericarditisConstrictive pericarditis Cardiac TamponadeCardiac Tamponade


Decreased ability of the right heart to Decreased ability of the right heart to move bloodmove blood Right ventricular failureRight ventricular failure

Myocardial infarctionMyocardial infarction CardiomyopathyCardiomyopathy

Left ventricular failure (late change in CVP)Left ventricular failure (late change in CVP)

An increase in CVP leads to a decrease in An increase in CVP leads to a decrease in blood return to the right heartblood return to the right heart

Central Venous Catheter:Central Venous Catheter:CVP ReadingCVP Reading

CVP is ideally read at the end of CVP is ideally read at the end of expiration because... expiration because...

Spontaneous inspiration causes CVP to fallSpontaneous inspiration causes CVP to fall Mechanical ventilation causes CVP to riseMechanical ventilation causes CVP to rise

Central Venous Catheter:Central Venous Catheter:ComplicationsComplications

InfectionInfection

BleedingBleeding

Pneumothorax – greatest hazardPneumothorax – greatest hazard

Pulmonary Artery CatheterPulmonary Artery Catheter Swan-Ganz CatheterSwan-Ganz Catheter Flow-directed, balloon Flow-directed, balloon

tipped cathetertipped catheter

PAPA

Monitoring heart rate, blood pressure, and CVP often do not Monitoring heart rate, blood pressure, and CVP often do not provide accurate or timely data for correct diagnosis and provide accurate or timely data for correct diagnosis and management of cardiopulmonary problems. Can monitor management of cardiopulmonary problems. Can monitor the right and left sides of the heartthe right and left sides of the heart

The pulmonary artery catheter has a number of variations The pulmonary artery catheter has a number of variations however it ishowever it is

• Typically 110 cm in lengthTypically 110 cm in length

• With 3 lumens (interior channels)With 3 lumens (interior channels)

• The exterior of the catheter is marked off in 10 cm segments The exterior of the catheter is marked off in 10 cm segments used to estimate catheter tip location upon insertionused to estimate catheter tip location upon insertion

Pulmonary Artery CatheterPulmonary Artery Catheter Distal lumen lies in the pulmonary arteryDistal lumen lies in the pulmonary artery

Measure pulmonary artery pressuresMeasure pulmonary artery pressures Aspirate mixed venous samplesAspirate mixed venous samples Inject medicationsInject medications Continuous monitoring of SvO2Continuous monitoring of SvO2

Swan GanzSwan Ganz

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http://www.youtube.com/watch?http://www.youtube.com/watch?v=PjRRPhMj0os&feature=relatedv=PjRRPhMj0os&feature=related

Pulmonary Artery CatheterPulmonary Artery Catheter BalloonBalloon

1.5 cc maximum inflation volume1.5 cc maximum inflation volume Used to help float catheter into placeUsed to help float catheter into place

Pulmonary Artery CatheterPulmonary Artery Catheter ThermistorThermistor

Temperature sensing deviceTemperature sensing device Used during thermodilution CO measurementsUsed during thermodilution CO measurements Measures core temperatureMeasures core temperature

Pulmonary Artery CatheterPulmonary Artery Catheter Proximal lumen lies in the right ventricleProximal lumen lies in the right ventricle

Measure CVPMeasure CVP Inject medicationsInject medications Aspirate blood samplesAspirate blood samples Inject thermal bolus for thermal dilution CO Inject thermal bolus for thermal dilution CO

measurementsmeasurements

Pulmonary Artery Catheter:Pulmonary Artery Catheter:IndicationsIndications

Hemodynamically Hemodynamically unstable patientsunstable patients

Complex, acute heart Complex, acute heart diseasedisease

Acute, severe Acute, severe pulmonary diseasepulmonary disease

Shock of all types if Shock of all types if severe or prolongedsevere or prolonged

Severe, multisystem Severe, multisystem trauma or large-area burn trauma or large-area burn injuryinjury

Major systems Major systems dysfunction undergoing dysfunction undergoing extensive operative extensive operative proceduresprocedures

Pulmonary Artery CatheterPulmonary Artery Catheter

Common usesCommon uses

Measure CVP, PAP, and PCWPMeasure CVP, PAP, and PCWP Collect mixed venous blood samplesCollect mixed venous blood samples Monitor mixed venous OMonitor mixed venous O22 saturation saturation

Measure cardiac outputMeasure cardiac output Provide cardiac pacingProvide cardiac pacing

Pulmonary Artery Catheter:Pulmonary Artery Catheter:InsertionInsertion

Insertion: Subclavian Insertion: Subclavian or internal jugular veinor internal jugular vein

Superior vena caveSuperior vena cave Right atriumRight atrium

Normal pressure:Normal pressure:

0-6 mmHg0-6 mmHg

RA/CVP PressureRA/CVP Pressure


Right ventricleRight ventricleNormal pressure: Normal pressure: 20-3020-30 mmHgmmHg

0-50-5

Pulmonary ArteryPulmonary ArteryNormal Pressure: Normal Pressure: 20-3020-30 mmHgmmHg

6-156-15

RV Pressure RV Pressure

Atrial Pressure MonitoringAtrial Pressure Monitoring

a – Atrial contractiona – Atrial contraction c – Closure of tricuspid valvesc – Closure of tricuspid valves X descent – Passive atrial fillingX descent – Passive atrial filling v – Atrial diastolev – Atrial diastole Y descent – Atrial emptyingY descent – Atrial emptying


““Wedge”Wedge”Normal Pressure: 4-12 Normal Pressure: 4-12 mmHgmmHg

LocationLocation Branch of pulmonary Branch of pulmonary

arteryartery

PCWPPCWP

Where it will eventually wedge in a smaller Where it will eventually wedge in a smaller branch of the pulmonary arterybranch of the pulmonary artery

The balloon is then deflated and the The balloon is then deflated and the catheter stabilized in placecatheter stabilized in place

The balloon remains deflated and the PAP The balloon remains deflated and the PAP tracing remains on the monitor at all timestracing remains on the monitor at all times

The balloon is inflated only when the The balloon is inflated only when the pulmonary capillary wedge pressure is pulmonary capillary wedge pressure is being takenbeing taken

Pulmonary Artery Catheter:Pulmonary Artery Catheter:WaveformWaveform

• As the pulmonary artery catheter is being inserted, its As the pulmonary artery catheter is being inserted, its movement can be followed on the bedside monitor by movement can be followed on the bedside monitor by observing various pressure waveforms as the catheter observing various pressure waveforms as the catheter passes freely from the right atrium to a wedged position passes freely from the right atrium to a wedged position in the pulmonary arteryin the pulmonary artery

• when the tip of the catheter reaches the great vessels, a when the tip of the catheter reaches the great vessels, a CVP waveform appears on the monitorCVP waveform appears on the monitor

• Right Atrial Pressure (RAP) normal: 0-6 mmHgRight Atrial Pressure (RAP) normal: 0-6 mmHg

When the tip of the catheter passes through the When the tip of the catheter passes through the tricuspid valve into the right ventricle we see a rapid tricuspid valve into the right ventricle we see a rapid increase in the height of the pressure waveformincrease in the height of the pressure waveform•Right Ventricular Pressure (RVP) normal: 20-30/0-5 Right Ventricular Pressure (RVP) normal: 20-30/0-5 mmHgmmHg•the waveform drops to zero during diastolethe waveform drops to zero during diastole•the tricuspid valve opens and blood begins to flow the tricuspid valve opens and blood begins to flow into the ventricle, causing the pressure wave to into the ventricle, causing the pressure wave to increase graduallyincrease gradually•end-diastolic pressure occurs just before the end-diastolic pressure occurs just before the upstrokeupstroke

Entry into the pulmonary artery is recognized by a change in the Entry into the pulmonary artery is recognized by a change in the diastolic portion of the waveformdiastolic portion of the waveform•Pulmonary Artery Pressure (PAP) Normal: 20-30/6-15 mmHg mean: Pulmonary Artery Pressure (PAP) Normal: 20-30/6-15 mmHg mean: 10-20 mmHg10-20 mmHg•The waveform is a miniature of the peripheral arterial waveform, The waveform is a miniature of the peripheral arterial waveform, with a dicrotic notch and a gradual diastolic runoff that does not drop with a dicrotic notch and a gradual diastolic runoff that does not drop to zeroto zero•This is where mixed venous blood samples are drawn from. When This is where mixed venous blood samples are drawn from. When the catheter wedges in a smaller branch of the pulmonary artery, the the catheter wedges in a smaller branch of the pulmonary artery, the forward flow of the pulmonary arterial blood is occluded (like a forward flow of the pulmonary arterial blood is occluded (like a pulmonary embolus)pulmonary embolus)•Pulmonary Capillary Wedge Pressure (PCWP, PAOcclusionP) Pulmonary Capillary Wedge Pressure (PCWP, PAOcclusionP) normal: 4-12 mmHgnormal: 4-12 mmHg•The pulmonary artery waveform should return when the balloon is The pulmonary artery waveform should return when the balloon is deflateddeflated

Pulmonary Artery Catheter:Pulmonary Artery Catheter:ComplicationsComplications

InfectionInfection BleedingBleeding PneumothoraxPneumothorax Pulmonary artery hemorrhagePulmonary artery hemorrhage Pulmonary infarctionPulmonary infarction Air embolismAir embolism Cardiac arrhythmiasCardiac arrhythmias

Pulmonary Artery PressurePulmonary Artery Pressure

Monitor blood moving into the lungsMonitor blood moving into the lungs

Normal: Normal: 20-3020-30 mmHg mmHg 6-156-15

Average: 22/8 mmHgAverage: 22/8 mmHg

Mean: 13 mmHgMean: 13 mmHg

Pulmonary Artery Pressure Pulmonary Artery Pressure DecreasesDecreases

Volume of blood ejected by the right Volume of blood ejected by the right ventricle decreases – (“afterload” of the ventricle decreases – (“afterload” of the RV)RV)

Pulmonary vasculature relaxes or dilatesPulmonary vasculature relaxes or dilates

Pulmonary Artery Pressure Pulmonary Artery Pressure IncreasesIncreases

Pulmonary blood flow increasesPulmonary blood flow increases

Pulmonary vascular resistance increasesPulmonary vascular resistance increases Constriction – hypoxemia, acidosis, drugs, diseases Constriction – hypoxemia, acidosis, drugs, diseases

that cause pulmonary hypertensionthat cause pulmonary hypertension

Obstruction – pulmonary embolusObstruction – pulmonary embolus

Compression – disease constricting pulmonary Compression – disease constricting pulmonary vasculaturevasculature

Pulmonary Capillary Wedge Pulmonary Capillary Wedge PressurePressure

Normal: 8 mm hg (4-12 range)Normal: 8 mm hg (4-12 range)

Monitors blood moving into the left heart.Monitors blood moving into the left heart.

Represents the pulmonary venous Represents the pulmonary venous drainage back to the left heart.drainage back to the left heart.

Inflation of BalloonInflation of Balloon

PCWPPCWP

PCWP is also referred to as:PCWP is also referred to as: Pulmonary artery occlusion pressure (PAOP)Pulmonary artery occlusion pressure (PAOP) Left atrial pressureLeft atrial pressure Left side preloadLeft side preload Left ventricular end-diastolic pressureLeft ventricular end-diastolic pressure Left ventricular filling pressureLeft ventricular filling pressure

PCWPPCWP

The PAP diastolic can be used to estimate The PAP diastolic can be used to estimate PCWP is some situationsPCWP is some situations

A comparison of PCWP and PAP can be A comparison of PCWP and PAP can be used to differentiate between cardiac and used to differentiate between cardiac and non-cardiac pulmonary edema.non-cardiac pulmonary edema. Increased PCWP and PAP = cardiacIncreased PCWP and PAP = cardiac Normal PCWP and Increased PAP = Normal PCWP and Increased PAP = Non-Non-

cardiaccardiac

Pulmonary Capillary Wedge Pulmonary Capillary Wedge Pressure DecreasesPressure Decreases

Right heart failureRight heart failure Cor pulmonaleCor pulmonale Pulmonary embolismPulmonary embolism Pulmonary hypertensionPulmonary hypertension Air embolismAir embolism HypovolemiaHypovolemia

PCWP may be normal in the above pulmonary PCWP may be normal in the above pulmonary conditions.conditions.

Pulmonary Capillary Wedge Pulmonary Capillary Wedge Pressure IncreasesPressure Increases

left heart failureleft heart failure

mitral valve stenosismitral valve stenosis

CHF/ pulmonary edemaCHF/ pulmonary edema

high PEEP effectshigh PEEP effects

hypervolemiahypervolemia

Clinical AssessmentClinical Assessment

Right heart failureRight heart failure

CVP - CVP -

PAP – N or DecreasePAP – N or Decrease

PCWP – N or DecreasePCWP – N or Decrease

CO - N or DecreaseCO - N or Decrease


Lung Disorders (PE, PTHN)Lung Disorders (PE, PTHN)

CVP - CVP - PAP - PAP - PCWP – Normal of DecreasePCWP – Normal of Decrease CO – Normal, decrease with large PECO – Normal, decrease with large PE


Left Heart FailureLeft Heart Failure

CVP – Normal, increase as late signCVP – Normal, increase as late sign PAP - PAP - PCWP - PCWP - CO - DecreaseCO - Decrease


Hypovolemia – Everything decreasesHypovolemia – Everything decreases

CVP – First and most dramatic signCVP – First and most dramatic sign PAPPAP PCWPPCWP COCO

Other Values to KnowOther Values to Know

Pulse Pressure – 40 mm HGPulse Pressure – 40 mm HG

Stroke Volume – 60 – 130 ml/beatStroke Volume – 60 – 130 ml/beat

EF – 65 – 75%EF – 65 – 75%

SVR - < 20 mmHg/L/minSVR - < 20 mmHg/L/min

PVR - < 2.5 mmHg/L/minPVR - < 2.5 mmHg/L/min


Right heart failureRight heart failure

CVPCVP

PAPPAP

PCWPPCWP

COCO

Pressure DampeningPressure Dampening

When the monitor does not show a sharp When the monitor does not show a sharp waveform, not dicrotic notch.waveform, not dicrotic notch.

Catheter can be obstructed or kinked.Catheter can be obstructed or kinked.

IABPIABP

http://www.youtube.com/watch?http://www.youtube.com/watch?v=naEaPo7PPJE&feature=relatedv=naEaPo7PPJE&feature=related

ShockShock

Inadequate tissue perfusion resulting in a Inadequate tissue perfusion resulting in a hypoxic insult and causing widespread hypoxic insult and causing widespread abnormal cell metabolism and membrane abnormal cell metabolism and membrane dysfunction.dysfunction. Hypovolemic ShockHypovolemic Shock Cardiogenic ShockCardiogenic Shock Septic ShockSeptic Shock Neurogenic ShockNeurogenic Shock Anaphylactic ShockAnaphylactic Shock

Hypovolemic ShockHypovolemic Shock

A decrease in the effective circulating A decrease in the effective circulating blood volumeblood volume Hemorrhage: loss of whole bloodHemorrhage: loss of whole blood Non-hemorrhage: loss from the interstitial Non-hemorrhage: loss from the interstitial

spacespace DehydrationDehydration

Vomiting, diarrhea, diuresisVomiting, diarrhea, diuresis

Third space fluid shiftThird space fluid shift Burns, trauma, sepsisBurns, trauma, sepsis

Cardiogenic ShockCardiogenic Shock

Systemic hypoperfusion due to profound Systemic hypoperfusion due to profound heart failure and/or the ability to meet heart failure and/or the ability to meet metabolic needs.metabolic needs.

End stage of heart disease caused byEnd stage of heart disease caused by MIMI MyocarditisMyocarditis Cardiac tamponadeCardiac tamponade Severe valve dysfunctionSevere valve dysfunction

Septic ShockSeptic Shock

Shock associated with any infectious Shock associated with any infectious disease which causes relative disease which causes relative hypovolemia.hypovolemia.

Caused by many infectious agentsCaused by many infectious agents Predisposing factorsPredisposing factors

Invasive proceduresInvasive procedures Organ damageOrgan damage ImmunocompromisedImmunocompromised

SepsisSepsis

A severe illness caused by over whelming A severe illness caused by over whelming infection of the bloodstream by toxin-infection of the bloodstream by toxin-producing bacteria. producing bacteria.

Neurogenic ShockNeurogenic Shock

Dysfunction of the sympathetic nervous Dysfunction of the sympathetic nervous system resulting in massive peripheral system resulting in massive peripheral vasodilation and systemic hypoperfusion.vasodilation and systemic hypoperfusion.

EtiologyEtiology Brain or spinal cord traumaBrain or spinal cord trauma Spinal anesthesiaSpinal anesthesia DrugsDrugs

Anaphylactic ShockAnaphylactic Shock

Systemic reaction causing circulatory Systemic reaction causing circulatory failure and biochemical abnormalities.failure and biochemical abnormalities.

EtiologyEtiology DrugsDrugs Blood productsBlood products FoodsFoods PollensPollens VenomsVenoms

ICU monitoring and equipmentICU monitoring and equipment

Chest TubesChest Tubes Tubes inserted into the chest between the lung and ribs Tubes inserted into the chest between the lung and ribs

to allow fluid and air to drain from the area surrounding to allow fluid and air to drain from the area surrounding the lungs. Removing this fluid and air from around the the lungs. Removing this fluid and air from around the lungs allows them to more fully expand. An accumulation lungs allows them to more fully expand. An accumulation of fluid and air in the lung cavity can cause the lung to of fluid and air in the lung cavity can cause the lung to collapse. Chest tubes drain into a large plastic container collapse. Chest tubes drain into a large plastic container near the foot of the patient's bed. The patient may have near the foot of the patient's bed. The patient may have one or more of these tubes in place. Nurses will monitor one or more of these tubes in place. Nurses will monitor the comatose patient for non-verbal signs of pain.the comatose patient for non-verbal signs of pain.

http://www.youtube.com/watch?v=y1gaC3yfhvwhttp://www.youtube.com/watch?v=y1gaC3yfhvw


Eye TapeEye Tape Tape used to close the patient's eyes. It is Tape used to close the patient's eyes. It is

important that the eyes be kept moist. We important that the eyes be kept moist. We do this naturally when we blink our eyes. do this naturally when we blink our eyes. This reflex is lost in the patient who is This reflex is lost in the patient who is unresponsive but has open eyes. To protect unresponsive but has open eyes. To protect the eyes and to prevent them from drying the eyes and to prevent them from drying out, eye drops may be put into the eyes and out, eye drops may be put into the eyes and eye tapes may be used to close themeye tapes may be used to close them


Foley CatheterFoley Catheter This is a tube (catheter) inserted into the This is a tube (catheter) inserted into the

urinary bladder for drainage of urine. This urinary bladder for drainage of urine. This helps to monitor the patient's fluid status helps to monitor the patient's fluid status and kidney function. The urine drains and kidney function. The urine drains through the tube into a plastic bag hanging through the tube into a plastic bag hanging low by the foot of the bed.low by the foot of the bed.

Note color and amount. Normal urine Note color and amount. Normal urine output is about 30-40 ml/hroutput is about 30-40 ml/hr


GI TubeGI Tube A tube inserted through a surgical opening A tube inserted through a surgical opening

into the stomach. It is used to introduce into the stomach. It is used to introduce liquids, food, or medication into the liquids, food, or medication into the stomach when the patient is unable to take stomach when the patient is unable to take these substances by mouth. Set on these substances by mouth. Set on intermittent suction, low around -10 to -20intermittent suction, low around -10 to -20

Must Have a GI tube in place during Must Have a GI tube in place during mechanical ventilationmechanical ventilation


Intracranial Pressure (ICP) MonitorIntracranial Pressure (ICP) Monitor A monitoring device to determine the pressure within the A monitoring device to determine the pressure within the

brain. It consists of a small tube (catheter) attached to the brain. It consists of a small tube (catheter) attached to the patient's skull by either a ventriculostomy, subarachnoid patient's skull by either a ventriculostomy, subarachnoid bolt or screw and is then connected to a transducer, which bolt or screw and is then connected to a transducer, which registers the pressure.registers the pressure.

Ventriculostomy is a procedure for measuring intracranial Ventriculostomy is a procedure for measuring intracranial pressure by placing an ICP monitor within one of the fluid-pressure by placing an ICP monitor within one of the fluid-filled, hollow chambers of the brain, called ventricles. filled, hollow chambers of the brain, called ventricles. These four natural cavities are filled with cerebrospinal These four natural cavities are filled with cerebrospinal fluid (CSF), which also surrounds the brain and spinal fluid (CSF), which also surrounds the brain and spinal chord.chord.


ShuntShunt A procedure to draw off excessive fluid in A procedure to draw off excessive fluid in

the brain. A surgically-placed tube running the brain. A surgically-placed tube running from the ventricles which deposits fluids from the ventricles which deposits fluids into either the abdominal cavity, heart or into either the abdominal cavity, heart or large veins of the necklarge veins of the neck

AV shunt used for hemodialysisAV shunt used for hemodialysis

EKG REVIEWEKG REVIEW

http://www.youtube.com/watch?http://www.youtube.com/watch?v=ex1k_MPF-w4&feature=relatedv=ex1k_MPF-w4&feature=related

http://www.youtube.com/watch?http://www.youtube.com/watch?v=ecTM2O940mg&feature=relmfuv=ecTM2O940mg&feature=relmfu

http://www.youtube.com/watch?http://www.youtube.com/watch?v=9TRYM7IdnDY&feature=relatedv=9TRYM7IdnDY&feature=related

hemodynamic monitoring

Documents

blood vessels

blood pressurepatients

ejection of blood

diastolic value

diastolic relaxation

diastolic phase

arterial waveform31

high bp