Hemodynamics

HemodynamicsCarole Rance, RN, BSN, CCRNDefinitionThe movement and forces involved with the movement of blood through the cardiovascular system.Hemo+dynamics=blood+always changing

Cardiac Blood Flow

Important termsPreload-The degree to which muscle fibers stretch prior to contraction.Afterload-Initial resistance that must be overcome by the ventricles to eject blood through the semilunar valves.Systemic vascular resistance-The resistance offered by the peripheral vasculature. Contractility-The hearts contractile strength.

Stroke VolumeThe amount of blood ejected by the left ventricle with each contraction.

SV=LVEDV-LVESV

Normal= 60-100mL

http://apbrwww5.apsu.edu/thompsonj/Anatomy%20&%20Physiology/2020/2020%20Exam%20Reviews/Exam%201/stroke%20volume%20diagram.bmpCardiac OutputThe amount of blood ejected by the left ventricle in one minute.

CO=SVxHR

drtedwilliams.netHypotension, decreased pulses, pallor, sob, chest pain, syncope, edema7Frank-Starling Law

http://apbrwww5.apsu.edu/thompsonj/Anatomy%20&%20Physiology/2020/2020%20Exam%20Reviews/Exam%201/Frank-Starling%20Law%20of%20the%20Heart01.jpgMini QuizA 53 year old female has been vomiting large amounts of red blood and is found to have a hemoglobin of 4.4g/dL. Her HR is 130, BP 70/40, RR 28, SpO2 100%. She is also showing signs of acute renal failure (diminished urine output and elevated BUN and creatinine).What would be true?A. Preload is lowB. Afterload is lowC. Preload is highD. Preload is normalWould we assume her cardiac output is high, low, or normal?Bonus question:What type of shock is this patient experiencing?

Types of Invasive Hemodynamic MonitoringInvasive arterial blood pressure monitoringCentral venous pressure monitoringPulmonary artery catheterArterial-based cardiac output monitoring

http://www.usa.philips.com/healthcare-product/HC865240/intellivue-mx800-bedside-patient-monitorArterial LinesIndicationsInvasive blood pressure monitoring of the acutely illRisksInfectionThrombus/EmbolusBlood lossAir embolus

http://www.sorbaviewshield.com/photos/Arterial LinesOther usesBlood samplingArterial blood gas (ABG) samplingCardiac Output monitoring (Flo Trac)

(Drawing by Paul W. Schiffmacher, Thomas Jefferson University, Philadelphia.) Assisting with InsertionPrior to procedureVerify informed consent.Ready supplies (list available on hospital policy).Set-up single-pressure transducer system.

Pressure line set-up

Assisting with InsertionProcedureAssure sterile technique is maintained.Assist physician as requested.Attach PRIMED tubing to catheter.Prime tubing as well as all side ports.Pressure bag should be in place.

Initial Set-upAttach pressure cable.Level the arterial air-fluid interface (zeroing stopcock) to the phlebostatic axis (right atrium).Zero the system.May need to adjust scale on monitor.Observe waveform.

(From Wiegand, D.L. [2011]. AACN procedure manual for critical care [6th ed.]. St. Louis: Saunders.) Zeroing pressure linesAll pressure lines are zeroed the same way.Be sure before starting the zeroing procedure ensure that the arterial air-fluid interface is leveled at the phlebostatic axis.Close the stopcock to the patient.Open the stopcock to air.Zero the line on the monitor.https://www.youtube.com/watch?v=5fh9YwQRPCwDemonstrate zeroing A-Line17Care and MaintainanceNEVER infuse medication to an arterial line!Dressing care, fluid changes, tubing changes, are to be done following your specific hospital policy.Care should be taken to observe for signs of decreased perfusion to extremity the arterial line is located.Check connections

http://seattleclouds.com/myapplications/dukeg/ican/ArtLine.htmlwww.aeronline.orgDrawing a Blood SampleMay draw lab and arterial blood gas samples.StepsAttach syringe to cleansed port.Turn the stopcock off to the flush bag.Aspirate waste, turn the stopcock off to the syringe and discard. Attach empty syringe and draw sample.Drawing a Blood SampleTurn the stopcock off to the syringe and remove syringe.Attach discard syringe, fast-flush blood from port into the syringe, and close stopcock to syringe (discard). Use fast-flush system to flush line to patient.Observe waveform

Arterial Waveform

http://ccrnnurse.blogspot.com/2012/05/arterial-blood-pressure-monitoring.htmlWhen the pressure in the ventricle is lower than the aortic root the aortic valve closes which is represented on the arterial waveform by the dicrotic notch.

Pulse PressureNarrow pulse pressure preloadCardiac tamponadeWide pulse pressurePart of Crushings TriadAtherosclerosis of the large arterieshttp://www.learningaboutelectronics.com/images/Pulse-pressure.png23Abnormal Waveform Patterns

http://ht.edwards.com/resourcegallery/products/pressuremonitoring/pdfs/invasivehdmphysprincbook.pdfhttp://ht.edwards.com/resourcegallery/products/pressuremonitoring/pdfs/invasivehdmphysprincbook.pdfSquare Wave TestFast-flush arterial line using pressure-system (pig-tail)There should be a sharp upstroke terminating in a flat line.Release the pig-tail.The baseline waveform should return to normal within 1-2 oscillations.

(From Darovic, G.O., Zbilut, J.P. [2002]. Fluid-filled monitoring systems. In G.O. Darovic (Ed.), Hemodynamic monitoring [3rd ed., p. 122]. Philadelphia: W.B. Saunders.)

OverdampeningFalsely low systolic pressure and falsely high diastolic pressure.Interventions/troubleshootingCheck the patient!Check level at the phlebostatic axis and re-zero.Check catheter and position.Check line for air.Check flush bag and pressure bag.Aspirate and then fast-flush.

(From Darovic, G.O., Zbilut, J.P. [2002]. Fluid-filled monitoring systems. In G.O. Darovic (Ed.), Hemodynamic monitoring [3rd ed., p. 122]. Philadelphia: W.B. Saunders.)

UnderdampeningFalsely high systolic blood pressure and potentially falsely low diastolic blood pressure.Interventions/troubleshootingCheck the patient!Check level at the phlebostatic axis and re-zero.Check catheter and position.Check line for air.Check the length of pressure tubing

(From Darovic, G.O., Zbilut, J.P. [2002]. Fluid-filled monitoring systems. In G.O. Darovic (Ed.), Hemodynamic monitoring [3rd ed., p. 122]. Philadelphia: W.B. Saunders.)27Troubleshooting Waveforms

DocumentationYou should document the waveform per hospital policy (typically once a shift).Document arterial blood pressure per unit policy and per patient condition.Arterial lines are documented in the same area that peripheral and central lines are by clicking add LDA.

Removing Arterial LineMay be done by nurse at bedside.Follow your specific hospital policy.Key PointsTurn off arterial monitoring on the monitor before removal.You may need to remove sutures. (DO NOT REMOVE CUTDOWN SUTURES)Maintain firm pressure until hemostasis is achieved.Keep site clean and dressed.Pulmonary Artery CathetersPulmonary Artery catheters (Swan-Ganz catheter) are used to assess the hemodynamic status of critically ill patients.Data providedCardiac Output (CO)Pulmonary artery wedge pressure (PAWP) or pulmonary artery occlusion pressure (PAOP)Central venous pressure (CVP) or right atrial pressure (RAP)Pulmonary artery pressure (PAP)Core temperature

http://lifeinthefastlane.com/ccc/pulmonary-artery-catheters/InsertionMost commonly used with patients following open heart surgery.Usually inserted in the cath lab or OR, but may be inserted at bedside.Hospital policy outlines the procedure and supplies needed for bedside insertion.

The PA catheter is inserted through an introducer (often referred to as a cordis).X-ray needed to verify placementInsertionhttps://www.youtube.com/watch?v=7putxZN7ij4

Central Venous Pressure or Right Atrial PressureTerms commonly used interchangeably. CVP-Distal port of central venous catheterRAP- PA catheter lumen opening in the right atriumCentral Venous Pressure or Right Atrium PressureProvides information regarding intravascular volume and preload.Normal CVP is about 2-6mmHg (varies per patient).LocationCentral line- Most distal port (MUST REMOVE CAPS)PA catheter-Blue line (blue=venous)CVP WaveformLooks like ventricular fibrillationMay vary with respiration

http://www.icufaqs.org/Abnormal CVPCauses of increased CVPRight heart failureCardiac tamponadePulmonary embolismPulmonary hypertensionChronic left ventricular failureTricuspid or pulmonic valve dysfunctionFluid overload38Abnormal CVPCauses of decreased CVPHypovolemiaDecreased mean arterial pressureVenodilationTreatment dependent on cause

Mini QuizA 79 year old male who has ESRD skipped his last 2 dialysis treatments and presents with jugular vein distention and peripheral edema.

Would his CVP most likely be high, low, or normal?Bonus QuestionWhat would his treatment be?

Pulmonary Artery PressureProvides the systolic, diastolic, and mean pressures of the pulmonary arteryLocationPulmonary arteryMost distal lumenYellow line

41Pulmonary Artery PressureNormal valuesSystolic 15-25mmHgDiastolic 8-15mmHgMixed venous blood gases are drawn from this port.NOT TO BE USED FOR INFUSION OR MEDICATIONS!

Pulmonary Artery WaveformsLooks similar to an arterial line waveform just a smaller scale.

http://www.derangedphysiology.com/php/PAC/2-insertion-of-the-PA-catheter.php

Abnormal PA PressuresElevated PAP Volume overloadPulmonary HypertensionPulmonary embolismLeft heart failureMitral valve diseaseLong-term systemic hypertensionCOPD and sleep apneaLow PAPVolume depletedhttp://www.cdc.gov/DHDSP/data_statistics/fact_sheets/fs_pulmonary_hypertension.htmPulmonary Artery Wedge PressurePulmonary artery wedge pressure (PAWP) is used to provide an estimate of pressures in the left side of the heart.Normal Values 4-12 mmHg

Why can we use the PADP? Over inflation can rupture the pulmonary artery!45Pulmonary Artery Wedge

Pulmonary Artery Wedge PressureStepsSlowly inflate balloon with no more than 1.5mL of air. Do not leave balloon inflated longer than 8-15 seconds or 2 respiratory cycles.Observe for waveform changesMeasure wedge pressure at end-expiration.Deflate balloon according to hospital policy (should be passive).

Pulmonary Artery Wedge WaveformDO NOT EVER LEAVE BALLOON INFLATED (this can cause lung infarction/ischemia)

http://www.derangedphysiology.com/php/PAC/2-insertion-of-the-PA-catheter.phpAbnormal ValuesHigh PAWPLeft heart failureCardiac tamponadeMitral valve diseaseFluid overloadLow PAWPHypovolemia

http://www.uofmmedicalcenter.org/healthlibrary/Article/115853ENhttps://www.youtube.com/watch?v=ND7F3HIu_OIMini QuizYour patient has a PA catheter and upon entering the room you see this waveform for the PA pressure.

What is your assessment?What should you do?

http://www.homesteadschools.com/nursing/courses/Cardiovascular%20Nursing/images/04_09.jpgMini QuizYour patient has a PA catheter and upon entering the room you see this waveform for the PA pressure.What is your assessment?What should you do?

What can happen from this? Why?52Mixed Venous Oxygen Saturation (SvO2)Measurement of the oxygen content of blood after returning back to the right side of the heart.Normal 60-80%Used to tell us if the cardiac output is sufficient to meet tissue oxygen needs.

http://ht.edwards.com/resourcegallery/products/swanganz/pdfs/svo2edbook.pdfCardiac OutputCardiac output (CO) measures how much blood the heart pumps in one minute.Normal CO is 4-8L/min Measurement should be taken per hospital policy or physician order.

How do you think PEEP would affect CO?Cardiac OutputCO doesnt take into account the patients size, so cardiac index is a more reliable measurement.Cardiac index is calculated with the patients body surface (BSA) in mind.

CO CI= BSANormal Cardiac Index is 2.5-4 L/min/m2

Abnormal Cardiac OutputLow COHeart failure/cardiomyopathyValve diseaseCardiac tamponadeCardiogenic shockArrhythmiasHypovolemiaHigh COSepsis

57Thermodilution MethodCheck height and weight are entered in monitor.Set computation constant If not already connected, connect closed system to proximal lumen of the PA catheter (Blue port/Right atrium).Administer room temperature injectate bolus 3-5 times.Discard outliers and those that do not have normal curves.Save cardiac output.

58

Cardiac Output Waveforms

(From Urden, L.D., Stacy, K.M., Lough, M.E. [2002]. Thelan's critical care nursing: Diagnosis and management [4th ed.]. St. Louis: Mosby.)Closed Injectate Delivery System

61

https://www.youtube.com/watch?v=isN5pSiKQBoMiscellaneous InformationObtain measurements at end of expiration. Why?Use consistent head of bed level for measurements 0-60 degrees is appropriate as determined by patient conditionRemoval of PA Catheter and Introducer SheathThe PA catheter and introducer sheath are removed separately!When removing PA catheter ectopy may occur. Watch for arrhythmias When removing the swan and introducer sheath the patient should hold his or her breath.

Swan removal(From Wadas, T.M. [1994]. Pulmonary artery catheter removal. Critical Care Nurse, 14[3], 63-72.) Air EmbolusPA pressures or an obstruction in the pulmonary vasculature can occur.Symptoms include:respiratory distress, cardiac arrhythmias/arrest, hypotension, AMSLeft-lateral trendelenburg position helps keep air in the right atrium.

http://www.safeinfusiontherapy.com/images/french/herz.pngDocumentationWaveforms (arterial, CVP, PAWP, and PAP) should be documented per hospital policy.Numeric values should be documented underDocFlowsheets-> Vital Signs Complex-> Invasive Hemodynamic MonitoringThe catheter should be documented in the same area as other IV catheters are located.Add a PA catheter by clicking add LDA and choosing introducer

Arterial-Based Cardiac Output Monitoring

http://ht.edwards.com/scin/edwards/sitecollectionimages/products/mininvasive/viglite.pngMinimally-invasiveProvides hemodynamic measurementsAvailable in some hospitals

Mini QuizHow do you know what computation constant to enter?What is more reliable cardiac output or cardiac index? Why?You have a 70 year old patient with a PA catheter in place. You notice his cardiac rhythm has switched from NSR to A-fib with RVR. His ABP is 73/41 (52), HR is 160, RR is 28.Would you expect his cardiac output/cardiac index to be the same as the last reading, lower, or higher? Why?

http://www.castenholz.org/ptguide/pacath_copy.JPG

http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/pulmonary/pulmonary-hypertension/images/figure-5.jpgCommon Continuous Infusions in Critical Care

http://ehealthinnovation.org/what-we-do/projects/mitigating-risks-associated-with-multiple-iv-infusions/Medication TypesVasopressors- Cause constriction of blood vessels, leading to an increase of blood pressure.Vasodilators- Causes dilation of blood vessels, leading to a decrease of blood pressure.ArterialVenousMixed

Medication TypesInotropes - Affects the contractility or the force of strength of the hearts contractions.Positive inotropeNegative inotropeAntiarrhythmicsVasopressorsDopamine HydrochlorideHemodynamic effects+ InotropeChronotropicVasopressorUsesHypotension not secondary to hypovolemiaDecreased cardiac outputSymptomatic bradycardiaUse for prevention or treatment of acute renal failure is controversial.

http://allmedtech.com/doinbindeprs.htmlDopamine Hydrochloride DosageSuggested initial dosing is 1-5 mcg/kg/min as a continuous IV infusion.May be titrated upward every 2-5 minutes to attain hemodynamic goals.Normal dose range is 1-20 mcg/kg/min. (higher doses up to 50 mcg/kg/min may be considered)If >20 mcg/kg/min is needed consider another vasopressor.

Dopamine Hydrochloride Potential side effects/adverse reactionsTachycardiaEctopyCan cause severe damage to tissue if IV extravasation occurs (NEED A CENTRAL LINE ASAP).AnxietyAnginaPeripheral and visceral organ ischemia

Dopamine Extravasation

http://www.joacp.org/article.asp?issn=0970-9185;year=2012;volume=28;issue=4;spage=534;epage=535;aulast=Bhosalehttp://www.joacp.org/article.asp?issn=0970-9185;year=2012;volume=28;issue=4;spage=534;epage=535;aulast=BhosalePhenylephrine HydrochlorideBrand name: Neo-SynephrineHemodynamic effectsPotent vasoconstrictorLacks inotropic and chronotropic effectsMay reduce HR and COUses of continuous infusionHypotension not secondary to hypovolemiaNot first choice for most shock states

http://www.west-ward.com/products.php?cid=122

What situations might neo be useful?81Phenylephrine HydrochlorideDosageNormal concentration 40mg/250mL in D5W.For Severe hypotension/shock state begin infusion at 100-140 mcg/min.Titrate to desired mean arterial pressure.Usual rate 40-180 mcg/minPhenylephrine HydrochloridePotential side effects/adverse reactionsAnginaPulmonary edemaCan cause damage to tissue if IV extravasation occurs (NEED A CENTRAL LINE ASAP).Peripheral and visceral organ ischemiaNorepinephrineBrand name- LevophedHemodynamic effectsPotent vasoconstrictor+ inotropeUses of continuous infusionHypotension not secondary to hypovolemiaVasopressor of choice for septic shock

http://www.xhbv.com/wp-content/uploads/2010/12/norepinephrine.jpgNorepinephrineDosageSuggested initial dosing is 8 mcg-12mcg/minMay be titrated 2mcg/min every minute to desired MAP.Normal dose range is 1-30mcg (higher doses may be considered).

NorepinephrinePotential side effects/adverse reactionsArrhythmiasCan cause severe damage to tissue if IV extravasation occurs (NEED A CENTRAL LINE ASAP).AnxietyAnginaPeripheral and visceral organ ischemia

VasopressinSynthetic antidiuretic hormoneHemodynamic effectsVasoconstrictorPromotes reabsorption of water in the renal tubuleUses of continuous infusionHypotension2nd or 3rd vasopressor for septic shockMay be used to replace 1st or 2nd dose of epinephrine during cardiac arrest.

http://checktheleads.com/2014/12/bye-bye-bye-vasopressin/VasopressinDosage of continuous infusionStandard concentration is 40units/100mL NS or D5WShock- 0.01-0.04units/minVariceal hemorrhage-0.2-0.4 units/minPotential side effects/adverse reactionsDiaphoresisGI symptomsArrhythmiasWater intoxication88EpinephrineAlso known as adrenalinHemodynamic effectsVasoconstrictor+ inotropeChronotropic

http://acls-algorithms.com/wp-content/uploads/2011/05/acls-drugs-epi.jpgEpinephrineUses of continuous infusionTo maintain heart rate and cardiac output following CPREmergency management of symptomatic bradycardiaHypotension and shockUsed during ACLS during cardiac arrest.Used as bronchodilator during anaphylactic reaction, acute bronchospasm, or severe asthma exacerbation

EpinephrineDosageRecommended initial dosage is 1mcg/min. Titrate to hemodynamic goal.Typical dose is 2-10 mcg/min

http://acls-algorithms.com/wp-content/uploads/2011/05/acls-drugs-epi.jpgEpinephrinePotential side effects/adverse reactionsArrythmias Can cause severe damage to tissue if IV extravasation occurs (NEED A CENTRAL LINE ASAP).AnxietyAnginaPeripheral and visceral organ ischemiaHyperglycemia

VasodilatorsNitroprussideBrand name-NiprideHemodynamic effectsEXTREMELY potent vasodilatorUsesHypertensive emergencyFor immediate reduction in preload and afterload in cardiac failure or cardiogenic shock.

http://o.quizlet.com/i/UAhw__yNB5qi1xwQVbbU5A_m.jpg94NitroprussideDosage**USE EXTREME CAUTION** Profound hypotension can occur very quickly.If this happens stop the infusion, as the drug has a short duration of action.Initial dosage 0.250.3 mcg/kg/min (possibly lower) The average maintenance dose is 3 mcg/kg/minThe usual dosage range is 0.2510 mcg/kg/min IV. Maximum dosage is 10 mcg/kg/min.

NitroprussideConsiderationsUse cautiously in patients with renal impairmentsNot a good choice for patients with increased ICPSide effects/adverse reactionCyanide poisoning particularly with high doses, renal impairment, and prolonged use.

NitroglycerinBrand name-TridilHemodynamic effectsArterial and venous vasodilatorUsesTreatment of angina/unstable unanginaAcute MITreatment of hypertension (severe and emergent)

http://www.hospira.com/Images/0409-1483-02_81-3288_1.jpgNitroglycerinDosageInitially, 5 mcg/minute IV infusion. Titrate by 5-20 mcg/minute IV every 35 minutes until clinical response, or to a dose of 20 mcg/minute IV. The effective dosage range is 5100 mcg/minute IV. Side effects/adverse reactionsHeadache (most common)NicardepineBrand name-CardeneCalcium channel blockerHemodynamic effectsArterial vasodilatorNegative inotropeDoes not increase ICP.UsesHypertensionIf no central line available, peripheral site should be changed every 12 hours.

http://www.pppmag.com/findit/product/305/CARDENENicardepineDosageInitiate therapy at 5 mg/hour as a continuous IV infusion. Increase 2.5 mg/hr every 15 minutesWhen target BP achieved decrease infusion to 3mg/hour (15mL/hour), monitor and titrate to lowest dose necessary to maintain stable BPMaximum rate 15 mg/hrPeripheral edema d/t vasodilator effects or worsening heart fx

100NicardepineSide effects/adverse reactionsMay precipitate or exacerbate heart failurePeripheral edema Flushing

http://www.pppmag.com/findit/product/305/CARDENEBeta blocker InfusionsLabetalolUsed for treatment of hypertensionReduces afterload without a substantial decrease in resting HR, CO, or SV as compared to other beta-blockers.DosageInfusion: 2mg/min, then may titrate up to 8mg/minReduced co and hr reduces cardiac o2 demand102Beta Blocker InfusionsEsmololUsed for short-term control of HR, hypertension, acute MI, and unstable angina.Negative chronotropic and inotropic effect, reduced sympathetic outflow from CNS, and suppresses renin release.Dosage dependent on indication

DiltiazemBrand name-CardizemCalcium channel blockerHemodynamic usesDilates coronary and systemic arteriesSlows conduction through the AV nodeSome negative inotropic effectshttp://www.hospira.com/en/products_and_services/drugs/DILTIAZEM_HYDROCHLORIDE_FOR_INJECTIONDiltiazemUses of continuous infusionVentricular rate control during A-fib/A-flutterTreatment of PSVT that is unconverted by adenosine, vagal maneuvers, or recurrent.DosageBolus may be used and repeated per physician order.Typical bolus dose is 0.25 mg/kg administered as an IV bolus over 2 minutes.Dose range is 5-15mg/hr.Typically titrated by 5mg/hr at a time.

DiltiazemSide effects/adverse reactionsHypotensionPulmonary edemaMay precipitate or exacerbate heart failure1st degree heart blockBradycardiaAntiarrhythmicsAmiodaroneBrand name-CordaroneBoth an antiarrhythmic and a vasodilatorClass III antiarrhythmicNegative inotropeUses of continuous infusionTreatment of ventricular arrhythmias Off label-Treatment of supraventricular arrhythmiasAlso can be used IV push during ACLS to treat pulseless ventricular arrhythmias.

https://www.nexterone.com/nexterone/Dosing.htmAmiodaroneDosageBolus dose-150mg in 100mL of D5W infused over 10 minutesLoading infusion-1mg/min for 6 hoursMaintenance infustion-0.5mg/min

More common with long-term and high doses109AmiodaroneSide effects/adverse reactionsHypotensionGastric disturbancesQT prolongationCan cause severe pulmonary reactionAmiodarone-induced pulmonary interstitial pneumonitis, hypersensitivity pneumonitis, or pulmonary fibrosisMany more potential side effects!

LidocaineAntiarrhythmic and local anestheticClass IBUse of continuous infusionVentricular arrhythmiasNo longer preferred choice.Can be used when amiodarone is unavailable, contraindicated, or not terminating arrhythmia.http://www.hospira.com/en/products_and_services/drugs/LIDOCAINE_HYDROCHLORIDE_DEXTROSELidocaineDosageLoading dose: 1 to 1.5 mg/kg IV; may repeat 0.5 to 0.75 mg/kg IV every 5 to 10 minutes Maximum total loading dose of 3 mg/kgDose range is 14 mg/minute (2050 mcg/kg/min).LidocaineSide effects/adverse reactionsLidocaine toxicityDizziness, confusion, euphoria, drowsiness, seizures, respiratory depressionCardiovascular effects (bradycardia, hypotension, conduction slowing, and cardiac arrest)This usually occurs after toxicity signs appear

+ InotropesDobutamineHemodynamic effectsPotent + inotropeSome + Chronotropic effectsSome vasodilator effectsUses of continuous infusionIncrease cardiac output due to CHF, cardiogenic shock, and following cardiac surgeryOff label use- increase cardiac output secondary to septic shock

http://www.berktree.com/assets/images/default/dobutamine-hydrochloride-in-5-dextrose-injection-solution-dobutamin-hcl-in-5-dex-500mg.jpgDobutamineDosageInitial rate: 0.5-1 mcg/kg/minUsual dose range: 2-20mcg/kg/minTypical recommended maximum dose is 20 mcg/kg/minSide effects/adverse reactionsHypertensionEctopy/arrhythmiasAnginaMilrinoneBrand name: PrimacorHemodynamic effectsPositive inotropeVasodilatorLittle Chronotropic activityIndicationsCongestive heart failureDecreased cardiac output

https://healthy.kaiserpermanente.org/static/drugency/images/HOS27760.JPGMilironeDosageBolus: 50mcg/kg over 10 minsInfusion: 0.375-0.75mcg/kg/minSide effects/adverse reactionsHypotensionEctopy/arrhythmiasAngina

IV FluidsIsotonic FluidsOsmolality of 250 to 375 mOsm/LExpands intravascular compartment

http://wildliferehabber.com/rehab-data/fluid-and-electrolyte-therapy120Isotonic FluidsIsotonic FluidsNormal saline; 0.9 NSLactated Ringers; LRDont give to patients with pH > 7.55% dextrose in water; D5WInitially isotonic, but becomes hypotonic5% albuminNursing considerationsWatch for fluid overload

Hypotonic FluidsOsmolality less than 250 mOsm/LWill pull intravascular fluid into the cellshttp://wildliferehabber.com/rehab-data/fluid-and-electrolyte-therapy

Hypotonic FluidsTypes of fluids normal saline;0.45 sodium chloride0.2 sodium chlorideNursing considerationsCan worsen hypovolemia/hypotensionDo NOT give to patients with or at risk for elevated ICPMonitor for signs of peripheral edema/third spacingHypertonic FluidsOsmolarity greater than 375 mOsm/LWill pull fluid from the interstitial space (cells) to the vascular compartment

http://wildliferehabber.com/rehab-data/fluid-and-electrolyte-therapyHypertonic FluidsFluid types3% sodium chloride25% albumin5% Dextrose in 0.9 NS; D5.95% dextrose in 0.45 NS; D5.4510% dextrose in water; D10WNursing considerationsWatch for fluid overloadMonitor blood sugar and electrolytesReferencesHardin, S. R. & Kaplow, R. (2010). Cardiac surgery essentials for critical care nursing. Sudbury, MA: Jones and Bartlett Publishers, LLC.Wiegand, D. (2010). AACN procedure manual for critical care, 6th edition. St. Louis, MO: Elsevier Science.Clinical Pharmacology Online DatabaseMosbys Nursing Skills