Chapter 9

Hemodynamic Monitoring

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Indications for Hemodynamic Monitoring
• Assesses cardiac function and evaluates effectiveness of
therapy
– Cardiogenic shock
– Severe heart failure
– Sepsis or septic shock
– Multiple organ system dysfunction (MODS)
– Acute respiratory distress syndrome (ARDS)
– Cardiac surgery

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

System Components

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Square-Wave Test

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Leveling and Zeroing

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question
• To ensure accurate arterial pressures, the nurse must
level the transducer to what landmark?
– A. Nipple line
– B. Phlebostatic axis
– C. Sternal notch
– D. Apical impulse

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer
• B. Phlebostatic axis
• Rationale: The phlebostatic axis is between the fourth
intercostal space and midaxillary line; this is the
approximate location of the right atrium.

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Arterial Pressure Monitoring
• Continuous monitoring of arterial blood pressure
• Vascular access for obtaining blood samples
• Guides therapy

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Interventions for Arterial Lines
• Ensure insertion site is visible at all times.
• Ensure monitor alarms are visible and audible.
• Set parameters according to the facility protocol.
– Typically 10 to 20 mm Hg of the patient’s trended
blood pressure
• DO NOT infuse IV solution or medication through the
arterial pressure monitoring system.

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Data Interpretation

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question
• Is the following question True or False?
• It is acceptable to infuse medications via an arterial line.

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer
• False
• Rationale: An arterial pressure line is used for monitoring
purposes only. NEVER infuse any medications or IV
solutions via this line.

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Complications of Arterial Lines
• Accidental blood loss
– Secure and tighten connections.
– Immobilize extremity.
– Expose extremity.
• Infection
– Observe a sterile technique.
– Maintain a closed system.
• Impaired circulation
– Assess color, sensation, temperature, and movement
of extremity.
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Central Venous Pressure Monitoring
• Normal values 2 to 8 mm Hg
• Measures right atrial pressure
• Left ventricular end-diastolic pressure
• Reflects intravascular blood volume

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Complications of Central Venous Catheters
• Infection
– Assess the site.
– Observe a sterile technique with any catheter
manipulation.
• Thrombosis
– Monitor waveform, ability to flush, blood return.
• Pneumothorax
– CXR postinsertion
• Air embolism
– Ensure tight connections.
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
• Is the following statement True or False?
• A central venous catheter measures right atrial pressure,
left ventricular end-diastolic pressure, and intravascular
blood volume.

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer
• True
• Rationale: Central venous catheter terminates in the
superior vena cava near the right atrium; it measures
right atrial pressures, left ventricular end-diastolic
pressure, and intravascular blood volume.

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Pulmonary Artery Catheter
• Four lumens
– Distal lumen
– Proximal lumen
– Thermistor lumen
– Balloon inflation lumen
*Some PACs may have additional lumens.

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Interventions for Pulmonary
Artery Catheters

• Assist with insertion.

• Monitor waveform.
• Observe for dysrhythmias.
• Observe for accidental wedging of the catheter.
• Maintain sterile dressing.
*Central catheter placement must be confirmed by CXR
before accessing the device.

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Data Interpretation

• Right atrial pressure 2 to 6 mm Hg

– Measures pressure in the right ventricle during
diastole, equals CVP
• Right ventricular pressure 20 to 30 mm Hg
– Equals the pulmonary artery systolic pressure

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Data Interpretation (cont.)
• Pulmonary artery pressure
– Systolic pressure equals right ventricular systolic
function 20 to 30 mm Hg.
– Diastolic pressure equals the left ventricular end-
diastolic pressure (LVEDP) 8 to 15 mm Hg.
• Pulmonary artery wedge pressure 8 to 12 mm Hg
– More accurate measure of LVEDP

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Complications of Pulmonary Artery
Catheters
• Ventricular dysrhythmias
• Pulmonary artery rupture or perforation
• Pulmonary infarction

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Cardiac Output
• Cardiac output (CO)—the amount of blood ejected from
the heart per minute
• Stroke volume (SV)—the milliliters of blood ejected from
the ventricle with each contraction
• HR x SV=CO
• 4 to 8L/minute at rest
• Cardiac index (CI)—relates cardiac output to body size;
normal is 2.5 to 4L/minute/m2.

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Stroke Volume

• Preload
– Amount of stretch on the myocardial muscle fibers at
end diastole
• Afterload
– The resistance to ejection of blood from the
ventricles
• Contractility
– Ability of the heart to contract independent of
preload and afterload

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Methods of Evaluating Cardiac Output
• Thermodilution
• Arterial pressure and waveform-based methods
• Electrical bioimpedance cardiography
• Esophageal Doppler monitoring

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question
• Determinants of stroke volume includes all of the
following except what?
– A. Preload
– B. Cardiac output
– C. Afterload
– D. Contractility

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer
• B. Cardiac output
• Rationale: Stroke volume is the volume of blood ejected
from the ventricle with each contraction. Preload,
afterload, and contractility determine stroke volume.
Stroke volume X heart rate = cardiac output

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Thermodilution Technique
• Gold standard for evaluating cardiac output
– Intermittent
• Measures change in blood temperature following
injection of indicator solution
– Continuous
• Specialized PACs with thermal filaments

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Thermodilution Technique (cont.)

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Cardiac Output Curves

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Thermodilution Technique (cont.)
• Ensure volume of injectate in the syringe is correct.
• Inject the volume smoothly and rapidly, less than 4
seconds.
• Wait approximately 1 minute between injections to allow
the catheter thermistor to return to baseline.
• Obtain three or more consecutive measurements.

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Arterial Pressure and Waveform-Based
Method

• Proportional relationship between pulse pressure and

stroke volume
• Inverse relationship between pulse pressure and aortic
compliance
• Measures using an arterial line, special sensor, and a
monitor that uses an algorithm for SV and CO

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Impedance Cardiography

• Electrodes placed on the base of the neck and lower

thorax
• Measures impedance over time and is mathematically
converted into SV and CO values using an algorithm

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Esophageal Doppler Monitoring
• Doppler transducer in nasogastric tube
• Placed in esophagus and monitors blood flow velocity
through the descending aorta
• Continuous CO and SV are calculated using an algorithm.

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question
• What is the most widely used method to determine
cardiac output?
– A. Arterial pressure and waveform method
– B. Impedance cardiography
– C. Esophageal Doppler monitoring
– D. Thermodilution

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer
• D. Thermodilution
• Rationale: Thermodilution is the most common method
used to measure cardiac output and is considered the
clinical gold standard.

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Evaluation of Oxygen Delivery and
Demand Balance
• Oxygen delivery (DaO2)
– Amount of oxygen transported to tissues
– Depends on cardiac output, hemoglobin levels, and
arterial oxygen saturation

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Balance Between Supply and Demand
• Oxygen consumption—the amount of oxygen used by the
cells of the body
• Primary determinants:
– Oxygen demand—the cells requirement for oxygen
– Oxygen delivery—need adequate supply of oxygen to
deliver to the cells
– Oxygen extraction—the amount of oxygen removed
from Hgb to be used by the cells

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Evaluation of Global Tissue Oxygenation
Status

• Metabolic indicators
– Lactate levels, serum pH, and base excess/base
deficit
• Venous oxygen saturation
– Evaluates oxygen supply versus oxygen demand
– Mixed venous oxygen saturation SvO2
– Venous oxygen saturation ScvO2

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question
• Is the following statement True or False?
• Oxygen extraction is the amount of oxygen removed
from Hgb to be used by the cells.

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer
• True
• Rationale: Oxygen extraction—the amount of oxygen
removed from Hgb to be used by the cells; oxygen
demand is the cells’ requirement for oxygen, oxygen
delivery the need for adequate supply of oxygen to
deliver to the cells.

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Factors Affecting Oxygen Supply Versus
Demand
• Surgery • Sepsis

• Infection • Anesthesia

• Pain • Suctioning

• Hypothermia • Pharmacological
paralysis
• Sedation
• Anxiety

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Evaluation of Regional Tissue
Oxygenation Status
• Gastric tonometry
– Specialized nasogastric tube measures partial
pressure of carbon dioxide (PCO2)
• Sublingual capnometry
– Measures PCO2 under the tongue

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins