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SEMINAR ON HEMODYNAMIC

MONITORING

BY UMAdevi.k
BY

UMA
IIND YEAR MSc NURSING
IIND YEAR MSC NURSING
The oxford college of nursing
INTRODUCTION
Critically ill patients require continuos assessment of their
cardiovascular system to diagnose and manage their complex
medical conditions.This is most commonly achieved by the use
of direct pressure monitoring systems,often refered to as
hemodynamic monitoring.Heart function is the main focus of
hemodynamic studies. Hemodynamic pressure monitoring
provides information about blood volume , fluid balance and how
well the heart is pumping. Nurses are responsible for the
collection measurement and interpretation of these dynamic
patient status parameters.
HEMODYNAMIC MONITORING
HEMODYNAMICS

 Hemodynamics are the forces which


circulate blood through the body.
Specifically, hemodynamics is the term
used to describe the intravascular
pressure and flow that occurs when the
heart muscle contracts and pumps blood
throughout the body.
DEFINITION
Hemodynamic monitoring refers to
measurement of pressure, flow and
oxygenation of blood within the cardiovascular
system.
OR
Using invasive technology to provide
quantitative information about vascular
capacity, blood volume, pump effectiveness
and tissue perfusion.

OR
Hemodynamic monitoring is the measurement
and interpretation of biological sytems that
describes the performance of cardiovascular
system
PURPOSES

 Early detection, identification and


treatment of life threatening conditions
such as heart failure and cardiac
tamponade.
 Evaluate the patient’s immediate response
to treatment such as drugs and
mechanical support.
 Evaluate the effectiveness of
cardiovascular function such as cardiac
output and index.
INDICATIONS
 Any deficits or loss of cardiac function: such
as myocardial infarction, congestive heart
failure, cardiomyopathy.

 All types of shock; cardiogenic shock,


neurogenic shock or anaphylactic shock.

 Decreased urine output from dehydration,


hemorrhage. G.I bleed, burns or surgery.
SPECIALISED EQUIPMENTS NEEDED
FOR INVASIVE MONITORING
 A CVP,pulmonary artery ,arterial catheter

 A flush system composed of intravenous solution,tubing stop cocks


and a flush device which provides for continous and manual flushing of
system.

 A pressure bag placed around the flush solution that is maintained at


300 mmhg pressure ;the pressurized flush system delivers 3-5ml of
solution per hour through the catheter to prevent clotting and backflow
of blood into the pressure monitoring system.

 A tranducer to convert the pressure coming from artery or heart


chamber into an electrical signal

 An amplifier or moniter which increases the size of electrical signal for


display on an occilloscope.
HEMODYNAMIC MONITER
SETUP FOR HEMODYNAMIC
PRESSURE MONITORING
 Obtain barrier kit, sterile gloves and correct swan catheter.
Also need extra iv pole, transducer holder, boxes and
cables.

 Check to make sure signed consent is in chart , and that


patient and or family understand procedure.

 Everyone in the room should be wearing a mask.

 Position patient supine and flat if tolerated.


 On the monitor , press “change screen” button , then select
“swan ganz” to allow physician to view catheter wave forms
which inserting.

 Assist physician in sterile draping and sterile setup for swan


insertion.
 Setup pressure lines and transducers. Level pressure flush
monitoring system and transducers to the phlebostatic axis.

 Connect tubings to patient when patient is ready to flush the


swann.

 While floating the swann, observe for ventricular ectopy on


the monitor.

 After swann is in place, assist with cleanup and let patient


know procedure is complete.

 Obtain all the values. For cardiac output inject 10mls of D5w
after pushing the start button.

 Perform hemocalculations.

 Document findings in ICU flow sheet.


PHLEBOSTATIC AXIS
DETERMINANTS OF CARDIAC
PERFORMNACE

 PRELOAD (estimated by end diastolic


volume CVP for RVEDV ; PAOP (wedge)
pressure for LVEDV

 AFTERLOAD (SVR = [MAP-CVP]/CO*80)

 CONTRACTILITY
METHODS OF HEMODYNAMIC
MONITORING
 1.ARTERIAL BLOOD PRESSURE
 a)Non Invasive
 b)Intra arterial blood pressure
measurement
 2.CENTRAL VENOUS PRESSURE
 3.PULMONARY ARTERY CATHETER
PRESSURE MONITORING
NON INVASIVE ARTERIAL BP
MONITORING
 With manual or automated devices

 Method of measurement

 Oscillometry (most common)


 MAP most accurate DP least accurate

 Auscultatory (korotkoff sounds)

 Combination
NON INVASIVE

HEMODYNAMIC
MONITORING
LIMITATIONS

 Cuff must be placed correctly and must be


appropriately sized

 Auscultatory method is very inaccurate


(Korotkoff sound is difficult to hear)

 Significant underestimation in low flow


(shock)

 Oscillometric also mostly in accurate


( >5mmhg off directly recorded pressures)
DIRECT INTRA ARTERIAL BP
MONITORING
 Intra-arterial BP monitoring is used to
obtain direct and continuous BP
measurements in critically ill patients who
have severe hypertension or hypotension
PROCEDURE
 Once an arterial site is selected (radial,
brachial, femoral, or dorsalis pedis), collateral
circulation to the area must be confirmed
before the catheter is placed. This is a safety
precaution to prevent compromised arterial
perfusion to the area distal to the arterial
catheter insertion site. If no collateral
circulation exists and the cannulated artery
became occluded, ischemia and infarction of
the area distal to that artery could occur.

 Collateral circulation to the hand can be


checked by the Allen test
 With the Allen test, the nurse compresses the
radial and ulnar arteries simultaneously and
asks the patient to make a fist, causing the
hand to blanch.

 After the patient opens the fist, the nurse


releases the pressure on the ulnar artery
while maintaining pressure on the radial
artery. The patient’s hand will turn pink if the
ulnar artery is patent.
COMPLICATIONS

 Local destruction with distal ischemia


 external hemorrhage
 massive ecchymosis
 dissection
 air embolism
 blood loss
 pain
 arteriospasm and
 infection.
NURSING INTERVENTIONS
 Before insertion of a catheter, the site is
prepared by shaving if necessary and by
cleansing with an antiseptic solution. A local
anesthetic may be used.

 Once the arterial catheter is inserted, it is


secured and a dry, sterile dressing is applied.

 The site is inspected daily for signs of


infection. The dressing and pressure
monitoring system or water manometer are
changed according to hospital policy.
 In general, the dressing is to be kept dry and air
occlusive.

 Dressing changes are performed with the use of sterile


technique.

 Arterial catheters can be used for infusing intravenous


fluids, administering intravenous medications, and
drawing blood specimens in addition to monitoring
pressure.

 To measure the arterial pressure, the transducer (when


a pressure monitoring system is used) or the zero mark
on the manometer (when a water manometer is used)
must be placed at a standard reference point, called
the phlebostatic axis .

 After locating this position, the nurse may make an ink


mark on the chest
CENTRAL VENOUS PRESSURE
MONITORING
The CVP, the pressure in the vena cava
or right atrium, is used to assess right
ventricular function and venous blood
return to the right side of the heart. The
CVP can be continuously measured by
connecting either a catheter positioned in
the vena cava or the proximal port of a
pulmonary artery catheter to a pressure
monitoring system
PROCEDURE

 Before insertion of a CVP catheter, the site is


prepared by shaving if necessary and by
cleansing with an antiseptic solution.

 A local anesthetic may be used. The


physician threads a single lumen or
multilumen catheter through the external
jugular, antecubital, or femoral vein into the
vena cava just above or within the right
atrium
NURSING INTERVENTIONS
 Once the CVP catheter is inserted, it is secured and a dry,
sterile dressing is applied.

 Catheter placement is confirmed by a chest x-ray, and the


site is inspected daily for signs of infection. The dressing
and pressure monitoring system or water manometer are
changed according to hospital policy.

 In general, the dressing is to be kept dry and air occlusive.

 Dressing changes are performed with the use of sterile


technique.
 CVP catheters can be used for infusing
intravenous fluids, administering intravenous
medications, and drawing blood specimens
in addition to monitoring pressure.

 To measure the CVP, the transducer (when a


pressure monitoring system is used) or the
zero mark on the manometer (when a water
manometer is used) must be placed at a
standard reference point, called the
phlebostatic axis .

 After locating this position, the nurse may


make an ink mark on the chest
PULMONARY ARTERY PRESSURE
MONITORING
 Pulmonary artery pressure monitoring is an important
tool used in critical care for assessing left ventricular
function, diagnosing the etiology of shock, and
evaluating the patient’s response to medical
interventions (eg, fluid administration, vasoactive
medications). Pulmonary artery pressure monitoring
is achieved by using a pulmonary artery catheter and
pressure monitoring system.
PULMONARY ARTERY PRESSURE
MONITORING
PULMONARY ARTERY CATHETER

 Development of the balloon-tipped flow


directed catheter has enabled continuous
direct monitoring of PA pressure.
Pulmonary artery catheter otherwise
known as “swan- ganz catheter”.
COMPONENTS OF CATHETER
INSERTION OF PAC

 PA monitoring must be carried out in a critical


care unit under careful scrutiny of an
experienced nursing staff.

 Before insertion of the catheter , explain to


the client that;
 The procedure may be uncomfortable but not
painful.
 A local anesthetic will be given at the
catheter insertion site. Support of the
critically ill client at this time helps promote
cooperation and lessen anxiety.
Procedure
 This procedure can be performed in the
operating room or cardiac catheterization
laboratory or at the bedside in the critical care
unit.Catheters vary in their number of lumens
and their types of measurement (eg, cardiac
output, oxygen saturation) or pacing
capabilities.

 All types require that a balloon-tipped, flow-


directed catheter be inserted into a large vein
(usually the subclavian, jugular, or femoral
vein); the catheter is then passed into the
vena cava and right atrium.
 In the right atrium, the balloon tip is inflated,
and the catheter is carried rapidly by the flow
of blood through the tricuspid valve, into the
right ventricle, through the pulmonic valve,
and into a branch of the pulmonary artery.

 (During insertion of the pulmonary artery


catheter, the bedside monitor is observed for
waveform andECG changes as the catheter
is movedthrough the heart chambers on the
right side and into the pulmonary Artery)
 When the catheter reaches a small pulmonary
artery, the balloon is deflated and the catheter is
secured with sutures.

 Fluoroscopy may be used during insertion to


visualize the progression of the catheter through
the heart chambers to the pulmonary artery.

 After the catheter is correctly positioned, the


following pressures can be measured:

 CVP or right atrial pressure


 pulmonary artery systolic and
 diastolic pressures, mean pulmonary artery
pressure, and pulmonary artery wedge
pressure).
NORMAL RESULTS

 Normal pulmonary artery pressure is


25/9 mm Hg, with a mean pressure of 15
mm Hg.
 Pulmonary capillary wedge pressure is
a mean pressure and is normally 4.5 to 13
mm Hg.
NURSING INTERVENTIONS
 Catheter site care is essentially the same as for a CVP
catheter. As in measuring CVP, the transducer must be
positioned at the phlebostatic axis to ensure accurate
readings .

 The nurse who obtains the wedge reading ensures that


the catheter has returned to its normal position in the
pulmonary artery by evaluating the pulmonary artery
pressure waveform.

 The pulmonary artery diastolic reading and the wedge


pressure reflect the pressure in the ventricle at end-
diastole and are particularly important to monitor in
critically ill patients, because they are used to evaluate
left ventricular filling pressures (preload)
 At end-diastole, when the mitral valve is
open, the wedge pressure is the same as
the pressure in the left atrium and the left
ventricle, unless the patient has mitral
valve disease or pulmonary hypertension.

 Critically ill patients usually require higher


left ventricular filling pressures to optimize
cardiac output. These patients may need
to have their wedge pressure maintained
as high as 18 mm Hg.
COMPLICATIONS
 Infection
 pulmonary artery rupture
 pulmonary thromboembolism
 pulmonary infarction
 catheter kinking,
 dysrhythmias, and
 air embolism.
TECHNIQUES WITH PULMONARY
ARTERY CATHETER
 CARDIAC OUTPUT MONITORING
 THERMODILUTION
 CONTINUOUS CARDIAC OUTPUT MONITORING
 FICK'S CARDIAC OUTPUT MEASUREMENT

 CO = VO2
 ---------
 CA-CV

DERIVED PARAMETERS
 Cardiac o/p measurements may be combined with systemic
arterial, venous, and PAP determinations to calculate a number
of variables useful in assessing the overall hemodynamic status
of the patient.
 They are,
 Cardiac index = Cardiac output / Body surface area
 Systemic vascular resistance = [(Mean arterial pressure -
resistance CVP or rt atrial pressure)/Cardiac output] x 80
 Pulmonary vascular resistance = [(PAP - PAWP) / Cardiac
vascular resistance output] x 80
 Mixed venous oxygen saturation (SvO2)
(SvO2 = SaO2 - [VO2 / (1.36 x Hb x CO)]
(6)
NURSING RESPONSIBILITIES
 Site Care and Catheter Safety:
 A sterile dressing is placed over the insertion site
and the catheter is taped in place. The insertion
site should be assessed for infection and the
dressing changed every 72 hours and prn.
 The placement of the catheter, stated in centimeters,
should be documented and assessed every shift.
 The integrity of the sterile sleeve must be maintained
so the catheter can be advanced or pulled back
without contamination.
 The catheter tubing should be labeled and all the
connections secure. The balloon should always be
deflated and the syringe closed and locked unless
you are taking a PCWP measurement
Patient Activity and
Positioning:
 Many physicians allow stable patients who
have PA catheters, such as post CABG
patients, to getout of bed and sit. The nurse
must position the patient in a manner that
avoids dislodging the
catheter.

 Proper positioning during hemodynamic


readings will ensure accuracy.
Dysrhythmia Prevention:

 Continuous EKG monitoring is essential


while the PA catheter is in place.

 Do not advance the catheter unless the


balloon is inflated.

 Antiarrhythmic medications should be


readily available to treat lethal
dysrhythmias.
Monitoring Waveforms for
Proper Catheter Placement:
 The nurse must be vigilant in assessing
the patient for proper catheter placement.
If the PA waveform suddenly looks like the
RV or PCWP waveform, the catheter may
have become misplaced. The nurse must
implement the proper procedures for
correcting the situation.
Monitoring Hemodynamic
Values for Response to
Treatments:

 The purpose of the PA catheter is to assist


healthcare team members in assessing
the patient’s condition and response to
treatment. Therefore, accurate
documentation of values before and after
treatment changes is necessary.
Assessing the Patient for Complications
Associated with the PA Catheter:
 Occluded ports
 Balloon rupture caused by overinflating the balloon or
frequent use of the balloon.
 Pneumothorax - may occur during initial placement.
 Dysrhythmias - caused by catheter migration
 Air embolism - caused by balloon rupture or air in the
infusion line.
 Pulmonary thromboembolism - improper flushing
technique, non-heparinized flush solution.
 Pulmonary artery rupture - perforation during
placement, overinflation of the balloon, overuse of the
balloon.
 Pulmonary infarction - caused by the catheter migrating
into the wedge position, the balloon left inflated, or
thrombus formation around the catheter which causes
an occlusion.
CONCLUSION
 Hemodynamics is the forces involved in blood circulation.
Hemodynamic monitoring started with the estimation of heart rate
using the simple skill of 'finger on the pulse' and then moved on to
more and more sophisticated techniques like stethoscope,
sphygmomanometer, ECG etc. The status of critically ill patients
can be assessed either from non-invasive single parameter
indicators or various invasive techniques that provide multi-
parameter hemodynamic measurements. As a result,
comprehensive data can be provided for the clinician to proactively
address hemodynamic crisis and safely manage the patient instead
of reacting to late indicators of hemodynamic instability
THANK
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