Hemodynamic Monitoring

1. Introduction to
HEMODYNAMIC
MONITORING

2. DEFINITION
HEMODYNAMIC MONITORING
DEFINITION
Measuring and
monitoring the
factors that
influence the
force and flow of
blood.
PURPOSE
To aid in diagnosing, monitoring and
managing critically ill patients.
2

3. INDICATIONS
 To diagnose shock states
 To determine fluid volume status
 To measure cardiac output
 To monitor and manage unstable patients
 To assess hemodynamic response to
therapies
 To diagnose primary pulmonary hypertension,
valvular disease, intracardiac shunts, cardiac
tamponade, and pulmonary embolus
3

4. CONTRAINDICATIONS
for an invasive PA Catheter
 Tricuspid or pulmonary valve mechanical
prosthesis
 Right heart mass (thrombus and/or tumor)
 Tricuspid or pulmonary valve endocarditis
4

5. Clinical Scenario Use of PAC
 Management of complicated MI
 Severe LVF/RMI (precise management of heart failure)
 Assessment of respiratory distress
 Cardiogenic vs non-cardiogenic pulmonary edema
 Assessment/Diagnosis of shock/ cardiac dysfunction
 Cardiogenic/hypovolemic/septic
 Tamponade
 Pulmonary embolism
 Severe dilated cardiomyopathy
 Management of Pulmonary Hypertension
 Management of high-risk surgical patients
 CABG, vascular, valvular, aneurysm repair
 Management of volume requirements in the critically
ill
 ARF, GI bleed, trauma, sepsis (precise management)
5

6. Hemodynamic Values
 CO / CI  Cardiac Output/Cardiac Index
 SV / SVI or SI  Stroke Volume/Stroke Volume Index
 SVO 2  Mixed Venous Saturation
 RVEDVI or EDVI  RV End-Diastolic Volume
 SVR / SVRI  Systemic Vascular Resistance
 PVR / PVRI  Pulmonary Vascular Resistance
 RVEF  RV Ejection Fraction
 VO 2 / VO 2 I  Oxygen Consumption
 Oxygen Delivery
 DO 2 / DO 2 I
 Pulmonary Artery Occlusive
 PAOP
Pressure
 CVP
 Central Venous Pressure
 PAP
 Pulmonary Artery Pressure
6

7. Index Values
 Values normalized for body size (BSA)
 CI is 2.5 – 4.5 L/min/m2
 SVRI is 1970 – 2390 dynes/sec/cm-5/m2
 SVI or SI is 35 – 60 mL/beat/m2
 EDVI is 60 – 100 mL/m2
7

8. Importance of Index Values
 Mr. Smith  Mr. Jones
 47 y/o male  47 y/o male
 60 kg  120 kg
 CO = 4.5  CO = 4.5
 6 ft tall (72 inches)  6 ft tall (72 inches)
 BSA = 1.8  BSA = 2.4
 CI = 2.5 L/min/m 2  CI = 1.9 L/min/m2
8

9. Basic Concepts
 Cardiac Output - amount of blood pumped out
of the ventricles each minute
 Stroke Volume - amount of blood ejected by
the ventricle with each contraction
 CO = HR x SV
Decreased SV usually produces compensatory
tachycardia..
So. . .changes in HR can signal changes in CO
9

10. Basic Concepts
 Systemic Vascular Resistance
 Measurement of the resistance (afterload) of blood
flow through systemic vasculature
 *Increased SVR/narrowing PP = vasoconstriction
 *Decreased SVR/widening PP = vasodilation
 Blood Pressure
BP = CO x SVR

** SVR can increase to maintain BP despite
inadequate CO
Remember CO = HR x SV
10

11. Basic Concepts
 BP = CO x SVR
 CO and SVR are inversely related
CO and SVR will change before BP
changes
* Changes in BP are a late sign of
hemodynamic alterations
11

12. Stroke Volume
 Components Stroke Volume
 Preload: the volume of blood in the ventricles
at end diastole and the stretch placed on the
muscle fibers
 Afterload: the resistance the ventricles must
overcome to eject it’s volume of blood
 Contractility: the force with which the heart
muscle contracts (myocardial compliance)
12

13. Stroke Volume
Preload Afterload Contractility
Filling Pressures Resistance to Strength of
& Volumes Outflow Contraction
CVP PVR, MPAP RVSV
PAOP (PAD may SVR, MAP LVSV
be used to
estimate PAOP)
Fluids, Volume Vasoconstrictors Inotropic
Expanders Vasodilators Medications
Diuretics
13

14. Clinical Measurements of Preload
 Right Side: CVP/RAP * filling pressures

Left Side: PAOP/LAP
 PAD may be used to estimate PAOP in the
absence of pulmonary disease/HTN
 The pulmonary vasculature is a low pressure
system in the absence of pulmonary disease
 These pressures are “accurate” estimations of
preload only with perfect compliance of heart
and lungs
14

15. Clinical Measurements of
Afterload
 RV Afterload
 MPAP
 PVR = 150-250 dynes/sec/cm-5
 PVRI = 255-285 dynes/sec/cm-5/m2
 LV Afterload
 MAP
 SVR = 800–1300 dynes/sec/cm-5
 SVRI = 1970-2390 dynes/sec/cm-5/m2
15

16. Clinical Estimation of Contractility
 Cardiac Output * flow
Normal = 4-8 L/min
 Cardiac Index
Normal = 2.5-4.5 L/min/m2

Stroke Volume *pump performance
Normal = 50-100 ml/beat
 Stroke volume Index
 Normal = 30-50 ml/beat/m2
16

17. Ventricular Compliance
 Ability of the ventricle to stretch
 Decreased with LV hypertrophy, MI,
fibrosis, HOCM
 *If compliance is decreased, small
changes in volume produce large
changes in pressure
17

18. The PA Catheter
18

19. Pulmonary Artery Catheters
19

20. The Pulmonary Artery Catheter
20

21. “Swan-Ganz” PA Catheter
 Large Markers = 50cm
 Small Markers = 10cm
 10 cm between small black markers on
catheter
 Several types
 Thermodilutional CO
 CCO
 Precep
 NICCO
 Multiple lumens
21

22. BREAK
Take 5 MINUTES
22

23. Demonstration of PA catheter
and
Hands-on practice
23

24. Risks With The PA Catheter
 Bleeding
 Infection
 Dysrhythmias
 Pulmonary Artery
Rupture
 Pneumothorax
 Hemothorax
 Valvular Damage
 Embolization
 Balloon Rupture
 Catheter Migration
24

25. 25

26. Hemodynamic
Waveforms

27. PA-Catheter Positioning
 Right  Right  Pulmonary  Pulmonary
 Artery
 Atrium  Ventricle  Artery
 Occlusion
 Pressure 27

28. PAC Insertion Sequence
28

29. Post PA Catheter Insertion
 Assess ECG for dysrhythmias.
 Assess for signs and symptoms of respiratory distress.
 Ascertain sterile dressing is in place.
 Obtain PCXR to check placement.
 Zero and level transducer(s) at the phlebostatic axis.
 Assess quality of waveforms (i.e., proper configuration, dampening,
catheter whip).
 Obtain opening pressures and wave form tracings for each
waveform.
 Assess length at insertion site.
 Ensure that all open ends of stopcocks are covered with sterile dead-
end caps (red dead-end caps, injection caps, or male Luer lock caps).
 Update physician of abnormalities.
29

30. General Rules for Hemodynamic
Measurements
 Measure all pressures at End-Expiration
“ Patient Peak”
“ Vent Valley”
30

31. Phlebostatic Axis
4th ICS Mid-chest, regardless of head elevation
31

32. Phlebostatic Axis
4th ICS Mid-chest, regardless of head elevation
32

33. Spontaneous Respirations
 Measure all pressures at end-expiration
 At top curve with spontaneous
respiration
“patient-peak”
 Intrathoracic pressure decreases during
spontaneous inspiration
 Negative deflection on waveforms
 Intrathoracic pressure increases during
spontaneous expiration
 Positive deflection on waveforms
33

34. Spontaneous Respirations
34

35. Mechanical Ventilation
 Measure all pressures at end-expiration
 At bottom curve with mechanical
ventilator
“vent-valley”
 Intrathoracic pressure increases during
positive pressure ventilations ( inspiration )
 Positive deflection on waveforms
 Intrathoracic pressure decreases during
positive pressure expiration
 Negative deflection on waveforms
35

36. 36

37. 37

38. General Rules for
Hemodynamic Measurements
 Measure all pressures with the HOB at a …
consistent level of elevation
 Level the transducer at the phlebostatic axis
 4th intercostal space, mid-chest
 Print strips with one ECG and one pressure
channel
 adequate scale
 allows accurate waveform analysis
 Confirm monitor pressures with pressures obtained
by waveform analysis
 ** correct waveform analysis is more accurate than pressures
from the monitor
38

39. Review of Normal Values
 RAP (CVP) 0-8 mmHg
 RVP 15-30/0-8 mmHg
 PAP 15-30/6-12 mmHg
 PAOP 8 - 12 mmHg
39

40. PA INSERTION WAVEFORMS
A B
C D
 A = RA (CVP) Waveform
 B = RV Waveform
 C = PA Waveform
 D = PAWP Waveform
40

41. PAC Insertion Sequence
41

42. Right Atrium (CVP)
Normal Value 0-8 mmHg
RAP = CVP
Wave Fluctuations Due To
Contractions
42

43. Components of the RA
(CVP) Waveform
 a-wave
 atrial contraction (systole)
 begins in the PR interval and QRS on the ECG
 correct location for measurement of CVP/RAP
 * average the peak & trough of the a-wave
 * (a-Peak + a-trough)/2 = CVP
 May not see if no atrial contractions as with. . .
43

44. Components of the RA
(CVP) Waveform
 Absent a waves
 Atrial fibrillation
 Paced rhythm
 Junctional rhythm
 Measure at the end of the QRS
44

45. Absent A Wave
* Measure at end of QRS!
*PACEP.ORG 2007 45

46. Components of the RA
(CVP) Waveform
 c-wave
 tricuspid valve closure
 Between ST segment
 Between a and v waves
 *may or may not be present
 v-wave
 Atrial filling
 begins at the end of the QRS to the beginning
of the T wave (QT interval)
46

47. Reading the RA CVP) Waveform
49

48. CVP Waveform
Vented Patient
50

49. CVP Waveform
a wave
Vented Patient – “Vent Valley”
51

50. Right Ventricle
Normal Value 15-25/0-8 mmHg
Catheter In RV May Cause Ectopy
Swan Tip May Drift From PA to RV
53

51. RV Waveform
54

52. Components of the RV
Waveform
 Usually only seen with insertion
 Systole
 measured at the peak
 peak occurs after the QRS
 Diastole
 measured just prior to the the onset of systole
 No dicrotic notch
 Dicrotic notch indicates valve closure
 *** Aids in differentiation from the PA tracing
55

53. Reading the RV Waveform
56

54. RV Waveform Interventions
 After PA catheter is correctly placed, RV
waveform should not be seen. If it is, then
interventions are necessary:
 Check for specific unit protocol first
 Inflate balloon with patient lying on their left side
(catheter may float back into PA)
 With deflated balloon, pull catheter into RA placement
or remove completely
 Document your actions and notify physician
** An RN should NEVER advance the catheter!
57

55. Pulmonary Artery
Normal Value 15-25/8-15 mmHg
Dicrotic Notch Represents PV Closure
PAD Approximates PAWP (LVEDP)
(in absence of lung or MV disease)
58

56. PA Waveform
59

57. Components of the PA Waveform
 Systole
 measured at the peak of the wave
 Diastole
 measured just prior to the upstroke of systole
(end of QRS)
 Higher than RV diastolic pressure
60

58. Components of the PA Waveform
 Dicrotic notch
 indicates pulmonic valve closure
 aids in differentiation from RV waveform
 aids in determining waveform quality
 Anachrotic Notch
 Before upsweep to systole
 Opening of pulmonic valve
61

59. Reading the PA Waveform
Dicrotic notch
62

60. PA Waveform
10/20/30
Identify that it is the PA tracing
Look at the scale
What is the PAP?
63

61. PA Waveform
Look for dichrotic notch
Look at scale
What is the PAP?
64

62. PAOP / Wedge
Normal Value 8-12 mmHg
Balloon Floats and Wedges in Pulmonary
Artery
PAWP = LAP = LVEDP 65

63. Components of the PA Waveform
 a-wave
 atrial contraction
 correct location for measurement of PAOP
 average the peak & trough of the a-wave
 begins near the end of QRS or the QT
segment
 * Delayed ECG correlation from CVP since
PA catheter is further away from left atrium
66

64. Components of the PA Waveform
 c-wave
 rarely present
 represents mitral valve closure
 v-wave
 represents left atrial filling
 begins at about the end of the T wave
67

65. Reading the PAOP Waveform
Begins within
the QRS or the
QT segment 68

66. Wedging Can Cause
Pulmonary Artery Rupture
69

67. PA Tracing to PAOP Tracing to PA
Tracing
70

68. Post PAC Insertion
 Assess ECG for dysrythmias
 Assess for S/S of respiratory distress
 Be sure sterile dressing is applied
 Order CXR for placement
 Get MD order before infusing through ports
 Zero and level all transducers
 Assess quality of waveforms
 Dampening, proper configuration, scale
 Obtain opening pressures and waveform tracings for
each waveform
 Note length at insertion site
 Place proper luer-lock connectors to lumens and cap all
ports
 Notify MD of any abnormalities
71

69. Precautions
 Always set alarms on monitor
 20mmHg above and below pt baseline
 If in PAOP with balloon down, have pt cough,
deep breath, change position
 If unable to dislodge from PAOP, notify MD
immediately to reposition catheter
 CXR to reconfirm placement
 If pt coughs up blood or it is suctioned via ETT,
suspect PA rupture and notify MD immediately
72

70. Intermittent Thermodilution CO
 Based on measuring blood temperature changes
 Must know the following:
 Computation constant
 Volume of injectate
 Temperature of injectate
 Iced or room temperature
 Inject rapidly and smoothly over 4 seconds max
 Thermister at end of PA catheter detects change
in temperature and creates CO curve
 At least 3 measurements and average results
73

71. Cardiac Output via Thermodilution
74
*PACEP.ORG 2007

72. Averaging CO Measurements
*PACEP.ORG 2007 75

73. Continuous Cardiac Output
 A heat signal is produced by the thermal filament
of the PA catheter
 The signal is detected by the thermistor on the
PA catheter and is converted into a
time/temperature curve
 The CCO computer produces a time-averaged
calculation
 Over 3 minutes
 Updates every 30-60 seconds
76

74. Mixed Venous Oxygen Saturation
77

75. Mixed Venous Oxygenation Monitoring
(SvO2)
 Measures the amount of O2 in the blood (on the Hgb
molecule) returned to the heart
 Helps to demonstrate the balance between O2 supply
& demand in the body (tissue oxygenation)
 Helps to interpret hemodynamic dysfunction when
used with other measurements
 Normal: 70% (60-80)
78

76. Mixed Venous Oxygen
Saturation
 End result of O2 delivery and
consumption
 Measured in the pulmonary artery
 An average estimate of venous saturation
for the whole body.
 **Does not reflect separate tissue
perfusion or oxygenation
79

77. Mixed Venous Oxygen Saturation
 Continuous measurement
 “Early” warning signal to detect oxygen
transport imbalances
 Evaluates the effect of the therapeutic
interventions
 Identify potential patient care
consequences (turning, suctioning)
80

78. Mixed Venous Oxygen Saturation
There are four factors that affect SVO 2:
1. Hemoglobin
2. Cardiac output
3. Arterial oxygen saturation (SaO2)
4. Oxygen consumption (VO2)
81

79. SvO2 Application
In a case of increased SVR with decreased CO. Nitroprusside was
started. The increase in SvO2 and increase in CO reflects the
appropriateness of therapy.
82

80. Ways To Increase O2 Delivery
 Increase CO
 increase HR, optimize preload, decrease
afterload, add positive inotropes
 Increase Hgb, increase SaO2
 Improve pulmonary function
 pulmonary toilet, prevent atelectasis
 ventilation strategies
83

81. Ways To Decrease O2 Demand
 Decrease muscle activity
 sedatives, (paralytics)
 prevent/control seizures
 prevent/control shivering
 space care activities
 Decrease temperature
 prevent/control fever
84

82. Removal of the PA Catheter
 Usually performed by the nurse with
an MD order
 Place patient supine with HOB flat
(reduces chance of air embolus)
85

83. Removal of the PA Catheter
 Make sure balloon is down, have
patient inhale and hold breath, pull
PA catheter out smoothly
 monitor for ventricular ectopy
 stop immediately & notify MD if resistance
is met
86

84. Removal of the PA Catheter
87

85. Removal of the PA Catheter
 If patient is unable to perform breath hold:
 Pull PA catheter during period of positive
intrathoracic pressure to minimize chance of
venous air embolus
 Mechanically ventilated patient
 pull PA catheter during delivery of vent breath
 Spontaneously breathing patient
 pull PA catheter during exhalation
88

86. Removal of the PA Catheter
 If introducer sheath (cordis) is to remain in
place, it must be capped.
 If introducer sheath (cordis) is to be removed,
repeat the steps used for PA catheter removal.
 Hold pressure on the site (5-10 min.), keep
patient flat until hemostasis is achieved.
 Apply sterile dressing or band-aid.
89

87. Break
Take 5 Minutes
90

88. Hemodynamic Waveform
Practice
91

89. MEASUREMENTS
92

90. SAMPLE MEASUREMENTS
93

91. SAMPLE MEASUREMENTS
94

92. SAMPLE MEASUREMENTS
95

93. SAMPLE MEASUREMENTS
96

94. SAMPLE MEASUREMENTS
97

95. SAMPLE MEASUREMENTS
98

96. SAMPLE MEASUREMENTS
99

97. SAMPLE MEASUREMENTS
100

98. SAMPLE MEASUREMENTS
101

99. SAMPLE MEASUREMENTS
102

100. SAMPLE MEASUREMENTS
103

101. SAMPLE MEASUREMENTS
104

102. SAMPLE MEASUREMENTS
105

103. SAMPLE MEASUREMENTS
106

104. Review
107

105. Review
 The
PA diastolic pressure is
measured at which part of the
waveform?
Just prior to the
upstroke of systole
108

106. Review
 Whichpart of the CVP and PAOP
waveforms is used to calculate
pressures?
The a wave
109

107. Review
 The RV waveform can be
distinguished from the PA
waveform by:
RV has lower
diastolic pressure
and no dicrotic notch
110

108. Review
 The
v wave of the CVP & PAOP
waveforms represents:
Atrial filling
111

109. Review
 Thea wave of the CVP waveform
correlates with which electrical
event?
The PR interval on the ECG
112

110. Review
 The a wave of the PAOP
waveform correlates with which
electrical event?
The QRS on the ECG
113

111. Questions?
114