Hemodynamic monitoring

1. Hemodynamic monitoring
BY,
Pooja Murkar

2. Hemodynamic
It is inter-relationship
of
various physical forces
that Affects
the blood circulation
through the body

3. INTRODUCTION:
• Hemodynamic meaning literally “blood flow, motion and
equilibrium under the action of force”. Hemodynamic is an important
part of cardiovascular physiology dealing with the forces the pump
(the heart) has to develop to circulate blood through the
cardiovascular system. Adequate blood circulation (blood flow) is a
necessary condition for adequate supply of oxygen to all tissues,
which, in return, is synonymous with cardiovascular health, survival
of surgical patients, longevity and quality of life.

4. • It refers to measurement of pressure, flow and oxygenation of blood
with in the cardiovascular system.
Or
• It means using technology to provide quantitative information about
vascular capacity, blood volume, pump effectiveness and tissue
perfusion.
Or
• It is the measurement and interpretation of biological systems that
describes the performance of cardiovascular system

5. • Hemodynamic is the interrelationship of pressure, flow,
resistance within cardiovascular system .
• Mechanical energy (contraction of heart & movement of blood) is
transmitted throughout blood vessels in series of pauses or waves which is
displayed on pressure monitor.
• It is monitoring of blood flow & pressure within the circulatory system

6. Hemodynamic monitoring
is
continuous measuring & recording
of
all vital physiological parameters
with
indwelling catheters & electronic monitoring equipment's
In
critically ill patients

7. PURPOSES:
• Early detection ,identification and treatment of life threatening
conditions such as heart failure and cardiac tamponed.
• Evaluate the patients immediate response to treatment such as drugs
and mechanical support.
• Evaluate the effectiveness of cardiovascular function such as cardiac
output and index.

8. INDICATIONS:
• Any deficits or loss of cardiac function; such as myocardial
infarction, congestive cardiac failure, cardiomyopathy.
• All types of shock
• Decreased urine output from dehydration and various other
conditions.

9. CONTRAINDICATIONS:
 Tricuspid or pulmonary valve mechanical prosthesis
 Right heart mass
 Endocarditis

10. UNDERLYING CONCEPTS:
• Physiological principles of hemodynamic describe the cardiovascular variables
that influence blood flow and oxygen delivery.
• These variables includes volume, pressure, flow, and resistance to flow.
• Basics of hemodynamic:
• Darcy's law of flow-
• As the pressure gradient increase flow increases if there is no change in the
resistance of the tube.
• Poiseuille’s laws of resistance and flow-
• Resistance is directly proportional to blood viscosity and length of vessel, and
inversely proportional to radius of the vessel.

11. Physiology of h.d.m :
• PRESSURE – Exertion of continuous pressure
• FORCE - Cause or product of effort
• RESISTANCE -Degree of opposition to force
Pressure = Force X Resistance.
BP= Cardiac output X Systemic Vascular Resistance
Blood pressure is the force or pressure with which the blood enters on the wall of the
blood vessels
CO=Heart Rate X Stroke Volume
Stroke Volume is the amount of blood ejected at each contraction

12. CARDIAC CYCLE:

13. NOTE:
• Haemodynamic monitoring per se has no favourable
impact on outcome. Only the interventions based on
haemodynamic data will impact outcome.

14. CLINICAL USE OF HEMODYNAMIC MONITORING:
• Preload- Volume of blood in left ventricle at end of
diastole, creating a “stretch” in muscle fibers
Measured by PAWP
– Normal values: 4-12mmHg

15. • Afterload is the resistance that the heart must
overcome in order to eject the blood volume from
the left ventricle.
• Measured by SVR
–Normal values: 900 - 1400 dynes/s/cm-5

16. .
• Oxygen Demand - Contractility
• Ability of muscle fibers to contract in order to eject blood
into the circulation
• Measured by Ejection Fraction (EF)
–Normal values: 60% - 75%

17. Principle of Hemodynamic monitoring system:
- Interrelationship of Pressure, Flow, Resistance within cardiovascular
system .
- Mechanical energy in the circulatory system produced by contraction of
the heart & movement of blood. The energy is transmitted throughout
blood vessels in series of pauses or waves which is displayed on Pressure
Monitor. The configuration of pressure wave form varies in each part of
the vascular system.

18. Systems in H.d.m :
Pressure monitoring system
Fluid filled system

19. A.PRESSURE MONITORING SYSTEM
A. Components of electrical system used for processing & display of
pressure waveform & obtaining derived HD parameters
• Amplifier-INCREASES OR AMPLIFIES THE SIGNAL FROM the
transducer
• Monitor – display of signal on monitor as a pressure wave form&
numerically in digital display
• Processor
• Recorder- document the pressure waveform on paper

20. B.FLUID FILLED SYSTEM:
• It carries the mechanical signals from the patients vascular system to the
transducer
• Vascular catheter
• Non compliant pressure tubing to transport pressure signals
• A flush device that allows continuous & manual flushing of the catheter tubing
system
• Stopcock-2-3
• Flush solution of NaCl with heparin to maintain patency of catheter
• Infusion pressure bag (300 mm of Hg) to allow the continuous flush device to
deliver a rate 1-3 ml /hour.
These components are disposable discarded after use to prevent infection.

21. COMPONENTS OF A HEMODYNAMIC
MONITORING SYSTEM:
There ARE FOUR COMPONENTS of a hemodynamic monitoring system.
1. CATHETER & PRESSURE TUBING The tubing must have a continuous flush
device as well as a manual one with transducer.
2. TRANSDUCER is needed which changes the mechanical energy or the pressures of
pulse into electrical energy. The pressure cable that carries information from the transducer
to the amplifier.
3. AMPLIFIER is located inside the bedside monitor. It increases the size of signal from the
transducer.
4. PRESSURE MONITOR (recorder )to display the signal and record information.
5. FLUSH SYSTEM

23. • CATHETER & PRESS TUBING
- Connected to Fluid, Fluid tubing
- Large internal diameter that allows the mechanical energy to press out of the vessels
without obstruction.
- Catheter is connected to Pressure tubing that has rigid walls & resist expansion &
contractions
- Rigidity minimizes the amount of energy lost in transmission of the pulse.
• TRANSDUCER
- it converts mechanical energy into electrical signals. The mechanical energy is
transmitted through the pressure tubing into the diaphragm of the transducer.
The diaphragm vibrates & produces the electrical signals that are amplified by the
monitor

24. • PRESSURE MONITOR
Waveform of the pulse is displayed on the OSCILLOSCOPE. Wave form vary in
amplitude depend on the pressure within the system.
each monitor has various pressure scale e.g. 0-60,0-100,0-200 mm of Hg.monitor
should be used appropriately to see clearly all the wave forms.
low pressure system monitor like 0-60 mm of Hg is best for pulmonary artery, Lt atrial
pressure etc
High pressure system monitor like 0-200 mm of Hg is best for Blood pressure .
• FLUSH SYSTEM
Heparin in a concentration of 1to5 units /ml is added to a bag of Normal saline
solution placed under 300 mm of Hg pressure by means of pressure bag & connected to
flush device. Heparin is added to prevent clot forming all around the catheter tip
Counter pressure from the bag is required to prevent the backflow.

25. OBTAINING MEASUREMENT
RELIABLE MEASUREMENTS :
RELIABLE MEASUREMENTS
• Level = Phlebostatic axis (4th intercostal space, midaxillary line)
• Balance = zero reference (negates atmosphere pressure)
• Calibration = numerical accuracy
• How often to check?
Re-leveling to be done at every shift, bed level changes or any
troubleshooting time

26. FIVE STEPS IN OBTAINING RELIABLE
MEASUREMENTS
• Step I Zeroing the catheter tubing – Transducer system
• Step- II Define the reference position – Phlebostatic axis
• Step-III Leveling to the Phlebostatic axis
• Step-IV- Assessing the sensitivity of the Transducer
• Step-V- Optimizing Dynamic Response Characteristics

27. Step I :Zeroing the catheter tubing – Transducer system
Zero the transducer one stopcock is opened to the atmosphere & that pressure is read to Zero & leveled
the transducer
Pressure is not adjusted to Zero then minor adjustment can be made in reading. Transducer must be
leveled to the position of Right Atrium(Phlebostatic axis) or External reference point
• Draw imaginary first line between 4th Intercostals space at the sternum to the side of the chest.
• 2nd line down at the mid chest position then point of intersection is marked on the patients chest.
• Used thereafter for obtaining reading.
• Transducer lower than point-pseudo elevated pressure
• Transducer Higher than point-pseudo low pressure

28. Step- II: Define the reference position – Phlebostatic axis
• Draw imaginary first line between 4th Intercostals space at the sternum
to the side of the chest.
• 2nd line down at the mid chest position then point of intersection is
marked on the patients chest.

29. Step-III :Leveling to the Phlebostatic axis
• Transducer must be leveled to the position of
Right Atrium (Phlebostatic axis) or External
reference point
• Used thereafter for obtaining reading.
• Transducer lower than point-pseudo elevated pressure
• Transducer Higher than point-pseudo low pressure

30. Step-IV- Assessing the sensitivity of the Transducer
Calibration of the pressure monitoring system is performed to
assess sensitivity of the transducer & verify the monitoring
system is converting mechanical signals of pressure into
electronic signals
This is performed at the time of set up of the system or during
any troubleshooting

31. Step-V: Optimizing Dynamic Response Characteristics
• Optimizing Dynamic Response means presence of 2 or 3 rapid
oscillations from top to bottom of the pressure tracing
• Optimizing Dynamic Response of the catheter
tubing transducer system is performed by activation of fast flush
device.(pressing spring loaded liver or pulling the elastic cord)
• Square wave on monitor display

32. LEVELS OF HDMINTENSITY
Depends upon clinical need of the patient
The simplest level includes
HR
Cvp
Arterial blood pressure
Intense level of HDM includes complex levels are
Pulmonary artery pressure
Pulmonary artery wedge capillary pressure
Cardiac output

33. methods OF HEMODYNAMIC MONITORING:
• 1.NON INVAISVE –
 HEART RATE
 BLOOD PRESSURE
 TEMPERATURE
 MENTAL STATUS
 CAPILLARY REFILL
 URINE OUTPUT
 PULSE OXYMETRY

34. • 2. INVASIVE:
CENTRAL VENOUS PRESSURE
ARTERIAL BLOOD PRESSURE
PULMONARY PRESSURE MONITORING

36. What is CVP ?
• The central venous pressure (CVP) is the pressure measured in the
central veins close to the heart. It indicates mean right atrial pressure
and is frequently used as an estimate of right ventricular preload.
• CVP reflects the amount of blood returning to the heart and the
ability of the heart to pump the blood into the arterial system.
• It is the pressure measured at the junction of the superior vena cava
and the right atrium.
• It reflects the driving force for filling of the right atrium & ventricle.

37. Purposes:
Clinical Utility:
Central venous pressure (CVP)
Indirectly:
• Right atrial pressure
• Right ventricular end-diastolic pressure
Relationship between intravascular volume and right ventricular
function

38. Indications:
Secure access:
• Fluid therapy
• Drug infusions
• Parenteral nutrition
Central venous pressure (CVP) monitoring
Assess RAP or CVP
Rt Ventricular Function
Others:
• Aspirate air emboli (neurosugery)
• Cardiac pacemaker placement
• Hemodialysis

39. contraindicATIONS:
Absolute
• Superior venacaval syndrome - neck, subclavian & upper extremities pressure is increased
Relative
• Vessel thrombosis
• Infection
• Bleeding diathesis/anti-coagulant therapy
• Right atrium/ ventricles tumor
• Clot

40. Relationship between water manometer and
calibrated transducer :
In terms of pressure
1cm H2O = 0.73 mmHg.
1 mmHg = 1.36 cm H2O.

41. Methods to measure CVP:
Fluid filled manometer connected to central
venous catheter.
Calibrated transducer.

42. Methods to measure CVP contd...
1. Fluid filled manometer connected to central venous catheter :
CVP is measured using a column of water in a marked manometer.
 CVP is the height of the column in cms of H2O when the column is at
the level of right atrium.
• Advantage: Simplicity to measure.
• Disadvantage: 1) Inability to analyze the CVP waveform.
2) Relatively slow response of the water column to changes in
intrathoracic pressure.

43. PROCEDURE:
• With the CV line in place, position the patient flat.
• Because CVP reflects right atrial pressure, you must align the right atrium (the zero
reference point) with the zero mark on the manometer.
• To find the right atrium, locate the fourth intercostal space at the midaxillary line.
• Mark the appropriate place on the patient’s chest so that all subsequent recordings will be
made using the same location.
• If the patient can’t tolerate a flat position, place him in semi-Fowler’s position.

44. • When the head of the bed is elevated, the phlebostatic axis remains constant but
the midaxillary line changes.
• Use the same degree of elevation for all subsequent measurements.
• Attach the water manometer to an I.V. pole or place it next to the patient’s chest.
• Make sure the zero reference point is level with the right atrium.

46. • Verify that the water manometer is connected to the I.V. tubing. Typically, markings
on the manometer range from –2 to 38 cm H2O.
• However, manufacturer’s markings may differ, so be sure to read the directions before
setting up the manometer and obtaining readings.
• Turn the stopcock off to the patient, and slowly fill the manometer with I.V. solution
until the fluid level is 10 to 20 cm H2O higher than the patient’s expected CVP value.
• Don’t overfill the tube because fluid that spills over the top can become a source of contamination

47. • Turn the stopcock off to the I.V. solution and open to the patient.
• The fluid level in the manometer will drop.
• When the fluid level comes to rest, it will fluctuate slightly with respirations.
• Expect it to drop during inspiration and to rise during expiration.
• Record CVP at the end of expiration, when intrathoracic pressure has a negligible effect.
• Depending on the type of water manometer used, note the value either at the bottom of the meniscus at the
midline of the small floating ball.
• After you’ve obtained the CVP value, turn the stopcock to resume the I.V. infusion.
• Adjust the I.V. drip rate as required.
• Place the patient in a comfortable position.

48. 2. Calibrated transducer
• Automated, electronic pressure monitor.
• Pressure wave form displayed on an oscilloscope or paper.
Advantages
 More accurate.
 Direct observation of waveform.

50. • Make sure the stopcock is turned so that the I.V. solution port, CVP column port, and
patient port are open.
• Be aware that with this stopcock position, infusion of the I.V. solution increases CVP.
• Therefore, expect higher readings than those taken with the stopcock turned off to
the I.V. solution.
• If the I.V. solution infuses at a constant rate, CVP will change as the patient’s
condition changes, although the initial reading will be higher.
• Assess the patient closely for changes.

51. • Make sure the CV line or the proximal lumen of a pulmonary artery catheter is
attached to the system.
• (If the patient has a CV line with multiple lumens, one lumen may be dedicated to
continuous CVP monitoring and the other lumens used for fluid administration.)
• Set up a pressure transducer system.
• Connect noncompliant pressure tubing from the CVP catheter hub to the transducer.
Then connect the flush solution container to a flush device.
• To obtain values, position the patient flat.
• If he can’t tolerate this position, use semi-Fowler’s position.

52. • Locate the level of the right atrium by identifying the phlebostatic axis.
• Zero the transducer, leveling the transducer air-fluid interface stopcock with the right
atrium.
• Read the CVP value from the digital display on the monitor, and note the waveform.
• Make sure the patient is still when the reading is taken to prevent artifact.
• Be sure to use this position for all subsequent readings.

65. Complications of cvp monitoring:
• Hemorrhage
• Pneumothorax (which typically occurs upon catheter insertion)
• Sepsis
• Thrombus
• Vessel or adjacent organ puncture
• Air embolism
• Skin infection and necrosis

66. Documentation:
• Document all dressing, tubing, and solution changes.
• Document the patient’s tolerance of the procedure,
• the date and time of catheter removal, and the type of dressing applied.
• Note the condition of the catheter insertion site and whether a culture
specimen was collected.
• Note any complications and actions taken.

67. ARTERIAL BLOOD PRESSURE
MONITORING

68. Measurement of arterial blood pressure
• Indirect cuff device
• manual intermittent technique
• automated intermittent technique
• automated continous technique
• . Direct arterial cannulation and pressure transduction
• percutaneous radial artery cannulation
• alternative arterial pressure monitoring sites

69. Invasive Blood pressure monitoring
• Invasive blood pressure monitoring is a commonly used
technique in the operation theater and in the ICU.
• It involves insertion of catheter in to the suitable artery
and then displaying the measured pressure wave on a
monitor .

70. INDICATIONS:
• Continuous real time blood pressure monitoring
• Planned pharmacologic or mechanical cardiovascular manipulation
• Repeated blood sampling
• Failure of indirect arterial blood pressure measurement
• Supplementary diagnostic information from the arterial wave form .
• Determination of volume responsiveness from systolic pressure or
pulse pressure variation

71. Complications:
• Distal ischemia
• Hemorrhage , hematoma
• Arterial embolism
• Local infection and sepsis.
• Peripheral neuropathy .
• Misinterpretation of data.
• Misuse of equipment

72. Components of an iabp measuring system:
• Intra arterial cannula
• Fluid filling tube
• Transducer
• Infusion and flushing system
• Signal processor and amplifier and display

73. 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

74. 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

75. • 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.

76. 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.

77. • 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

78. Sites for arterial lines:
• Radial Artery(most frequently used)
• Brachial Artery
• Femoral Artery

79. PULMONARY PRESSURE
MONITORING

80. PULMONARY ARTERY PRESSURE (PAP)
• The pulmonary artery flow directed balloon tipped catheter
was introduced in 1970.
• The pressure is monitored by Swan Ganz catheter.
• It is Quadruple lumen, provides valuable information about
left ventricle function. it gives measurements of pulmonary
artery systolic & diastolic & mean arterial pressure, pulmonary
artery wedge pressure etc.
• The catheter is allowed to move into the pulmonary artery.

81. PULMONARY PRESSURE MONITORING:
• Pulmonary artery pressure monitoring is an important tool
used in critical care for assessing various cardiac pressures
along with left ventricular function, diagnosing and
evaluating the patient’s response to medical interventions
(e.g, fluid administration, vasoactive medications).
Pulmonary artery pressure monitoring is achieved by using a
pulmonary artery catheter and pressure monitoring system.

82. 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”.

83. SWAN GANZ CATHETER:

84. SWAN GANZ COMPONENTS:

85. Pulmonary Artery Catheter
FOUR PORTS
1. The proximal port can be used to measure central venous pressure
2. Injectate port during the measurement of cardiac output.
3. Distal port which is connected to pressure line .
4. A balloon port is also present where a 1.5-ml special syringe is
connected. This is used during the determination of pulmonary artery
wedge pressure. No more than 1.5 ml of air should ever be injected
into a pulmonary artery catheter during wage determination.

86. SWAN GANZ PLACEMENT:

87. RISKS WITH SWAN GANZ:
 Bleeding
 Infection
 Dysrhythmias
 Pulmonary Artery Rupture
 Pneumothorax
 Hemothorax
 Valvular Damage
 Embolization
 Balloon Rupture
 Catheter Migration

88. RA WAVEFORM:
Normal Value 0-8
mmHg
RAP = CVP
Wave Fluctuations
Due To Contractions

89. RV WAVEFORM
Normal Value 15-25/0-8
mmHg
Catheter In RV May Cause
Ventricular Ectopy
Swan Tip May Drift From
PA to RV

90. PA WAVEFORM
Normal Value 15-25/8-15
mmHg
Dicrotic Notch Represents
PV Closure
PAD Approximates PAWP
(LVEDP)
(in absence of lung or MV
disease)

91. PAWP WAVEFORM
Normal Value 8-12 mmHg
Balloon Floats and Wedges
in Pulmonary Artery
PAWP = LAP = LVEDP
Wedging Can Cause
Capillary Rupture

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

93. RESPIRATORY VARIATION:
• SPONTANEOUS
• Intrathoracic pressure  decreases during spontaneous inspiration
 (ventilation)
• This presents a negative () deflection on a PAWP tracing
• Intrathoracic pressure  increases during spontaneous expiration 
• This present a positive () deflection on a PAWP tracing

94. RESPIRATORY VARIATION:
• POSITIVE PRESSURE VENTILATION:
• Intrathoracic pressure  increases during positive pressure
ventilation  (ventilator breaths)
• This presents a positive () deflection on a PAWP tracing
• Intrathoracic pressure  decreases during positive pressure
expiration 
• This present a negative () deflection on a PAWP tracing

95. TROUBLE SHOOTING
• OVER DAMPED PRESSURE TRACING
• UNDER DAMPED PRESSURE TRACING
• MIGRATION OF PA CATHETER INTO THE RIGHT
VENTRICLE
• ABSENCE OF PAWP TRACING
• OVERWEDGING

96. CARDIAC OUTPUT
Cardiac output is the volume of blood pumped by the
heart per minute (mL blood/min). Cardiac output is a
function of heart rate and stroke volume. The heart rate
is simply the number of heart beats per minute. The
stroke volume is the volume of blood, in ml, pumped out
of the heart with each beat.

97. CARIAC OUTPUT MEASUREMENT BY
THERMODILUTION
Trans pulmonary thermodilution, which uses the stewart-hamilton
principle but measures temperatures changes from central venous line to a
central arterial line, i.e., The femoral or axillary arterial line, is used as the
calibrating technique. The Q value derived from cold-saline
thermodilution is used to calibrate the arterial PP contour, which can then
provide continuous Q monitoring.

99. Hemodynamic Monitoring consists of:
A. Non-Invasive
B. Invasive
C. Both
D. None of the above

100. Invasive monitoring consists of:
A. Blood pressure cuff
B. Arterial and/or pulmonary artery catheter
C. ECG leads
D. Mechanical ventilation

101. Arterial line insertion sites are:
A. Brachial
B. Radial
C. Internal Jugular
D. Femoral
E. Subclavian

102. The purpose of arterial lines are to:
A. Obtain frequent arterial blood gases
B. Infuse mediations
C. Monitor CVP
D. Monitor blood pressures continuously

103. • The purpose of pulmonary artery catheters are to:
• Measure cardiac pressures
• Infuse fluids
• Obtain ABG
• Infuse injections
• None of the above

104. Pulmonary artery catheters may be inserted at which of the following sites:
A. IJV
B. Femoral
C. Radial
D. Brachial
E. Subclavian

105. Which of the following measures left ventricular preload?
A. SVR
B. Wedge
C. CVP
D. LVSWI

106. Which of the following measures preload?
A. CVP
B. SVR
C. RAP
D. LVSWI
E. PAWP

107. Which of the following measures contractility?
A. CVP
B. SVR
C. RAP
D. Ejection fraction
E. PAWP

108. THANK YOU