Arterial Line

Because intraarterial cannulation allows continuous, beat-to-beat blood pressure

measurement, it is considered the gold standard of blood pressure monitoring
techniques. The quality of the transduced waveform, however, depends on the
dynamic characteristics of the catheter-tubing-transducer system.
The addition of tubing, stopcocks, and air in the line all decrease the frequency of
the system. If the frequency response is too low, the system will be
overdamped and will not faithfully reproduce the arterial waveform,
underestimating the systolic pressure. Underdamping is also a serious
problem, leading to overshoot and a falsely high SBP

CVP MONITORING

a waves: from atrial contraction, absent if atrial fibrillation; Cannon a waves are
due to the atrium contracting against a closed tricuspid valve, as during
atrioventricular dissociation.
c waves : tricuspid valve elevation during early ventricular contraction;
x descent: downward displacement of Tricupsid during systole
v waves: venous return against a closed tricuspid valve;
y descent: tricuspid opening during diastole.

Indications

Measurement of the right heart filling pressures to assess intravascular volume and right
heart function.
Drug administration to the central circulation.

Intravenous access for patients with poor peripheral access.

Indicator injection for cardiac output determination (e.g., green dye cardiac output).

Access for insertion of pulmonary artery catheter.

Swan Tracing

Indications:

Unexplained hypotension.
Access for cardiac pacing.

Surgical procedures with significant physiologic changes (e.g., open aortic aneurysm
repair, lung or liver transplant).

Acute myocardial infarction with shock.

The PAC should be used only if the potential benefit of diagnosis or guidance in
treatment outweighs the risks of complications. The PAC should be discontinued once
active measurement is no longer necessary.

Thermodilution
Typically, 10 mL of cold (room temperature or less) saline or 5% dextrose in water is injected into
the CVP port over 4 seconds and the change in temperature is monitored at the thermistor located
at the tip of the catheter within the main pulmonary artery. The area under the bell-shaped

temperature-time curve is inversely proportional to the blood flow and correlates with the cardiac
output in the absence of intracardiac shunting. Injectate spillage, very slow injection, or use of the
wrong catheter constant produces errors in measured cardiac output. TR tends to

underestimate the cardiac output/cardiac index by prolonging and increasing the area
under the cardiac output curve, although values may be erroneously high as well.
Intracardiac shunting will produce erroneous cardiac output measurements.
Factors Influencing the Accuracy of Thermodilution Cardiac Output Measurement

Intracardiac shunts
Tricuspid or pulmonic valve regurgitation
Inadequate delivery of thermal indicator
Central venous injection site within the catheter introducer sheath
Warming of iced injectate
Thermistor malfunction from fibrin or a clot
Pulmonary artery blood temperature fluctuations
Postcardiopulmonary bypass status
Rapid intravenous fluid administration
Respiratory cycle influences
Swan Formulas

SVO2
A decrease in SvO2 is the result of either decreased cardiac output, decreased hemoglobin, increased
oxygen consumption, or decreased Sao2.
Oxygen Delivery

Table 40-2 -- Normal Cardiovascular Pressures

Pressure

Average (mm Hg)

Range (mm Hg)

a wave

2-7

v wave

2-7

Mean

1-5

Peak systolic

25

15-30

End-diastolic

1-7

Peak systolic

25

15-30

End-diastolic

4-12

Mean

15

9-19

Right Atrium

Right Ventricle

Pulmonary Artery

Pulmonary Artery Wedge

Mean

4-12

a wave

10

4-16

v wave

12

6-21

Mean

2-12

130

90-140

Left Atrium

Left Ventricle
Peak systolic

Pressure

Average (mm Hg)

Range (mm Hg)

End-diastolic

5-12

Peak systolic

130

90-140

End-diastolic

70

60-90

Mean

90

70-105

Central Aorta

TEE
20 views

LV Function/Assesment

MITRAL VALVE ASSESMENT