Hemodynamic Monitoring

Part I

(ABP, CVP, Ao)

MICU Competencies
2006-2007

1
 What is Hemodynamic Monitoring?

Non-invasive = clinical assessment & NBP

Direct measurement of arterial pressure

Invasive hemodynamic monitoring

2
 Noninvasive Hemodynamic Monitoring

Noninvasive BP Skin Temperature

Heart Rate, pulses

Capillary Refill

Mental Status
Urine Output

Mottling (absent)

3
Proper Fit of a Blood Pressure Cuff

Width of bladder = 2/3 of upper arm

Length of bladder encircles 80% arm

Lower edge of cuff approximately 2.5 cm

above the antecubital space

4
 Why A Properly Fitting Cuff?

Too small causes false-high reading

Too LARGE causes false-low reading

5
 Indications for
Arterial Blood Pressure

Frequent titration of vasoactive drips

Unstable blood pressures

Frequent ABGs or labs

Unable to obtain Non-invasive BP

6
 Supplies to Gather

Arterial Catheter
Pressure Bag
Pressure Tubing
Flush 500cc NS
Pressure Cable

7
 Supplies to Gather

Sterile Gown (2) Suture (silk 2.0)

Sterile Towels (3) Chlorhexidine Swabs

Sterile Gloves Mask

8
 Leveling and Zeroing

Leveling
Before/after insertion
If patient, bed or transducer move

Zeroing
Performed before insertion & readings

Level and zero at the insertion site

9
 Potential Complications
Associated With Arterial Lines
Hemorrhage

Air Emboli

Infection

Altered Skin Integrity

Impaired Circulation
10
 Documentation

Insertion procedure note

ABP readings as ordered

Neurovascular checks every two hours

(in musculoskeletal assessment of HED)

Pressure line flush amounts (3ml/hr)

Tubing and dressing changes

11
Central Venous Pressure Assesses . . .

Intravascular volume status

Right ventricular function

Patient response to drugs &/or fluids

12
 Central Venous Pressure (CVP)
Central line or pulmonary artery catheter

Normal values = 2 8 mm Hg

Low CVP = hypovolemia or venous return

High CVP = over hydration, venous return,

or right-sided heart failure

13
 Leveling and Zeroing

Leveling
Before/after insertion
After patient, bed or transducer move
Aligns transducer with catheter tip

Zeroing
Performed before insertion & readings

Level and zero transducer at the phlebostatic

axis
14
 Phlebostatic Axis

4th intercostal space, mid-axillary line

Level of the atria

(Edwards Lifesciences, n.d.)

15
 More on Leveling and Zeroing

HOB 0 60 degrees

No lateral positioning

Phlebostatic axis with

any position (dotted line)

(Edwards Lifesciences, n.d.)

16
Dynamic Flush

Dynamic flush ensures the integrity

of the pressure tubing system.
Notice how it ascends - forms a
square pattern - and bounces below
the baseline before returning to
the original waveform.
Check dynamic flush after zeroing
any pressure tubing system

17
 System Maintenance

Change tubing and fluid bag q 96hrs

No pressors through CVP port

Antibiotics, NS boluses, blood, & IV pushes

are allowed through the CVP line

18
 Troubleshooting

Improper set-up and equipment malfunction

are the primary causes for hemodynamic
monitoring problems

Retracing the set-up process or tubing

(patient to monitor) may identify the problem
and solution quickly

Use your staff resources: Help All, Charge

Nurse, Educator, Preceptors, MICU experts

19
 Troubleshooting
Damped Waveforms

Pressure bag inflated to 300 mmHg

Reposition extremity or patient

Verify appropriate scale

Flush or aspirate line

Check or replace module or cable

20
 Troubleshooting

Inability to obtain/zero waveform

Connections between cable & monitor

Position of stopcocks

Retry zeroing after above adjustments

21
 Continuous Airway Pressure (Ao)

Also known as Paw, Ao

Purpose:
Improves accuracy of hemodynamic
waveform measurements
Identification of end-expiration

Positive waveform deflections = positive

pressure ventilation

Negative deflections = spontaneous

inspiratory effort 22
 Supplies to Gather

Pressure Cable

Pressure Tubing

Connector
(Edwards Lifesciences, n.d.)

23
 Setting up the Ao

Discard infusion spike end & cap port

Connect pressure tubing to vent tubing

(using connector opposite heating cable)

Connect cables

Zero the tubing (leveling not necessary)

24
 Troubleshooting Ao

Do not prime tubing with fluids!

Damping will occur with fluid or secretions

To evacuate any fluids, disconnect pressure

tubing from vent tubing and push air through
the pressure tubing with a 10 ml syringe
connected at one end until fluid-free

25
 Pressure Measurement
1) Record Ao and CVP on the same strip
2) Find end-expiration by drawing a vertical line with a straight edge 200 ms prior to the rise or dip in Ao (1 large box)
associated with a breath.
3) Draw a horizontal line through the visually assessed average vascular pressure starting at end-expiration going backward
200 ms (1 large box).
4) Read the pressure at the horizontal line.

15
10
5
0
5
CVP=13

26
 Assist-Control

200 ms

{
Ao

{
CVP 200 ms
27
 CPAP with Pressure Support

200 ms

{
Ao

{
CVP 200 ms
28
 CPAP without Pressure Support

200 ms

{
Ao

{
CVP 200 ms
29
 Incorrect method!
This point was
40 identified as end-
30
20
expiration for a pt.
10 who did not have an
0 Ao set up.
10

Correct method!
30 sec after the above
tracing, Ao was added & true
end-expiration clearly
identified.
30
 Same patient 20 minutes later

4040
3030
2020
1010
00
10
10

31

15
10
5
0
5

CVP=13

32
 Summary

Record Ao with CVP

Read mean CVP at end-expiration as

described. No need read vascular pressure at
any particular time in the cardiac cycle

33
 Documentation of CVP

Include on waveform strip

Position of the HOB
Vasopressors and rates
Amount of PEEP
Scale
CVP measurement
Signature of the nurse

(post in green chart behind graphics tab)

34
 References & Resources

Burns, S. M. (2004). Continuous airway pressure monitoring. Critical Care Nurse, 24(6), 70-74.

Chulay, M., & Burns, S. M. (2006). AACN Essentials of critical care. McGraw-Hill: New York.

Edwards. (2006). Pulmonary Artery Catheter Educational Project. http://www.pacep.org

Edwards Lifesciences. (n.d.) Educational videos. www.edwards.com

MICU Routine Practice Guidelines. www.vanderbiltmicu.com

MICU Bedside Resource Books

MICU Education Kits (Red cart in conference room)

MICU Preceptors, Help All Nurses, & Charge Nurses

VUMC policies. http://vumcpolicies.mc.vanderbilt.edu

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