HEMODYNAMICS

In the CRITICAL CARE UNIT

Sherry L. Knowles, RN, CCRN, CRNI

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.

OBJECTIVES
Upon completion of this program the student will be able to: ` ` ` ` ` ` ` ` Define Basic Hemodynamics Understand The Risks and Benefits Identify PA Catheter Components Analyze Cardiac Profiles Interpret Shock States Learn Appropriate Interventions Describe How To Optimize Cardiac Output Recognize Potential Complications

OBJECTIVES
Upon completion of this program the student will be able to:
` Collect appropriate equipment/supplies necessary to set-up a transducer pressure system. ` State the correct solutions/medications used at Kaiser Vallejo for the flush bags. ` Correctly level and zero the transducer. ` Correctly identify the location and purpose of each port/ lumen of the PA catheter ` Identify in sequence the normal waveforms observed during PA catheter insertion, and state the corresponding pressure. ` Correctly obtain the following pressures: y y y Pulmonary artery systolic, diastolic and mean Pulmonary capillary wedge. Central venous pressure.

` Briefly describe the indications, limitations and complications of PA catheterization, guidelines for accurate monitoring, and troubleshooting techniques.

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

CONTRAINDICATIONS
` Tricuspid or pulmonary valve mechanical prosthesis ` Right heart mass (thrombus and/or tumor) ` Tricuspid or pulmonary valve endocarditis

SWAN-GANZ CATHETERS

` The Cordis Offers A Large Bore Infusion Port ` There Are Ten Types Of Swan-Ganz Catheters ` VIP Catheter Has Three Other Infusion Ports ` Large Markers = 50cm, Small Markers = 10cm

SWAN GANZ CATHETER

SWAN GANZ COMPONENTS

SWAN GANZ PLACEMENT

SWAN GANZ PLACEMENT

RISKS WITH SWAN GANZ

` Bleeding ` Infection ` Dysrhythmias ` Pulmonary Artery Rupture ` Pneumothorax ` Hemothorax ` Valvular Damage ` Embolization ` Balloon Rupture ` Catheter Migration

INSERTION EQUIPMENT
EQUIPMENT NECESSARY FOR INSERTION f Flush solution for transducer system f Flush solution for cardiac output system f Arterial access line f Disposable triple pressure transducer system f Pulmonary artery catheter f Monitor, module, electrodes, cables f Central line kit f Transducer holder, I.V. pole, pressure bag f Emergency resuscitation equipment f Prepackaged Introducer Kit; sutures f Sterile gowns, gloves, and masks

RA WAVEFORM

` Normal Value 0-8 mmHg ` RAP = CVP ` Wave Fluctuations Due To Contractions

RV WAVEFORM

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

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)

PAWP WAVEFORM

` ` ` `

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

PA INSERTION WAVEFORMS
A B

` ` ` `

A= B= C= D=

RA (CVP) Waveform RV Waveform PA Waveform PAWP Waveform

PA CATHETER WAVEFORMS

A wave - due to atrial contraction. Absent in atrial fibrillation. Enlarged in tricuspid stenosis, pulmonary stenosis and pulmonary hypertension. C wave - due to bulging of tricuspid valve into the right atrium or possibly transmitted pulsations from the carotid artery. X descent - due to atrial relaxation. V wave - due to the rise in atrial pressure before the tricuspid valve opens. Enlarged in tricuspid regurgitation. Y descent - due to atrial emptying as blood enters the ventricle. Canon waves - large waves not corresponding to a, v or c waves. Due to complete heart block or junctional arrhythmias.

PA INSERTION SEQUENCE

POST INSERTION
1. 2. 3. 4. 5. 6. 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). 7. Obtain opening pressures and wave form tracings for each waveform. 8. Assess length at insertion site. 9. 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). 10. Update physician of abnormalities.

ZEROING & REFERENCING

` Zeroing is performed by opening the system to air to establish atmospheric pressure as zero.

` Referencing is accomplished by placing the air-fluid interface of the catheter (the transducer) at the phlebostatic axis.

PHLEBOSTATIC AXIS

RESPIRATORY VARIATION
SPONTANUOUS VENTILATION:
` 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

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

RESPIRATORY VARIATION
Spontaneous Breathing

RESPIRATORY VARIATION

END EXPIRATION

RAP WAVEFORM
RAP WAVEFORM

(CVP) RA WAVEFORM & ECG

(CVP) RA WAVEFORM
(CVP) RA WAVEFORM

WEDGING THE CATHETER

PAWP TRACING
PAWP WAVEFORM

PAWP WAVEFORM
PAWP WAVEFORM

PA vs PAWP WAVEFORM
PA vs PAWP WAVEFORM

PAWP WAVEFORM & ECG

PAWP WAVEFORM

PAWP WAVEFORM
PAWP WAVEFORM

V WAVES
PAWP WAVEFORM

PAWP WITH V WAVES

SVO2 MONITORING

SVO2 MONITORING
` Normal Values: 60-75% ` Decreased () SVO2 Values Indicate
Increased Extraction From Decreased Oxygen Delivery or From Increased Oxygen Demands

POTENTIAL COMPLICATIONS
POTENTIAL COMPLICATIONS
Same as arterial pressure monitoring plus the following:
Air emboli Thromboembolism Catheter displacement Infection Inaccurate pressures Equipment malfunction Pneumothorax/Hemothorax Loss of balloon integrity Pulmonary artery extravasation Air emboli Cardiac tamponade Dysrhythmias Balloon rupture Lung ischemia Electromicroshock Pulmonary artery rupture Frank Hemorrhage Altered skin integrity PA hemorrhage or infarction Cardiac arrest

POTENTIAL COMPLICATIONS

` Wedging Can Cause Capillary Rupture ` Catheter In RV Can Cause Ventricular Ectopy ` Swan Tip Can Drift From PA to RV

PERICARDIAL TAMPONADE
` Hemodynamic monitoring can diagnose tamponade: ` Pericardial tamponade presents with equalization of the diastolic pressures on the left and right side of the heart ` Other PAP signs of pericardial tamponade include:
Elevated right atrial pressure Kussmaul sign (increase in right atrial pressure with inspiration) Pulsus Paradoxus Elevated right atrial pressure (RAP) Pulmonary artery diastolic pressure (PAD) = mean right atrial pressure(RA) = right ventricular (RV) diastolic pressure = mean wedge pressure

PRECAUTIONS
1) Always set alarms, approximately 20 mmHg above and below the patients readings. 2) If balloon is down and you find PA catheter tracing in wedge position, you may ask the patient to deep breathe and cough, or reposition patient in bed to dislodge it. 3) If unable to dislodge catheter from wedge position by above measures notify physician immediately to reposition catheter by pulling back gently; then, get chest x-ray to confirm proper placement. 4) If patient coughs up blood or it is suctioned via endotracheal tube, suspect PA rupture and notify physician immediately.

TROUBLESHOOTING

NORMAL VALUES
` Right Atrial Pressure (CVP) = 0-8 mm Hg ` Pulmonary Artery Pressure = 15-25 / 8-15 mm Hg ` Pulmonary Artery Wedge Pressure = 8-12 mm Hg ` Left Ventricular Diastolic Pressure = 8-12mm Hg ` Stroke Volume = 50-100 ml/beat ` Cardiac Output = 4-8 L/min ` Cardiac Index = 2.5-4.0 L/min M2 ` SVO2 = 0.60-0.75

DAMPENED PA WAVEFORM
PAWP WAVEFORM

ALTERATIONS IN SVO2

ALTERATIONS IN SVO2

OPTIMIZING CARDIAC OUTPUT

` Optimize HR and SV (Stroke Volume) ` Stroke Volume =

PRELOAD AFTERLOAD CONTRACTILITY

` ` ` ` ` Chronotropic Medications Diuretics / Volume Vasodilators / Vasoconstrictors Inotropic Medications (Positive or Negative) IABP

CARDIAC PROFILES
` Shock States
Cardiogenic Shock Hypovolemic Shock Septic Shock Anaphylactic Shock

` ` ` `

Cardiac Tamponade Left Ventricular Failure Right Ventricular Failure Pulmonary Hypertension

SHOCK PARAMETERS
Parameter CVP/ AP PAWP CO BP SV H Normal or Norm Hy v lemic Car i enic Neur enic Anaphylactic Early Septic Late Septic

Cardiogenic Shock is the only shock with PAWP. Early (Hyperdynamic) Shock is the only shock with CO and SVR. Neurogenic Shock is the only shock with bradycardia. Anaphylactic Shock has the definitive characteristic of wheezing due to bronchospasm.

TREATMENTS

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SUMMARY

` Hemodynamic monitoring measures factors that influence the force and flow of blood. ` Hemodynamic monitoring aids in diagnosing, monitoring and managing critically ill patients.

THE END

REFERENCES
` ` AACN (American Association of Critical Care Nurses). Clinical Care References. 2002 SCCM (Society of Critical Care Medicine. PACEP (Pulmonary Artery Catheter Education Project). 701 Lee Street, Suite 200, Des Plaines, Illinoise 60016. 2000. Bridges, EJ, and Woods, SL. Pulmonary artery pressure measurement: State of the art. Heart Lung 1993; 22:99. Mirini, JJ. Pulmonary artery occlusion pressure: Clinical physiology, measurement and interpretation. Am Rev Respir Dis 1983; 128:319. Putterman, C. The Swan-Ganz catheter: A decade of hemodynamic monitoring. J Crit Care 1989; 4:127. Nemens, EJ, Woods, SL. Normal Fluctuations in pulmonary artery and pulmonary capillary wedge pressures in acutely ill patients. Heart Lung 1982; 11:393. Darovic, G.O., (1995) Hemodynamic monitoring: invasive and noninvasive clinical application (2d ed), New York: W. B. Saunders

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