Lec # 6 hemodynamic monitoring

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  • ALWAYS EXPLAIN ANY PROCEDURE TO THE PATIENT
    HOW DO WE DO THIS?
    WHY DO WE LIE THE PATIENT SUPINE?
    OFF TO PATIENT OPEN TO AIR AND PRESS ZERO ON THE MONITOR. THIS REMOVES EXTRANEOUS PRESSURE
    TO ENSURE A CORRECT TRACE
  • Lec # 6 hemodynamic monitoring

    1. 1. HEMODYNAMIC MONITORING By Yasmeen Rahim
    2. 2. OBJECTIVES By the end of this session, learners will be able to:  Define what is hemodynamic monitoring.  List down the importance of hemodynamic monitoring in hospital.  Discuss about pressure monitoring system.  Identify troubleshooting in the pressure monitoring system.
    3. 3. CONT.  Explain in detail about arterial pressure monitoring, central venous pressure monitoring and pulmonary artery pressure monitoring.  Evaluate oxygen delivery and demand.
    4. 4. HEMODYNAMIC MONOTORING  It is the study of interrelationship of blood pressure, blood flow, vascular volumes, heart rate, ventricular function and the physical properties of blood at bedside  Is an integral part of critical care nursing
    5. 5. Cont..  CCN should have knowledge of how to obtain accurate data, analyze waveforms and interpret and integrate the data.  The information provided by invasive catheters can give us accurate and timely information to clinicians so that appropriate interventions can be taken.
    6. 6. IMPORTANCE OF HDM  Early detection, identification, and treatment of life-threatening conditions such as heart failure and cardiac temponade.  Evaluate the patient’s immediate response to treatment such as drugs and mechanical support.  Evaluate the effectiveness of cardiovascular function such as cardiac output and index.
    7. 7. PURPOSE OF HDM:  The purpose of HDM is to:  Early detection, identification, and treatment of life-threatening conditions  Aid in the diagnosis of various cardiovascular disorders  Guide therapies to optimize cardiac functions  Minimize cardiovascular dysfunctions  Evaluate the patient’s immediate response to treatment modalities
    8. 8. INDICATION OF HDM  It is essential in conditions when cardiac output is insufficient to deliver oxygen to the cells (altered preload, afterload and contractility).  Any deficit or loss of cardiac function: such as AMI, CHF, Cardiomyopathy.  All types of shock; cardiogenic, septic, neurogenic or anaphylactic.  Dehydration, hemorrhage, G.I. bleed, severe burn, ARDS or any major surgery.  Severe sepsis or multiple organ failure.  It aids in assessing body oxygen supply and demand.
    9. 9. HDM PARAMETERS:  Cardiac output.  Heart rate  Rhythm  Cardiac index.  Stroke volume.  Preload  Afterload  Contractility
    10. 10. PRESSURE MONITORING SYSTEM  Catheter (hollow tube).  Central venous catheter for CVP  Arterial catheter for Arterial pressure monitoring  Pulmonary catheter / SWAN Ganz for PAP monitoring.  Pressure tubing.  Flush solution (N/S or D5W, heparinized)  IV tubing with drip chamber  Pressure bag (pressure of 300 mmHg) and stopcock  Pressure transducer.  Pressure amplifier.  Cardiac monitor
    11. 11. SQUARE WAVE TEST:  Square wave test is performed to quickly assess the response of the system.  Flush device is released rapidly which will increase fluid flow through the system.  Record the square wave formed on the monitor.
    12. 12. LEVELING & ZEROING:  A fundamental step in obtaining accurate hemodynamic values is to zero the transducer amplifier system.  This step is performed at least once before obtaining the first hemodynamic reading after catheter insertion.  The pressure monitoring system is leveled to an external landmark and then zeroed to atmospheric pressure.  Zeroing is done to eliminate the effect of atmospheric and hydrostatic pressure.
    13. 13. Cont..  The phlebostatic axis is used as the reference point for leveling and zeroing.  The site of the phlebostatic axis is at the intersection of the fourth intercostal space and mid axillary line (approx level of right atrium and pulmonary artery.  Leveling (referencing) and zeroing ensures that hemodynamic values obtained with the catheter are accurate.
    14. 14. STEPS FOR ZEROING AND LEVELING:  Position patient on their back  Patient may be positioned with the head of the bed elevated between 0-60°  Flush the system  Level transducer to phlebostatic axis (may mark this with an x on patient)  Turn stop-cock on transducer so that it is off to the patient.  Remove cap  Press zero on the module  Ensure that zero appears on screen replace cap and turn stop-cock so that it is open to monitoring and patient.
    15. 15. ARTERIAL PRESSURE MONITORING:  Arterial blood pressure is a basic hemodynamic index often utilized to guide therapeutic interventions  Continuous monitoring of blood pressure is indicated for patients with hemodynamic instability that requires inotropic or vasopressor medication
    16. 16. Cont.  An arterial line is a cannula usually positioned in a peripheral artery such as  Radial artery (most commonly used site)  Brachial artery (rarely used)  Dorsalis pedis artery (rarely used)  Femoral artery (second option other than radial artery, more chances of getting contaminated)
    17. 17. Cont..  An arterial line allows for consistent and continuous monitoring of blood pressure to facilitate the reliable titration of supportive medications  In addition, arterial lines allow for reliable access to the arterial circulation for the measurement of arterial oxygenation and for frequent blood sampling
    18. 18. ARTERIAL LINE INSERTION:  http://content.nejm.org/cgi/video/354/15/e13/
    19. 19. ARTERIAL PRESSURE  Arterial pressure waveform has three parts:  Rapid upstroke wave (systolic pressure)  Dicrotic notch  Diastolic pressure waveform  Normal systolic BP is 90 – 140 mm Hg.  Normal diastolic BP is 60 – 90 mm Hg.  Dicrotic notch is small downward deflection following the closure of semilunar valve, indicate the end of systole and beginning of diastole.
    20. 20. MEAN ARTERIAL PRESSURE:  Mean arterial pressure (MAP) is used to evaluate perfusion of vital body organs.  Normal MAP is 70 to 105 mm Hg.  MAP can be calculated by: Systolic BP + (Diastolic *2) / 3
    21. 21. EJECTION FRACTION  Ejection Fraction (EF) is the fraction of blood ejected by the ventricle relative to its end-diastolic volume.  EF is calculated from: EF = (SV / EDV) * 100  For example if SV is 75 and EDV is 120 then EF would be 63%.
    22. 22. POTENTIAL COMPLICATIONS  HAEMORRHAGE: PREVENTION:  Keep limb visible at all times  Ensure alarm is on so that any accidental disconnection can be dealt quickly  Ensure that arm is immobile with arm board  Ensure all connections are tight SOLUTION  Apply pressure to limb  Assess leak  If hemorrhage persists notify medical officer
    23. 23. CONT..  INFECTION PREVENTION  Assess area regularly for redness or swelling  Avoid interrupting circuit as much as possible  Use gloves when touching arterial line SOLUTION  Remove arterial Line  Ensure proper hand washing when handling arterial line or transducer
    24. 24. CONT..  BLOCKAGE, CLOTTING & AIR EMBOLI PREVENTION  Keep pressure bag inflated to 300 mmHg  ensure 3-5ml auto flush is continuous.  Attempt to aspirate blood  Use fast flush device to clear line to prevent clot formation SOLUTION  Attempt to aspirate blood to remove clot  Ensure all connections are secure
    25. 25. CONT..  INTERUPTION TO PERIPHERAL CIRCULATION PREVENTION  Regularly check distal pulses and capillary refill. SOLUTION  Notify MO and consider removing arterial line
    26. 26. NURSING CONSIDERATIONS  Nursing care mainly directed to preventing complications  Ensure that the insertion site is visible at all times for early detection of disconnection  All connections must be secured  Ensure that the cannula site is covered with an appropriate dressing to maintain asepsis
    27. 27. Cont.  Never inject anything into an arterial cannula or arterial line  Ensure that the flush bag has adequate fluid.  Use only heparinized 0.9% sodium chloride  Ensure that the pressure in the pressure bag is maintained at 300mmHg.  Always set and keep the alarms on.
    28. 28. Cont.  Do not allow the flush bag to empty  To maintain patency of arterial cannula.  To prevent air embolism  To maintain accuracy of blood pressure reading  To maintain accuracy of fluid balance chart  To prevent backflow of blood
    29. 29. Cont.  Monitor color & temperature of limb distal to arterial line & compare to other limb  To confirm that circulation to the limb is adequate.  To ensure the early detection of impaired circulation
    30. 30. Cont.  Monitor and display the arterial waveform at all times  To detect cannula disconnection.  Level and zero transducer once per shift  To ensure accuracy in measuring blood pressure  Maintain the transducer level with the patient’s phlebostatic axis (fourth intercostal space midaxillary line)
    31. 31. Cont.  On removal of arterial cannula maintain pressure over puncture site for at least 5 minutes until bleeding has stopped  To prevent bleeding and haematoma formation  Send cannula tip to microbiology  Only if suspected infection  To detect infection
    32. 32. CENTRAL VENOUS PRESSURE  Is the pressure within the superior vena cava or the right atrium  It serve as a guide to fluid balance in critically ill patients  It give estimation of the circulating blood volume  It also assist in monitoring of rt ventricular function  Route for delivery of medications
    33. 33. Cont.  CVP is a helpful tool in the assessment of cardiac function, circulating blood volume, and patient’s response to treatment  CVP should not be interpreted solely but in conjunction with other systemic measurements, as isolated CVP measurements can be misleading  Normal CVP is less than 8 mm Hg  CVP is raised in mechanical ventilation.
    34. 34. CVP INSERTION:  http://content.nejm.org/cgi/video/356/21/e21/
    35. 35. METHODS OF CVP MONITORING  There are two methods of CVP monitoring  manometer system: enables intermittent readings and is less accurate than the transducer system  transducer system: enables continuous readings which are displayed on a monitor.
    36. 36. MONITORING WITH TRANSDUCERS  Transducers enable the pressure readings from invasive monitoring to be displayed on a monitor  To maintain patency of the cannula a bag of normal saline or heparinized saline should be connected to the transducer tubing and kept under continuous pressure of 300mmHg. (autoflush 3ml/hr)
    37. 37. PROCEDURE FOR CVP MEASUREMENT USING A TRANSDUCER  Explain the procedure to the patient  Ensure that central line is patent  Position the patient supine (if possible) and align the transducer with the phlebostatic axis  Zero the monitor  Observe the CVP tracing  Document the reading and report any changes or abnormalities
    38. 38. COMPLICATIONS  Infection  Arterial puncture  Hematoma  Pneumothorax  Hemothorax  Arrhythmias  Thrombosis  Air embolism
    39. 39. MANAGEMENT OF A PATIENT WITH A CVP LINE  Monitor patient for signs of complications  Label CVP lines with drugs/fluids etc. being infused in order to minimise the risk of accidental bolus injection  Ensure all connections are secure to prevent infection and introduction of air emboli  Observe the insertion site frequently for signs of infection.  CVP lines should be removed when clinically indicated
    40. 40. REMOVAL OF CENTRAL LINES  This is an aseptic procedure  The patient should be supine with head tilted down  Ensure no drugs are attached and running via the central line  Remove dressing  Cut the stitches  Slowly remove the catheter  If there is resistance then call for assistance  Apply digital pressure with gauze until bleeding stops  Dress with gauze and do clear dressing eg tegaderm
    41. 41. PA PRESSURE MONITORING  Pulmonary artery pressure monitoring is measuring the pressure in the pulmonary artery leading to the lungs  It also allows for indirect measurement of left heart pressures since the pulmonary veins have no valves in them and collects the information needed to calculate cardiac output and resistance
    42. 42. Cont.  The PA catheter assesses right ventricular function, pulmonary vascular status, indirectly left ventricular function and all 3 components of stroke volume  PAC aids in diagnosis of cardiovascular and cardiopulmonary dysfunction, therapy needed, and evaluate effectiveness of interventions.
    43. 43. PULMONARY ARTERY CATHETER  A Pulmonary artery catheter is a multi lumen catheter inserted into pulmonary artery.  Each lumen or port has specific functions.  Veins used for PA catheter insertion include the internal jugular, subclavian, femoral and very less commonly brachial.
    44. 44. Components of Swan-Ganz [con’t]  Proximal port – [Blue] used to measure central venous pressure/RAP and injectate port for measurement of cardiac output  Distal port – [Yellow] used to measure pulmonary artery pressure and for withdrawal of mixed venous saturation. Medication administration from this port is not recommended.
    45. 45. Cont..  Balloon port – [Red] used to determine pulmonary wedge pressure;1.5 ml air is injected via special syringe already attached with the catheter.  Thermister port- [White] it measures patients temperature in the pulmonary artery and reflect the temperature change when fluid is injected for cardiac output.
    46. 46. PA CATHETER INSERTION  http://www.edwards.com/products/pacatheters/c  http://www.edwards.com/Products/PACathe ters/HDMTroubleshooting.htm
    47. 47. INDICATIONS:  To assess volume status and myocardial function.  To assist in making a differential diagnosis  To guide the management of the patient with heart/lung disease/shock of all types  To monitor hemodynamic pressures during fluid resuscitation  Inotropic/vasoconstrictor/vasodilator drug infusion therapy  To assess complications of MI and heart failure  To monitor hemodyanamics with complicated surgical procedures  Sepsis and multi system organ failure  Complex surgery, complicated myocardial infarction
    48. 48. CONTRAINDICATION:  Severe coagulopathy.  Patient receiving thrombolytics (e.g-TPA).  Prosthetic right heart valve - catheter may cause the valve to malfunction.  Endocardial pacemaker - catheter may dislodge or knot around the electrode.  Severe pulmonary hypertension - increased risk of PA rupture.  Severe vascular disease - catheter may puncture an abnormal vessel.  Significant immunodeficiency.  If there are no skilled physicians/staff.  If the patient's disease or injury can't be modified or corrected by therapy.
    49. 49. COMPLICATIONS DURING INSERTION:  Pneumothorax  Venous air embolism  Dysrhythmias  Dislodgement of the catheter guide wire  Excessive bleeding
    50. 50. COMPLICATIONS AFTER INSERTION:  Dysrhythmias  Infection  Catheter dislodgement  Thrombophlebitis  Pulmonary artery rupture  Tension Pnuemothorax
    51. 51. Cont..  Catheter wedges permanently—considered an emergency, notify MD immediately, can occur when balloon is left inflated or catheter migrates too far into pulmonary artery (flat PA waveform)… can cause pulmonary infarct after only a few minutes!  Ventricular irritation – occurs when catheter migrates back into RV or is looped through the ventricle, notify MD immediately…can cause VT
    52. 52. • Check coagulation labs (pt, ptt, INR, platelets) • Transfuse if Platelets < than 70 and INR > 1.5 • Ensure Packed Red Blood Cells in cooler at bedside (Remember two RN check for PRBCs. Instructions for blood in cooler, taped to cooler) • Ensure good vascular access • Evaluate need for sedation. (if too active ↑ BP may → bleeding) NURSING CARE BEFORE REMOVAL OF PAC
    53. 53. • Keep PRBCs for a minimum of 1 hour • Continuous hemodynamic monitoring for minimum 1hour • Assess for signs of tamponade-dampening arterial wave form, narrowing pulse pressure and bleeding- blood in chest tubes, decrease blood pressure, pallor altered LOC) • Document vital signs every 15 minutes • Check HCT if bleeding suspected • Ensure patency of chest tubes • Do not transfer patient for at least 2 hours NURSING CARE AFTER REMOVAL OF PAC
    54. 54. TROUBLESHOOTING:  Remove multiple stopcocks, multiple injection ports, and long lengths of tubing whenever possible  The optimal length of pressure tubing is 4 feet  Overly compliant tubing leads to over damping  Avoid large diameter tubing  Remove all air bubbles from the system  Ensure that all connections are tight and periodically flush all tubing and stopcocks to remove air bubbles
    55. 55. Cont…  Whenever you are evaluating a patient’s changing hemodyanamics check all transducers, stopcocks, tubing, and injection ports for air  Gently tap the tubing and stopcocks as the continuous flush valve is opened to dislodge any bubbles.  This will usually clear the system and restore measurement accuracy  Flushing a few small bubbles through the catheter is OK; if more air is present, aspirate it from the tubing
    56. 56. Cont…  Changes in bed positioning generally require re zeroing the pressure transducer  If the transducer is below the phlebostatic axis, the resulting arterial pressure will be erroneously high  If the transducer is above the phlebostatic axis, the resulting arterial pressure will be erroneously low
    57. 57. Documentation  Document PAS, PAD, and PCWP on nursing flowsheet under Hemodynamic Parameters  PCWP will rarely be > PAD (if so, means blood is flowing backwards) If PCWP = PAD, look for tamponade  Under circumstances where the catheter will not wedge (or should not be), do not document any values in the PCWP column on the flowsheet.

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