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
By the end of this session, learners will be
Define what is hemodynamic monitoring.
List down the importance of hemodynamic
monitoring in hospital.
Discuss about pressure monitoring system.
Identify troubleshooting in the pressure
Explain in detail about arterial pressure
monitoring, central venous pressure
monitoring and pulmonary artery pressure
Evaluate oxygen delivery and demand.
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
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.
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
Evaluate the effectiveness of cardiovascular
function such as cardiac output and index.
PURPOSE OF HDM:
The purpose of HDM is to:
Early detection, identification, and treatment of
Aid in the diagnosis of various cardiovascular
Guide therapies to optimize cardiac functions
Minimize cardiovascular dysfunctions
Evaluate the patient’s immediate response to
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,
All types of shock; cardiogenic, septic, neurogenic or
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.
Catheter (hollow tube).
Central venous catheter for CVP
Arterial catheter for Arterial pressure monitoring
Pulmonary catheter / SWAN Ganz for PAP monitoring.
Flush solution (N/S or D5W, heparinized)
IV tubing with drip chamber
Pressure bag (pressure of 300 mmHg) and stopcock
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.
LEVELING & ZEROING:
A fundamental step in obtaining accurate
hemodynamic values is to zero the transducer
This step is performed at least once before
obtaining the first hemodynamic reading after
The pressure monitoring system is leveled to an
external landmark and then zeroed to
Zeroing is done to eliminate the effect of
atmospheric and hydrostatic pressure.
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
Leveling (referencing) and zeroing ensures that
hemodynamic values obtained with the catheter
STEPS FOR ZEROING AND
Position patient on their back
Patient may be positioned with the head of the bed elevated
Flush the system
Level transducer to phlebostatic axis (may mark this with an x
Turn stop-cock on transducer so that it is off to the patient.
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.
Arterial blood pressure is a basic
hemodynamic index often utilized to guide
Continuous monitoring of blood pressure is
indicated for patients with hemodynamic
instability that requires inotropic or
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)
An arterial line allows for consistent and
continuous monitoring of blood pressure to
facilitate the reliable titration of supportive
In addition, arterial lines allow for reliable
access to the arterial circulation for the
measurement of arterial oxygenation and
for frequent blood sampling
ARTERIAL LINE INSERTION:
Arterial pressure waveform has three parts:
Rapid upstroke wave (systolic pressure)
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.
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
Ejection Fraction (EF) is the fraction of
blood ejected by the ventricle relative to its
EF is calculated from:
EF = (SV / EDV) * 100
For example if SV is 75 and EDV is 120
then EF would be 63%.
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
Apply pressure to limb
If hemorrhage persists notify medical officer
Assess area regularly for redness or swelling
Avoid interrupting circuit as much as possible
Use gloves when touching arterial line
Remove arterial Line
Ensure proper hand washing when handling
arterial line or transducer
BLOCKAGE, CLOTTING & AIR EMBOLI
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
Attempt to aspirate blood to remove clot
Ensure all connections are secure
INTERUPTION TO PERIPHERAL
Regularly check distal pulses and capillary refill.
Notify MO and consider removing arterial line
Nursing care mainly directed to preventing
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
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.
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
Monitor color & temperature of limb distal to
arterial line & compare to other limb
To confirm that circulation to the limb is
To ensure the early detection of impaired
Monitor and display the arterial waveform at
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)
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
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
It give estimation of the circulating blood volume
It also assist in monitoring of rt ventricular function
Route for delivery of medications
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
Normal CVP is less than 8 mm Hg
CVP is raised in mechanical ventilation.
METHODS OF CVP
There are two methods of CVP monitoring
manometer system: enables intermittent
readings and is less accurate than the
transducer system: enables continuous readings
which are displayed on a monitor.
Transducers enable the pressure readings
from invasive monitoring to be displayed on
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)
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
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
Ensure all connections are secure to prevent
infection and introduction of air emboli
Observe the insertion site frequently for signs of
CVP lines should be removed when clinically
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
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
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
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
PULMONARY ARTERY CATHETER
A Pulmonary artery catheter is a multi
lumen catheter inserted into pulmonary
Each lumen or port has specific functions.
Veins used for PA catheter insertion include
the internal jugular, subclavian, femoral and
very less commonly brachial.
Components of Swan-Ganz [con’t]
Proximal port – [Blue] used to measure
central venous pressure/RAP and
injectate port for measurement of cardiac
Distal port – [Yellow] used to measure
pulmonary artery pressure and for
withdrawal of mixed venous saturation.
Medication administration from this port
is not recommended.
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.
PA CATHETER INSERTION
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
Sepsis and multi system organ failure
Complex surgery, complicated myocardial infarction
Patient receiving thrombolytics (e.g-TPA).
Prosthetic right heart valve - catheter may cause the valve to
Endocardial pacemaker - catheter may dislodge or knot around
Severe pulmonary hypertension - increased risk of PA rupture.
Severe vascular disease - catheter may puncture an abnormal
If there are no skilled physicians/staff.
If the patient's disease or injury can't be modified or corrected by
Venous air embolism
Dislodgement of the catheter guide wire
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
Ventricular irritation – occurs when catheter
migrates back into RV or is looped through the
ventricle, notify MD immediately…can cause VT
• 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
• 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
Remove multiple stopcocks, multiple injection
ports, and long lengths of tubing whenever
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
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
This will usually clear the system and restore
Flushing a few small bubbles through the catheter
is OK; if more air is present, aspirate it from the
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
If the transducer is above the phlebostatic
axis, the resulting arterial pressure will be
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.