0
Introduction to
HEMODYNAMIC
MONITORING
DEFINITION

HEMODYNAMIC MONITORING
DEFINITION
Measuring and
monitoring the
factors that
influence the
force and flow of
bl...
INDICATIONS


To diagnose shock states



To determine fluid volume status



To measure cardiac output



To monitor ...
CONTRAINDICATIONS
for an invasive PA Catheter


Tricuspid or pulmonary valve mechanical
prosthesis



Right heart mass (...
Clinical Scenario Use of PAC


Management of complicated MI




Assessment of respiratory distress










Card...
Hemodynamic Values
CO / CI
SV / SVI or SI
SVO 2

 Cardiac Output/Cardiac Index



VO 2 / VO 2 I



DO 2 / DO 2 I

 Oxy...
Index Values


Values normalized for body size (BSA)


CI is 2.5 – 4.5 L/min/m2



SVRI is 1970 – 2390 dynes/sec/cm-5/m...
Importance of Index Values


Mr. Smith







47 y/o male
60 kg
CO = 4.5
6 ft tall (72 inches)
BSA = 1.8
CI = 2.5 L...
Basic Concepts






Cardiac Output - amount of blood pumped out
of the ventricles each minute
Stroke Volume - amount o...
Basic Concepts


Systemic Vascular Resistance







Measurement of the resistance (afterload) of blood
flow through ...
Basic Concepts



BP = CO x SVR
CO and SVR are inversely related
CO and SVR will change before BP
changes
* Changes in B...
Stroke Volume


Components Stroke Volume
 Preload: the volume of blood in the ventricles
at end diastole and the stretch...
Stroke Volume
Preload

Afterload

Contractility

Filling Pressures
& Volumes

Resistance to
Outflow

Strength of
Contracti...
Clinical Measurements of Preload


Right Side: CVP/RAP * filling pressures



Left Side: PAOP/LAP







PAD may be u...
Clinical Measurements of
Afterload


RV Afterload






MPAP
PVR = 150-250 dynes/sec/cm-5
PVRI = 255-285 dynes/sec/cm...
Clinical Estimation of Contractility


Cardiac Output

* flow

Normal = 4-8 L/min



Cardiac Index

Normal = 2.5-4.5 L/m...
Ventricular Compliance





Ability of the ventricle to stretch
Decreased with LV hypertrophy, MI,
fibrosis, HOCM
*If c...
The PA Catheter

18
Pulmonary Artery Catheters

19
The Pulmonary Artery Catheter

20
“Swan-Ganz” PA Catheter





Large Markers = 50cm
Small Markers = 10cm
10 cm between small black markers on
catheter
S...
BREAK
Take 5 MINUTES

22
Demonstration of PA catheter
and
Hands-on practice

23
Risks With The PA Catheter












Bleeding
Infection
Dysrhythmias
Pulmonary Artery
Rupture
Pneumothorax
Hem...
25
Hemodynamic
Waveforms
PA-Catheter Positioning




Right
Atrium




 Pulmonary  Pulmonary
Right
 Artery
Ventricle  Artery
 Occlusion
 P...
PAC Insertion Sequence

28
Post PA Catheter Insertion
Assess ECG for dysrhythmias.
 Assess for signs and symptoms of respiratory distress.


Ascert...
General Rules for Hemodynamic
Measurements


Measure all pressures at End-Expiration
“ Patient
“ Vent

Peak”

Valley”

...
Phlebostatic Axis

4th ICS Mid-chest, regardless of head elevation
31
Phlebostatic Axis

4th ICS Mid-chest, regardless of head elevation
32
Spontaneous Respirations



Measure all pressures at end-expiration
At top curve with spontaneous
respiration

“patient-...
Spontaneous Respirations

34
Mechanical Ventilation



Measure all pressures at end-expiration
At bottom curve with mechanical
ventilator

“vent-vall...
36
37
General Rules for
Hemodynamic Measurements




Measure all pressures with the HOB at a …
consistent level of elevation
L...
Review of Normal Values
 RAP

(CVP)

0-8 mmHg

 RVP

15-30/0-8 mmHg

 PAP

15-30/6-12 mmHg

 PAOP

8 - 12 mmHg
39
PA INSERTION WAVEFORMS
A

C






A
B
C
D

B

D

= RA (CVP) Waveform
= RV Waveform
= PA Waveform
= PAWP Waveform
40
PAC Insertion Sequence

41
Right Atrium (CVP)

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

42
Components of the RA
(CVP) Waveform



a-wave




atrial contraction (systole)
begins in the PR interval and QRS on th...
Components of the RA
(CVP) Waveform


Absent a waves




Paced rhythm





Atrial fibrillation

Junctional rhythm

Me...
Absent A Wave

* Measure at end of QRS!
*PACEP.ORG 2007

45
Components of the RA
(CVP) Waveform



c-wave







tricuspid valve closure
Between ST segment
Between a and v wave...
Reading the RA CVP) Waveform

49
CVP Waveform

Vented Patient
50
CVP Waveform

a wave

Vented Patient – “Vent Valley”
51
Right Ventricle

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

53
RV Waveform

54
Components of the RV
Waveform
Usually only seen with insertion
 Systole







Diastole




measured at the peak
pe...
Reading the RV Waveform

56
RV Waveform Interventions


After PA catheter is correctly placed, RV
waveform should not be seen. If it is, then
interve...
Pulmonary Artery

Normal Value 15-25/8-15 mmHg
Dicrotic Notch Represents PV Closure
PAD Approximates PAWP (LVEDP)

58
(in ...
PA Waveform

59
Components of the PA Waveform
 Systole


measured at the peak of the wave

 Diastole




measured just prior to the u...
Components of the PA Waveform
 Dicrotic




notch

indicates pulmonic valve closure
aids in differentiation from RV wa...
Reading the PA Waveform

Dicrotic notch

62
PA Waveform

10/20/30

Identify that it is the PA tracing
Look at the scale
What is the PAP?
63
PA Waveform

Look for dichrotic notch
Look at scale
What is the PAP?
64
PAOP / Wedge

Normal Value 8-12 mmHg
Balloon Floats and Wedges in Pulmonary
Artery
PAWP = LAP = LVEDP
65
Components of the PA Waveform
 a-wave


atrial contraction



correct location for measurement of PAOP




average th...
Components of the PA Waveform
 c-wave

rarely present
 represents mitral valve closure


 v-wave

represents left atri...
Reading the PAOP Waveform

Begins within
the QRS or the
QT segment
68
Wedging Can Cause
Pulmonary Artery Rupture
69
PA Tracing to PAOP Tracing to PA
Tracing

70
Post PAC Insertion


Assess ECG for dysrythmias



Assess for S/S of respiratory distress



Be sure sterile dressing i...
Precautions


Always set alarms on monitor






If in PAOP with balloon down, have pt cough,
deep breath, change posi...
Intermittent Thermodilution CO


Based on measuring blood temperature changes



Must know the following:


Computation...
Cardiac Output via Thermodilution

*PACEP.ORG 2007

74
Averaging CO Measurements

*PACEP.ORG 2007

75
Continuous Cardiac Output






A heat signal is produced by the thermal filament
of the PA catheter
The signal is dete...
Mixed Venous Oxygen Saturation

77
Mixed Venous Oxygenation Monitoring
(SvO2)








Measures the amount of O2 in the blood (on the Hgb
molecule) return...
Mixed Venous Oxygen
Saturation




End result of O2 delivery and
consumption
Measured in the pulmonary artery




An a...
Mixed Venous Oxygen Saturation







Continuous measurement
“Early” warning signal to detect oxygen
transport imbalan...
Mixed Venous Oxygen Saturation
There are four factors that affect SVO 2:
1. Hemoglobin
2. Cardiac output
3. Arterial oxyge...
SvO2 Application

In a case of increased SVR with decreased CO. Nitroprusside was
started. The increase in SvO2 and increa...
Ways To Increase O2 Delivery


Increase CO


increase HR, optimize preload, decrease
afterload, add positive inotropes

...
Ways To Decrease O2 Demand


Decrease muscle activity



prevent/control seizures



prevent/control shivering





...
Removal of the PA Catheter




Usually performed by the nurse with
an MD order
Place patient supine with HOB flat
(reduc...
Removal of the PA Catheter


Make sure balloon is down, have
patient inhale and hold breath, pull
PA catheter out smoothl...
Removal of the PA Catheter

87
Removal of the PA Catheter


If patient is unable to perform breath hold:




Pull PA catheter during period of positiv...
Removal of the PA Catheter








If introducer sheath (cordis) is to remain in
place, it must be capped.
If introduc...
Break
Take 5 Minutes

90
Hemodynamic Waveform
Practice

91
MEASUREMENTS

92
SAMPLE MEASUREMENTS

93
SAMPLE MEASUREMENTS

94
SAMPLE MEASUREMENTS

95
SAMPLE MEASUREMENTS

96
SAMPLE MEASUREMENTS

97
SAMPLE MEASUREMENTS

98
SAMPLE MEASUREMENTS

99
SAMPLE MEASUREMENTS

100
SAMPLE MEASUREMENTS

101
SAMPLE MEASUREMENTS

102
SAMPLE MEASUREMENTS

103
SAMPLE MEASUREMENTS

104
SAMPLE MEASUREMENTS

105
SAMPLE MEASUREMENTS

106
Review

107
Review
 The

PA diastolic pressure is
measured at which part of the
waveform?

Just prior to the
upstroke of systole
108
Review
 Which

part of the CVP and PAOP
waveforms is used to calculate
pressures?

The a wave
109
Review
 The

RV waveform can be
distinguished from the PA
waveform by:

RV has lower
diastolic pressure
and no dicrotic n...
Review
 The

v wave of the CVP & PAOP
waveforms represents:

Atrial filling

111
Review
 The

a wave of the CVP waveform
correlates with which electrical
event?

The PR interval on the ECG
112
Review
 The

a wave of the PAOP
waveform correlates with which
electrical event?

The QRS on the ECG
113
Questions?

114
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Advanced haemodynamics

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  • Changes in CO and SV!
  • The CO and the SVR will modulate to maintain blood pressure even if CO is very low. Because of this phenomenon, the BP is not a good measure of cardiac output
  • The pulse pressure tells you more about afterload than the BP does
  • 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
    Components:
    1. Proximal port – approximately 30 cm from tip of catheter.
    Also known as the CVP port (central venous pressure). It lies in the right atrium and measures CVP. It can be used for infusion of IV solutions or medications, for drawing blood and for injecting cardiac output boluses. It is usually color coded blue.
    2. Distal port – opening is at the tip (end) of the catheter.
    Also known as the PA port. It lies directly in the pulmonary artery and measures the pulmonary artery pressures (PAP), systolic (PAS), and diastolic (PAD). It also measures the pulmonary capillary wedge pressure (PCWP) when the balloon is inflated. The PA pressures should always be monitored continuously. NEVER USE the PA port for medication infusion. It can be used for drawing "mixed venous" blood gas samples. It is usually color coded yellow.
    3. Thermistor and connector port
    The thermistor connector connects the pulmonary catheter to the cardiac output computer. The connector is at the end of a separate catheter lumen outside the patient thermistor wire. Blood temperature is transmitted within the lumen (the core temperature is the most accurate reflection of the body temperature). It is used in determining cardiac output. The connector tip should always have a protective covering to protect patient from microshock. It is usually color coded yellow with a red connector.
    4. Balloon port
    The balloon port is located < 1 cm from the tip of the catheter. When the balloon is inflated with approximately 0.8 to 1.5 cc of air, the catheter will become lodged (wedged) in the pulmonary artery and gives a wedge tracing. It reflects the pressures that are in the left side of the heart when inflated. DO NOT INFLATE WITH LIQUID---- ALWAYS INFLATE WITH AIR. When deflated, turn stopcock to off position and leave syringe connect to the port. It is usually color coded red.
    5. A 5 - lumen Swan Ganz catheter has either an infusion port or a pacing port
    A pacing port allows for insertion of a transvenous pacing wire. The infusion port allows for infusion of IV solutions or medications. It is usually color coded white.
  • EQUIPMENT NECESSARY FOR INSERTION
    Flush solution for transducer system
    Flush solution for cardiac output system
    Arterial access line
    Disposable triple pressure transducer system
    Pulmonary artery catheter                               
    Monitor, module, electrodes, cables
    Central line kit                           
    Transducer holder, I.V. pole, pressure bag
    Emergency resuscitation equipment    
    Prepackaged Introducer Kit; sutures
    Sterile gowns, gloves, and masks
  • Correct the students about the location of the phlebostatic axis
  • 1) Normal Pressures:
    RA = 1-7
    RV = 15-25/1-7
    PA = 15-25/8-15
    PAD = 8-15
    PAWP = 6-12
  • It is essential that you be able to recognize the RV waveform – If the tip migrates to the RV during monitorin it can cause dysrhythmias. The proper intervention is to have an MD or qualified PA/CRNA advance the catheter or you can pull the tip back to the RA. Check your unit’s protocols.
  • Action taken will depend on unit protocols and availability of an MD or advanced practitioner to reposition the catheter. Know your unit’s protocols before you do anything
  • Looks like a CVP waveform, but the timing is different
  • Looks like a CVP waveform – just occurs later
  • CVP Example
  • CVP Answer
  • Example 1
  • Answer 1
  • Example 2
  • Answer 2
  • Example 3
  • Answer 3
  • Example 4
  • Answer 4
  • Example 5
  • Answer 5
  • Example 6
  • Answer 6
  • Transcript of "Advanced haemodynamics"

    1. 1. Introduction to HEMODYNAMIC MONITORING
    2. 2. 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. 2
    3. 3. 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 3
    4. 4. CONTRAINDICATIONS for an invasive PA Catheter  Tricuspid or pulmonary valve mechanical prosthesis  Right heart mass (thrombus and/or tumor)  Tricuspid or pulmonary valve endocarditis 4
    5. 5. Clinical Scenario Use of PAC  Management of complicated MI   Assessment of respiratory distress       Cardiogenic/hypovolemic/septic Tamponade Pulmonary embolism Severe dilated cardiomyopathy Management of Pulmonary Hypertension Management of high-risk surgical patients   Cardiogenic vs non-cardiogenic pulmonary edema Assessment/Diagnosis of shock/ cardiac dysfunction   Severe LVF/RMI (precise management of heart failure) CABG, vascular, valvular, aneurysm repair Management of volume requirements in the critically ill  ARF, GI bleed, trauma, sepsis (precise management) 5
    6. 6. Hemodynamic Values CO / CI SV / SVI or SI SVO 2  Cardiac Output/Cardiac Index  VO 2 / VO 2 I  DO 2 / DO 2 I  Oxygen Consumption  Oxygen Delivery            Stroke Volume/Stroke Volume Index  Mixed Venous Saturation RVEDVI or EDVI  RV End-Diastolic Volume  Systemic Vascular Resistance SVR / SVRI  Pulmonary Vascular Resistance PVR / PVRI  RV Ejection Fraction RVEF PAOP CVP PAP  Pulmonary Artery Occlusive Pressure  Central Venous Pressure  Pulmonary Artery Pressure 6
    7. 7. Index Values  Values normalized for body size (BSA)  CI is 2.5 – 4.5 L/min/m2  SVRI is 1970 – 2390 dynes/sec/cm-5/m2  SVI or SI is 35 – 60 mL/beat/m2  EDVI is 60 – 100 mL/m2 7
    8. 8. Importance of Index Values  Mr. Smith       47 y/o male 60 kg CO = 4.5 6 ft tall (72 inches) BSA = 1.8 CI = 2.5 L/min/m 2  Mr. Jones       47 y/o male 120 kg CO = 4.5 6 ft tall (72 inches) BSA = 2.4 CI = 1.9 L/min/m2 8
    9. 9. Basic Concepts    Cardiac Output - amount of blood pumped out of the ventricles each minute Stroke Volume - amount of blood ejected by the ventricle with each contraction CO = HR x SV Decreased SV usually produces compensatory tachycardia.. So. . .changes in HR can signal changes in CO 9
    10. 10. Basic Concepts  Systemic Vascular Resistance     Measurement of the resistance (afterload) of blood flow through systemic vasculature *Increased SVR/narrowing PP = vasoconstriction *Decreased SVR/widening PP = vasodilation Blood Pressure BP = CO x SVR ** SVR can increase to maintain BP despite inadequate CO  Remember CO = HR x SV 10
    11. 11. Basic Concepts   BP = CO x SVR CO and SVR are inversely related CO and SVR will change before BP changes * Changes in BP are a late sign of hemodynamic alterations 11
    12. 12. Stroke Volume  Components Stroke Volume  Preload: the volume of blood in the ventricles at end diastole and the stretch placed on the muscle fibers  Afterload: the resistance the ventricles must overcome to eject it’s volume of blood  Contractility: the force with which the heart muscle contracts (myocardial compliance) 12
    13. 13. Stroke Volume Preload Afterload Contractility Filling Pressures & Volumes Resistance to Outflow Strength of Contraction CVP PVR, MPAP RVSV PAOP (PAD may be used to estimate PAOP) Fluids, Volume Expanders SVR, MAP LVSV Vasoconstrictors Inotropic Vasodilators Medications Diuretics 13
    14. 14. Clinical Measurements of Preload  Right Side: CVP/RAP * filling pressures  Left Side: PAOP/LAP    PAD may be used to estimate PAOP in the absence of pulmonary disease/HTN The pulmonary vasculature is a low pressure system in the absence of pulmonary disease These pressures are “accurate” estimations of preload only with perfect compliance of heart and lungs 14
    15. 15. Clinical Measurements of Afterload  RV Afterload     MPAP PVR = 150-250 dynes/sec/cm-5 PVRI = 255-285 dynes/sec/cm-5/m2 LV Afterload    MAP SVR = 800–1300 dynes/sec/cm-5 SVRI = 1970-2390 dynes/sec/cm-5/m2 15
    16. 16. Clinical Estimation of Contractility  Cardiac Output * flow Normal = 4-8 L/min  Cardiac Index Normal = 2.5-4.5 L/min/m2  Stroke Volume *pump performance Normal = 50-100 ml/beat  Stroke volume Index  Normal = 30-50 ml/beat/m2 16
    17. 17. Ventricular Compliance    Ability of the ventricle to stretch Decreased with LV hypertrophy, MI, fibrosis, HOCM *If compliance is decreased, small changes in volume produce large changes in pressure 17
    18. 18. The PA Catheter 18
    19. 19. Pulmonary Artery Catheters 19
    20. 20. The Pulmonary Artery Catheter 20
    21. 21. “Swan-Ganz” PA Catheter     Large Markers = 50cm Small Markers = 10cm 10 cm between small black markers on catheter Several types      Thermodilutional CO CCO Precep NICCO Multiple lumens 21
    22. 22. BREAK Take 5 MINUTES 22
    23. 23. Demonstration of PA catheter and Hands-on practice 23
    24. 24. Risks With The PA Catheter           Bleeding Infection Dysrhythmias Pulmonary Artery Rupture Pneumothorax Hemothorax Valvular Damage Embolization Balloon Rupture Catheter Migration 24
    25. 25. 25
    26. 26. Hemodynamic Waveforms
    27. 27. PA-Catheter Positioning   Right Atrium    Pulmonary  Pulmonary Right  Artery Ventricle  Artery  Occlusion  Pressure 27
    28. 28. PAC Insertion Sequence 28
    29. 29. Post PA Catheter Insertion 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).  Obtain opening pressures and wave form tracings for each waveform.  Assess length at insertion site.  Ensure that all open ends of stopcocks are covered with sterile deadend caps (red dead-end caps, injection caps, or male Luer lock caps).  Update physician of abnormalities.  29
    30. 30. General Rules for Hemodynamic Measurements  Measure all pressures at End-Expiration “ Patient “ Vent Peak” Valley” 30
    31. 31. Phlebostatic Axis 4th ICS Mid-chest, regardless of head elevation 31
    32. 32. Phlebostatic Axis 4th ICS Mid-chest, regardless of head elevation 32
    33. 33. Spontaneous Respirations   Measure all pressures at end-expiration At top curve with spontaneous respiration “patient-peak”  Intrathoracic pressure decreases during spontaneous inspiration   Negative deflection on waveforms Intrathoracic pressure increases during spontaneous expiration  Positive deflection on waveforms 33
    34. 34. Spontaneous Respirations 34
    35. 35. Mechanical Ventilation   Measure all pressures at end-expiration At bottom curve with mechanical ventilator “vent-valley”  Intrathoracic pressure increases during positive pressure ventilations ( inspiration )   Positive deflection on waveforms Intrathoracic pressure decreases during positive pressure expiration  Negative deflection on waveforms 35
    36. 36. 36
    37. 37. 37
    38. 38. General Rules for Hemodynamic Measurements   Measure all pressures with the HOB at a … consistent level of elevation Level the transducer at the phlebostatic axis   Print strips with one ECG and one pressure channel    4th intercostal space, mid-chest adequate scale allows accurate waveform analysis Confirm monitor pressures with pressures obtained by waveform analysis  ** correct waveform analysis is more accurate than pressures from the monitor 38
    39. 39. Review of Normal Values  RAP (CVP) 0-8 mmHg  RVP 15-30/0-8 mmHg  PAP 15-30/6-12 mmHg  PAOP 8 - 12 mmHg 39
    40. 40. PA INSERTION WAVEFORMS A C     A B C D B D = RA (CVP) Waveform = RV Waveform = PA Waveform = PAWP Waveform 40
    41. 41. PAC Insertion Sequence 41
    42. 42. Right Atrium (CVP) Normal Value 0-8 mmHg RAP = CVP Wave Fluctuations Due To Contractions 42
    43. 43. Components of the RA (CVP) Waveform  a-wave    atrial contraction (systole) begins in the PR interval and QRS on the ECG correct location for measurement of CVP/RAP * average the peak & trough of the a-wave  * (a-Peak + a-trough)/2 = CVP   May not see if no atrial contractions as with. . . 43
    44. 44. Components of the RA (CVP) Waveform  Absent a waves   Paced rhythm   Atrial fibrillation Junctional rhythm Measure at the end of the QRS 44
    45. 45. Absent A Wave * Measure at end of QRS! *PACEP.ORG 2007 45
    46. 46. Components of the RA (CVP) Waveform  c-wave      tricuspid valve closure Between ST segment Between a and v waves *may or may not be present v-wave   Atrial filling begins at the end of the QRS to the beginning of the T wave (QT interval) 46
    47. 47. Reading the RA CVP) Waveform 49
    48. 48. CVP Waveform Vented Patient 50
    49. 49. CVP Waveform a wave Vented Patient – “Vent Valley” 51
    50. 50. Right Ventricle Normal Value 15-25/0-8 mmHg Catheter In RV May Cause Ectopy Swan Tip May Drift From PA to RV 53
    51. 51. RV Waveform 54
    52. 52. Components of the RV Waveform Usually only seen with insertion  Systole     Diastole   measured at the peak peak occurs after the QRS measured just prior to the the onset of systole No dicrotic notch   Dicrotic notch indicates valve closure *** Aids in differentiation from the PA tracing 55
    53. 53. Reading the RV Waveform 56
    54. 54. RV Waveform Interventions  After PA catheter is correctly placed, RV waveform should not be seen. If it is, then interventions are necessary:     Check for specific unit protocol first Inflate balloon with patient lying on their left side (catheter may float back into PA) With deflated balloon, pull catheter into RA placement or remove completely Document your actions and notify physician ** An RN should NEVER advance the catheter! 57
    55. 55. Pulmonary Artery Normal Value 15-25/8-15 mmHg Dicrotic Notch Represents PV Closure PAD Approximates PAWP (LVEDP) 58 (in absence of lung or MV disease)
    56. 56. PA Waveform 59
    57. 57. Components of the PA Waveform  Systole  measured at the peak of the wave  Diastole   measured just prior to the upstroke of systole (end of QRS) Higher than RV diastolic pressure 60
    58. 58. Components of the PA Waveform  Dicrotic    notch indicates pulmonic valve closure aids in differentiation from RV waveform aids in determining waveform quality  Anachrotic   Notch Before upsweep to systole Opening of pulmonic valve 61
    59. 59. Reading the PA Waveform Dicrotic notch 62
    60. 60. PA Waveform 10/20/30 Identify that it is the PA tracing Look at the scale What is the PAP? 63
    61. 61. PA Waveform Look for dichrotic notch Look at scale What is the PAP? 64
    62. 62. PAOP / Wedge Normal Value 8-12 mmHg Balloon Floats and Wedges in Pulmonary Artery PAWP = LAP = LVEDP 65
    63. 63. Components of the PA Waveform  a-wave  atrial contraction  correct location for measurement of PAOP   average the peak & trough of the a-wave begins near the end of QRS or the QT segment  * Delayed ECG correlation from CVP since PA catheter is further away from left atrium 66
    64. 64. Components of the PA Waveform  c-wave rarely present  represents mitral valve closure   v-wave represents left atrial filling  begins at about the end of the T wave  67
    65. 65. Reading the PAOP Waveform Begins within the QRS or the QT segment 68
    66. 66. Wedging Can Cause Pulmonary Artery Rupture 69
    67. 67. PA Tracing to PAOP Tracing to PA Tracing 70
    68. 68. Post PAC Insertion  Assess ECG for dysrythmias  Assess for S/S of respiratory distress  Be sure sterile dressing is applied  Order CXR for placement  Get MD order before infusing through ports  Zero and level all transducers  Assess quality of waveforms      Dampening, proper configuration, scale Obtain opening pressures and waveform tracings for each waveform Note length at insertion site Place proper luer-lock connectors to lumens and cap all ports Notify MD of any abnormalities 71
    69. 69. Precautions  Always set alarms on monitor    If in PAOP with balloon down, have pt cough, deep breath, change position If unable to dislodge from PAOP, notify MD immediately to reposition catheter   20mmHg above and below pt baseline CXR to reconfirm placement If pt coughs up blood or it is suctioned via ETT, suspect PA rupture and notify MD immediately 72
    70. 70. Intermittent Thermodilution CO  Based on measuring blood temperature changes  Must know the following:  Computation constant  Volume of injectate  Temperature of injectate     Iced or room temperature Inject rapidly and smoothly over 4 seconds max Thermister at end of PA catheter detects change in temperature and creates CO curve At least 3 measurements and average results 73
    71. 71. Cardiac Output via Thermodilution *PACEP.ORG 2007 74
    72. 72. Averaging CO Measurements *PACEP.ORG 2007 75
    73. 73. Continuous Cardiac Output    A heat signal is produced by the thermal filament of the PA catheter The signal is detected by the thermistor on the PA catheter and is converted into a time/temperature curve The CCO computer produces a time-averaged calculation  Over 3 minutes  Updates every 30-60 seconds 76
    74. 74. Mixed Venous Oxygen Saturation 77
    75. 75. Mixed Venous Oxygenation Monitoring (SvO2)     Measures the amount of O2 in the blood (on the Hgb molecule) returned to the heart Helps to demonstrate the balance between O2 supply & demand in the body (tissue oxygenation) Helps to interpret hemodynamic dysfunction when used with other measurements Normal: 70% (60-80) 78
    76. 76. Mixed Venous Oxygen Saturation   End result of O2 delivery and consumption Measured in the pulmonary artery   An average estimate of venous saturation for the whole body. **Does not reflect separate tissue perfusion or oxygenation 79
    77. 77. Mixed Venous Oxygen Saturation     Continuous measurement “Early” warning signal to detect oxygen transport imbalances Evaluates the effect of the therapeutic interventions Identify potential patient care consequences (turning, suctioning) 80
    78. 78. Mixed Venous Oxygen Saturation There are four factors that affect SVO 2: 1. Hemoglobin 2. Cardiac output 3. Arterial oxygen saturation (SaO2) 4. Oxygen consumption (VO2) 81
    79. 79. SvO2 Application In a case of increased SVR with decreased CO. Nitroprusside was started. The increase in SvO2 and increase in CO reflects the appropriateness of therapy. 82
    80. 80. Ways To Increase O2 Delivery  Increase CO  increase HR, optimize preload, decrease afterload, add positive inotropes  Increase Hgb, increase SaO2  Improve pulmonary function  pulmonary toilet, prevent atelectasis  ventilation strategies 83
    81. 81. Ways To Decrease O2 Demand  Decrease muscle activity   prevent/control seizures  prevent/control shivering   sedatives, (paralytics) space care activities Decrease temperature  prevent/control fever 84
    82. 82. Removal of the PA Catheter   Usually performed by the nurse with an MD order Place patient supine with HOB flat (reduces chance of air embolus) 85
    83. 83. Removal of the PA Catheter  Make sure balloon is down, have patient inhale and hold breath, pull PA catheter out smoothly   monitor for ventricular ectopy stop immediately & notify MD if resistance is met 86
    84. 84. Removal of the PA Catheter 87
    85. 85. Removal of the PA Catheter  If patient is unable to perform breath hold:   Pull PA catheter during period of positive intrathoracic pressure to minimize chance of venous air embolus Mechanically ventilated patient  pull PA catheter during delivery of vent breath  Spontaneously breathing patient  pull PA catheter during exhalation 88
    86. 86. Removal of the PA Catheter     If introducer sheath (cordis) is to remain in place, it must be capped. If introducer sheath (cordis) is to be removed, repeat the steps used for PA catheter removal. Hold pressure on the site (5-10 min.), keep patient flat until hemostasis is achieved. Apply sterile dressing or band-aid. 89
    87. 87. Break Take 5 Minutes 90
    88. 88. Hemodynamic Waveform Practice 91
    89. 89. MEASUREMENTS 92
    90. 90. SAMPLE MEASUREMENTS 93
    91. 91. SAMPLE MEASUREMENTS 94
    92. 92. SAMPLE MEASUREMENTS 95
    93. 93. SAMPLE MEASUREMENTS 96
    94. 94. SAMPLE MEASUREMENTS 97
    95. 95. SAMPLE MEASUREMENTS 98
    96. 96. SAMPLE MEASUREMENTS 99
    97. 97. SAMPLE MEASUREMENTS 100
    98. 98. SAMPLE MEASUREMENTS 101
    99. 99. SAMPLE MEASUREMENTS 102
    100. 100. SAMPLE MEASUREMENTS 103
    101. 101. SAMPLE MEASUREMENTS 104
    102. 102. SAMPLE MEASUREMENTS 105
    103. 103. SAMPLE MEASUREMENTS 106
    104. 104. Review 107
    105. 105. Review  The PA diastolic pressure is measured at which part of the waveform? Just prior to the upstroke of systole 108
    106. 106. Review  Which part of the CVP and PAOP waveforms is used to calculate pressures? The a wave 109
    107. 107. Review  The RV waveform can be distinguished from the PA waveform by: RV has lower diastolic pressure and no dicrotic notch 110
    108. 108. Review  The v wave of the CVP & PAOP waveforms represents: Atrial filling 111
    109. 109. Review  The a wave of the CVP waveform correlates with which electrical event? The PR interval on the ECG 112
    110. 110. Review  The a wave of the PAOP waveform correlates with which electrical event? The QRS on the ECG 113
    111. 111. Questions? 114
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