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
  • 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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