It can be performed by invasive and non-invasive monitoring

1. PRESENTED BY
SHEELA M JOHN
2ND YR MSC NURSING
HEMODYNAMIC
MONITORING

2. INTRODUCTION
• Critically ill patients require continuos assessment of their
cardiovascular system to diagnose and manage their complex
medical conditions.
• This is most commonly achieved by the use of direct pressure
monitoring systems,often refered to as hemodynamic monitoring.
• Heart function is the main focus of hemodynamic studies.
Hemodynamic pressure monitoring provides information about
blood volume , fluid balance and how well the heart is pumping.
• Nurses are responsible for the collection measurement and
interpretation of these dynamic patient status parameters.

3. HEMODYNAMIC MONITORING

4. HEMODYNAMICS
 Hemodynamics
circulate blood
are the
through
forces
the
Specifically, hemodynamics is the
which
body.
term
used to describe the intravascular pressure and
flow that occurs when the heart muscle
contracts and pumps blood throughout the
body.

5. DEFINITION
Hemodynamic monitoring refers to measurement of
pressure, flow and oxygenation of blood within the
cardiovascular system.

6. PURPOSES
1. Early detection, identification and
treatment of life threatening conditions
such as heart failure and cardiac
tamponade.
2. Evaluate the patient’s immediate response to
treatment such as drugs and mechanical
support.
3. Evaluate the effectiveness of
cardiovascular function such as cardiac
output and index.

7. INDICATIONS
 Any deficits or loss of cardiac function:
such as myocardial infarction, congestive
heart failure, cardiomyopathy.
 All types of shock; cardiogenic
shock, neurogenic shock or
anaphylactic shock.
 Decreased urine output from
dehydration, hemorrhage. G.I bleed, burns
or surgery.

8. SPECIALISED EQUIPMENTS
NEEDED FOR INVASIVE
MONITORING
 A CVP,pulmonary artery ,arterial catheter
 A flush system composed of intravenous solution,tubing stop cocks and a
flush device which provides for continous and manual flushing of system.
 A pressure bag placed around the flush solution that is maintained at 300
mmhg pressure ;the pressurized flush system delivers 3-5ml of solution
per hour through the catheter to prevent clotting and backflow of blood
into the pressure monitoring system.
 A tranducer to convert the pressure coming from artery or heart
chamber into an electrical signal
 An amplifier or moniter which increases the size of electrical signal for
display on an occilloscope.

10. HEMODYNAMIC MONITER

11. SETUP FOR
HEMODYNAMIC
PRESSURE MONITORING
 Obtain barrier kit, sterile gloves and correct swan catheter. Also need extra
iv pole, transducer holder, boxes and cables.
 Check to make sure signed consent is in chart , and that
patient and or family understand procedure.
 Everyone in the room should be wearing a mask.
 Position patient supine and flat if tolerated.
 On the monitor , press “change screen” button , then select “swan ganz”
to allow physician to view catheter wave forms which inserting.
 Assist physician in sterile draping and sterile setup for swan insertion.

12. Setup pressure lines and transducers. Level pressureflush
monitoring system and transducers to the phlebostaticaxis.
 Connect tubings to patient when patient is ready to flushthe
swann.
 While floating the swann, observe for ventricular ectopyon
the monitor.
 After swann is in place, assist with cleanup and let patient
know procedure is complete.
 Obtain all the values. For cardiac output inject 10mls ofD5w
after pushing the start button.
 Perform hemocalculations.
 Document findings in ICU flow sheet.

13. PHLEBOSTATIC AXIS

14. DETERMINANTS OF CARDIAC
PERFORMNACE
 PRELOAD (estimated by end diastolic
volume CVP for RVEDV ; PAOP(wedge)
pressure for LVEDV
 AFTERLOAD (SVR = [MAP-CVP]/CO*80)
 CONTRACTILITY

15. METHODS OF
HEMODYNAMIC
• MONITORING
 1.Arterial Blood Pressure
 a)Non-Invasive
 b)Intra-Arterial Blood Pressure
Measurement
 2.Central Venous Pressure
 3.Pulmonary Artery Catheter Pressure
Monitoring

16. NON INVASIVE ARTERIALBP
MONITORING
 With manual or automated devices
 Method of measurement
 Oscillometry (most common)
 MAP most accurate DP least accurate
 Auscultatory (korotkoff sounds)
 Combination

17. NON INVASIVE
HEMODYNAMIC
MONITORING

18. LIMITATIONS
 Cuff must be placed correctly and must be
appropriately sized
flow
 Auscultatory method is very inaccurate
(Korotkoff sound is difficult to hear)
 Significant underestimation in low
(shock)
 Oscillometric also mostly in accurate
( >5mmhg off directly recorded pressures)

19. DIRECT INTRA ARTERIAL BP
MONITORING
 Intra-arterial BP monitoring is used to obtain
direct and continuous BP measurements in
critically ill patients who have severe
hypertension or hypotension

20. PROCEDURE
 Once an arterial site is selected (radial, brachial,
femoral, or dorsalis pedis), collateral circulation
to the area must be confirmed before the catheter
is placed. This is a safety precaution to prevent
compromised arterial perfusion to the area distal
to the arterial catheter insertion site. If no
collateral circulation exists and the cannulated
artery became occluded,
ischemia and infarction of the area distal to that
artery could occur.
 Collateral circulation to the hand can be checked
by the Allen test

21.  With the Allen test, the nurse compresses the
radial and ulnar arteries simultaneously and asks
the patient to make a fist, causing the hand to
blanch.
 After the patient opens the fist, the nurse
releases the pressure on the ulnar artery
while maintaining pressure on the radial
artery. The patient’s hand will turn pink if the
ulnar artery is patent.

22. COMPLICATION
S
 Local destruction with distal ischemia
 external hemorrhage
 massive ecchymosis
 dissection
 air embolism
 blood loss
 pain
 arteriospasm and
 infection.

23. NURSING INTERVENTIONS
 Before insertion of a catheter, the site is prepared
by shaving if necessary and by cleansing with an
antiseptic solution. A local anesthetic may be
used.
 Once the arterial catheter is inserted, it is secured
and a dry, sterile dressing is applied.
 The site is inspected daily for signs of infection.
The dressing and pressure monitoring system or
water manometer are changed according to
hospital policy.

24.  In general, the dressing is to be kept dry and air
occlusive.
 Dressing changes are performed with the use of sterile
technique.
 Arterial catheters can be used for infusing intravenous
fluids, administering intravenous medications, and drawing
blood specimens in addition to monitoring pressure.
 To measure the arterial pressure, the transducer (when a
pressure monitoring system is used) or the zero mark on the
manometer (when a water manometer is used) must be
placed at a standard reference point, called the phlebostatic
axis .
 After locating this position, the nurse may make an ink mark
on the chest

25. CENTRAL VENOUS PRESSURE
MONITORING
The CVP, the pressure in the vena cava or
right atrium, is used to assess right ventricular
function and venous blood return to the right
side of the heart. The CVP can be
continuously measured by connecting either a
catheter positioned in the vena cava or the
proximal port of a pulmonary artery catheter
to a pressure monitoring system

26. PROCEDUR
E
 Before insertion of a CVP catheter, the site is
prepared by shaving if necessary and by
cleansing with an antiseptic solution.
 A local
physician
anesthetic
threads
used. The
lumen or
multilumen catheter
may be a
single
through the external
jugular, antecubital, or femoral vein into the vena
cava just above or within the right atrium

27. NURSING INTERVENTIONS
 Once the CVP catheter is inserted, it is secured and a dry, sterile
dressing is applied.
 Catheter placement is confirmed by a chest x-ray, and the site is
inspected daily for signs of infection. The dressing and pressure
monitoring system or water manometer are changed according to
hospital policy.
 In general, the dressing is to be kept dry and airocclusive.
 Dressing changes are performed with the use of sterile
technique.

28.  CVP catheters can be used for infusing
intravenous fluids, administering intravenous
medications, and drawing blood specimens in
addition to monitoring pressure.
 To measure the CVP, the transducer (when a
pressure monitoring system is used) or the zero
mark on the manometer (when a water
manometer is used) must be placed at a standard
reference point, called the phlebostatic axis .
 After locating this position, the nurse may make
an ink mark on the chest

29. PULMONARY ARTERY PRESSURE
MONITORING
 Pulmonary artery pressure monitoring is an important tool
used in critical care for assessing left ventricular
function, diagnosing the etiology of shock, and
evaluating
interventions
the patient’sresponse to medical
(eg, fluid administration, vasoactive
medications). Pulmonary artery pressure monitoring is
achieved by using a pulmonary artery catheter and
pressure monitoring system.

30. PULMONARY ARTERY PRESSUREMONITORING

31. PULMONARY ARTERY
CATHETER
 Development of the balloon-tipped
flow directed catheter has enabled
continuous direct monitoring
Pulmonary artery catheter
of PA pressure
known as “swan- ganz catheter”.

32. COMPONENTS OF
CATHETER

33. INSERTION OF PAC
 PA monitoring must be carried out in a critical
care unit under careful scrutiny of an experienced
nursing staff.
 Before insertion of the catheter , explain to the
client that;
 The procedure may be uncomfortable but not
painful.
 A local anesthetic will be given at the catheter
insertion site. Support of the critically ill client at
this time helps promote cooperation and lessen
anxiety.

34. PROCEDURE
 This procedure can be performed in the operating
room or cardiac catheterization laboratory or at the
bedside in the critical care unit.Catheters vary in
their number of lumens and their types of
measurement (eg, cardiac output, oxygen
saturation) or pacing capabilities.
 All types require that a balloon-tipped, flow-
directed catheter be inserted into a large vein
(usually the subclavian, jugular, or femoral vein);
the catheter is then passed into the vena cava and
right atrium.

35.  In the right atrium, the balloon tip is
inflated, and the catheter is carried rapidly by the
flow of blood through the tricuspid valve, into the
right ventricle, through the pulmonic valve, and
into a branch of the pulmonary artery.
 (During insertion of the pulmonary artery
catheter, the bedside monitor is observed for
waveform andECG changes as the catheter is
movedthrough the heart chambers on the right
side and into the pulmonary Artery)

36.  When the catheter reaches a small pulmonary artery,
the balloon is deflated and the catheter is secured
with sutures.
 Fluoroscopy may be used during insertion to
visualize the progression of the catheter through the
heart chambers to the pulmonary artery.
 After the catheter is correctly positioned, the
following pressures can be measured:
 CVP or right atrial pressure
 pulmonary artery systolic and
 diastolic pressures, mean pulmonary artery
pressure, and pulmonary artery wedge pressure).

38. NORMAL
RESULTS
 Normal pulmonary artery pressure is 25/9
mm Hg, with a mean pressure of 15 mm Hg.
 Pulmonary capillary wedge pressure is a
mean pressure and is normally 4.5 to 13 mm
Hg.

39. NURSING INTERVENTIONS
 Catheter site care is essentially the same as for a CVP
catheter. As in measuring CVP, the transducer must be
positioned at the phlebostatic axis to ensure accurate
readings .
 The nurse who obtains the wedge reading ensures that the
catheter has returned to its normal position in the pulmonary
artery by evaluating the pulmonary artery pressure
waveform.
 The pulmonary artery diastolic reading and the wedge
pressure reflect the pressure in the ventricle at end- diastole
and are particularly important to monitor in critically ill
patients, because they are used to evaluate left ventricular
filling pressures (preload)

40.  At end-diastole, when the mitral valve is
open, the wedge pressure is the same as the
pressure in the left atrium and the left
ventricle, unless the patient has mitral valve
disease or pulmonary hypertension.
 Critically ill patients usually require higher
left ventricular filling pressures to optimize
cardiac output. These patients may need to
have their wedge pressure maintained as high
as 18 mm Hg.

41. COMPLICATION
S
 Infection
 pulmonary artery rupture
 pulmonary thromboembolism
 pulmonary infarction
 catheter kinking,
 dysrhythmias, and
 air embolism.

42. DERIVED PARAMETERS
 Cardiac o/p measurements may be combined with systemic arterial,
venous, and PAP determinations to calculate a number of variables
useful in assessing the overall hemodynamic status of the patient.
 They are,
 Cardiac index = Cardiac output / Body surfacearea
 Systemic vascular resistance = [(Mean arterial pressure -
resistance CVP or rt atrial pressure)/Cardiac output] x80
 Pulmonary vascular resistance = [(PAP - PAWP) / Cardiac vascular
resistance output] x 80
 Mixed venous oxygen saturation (SvO2)
(SvO2 = SaO2 - [VO2 / (1.36 x Hb x CO)]
(6)

43. NURSING RESPONSIBILITIES
 Site Care and Catheter Safety:
 A sterile dressing is placed over the insertion site and the
catheter is taped in place. The insertion site should be
assessed for infection and the dressing changed every 72
hours and prn.
 The placement of the catheter, stated in centimeters,
should be documented and assessed every shift.
 The integrity of the sterile sleeve must be maintained so
the catheter can be advanced or pulled back without
contamination.
 The catheter tubing should be labeled and all the
connections secure. The balloon should always be
deflated and the syringe closed and locked unless you are
taking a PCWP measurement

44. PATIENTACTIVITYAND
POSITIONING:
 Many physicians allow stable patients who have
PA catheters, such as post CABG patients, to
getout of bed and sit. The nurse must position
the patient in a manner that avoids
dislodging the catheter.
 Proper positioning during hemodynamic
readings will ensure accuracy.

45. DYSRHYTHMIA
PREVENTION:
 Continuous EKG monitoring is essential
while the PAcatheter is in place.
 Do not advance the catheter unless the
balloon is inflated.
 Antiarrhythmic medications should be
readily available to treat lethal
dysrhythmias.

46. MONITORING WAVEFORMS FOR
PROPER CATHETERPLACEMENT:
 The nurse must be vigilant in assessing the
patient for proper catheter placement. If the
PA waveform suddenly looks like the RV or
PCWP waveform, the catheter may have
become misplaced. The nurse must implement
the proper procedures for correcting the
situation.

47. MONITORING
HEMODYNAMIC VALUES
FOR RESPONSETO
TREATMENTS:
 The purpose of the PA catheter is to assist
healthcare team members in assessing the
patient’s condition and response to treatment.
Therefore, accurate documentation of
values before and after treatment changes is
necessary.

48. ASSESSING THE PATIENT FOR
COMPLICATIONS ASSOCIATED WITH THE
PA-CATHETER:
 Occluded ports
 Balloon rupture caused by overinflating the balloon or
frequent use of the balloon.
 Pneumothorax - may occur during initial placement.
 Dysrhythmias - caused by catheter migration
 Air embolism - caused by balloon rupture or air in the
infusion line.
 Pulmonary thromboembolism - improper flushing
technique, non-heparinized flush solution.
 Pulmonary artery rupture - perforation during placement,
overinflation of the balloon, overuse of the balloon.
 Pulmonary infarction - caused by the catheter migrating into
the wedge position, the balloon left inflated, or thrombus
formation around the catheter which causes an occlusion.

49. CONCLUSION
 Hemodynamics is the forces involved in blood circulation. Hemodynamic
monitoring started with the estimation of heart rate using the simple skill
of 'finger on the pulse' and then moved on to more and more sophisticated
techniques like stethoscope, sphygmomanometer, ECG etc.
 The status of critically ill patients can be assessed either from non-invasive
single parameter indicators or various invasive techniques that provide
multi- parameter hemodynamic measurements.
 As a result, comprehensive data can be provided for the clinician to
proactively address hemodynamic crisis and safely manage the patient
instead of reacting to late indicators of hemodynamic instability