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Determinants of Cardiac Output Intro to Tele Leslie Binder MSN, RN
Heart Facts <ul><li>The adult heart pumps about 5 quarts of blood each minute - approximately 2,000 gallons of blood each ...
Cardiac Anatomy
 
Goal of the Heart <ul><li>Main goal of the heart is to get blood and oxygen to organs and body tissues. </li></ul>Blood Ox...
Hemodynamics <ul><ul><li>Study of the movement and forces of blood within the cardiovascular system (chambers & great vess...
Why is understanding hemodynamics so important?
Hemodynamics will help you evaluate the effectiveness of your patients cardiac function.
Indications for Hemodynamic Monitoring <ul><li>Decreased cardiac output </li></ul><ul><li>Hypovolemia </li></ul><ul><li>He...
Methods of Obtaining Hemodynamic Measurements Heart Rate
Methods of Obtaining Hemodynamic Measurements <ul><ul><li>Non Invasive Blood Pressure Monitoring   </li></ul></ul>Dinamap ...
Invasive Methods of Obtaining Hemodynamic Measurements Arterial Line
Invasive Methods of Obtaining Hemodynamic Measurements <ul><li>Pulmonary Artery </li></ul><ul><li>Catheter (PA Catheter) <...
Signs of Inadequate Perfusion
Factors Influencing  Cardiac Function <ul><li>Autonomic Nervous System </li></ul><ul><li>Renin-Angiotensin System </li></u...
Autonomic Nervous System <ul><li>Internal regulating system that maintains homeostasis within the body. </li></ul><ul><li>...
Baroreceptors and Chronic Hypertension Do not drop BP too low too fast especially in those with chronic hypertension.
Autonomic Nervous System
Renin-Angiotensin System (ARB)
Medications that affect the RAS  <ul><li>Beta Blockers </li></ul><ul><li>Angiotensin converting enzyme inhibitors (ACE ihi...
Role of Electrolytes in Hemodynamcis <ul><li>Electrolytes play a major role in heart muscle function </li></ul><ul><li>Pot...
Example of diseases that affect cardiac function: Cardiomyopathies
Diseases of the Circulatory System that Affect Hemodynamics <ul><li>Atrial Fibrillation </li></ul><ul><li>Aortic Stenosis ...
Basic Hemodynamic Terminology <ul><li>Heart Rate </li></ul><ul><li>Cardiac Output </li></ul><ul><li>Stroke Volume </li></u...
Heart Rate
Factors Affecting Heart Rate Causes of Rapid Heart Rate
Medications That Increase  Heart Rate <ul><li>Meds that increase Heart Rate </li></ul><ul><ul><li>Atropine </li></ul></ul>...
Causes of Low  Heart Rate
Medications that Lower Heart Rate Adenosine Beta Blockers Digoxin Calcium Channel Blockers
Cardiac Output <ul><li>CO= HR x SV </li></ul><ul><li>Example: </li></ul><ul><ul><li>Heart Rate 100bpm </li></ul></ul><ul><...
Factors Causing  Low Cardiac Output <ul><li>Inadequate Left Ventricular Filling  </li></ul><ul><ul><li>Tachycardia </li></...
Factors Causing  Low Cardiac Output <ul><li>Inadequate Left Ventricular Ejection </li></ul><ul><ul><li>Coronary Artery Dis...
High Cardiac Output <ul><li>Healthy patient </li></ul><ul><ul><li>CO ↑ secondary to increased 02 demand (exercise, fear, a...
Stroke Volume <ul><li>Stroke Volume </li></ul><ul><ul><li>Volume of blood ejected from each ventricle with each heartbeat ...
Preload <ul><li>Stretch of the ventricular wall </li></ul><ul><li>Usually related to volume </li></ul><ul><li>Frank Starli...
Preload <ul><li>Factors affecting preload: </li></ul><ul><ul><li>Absolute blood volume </li></ul></ul><ul><ul><li>Distribu...
Conditions Affecting Preload <ul><li>Increased Preload seen in: </li></ul><ul><ul><li>Increased circulating volume/hypervo...
Interventions Affecting Preload  <ul><li>To Increase Preload </li></ul><ul><ul><li>Fluids (0.9% NS, LR) </li></ul></ul><ul...
Afterload <ul><li>The resistance or pressure which the ventricle must overcome to eject its volume of blood during contrac...
Factors Affecting Afterload <ul><ul><li>Ventricular outflow obstruction </li></ul></ul><ul><ul><ul><li>Aortic valve stenos...
Interventions to Increase Afterload  <ul><li>To Increase Afterload: </li></ul><ul><ul><li>Give Vasoconstrictors/Vasopresso...
Interventions to Decrease Afterload  <ul><li>To Decrease Afterload: </li></ul><ul><ul><li>Vasodilators </li></ul></ul><ul>...
Contractility <ul><li>Refers to the inherent ability of the myocardium to contract normally.  Contractility is influenced ...
Conditions That Increase Contractility <ul><li>Sympathetic Stimulation </li></ul><ul><ul><li>Fear or anxiety </li></ul></u...
Conditions That Decrease Contractility <ul><li>Negative Inotropes </li></ul><ul><ul><li>Beta Blockers, Calcium Channel Blo...
How it’s all related Cardiac Output Heart Rate Stroke Volume Preload Afterload Contractility Usually set by  SA node
Mean Arterial Pressure <ul><li>MAP is considered to be the perfusion pressure seen by the organs in the body. </li></ul><u...
Pulse Pressure <ul><li>Difference between systolic and diastolic pressures </li></ul><ul><ul><li>Representative of Stroke ...
Cardiac Index <ul><li>CI = CO/BSA </li></ul><ul><li>Normal range for CI is 2.5-4.0 L/min/m² </li></ul>
Ejection Fraction <ul><li>The amount of blood estimated to be pumped out of the LV to the rest of the body with each heart...
Assessment Findings in Compromised Hemodynamics <ul><li>Drop in BP </li></ul><ul><li>Rapid weak pulses </li></ul><ul><li>C...
Nursing Considerations <ul><li>Know your patient’s baseline blood pressure. </li></ul><ul><li>Rapid heart rates lead to mo...
Conclusion
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Determinants of cardiac output for captivate

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Determinants of cardiac output for captivate

  1. 1. Determinants of Cardiac Output Intro to Tele Leslie Binder MSN, RN
  2. 2. Heart Facts <ul><li>The adult heart pumps about 5 quarts of blood each minute - approximately 2,000 gallons of blood each day - throughout the body. </li></ul><ul><li>The heart beats about 100,000 times each day. </li></ul><ul><li>In a 70-year lifetime, the average human heart beats more than 2.5 billion times. </li></ul>
  3. 3. Cardiac Anatomy
  4. 5. Goal of the Heart <ul><li>Main goal of the heart is to get blood and oxygen to organs and body tissues. </li></ul>Blood Oxygen and Glucose
  5. 6. Hemodynamics <ul><ul><li>Study of the movement and forces of blood within the cardiovascular system (chambers & great vessels) </li></ul></ul><ul><ul><li>Often monitored via the use of invasive lines and accompanying equipment </li></ul></ul><ul><ul><li>Can be obtained using direct and indirect measures </li></ul></ul>
  6. 7. Why is understanding hemodynamics so important?
  7. 8. Hemodynamics will help you evaluate the effectiveness of your patients cardiac function.
  8. 9. Indications for Hemodynamic Monitoring <ul><li>Decreased cardiac output </li></ul><ul><li>Hypovolemia </li></ul><ul><li>Hemorrhage </li></ul><ul><li>GI bleed </li></ul><ul><li>Burns </li></ul><ul><li>Shock (Cardiogenic, Septic, Neurogenic) </li></ul><ul><li>Post Surgery </li></ul><ul><li>Acute MI </li></ul><ul><li>Cardiomyopathy </li></ul><ul><li>Congestive Heart Failure </li></ul>
  9. 10. Methods of Obtaining Hemodynamic Measurements Heart Rate
  10. 11. Methods of Obtaining Hemodynamic Measurements <ul><ul><li>Non Invasive Blood Pressure Monitoring </li></ul></ul>Dinamap Manual Method Doppler
  11. 12. Invasive Methods of Obtaining Hemodynamic Measurements Arterial Line
  12. 13. Invasive Methods of Obtaining Hemodynamic Measurements <ul><li>Pulmonary Artery </li></ul><ul><li>Catheter (PA Catheter) </li></ul>
  13. 14. Signs of Inadequate Perfusion
  14. 15. Factors Influencing Cardiac Function <ul><li>Autonomic Nervous System </li></ul><ul><li>Renin-Angiotensin System </li></ul><ul><li>Electrolytes </li></ul><ul><li>Diseases and or abnormalities of the circulatory system </li></ul>
  15. 16. Autonomic Nervous System <ul><li>Internal regulating system that maintains homeostasis within the body. </li></ul><ul><li>Composed of a network of nerves that send signals to the heart and other organs. </li></ul><ul><li>Divided into Parasympathetic and Sympathetic Nervous System. </li></ul><ul><li>Baroreceptors play a role in </li></ul><ul><li>blood pressure regulation. </li></ul>
  16. 17. Baroreceptors and Chronic Hypertension Do not drop BP too low too fast especially in those with chronic hypertension.
  17. 18. Autonomic Nervous System
  18. 19. Renin-Angiotensin System (ARB)
  19. 20. Medications that affect the RAS <ul><li>Beta Blockers </li></ul><ul><li>Angiotensin converting enzyme inhibitors (ACE ihibitors) </li></ul><ul><li>Angiotensin receptor blockers </li></ul><ul><li>Aldosterone blockade </li></ul><ul><li>Direct Renin Inhibitors </li></ul>
  20. 21. Role of Electrolytes in Hemodynamcis <ul><li>Electrolytes play a major role in heart muscle function </li></ul><ul><li>Potassium </li></ul><ul><li>Magnesium </li></ul><ul><li>Calcium </li></ul>
  21. 22. Example of diseases that affect cardiac function: Cardiomyopathies
  22. 23. Diseases of the Circulatory System that Affect Hemodynamics <ul><li>Atrial Fibrillation </li></ul><ul><li>Aortic Stenosis </li></ul><ul><li>Bradycardia </li></ul><ul><li>Cardiac Tamponade </li></ul><ul><li>Heart Blocks </li></ul><ul><li>Myocardial Infarction </li></ul><ul><li>Supraventricular Tachycardias </li></ul><ul><li>Ventricular Arrhythmias </li></ul>
  23. 24. Basic Hemodynamic Terminology <ul><li>Heart Rate </li></ul><ul><li>Cardiac Output </li></ul><ul><li>Stroke Volume </li></ul><ul><li>Preload </li></ul><ul><li>Afterload </li></ul><ul><li>Contractility </li></ul><ul><li>Mean Arterial Pressure </li></ul><ul><li>Ejection Fraction </li></ul><ul><li>Cardiac Index </li></ul>
  24. 25. Heart Rate
  25. 26. Factors Affecting Heart Rate Causes of Rapid Heart Rate
  26. 27. Medications That Increase Heart Rate <ul><li>Meds that increase Heart Rate </li></ul><ul><ul><li>Atropine </li></ul></ul><ul><ul><li>Epinepherine </li></ul></ul><ul><ul><li>Dopamine (2-10mcg/kg/min) </li></ul></ul><ul><li>Pacemaker </li></ul>
  27. 28. Causes of Low Heart Rate
  28. 29. Medications that Lower Heart Rate Adenosine Beta Blockers Digoxin Calcium Channel Blockers
  29. 30. Cardiac Output <ul><li>CO= HR x SV </li></ul><ul><li>Example: </li></ul><ul><ul><li>Heart Rate 100bpm </li></ul></ul><ul><ul><li>Stroke Volume 50mL/beat </li></ul></ul><ul><ul><li>CO=5,000 mL per min or 5 L/min </li></ul></ul><ul><ul><li>Normal CO is 4-6 L/min </li></ul></ul>
  30. 31. Factors Causing Low Cardiac Output <ul><li>Inadequate Left Ventricular Filling </li></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li>Rhythm disturbance </li></ul></ul><ul><ul><li>Hypovolemia </li></ul></ul><ul><ul><li>Mitral or Tricuspid Stenosis </li></ul></ul><ul><ul><li>Pulmonic Stenosis </li></ul></ul><ul><ul><li>Constrictive Pericarditis or Tamponade </li></ul></ul><ul><ul><li>Restrictive Cardiomyopathy </li></ul></ul>
  31. 32. Factors Causing Low Cardiac Output <ul><li>Inadequate Left Ventricular Ejection </li></ul><ul><ul><li>Coronary Artery Disease causing LV ischemia or infarction </li></ul></ul><ul><ul><li>Myocarditis or cardiomyopathy </li></ul></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>Aortic Stenosis </li></ul></ul><ul><ul><li>Mitral Regurgitation </li></ul></ul><ul><ul><li>Drugs that are negative inotropes </li></ul></ul><ul><ul><li>Metabolic disorders </li></ul></ul>
  32. 33. High Cardiac Output <ul><li>Healthy patient </li></ul><ul><ul><li>CO ↑ secondary to increased 02 demand (exercise, fear, anxiety). </li></ul></ul><ul><li>In hospital </li></ul><ul><ul><li>Response to systemic inflammation (Sepsis). </li></ul></ul>
  33. 34. Stroke Volume <ul><li>Stroke Volume </li></ul><ul><ul><li>Volume of blood ejected from each ventricle with each heartbeat </li></ul></ul><ul><ul><li>Normal 50-100 mL per beat </li></ul></ul><ul><ul><li>Decreased SV= increased HR </li></ul></ul>Determinants of Stroke Volume Preload Afterload Contractility
  34. 35. Preload <ul><li>Stretch of the ventricular wall </li></ul><ul><li>Usually related to volume </li></ul><ul><li>Frank Starlings Law: </li></ul><ul><li>How full is the tank? </li></ul>
  35. 36. Preload <ul><li>Factors affecting preload: </li></ul><ul><ul><li>Absolute blood volume </li></ul></ul><ul><ul><li>Distribution of blood in body </li></ul></ul><ul><ul><li>Atrial kick </li></ul></ul><ul><ul><li>Ventricular function </li></ul></ul><ul><ul><li>Ventricular compliance </li></ul></ul>
  36. 37. Conditions Affecting Preload <ul><li>Increased Preload seen in: </li></ul><ul><ul><li>Increased circulating volume/hypervolemia </li></ul></ul><ul><ul><li>Mitral insufficiency </li></ul></ul><ul><ul><li>Aortic insufficiency </li></ul></ul><ul><ul><li>Heart Failure </li></ul></ul><ul><li>Decreased Preload seen in: </li></ul><ul><ul><li>Decreased circulating volume (bleeding, third spacing) </li></ul></ul><ul><ul><li>Mitral stenosis </li></ul></ul><ul><ul><li>Vasodilator use (NTG) </li></ul></ul><ul><ul><li>Asynchrony of atria and ventricles </li></ul></ul><ul><ul><li>Cardiac tamponade </li></ul></ul><ul><ul><li>Atrial Fib </li></ul></ul>
  37. 38. Interventions Affecting Preload <ul><li>To Increase Preload </li></ul><ul><ul><li>Fluids (0.9% NS, LR) </li></ul></ul><ul><ul><li>Vasopressors (only effective if tank is “full”) </li></ul></ul><ul><ul><li>Blood and or blood products </li></ul></ul><ul><ul><li>Volume expanders </li></ul></ul><ul><li>Decrease Preload </li></ul><ul><ul><li>Diuretics </li></ul></ul><ul><ul><ul><li>Lasix, Aldactone </li></ul></ul></ul><ul><ul><li>Vasodilators such as nitrates, Morphine </li></ul></ul>
  38. 39. Afterload <ul><li>The resistance or pressure which the ventricle must overcome to eject its volume of blood during contraction. </li></ul><ul><li>Right Ventricle </li></ul><ul><ul><li>Pulmonary Vascular Resistance (PVR) </li></ul></ul><ul><li>Left Ventricle </li></ul><ul><ul><li>Systemic Vascular Resistance (SVR) </li></ul></ul>
  39. 40. Factors Affecting Afterload <ul><ul><li>Ventricular outflow obstruction </li></ul></ul><ul><ul><ul><li>Aortic valve stenosis </li></ul></ul></ul><ul><ul><li>Sympathetic NS stimulation </li></ul></ul><ul><ul><ul><li> epinephrine released  increased PVR </li></ul></ul></ul><ul><ul><li>HTN </li></ul></ul><ul><ul><li>Hypercoagulability </li></ul></ul>
  40. 41. Interventions to Increase Afterload <ul><li>To Increase Afterload: </li></ul><ul><ul><li>Give Vasoconstrictors/Vasopressors </li></ul></ul><ul><ul><ul><li>Dopamine (↑contractility,↑02 consumption) </li></ul></ul></ul><ul><ul><ul><li>Dobutamine </li></ul></ul></ul><ul><ul><ul><li>Epinepherine- vasoconstrictor, ↑HR </li></ul></ul></ul><ul><ul><ul><li>Norepinepherine </li></ul></ul></ul><ul><li>Be sure to correct hypovolemia with volume replacement before considering vasopressors. </li></ul>
  41. 42. Interventions to Decrease Afterload <ul><li>To Decrease Afterload: </li></ul><ul><ul><li>Vasodilators </li></ul></ul><ul><ul><li>Arterial Dilators: Morphine, Nitroprusside, Hydralazine, Clonidine, Labetelol, Ace Inhibitors, ARBs </li></ul></ul><ul><ul><li>Intra Aortic Balloon Pump (IABP) </li></ul></ul>
  42. 43. Contractility <ul><li>Refers to the inherent ability of the myocardium to contract normally. Contractility is influenced by preload. </li></ul><ul><li>Affected by: </li></ul><ul><ul><li>Ventricular muscle mass </li></ul></ul><ul><ul><li>Heart Rate </li></ul></ul><ul><ul><li>Oxygen status </li></ul></ul><ul><ul><li>Chemical or pharmacological effects </li></ul></ul>
  43. 44. Conditions That Increase Contractility <ul><li>Sympathetic Stimulation </li></ul><ul><ul><li>Fear or anxiety </li></ul></ul><ul><li>Calcium </li></ul><ul><li>Inotropes </li></ul><ul><ul><li>Digitalis </li></ul></ul><ul><ul><li>Milrinone </li></ul></ul><ul><ul><li>Epinepherine </li></ul></ul><ul><ul><li>Dobutamine </li></ul></ul>
  44. 45. Conditions That Decrease Contractility <ul><li>Negative Inotropes </li></ul><ul><ul><li>Beta Blockers, Calcium Channel Blockers, barbituates and most antidysrythmics. </li></ul></ul><ul><li>Infarction </li></ul><ul><li>Cardiomyopathy </li></ul><ul><li>Vagal Stimulation </li></ul><ul><li>Hypoxemia </li></ul><ul><li>Acidosis </li></ul>
  45. 46. How it’s all related Cardiac Output Heart Rate Stroke Volume Preload Afterload Contractility Usually set by SA node
  46. 47. Mean Arterial Pressure <ul><li>MAP is considered to be the perfusion pressure seen by the organs in the body. </li></ul><ul><li>Goal = MAP > 60mm/Hg </li></ul><ul><li><60 leads to ischemia </li></ul><ul><li>Calculated MAP= 2 x Dialstolic +Systolic </li></ul><ul><ul><ul><ul><ul><li>3 </li></ul></ul></ul></ul></ul>
  47. 48. Pulse Pressure <ul><li>Difference between systolic and diastolic pressures </li></ul><ul><ul><li>Representative of Stroke Volume and arterial capacitance </li></ul></ul><ul><ul><li>Normal range 30-40mm/Hg </li></ul></ul><ul><ul><li>Changes in pulse pressure can indicate certain conditions (exercise, shock, heart failure). </li></ul></ul>
  48. 49. Cardiac Index <ul><li>CI = CO/BSA </li></ul><ul><li>Normal range for CI is 2.5-4.0 L/min/m² </li></ul>
  49. 50. Ejection Fraction <ul><li>The amount of blood estimated to be pumped out of the LV to the rest of the body with each heartbeat. </li></ul><ul><li>Normal range is 50- 75%. </li></ul><ul><li>Systolic dysfunction occurs when EF falls below 50%. </li></ul><ul><li>Measured by echocardiogram, nuclear study, MRI, CT. </li></ul>
  50. 51. Assessment Findings in Compromised Hemodynamics <ul><li>Drop in BP </li></ul><ul><li>Rapid weak pulses </li></ul><ul><li>Change in LOC </li></ul><ul><li>Cold, mottled, cyanotic skin </li></ul><ul><li>Tachycardia </li></ul><ul><li>Tachypnea </li></ul><ul><li>Complaints of lightheadedness </li></ul><ul><li>Decreased urine output </li></ul><ul><li>Hypoxia </li></ul><ul><li>Edema </li></ul>
  51. 52. Nursing Considerations <ul><li>Know your patient’s baseline blood pressure. </li></ul><ul><li>Rapid heart rates lead to more oxygen consumed. </li></ul><ul><li>To decrease workload of the heart consider grouping patient activities throughout the shift. </li></ul><ul><li>Use caution when lowering blood pressure too rapidly in patients with chronic HTN. </li></ul><ul><li>In states of low perfusion or low BP, body compensates by increasing heart rate. </li></ul>
  52. 53. Conclusion

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