2. 2
What is Hemodynamic Monitoring?
• Non-invasive = clinical assessment & NBP
• Direct measurement of arterial pressure
• Invasive hemodynamic monitoring
3. 3
Noninvasive Hemodynamic Monitoring
• Noninvasive BP
• Heart Rate, pulses
• Mental Status
• Mottling (absent)
• Skin Temperature
• Capillary Refill
• Urine Output
4. 4
Proper Fit of a Blood Pressure Cuff
• Width of bladder = 2/3 of upper arm
• Length of bladder encircles 80% arm
• Lower edge of cuff approximately 2.5 cm
above the antecubital space
5. 5
Why A Properly Fitting Cuff?
• Too small causes false-high reading
• Too LARGE causes false-low reading
6. 6
Indications for
Arterial Blood Pressure
• Frequent titration of vasoactive drips
• Unstable blood pressures
• Frequent ABGs or labs
• Unable to obtain Non-invasive BP
9. 9
Leveling and Zeroing
• Leveling
– Before/after insertion
– If patient, bed or transducer move
• Zeroing
– Performed before insertion & readings
• Level and zero at the insertion site
11. 11
Documentation
• Insertion procedure note
• ABP readings as ordered
• Neurovascular checks every two hours
(in musculoskeletal assessment of HED)
• Pressure line flush amounts (3ml/hr)
• Tubing and dressing changes
12. 12
Central Venous Pressure Assesses . . .
• Intravascular volume status
• Right ventricular function
• Patient response to drugs &/or fluids
13. 13
Central Venous Pressure (CVP)
• Central line or pulmonary artery catheter
• Normal values = 2 – 8 mm Hg
• Low CVP = hypovolemia or ↓ venous return
• High CVP = over hydration, ↑ venous return,
or right-sided heart failure
14. 14
Leveling and Zeroing
• Leveling
– Before/after insertion
– After patient, bed or transducer move
– Aligns transducer with catheter tip
• Zeroing
– Performed before insertion & readings
• Level and zero transducer at the phlebostatic
axis
15. 15
Phlebostatic Axis
• 4th intercostal space, mid-axillary line
• Level of the atria
(Edwards Lifesciences, n.d.)
16. 16
More on Leveling and Zeroing
• HOB 0 – 60 degrees
• No lateral positioning
• Phlebostatic axis with
any position (dotted line)
(Edwards Lifesciences, n.d.)
17. 17
Dynamic Flush
Dynamic flush ensures the integrity
of the pressure tubing system.
Notice how it ascends - forms a
square pattern - and bounces below
the baseline before returning to
the original waveform.
•Check dynamic flush after zeroing
any pressure tubing system
18. 18
System Maintenance
• Change tubing and fluid bag q 96hrs
• No pressors through CVP port
• Antibiotics, NS boluses, blood, & IV pushes
are allowed through the CVP line
19. 19
Troubleshooting
• Improper set-up and equipment malfunction
are the primary causes for hemodynamic
monitoring problems
• Retracing the set-up process or tubing
(patient to monitor) may identify the problem
and solution quickly
• Use your staff resources: Help All, Charge
Nurse, Educator, Preceptors, MICU experts
24. 24
Setting up the Ao
• Discard infusion spike end & cap port
• Connect pressure tubing to vent tubing
(using connector opposite heating cable)
• Connect cables
• Zero the tubing (leveling not necessary)
25. 25
Troubleshooting Ao
• Do not prime tubing with fluids!
• Damping will occur with fluid or secretions
• To evacuate any fluids, disconnect pressure
tubing from vent tubing and push air through
the pressure tubing with a 10 ml syringe
connected at one end until fluid-free
26. 26
1) Record Ao and CVP on the same strip
2) Find end-expiration by drawing a vertical line with a
straight edge 200 ms prior to the rise or dip in Ao (1
large box) associated with a breath.
3) Draw a horizontal line through the visually assessed
average vascular pressure starting at end-expiration
going backward 200 ms (1 large box).
4) Read the pressure at the horizontal line.
Pressure Measurement
15
10
5
0
-5
CVP=13
30. 30
40
30
20
10
0
-10
Incorrect method!
This point was
identified as end-
expiration for a pt.
who did not have an
Ao set up.
Correct method!
30 sec after the above
tracing, Ao was added & true
end-expiration clearly
identified.
33. 33
Summary
•Record Ao with CVP
•Read mean CVP at end-expiration as
described. No need read vascular pressure at
any particular time in the cardiac cycle
34. 34
Documentation of CVP
• Include on waveform strip
– Position of the HOB
– Vasopressors and rates
– Amount of PEEP
– Scale
– CVP measurement
– Signature of the nurse
(post in green chart behind graphics tab)
35. 35
References & Resources
Burns, S. M. (2004). Continuous airway pressure monitoring. Critical Care Nurse, 24(6), 70-74.
Chulay, M., & Burns, S. M. (2006). AACN Essentials of critical care. McGraw-Hill: New York.
Edwards. (2006). Pulmonary Artery Catheter Educational Project. http://www.pacep.org
Edwards Lifesciences. (n.d.) Educational videos. www.edwards.com
MICU Routine Practice Guidelines. www.vanderbiltmicu.com
MICU Bedside Resource Books
MICU Education Kits (Red cart in conference room)
MICU Preceptors, Help All Nurses, & Charge Nurses
VUMC policies. http://vumcpolicies.mc.vanderbilt.edu
