This document discusses hemodynamic monitoring, which involves measuring the pressure, flow, and oxygenation of blood within the cardiovascular system. It describes both noninvasive and invasive methods of hemodynamic monitoring. Noninvasive methods include measuring vital signs like blood pressure and heart rate, while invasive methods involve placing catheters in the central circulation to directly measure pressures. Specific invasive monitoring techniques covered are arterial line placement, central venous pressure monitoring via a central line, and pulmonary artery catheterization to measure pressures and determine cardiac output. Normal ranges for various hemodynamic parameters are also provided.

1. Hemodynamic
Monitoring
Manisha
2nd Year

2. Definition
• Haem+Dynamo
• Measure perfusion to the whole body
• The measurement and interpretation of biological systems
that describe performance of the cardiovascular system
• It refers to measurement of pressure, flow and oxygenation
of blood within the cardiovascular system.

3. Goals of Monitoring
 To assure the adequacy of perfusion.
 Early detection of an inadequacy of perfusion - decision
making: is monitoring sufficient, or does the patient need
active intervention?
 To titrate therapy to specific hemodynamic endpoints in
unstable patients.
 To differentiate among various organ system
dysfunction's.

4. Purpose of monitoring
 Early detection, identification and treatment of life threatening
conditions such as heart failure and cardiac tamponade.
 Evaluate the patient’s immediate response to treatment such
as drugs and mechanical support.
 Evaluate the effectiveness of cardiovascular function such as
cardiac output and index.

5. 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, haemorrhage. G.I
bleed, burns or surgery.

6. Principles
 Hemodynamic monitoring involves assessment of
several physiological parameters pertaining to
the circulatory system
 preload (Filling pressure)
 Contractility (Force of contraction)
 afterload

7. Principles contd..
 Single readings of data are not as significant as trends
of data- The question for the nurse is what is the expected
range for this particular patient? Use the patient's own values
for a norm of reference for one's expected range.
 The context of the readings are important. What were
the previous readings? How has the patient changed? What
interventions occurred prior to this set of readings? How do
the readings compare to the physical assessment of the
patient?

8. Principles contd..
 Know your equipment. know when equipment is
malfunctioning, to recognize critical situations with the
equipment, and to respond appropriately to crises
associated with the equipment.
 The phlebostatic axis on the patient is the anatomical
landmarks which show placement of a transducer level
to the right atrium of the heart.

9. Types of Hemodynamic Monitoring
Noninvasive Hemodynamic Monitoring
• Blood Pressure
• Heart Rate
• Mottling
• Skin Temperature
• Capillary Refill
• Urine Output
• Pulse Oximetry

10. Invasive Hemodynamic Monitoring
 Central Venous Pressure
 Arterial Pressure
 Pulmonary Artery Pressure
 Cardiac Output
 Stroke Volume
 Stroke Volume Variance
 Systemic Vascular
Resistance
 Cardiac Index
 Right Ventricular Pressure (systolic)
 Right Ventricular Pressure (end
diastolic)
 Pulmonary Artery Systolic Pressure
 Pulmonary Artery Diastolic Pressure
 Pulmonary Artery Mean Pressure
 Pulmonary Artery Occlusion Pressure

11. Non-Invasive
methods

12. Non-Invasive Methods
• Look listen and feel
• Decreased perfusion causes:
 Primary signs:- Skin and gut
 Cold-clammy skin- pale and cyanotic
 Decreased bowel sounds, Diarrhea/constipation
 Secondary signs:- Kidney, Liver and lungs
 Inc RR, SOB, dec pao2, spo2
 Conc. Urine, dec UO, inc BUN/Creat/K
 Inc ALT/AST/Clotting

13. Contd..
 Final Signs:- Brain and Heart
 Dec LOC, Disorientation, chest pain, inc/dec HR

14. Non-Invasive Blood Pressure
monitoring
• Systolic Blood Pressure
• Diastolic Blood Pressure
• Pulse Pressure
Mean Arterial pressure
• MAP = SBP + 2 (DBP)
3
• Tells about the organ perfusion
• 70-100 mmHg

15. Non-Invasive Methods
• Heart Rate (60-100 bpm)
• Capillary refill time ( <3 sec)
• Skin temperature-
• Pulse oximetry
• Urine output- oliguria and anuria

16. Skin mottling

17. Invasive
methods

18. Arterial BP Monitoring
Indication:-
• Continuous monitoring of systemic arterial blood
pressure.
• Frequent ABG
• Continuous real time monitoring
• Failure of non-Invasive BP

19. Basic principles
• The pressure waveform of the arterial pulse is
transmitted via the column of fluid, to a pressure
transducer where it is converted into an electrical signal.
• The electrical signal is then processed, amplified and
then converted into a visual display by a microprocessor.

21. Components of IBP system

22. Phlebostaxis axis
• Intersection of 4th ICS and ½ of the AP diameter of the
chest.

24. Arterial Waveform

27. Central Line
Indications
 Medical condition requiring intravenous access to central
circulation
 Post-operative monitoring for management of fluid volume
status
 Hypovolemic shock
 Burns or trauma requiring rapid fluid resuscitation
 Total parenteral nutrition (TPN)
 Monitoring of central venous pressure (CVP)

28. Central Venous pressure
• It is the pressure measured at the junction of the
superior vena cava and the right atrium (RAP)
• It indicates estimate of right ventricular preload.
• Normal range=5 to 10 cm H2O or 3 to 8 mm Hg

29. Common sites

30. CVP Insertion site

31. CVP Catheter
• Distal – 16 gauge- CVP monitoring
• Proximal- 18 gauge
• Medial- 18 gauge

32. CVP catheter

33. Monitoring of CVP with transducer
 Position patient supine.
 Check level of transducer with phlebostatic axis.
 During first assessment of shift, zero transducer to air.
 Assess waveform for dampness.
 Maintain tight luer-lok connections and nonvented caps
on stopcocks of pressure tubing.
 Record CVP pressure from the monitor
• Normal Range 2-6 mmHg (3-8 cm H2O)

34. CVP Interpretations
If CVP is LOW
• The patient's circulating fluid volume is low (dehydration,
diuresis, bleeding, Cardiac temponade). The patient might
go into hypovolemic shock.
Nursing Interventions
 Encourage patient to drink more fluids.
 Increase IV fluid infusion rate.
 Transfuse blood if indicated.

35. Contd..
If CVP is HIGH
• The patient is in an Overhydration or fluid overload state. Possibly the
patient is in renal failure. Perhaps IV fluids are infusing too fast a rate.
Nursing Interventions
 Fluid restriction.
 Diuretic to enhance fluid elimination.
 Reduce IV infusion rates.
 Assess urine output to see if there are any obstructions to urine flow or
evidence of acute renal failure.
 Assess laboratory work for possibility of renal failure.

36. CVP Waveforms

37. Pulmonary Arterial Catheter
Indications
 Medical condition associated with heart failure or
cardiogenic shock
 Assessment of volume status
 Post-operative monitoring for management of
hemodynamics after cardiac surgery
 Continuous thermodilution measurement of cardiac
output.
 Monitoring core body temperature

38. Pulmonary artery catheters
• 7-7 Fr circumferences
• 110 cm long
• Four internal lumen
1. Distal-pulmonary artery pressure monitoring
2. Proximal- CVP monitoring
3. Balloon inflation tip
4. Thermistor tip

40. Pulmonary artery wedge pressure-
• It is the pressure measured by wedging a pulmonary
catheter with an inflated balloon into a small pulmonary
arterial branch.
• It estimates the left atrial pressure.

41. Monitoring Pressure
 Position patient supine.
 Check level of transducer with phlebostatic axis.
 During first assessment of shift, zero transducer to air.
 Assess waveform for dampness.
 Maintain tight luer lok connections and nonvented caps
on stopcocks of pressure tubings.
 Record PA systolic, PA diastolic, and PA mean pressures
 Open the PA catheter balloon port.

42. Contd..
 Use the safety syringe that comes with the catheter
kit. While watching the waveform on the monitor, inject
air into the balloon port until the waveform changes to
PAOP.
 Record PAOP reading.
 Release the safety syringe and allow it to deflate
passively. If necessary, remove the syringe from the
balloon port leaving the balloon port open to air.
 Check the waveform to insure that it has changed back to
the pulmonary artery waveform.

44. Normal Ranges
 Right Ventricular Pressure (systolic): 15 – 30 mm Hg
 Right Ventricular Pressure (end diastolic): < 6 mm Hg
 Pulmonary Artery Systolic Pressure: 20 – 30 mm Hg
 Pulmonary Artery Diastolic Pressure: 5 – 10 mm Hg
 Pulmonary Artery Mean Pressure: 10 – 15 mm Hg
 Pulmonary Artery Occlusion Pressure: 5 – 12 mm Hg

45. Thermodilution
• Determination of cardiac output by measurement of the
change in temperature in the bloodstream after injection
of a known amount of cooled saline fluid.
Indications
• Shock- cardiogenic, septic and hypovolemic
• Sepsis, trauma.

46. Process
• 2 lines needed.
• Inject Cold saline (5,10,15,20ml) from pulmonary
catheter site
• Using thermistor for checking temperature
• Perform settings in monitor also (CVP, Injectate)
• Monitor will give CO for each cycle
• Perform process atleast for 3 times
• Take average of all 3 readings.

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