Blood pressure monitoring NIBP IBP Central venous pressure monitoring Pulmonary artery pressure monitoring Mixed venous oxygen monitoring Cardiac output

1. Clinical monitoring in
the ICU
Dr. Abhijit Diwate (Associate Professor)
Cardio-Vascular & Respiratory PT
DVVPF College of Physiotherapy,
Ahmednagar 414111

2. Objectives
 Blood pressure monitoring
 NIBP
 IBP
 Central venous pressure monitoring
 Pulmonary artery pressure monitoring
 Mixed venous oxygen monitoring
 Cardiac output

3. Why monitor BP?
 Alterations inherent
 Provides data for interpretation/therapeutic
decisions
 Important for determining organ perfusion (MAP
most important, except with the heart)

4. Noninvasive Hemodynamic Monitoring
 Noninvasive BP
 Heart Rate, pulses
 Mental Status
 Mottling (absent)
 Skin Temperature
 Capillary Refill
 Urine Output

5. Central Venous
Pressure Monitoring

6.  CVP measures the filling pressure
of the right ventricular (RV); it
gives an estimate of the
intravascular volume status and is
an interplay of the:
(1) circulating blood volume
(2) venous tone and
(3) right ventricular function.

7. NORMAL CVP
MEASUREMENTS
 CVP monitoring should normally show
measurements as follows:
 Mid Axilla: 0 - 8 mmHg
 An isolated CVP reading is of limited value;
a trend of readings is much more significant
and should be viewed in conjunction with
other parameters e.g. BP and urine output.

8. sites
A. Central line from peripheral site (antecubital
fossa commonly selected)
B. Femoral site
C. External jugular site
D. Subclavian site
E. Internal jugular site
 All have their own indications, contraindications,
advantages & disadvantages

9. Equipment
 Sterile gloves
 Sterile gown and mask (optional)
 Sterile prep solution
 Local anesthetic
 Syringes
 Sterile flush solution
 Suture material (might be included in the kit)
 Dressing material
 Manometer set (this may vary according to whether C.V.P. to be
transduced or not )
 500ml of0.9% Sodium Chloride. (500ml Sodium Chloride with 500
units heparin used in transduced circuits only)
 Pressure bag (only used in transduced circuits)
 Sedatives (if required)

10. WATER MANOMETER:
 Simple & inexpensive
 Any piece of open IV tubing can be used
 Specific problems include:
 Placement of the catheter in the right ventricle
 TR with a large reflux pressure wave
 Giant ‘a’ waves from the atrium ( cannon waves, A-V
dissociation & nodal rhythms)
Each of these will lead to CVP measurements which
may be misleading, & markedly different from the real
prassure

11. EQUIPMENT
(a) a sterile bag of fluids
(b) attached fluid administration set
(c) an IV extension set
(d) a manometer and
(e) a stopcock
a.
b.
c.
d.
e.

12. PRESSURE
TRANSDUCER:
 An electronic system with fast response time &
gives a more accurate wave representation
 This enables maximum & minimum pressures to
be identified as well as visualization of the wave
form which may supply information about the
presence, for example of tricuspid
incompetence
 Further more the mean pressure can be
measured & this is usually the true CVP as it
takes in to account the respiratory cycle

13.  Disadvantages:
 Complex in setting up the system
 Costly
 Nursing staff need to be familiar with the system
 There is always a risk of electronic problems
(such as ‘baseline drift‘ or mechanical damping
of the system by unnoticed air bubbles in the line
or transducer dome

14. INFORMATION FROM THE CVP
WAVEFORM
 Besides the actual pressure measurement
there is much information that can be gained
from examining the waveforms

15. WAVEFORMS IN CVP
consists of three upwards (a, c, & v waves) and two
downward defections (x and y descents).
1. ‘a’ wave → by right atrial contraction and occurs just
after the P wave on the ECG.
2. The ‘c’ wave → due to isovolumic ventricular contraction
forcing the tricuspid valve to bulge upward into the RA
3. The pressure within the RA then decreases as the
tricuspid valve is pulled away from the atrium during
right ventricular ejection, forming the X descent.
4. The RA continues to fill during late ventricular systole,
forming the V wave
5. The Y descent occurs when the tricuspid valve opens
and blood from the RA empties rapidly into the RV
during early diastole

16. THE CVP WAVEFORM
 Reflects changes in right atrial pressure
during the cardiac cycle

17. Respiratory variation in CVP
 The respiratory pattern in CVP can be used to
predict fluid responsiveness
 patients who have no inspiratory fall in CVP are
on the flat part of their cardiac function curve
and will not respond to fluids whereas patients
who have an inspiratory fall in CVP are on the
ascending part of the cardiac function curve and
may or may not respond to fluids, depending
how close they start to the plateau
 Patients with an inspiratory fall in CVP are also
more likely to have a fall in cardiac output with
the application of PEEP

18. Complications of central venous
catheterization
 Complications of central venous cannulation
 Arterial puncture with hematoma
 Arteriovenous fistula
 Hemothorax
 Chylothorax
 Pneumothorax
 Nerve injury Brachial plexus Stellate ganglion (Horner’s syndrome)
 Air emboli
 Catheter or wire shearing
 Complications of catheter presence
 Thrombosis, thromboembolism
 Infection, sepsis, endocarditis
 Arrhythmias
 Hydrothorax

19. REMOVAL OF CENTRAL LINE
 THIS IS AN ASEPTIC PROCEDURE
 THE PATIENT SHOULD BE SUPINE WITH HEAD
TILTED DOWN
 ENSURE NO DRUGS ARE ATTACHED AND
RUNNING VIA THE CENTRAL LINE
 REMOVE DRESSING
 CUT THE STITCHES
 SLOWLY REMOVE THE CATHETER
 IF THERE IS RESISTENCE THEN CALL FOR
ASSISTANCE
 APPLY DIGITAL PRESSURE WITH GAUZE UNTIL
BLEEDING STOPS
 DRESS WITH GAUZE AND CLEAR DRESSING EG
TEGADERM

20. PULMONARY ARTERY AND PULMONARY
CAPILLARY WEDGE PRESSURE
MONITORING
 The introduction of pulmonary artery catheter
(PAC) in clinical medicine  one of the most
popular and important advances in monitoring.
 With this catheter:
 PAP, PCWP & CVP can be measured easily
 under most circumstances provides an accurate
estimate of the diastolic filling (preload) of the left
heart
 Cardiac output determination using thermo-dilution
technique is an equally important use of this catheter

21. Indications For PAP & PCWP
Monitoring
A. Cardiac problems/surgery:
 Poor LV function (EF<0.4; LVEDP> 18 mm Hg)
 Recent MI
 Pts with right heart failure
 Procedures involving CPB
 Complications of MI eg. MR, VSD, ventricular aneurysm.
 Combined lesions eg. CAD+MR or CAD+AS
 Complicated lesions eg. IHSS
 Hemodynamically unstable pts requiring inotropes or IABP counterpulsation
 Major procedures with large fluid shifts and/or blood loss in pts with CAD
B. Non-cardiac situations:
 Shock of any cause or MOF
 Severe pulmonary disease , COPD , PHTN, or PE
 Pts requiring high levels of PEEP
 Bleomycin toxicity
 Complicated surgical procedure
 Massive trauma
 Hepatic transplantation

22. PA (Swan-Ganz) Catheter description
 The standard 7F thermo-dilution pulmonary
artery catheter consists of a single catheter 110
cm in length containing four lumina.
 It is constructed of flexible, radio-opaque
polyvinyl chloride.
 10 cm increments are marked in black on the
catheter beginning at the distal end.
 At the distal end of the catheter is a latex balloon
of 1.5 cc capacity.
 When inflated, the balloon extends slightly
beyond the tip of the catheter but does not
obstruct it

24. PULMONARY ARTERY
CATHETER

25. Types of PA catheters
1.1. The thermo dilution catheter:The thermo dilution catheter:
 is the one described above; using this catheter,
thermo dilution cardiac output & other divided
haemodynamic parameters may be measured
2.2. Pacing:Pacing:
 Some PAC’s have the capacity to provide intra
cardiac pacing

26. 3.3. Mixed venous oxygen saturation:Mixed venous oxygen saturation:
 Special fiber-optic PAC can be used to monitor
mixed venous oxygen saturation SVO2
continuously by the principle of absorption and
reflectance of light through blood
 The normal SVO2 is 75%normal SVO2 is 75% and a 5– 10 %
increase or decrease is considered significant
 A significant decrease in SVO2decrease in SVO2 may be due to:
(a) a decrease in the cardiac output
(b) increase in metabolic rate
(c) decrease in arterial oxygen saturation.

27. 4.4. Ejection fraction catheter :Ejection fraction catheter :
 New-catheters with faster thermistor response times
can be used to determine the right ventricular ejectionright ventricular ejection
fraction in addition to the cardiac outputfraction in addition to the cardiac output
5.5. Continuous cardiac output measurement :Continuous cardiac output measurement :
 Continuous cardiac output measuring PACs contain an
integrated thermal filament at level of the RV
 This filament is activated in a programmed sequence
to provide small amounts of heat, which is then
detected in the PA by a thermistor
 The data by the device yields a rapidly updated, near
continuous value for cardiac output

32. INVASIVE HEMODYNAMIC
MONITORING

33. PA Insertion Waves

34. Components of the Monitoring
System
 Bedside monitor – amplifier is located inside
 The amplifier increases the size of signal
 Transducer – changes the mechanical energy
or pressures of pulse into electrical energy;
should be level with the phlebostatic axis
(intersecting lines from the 4th
ICS,mid axillary
line)

35. Phlebostatic Axis

36. Pulmonary Artery Pressure
Monitoring
 Contraindications
 AbsoluteAbsolute
 Tricuspid or Pulmonary valve stenosis
 RA or RV masses
 Tetralogy of Fallot
 RelativeRelative
 Severe arrhythmias
 Coagulopathy
 Newly inserted pacemaker wires

37. Complications of Swan-Ganz
A. Complications of cannulationComplications of cannulation
 Arterial puncture (carotid, subclavia)
 Haematoma, haemothorax
 Pleural effusion iv) Nerve injury (brachial plexus, stellate
ganglion)
 Emboli (air, catheter insertion)
B. Complications of catheter insertionComplications of catheter insertion
 Cardiac perforation
 Cardiac dysrhythmia , heart block
 Knotting
 Tricuspid, pulmonary valve injury
C. Complications of catheter presenceComplications of catheter presence
 Thrombosis, thromboembolism
 Infection, endocarditis, sepsis
 Pulmonary artery rupture iv) Pulmonary infarction

38. Summary
 Blood pressure monitoring
 NIBP
 IBP
 Central venous pressure monitoring
 Pulmonary artery pressure monitoring
 Mixed venous oxygen monitoring
 Cardiac output

39. QUESTIONS
1. WRITE ABOUT PRESSURE
TRANSDUCRE. 5MARKS
2. WRITE COMPLICATIONS OF SWAN-GANZ.
3MARKS

40. Thank you