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Parameter Normal Value 60-70% Importance
Determining the Accuracy of Hemodynamic Values
Steps Technique How often should it be done ? Only if the patient has moved from the original position. Relevel if reading has unexplainably changed. Must zero on initial setup. Rezero if readings have unexplainably changed.
PR, QRS, and QT interval SvO2 Indicates adequacy of tissue oxygenation, the primary reason many patients receive hemodynamic monitoring Stroke Index (SI) How much blood is pumped with each beat referenced against body size. Cardiac Index How much blood is pumped during one minute reference against body size. It is a product of stroke index and heart rate Pulmonary artery pressure (PAP)
The SvO2 helps identify which blood pressue and cardiac output are acceptable for each patient.
Level the transducer to the phlebostatic axis
Place any stopcock at the phlebostatic axis. Patient should be supine. Elevation can be from flat to 45 degrees With the stopcock off to the patient and open to air cap , removed and leveled at the phlebostatic axis, activate the monitor’ zero function. Close transs ducer to air and open to patient and then recap stopcock. Activate the fast flush device and release. Interpret the response. See illustration below
Heart rate at 25 mm/sec (Measure two cardiac cycles from the reference arrow)
Used in conjunction with cardiac pressures to diagnose and evaluate treatment.
Zero the Transducer/amplifier
Not as early an indicator of a hemodynamic problem as stroke index due to the compensating role of heart rate when stroke index is low.
Perform a square wave test. The square wave test checks the accuracy of the tubing/ catheter system.
Prior to obtaining readings It is better way of verifying the arterial line accuracy than the blood pressure cuff comparison.
About 25/10 mmHg
Useful in assessing response to therapies for pulmonary hypertension. Normally not a primary parameter in assessing hemodynamics. When the stroke index is low, the PAOP helps differentiate left ventricular dysfunction (PAOP>12mmHg) and hypovolemia (PAOP< 8mmHg). When stroke index is low, the CVP helps differentiate right ventricular dysfunction (CVP> 6 mmHg) and hypovolemia (CVP is normal or < 2 mmHg.
Performing Square Wave Test
Characteristics Optimal Dampening 1 Should have a small ) overshoot, followed by a small overshoot (about 1 the distance /3 of the undershoot) 2) Should have 1 blocks -2 between oscillations Under Dampening 1 Either extra oscillations ) are present or 2) Prolonged distance (more than 2 blocks between bounces. Over Dampening 1 Obstruction in line ) prevents oscillation 2) Note slurring on downstroke. Illustration How to correct? Clinical Result No necessary correction Waveforms are accurately reproduced
Pulmonary artery occlusive pressure (PAOP or wedge)
100 90 80
About 8- 2 1 mmHg
6 7 8
Central venous pressure (CVP) Right atrial pressure. A reflection of right ventricular end diastolic pressure. The CVP is an estimation of preload. Blood Pressure Reflects pressure in systemic arterial system.
About 2-6 mmHg
1 ) 2)
Varies with site, size, age and sex. 900- 300 1 dynes/sec/ cm5
A common less invasive form of estimating blood flow. With hemodynamic monitoring available (SvO2, SI, CI), blood pressure is less useful. Often used to assess the response of arterial dilators.
Remove excess tubing. Insert dampening device Systole is artificially depressed, diastole may be higher than actual. Use mean values if unable to correct.
A supplement to CRITICAL CARE NURSE®
Systemic Vascular Resistance (SVR)
Find source of problem. 1 Air in line ) 2) Blood in line 3) Kink in tubing/catheter
Printed in the USA, July 1999
How to read a CVP waveform
Method Pre C wave Technique Find the c wave on the downstroke of the a wave (usually near the end of the QRS complex) Indications Theoretically the most sound method. Use this method if possible
How to read a Right Ventricular & PA waveform
Waveform Characteristics Example Types of Artifact Right Ventricular 1) Rapid upstroke to waveform systole. Systole found after the QRS but before the T-wave. 2) Terminal diastolic rise-diastole found near the end of the QRS complex Pulmonary 1) Rapid upstroke to Artery waveform systole. Systole found after the QRS but before the T-wave. 2) Progressive diastolic runoff-diastole found near the end of the QRS complex. 3) A dicrotic notch (closure of the pulmonic valve) is sometimes visible during the progressive diastolic runoff.
Avoiding Respiratory Artifact
How to Read Example
Patient initiated includes spontaneous breathing and patient initiated ventilator breaths
1) Locate where the baseline drops 2) Read the last clear wave before the drop occurs
Average of the a-c waves
Find the a wave in the PR interval. Locate top and bottom of a-c wave. Average the two values.
Often the easiest to use since the c waves are not always visible. Use this method if c wave is not present.
1) Locate where the baseline moved upward 2) Read the last clear wave before the baseline elevates.
How to read a PAOP waveform Avoiding Abnormal Waveforms
Method Average of the a-c waves Z point Draw a line down from the end of the QRS complex. Where the line hits the baseline, is the CVP reading. Use this method when no clear a or c wave present. (e.g. atrial fibrillation and paced rhythms) Technique Find the a wave after the QRS complex. Locate top and bottom of a-c wave. Average the two values. Indications Often the easiest to use since the c waves are not always visible. Use this method if c wave is not present Clinical Situation Large V wave Common with CHF How to Read Example
Locate the pre c point or the mean of the a-c wave before the large V wave.
Draw a line down from about .08 to . 2 seconds after 1 the QRS complex. Where the line hits the baseline, is the PAOP reading.
Use this method when no clear a or c wave present (e.g. atrial fibrillation and paced rhythms)
Large or absent a Use the Z point method. wave