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NTI 2010

Cardiovascular Boot Camp:


Hemodynamic Monitoring

Carol Jacobson RN, MN


Cardiovascular Nursing Education Associates
www.cardionursing.com

Function of CV
system is to deliver
O2 to tissues
Heart
Arteries
Veins
Volume

Hemodynamic monitoring
evaluates the ability of CV system
to deliver blood flow to tissues:
Determinants of CO
Blood volume
Vascular tone

Carol Jacobson RN, MN 2010


Cardiovascular Nursing Education Associates: www.cardionursing.com

Lungs job:
oxygenate
blood

Tissues job:
extract and use O2

Hemodynamic Data:
What do we need to know?

CO = HR X SV
BP = CO X SVR
TISSUE OXYGENATION

Most important piece of hemodynamic


information is STROKE VOLUME
Amount of blood ejected with each beat
- Normal = 60 130 ml/beat

Cant measure directly invasively or


noninvasively

Heart Rate and BP easy to obtain but


dont tell us anything about whats
wrong with the patient

Carol Jacobson RN, MN 2010


Cardiovascular Nursing Education Associates: www.cardionursing.com

So What We Really Want to Know


From Hemodynamic Monitoring is:
What is the stroke volume?
Must assess determinants of SV to get that
information:
Preload
Afterload
Contractility

Pulmonary artery catheter is an invasive way


to get some of this information
There are some newer noninvasive methods
of obtaining CO that can give us SV but are
not widely used at present

Invasive Methods of Obtaining


Hemodynamic Data

Carol Jacobson RN, MN 2010


Cardiovascular Nursing Education Associates: www.cardionursing.com

Pulmonary Artery Catheter


Cardiac output
connection
Distal (PA) tail

Distal port
Proximal (CVP) tail

Proximal port

Balloon port

Pulmonary Artery Catheter


CVP measures right atrial
pressure and is used as a
clinical indicator of RV
preload
- Normal CVP = 2-6 mmHg

PWP reflects left atrial


pressure and is used as a
clinical indicator of LV
preload

PWP
CVP

- Normal PWP = 8-12 mmHg

Carol Jacobson RN, MN 2010


Cardiovascular Nursing Education Associates: www.cardionursing.com

PA Catheter
PVR is a calculated value
based on mean PA pressure
and PWP and is used as a
clinical indicator of RV
afterload

PVR

- Normal PVR = < 250 dynes

SVR is a calculated value


based on mean arterial
pressure and CVP and is
used as a clinical indicator of
LV afterload

SVR

- Normal SVR = 900-1200 dynes


In order for these calculated values to be accurate, the parameters
they are based on need to be accurate: CVP & PWP

Cardiac Output
Can be measured by intermittent injection or
continuously
Normal CO = 4-8 liters/minute
CO should be indexed to patients size by
dividing CO by BSA
- Normal CI = 2.5 -4.5 L/min/M2

Stroke Volume can be estimated by


dividing CO by HR
Normal SV = 60-130 ml/beat

Carol Jacobson RN, MN 2010


Cardiovascular Nursing Education Associates: www.cardionursing.com

Newer Noninvasive Methods


Aortic Doppler
Bioimpedance
LidCo (lithium injection, requires arterial

line and venous line)


PiCCO (pulse contour analysis, requires
arterial line and venous line)
Flotrac (uses arterial waveform and
works only in ventilated patients with no
arrhythmias)

Hemodynamic
Monitoring:
Getting Accurate Data From a
Pulmonary Artery Catheter

Carol Jacobson RN, MN 2010


Cardiovascular Nursing Education Associates: www.cardionursing.com

Pressure Monitoring System


Fluid System
Fluid source: IV bag of 500 cc of NS
Caution: if patient has history of or suspected
heparin induced thrombocytopenia (HIT) DO NOT
use heparin in flush solution!
A continuous fluid filled line from the IV bag to the
transducer and from the transducer to the catheter
tip is needed in order to monitor pressures.

Pressure bag: IV bag must be pressurized at


300 mmHg to overcome the resistance of the
flush device in the transducer and to deliver
3ml per hour through the catheter to keep the
line from clotting off.

Tubing: high pressure rigid tubing is


necessary to accurately transmit
vascular pressures to the transducer.
Transducer with flush device:
contains a one-way valve that allows
3ml/hr of fluid to pass through unless
the resistance is released by pulling
the tail or pushing the lever on the
device which allows the line to run
wide open.
PA Catheter

Carol Jacobson RN, MN 2010


Cardiovascular Nursing Education Associates: www.cardionursing.com

Electrical System
Transducer: contains fine wires that move
back and forth with pressure changes and
convert the pressure to an electrical signal
that is sent to the monitor. Must be filled with
fluid and be bubble-free to accurately transmit
pressure.
Connecting cable: connects the transducer
to the bedside monitor and transmits the
electrical signal to the monitor.
Monitor: converts electrical signal to a
waveform and displays it on the screen.

Carol Jacobson RN, MN 2010


Cardiovascular Nursing Education Associates: www.cardionursing.com

AACN Practice Alert for Pulmonary


Artery Pressure Monitoring - 2004
Perform square waveform test each shift
Position patient supine with HOB between
0 60
Level stopcock air-fluid interface to
phlebostatic axis
Use graphic tracing that includes the ECG
Take measurements at end expiration

Square Waveform Test


Fast Flush
Determines ability of transducer to
correctly reflect pressures in PA
Identifies system problems

Air bubbles
Tubing too long
Loose connections
Loss of pressure on bag
Catheter patency

Carol Jacobson RN, MN 2010


Cardiovascular Nursing Education Associates: www.cardionursing.com

Square Waveform Test


Perform the test
Once each shift
After opening system
- Zeroing
- Blood draws
- Tubing changes

Whenever PAP waveform appears damped or


distorted

Method of Performing Test


Verify 300 mmHg pressure on bag
Pull pigtail and release - watch response of
system on monitor
If abnormal
Tighten connections
Pump up bag
Flush system

Change transducer and tubing to patient if


unable to correct

Carol Jacobson RN, MN 2010


Cardiovascular Nursing Education Associates: www.cardionursing.com

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Normal Square Waveform Test

Abnormal Fast Flush Tests


Over damped

Results in erroneously low SBP and high DBP


Caused by:
- Large air bubbles
- Loose/open connections
- Low fluid level in flush bag

Carol Jacobson RN, MN 2010


Cardiovascular Nursing Education Associates: www.cardionursing.com

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Abnormal Fast Flush Tests


Under damped

Results in erroneously high SBP and low DBP


Caused by:
- Small air bubbles
- Tubing too long
- Defective transducer

Marking the Phlebostatic Axis


Phlebostatic axis is 4th intercostal space at mid
anterior-posterior chest level (left atrial level)
System needs to be zeroed and leveled at the
phlebostatic axis
Measure accurately and mark on chest

Carol Jacobson RN, MN 2010


Cardiovascular Nursing Education Associates: www.cardionursing.com

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Zeroing and Leveling


Zeroing tells the monitoring system that
atmospheric pressure is zero
It removes the effect of hydrostatic pressure in
the tubing system and establishes a baseline
of zero so all pressure recorded by the
system is patient pressure

Leveling means that the stopcock that


was used to zero must be at the
phlebostatic axis for all pressure readings
Keep the transducer at the phlebostatic axis
while monitoring pressure

To Zero the System


Place the stopcock located on top of the
transducer at the level of the phlebostatic axis
Open the stopcock to air (turn it off to the
patient)
Push the Zero button on the monitor.
This tells the transducer that atmospheric pressure
is Zero and sets a baseline for pressure
measurements.

Close the stopcock to air (turn back to neutral


position)
This opens the line between the patient and the
transducer and allows the transducer to see the
patients pressure

Carol Jacobson RN, MN 2010


Cardiovascular Nursing Education Associates: www.cardionursing.com

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Leveling
Stopcock used to zero must remain at
phlebostatic level regardless of patient position.
Leveling must occur with every reading
For every cm deviation from true phlebostatic
axis, pressures can change 1.86 mmHg

Carol Jacobson RN, MN 2010


Cardiovascular Nursing Education Associates: www.cardionursing.com

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Obtain measurements from graphic


tracing that includes the ECG
Read at end expiration

Right Atrial Waveforms

2-6 mmHg

 a wave = atrial contraction


and follows P wave
 c wave = closure of
tricuspid valve
 v wave = atrial filling and
follows QRS

Record the mean of the a wave for the CVP

Carol Jacobson RN, MN 2010


Cardiovascular Nursing Education Associates: www.cardionursing.com

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Normal CVP

ac v

CVP

a
v

Identify a and v waves


What is the CVP measurement?

Carol Jacobson RN, MN 2010


Cardiovascular Nursing Education Associates: www.cardionursing.com

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Swan Insertion RA to RV

RV

RA

Right Ventricular Waveforms


The monitor is never
right on the RV
diastolic pressure!
It reads the lowest point
We want to record the
plateau (true RVEDP)
15-30
2-6

30- Systolic
20100-

Carol Jacobson RN, MN 2010


Cardiovascular Nursing Education Associates: www.cardionursing.com

Diastolic

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Normal RV Waveform
Identify RV systolic and diastolic pressure.

RV Pressure = 38/10

RV Pressure
Identify RV Systolic and Diastolic Pressure
3020100RV Pressure = 22/7

Carol Jacobson RN, MN 2010


Cardiovascular Nursing Education Associates: www.cardionursing.com

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Swan Insertion RV to PA

PA

RV

Pulmonary Artery Waveforms


15-30
8-12

The monitor is usually


right about PA pressures
No false lows
Ignore the pre-systolic
bump

Systolic

Diastolic

Carol Jacobson RN, MN 2010


Cardiovascular Nursing Education Associates: www.cardionursing.com

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PA Waveform

Identify PA Systolic and Diastolic pressure


What is the pressure?
PAP = 54/20

Swan Insertion PA to PWP

PA

Carol Jacobson RN, MN 2010


Cardiovascular Nursing Education Associates: www.cardionursing.com

PWP

20

Wedge Pressure Waveform


Same a, c, and v
waves as CVP
Further removed from the
ECG waves
a wave near end of QRS
v wave after T wave

8-12 mmHg

Record the mean of the a wave


for the PWP

PWP Waveform
Identify a and v waves and state the value of the PWP

1050-

PWP = 6 mmHg

Carol Jacobson RN, MN 2010


Cardiovascular Nursing Education Associates: www.cardionursing.com

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Normal PAW

20-

a
100-

Identify a and v waves and state the PWP measurement


PAW = 10 11 mmHg

Large v Waves in PAW Waveform

v
a

Identify two problems this patient has.


LV failure: elevated PAWP (mean of a wave)
Mitral regurgitation: large v wave

Carol Jacobson RN, MN 2010


Cardiovascular Nursing Education Associates: www.cardionursing.com

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End Expiration in
Spontaneous Breathing
Inspiration is a negative dip in waveform.

Carol Jacobson RN, MN 2010


Cardiovascular Nursing Education Associates: www.cardionursing.com

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Spontaneous Breathing

Find end-expiration.
Where would you read the PA and the PAW pressure?

PA to PAW
Spontaneous Breathing

a v

PA pressure = 58/32
PAW pressure = 25

Carol Jacobson RN, MN 2010


Cardiovascular Nursing Education Associates: www.cardionursing.com

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End Expiration in
Ventilator Breath
Inspiration is a rise the in waveform

Ventilator Breaths

a v

Find the ventilator breath.


Where would you read this PAW pressure?
PWP = 16

Carol Jacobson RN, MN 2010


Cardiovascular Nursing Education Associates: www.cardionursing.com

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Goals of Hemodynamic
Monitoring
Determine magnitude of pulmonary
congestion (LV preload)
Assess peripheral perfusion
(forwards flow)

Determine LV function based on


preload and forwards flow

Carol Jacobson RN, MN 2010


Cardiovascular Nursing Education Associates: www.cardionursing.com

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Forwards flow:
CI/SV, skin temp (warm or cold)

Left Ventricular Function Curves


5
4
3
2
1
0
2

10 12 14 16 18 20 22 24 26 28 30 32 34 36

Preload: PWP, lung sounds (dry or wet)

Forwards flow:
CI/SV, skin temp (warm or cold)

Changing Preload: moves patient along the curve they are on.
5
4
3
2
1
0
2

10 12 14 16 18 20 22 24 26 28 30 32 34 36

Preload: PWP, lung sounds (dry or wet)

Carol Jacobson RN, MN 2010


Cardiovascular Nursing Education Associates: www.cardionursing.com

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Forwards flow:
CI/SV, skin temp (warm or cold)

Changing Contractility: moves patient to a higher curve


5
4
3
2
1
0
2

10 12 14 16 18 20 22 24 26 28 30 32 34 36

Preload: PWP, lung sounds (dry or wet)

Changing Afterload: moves patient up and to the left


Forwards flow:
CI/SV, skin temp (warm or cold)

(improves forwards flow and reduces preload)


5
4
3
2
1
0
2

10 12 14 16 18 20 22 24 26 28 30 32 34 36

Preload: PWP, lung sounds (dry or wet)

Carol Jacobson RN, MN 2010


Cardiovascular Nursing Education Associates: www.cardionursing.com

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Relationship of PWP to Clinical


Signs of Pulmonary Congestion
Clinical State

PWP
18 20 mmHg
20 25 mmHg
25 30 mmHg
> 30 mmHg

Pulmonary Congestion
Moderate Congestion
Severe Congestion
Pulmonary Edema

The value for PWP that best separates patients with and
without pulmonary congestion is 18 mmHg
Physical assessment: lung sounds dry or wet.

Relationship of CI to Clinical
Signs of Hypoperfusion
CI
2.7 4.7
2.2 2.7
1.8 2.2
< 1.8

Clinical State
Normal
Subclinical depression
Clinical hypoperfusion
Cardiogenic shock

The value for CI that best separates patients with and


without hypoperfusion is 2.2 L/min/M2
Physical assessment: skin temperature warm or cold

Carol Jacobson RN, MN 2010


Cardiovascular Nursing Education Associates: www.cardionursing.com

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Forwards flow:
CI/SV, skin temp (warm or cold)

Hemodynamic and Clinical Subsets


5
4
3

Normal Hemodynamics (I)

Backwards Failure (II)

No pulmonary congestion:
PWP < 18; Dry lungs
No hypoperfusion:
CI > 2.2; Warm skin

Pulmonary congestion
PWP > 18; Wet lungs
No hypoperfusion
CI > 2.2; Warm skin

Warm & Dry

Warm & Wet

2
1

Forwards Failure (III)

The Shock Box (IV)

No pulmonary congestion
PWP < 18; Dry lungs
Hypoperfusion
CI < 2.2; Cold skin

Pulmonary congestion
PWP > 18; Wet lungs
Hypoperfusion
CI < 2.2; Cold skin

Cold & Dry

0
2

Cold & Wet

10 12 14 16 18 20 22 24 26 28 30 32 34 36

Preload: PWP, lung sounds (dry or wet)

Mini Case #1

Forwards flow:
CI/SV skin temp (warm or cold)

A patient returns to the ICU after a AAA repair with a PA catheter


in place. This is the first set of data: HR = 96, BP = 114/72,
CO = 4.2, CI = 2.2, CVP = 3, PWP = 8, SVR = 1580.
5

0
2

10 12 14 16 18 20 22 24 26 28 30 32 34 36

Preload: PWP, lung sounds (dry or wet)

Carol Jacobson RN, MN 2010


Cardiovascular Nursing Education Associates: www.cardionursing.com

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Mini Case #2

Forwards flow:
CI/SV skin temp (warm or cold)

A patient with acute anterior MI returns from the cath lab with a
PA catheter in place following two stents to the LAD coronary
artery. The first set of numbers looks like this: BP 100/60, HR =
106, CO = 3.0, CI = 1.8, CVP = 10, PWP = 30, SVR = 1680.
5

0
2

10 12 14 16 18 20 22 24 26 28 30 32 34 36

Preload: PWP, lung sounds (dry or wet)

Mini Case #3

Forwards flow:
CI/SV skin temp (warm or cold)

A 20 year old motor cycle accident victim with multiple trauma is on the
ventilator in the ICU and becomes hypotensive and febrile. His BP is 80/45, HR
120 in sinus tachycardia, skin is hot and dry. A PA catheter is inserted and these
are the numbers: CO = 10.4, CI = 5, CVP = 4, PWP = 10, SVR = 404.
5

0
2

8 10 12 14 16 18 20 22 24 26 28 30 32 34 36

Preload: PWP, lung sounds (dry or wet)

Carol Jacobson RN, MN 2010


Cardiovascular Nursing Education Associates: www.cardionursing.com

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Mini Case #4

Forwards flow:
CI/SV skin temp (warm or cold)

A 65 year old woman with a history of HF returns from CABG


with the following data: BP 136/76, HR = 84, CO = 5.5,
CI = 3.1, CVP = 8, PWP = 26, SVR = 1280.
5

0
2

10 12 14 16 18 20 22 24 26 28 30 32 34 36

Preload: PWP, lung sounds (dry or wet)

Carol Jacobson RN, MN 2010


Cardiovascular Nursing Education Associates: www.cardionursing.com

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Forwards flow:
CI/SV skin temp (warm or cold)

Preload changes: move patient along the current curve


5
4
3
2
1
0
2

10 12 14 16 18 20 22 24 26 28 30 32 34 36

Preload: PWP, lung sounds (dry or wet)

Afterload changes: move patient up and to the left:

Forwards flow:
CI/SV skin temp (warm or cold)

improves forwards flow and reduces preload


5
4
3
2
Must have adequate BP
SVR must be elevated

1
0
2

10 12 14 16 18 20 22 24 26 28 30 32 34 36

Preload: PWP, lung sounds (dry or wet)

Carol Jacobson RN, MN 2010


Cardiovascular Nursing Education Associates: www.cardionursing.com

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Contractility changes: move patient to a higher curve


Forwards flow:
CI/SV skin temp (warm or cold)

5
4
3
2
1
0
2

10 12 14 16 18 20 22 24 26 28 30 32 34 36

Preload: PWP, lung sounds (dry or wet)

Forwards flow:
CI/SV skin temp (warm or cold)

Summary of the Effects of Therapies

V+I

D = Diuresis (preload reduction)


F = Fluids (increase preload)
I = Inotropes (increase contractility)
V = Vasodilators ( reduce afterload)
V + I = Vasodilator + Inotrope

3
2

0
2

10 12 14 16 18 20 22 24 26 28 30 32 34 36

Preload: PWP, lung sounds (dry or wet)

Carol Jacobson RN, MN 2010


Cardiovascular Nursing Education Associates: www.cardionursing.com

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Potential Therapies by Subset


Forwards Flow: Cardiac Index
Skin temp (warm or cold)

Normal Hemodynamics

Backwards Failure

In sepsis or trauma:
? Inotropes

3
2
1

Forwards Failure
Volume (if PWP low)
Inotropes (if PWP adequate)
Pacing (if HR low)
IABP

0
2

Diuretics
Venous Dilators
Shock Box
Afterload reduction (if BP adequate
and SVR high)

Preload reduction (diuretics, venous


dilators)

Inotropes, Vasopressors, IABP

10 12 14 16 18 20 22 24 26 28 30 32 34 36

Preload: PWP, lung sounds (dry or wet)

Mini Case #2

Forwards flow:
CI/SV skin temp (warm or cold)

A patient with acute anterior MI returns from the cath lab with a
PA catheter in place following two stents to the LAD coronary
artery. The first set of numbers looks like this: BP 100/60, HR =
106, CO = 3.0, CI = 1.8, CVP = 10, PWP = 30, SVR = 1680.
5

0
2

10 12 14 16 18 20 22 24 26 28 30 32 34 36

Preload: PWP, lung sounds (dry or wet)

Carol Jacobson RN, MN 2010


Cardiovascular Nursing Education Associates: www.cardionursing.com

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Mini Case #2

Where do you want him to go?

Where would he go with preload reduction?


Where would he go with an inotrope?
Where should he go with afterload reduction?
Forwards flow:
CI/SV skin temp (warm or cold)

What drugs could you use?

Is he a candidate for
afterload reduction?
Yes: BP is reasonable
and SVR is high

0
2

10 12 14 16 18 20 22 24 26 28 30 32 34 36

Preload: PWP, lung sounds (dry or wet)

Forwards flow:
CI/SV skin temp (warm or cold)

More than one way to accomplish a goal

Diuretic

Inotrope

0
2

10 12 14 16 18 20 22 24 26 28 30 32 34 36

Preload: PWP, lung sounds (dry or wet)

Carol Jacobson RN, MN 2010


Cardiovascular Nursing Education Associates: www.cardionursing.com

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Hemodynamic Profiles in Shock


Preload Afterload
Pump
Tissue
(PWP)
(SVR)
Function Perfusion
(CI/SV)
(SVO2)
Hypovolemic

Therapy

Volume

(Subset III)

Cardiogenic

Inotropes
Preload
reduction
Afterload
reduction

(Subset IV)

Vasodilated

Volume
Vasopressors

(Subset I early)
(Subset IV late)

Handout available at:


www.cardionursing.com

Carol Jacobson RN, MN 2010


Cardiovascular Nursing Education Associates: www.cardionursing.com

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