Stress Testing & Hemodynamic Monitoring

Basic Components & Setup

Basic components
● Transducer:​ Converts one form of energy to
another
● Amplifier:​ Converts transducer signal to
readable level
● Monitor / Recorder:​ Displays numbers &
waveforms

Plumbing system
● Transmits pressure from to the transducer
● Heparinized solution
● Flush device
● Delivers 3 – 5 mL/hr solution when at 300 mmHg
● Tubing should be short & non-distendable

Set-up
● Spike bag of heparinized saline
● Flush tubing to gravity
● Pay attention to bubbles
● Pump pressure bag to 300 mmHg
● Attach transducer
● Place transducer level with the phlebostatic axis (right atrium of heart)
● Zero the monitor

Blood Pressure Monitoring

● Direct:
o Arterial line
● Manual:
o Mean arterial pressure (MAP)
o SBP + (2 x DBP) ÷ 3
o Normal: 70 – 90 mmHg

A-Line Waveform
Includes a dicrotic notch
Waveforms change depending on location

RA: Smaller waves

RV: Bigger waves
PAP: Bigger waves with notch
PAWP: Waves that resemble right atrium
VAMP System
​ ​rterial blood M
● V​enous A ​ ​anagement ​P​rotection System
● Closed blood sampling system that can be connected to
A-lines
● System is completely needless, attaches to
hemodynamics
● Provides safe & convenient method to withdrawal blood

Cardiovascular overview
● The heart is a muscular pump which propels blood through pulmonary & systemic circulations
● Right heart:
o ↑ Volume
o ↓ Pressure
o ↓ Resistance
● Left heart:
o ↓ Volume
o ↑ Pressure
o ↑ Resistance
● Lungs (between the two hearts)
o ↑ Flow
o ↓ Pressure
o ↓ Resistance

The Frank-Starling law of the heart

● The ↑ the volume of blood entering the heart during diastole
● The ↑ the volume of blood ejected from the heart during systole

Calculating cardiac values

● Cardiac Output = Stroke volume (SV) x Heart rate (HR)
● Blood pressure = Cardiac output (CO) x Systemic vascular resistance (SVR)

Preload
● The volume stretching the resting
ventricle at the end of diastole
● It correlates with the pressure
generated at end of diastole

Factors influencing preload

● Total blood volume
 ● Atrial kick
● Distribution of blood volume
● Sympathetic stimulation

Drugs affecting preload

● Diuretics
o Furosemide (Lasix)​, ​Spironolactone (Aldactone)
o Interferes with Na​+ ​reabsorption in the kidneys
o ↓ Preload

Afterload
● The impedance of resistance to
ejection of blood from the left
ventricle chamber
● The pressure against which the
contractile force of the ventricle is
exerted

Factors influencing afterload

● Outflow obstruction
● Vascular resistance
● Dilation

Drugs affecting afterload

● Vasoconstrictors
o Levarterenol (Levophed)​, ​Phenylephrine (Neo-synephrine)
o ↑ Afterload
● Inotropic agents
o Dopamine (Intropin)
o > 10 mcg / kg / min
o Ineffective tissue perfusion
o ↑ Afterload
● Catecholamines
o Dobutamine (Dobutrex)
o ↓ Afterload
● Antihypertensives
o Captopril (Capoten)​, ​Clonidine (Catapress)​, H
​ ydralazine (Aprestoline)​, ​nitroprusside
(Nipride)​, ​Metoprolol (Lopressor)
o ↓ Afterload

Cardiac Output
● CO = L / min
 ● CO = SV x HR
● Pregnancy = ↑
● Kids (heart rate):
o Infant: 120 1 year: 80 – 120
o Child: 70 – 110 Teen: 55 – 90
Drugs affecting cardiac output
● Cardiac stimulants
o Atropine​, ​Epi​, ​Isoproterenol (Isuprel)
o ↑ Cardiac output
● Diuretics
o Furosemide (Lasix)​, ​Spironolactone (Aldactone)
o ↓ Cardiac output
● Vasoconstrictors
o Levarterenol (Levophed)​, ​Phenylephrine (Neo-synephrine)
o ↓ Cardiac output
● Inotropic Agents
o Dopamine (Intropin)
o > 10 mcg / kg / min
o ↓ Cardiac output
● Catecholamines
o Dobutamine (Dobutrex)
o ↑ Cardiac output

Contractility
● If preload & afterload remain unchanged but CO ↓, contractility may have changed

Drugs affecting contractility

● Cardiac Glycosides
o Digoxin
o ↑ Contractility
● Catecholamines
o Dobutamine (Dobutrex)
o ↑ Contractility
● Inotropic Agents
o Dopamine (Intropin)
o > 10 mcg / kg / min
o ↑ Contractility

Hemodynamic Monitoring
● Involves special indwelling catheters which provides information
o Blood volume, perfusion, fluid status, & how well the heart is pumping
● Assessed with several parameters:
o Right atrium pressure (RAP)
o Central venous pressure (CVP)
 o Pulmonary Artery Pressure (PAP)
o Pulmonary Artery Wedge Pressure (PAWP)
o Cardiac Output (CO)
o Intra – arterial blood pressure

Hemodynamic Monitoring Continued

● A hemodynamic monitoring system is used to display a client’s hemodynamic data
o Pressure transducer, pressure tubing, monitor, pressure bag & flush device
● Arterial lines are placed in the radial (most common), brachial, or femoral artery
o Provide continuous info about changes in BP & permit withdrawal of samples of blood
o Intra-arterial pressures can differ from cuff pressures
o Arterial lines are NOT used for fluid administration
o Assess the integrity of the waveform for accuracy & assess circulation of limb

Pulmonary Artery (PA) Catheter / Swan-Ganz Catheter

● Catheter inserted into a large vein (internal jugular, femoral, subclavian, brachial)
● Threaded through the right atria and ventricle into a branch of the pulmonary artery
● PA catheters normally have 4 ports (color coded)
o Proximal port:
▪ Measure Central venous pressure (CVP) & right atrial pressure (RAP)
▪ Injectate port for measurement of cardiac output (CO)
o Distal port:
▪ Measure Pulmonary arterial pressure (PAP)
o Balloon port:
▪ Measure pulmonary wedge pressure (PAWP)
▪ 1.5 special syringe is connected
▪ When not in use, it should be left deflated and in locked position
o Infusion port (white):
▪ Used for fluid administration

PA Catheter Indications
● Serious or critical illness
● Heart failure
● Post coronary artery bypass graft (CABG) clients
● Acute kidney injury
● Burn injury
● Trauma injury

PA Catheter Insertion (Pre-procedure)

● Ensure the clients understanding and witness informed consent
● Assemble pressure monitoring system, purge air from system, maintain sterility
 ● Place client in supine or Trendelenburg position
● Administer sedation & pain medications as prescribed
● Level transducer with phlebostatic axis (4​th​ intercostal space midaxillary line)
● Zero system with atmospheric pressure (& anytime there is abnormal readings)
● Pressure lines must be calibrated to read zero atmospheric pressure
● Obtain initial readings as prescribed
● Compare arterial BP to noninvasive BP (NIBP)
● Document the clients response
PA Catheter Insertion (Intra-procedure)
● Monitor for manifestations of altered hemodynamics

PA Catheter Insertion (Post-procedure)

● Obtain chest x-ray to confirm placement
● Continually monitor respiratory and cardiac status (vitals, heart rhythm, SaO​2​)
o Observe respiratory pattern & effort. Compare noninvasive BP to arterial
● Maintain line placement and integrity
o Observe/document waveforms, report changes, document catheter placement
o Monitor & secure connections between pressure tubing, transducers, ports
● Obtain readings from hemodynamic catheter
o Place client in supine position prior to recording (HOB can be elevated 15-30◦)
o Level transducer to right atrium, zero system to atmospheric pressure
o Compare readings to physical assessment, monitor trends over time

Interpretation of Findings:

Hemodynamic Monitoring Expected Reference Ranges

Cardiac Output (CO) 4 – 8 L/min
Cardiac Index (CI) 2.5 – 4 L/min/m​2
Stroke Volume (SV) 50 – 100 mL
Stroke Index (SI) 25 – 45 mL/m​2
Central Venous Pressure (CVP) 2- 6 mmHg
Mean Arterial Pressure (MAP) 70 – 100 mmHg

Systolic: 90 – 140 mmHg

Blood Pressure (BP)
Diastolic: 60 – 90 mmHg

Systolic: 20 – 30 mmHg
Right Ventricular Pressure (RVP)
Diastolic: 0 – 5 mmHg

Systolic: 20 – 30 mmHg
Pulmonary Artery Pressure (PAP) Diastolic: 8 – 12 mmHg
Mean: 12 mmHg
 Pulmonary Capillary Wedge Pressure (PCWP) 4-12 mmHg
Pulmonary Vascular Resistance (PVR) 37 – 250 dynes/sec/cm5
Systemic Vascular Resistance (SVR) 800 – 1200 dynes/sec/cm5
SVO​2 60% – 80%

Manifestations of Altered Hemodynamics:

PRELOAD AFTERLOAD
Right heart: CVP Right heart: Pulmonary vascular resistance
Left heart: PAWP Left heart: Systemic vascular resistance

ELEVATED DECREASED ELEVATED DECREASED

Crackles in lungs
Jugular vein distention
Poor skin turgor Cool extremities Warm extremities
Hepatomegaly
Dry mucus membranes Weak peripheral pulses Bounding peripheral pulses
Peripheral edema
Taut skin turgor

Hemodynamic Monitoring: Complications

● Infection / Sepsis
o Infection at insertion site can occur if aseptic technique is not used
o Use occlusive dressing & Biopatch as with any central venous lines
o Collect specimens (blood cultures, catheter tip cultures) & deliver to lab
o Administer antibiotic therapy & IV fluids as prescribed
o Administer vasopressors (dopamine) for vasodilation secondary to sepsis
o Change gauze every other day, change transparent dressing every 7 days
● Emboli & Thrombosis
o Plaque or clot can become dislodged during the procedure
o Use NS for flushing system (Heparin is no longer used)
o Air embolism may occur when balloon ruptures or air introduced to flushing system
o Clot at end of catheter can result in a pulmonary embolism
● Catheter Wedges Permanently
o Considered emergency, notify MD immediately, pull catheter till wedge wave not seen
o Can occur when balloon is left inflated or catheter moves too far into PA (flat PA wave)
o Can cause pulmonary infarct after only a few minutes
● Ventricular irritation
o Occurs when catheter migrates back into RV or is looped through the ventricle
o Withdraw catheter to right atrium & notify MD immediately
o Can cause ventricular tachycardia (VT)

Square Wave Test

● The Natural Resonance Frequency
 o How fast the system vibrates in response to a pressure signal
● The Damping Coefficient
o How quickly those vibrations/oscillations come to rest in the system
Optimally Damped
A good art line trace has a distinct
dicrotic arch, & after the fast flush
test there are “​2​” oscillations only

Overdamped
The over-damped tracing will lose
its dicrotic notch, and there won’t
be more than one oscillation. This
happens when there is clot in the
catheter tip, or an air bubble in the
tubing line

Overdamped Physiologic Issues

● Aortic stenosis
● Vasodilatation
● Low cardiac output
o Cardiogenic shock
o Sepsis
o Severe hypovolemia

Overdamped Troubleshooting
● Pressure bag inflated to 300 mmHg
● Reposition extremity or patient
● Verify appropriate scale
● Flush or aspirate line
● Check or replace module or cable

Underdamped
The under-damped trace will
overestimate the systolic, and
there will be many post-flush
oscillations
Underdamped Technical Issues
● Falsely higher systolic pressures
● Falsely wider pulse pressures
● Excessive artifact
● Catheter whip
● Systolic overshoot (the artificial exaggeration of systolic pressure)

Underdamped Physiologic Issues

● Hypertension
● Atherosclerosis
● Vasoconstriction
● Aortic regurgitation
● Hyperdynamic states such as fever
● Heart rates above 150 BPM

Underdamped Troubleshooting
● Minimize movement
● Correct underlying physiologic cause

Dampened waveform
● Can occur with physical defects of the heart or catheter
● Can be caused by kinks or air bubbles in the system, or clots
● Solution:
o Check your line for kinks & air bubbles
o Aspirate (not flush) for clots
o Straighten out tubing or patient as much as possible

No waveform
● Can occur with non-perfusing arrhythmias or line disconnection
● Solution:
o Check your line for disconnection
o Check your patient for pulse
o Check for a wet transducer or broken cable or box

Length of insertion
● Usual conditions (vary greatly between patients)
o RV: 35 cm
o PA: 45 cm
o Wedge: 55 cm
Central Venous Pressure (CVP):

● Waveform when catheter is located in the right atrium

● Zero transducer to the patients phlebostatic axis
● Always read CVP at end expiration
● CVP is a direct measurement of right ventricular end diastolic pressure

Right ventricular waveform:

● Waveform when the catheter is located in the right ventricle

● If the catheter falls into the right ventricle (RV), it is considered a PA catheter emergency
● If you see this waveform (looks like VT), pull the catheter immediately
● If catheter remains in the RV, it can cause the patient to go into ventricular tachycardia (VT)
 Pulmonary Capillary Wedge Pressure (PCWP)
● Waveform when catheter is passed PA & into smaller
capillaries
● Resembles the waveform when the catheter is in the RA
(CVP)
● Zero the transducer to the patients phlebostatic axis
● Measure the PCWP at end expiration
● PCWP should NOT be higher than PA diastolic
● PCWP is an indirect measurement of LV end diastolic pressure

Continuous Cardiac Output Monitoring

● CCO measurement utilizes a specialized PA catheter with an electric coil at tip of catheter
● Attached to a free standing monitor
● Automatically measures CO every few minutes

Arterial Based Cardiac Output

● An arterial pressure-based cardiac output (APCO) method in which cardiac output can be
continuously measured real time using an arterial catheter
● Brands include Flotrac, etc.
● Less invasive, easily connects to an existing arterial catheter, enabling nurse-driven care
● Automatically calculates key flow parameters every 20 seconds
● Recognizes and adjusts for hyperdynamic and vasodilated patient conditions
● Broader patient monitoring through expanded patient algorithm database
● Enables the formulation of a differential diagnosis leading to either a volume or cardiovascular
intervention (preload, afterload and contractility)
● Provides CO/CI, SV/SVI, and SVR/SVRI