Hemodynamic Monitoring

• Non-invasive = clinical assessment & NBP

• Direct measurement of arterial pressure

• Invasive hemodynamic monitoring

Noninvasive Hemodynamic Monitoring

• Noninvasive BP
• Heart Rate, pulses
• Mental Status
• Mottling (absent)
• Skin Temperature
• Capillary Refill
• Urine Output

Proper Fit of a Blood Pressure Cuff

• Width of bladder = 2/3 of upper arm
• Length of bladder encircles 80% arm
• Lower edge of cuff approximately 2.5 cm above the antecubital space

Why A Properly Fitting Cuff?

• Too small causes false-high reading
• Too LARGE causes false-low reading

Indications for Arterial Blood Pressure

• Frequent titration of vasoactive drips
• Unstable blood pressures
• Frequent ABGs or labs
• Unable to obtain Non-invasive BP

Supplies to Gather
 • Arterial Catheter
• Pressure Tubing
• Pressure Cable
• Pressure Bag
• Flush – 500cc NS

• Sterile Gown (2)

• Sterile Towels (3)
• Sterile Gloves
• Suture (silk 2.0)
• Chlorhexidine Swabs
• Mask

Leveling and Zeroing

• Leveling
– Before/after insertion
– If patient, bed or transducer move
– Zeroing
– Performed before insertion & readings
– Level and zero at the insertion site
Potential Complications Associated With Arterial Lines
• Hemorrhage
• Air Emboli
• Infection
• Altered Skin Integrity
• Impaired Circulation

Documentation
• Insertion procedure note
• ABP readings as ordered
• Neurovascular checks every two hours
(in musculoskeletal assessment of HED)
• Pressure line flush amounts (3ml/hr)
• Tubing and dressing changes

Central Venous Pressure Assesses

• Intravascular volume status
• Right ventricular function
• Patient response to drugs &/or fluids
• Central line or pulmonary artery catheter
• Normal values = 2 – 8 mm Hg
• Low CVP = hypovolemia or ↓ venous return
• High CVP = over hydration, ↑ venous return, or right-sided heart failure
Leveling and Zeroing
• Leveling
– Before/after insertion
– After patient, bed or transducer move
– Aligns transducer with catheter tip
 – Zeroing
– Performed before insertion & readings
– Level and zero transducer at the phlebostatic axis

Phlebostatic Axis
• 4th intercostal space, mid-axillary line
• Level of the atria

More on Leveling and Zeroing

• HOB 0 – 60 degrees
• No lateral positioning
• Phlebostatic axis with any position (dotted line)

Dynamic Flush
• Dynamic flush ensures the integrity of the pressure tubing system. Notice how it ascends -
forms a square pattern - and bounces below the baseline before returning to the original
waveform.
• Check dynamic flush after zeroing any pressure tubing system
System Maintenance
• Change tubing and fluid bag q 96hrs
• No pressors through CVP port
• Antibiotics, NS boluses, blood, & IV pushes are allowed through the CVP line
Troubleshooting
• Improper set-up and equipment malfunction are the primary causes for hemodynamic
monitoring problems
• Retracing the set-up process or tubing (patient to monitor) may identify the problem
and solution quickly
• Use your staff resources: Help All, Charge Nurse, Educator, Preceptors, MICU experts
Damped Waveforms
 Pressure bag inflated to 300 mmHg
 Reposition extremity or patient
 Verify appropriate scale
 Flush or aspirate line
 Check or replace module or cable
Inability to obtain/zero waveform
 Connections between cable & monitor
 Position of stopcocks
 Retry zeroing after above adjustments
Continuous Airway Pressure (Ao)
• Purpose:
– Improves accuracy of hemodynamic waveform measurements
– Identification of end-expiration
– Positive waveform deflections = positive pressure ventilation
• Negative deflections = spontaneous inspiratory effort
Supplies to Gather
• Pressure Cable
• Pressure Tubing
• Connector
Setting up the Ao
• Discard infusion spike end & cap port
• Connect pressure tubing to vent tubing
(using connector opposite heating cable)
• Connect cables

• Zero the tubing (leveling not necessary)

Troubleshooting Ao
• Do not prime tubing with fluids!
• Damping will occur with fluid or secretions
• To evacuate any fluids, disconnect pressure tubing from vent tubing and push air
through the pressure tubing with a 10 ml syringe connected at one end until fluid-free

Pressure Measurement
) Record Ao and CVP on the same strip
2) Find end-expiration by drawing a vertical line with a straight edge 200 ms prior to the
rise or dip in Ao (1 large box) associated with a breath.
3) Draw a horizontal line through the visually assessed average vascular pressure starting
at end-expiration going backward 200 ms (1 large box).
4) Read the pressure at the horizontal line.

Documentation of CVP
• Include on waveform strip
– Position of the HOB
– Vasopressors and rates
– Amount of PEEP
– Scale
– CVP measurement
– Signature of the nurse