Lesson 3 Hemodynamic Monitoring Semi Finals 3

SKILLS LABORATORY MODULE
BASIC NURSING SKILLS FOR CLIENTS WITH LIFE-THREATENING CONDITIONS, ACUTELY ILL/ MULTI-
ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY SITUATION
LESSON 3: HEMODYNAMIC MONITORING: PULMONARY ARTERY CATHETERIZATION & ARTERIAL LINE,
Hemodynamics, by definition, is the study of the motion of blood through the body. In a simple
patient assessment this may include the observation of a patient’s heart rate, pulse quality,
blood pressure, capillary refill, skin color, or skin temperature, ECG, CVP, ABG, pulse oximetry, etc).

As a patient's condition worsens, invasive approach such as invasive hemodynamic monitoring and
invasive blood pressure monitoring (arterial line) may be utilized to provide a more advanced
assessment and guide therapeutic interventions.
Invasive monitoring is used routinely in many critical care units to assist in the assessment of both single
and multi-system disorders and their treatment
Goals of Monitoring:
 To assure the adequacy of perfusion.
 Early detection of an inadequacy of perfusion
 To titrate therapy to specific hemodynamic endpoints in unstable patients.
 To differentiate among various organ system dysfunction.
I. PULMONARY ARTERY CATHETERIZATION (PAC)
A PA catheterization or often referred to as Right Heart Catheterization is the insertion of a

flow-directed, balloon-tipped catheter into a pulmonary catheter. The pulmonary artery
catheter allows direct, simultaneous measurement of pressures in the right atrium, right
ventricle, pulmonary artery, and the filling pressure ("wedge" pressure) of the left atrium.
It is also known as The Swan-Ganz Catheter in honor of its inventors Jeremy Swanz and
William Ganz.
PA catheters may be used for both diagnosis and therapy. Clinical indications include:
 Postmyocardial infarction: to assess hemodynamic status and monitor and
guide therapy.
 Cardiac surgery: to monitor cardiac function.
 Major surgery: in the presence of myocardial dysfunction or for preoperative
optimization of hemodynamics.
 Resuscitation: in case of hemodynamic instability during fluid replacement:
to assess left ventricular function.
 Septic shock: assessment of LV function and fluid status.
 Diagnosis of high and low pressure pulmonary edema.
 Measurement of oxygen transport, enabling optimization of ventilation and
perfusion.
Prepared by Prof. Sonia M. Dignadice and Prof. Amelia Z. Manaois for AU - College of Nursing to be used as Instructional Material only for the
NCM118 – SKILLS LAB Lecture. Refrain from reproducing this material without the consent of the preparer and the AU-CON
 Pre-eclampsia and eclampsia: to monitor fluid status and assess intravascular
volume.
As depicted in the photo above, the catheter is introduced through a large vein—
often the internal jugular, subclavian, or femoral veins. From this entry site, it is
threaded through the right atrium of the heart, the right ventricle, and subsequently
into the pulmonary artery. The passage of the catheter may be monitored by dynamic
pressure readings from the catheter tip or with the aid of fluoroscopy.
The standard pulmonary artery catheter has two lumens (Swan-Ganz) and is
equipped with an inflatable balloon at the tip, which facilitates its placement into the
pulmonary artery through the flow of blood. The balloon, when inflated, causes the
catheter to "wedge" in a small pulmonary blood vessel.
PRE-SELECTED VIDEO FOR LEARNING REINFORCEMENT:
https://www.youtube.com/watch?v=y241HEaBkLA : Swan-Ganz Catheter Placement

Animation
https://www.youtube.com/watch?v=YkN30T6ig30 : PAC Placement and Physiology
TERMINOLOGIES OF HEMODYNAMIC MONITORING:
a. The cardiac output pushes the blood through the vascular system.

Cardiac output (CO) is calculated by multiplying the heart rate (HR) by the stroke volume
(SV).
Cardiac output/cardiac index are used to assess the heart’s ability to meet the body’s
oxygen demands.
Cardiac index is a more precise measurement of heart function since body size affects
overall cardiac output.
The cardiac index is a calculation of cardiac output per square meter of body surface area.
The normal cardiac index is 2.8-4.2 L/min/m2.
CO = SV x HR.
Normal resting CO is 4-8 L/min and varies with body size.
b. Stroke volume is the volume of blood pumped out of the heart with each heartbeat. If
the stroke volume drops, the body will compensate by increasing the heart rate to
maintain cardiac output. This is known as compensatory tachycardia. Tachycardia is an
effective compensatory mechanism at a certain point. At heart rates greater than 150
bpm, diastolic filling time becomes so short that the tachycardia itself produces a drop
in stroke volume, and cardiac output can no longer be maintained. Stroke volume is
affected by three factors, preload, afterload, and contractility:
1. PRELOAD –
Preload is the force that stretches the muscle fibers of a resting heart – how much
they are stretched just prior to contraction. It is the degree of muscle fiber
stretching present in the ventricles right before systole
It is the amount of blood in a ventricle before it contracts; also known as “filling
pressures”
The amount of blood present within the right and left atria and ventricles prior to
contraction and the condition of the myocardium determine the stretch or preload
of the heart muscle
The greater the volume of blood in a heart chamber, the greater the preload
Ideally, an adequately filled and stretched left ventricle should briskly contract, snap
like a rubber band, to send blood on its way
Left ventricular preload is reflected by the PCWP (Pulmonary Capillary Wedge

Pressure)
2. AFTERLOAD
Afterload is defined as the resistance that the ventricle must overcome to eject its
volume of blood.
It refers to any resistance against which the ventricles must pump in order to eject
its volume
How hard the heart [either side left or right] has to push to get the blood out
The most important determinant of afterload is vascular resistance
a. As arterial vessels constrict, the afterload increases; as they dilate, afterload

decreases.
b. High afterload increases myocardial work and decreases stroke volume.
c. Low afterload decreases myocardial work and results in increased stroke
volume.
d. As preload (fluid volume) increases, cardiac output will also increase until
the cardiac output levels off.
e. Too little preload and the cardiac output cannot propel enough blood
forward, too much and the heart will become overwhelmed leading to
failure.
f. Just the right amount of preload produces the best possible cardiac output;
finding this level of preload is called “preload optimization
3. CONTRACTILITY
The inherent ability of the cardiac muscle to contract regardless of preload or
afterload status.
QUICK RECALL:
PRE-LOAD: Filling & Stretching (Diastole)
AFTER-LOAD: Pressure to pump (Systole)
PRE-SELECTED VIDEO FOR ADDITIONAL LEARNING:
https://www.youtube.com/watch?v=stA5pwoOZNA : Cardiomyopathy Preload vs

Afterload
II. PERIPHERAL ARTERIAL LINE: INVASIVE BLOOD PRESSURE MONITORING

Peripheral arterial lines (A. radialis) offer several advantages in comparison of monitoring
blood pressure with a cuff. The line provides continuous measurement of blood pressure
and can be used for sampling of blood gases. A strong variation in the amplitude may
indicate volume deficiency.
In the setting of marked vasoconstriction or hypotension, the arterial line gives more
accurate pressure values than a blood pressure cuff; however, in case of strong
centralization of circulation, blood pressure measurements done with peripheral arterial
lines may considerably differ from the core hemodynamics.
The arterial line gives an accurate representation of MAP or mean arterial pressure
Indications include:
a. Continuous blood pressure measurement in a rapidly changing clinical circumstances in
critically ill patients (e.g. hemorrhage, sepsis).
b. Frequent blood gas measurement
c. Monitoring and guiding the use of vasoactive drugs with rapid cardiovascular effects.
d. Monitoring and guiding acute interventions (e.g. major surgery, resuscitation).
e. Blood sampling.
PRE-SELECTED VIDEO FOR ADDITIONAL LEARNING
https://www.youtube.com/watch?v=3z9vHu4r6HE : Arterial Line Placement
III. NURSING DUTIES AND RESPONSIBILITIES

Only physicians are allowed to conduct PAC. Nurses however have duties and
responsibilities to assume before, during and after catheterization:
1.Informed Consent - An informed procedure consent is required prior to

insertion of a PA catheter. If the patient is unable to sign and there are no next
of kin available to sign for the patient, two physicians must document in the
progress notes that it is an emergent need. Always follow the facilities
procedure for obtaining consents.
2.Gathering and preparing supplies and materials.
3.Assist with insertion and removal of invasive hemodynamic lines.
4.Monitor heart rate and rhythm.
5.Zero and calibrate equipment every 4 to 12 hours, as appropriate, with
transducer at the level of the right atrium to ensure accuracy of waveform.
6.Monitor blood pressure (systolic, diastolic, and mean), central venous/right
atrial pressure, pulmonary artery pressure (systolic, diastolic, and mean), and
pulmonary capillary/artery wedge pressure.
7.Monitor hemodynamic waveforms for changes in cardiovascular function.
8.Compare hemodynamic parameters with other clinical signs and symptoms.
9.Monitor pulmonary artery and systemic arterial waveforms; if dampening
occurs, check tubing for kinks or air bubbles, check connections.
10.Document pulmonary artery and systemic arterial waveforms.
11.Monitor peripheral perfusion distal to catheter insertion site every 4 hours or
as appropriate.
12.Refrain from inflating balloon more frequently than every 1 to 2 hours, or as
appropriate.
13.Maintain sterility of ports.
14.Perform sterile dressing changes and site care, as appropriate.
15.Inspect insertion site for signs of bleeding or infection.
16.Change IV solution and tubing every 24 to 96 hours, based on protocol.
17.Keep hemodynamic monitoring alarms ON.
The right atrium and ventricle transfer deoxygenated blood to the lungs via
the pulmonary arteries. Blood is oxygenated and returned to the left artium
via the pulmonary veins. The left ventricle then pumps the oxygenated blood
to the body, exiting the heart through the aorta. Systemic circulation flows
through arteries, then arterioles, then capillaries where gas exchange occurs
to tissues. Blood is then returned to the heart through venules and veins,
which merge into the superior and inferior vena cavae and empty into the
right atrium to complete the circuit.
Systemic circulation is ordered from the left ventricle to the aorta, through the
structures of the body, to the superior or inferior vena cava, and reenters the
heart in the right atrium.
The aorta carries blood from the left ventricle to the body for systemic
circulation. The vena cavae return the blood from systemic circulation to the
right atrium. The superior vena cava returns blood from the head upper
extremities, while the inferior vena cava returns blood from the abdomen and
lower extremities.
PRE-SELECTED VIDEO FOR LEARNING REINFORCEMENT:
https://www.youtube.com/watch?v=4C_fAHVvdRo : Advance Critical Care Nursing PA

Catheter
https://www.youtube.com/watch?v=jOAvLHjmLIw : Advance Critical Care Nursing:
Arterial Lines
POST-TASK ACTIVITY
1. Quizzes
 Quiz 1 – PULMONARY ARTERY CATHETERIZATION (PAC): INVASIVE
HEMODYNAMIC MONITORING
 Quiz 2 – PERIPHERAL ARTERIAL LINE: INVASIVE BLOOD PRESSURE MONITORING
2. Oral Revalida - equivalent to Major Exam
References:
1. Medical-Surgical Nursing Concepts for Interprofessional Collaborative Care, 9 th

edition, 2018, Single Volume by Donna D. Ignatavicius, M. Linda Workman Cherie
Rebar
2. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, 10th edition by
Smeltzer, Suzanne C and Bare Brenda
SKILLS LABORATORY MODULE
BASIC NURSING SKILLS FOR CLIENTS WITH LIFE-THREATENING CONDITIONS, ACUTELY ILL/ MULTI-
ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY SITUATION
LESSON 4: MECHANICAL CIRCULATORY ASSIST DEVICE - INTRAAORTIC BALLOON PUMP, VENTRICULAR

ASSIST DEVICE and IMPLANTABLE ARTIFICIAL HEART
Circulatory assist devices are mechanical and artificial devices that perform some or all of the functions
of the heart. They vary significantly in design and indication but are typically used to provide either
partial or full support for a heart that is unable to function adequately. Those used for temporary
support include the Intraaortic Balloon Pump or IABP, Left and Right Ventricular Assist Device (LVAD /
RVAD). Those used for full support include Biventricular Assist Device (BiVAD) and Total Artificial Heart
(TAH).
INDICATIONS FOR MECHANICAL CIRCULATORY ASSIST DEVICES:

1. Temporary support for a heart that is expected to recover
2. Bridge therapy to cardiac transplantation
3. Destination therapy for a patient whose heart is unlikely to regain adequate function
Nursing care has dual roles. It involves care of the Mechanical Circulatory Assist Devices as well as the
care of the patient by assessing patient from a cardiovascular and hemodynamic perspective, keeping
them safe, comfortable and free from complications.
I. INTRAAORTIC BALLOON PUMP (IABP)

a. Description: An IABP is a circulatory assist device that is intended to provide temporary
support to a failing heart through synchronized actions focused on reducing afterload
and augmenting diastolic pressure.
 The system consists of a 30- to 50-cc balloon attached to a catheter.
 The balloon rests within the lumen of the descending thoracic aorta, and the
attached catheter snakes through the arterial vessels and out of the body.
 The catheter relays with an external console that monitors aortic pressure
tracings and electrocardiogram (ECG) readings, inflating the internal balloon at
the appropriate times. The balloon is inflated with either helium or CO2.
Although CO2 has higher blood solubility and therefore a lower risk of
embolization, helium is much more common because it is less dense and thus
allows for faster filling and emptying times (Weidman, 2013)
b. Site and Placement: The femoral artery is the most common insertion site of IABP.
 Alternative insertion sites include the iliac, axillary, and subclavian arteries.
 IABP placement may even be accomplished via the ascending aorta, as is
occasionally done after cardiac surgery.
 The ideal location for the tip of the balloon is just distal to the aortic arch, 1 to 2
cm beyond the left subclavian artery. The other end of the balloon should sit
proximal to the takeoff of the celiac axis. Correct positioning of the balloon may
be confirmed at the time of placement with either transesophageal
echocardiography or fluoroscopy.
 Alternatively, confirmation may be performed after placement by chest
radiograph.
Intra-aortic balloon pump (IABP) catheter insertion using a novel left
external iliac artery approach and a subcutaneous channel in a 67-year-
old woman with chronic heart failure due to dilated cardiomyopathy.
The catheter was removed subcutaneously from the left retroperitoneal
space to the right lower quadrant of the abdomen. 1. The insertion of
the intra-aortic balloon pump (IABP) catheter in the external iliac artery.
2. The subcutaneous pocket from left retroperitoneal space to the right
lower quadrant of the abdomen. 3. The external part of the IABP device.
Yellow indicates the Dacron conduit. The dressing on the patient's left
side indicates the retroperitoneal surgical access. The dressing on the
patient's right side indicates the external approach and exit of the IABP
device.
c. Mechanism of Action: The IABP is designed to inflate during diastole and deflate during
systole.
 It is beneficial in both phases of the cardiac cycle.
 During diastole, inflation of the balloon displaces blood proximally, increasing
perfusion pressure to the coronary arteries and the critical vessels branching off
the aortic arch. Perfusion and blood flow are equally improved in the aorta
distal to the balloon through the vessels supplying blood to the mesentery and
the lower extremities.
 In systole, deflation of the balloon creates a relative negative space within the
aorta, which reduces afterload.
 As a consequence, not only is cardiac function improved because of lower
systemic resistance, but the duration of isovolumic contraction, the most
energy-demanding phase of the cardiac cycle, is also reduced.
 AIM / GOAL:
 Increase coronary artery perfusion by improving myocardial oxygen
supply
 Reduction in afterload by reducing myocardial oxygen demand
d. Indications: Although it was originally designed to support patients in cardiogenic shock

the indications have expanded because of continued research. The most common
indications are:
 Low cardiac output due to left ventricular dysfunction and myocardial ischemia.
 Septic shock,
 Cardiac support for non-cardiac related surgery and support post correction of
anatomical defects.
e. Nursing Care / Duties and Responsibilities:

 ASSESSMENT: Prior to insertion of the IABP a baseline assessment is performed
incorporating lower and upper limb perfusion.
 This serves as a baseline for assessments post insertion. Upper limb
assessment is essential so that balloon migration obstructing blood flow
down the left subclavian artery can be detected promptly.
 Assessment involves:
a. Documentation of palpation of the relevant pulses, assessing
capillary refill, temperature and color of the limbs.
b. A set of baseline vital signs is recorded – heart rate, blood
pressure, respiratory rate, oxygen saturations and temperature,
which are used to assess improvement or deterioration in the
patient’s condition.
 PLANNING AND IMPLEMENTATION:
 Education plays a pivotal part in nursing care. This is a frightening time
for the patient and family. Patient education should include:
a. The reasons why the IABP is being inserted,
b. What the pump does
c. Potential complications: Bleeding
d. Nursing care such as:
 Hourly nursing assessments.
 The limitations in activity that the patient will
experience should be explained such as bed rest and
reduced movement of the affected leg.
 In relation to complications patients are educated about
the risk of bleeding at the insertion site and are advised
to put pressure on the site when coughing or sneezing
 To notify the nurse promptly if they experience pain in
the lower back or a sudden burning, pain or wetness at
the insertion site.
 Patients and families are instructed to report symptoms
that may be suggestive of impaired peripheral perfusion
such as tingling, numbness, coldness, pallor and pain as
this may be indicative of limb ischemia.
 Prior to Insertion - Aside from gathering the equipment specific to IABP

insertion, nursing care involves preparing the patient to the following:
a. Attaching the patient to the pump’s ECG leads and labelling
them,
b. Setting up the transducer and levelling it with the patient’s
phlebostatic axis (fourth intercostal space mid axilla which is the
level of the left atrium
c. Prepping the groin site.
d. Tolerance of lying flat and also their need for sedation or
anxiolytics as per hospital guidelines.
e. Following insertion, nursing care involves cardiovascular/

hemodynamic assessment, fluid balance, positioning and
pressure area care, observation of the balloon catheter and line,
the catheter insertion site, limb perfusion, neurological status
and providing psychological support for patient and family.
 After Insertion – Maintaining the patency of the IABP and safety and
comfort of the patient through the following nursing actions:
a. Assess cardiovascular hourly, or more frequently depending on
clinical acuity, noting mean arterial pressure, augmented
pressure heart rate, oxygen saturation and perfusion state
(lower and upper limb perfusion assessment)
b. Assess and observe for any alteration in neurological status
c. Confirm timing, ratio and trigger of intra-aortic balloon pump
hourly
d. Strict intake and output record – aim for output 0.5ml/kg/hr –
report any sudden decrease in urinary output (signs of
decreased renal perfusion due to low cardiac output or
migration of the catheter to the renal arteries obstructing blood
flow)
e. Ensure the transducer is level with the phlebostatic axis, flushed
hourly and zeroed four hourly or on change of patient position.
Always flush with the pump on standby
f. Check all connections, observe the balloon catheter for
presence of blood which may indicate balloon puncture/rupture
hourly
g. Monitor for signs of pulmonary edema or ischemia
h. Monitor temperature two-to-four-hourly, observing for signs of
infection such as erythema/inflammation and pain at the
insertion site and a raised white cell count
i. Observe for bleeding at cannulation sites, venipuncture sites,
urinary catheter, and insertion site as a complication of
anticoagulation therapy
j. Educate the patient re importance of passive limb exercises,
keeping the affected leg straight
k. Encourage deep breathing exercises to promote adequate
ventilation and lung expansion preventing the development of
chest infections
l. Provide skin care and pressure area care – may need a pressure
relieving mattress and if needed two-hourly turns
m. Assist with nutrition and hydration as patient should be no
higher than 30° which is challenging when eating or drinking
n. Provide ongoing psychological support and education as
required
 Weaning and removal

Once the patient’s condition has stabilized the IABP is considered for
removal. This is preceded by a process of weaning the pump from 1:1 to
1:2 and finally 1:3, and observing the patient for ischemic chest pain or
development of heart failure symptoms such as breathlessness,
hypotension and tachycardia. Once the patient is stable the IABP can be
removed. Post removal the patient is kept on bed rest with the leg kept
straight as per local guidelines.
 Nursing care involves observing for recurrence of symptoms as well as

checking the insertion site for hematoma formation ooze or symptoms
suggestive of retroperitoneal bleed every 15 minutes for the first hour,
half hourly for the next two hours and thereafter hourly or as clinical
acuity dictates. In addition, lower limb perfusion is assessed at these
times confirming adequate perfusion and presence of pedal pulses.
f. PRE-SELECTED VIDEO FOR ADDITIONAL LEARNING:

 https://www.youtube.com/watch?v=mADxD7C8jBw : Cardiogenic Shock and
Intra-aortic Balloon Pump
 https://www.youtube.com/watch?v=jH__qHDFw8A : Inserting an Intra-Aortic
Balloon Pump in the ICU
II. VENTRICULAR ASSIST DEVICE (VAD) and TOTAL ARTIFICIAL HEART (TAH)
a. A VENTRICULAR ASSIST DEVICE (VAD) is an implantable mechanical pump that helps

pump blood from the lower chambers of the heart (the ventricles) towards the aorta
and to the rest of the body. A VAD is used in people who have weakened hearts or heart
failure.
Although a VAD can be placed in the left, right or both ventricles of your heart, it is most
frequently used in the left ventricle. When placed in the left ventricle it is called a left
ventricular assist device (LVAD).
b. IMPLANTABLE ARTIFICIAL HEART / TOTAL ARTIFICIAL HEART (TAH)

For many years, heart transplantation has been the definitive end-stage treatment once
medical therapy no longer provides adequate support to attain acceptable quality of life
for people experiencing heart failure.
Donors for heart is not always immediately available, making it more difficult for those
with end-stage heart failure to improve quality and longer life. Besides the scarcity of
heart donor, there are certain patients who are not a good candidate to receive live
heart for transplant.
An alternative now made available for heart replacement is in the form of Total
Artificial Heart.
A total artificial heart (TAH) is a pump that is surgically installed to provide circulation
and replace heart ventricles that are diseased or damaged. The ventricles pump blood
out of the heart to the lungs and other parts of the body. Machines outside the body
control the implanted pumps, helping blood flow to and from the heart.
As with any surgery, TAH surgery can lead to serious complications such as blood clots
or infection.
Mechanism of TAH
The TAH is an FDA approved device that weighs 14 pounds and can be recharged at
home or in a car. It replaces the function of the ventricles of the heart. Tubes connect
the TAH to a power source that is outside the body. The TAH then pumps blood through
the heart’s major artery to the lungs and the rest of the body.
The TAH has four mechanical valves that work like the heart’s own valves to control
blood flow. These valves connect the TAH to your heart’s atrium, and to the major
arteries, the pulmonary artery, and the aorta. Once the TAH is connected, it duplicates
the action of a normal heart, providing mechanical circulatory support and restoring
normal blood flow through the body.
c. USES OF VENTRICULAR ASSIST DEVICE and TOTAL ARTIFICIAL HEART:
 Bridge to Transplant (BTT)

 For patients with End-Stage-Heart-Failure and are candidate for heart
transplant, need to survive while waiting, until a donor heart becomes
available. The LVAD / TAH assists the heart and allows the patient to
have better quality of life and fewer symptoms; and is then removed at
the time of transplant.
 Destination Therapy (DT)
 For patients with End-Stage-Heart Failure who were not candidates for
heart transplant surgery. It is considered only for patients when all
other treatment options, such as medications, lifestyle changes and
heart procedures, have been tried and not effectively managed heart
failure. DT support the patient’s heart to function and improve quality
of life for the rest of the patient’s life.
III. NURSING DUTIES AND RESPONSIBILITIES FOCUS ON THE PREVENTION OF MAJOR

COMPLICATIONS OF VENTRICULAR ASSIST DEVICE and TOTAL ARTIFICIAL HEART:
Patients with VAD or TAH generally are in a home setting. HEALTH TEACHINGs, therefore
are the most essential for the nurses to render for patients living with these devices,
including the maintenance of the device, the signs and symptoms of its major
complications such as:
 Hypotension. Patients with an LVAD / TAH can experience hypotension for a

number of reasons, including infection, gastrointestinal bleeding, and
dehydration. Continuous flow LVADs have a narrow pulse pressure, usually less
than 15 mm Hg, resulting in diminished peripheral pulses that frequently can't
be palpated. For this reason, standard noninvasive BP measurements are
difficult to obtain, but BP measurements can be obtained with a Doppler or
electronic noninvasive BP cuff
 Infection. A significant cause of morbidity and mortality in patients with an

LVAD / TAH is infections. They're divided into three categories:
 Device-specific infections involve the pump, cannula, pocket, or
percutaneous driveline
 Device-related infections include infective endocarditis, bacteremia, and
mediastinitis
 Non-device-related infections include urinary tract infections,
respiratory tract infections, cholecystitis, and Clostridium
difficile infection.
 Sepsis. Managing patients with an LVAD / TAH and sepsis is similar to
managing patients with sepsis who don't have the device except that
assessing changes in BP and fluid management are more challenging in
patients with an LVAD/TAH. Treatment includes obtaining blood
cultures, possibly culturing the LVAD/TAH driveline site, providing
antibiotic therapy when indicated, and administering fluids to prevent
hypovolemia. If the infection is refractory to medical therapy, surgical
intervention may be warranted. This may include debridement or, in
some cases, removal of the device and placement of a new LVAD /TAH
 Gastrointestinal bleeding. Another notable adverse event after
implantation is gastrointestinal bleeding (GIB). Patients with an LVAD /
TAH are on multimodal anticoagulation to prevent thrombus formation,
and this can predispose patients to bleeding. Many patients take
warfarin, clopidogrel, or aspirin for thrombosis prophylaxis.
 Dysrhythmias. Patients with an LVAD / TAH are at high risk for atrial and
ventricular dysrhythmias. Alterations in cardiac rate and rhythm are
sometimes poorly tolerated because right and left ventricular filling and
function are compromised, which can lead to decompensated HF,
syncope, and sometimes death. Management of atrial dysrhythmias in
patients with devices is similar to patients without an LVAD / TAH. For
rate control, beta-blockers are preferred over calcium channel blockers
because calcium channel blockers provide no functional or mortality
benefit and may worsen outcomes. If beta-blockers aren't well
tolerated, amiodarone is preferred for atrial dysrhythmias. To treat
ventricular dysrhythmias, amiodarone, lidocaine, are often prescribed
 Neurologic events. Patients with an LVAD / TAH are at increased risk for
ischemic and hemorrhagic strokes. Head CT scan is needed to identify
the type of stroke. Acute ischemic strokes result from thromboembolic
events due to pump thrombosis, subtherapeutic anticoagulation, or a
prothrombotic state associated with activation of the immune system.
Ischemic strokes occur in 8% to 10% of patients with an LVAD / TAH.
Causes of hemorrhagic stroke in these patients include hemorrhagic
transformation of an ischemic stroke, over anticoagulation, or infection.
b. PRE-SELECTED VIDEO FOR ADDITIONAL LEARNING:

 https://www.youtube.com/watch?v=mOZIYoq32SQ : LVAD
 https://www.youtube.com/watch?v=_vma7myqIyo : Medical Device
Animation: Heartware System LVAD Pump
 https://www.youtube.com/watch?v=CI-CKgvc7PY : Living with an LVAD
 https://www.youtube.com/watch?v=YKesLS2j2WU : Medical Animation –
Total Artificial Heart Implantation
 https://www.youtube.com/watch?v=EyzrqeWJR0s : University of Michigan
TAH Bridge to Transplant

Lesson 3 Hemodynamic Monitoring Semi Finals 3

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SKILLS LABORATORY MODULE

LESSON 3: HEMODYNAMIC MONITORING: PULMONARY ARTERY CATHETERIZATION & ARTERIAL LINE,

I. PULMONARY ARTERY CATHETERIZATION (PAC)

A PA catheterization or often referred to as Right Heart Catheterization is the insertion of a

PRE-SELECTED VIDEO FOR LEARNING REINFORCEMENT:

https://www.youtube.com/watch?v=y241HEaBkLA : Swan-Ganz Catheter Placement

https://www.youtube.com/watch?v=YkN30T6ig30 : PAC Placement and Physiology

a. The cardiac output pushes the blood through the vascular system.

Left ventricular preload is reflected by the PCWP (Pulmonary Capillary Wedge

The most important determinant of afterload is vascular resistance

a. As arterial vessels constrict, the afterload increases; as they dilate, afterload

PRE-SELECTED VIDEO FOR ADDITIONAL LEARNING:

https://www.youtube.com/watch?v=stA5pwoOZNA : Cardiomyopathy Preload vs

II. PERIPHERAL ARTERIAL LINE: INVASIVE BLOOD PRESSURE MONITORING

PRE-SELECTED VIDEO FOR ADDITIONAL LEARNING

https://www.youtube.com/watch?v=3z9vHu4r6HE : Arterial Line Placement

III. NURSING DUTIES AND RESPONSIBILITIES

1.Informed Consent - An informed procedure consent is required prior to

https://www.youtube.com/watch?v=4C_fAHVvdRo : Advance Critical Care Nursing PA

1. Medical-Surgical Nursing Concepts for Interprofessional Collaborative Care, 9 th

LESSON 4: MECHANICAL CIRCULATORY ASSIST DEVICE - INTRAAORTIC BALLOON PUMP, VENTRICULAR

INDICATIONS FOR MECHANICAL CIRCULATORY ASSIST DEVICES:

I. INTRAAORTIC BALLOON PUMP (IABP)

d. Indications: Although it was originally designed to support patients in cardiogenic shock

e. Nursing Care / Duties and Responsibilities:

 Prior to Insertion - Aside from gathering the equipment specific to IABP

e. Following insertion, nursing care involves cardiovascular/

 Weaning and removal

 Nursing care involves observing for recurrence of symptoms as well as

f. PRE-SELECTED VIDEO FOR ADDITIONAL LEARNING:

a. A VENTRICULAR ASSIST DEVICE (VAD) is an implantable mechanical pump that helps

b. IMPLANTABLE ARTIFICIAL HEART / TOTAL ARTIFICIAL HEART (TAH)

c. USES OF VENTRICULAR ASSIST DEVICE and TOTAL ARTIFICIAL HEART:

 Bridge to Transplant (BTT)

 Destination Therapy (DT)

III. NURSING DUTIES AND RESPONSIBILITIES FOCUS ON THE PREVENTION OF MAJOR

 Hypotension. Patients with an LVAD / TAH can experience hypotension for a

 Infection. A significant cause of morbidity and mortality in patients with an

b. PRE-SELECTED VIDEO FOR ADDITIONAL LEARNING:

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