Hemodynamic

Monitoring
HEMODYNAMIC MONITORING
 Hemo
Hemo Dynamics Dynamics
Blood Movement Movement
of blood
flow
 HAEMODYNAMICS
Systole Diastole
 60-90mm Hg

100-140 mm Hg
 METHODS OF HAEMODYNAMIC
MONITORING
• Non invasive hemodynamic assessment
• Arterial Blood Pressure
 Non-invasive
 Direct arterial pressure measurement
• Central Venous Pressure
• The Pulmonary Artery Catheter
• Cardiac Output Measurement
 NON INVASIVE HAEMODYNAMIC
ASSESSMENT
• Take vital signs
 NON INVASIVE HAEMODYNAMIC
ASSESSMENT

• Precordium

Inspect anterior chest for

heaves and an increase in
visible pulsations
 NON INVASIVE HAEMODYNAMIC
ASSESSMENT
• Palpate the PMI
NON INVASIVE HAEMODYNAMIC
ASSESSMENT
 NON INVASIVE HAEMODYNAMIC
ASSESSMENT

• Ausultate the
aortic, pulmonic,
second
pulmonic, mitral
and tricuspid
areas of the
precordium
 NON INVASIVE HAEMODYNAMIC
ASSESSMENT

• Peripheral vascular

• Inspect and palpate the skin for colour, texture,

moisture and turgor
 NON INVASIVE HAEMODYNAMIC
ASSESSMENT

• Palpate the peripheral pulses and check nail

bed capillary refill
 NON INVASIVE HAEMODYNAMIC
ASSESSMENT
• Inspect the neck for jugular venous distension
 NON INVASIVE HAEMODYNAMIC
ASSESSMENT
• Auscultate and palpate the carotid arteries
 NON INVASIVE HAEMODYNAMIC
ASSESSMENT
• Assess for hepato jugular reflux
 ARTERIAL BP MONITORING

Indirect methods
Traditional method of cuff and mercury
manometer (Auscultation from the Latin for
listening)
NIBP machine or oscillometry
Direct methods
Intra-arterial catheter / transducer system
Traditional method of cuff and
mercury manometer
 OSCILLOMETRIC METHODS

• With an electronic pressure

sensor (transducer) fitted in
to detect blood flow,
• The pressure sensor is a
calibrated electronic device
with a numerical readout of
blood pressure.
 Advantages of non invasive BP
monitoring
• Simpler and quicker than invasive
measurements

• Require less expertise in fitting

• Have virtually no complications

 Limitations of Non-invasive Blood
Pressure Monitoring

• Cuff must be placed correctly and must be appropriately sized

– Auscultatory method is very inaccurate

– Korotkoff sounds difficult to hear

– Significant underestimation in low-flow (i.e. shock) states

• Oscillometric measurements also commonly inaccurate (> 5

mm Hg off directly recorded pressures)
ARTERIAL LINE
BPMONITORING
Arterial line

Uses

• Record blood pressure

(systolic, diastolic, mean and
pulse pressure)

• Arterial blood sampling

Arterial line BP monitoring
Specific indications
• Labile blood pressure
• Anticipation of haemodynamic
instability
• Titration of vasoactive drugs
• Frequent blood sampling
• Morbid obesity (unable to fit an
appropriately sized NIBP cuff)
CONTRAINDICATIONS

Absolute contraindications
• Absent pulse
• Thromboangiitis obliterans (Buerger
disease)
• Full-thickness burns over the
cannulation site
• Inadequate circulation to the extremity
• Raynaud syndrome
CONTRAINDICATIONS
Relative contraindications

• Anticoagulation

• Atherosclerosis

• Coagulopathy

• Inadequate collateral flow

• Infection at the cannulation site

• Partial-thickness burn at the cannulation

site

• Previous surgery in the area

• Synthetic vascular graft

 Site selection
• Radial artery

• Brachial artery.

• Dorsalis pedis artery.

• Femoral artery
 Arterial BP monitoring system
• An intravascular catheter.
• A fluid-filled electro-mechanic monitoring system
containing tubing, pressure transducer, and flush
system.
• A monitor containing an amplifier to convert the small
electronic signal generated by the transducer to a
waveform that is displayed on a screen
Arterial BP monitoring system
Arterial cannula
• A short, narrow, parallel
sided cannula made of
polyurethane or Teflon™

• Larger gauge cannula

increase the risk of
thrombosis, smaller
cannula cause damping
of the signal.
Fluid filled tubing
Fluid filled tubing
• This is attached to the arterial cannula, and provides a
column of non compressible, bubble free fluid between
the arterial blood and the pressure transducer for
hydraulic coupling
• This tubing should be colour coded with red or clearly
labelled.
• A 3way tap is incorporated to allow the system to be
zeroed and blood samples to be take
Transducer
Converting the
pressure
waveform into
an electrical
signal
Infusion/flushing system
• A bag of either plain 0.9% saline
or heparinised 0.9% saline is
pressurized to 300mmHg
• This allows a slow infusion of
fluid at a rate of about 2-4ml/hour
to maintain the patency of the
cannula.
• Signal processor, amplifier and display

Arterial line monitoring system

 Articles
• Tape
• An arm board or towel roll
• Opsite or Tegaderm cover dressing
• Local anesthetic (1% or 2% lidocaine ,lidocaine cream)
• Suture material for femoral arterial line placement (2.0 silk)
• Scissors
• Monitor cable for transducing arterial waveform.

• Antiseptic solution
 Technique of insertion

• Ensure there is an adequate pulse in the radial

artery prior to attempting the procedure.
 Allen test
• To assess collateral perfusion
• The test is performed by asking the
patient to clench their hand. The ulnar and
radial arteries are occluded with digital
pressure.
• The hand is unclenched and pressure over
the ulnar artery is released. If there is
good collateral perfusion, the palm should
flush in less than 6 seconds.
 PREPARATION

• Prepare an area over the radial artery about 4-5

cm proximal to the wrist, and cover with the
drape provided.

• Anesthetizing the area over the artery with

lidocaine.
 PROCEDURE
• Palpate the artery with your
non-dominant hand
• Use the large needle to
advance through the skin at
a 30 degree angle.
• When the artery is entered,
a pulsatile flow of blood
will be seen
 PROCEDURE
• Once in the artery, advance the guide wire through the needle, and remove
the needle, always making sure to be holding on to the guide wire

• Place the 12 cm catheter over the guide wire, and advance until the hub is
up to the skin.

• Remove the guide wire, and connect the catheter to a stopcock for
measuring.

• See if an arterial tracing is obtained.

• Suture the sides of the catheter to the skin to ensure it doesn't fall out.

Click here arterial line insertion

 Transducer - A couple of things to remember
• The transducer has to sit in a “transducer holder” – this is the white
plastic plate that screws onto the rolling pole that holds the whole setup.

• The transducer has to be levelled correctly-to make sure that it’s at the
fourth intercostal space, at the mid-axillary line (Phlebostatic axis)

• Make sure there’s no air in the line before you hook it up to the patient –
use the flusher to clear bubbles out of the tubing.

• Zero the line to atmospheric pressure properly

• Choose a screen scale that lets you see the waveform clearly.
 Zeroing
• To ensure accuracy of readings
• Flush the device & turn it off to patient but open to
atmosphere
• These exert pressure on transducer
• This pressure is called zero
• Zero once per shift or if values are questionable
• Ensure flush bag is pumped up
 COMPLICATIONS
• Haemorrhage may occur if there are leaks in the system.
Connections must be tightly secured and the giving set and line
closely observed..

• Emboli. Air or thrombo emboli may occur.

Care should be taken to aspirate air bubbles

• Accidental drug injection may cause severe, irreversible damage to

the hand.
-No drugs should be injected via an arterial line

- The line should be labelled (in red) to reduce the likelihood of this
occurring
 COMPLICATIONS

• Arterial vasospasm

• Partial occlusion due to large cannula width, multiple attempts at

insertion and long duration of use

• Permanent total occlusion

• Sepsis or bacteraemia secondary to infected radial arterial lines is

very rare (0.13%);
-local infection is more common.
-if the area looks inflamed the line site should be changed.
 Never inject anything into an arterial
cannula or arterial line

• –Concentration of a drug into

the tissues served by the
cannulated artery can result in
cell death
• –Skin necrosis, severe
gangrene, limb ischemia,
amputation & permanent
disabilities
 Arterial pressure waveform

• Once inserted, an arterial

waveform trace should be
displayed at all times

• This confirms that the invasive

arterial BP monitoring is set
up correctly, and minimizes
problems.
ARTERIAL WAVE FORM
 Is it accurate?
• Now we know how the arterial pressure monitoring
system works, we need to be able to decide whether or not
the trace (and BP in numerical format) is accurate.

• Failure to notice this may lead to unnecessary, or

missed treatments for our patients.
• There are 2 main abnormal tracing problems that can
occur once the monitor gain is set correctly.
Sources of error

• Failure of any one of the components in system

• Transducer position
– pressure displayed is pressure relative to position of transducer

– in order to reflect blood pressure accurately transducer should be

at level of heart. Over-reading will occur if transducer too low
and under-reading if transducer too high

– transducer must be zeroed to atmospheric pressure

• Damping.
• Dampened trace
 Dampened: wide, flattened tracing
• Dampening occurs due to:

– air bubbles

– overly compliant, distensible tubing

– catheter kinks

– clots

– low flush bag pressure or no fluid in the flush bag

– Improper scaling

– Severe hypotension if everything else is ruled out

• Resonant trace
 Resonant: ‘spiked’ tracing
• Resonance occurs due to:
– long tubing

– overly stiff, non-compliant tubing

– increased vascular resistance

– non-fully opened stopcock valve

Comparison with non-
invasive BP
• Arterial lines measure systolic BP
approximately 5 mmHg higher and
the diastolic BP approximately 8
mmHg lower compared to non-
invasive BP (NIBP) measurement
Advantages of IBP measurement

• Continuous blood pressure recording

• Accurate blood pressure recording even

when patients are profoundly hypotensive

vs NIBP which is difficult or inaccurate

• Real time Visual Display

Disadvantages of IBP measurement

• Potential complications

• Skilled technique reqd

• Expensive
NURSE’S RESPONSIBILITY
CVP MONITORING
 CENTRAL VENOUS PRESSURE

Right Atrium
The presure of the blood
within the right atrium is
the central venous pressure

The normal value

for CVP ranges
from 8-12cm of
H2O
NON INVASIVE HAEMODYNAMIC
ASSESSMENT
CENTRAL LINE INSERTION
 INDICATIONS

• CVP Monitoring
• Rapid infusion
• Infusion of hypertonic solutions and
medications that could damage veins
• Serial venous blood assessment
Articles required for CVP insertion
Methods of CVP Monitoring
Transducers

Manometers
Manometer Method
Measuring CVP using manometer
Line up the manometer with phlebostatic
axis

Move the manometer scale up and down

the bubble to be aligned with zero on the
scale. This is referred as zeroing of
manometer

Turn the three way tap off to the

patient and open to the manometer

Open the IV fluid bag and slowly fill

the manometer to a level higher than the
expected CVP
Measuring CVP using manometer
Turn off the flow from the fluid bag and
open the three way tap from the
manometer to the patient

The fluid level inside the manometer

should fall until the gravity equals the
pressure in the central veins

When the fluid stops falling the CVP

measurement can be read. If the fluid
moves with the patients breathing, read
the measurement from the lower number

Turn the tap off to the manometer

CVP Monitor with transducer and
monitor
Precautions while handling central line

• Hand hygiene before and after any manipulation

of vascular access devices or catheter

• An aseptic technique

• Standard precautions.

• Sterile disposable transducers, pressure tubing

and line are replaced at 96 hour intervals
 PROCEDURE FOR CVP MONITORING
• Obtain verbal consent

• Position patient supine or semi recumbent to 30-45 degree elevation

• Prime pressure tubing with Sodium chloride 0.9%, close connection

• Check flushing mechanism

• Apply the pressure bag and inflate to 300mmHg

• Connect to monitor transducer cable

• Calibrate zero and level the transducer to the phlebostatic axis

 PROCEDURE FOR CVP MONITORING
• Attach extension tubing to central venous catheter, open fluid path,
and adjust rate

• Close the stopcock to the patient and open to air and read the display
monitor at end of expiration

• Reopen stopcock to patient; recommence intravenous transfusion at

prescribed rate

• Record the result

• Report abnormal readings or change in trends

• Monitor insertion site for infection, bleeding and disconnection. See

Typical CVP waveform
 Typical CVP waveform
Three peaks
• a- atrial contraction
• c- closure of tricuspid valve
• v-ventricular diastole
Two descents
• x – atrial relaxation
• y- tricuspid valve reopening
• Click here CVP wave form
• CVP is elevated by :
– overhydration which increases venous return

– heart failure or PA stenosis which limit venous

outflow and lead to venous congestion

– positive pressure breathing, straining,

• CVP decreases with:
– hypovolemic shock from hemorrhage, fluid shift,
dehydration

– Negative pressure breathing

 COMPLICATIONS
• Pneumothorax

• Haemothorax

• damage to vein or adjacent structures

• vein thrombosis or thrombophlebitis

• infection

• cardiac arrhythmias

• haemorrhage

• air embolism
NURSE’S RESPONSIBILITY
PULMONARY ARTERY
CATHETER
• Swan and Santa Monica Bay sailboats
discovered swanz ganz catheter(Triple lumen
catheter)

• Measures CVP, PAP, PAOP, Cardiac Index and

SVO 2
 Indications for Pulmonary Artery
Catheterization
• Identification of the type of shock
 Cardiogenic (acute MI)
 Hypovolemic (hemorrhagic)
 Obstructive (PE, cardiac tamponade)
 Distributive (septic)
• Monitoring the effectiveness of therapy
PA catheter
 Complications of Pulmonary Artery
Catheterization
• General central line complications
• Pneumothorax
• Arterial injury
• Infection
• Embolization
• Inability to place PAC into PA
• Arrhythmias (heart block)
• Pulmonary artery rupture
 NORMAL HEMODYNAMIC VALUES
PARAMETERS NORMAL VALUE

Stroke volume 50-100 mL

Cardiac output 4-8 L/min

Cardiac index 2.5-4.0 L/min/M 2

MAP MAP 60-100 mm Hg

CVP 2-6 mm Hg

PAP systolic 20-30 mm Hg

PAP diastolic 5-15 mm Hg

PAWP (wedge) 8-12 mm Hg

Colour code for various lines
CARDIAC OUTPUT MONITORING
Thermodilution (pulmonary
artery catheter)

• Boluses of ice-cold fluid are

injected into the pulmonary artery
and the change in temperature
detected in the blood of the
pulmonary artery
Any doubts?