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 Hemodynamic
Monitorin

-,
1= PJi~Jr~\BUNA
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RC670.5.H45H462006
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ISBN1 3978-1-58255-503-4
ISBN10 1-58255-503-6 (alk. paper) 2006004285 en
L-________________ ~ ____________-J o
~

(JJ
0::
0::
 Contents
On the red carpet iv
Contributors and consultants vi

1 Cardiopulmonary anatomy and physiology

Unaerstanding a pressure monitoring system 17

Vascular access 27

Arterial pressure monitoring 39

Central venous ressure monitoring 53

Pulmonary artery pressure monitoring 67

l Car~iao9utput monitoring 87

Tissue oxygenation monitoring 103

9 Non invasive hemodynamic monitoring 117

-4 r;i'rcu}~~Qryas6ist devices 133

I

Selected references 149

Credits 150
Index 151
 \

--- - ~ ---- - - -
- --/-----------~
\
Well, we're here at
the premiere of
Hemodynamic
Monitoring Made
Incredibly Visual and
I've got to tell you
this is quite an
experience! Everyone
who's anyone has
come out tonight!

It seems Mr. Hea rt

has accompan ied a
I think I see key star - the "On
some of the the level" logo that
stars of this outlines normal and
blockbuster abnorma l pressure
arriving now! readings! Who knew
they were an item??
 And now it seems
~~ __ II 1.1
another
, famo us Iogo
IS making her
entrance!
I
------- Now we're t I '
the "R'd
You played
a ki ng with
I e the w "
,ave logo,
this prod a vital role in
uctlon
a little bit b - te ll me
a out how
prepared for it, you

I rea lly focused 0

explain ing th n
hope my me waveforms, I
essage
across to th gets
was exhaust' e audience! It
head d f Ing though - I'
e or the " m
some surf pipeline for
Ing after this!

~)1 \~ t~~cC:;
The last of th
are arriving n::'~~: .... l \..,..0> .....

has been '

--- Oh, I think it's

_I
evening qUite an
- and th' a:out to begin! Tu rn
just b IS has
heen a peek as to o page 1 and let's
w at you'll see! start the shawl
Contributors and consultants
Helen Christina Ballestas, RN, MSN, Todd Isbell, RN, BSN,CCRN-CSC
PhD(C),CRRN Director, Critical Care
Nurse Educator MountainView Hospital
New York Institute of Technology Las Vegas
Old Westbury, N.Y.
Theresa M. Leonard, RN, BSN, CCRN
Natalie Burkhalter, RN, MN, FNP, ACNP, Unit Educator, Invasive Cardiology
CCRN Stony Brook (N.Y.) University Hospital
Associate Professor
Amy Shay, RN, MS, CCRN, CNS
Texas A&M International University
Pulmonary Clinical Nurse Specialist
Laredo
Miami Valley Hospital
Marissa U. Camanga-Reyes, RN MN, Dayton, Ohio
CCRN
Nurse Manager
Harbor-UCLA Medical Center
Torrance, Calif.
Jessie Casida, RN, PhD(C), CCRN, APN,C
Assistant Professor, Department of
Adult Health
Seton Hall University College of Nursing
South Orange, N.J.
 • Understanding the
pulmonary system 2
• Understanding the
OK, people, settle
down, For this chapter,
cardiac system 8
we need to set the
scene, All oxygen • Vision quest 16
characters enter left!
And make sure al l you
blood characters know
your cues!
 Cardiopulmonary anatomy and physiology

You'd think
with 300 mill ion
alveol i I'd won the
lottery but, we!!,
Understa nd ing
I I
t-ne pUlmonary
I
it's just typical .

system
The pulmonary system delivers oxygen to the bloodstream and removes excess
carbon dioxide from the body. The alveoli are the gas-exchange units of the
lungs. The lungs in a typical adult contain about 300 million alveoli.
Structure of intrapulmonary airways
ok at alveoli Alveolar sac - - - - , Respiratory bronchioles
Gas exchange occurs rapidly in the tiny, thin-membraned alve- Alveolar Smooth
oli. Inside these air sacs, oxygen from inhaled air diffuses into pore - ---, muscle - -- - - ,
the blood as carbon dioxide diffuses from the blood into the air
and is exhaled.
Alveoli consist of type I and type II epithelial cells:
• Type I cells form the alveolar walls, through wh ich gas ex-
change occurs .
• Type II cells produce surfactant, a lipid-type substance that
coats the alveoli. During inspiration, the alveolar surfactant al-
lows the alveoli to expand uniformly. During expiration, the sur-
factant prevents alveolar collapse.
This illustration shows a cross-section view of an alveolus.

Alveolar duct _ _ __ Pulmonary artery - - - - - ---='.......

Smooth muscle - - -
Pulmonary vein ----:r=7----:----"'-'-"'ii1II~~".t;'=;t__

Capillary - - - - - - Alveolus - - - ----t"""......

Capi llary beds

Elastic fiber - -- -- cover all alveoli ---:---==
Collagen fibri l - - - -

Alveolar cel/:
• Type II - -- - -+-
• Type 1- - -- - - 1 - - - - '
 """'-"""'-_ _ _ _ _ _ _ _ _ _"""'-_ _ _ _ _ _ _U_n_d_o,.,;tandlng tho pulmonary .y.tom e
Structures of the pulmonary system

Frontal sinus - - - - - ------j

Sphenoid sinus - - - - - -

Nasal cavity - - - - -- --,'

----::~"="~-.."..,...--~_c;f------------ Opening of eustachian

tube
Oral cavity - - - - - - - - + - 1 ~--~~--o~---------Nasopha~nx

----~~+---------- Soft palate

- - - - - - , - - - - --4-- - - - - - - - - Oropha~nx

~---~--;--------- Epiglottis

Hyoid bone - - - -- - - -"=' -'--- - - - - -f------ - - - - - - - Esophagus

Thyroid cartilage _ _ _ _ _ _ _ _ _ _-----,,--L_

Cricoid cartilage - - - -- - - - - - - - --"

~~-~-~~-------- Trachea
Apex of lung - - - - - -- - - - - -
- - - - - -- - Superior lobe
Superior lobe - - - - - - - - ------::t=
~------ Left main bronch us

Horizontal fissure - - --1'+""

Oblique fissure

Heart

Middle lobe - - - --1+--

Oblique fissure -------!-t"-
Inferior lobe
Inferior lobe - - -- l"-

Diaphragm _ _ _ __£_:
 Cardiopulmonary anatomy and tm'1f6101C::'tAV

espiration
2ectiYe respiration requires gas exchange
in the lungs (external respiration) and in the
--=-Iles (internal respiration). Three external Ventilation
respiration processes are needed to maintain (gas distribution into and out
adequate oxygenation and acid-base balance: of the pulmonary airways)

Pulmonary perfusion
Ventilation,
pulmonary
(blood flow from the right side of the
perfusion, and heart, through the pulmonary circula-
diffusion are the tion, and into the left side of the heart)
magic 3 processes
for adequ ate Diffusion
oxygenation and (gas movement from an area of
acid-base ba lance. greater to lesser concentration
through a semipermeable membrane)

Ventilation
Breathing, or ventilation, is the movement of air into and out of the respiratory system. During inspiration,
the diaphragm and external intercostal muscles contract, causing the rib cage to expand and the volume of
the thoracic cavity to increase. Air then rushes in to equalize the pressure. During expiration, the lungs
p assively recoil as the diaphragm and intercostal muscles relax, pushing air out of the lungs.

The mechanics of breathing

Mechanical forces, such as movement of the diaphragm and intercostal muscles, drive the breathing process. In these depictions ,
a plus sign (+ ) indicates positive pressure and a minus sign (- ) indicates negative pressure.

At rest Inspiration Expiration

• Inspiratory muscles relax.
• Atmospheric pressure is maintained in
the tracheobronchial tree.
• No air movement occurs.
• Inspiratory muscles contract.
• The diaphragm descends.
• Negative alveolar pressure is main-
tained .
• Air moves into the lungs.
• Inspiratory muscles relax, causing lungs
to recoil to their resting size and position.
• The diaphragm ascends.
• Positive alveolar pressure is maintained.
• Air moves out of the lungs.
 Undere;tanding the pulmonary e;ye;tem

--------------------~~~-.---------- The right ventricle is

connected to the . .. pulmonary
arteries. The arteries are
connected to the ... arterioles.
The arterioles are connected to
the ... capillary network ... that
Pulmonary perfusion ends in the alveoli !
Blood flow through the lungs is powered by the right ventricle. The right
and left pulmonary arteries carry deoxygenated blood from the right ven-
tricle to the lungs. These arteries divide to form distal branches called ar-
terioles, which terminate as a concentrated capillary network in the alve-
oli and alveolar sac, where gas exchange occurs.
Venules - the end branches of the pulmonary veins - collect oxy-
genated blood from the capillaries and transport it to larger vessels,
which carry it to the pulmonary veins. The pulmonary veins enter the left
side of the heart and distribute oxygenated blood throughout the body.

Tracking pulmonary perfusion

_.....r9I~ 16.[.3..-I---'t--"<- - - - Trachea

Pulmonary arterioles ----,!'--aiII Aorta
Superior vena cava Pulmonary artery
Bronchus Pulmonary trunk
Pulmonary vein Left atrium
Bronchiole Left ventricle
Right atrium Right ventricle
Pulmonary venules - I-'111/PI
Inferior vena cava
Alveoli -----~~S9'
Diaphragm - - ---+.,....."

That's NOT Hey, you

how the song s ing your
goes, you song; I'll sing
know! mine!
«It Cardiopulmonary anaL-(J[
When we al l work
tog eth er, gas
exchange goes off
without a hitch!
Blood in the pulmonary capillaries gains oxygen and loses carbon dioxide
through the process of diffusion (gas exchange). In this process, oxygen and
carbon dioxide rnove frorn an area of greater concentration to an area of
lesser concentration through the pulmonary capillary, a semipermeable
membrane. This illustration shows how the differences in gas concentration
between blood in the pulmonary artery (deoxygenated blood from the right
side of the heart) and alveolus make this process possible. Gas concentra-
tions depicted in the pulmonary vein are the end result of gas exchange and
represent the blood that's delivered to the left side of the heart and systemic
circulation.
Diffusion across the alveolar-capillary membrane

Alveolus
• Partial pressure of oxygen
(Po2) 104 mm Hg
• Partial pressure of carbon
dioxide (Pco 2 ) 40 mm Hg

Wh en gas
exchang e doesn't
work, we're al l in
for hard ti mes!

Pulmonary capillary

Ventilation and perfusion ratio

Areas where perfusion and ventilation are similar have a ventilation-perfusion
CV/Q) match. Gas exchange is most efficient in such areas. For example, in
normal lung function, the alveoli receive air at a rate of about 4 Uminute while
the capillaries supply blood to the alveoli at a rate of about 5 Uminute, creat-
ing a V/Q ratio of 4:5, or O.S (the normal range for a V/Q ratio is from O.S to 1.2).
A V/Q mismatch, resulting from ventilation-perfusion dysfunction or altered
lung mechanics, indicates ineffective gas exchange between the alveoli and
pulmonary capillaries, and can affect all body systems by changing the amount
of oxygen delivered to living cells.

~----------------------~----
Understanding ventilation and perfusion
Key
~ Blood with CO2
c:J Blood with 02
~ Blood with CO2 and 02
Causes
Conditions that may produce
a V/Q mismatch
include:
Shunting (reduced
ventilation to a lung
unit) causes unoxy-
genated blood to move from
the right side of the heart to
the left side of the heart and
into systemic circulation; it
may result from physical de-
fects or airway obstruction.
Dead-space
ventilation
(reduced perfusion
to a lung unit) occurs when
alveoli don't have adequate
blood supply for gas ex-
change to occur, such as with
pulmonary emboli and pul-
monary infarction.
A silent unit
." (a combination of
_. r:' shunting and dead-
space ventilation) occurs
when little or no ventilation
and perfusion are present,
such as in cases of pneumo-
thorax and acute respiratory
distress syndrome.
Normal ventilation
and perfusion
From pulmonary artery
Normal capillary ------'~
Inadequate ventilation
(shunt)
From pulmonary artery
Inadequate perfusion
(dead-space ventilation)
From pulmonary artery
Perfusion blockage
Narrowed capil lary-~~;;;iiIII"
Inadequate ventilation
and perfusion
(silent unit)
From pulmonary artery
Perfusion blockage
Under6tanding th~ pulmonary 6Y6tem
When ventilation and
(V/O) are matched,
blood from the venous system re-
To pulmonary vein turns to the right side of the heart
through the pulmonary artery to
the lungs, carrying carbon dioxide
(C0 2). The arteries branch into
the alveolar capillaries . Gasex-
change takes place in the
capillaries .
Ventilation blockage
When the V/O ratio is low,
To pulmonary vein
vessels doesn't become
genated .
When the V/O ratio is high , 9s ',
shown here, ventilation is normal,
but alveolar perfusion is reduced
To pulmonary vein or absent. Note the narrowed· C
capi llary, indicating poor perfu-
sion. This commonly results from
a perfusion defect, such CJ.S
monary embolism or a
-lJ--- - Alveolus
that decreases card iac
Ventilation blockage
The silent unit indicates an· ab-
sence of ventilation and perfUSion.
To pulmonary vein to the lung area. The silent unit - .
"may help compensate for a V/O .
imbalance by delivering bloo d,;
flow to better ventilated lung
areas.
 Cardiopulmonary anatomy and phY6ioiogy

Volume, volume,

Understanding the vol ume! That's the

name of the game in
cardiovascular

cardiac system
functio n. I pump the
body's entire volume
of blood to the lung s
and all other organs.
Oh,
The cardiac system: what a
• carries life-sustaining oxygen and nutrients in the blood to all beautifu l
cells of the body morning!
• removes metabolic waste products in the blood from the cells. Oh, what a
The heart is a cone-shaped muscle that pumps the body's entire beautiful
volume of blood to the lungs (right ventricle) and all ofthe other day ...
organs (left ventricle). The major blood vessels of the heart are
the left and right coronary arteries, which branch from the base of
the aorta.

A closer look at the heart

Branches of right
pulmonary artery
Aortic arch
Superior vena cava
Pulmonary Branches of left
semilunar valve pulmonary artery

Right atrium Left atrium

Right pulmonary Left pulmonary veins

veins
Aortic semilunar valve

Tricuspid valve
Mitral valve
Chordae tendineae
Left ventricle
Right ventricle
Interventricu lar
muscle
Papillary muscle
Myocardium

Inferior vena cava

+-- - - - - - Descending aorta

 ~~_ _......._ _ _........._ __ _.....;..._~~_.........Und....tlmdi~;:he cardiac system 0
Viewing coronary vessels
Left subclavian artery -----------~

Normal Left common carotid artery -------~

intracardiac Brachiocephalic artery - - - - - --. Anterior view
pressures Aortic arch-------------:
Structure Normal pressure Superior vena cava - - - -

Righ~.~.trium i' O to 8 mm Hg Pulmonary t r u n k - - - - -

Righ f ' Systolic: 15 to 2.5 mm Hg

ventriCle Diastolic: 0 to 8 mm Hg Right atrium - - - - -

Pulmonary Systolic: 15 to 25 mm Hg Right coronary artery

artery Diastolic: 8 to 15 mm Hg
Great cardiac vein

Left atrium 4 to 12 mm Hg Circumflex branch of

left coronary artery
Left Systolic: 110 to 130 mm Hg
ventricle Diastolic: 4 to 12 mm Hg Small cardiac vein - - -----';

Aorta Systolic: 110 to 130 mm Hg Anterior interventricular

Diastolic: 70 to 80 mm Hg (descending) branch of
left main coronary artery -----~

These two views of Left common carotid artery - - - - - - - ,

the heart might help
you put together the
pieces of the heart
puzzle! They show the
great vessels and
some major coronary
vessels.
Left subclavian a r t e r y - - - - - - - Posterior view
------Brachiocephalic artery
- - - - - A o r t i c arch
Pulmonary artery -------,
-----Superior vena cava
Left pulmonary veins
Right pulmonary veins
Left atrium - - - - - -
Right atrium
Great cardiac vein
Inferior vena cava
Circumflex branch of
left coronary artery
Small cardiac vein
Posterior vein of
left ventricle - - - - =-:L- - - Right coronary artery

Middle cardiac vein :...-- - - Posterior interventricular

(descending) branch of
right coronary artery
e Ca"Uopulmonary anato~m_y_a_n_d_p_h_Y.6;.;i.~._IO_g_y_ _ _ _ _ _ _ _ _,,--__________=
Cardiac conduction
The conduction system of the heart begins with the heart's pacemaker, the sinoatrial (SA) node.
When an impulse leaves the SA node, it travels through the atria along Bachmann's bundle and
the internodal pathways on its way to the atrioventricular (AV) node and the ventricles. After
the impulse passes through the AV node, it travels to the ventricles, first
down the bundle of His, then along the bundle branches and, lastly,
down the Purkinje fibers.

The cardiac conduction

system Bachmann's bundle - - - - - - - ,

SAnode--- - - -- -

Internodal tract:
• Posterior (Thorel's bundle)
• Middle (Wenckebach's bundle)
• Anterior - - - - - - -

AVnode - -- - - --

Bundle of H i s - - - - - - -

Right bundle branch - - - - - - - - - '

Left bundle branch - - --------'

Purkinje fibers ---------~_

Okay, so like I was Got it, boss.

sayin', go through the
atria along this here
Bachmann's bund le,
using the internodal
pathways to get to
my cousin, the AV
node, and on to his
peeps, the ventricles.
Wa it, should I take
the bundle of His to
the branches and
down the Purkinje
f ibers to get to the
ventricles? I think
the expressway will
be jammed at this
time of day.
 Understanding the cardiac system
~~--------~----~-------

Events of the cardiac cycle

Isovolumetric
ventricular Ventricular ejection
contraction
When ventricular pressure
1:1 response to ventricular
exceeds aortic and pulmo-
depolarization, tension in the
nary arterial pressure, the
tentricles increases. This
aortic a~d pulmonic valves
rise in pressure within the
open and the ventricles eject
entricles leads to closure of
blood.
:he mitral and tricuspid
'1alves. The pulmonic and
aortic valves stay closed
during the entire phase.

Isovolumetric
Atrial systole relaxation
When ventricular pressure
Know n as the atrial kick,
falls below the pressure in
atrial systole (coinciding with
the aorta and pulmonary
late ventricular diastole)
artery, the aortic and pul-
supplies the ventricles with
monic valves close. All
me remaining 30% of the valves are closed during this
blood for each heartbeat.
phase. Atrial diastole occurs
as blood fills the atria.

Ventricular filling
Atrial pressure exceeds ventricular
pressure, which causes the mitral and
tricuspid valves to open. Blood then
flows passively into the ventricles.
About 70% of ventricular filling takes
place during this phase.
 ~7~
Cardiopulmonary anatomy and pby.s~logy
-=-~~-~-=====---~--------~~----------------------~

Cardiovascular circuit
The cardiovascular circuit is a continuous, closed, fluid-filled elastic system of arteries, capillaries,
and veins. The heart acts as a pump for this system.

Blood circulation
Blood enters the right atrium from the vena cava and flows into the right ventricle. Heart muscles contract to send
blood through the pulmonary trunk to the lungs for oxygenation. Blood retums to the left atrium through the pulmonary
veins and flows into the left ventricle. Heart muscles contract again to drive blood through the aorta into the arterial
system of the body. As arteries become ,.,- ___
increasingly smaller, blood reaches
capillary beds where oxygen is released (
At~(S',,-~~
.
.f;f:. "-...
~ ~" Brain
to the cells of organs and tissues. \.,.J " 0"/'\..-
\ .
Veins then carry oxygen-poor ~..;f
____ (J> ~
blood back to the vena cava. .r~--..~~ \;/~~ ~ --- ----- """-
,rr--- ~'C.>'- CJ 1- ~ --- ------ "
. / .
/
~>r :.-/)
&-( ~
'x. \
I
IlI / l8J
Pulmonary Pulmonary \
Right and arterioles venu les \)
~~~~~~~ ~ ~ r........ ~1 ~felivery
\1 ( ,/-". . .
Pulmonary
arteries ~ungs ve ins j' blood
{ Main ....--~ to
)
pulmonary
trunk
c:.. h-...;; J ...." " ~ ~
~
organs
.// ~ . ~ a.nd

Return
~(1 (?
~~
("\\
Right Side of
\
\
~\~,moo~r,J
~ ~~Pillar~7 ~
~~\~)\~ \~e ~
Pulmonary vascu lar bed "
I)
~~~\
.
the heart
\ \ ."...
'.=;,~
of
blood
to the
( ~r ~~-d lot"t;o" Stom,," ~~~y j1\
heart
r~K i·.~: ." li '

/16( Sklo
Veins f1J '\ Musc Ie Arteries... I li,iii,,'
'ii. /

S:':~';;> r;~:~; ~~:,

bed VJ ~ I\ r_ ~~ ~ 1~ bed

'~J,~~~:' C'P"''';''
(nutrient bed)
1) Y " ; (
Systemic arterioles
Systemic vascular resistance
Systemic vascular resistance (SVR) represents
the resistance against which the left ventricle
must pump to move blood throughout systemic
circulation. SVR can be affected by:
• tone and diameter of the blood vessels
• viscosity of the blood
Measurements
• resistance from the inner lining of the ofSVR
blood vessels.
Normal measurements of systemic vascular resistance (SVR) range
from 770 to 1 ,500 dynes/sec/cm-5

My
output is
high when
SVR is low.
That's the
way I like it!

SVR usually has an inverse relationship to

cardiac output; that is, when SVR decreases,
cardiac output increases, and when cardiac
output decreases, SVR will increase.
Although newer electronic monitors can
automatically calculate SVR from hemodynam-
ic measurements, the following formula can be
used to calculate it by hand:

mean arterial press~re - central venous pressure X 80

SVR
cardiac output
o Cardlopulmona'Y anatomy and phY.iology_'"_~______________~~_----,

Cardiac output
Cardiac output is the amount of blood the heart pumps in 1 minute. It's equal to the heart rate multiplied by
the stroke volume (the amount of blood ejected with each heartbeat).

Cardiac output == heart rate X stroke volume

Stroke volume depends on three major factors:

Preload Contractility Afterload

Influences on stroke volume and cardiac output

Vent ricular
Diastolic
size
filing -~---.3IIIi,"--
Wall
thickness

Guess thi s
is what's meant
by low card iac
output.
 Understandina the cardiac ""stem e
Understanding preload, Effects of preload and afterload
contractility, and afterload on the heart
; you think of the heart as a balloon, it will help you
J1derstand preload , contractility, and afterload.
.. .- Effects on heart

Increased • Increased fluid • Increases stroke

Preload preload volume volume

Blowing up the balloon • Vasoconstriction • Increases ventricular

work
Preload is the stretching of muscle • Increases
fibers in the ventricle. This stretch- myocardial oxygen
ing results from blood vo lume in requirements
the ventricles at end-diastole. Ac-
Decreased • Hypovolemia • Decreases stroke
cording to Starling 's law, the more
preload • Vasodilation volume
the heart muscles stretch during
• Decreases
diastole, the more forcefully they
ventricular work
contract during systole. Think of • Decreases
preload as the balloon stretching myocardial oxygen
as air is blown into it. The more air, requirements
the greater the stretch.
Increased • Hypovolemia • Decreases stroke
Contractility afterload • Vasoconstriction volume
• Increases ventricular
. -~ The balloon's stretch work
"\'_-~ • Increases
- r \ Contractility refers to the inherent
myocardial oxygen
~_- I~ ability of the myocardium to con- requirements
,1 ~J\~ I ,, ' [ ; / tract normally. Contractility is influ-
f ~\ \ '- ' - / enced by preload. The greater the Decreased • Vasodilation • Increases stroke
~A 71 stretch the more forceful the con- afterload volume
> I traction- or, the more air in the • Decreases
I I V\ balloon, the greater the stretch, ventricular work
c:- I' \ and the farther the balloon will fly Thi s chart • Decreases
when air is allowed to expel. myocardial oxygen
might show the
requirements
effects of pre load
a nd afterload,
but I t hink you
The knot that ties can tel l by looking
tbe bd l at me what
happens when my
Afterload refers to the pressure work increases ...
that the ventricular muscles must
generate to overcome the higher
pressure in the aorta to get the
blood out of the heart. Resistance
is the knot on the end of the bal-
loon, which the balloon has to
work against to get the air out.
1. cardiac output A. The pressure that the ventricular
muscles must generate to overcome
2. stroke volume the higher pressure in the aorta
3. preload B. The stretching of muscle fibers
in the ventricle
4. afterload C. The amount of blood the heart
5. contractility pumps in 1 minute
D. The amount of blood ejected with
each heartbeat
E. The inherent ability of the
myocardium to contract normally

'~ '.s'V '1>' '<;! '2- '(1 "z 'J '\ A~~"'''''''''l:':>-+'''W 'SAO l0:':>
-+:':>~"""O:':> ¥'''''' MOld- d-0 "l-+",d -+:':>;;>"""0:':> A0d- .8 ;;>G",d "0 "O!-+"'",,-+SYlll! ;;>;;>So ¥' IAOM A,..." AOloJ :SA;;>MS"''I
 Component5 of a
pre5sure monitori.ng
system 18
• Leveling the
transaucer 20
Just like this
chapter, film ing • Zeroing the
movies is
sometimes all transaucer 22
about pressure.
Some people get a Square wave testing 23
headache ... others
an ache in
thei r nec k. . . Vision quest 26
 Component~Qt~_ . . ._
a pressure ~
monitoring
system
Hemodynamic monitoring is used to as-
sess cardiac function and guide and deter-
mine the effectiveness of therapy to mini-
mize cardiac dysfunction. It's performed
by using a pressure monitoring system to
measure cardiovascular pressures. Let's
take a closer look at this system.

The transducer senses pressure

changes that are transmitted from
the intravascular space or cardiac
chamber to the fluid in the non pliable
pressure tubing through the
catheter in the patient, and from
the non pl iable pressure tubing to the
transducer. These pressure changes
are transmitted to the monitor via
electrical impulses sent through the
transducer cable.

f - - - To catheter
.......
Flush dellice

The f lush device is

used to manual ly
flush the system.
F"' O
, ......... .. . ......................................... _ - -- - - -- - - -- - - -- - -

L;.;.._ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _om ponent5 of a pre&.;ure monitoring system

C _

A closer look at a pressure monitoring system

LV. fluid Th is system

measures cardiac
A continuous infusion of flush solution function and helps
(usually normal saline or heparinized normal determine the
sal ine) is placed in a pressure bag that's effectivenes s of
inflated to 300 mm Hg, maintains a
thera py. It's
constant pressure through the transducer ha ndy-da ndy!
The monitor converts the
and flush device, and is kept at a low
transducer's electrica l
continuous flow of approximately 3 ml/hour
signals into a pressure
to maintain patency, prevent the
trac ing (waveform) and
backflow of blood, and allow for
digita l value that's
accurate pressure transmissions.
displayed on the screen .

The
three-way
stopcock is a
device that
controls the flow
of I.V solution
through the
system.

00000

Transducer cable

The transducer
cable con nects the
pressure
The pressure tubing serves as a connecting tube transducer t o the
from the catheter in the patient to the f lush device monitor.
and transducer system . This t ubing shou ld be rigid
and non pl iable to transmit the most accurate
pressure measurem ents.
 Understanding a pressure monitoring system"

--~~~--------~--~--------------------~

Leveling the transducer

To ensure accurate he-
modynamic measure- Understanding leveling
ments, the patient and
the transducer must be
positioned on the same Determine the phlebostatic axis
level before the system The phlebostatic axis (level of patient's atria) is the zero-referencing point for the pressure
is zeroed. Leveling in- monitoring system. The patient should be lying flat in bed, and the axis is established
volves positioning the midway between the posterior chest and his sternum at the fourth intercostal space.
air-reference stopcock
or the air-fluid inter- lateral view /~;\. l
face of the transducer
I {~~~
on the same level as J~~"""''''\~
I~ __
the phlebostatic axis. Outermost ( ~~ ~-d ~
Alternatively, the air- pOint of __ -<.~=-!:'-~\\:-
reference stopcock or
the air-fluid interface
~~!~~~r.or $~~
i~~I
}I\ Outermost
may be leveled to the l~ point of
~~ sternum
same position as the
catheter tip.

Nurses use a
lot of tools - even
a carpenter's leve l
comes in handy for
Level the system
g
u s:n acarpen-
ters level, place
the air-reference
~
,--c'-I
1--o::r-1
Air-fluid interface
__ @_.c.r .
l-€.~J
hemodynamic stopcock or the tJ --= '--.
monitoring! air-fluid interface . I , / ,{'-r-,\ ~~'r~~
-~ ~Jf~ I YI
~
of the transducer : r
~\~ ~~I~2.S!2t! _ , _________ }, »})M
on the same hor-
izontal level with
thephlebostatic
I )
l,,_
level \
\.
:;lWf
Y~' "
~
axis . ~ ..........
:--..
~ -:;.,.--= --- ~

Readjust as necessary
If the head of the patient's bed is
changed (raised or lowered) , re-
member that the reference level
will also change. Relevel and zero
the system to allow for accurate
measurements. 0° ----~.... - ........
 Leveling the t ... n.ducer fit
Effects of position changes on hemodynamic measurements
Catheter tip and transducer dome at same vertical level - +6

- +4
Midchest (phlebostat ic) level _ +2

- 0
- -2
_ -4
t here are no effects of hydrostat ic pressure on t he trans- True pressure
is assumed
_ -6
ducer diaphragm and the displayed intravasc ular or in-
tracardiac pressures are accurate. to be zero.
Position is
<o:y - in su rfing
an d in Air fluid interface 3" below catheter tip
hemodynam ic
monit oring! If Midchest (phlebostat ic) level

you want to
6 mm Hg greater
-:ang 10 with t he than true pressure.
tran sducer, 3" (7. 6 cm) True pressure is - +6
ow th e effects assumed to be zero.
of position on - +4
pre ssure! _ +2

- 0
- -2
For every inch the t ransducer is below midchest level,
the weight of the fluid on the transducer diaphragm w ill - -4
add 2 mm Hg to t he true int ravascular or intracardiac - -6
pressure.

Air fluid interface 3" above catheter tip

- +6
For every inch the transducer is above midchest level,
the displayed intravascular or int racardiac pressure wi ll - +4
be about 2 mm Hg less t han actual pressures. - +2

- 0
- -2
- -4
6 mm Hg less
than true pressure. - -6
True pressure is
assumed to be zero.

Midchest (phlebostatic) level

_ Und'r6tandlng a pre.,;ure monitoring .y.tem

Zeroing the t ransducer

ens ures t hat pressu re
mea sure ments reflect only

Zeroing the
• I
the pressu re values in my
cham ber. That 's enough
pressure fo r me, thanks!

t,ra nSc;1 Uce r

After the pressure monitoring system is leveled, it's time to zero the trans-
ducer. Zeroing adjusts the transducer so that it reads zero pressure when it's
open to the atmosphere. Zeroing is important because physiological pres-
sures, such as arterial blood pressure, are relative to the atmospheric pres-
sure. By zeroing the transducer, effects from atmospheric pressure are elimi-
nated and the monitoring system begins pressure measurement at a neutral
pressure point of 0 mm Hg. Establishing this neutral point ensures that pres-
sure measurements reflect only the pressure values in the vessel or heart
chamber being monitored.

Remember
t hese key
steps when
zeroi ng your
patient 's
pressure
monito ring
system .

itar indicates
the system is
properly zeroed,
replace the
vating the zem stopeock port
function key on
cap and turn
the monitor.
the stopcock
place inside an so that it's
cock next to the closed to air
opened sterile
transducer off and open to the
Level the gauze package
to the patient patient. Now
transducer. to prevent con-
and open to air. the monitoring
tamination.
can begin!
 Sometimes,
it's hip to be Square wave testing
square!

quare wave testing

square wave test is a simple process performed to evaluate the dynamic response of
pressure monitoring system. If the waveform obtained when performing this test is
~ you can be assured that the pressure monitoring system is providing accurate
:.;;r.;:s:::;ures and waveforms from the patient.

Performing and interpreting the square wave test

~ SQuare wave test is performed by activating the fast flush device for 1 to 2 seconds and immediately evaluating the configuration
::r me monitor. The patient's pressure waveform displayed on the monitor will be replaced with a square wave.

Optimally damped system Overdamped system Underdamped system

Optimally damped Overdamped Underdamped

waveform waveform waveform

Characteristics Characteristics Characteristics

• Straight vertical upstroke from the
baseline
• Straight horizontal component
• Straight vertical downstroke back
to baseline with one or two rapid oscil-
lations (most important component)
Interventions
• None required.
• Slurred upstroke and downstroke • Numerous oscillations above and
of the square wave below baseline after activation of the
• No oscillations above or below the fast flush device
baseline
Interventions
Interventions • Examine the tubing and remove all
• Examine the system from the air bubbles from the fluid system.
catheter to the transducer, checking
for and eliminating blood clots, blood
left in the catheter or tubing following
sampling, or air bubbles at any point.
• Be sure to use nonpliable (stiff) tub-
ing that 's less than 4' (1.2 m) long.
• Make sure that all components of
the system are connected securely;
unravel any kinks in the tubing.
 ~
Understanding a pressure monitoring~ystem
Troubleshooting the pressure monitoring system
No waveform
Drifting waveforms
Line fails to flush
A.rtifact(waveform interference)
False-high readings-
False-low readings
Damped waveform
• Power supply turned off
• Monitor screen pressure range set too low
• Loose connection in line
• Transducer not connected to amplifier
• Stopcock off to patient
• Catheter occluded or out of blood vessel
• Improper warm-up
• Electrical cable kinked or compressed
• Temperature change in room air or I.V. flush solution
• Stopcocks positioned incorrectly
• Inadequate pressure from pressure bag
• Kink in pressure tubing
• Blood clot in catheter
• Patient movement
• Electrical interference
• Catbeter fling (tip of pulmonary artery catheter moving rapidly in
large blood vessel in heart chiJ.mber)
• Transducer balancing port QDsitioned below patient's right atrium
• Flush solution flow rate is too fast
• Air in system .~q:
• Catheter fling (tip of pulmonary artery catheter mOIling rapidly in
large blood vessel"or heart chamber)
• Transducer balancing port positioned above right atrium
• Transducer imbalance
• Loose connection
• Air bubbles
• Blood clot in catheter
• Blood flashback in line
• Incorrect transducer position
• Arterial catheter out of blood vessel or pressed against vessel wall
 5~uare wave testing __

Nursing interventions

Check the power supply.

• Raise the monitor screen pressure range if necessary.
Rebalance and recalibrate the equipment.
• - lQhten loose connections.
I Position the stopcock correctly.

Use the fast-flush valve to flush the line, or try to aspirate blood from the catheter. If the line remains blocked , notify the
::.octor and prepare to replace the line.

• • w the monitor and transducer to warm up for 10 to 15 minutes.

• Place the monitor's cable where it can't be stepped on or compressed .
• "ioutinely zero and calibrate the equipment 30 minutes after setting it up to allow LV. fluid to warm to room temperature.

• Make sure .§;ICJpc:ocks arE? positiol}ed correctly.

• .take sure ~ft1\" pFessure bag gauge reads 30b mm rig.
• Check the p'ressure tubing for kinks .
• :iy to aspin'ttEJ. tne clot with a syringe. If the line still won 't flush, notify the doctor and prepare to replace the line., if
-ecessary. trrrg9pant: Never use a syrin§e to flush a hemodynamic line.
_.j£ ;:~;4"

ntiS'quietbeforetakir:ig a reading . .
l.cal eqliiipment iSCODl}ec~ed and grounded correctly.
~.who may t ry to fE?Position the. catheter.
-ffi ' 7 ~

• "osition the. balancing port level with the patient's right atrium.
• ake sure the transducer's flow system isn't kinkedur occluded, and rebalance and recalibrate the equipment.
• Tighten loose connections.

• Secure all connections.

• Remove air from the lines and the transducer.
• Check for and replace cracked equipment.
• Refer to " Line fails to flush " (earlier in this chart).
• Make sure stopcock positions are correct; tighten loose connections and replace cracked equipment; flush the line with
:ne fast-flush valve; replace the transducer dome if blood backs up into it.
• Make sure the transducer is kept at the level of the right atrium at all times. Improper levels give false-high or false-low
:JreSSure readings .
• Reposition the catheter if it's against the vessel wall.
• Try to aspirate blood to confirm proper placement in the vessel. If you can 't aspirate blood, notify the doctor and
:Jrepare to replace the line. Note: Bloody drainage at the insertion site may indicate catheter displacement. Notify the
~octo r immediately.
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l~~O!~ ~)f~ r; :j '""~/ J~ r(
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8
 Arterial line
insertion
A closer look at
arterial insertion
sites • Axillary artElrv ----+-h l-f

monitoring; .,... • Brachial artery - - l- lf-ll

a standa;nfiSG

is inserted .ip:to a
art~ry, usually
brachial, of, • Radial artery - - + -II-!
artery. The ..radial
is the preferreqsite.
• Femoral artery --~lM1rl~____1

Arterial line
insertion usually
happens at one of
three sites: the
rad ial, brachial, or
femoral artery.

• Dorsalis pedis artery - - - - - - - ,;'--\1

 Let's make a list of
all the pros and cons
when it comes t o Arterial line insertion
choosing an arterial
catheter site.

oosing an arterial catheter site

your patient needs arterial pressure monitoring, an arterial catheter will
::cebly be inserted in a radial or brachial artery. If these sites are unsuitable,
;;-e catheter may be inserted in the femoral, axi llary, or dorsalis pedis artery.

In sertion Advantages Disadvantages

site

Radial • Easy to locate • Relatively small lumen, possibly making catheter

artery • Good collateral circulation to the hand provid- insertion difficult and painful
ed by the ulnar artery • High risk of thrombus formation with prolonged use due to
• Easy to observe and maintain the small vessel size and small-gauge catheter required to
• Anatomically stable (The radius acts as a nat- cannulate it
ural splint.) • Risk of nerve injury due to hematoma formation or trauma
• Comfortable for the patient during catheter insertion
• Risk of false-high pressure readings because of the site's
distance from the heart

Brachial • Larger than the radial artery and easily located
artery • Easy to observe and maintain
• Good collateral circulation provided by blood
vessels at the elbow joint
• Control or prevention of bleeding usually pos-
sible by direct pressure
• More accurate pressure readings because of
the site's proximity to the heart
• Risk of median nerve damage during catheter insertion
• Difficult to immobilize (The patient's elbow must be splinted,
which may result in joint stiffness.)
• Risk of thrombosis if the artery is small (in children and small
women) or if the patient has low cardiac output

Femoral • Possibly the easiest artery to locate and punc-
artery ture during an emergency (when peripheral
pulses are non palpable) due to its large lumen
• Anatomically stable (The femur acts as a nat-
ural splint.)
• Difficult catheter insertion in the presence of atherosclerotic
plaque (Additionally, the plaques may embolize if disturbed.)
• Possible damage to the nearby femoral vein and major
nerves during catheter insertion
• Possible tissue damage if the artery occludes because of in-
adequate collateral circulation
• Difficulty securing catheter
• Difficulty controlling or preventing bleeding
• High risk for infection with prolonged use due to close prox-
imity to perineal area

Axillary • Fewer complications with prolonged use due
artery to large size
• Easy to identify and puncture, especially if
peripheral pulses are difficult to palpate
• Reduced risk of distal arterial insufficiency
due to adequate collateral blood flow
• Useful in patients with severe peripheral vas-
cular disease
• Difficult catheter insertion and uncomfortable for the patient
• Risk of hematoma formation increases the possibility of neu-
rovascular complications
• Risk of cerebral air or clot embolism during flushing of the
system or blood sampling

• Dorsalis • May be used when other sites can't be used • High risk of thrombosis due to the small vessel size and
pedis because of burns or other injuries small-gauge catheter required for insertion
artery • Uncomfortable for the patient and difficult to immobilize (The
patient won't be able to stand or walk until the catheter is dis-
continued.)
 Remember: Use
Vascular access
Allen's t est to ensure
that, if the rad ia l
artery is blocked, the
ulnar artery wil l be able
Allen's test to supp ly blood to th e
Before accessing the radial artery for peripheral arterial line insertion, the hand. (Just don't tie
your rem inder string
patient's ulnar and radial circulation must be checked. Why? If the radial
too tight! Ouch!)
artery is blocked by a blood clot (a common complication of arterial

-~- ~ r~ ""'~
lines), the ulnar artery alone must supply blood to the hand. A simple,
reliable test of circulation can be done by performing Allen's test, which
demonstrates how well both arteries supply blood to the hand.
~
Performing Allen's test
~~~ «" J ~ li?
r'~~~ \
I)
{ ttJ:J{ /~ l\~
Rest the patient's
arm on the mat-
,-.!4;tf ,/ \
tress or bedside I 'I .
stand, and sup- -L ~
port his wrist with a rolled tow -
el. Have him clench his fist. ~ · ~f /
Then, using your index and mid -
dle fingers , press on the radial
and ulnar arteries. Hold this posi- Without removi ng your fingers from the patient's arter-
tion for a few seconds. ies, ask him to unclench his fist and hold his hand in a
relaxed position.
The palm will be
blanched because pressure
from your fingers has im-
paired the normal blood flow.

Release pressure on
the patient's ulnar
artery but keep pres-
sure on the rad ial
artery, as shown at right. Observe
the palm for a brisk return of color,
w hich should occur w ithin 7 sec-
onds (show ing a patent ulnar
artery and adequate blood flow to
the hand). If color returns in 7 to 15 seconds, blood flow is impaired; if color
returns after 15 seconds, consider the flow inadequate.
If blood flow is impaired or inadequate, the radial artery in this hand
shouldn't be used. At this pOint, proceed with Allen's test in the other hand.
If neither hand colors, the brachial artery site may be considered for catheter
insertion .
 Vaacular acceaa

CV
,
and PA catheter
Inse CV and PA catheter insertion sites
The most common sites for percutaneous insertion of a CV or PA catheter in-
clude t he internal jugular, subclavian, and femoral veins. The right internal jugular
vein is considered t he safest insertion site. Alt hough the subclavian vein is easily
accessed, its use carries certain risks . The most significant risk is pneumothorax,
resulting from puncturing the lung at a level above the clavicle during cat heter in-
sertion. Additionally, using the subclavian vein may cause the catheter or the in-
venous (C\l)and pul- troducer to bend or kink during insertion. Although the femoral vei n is also easily
artery cPA) c,atheteri- accessible, use of this site carries an increased risk of infection due to the prox-
can help yoU: learn about imity to the groin .
cardiovascular and
stgttus,"obtain blood
'ot"", jogo'" "'0 ~
~
and infuse solutions. •
• E"''"''.jO'"'' ,,'0
• SubclaVian vein ~ .
Superior vena cava j~ •

Cephalic vein I /I
allowmgvenous
• Basilic vein l {/ ,'I
to carry,lt through
\,...<nhnfi in or near the Inferior vena cava l g /I "c

.....,.."' . . . . " Cfof CV catheters)

the tight atiium and
the pulmonary
FA catheters).

It's all about flow, ladies and • Femoral vein I ~ I

gents! Because t he catheter is flow-
directed, venous circulation ca rri es it
through to the right positi on.

!'~

....-...-.:)
~~ ~
- - - -- -- - - - - - - - - - - -- .....-.iAlmllllllllnllllllllllinlllllllllllllllOlllnIIIGIIiOiIIniruHlMlnlllmJF.Jim~mllllmfil~.I~~lll_iillIl~n~~@IJii~lliiJilijlwilli!ulilll1tffili~jJllibtL . ..... ,.
 I'm looking
for th e perfect
site .. . CV and PA catheter insertion
~ .,
-

/',~ I~L
i''-..~

,-.l I'~f-

Choosing a CV or PA catheter insertion site U~r::­

~ C" ( .'
,) fy'
n is chart highlights the advantages and disadvantages of the most common sites used U .!I
=;x CV or PA catheter insertion . Catheter-related infection is the most common risk of
"",ery insertion site, occurring in up to 5% of cases.

Insertion Advantages Disadvantages

site

Internal • Provides a short, direct route to the superior
jugular vena cava or right atrium
vein • Carries a low risk of catheter displacement
• Has a lower incidence of pneumothorax or per-
foration of an artery than with a subclavian vein
• Has a lower risk of thrombotic complications
because rapid infusion rates may be used
• Several possible complications, including:
- air embolism
- common carotid artery perforation
- perforation of the trachea or endotracheal (ET) tube cuff
- pneumothorax (more common in the left internal jugular vein)
- injury to the thoracic duct (applicable only to left internal
jugular vein)

External • Is easily accessible due to its superficial loca- • Difficult passage to the central veins
jugular tion • Increased risk of thrombosis because infusion rates must be
vein • Carries a low risk of pneumothorax or puncture slower
of the carotid artery • Difficulty maintaining a sterile dressing, especially with the
presence of a tracheostomy
• Several possible complications, including :
- carotid artery perforation
- pneumothorax
- displacement into axillary vein

Subclavian • Is easily accessible • Several possible complications, including:

vein • Enables easy maintenance of a sterile, intact
dressing
• Allows the patient to move neck and arm freely
• Carries minimal risk of catheter displacement
after it's secured
• Carries a reduced risk of thrombosis because
rapid infusion rates are allowable
- air ernbolism
- subclavian artery perforation
- life-threatening blood loss (because pressure can 't be ap-
plied to an anterior subclavian tear)
- pneumothorax
- phrenic or brachial nerve injury
- ET tube cuff perforation

Femoral • Is easily accessible • Possibly difficult to identify in obese patients

vein • Enables greater ease of insertion in patients
with tortuous subclavian and jugular veins (such
as elderly patients)
• Carries no risk of pneurnothorax and a minimal
risk of air embolism
• Increased risk of infection due to proximity to the groin
• Difficulty maintaining a sterile, intact dressing
• Increased risk of catheter displacement because the site is dif-
ficult to immobilize
• Several possible complications, including:
- inadvertent cannulation of local smaller veins
- thrombosis

Basilic • Carries no risk of pneumothorax or rnajor • Difficult to identify in obese or edematous patients
vein hemorrhage • Possible difficulty advancing the catheter to the central veins
• Enables greater control in bleeding from the from this distal site
site • Increased risk of catheter displacement
• Several possible complications, including :
- thrombosis
- venous spasm
 Vaacular acceaa
No matter which
technique you use to
insert a CV or FA
Insertion of the catheter catheter, it should be
performed under stri ct
CV and PA catheters share the same approaches to insertion - a surgical
steri le cond itions.
cutdown technique or a percutaneous technique.
A surgical cutdown involves identifying the vein to be used for insertion,

~
administering a local anesthetic, and making a small incision directly above --.
".,1.\1
the vessel. The catheter is then inserted by direct needle-puncture of the ves- ··_ifm!n!~
sel, or by creating a tiny incision in the vessel through which the catheter is in- <::.-~ "~ij
serted and then sutured in place. Surgical cutdown is typically performed for ~\ci....,
central catheters inserted through the basilic vein or when percutaneous ac-
cess isn't possible.
The more commonly used percutaneous technique involves the use of an
introducer to access the vessel. A locator needle is first inserted in the vein, IJ {\
~
and a guide wire is threaded through the needle. The needle is removed, and
an introducer catheter is inserted over the wire. Then the wire is removed,
leaving the introducer in place in the blood vessel. The CV or PA catheter is
then inserted through the introducer sheath. Prepackaged introducer kits are ) \
available to facilitate gathering and preparation of equipment, as shown below.
I~~I
Introducer kit If {
 Cl'and PA catheter in ••rtion _

No need to turn the

tient positioning patient's head away from
:?!vper patient positioning during CV or PA catheter insertion the inserti on site. That is,
if you want me to set up
ntial to enable optimal access to the site and prevent
ca mp! Heh, heh, heh .
~ation. These guidelines will help you position your
~ent based on the insertion site you're using:
Place the patient in Trendelenburg's position to dilate the
- and reduce the risk of air embolism. (This position isn't
ary if you're using the femoral vein site.) A\
Lor subclavian insertion, place a rolled blanket or towel
mhwise between the shoulders to increase venous disten-
/~/ ~
~';7/f~ I-~\
For jugular insertion, place a rolled blanket or towel under / { J ~~j~ \
opposite shoulder to extend the neck, making anatomic J;cI ~llJ '
~~J~L~t~~it
I \
kldmarks more visible.
Turn the patient's head away from the site to prevent possi-
e contamination from airborne pathogens and to make the
- .e more accessible.

==~-

t7ositioning for subclavian vein access

~ e::ldition to placing a rolled blanket or towel lengthwise between the patient 's shoulders,
~ patient should be positioned with her head turned away from the access site with the
pointed upward, as shown here.

Anterior scalene
muscle - - -

Right axillary vein -------+--.

Right axi llary artery ,c , (il - ~'- J =>12 .os-, Sternocleidomastoid

muscle

-·~V ..c
...J.- I ") < -'"",/ , Right subclavian
artery and vein

~'fi:
 Vascular access

A closer look at catheter insertion

l1ese photos show a PA catheter being inserted throug h an introducer during a percutaneous insertion proced ure.
 Boy, there's a lot
to remember to keep
you happy.
{;Vand PA catheter In .....lon G
If you
want me to
ey steps in hang out, ya
hanging a CV gotta keep it
clean!
ressing
~t to change your patient's CV dress-
rg f'Nery 48 hours if it's a gauze dressing
3"D at least every 7 days if it's transparent.
1aly facilities specify dressing changes
"'"BfI€ver the dressing becomes soiled,
;:ist, or loose. These illustrations show
::lS key steps you'll perform.

~
:;;:,- First, put on clean gloves and remove the old
::I5SSing by pulling it toward the exit site of a long-term
:::Eheter or toward the insertion site of a short-term catheter. This
ique helps you avoid pulling out the line. Remove and discard ~
.~ Allow the skin to dry completely.

~~
,aJ gloves.

~
:!!J; After the solution has dried, cover the site with a dress-
Next, put on sterile gloves and clean the skin around the ing, such as a gauze dressing or the transparent semipermeable
:::Eheter, using a vigorous side-to-side motion (as shown below). dressing shown below. Write the time and date on the dressing.
1.

2.

3.

4.

5.

Question: Which nerve could be damaged during

catheter insertion at the brachial artery?
1. srinsdeg 0 - 0 -----
2. milzinoimbig Q - O - - - - - - - - -
3. sesangsis 0 ------ 0 -
Answer: _____ _

."''''!'f;;>'"''
:"'OHS;;>"'D :G",!ss;;>ss'" ·z.'G"'tZ!l!c..OWlWl! ·z 'G",!ss;;>.A'f·\ 'f.AOIV\ AW ·A.A;;>-r.A'" S!'f;;>d I"'S.AO(\ ..$ 'A.A;;>-r.A'"
1"'.AOWl;;>;:l ·it 'A.A;;>-r.A'" I"'!'f"'~ .~ 'A.A;;>-r.A'" 1"'!'1.;)"'.Ag ·z 'A.A;;>-r.A'" A.A"'II!XV·\ 1;;>c.."'1 0-r ;;>1c..V :S.A;;>IV\S'-l:-
 1:18eioe
Zeroing
Arterial
pressure'? eyatem
Nothing gets
the 01' heart How to
pumping like a
little adventure! a diaplaGe~
arterial line
• VieJon q,ueat
 Arterial pressure mo~ttorin0

Artdria I pres
•
monitoring b SICS
A closer lo~ k atan
arterial pre
monitoring
Pressure infuser bag

Arterial pressure monitoring

Arterial pressure monitoring measures Flush solution

arterial pressure directly, using an
indwelling arterial catheter connected
to an external pressure transducer
and fluid-fIlled tubing. The tubing is
attached to a pressure bag of saline
or heparin flush solution and
the transducer is attached
to a monitor. The pressure When
transducer converts the everything Pressure gauge
pressure into an electrical works t ogeth er,
it flows
signal that's interpreted
bea utifu IIy.
and displayed on a monitor
Drip chamber
screen as a continuous
waveform. The pressure may
also be shown as a digital readout.
Most commonly, the radial artery is
the site of catheter insertion because
this artery is readily accessible. How-
ever, the axillary, femoral, brachial, or
pedal arteries may also be used.
 "'. Arterial pre.;sure monitoring ba,5ic s 8
Arterial pressure
extension tubing

Transducer

3-way stopcock

3-way stopcock

Connection for blood

sample wifhdr,awal
CD A....rial pre•• ure mon~~ng

Uses for arterial pressure monitoring

Direct arterial pressure monitoring permits con-
tinuous measurement of systolic, diastolic, and
mean pressures and allows arterial blood sam-
pling. Because direct measurement reflects sys-
temic vascular resistance as well as blood flow,
it's generally more accurate than indirect meth-
ods that are based on blood flow (such as pal-
pation and auscultation of Korotkoff sounds).
Moreover, direct arterial pressure monitoring
/f': , aids in determining mean
,~ .~ arterial pressure, an impor-
~-\J.;f
17 ' , -
tant indicator of tissue
~--!.f\ _~,~~ perfusion.
(r\~
It rl
/-! ~ ' I on the level
fitl .J"\
~~ Normal arterial pressure parameters
!~:c!')
In general, arterial systolic pressure reflects Mean arterial pressure (MAP) is the average pressure in the arter-
the peak pressure generated by the left ventricle. It also indicates ial system during systole and diastole. It reflects the driving, or per-
compliance of the large arteries, or the peripheral resistance. fusion, pressure and is determined by arterial blood volume and
Arterial diastolic pressure reflects the runoff velocity and elasticity blood vessel elasticity and resistance. To compute MAP, use this
of the arterial system, particularly the arterioles. formula:

MAP = systolic pressure + 2 (diastolic pressure)

:3
Normal values mmHg
--------------------------------------------------------- 14o
--------------------------------------------------------- 130
~------------------------------------ 120
~------------------------------------ 110
L------------------------------------- 100
90
80
70
60
50
40
30
20
10
o
SystOlic pressure MAP Diastolic pressure
100 to 119 mm Hg 70to 92 mm Hg 60 to 79 mm Hg
• Arte~lal pre..u," monitoring 'aslcs CD
ride the wave

Understanding an arterial waveform

~rm al arterial blood pressure produces a characteristic waveform representing ventricular systole and diastole.
n e waveform has five distinct components:
• anacrotic limb
• systolic peak
• d icrotic li mb Knowing the
• dicrotic notch components of an
• end diastole. arterial waveform keeps
The anacrotic limb marks the waveform's initial upstroke, which results as blood is you ahead of the wave
-apidly ejected from the ventricle through the open aortic valve into the aorta. The rapid on arteria l pressure
ejection causes a sharp rise in arterial pressure, which appears as the waveform's high- monitoring.
est point. This point is called the systolic peak.
As blood continues into the peripheral vessels, arterial pressure falls and the waveform
begins a downward trend. This part is called the dicrotic limb. Arterial pressure usually
conti nues to fall until pressure in the ventricle is less than pressure in the aortic root.

~I V
~' -;;~
'oVhen this unequal pressure occurs, the aortic valve closes. This event appears as a ~ • #
' .1'
.~
small notch on the waveform's downside, known as the dicrotic notch.
When the aortic valve closes, diastole begins, progressing until the aortic root pressure
gradually descends to its lowest point. On the waveform, this is known as end diastole.

ormal arterial waveform

Anacrotic limb Systolic peak Dicrotic limb

- Arterial pressure monitoring
. , <'"<"",""'i7",,,gg;",g~,, !

ride the wave

Recognizing abnormal arterial waveforms

Understanding a normal arterial waveform is relatively straightforward Unfortunately, an abnormal waveform isn't
<

so easy to decipher. Abnormal patterns and markings, however, may provide important diagnostic clues to the
patient's cardiovascular status, or they may simply signal trouble in the monitor. Use this chart to help you recog-
nize and resolve waveform abnormalities.

Waveform Abnormality
I suspect

1~~ll1WtUlUl
Alternating high
pulsus paradoxus and low waves in
from cardiac a regular pattern
tamponade!
->L.!l
~ -/...f
()~i~_~l\
')
',t:J \
'~) • 6----
)
'~~ tlittlllU1DI Flattened
waveform

\,'&'? r;_-:;~r.J~

'~~ ntiNililiil
,fl.'fiA;r~\' ~/ )1
Slightly rounded
~ ~<JL~ waveform with
[r~<;P= consistent
variations in
:::-:>~ systolic height

~~~mttOOHID1l
Slow upstroke

~~HmHJ1N!mfN
Diminished
amplitude on
inspiration

~~~mNffl.I {1
Alteration in beat-
to-beat amplitude
(in otherwise
normal rhythm)
 Arterial pressure monitoring basics
CD
Now that's
interesting . I bet ]
it's a clue!
Maybe there are
more where th is
came from . ..

Possible causes Nursing interventions

(
• Ventricular • Check the patient's ECG to confirm ventricular

l\~
bigeminy bigeminy. The tracing sh ould reflect premature ventricu-
lar contractions every second beat.

(~\ ~
~~.~
w -'
• Overdamped • Check the patient's blood pressure with a sphygmo-
~
waveform or
hypotensive patient
manometer. If you obtain a higher reading , suspect over-
damping . Correct t he problem by trying to aspirate the
arterial line. If you succeed , flush the line. If the reading is
~/1{
(- I. I
')
--:- \
~JI( , ~_.::,.; 1

·~1'. Y:{\\
very low or absent, suspect hypotension .

• Patient on • Check the patient's systolic blood pressure regularly.

ventilator with The difference between the highest and lowest systolic
positi ve end-
expiratory pressure
pressure reading should be less than 10 mm Hg. If the
difference exceeds that amount, suspect pulsus para- l ___ I)
doxus, possibly from cardiac tamponade.
j ,/
~.~\
• Aortic stenosis • Check the patient's heart sounds for signs of aortic
stenosis. Also notify the doctor, who will document sus-
pected aortic stenosis in his notes.

• Pulsus paradoxus, • Note systolic pressure during inspiration and expira-

possibly from car- tion. If inspiratory pressure is at least 10 mm Hg less
diac tamponade, than expiratory pressure, call the doctor.
constrictive peri- • If you're also monitoring pulmonary artery pressure,
carditis, or lung observe for a diastolic plateau. This abnormality occurs
disease when the mean central venous pressure (right atrial
pressure), mean pulmonary artery pressure, and mean
pulmonary artery wedge pressure (pulmonary artery ob-
structive pressure) are within 5 mm Hg of one another.

• Pulsus alternans, • Observe the patient's ECG , noting any deviation in the
which may indicate waveform.
left ventricular • Notify the doctor if this is a new and sudden abnor-
failure mality.
CD Art,,,'.' p.....ure mon"<>r'ng

When it comes to

Zeroing accurate arteria l

pressure mon itoring,
ze ro is t he magic
number!

the system
Because it's fluid-filled, an arterial pressure monitoring
system must be zeroed. Remember that zeroing balances
the transducer to atmospheric pressure, so that it reads
omm Hg when open to air. The procedure for zeroing
the monitoring system is described fully in chapter 2,
"Understanding the pressure monitoring system." These
photos highlight some of the key steps in the procedure
as it's performed on a peripheral arterial line.

//
Stopcock off to the
patient, open to air

Arterial catheter
insertion site
 CD Arterial pressure monitoring

How to handle Withdraw blood for a

a displaced complete blood count

and arterial
blood gas analysis,
as ordered.

arterial line Assist the doctor as he inserts another

Your patient is in danger of hypovolemic shock catheter. Make sure that the patient's
from blood loss if his arterial line is pulled out arm is immobilized and that the tubing
or otherwise displaced. and catheter are secure.

A-P+-ev +-~e Estimate the an10unt of blood loss from

your observations of the blood and

"lee~l\\B S+-CpS
from the changes in the patient's blood
pressure and heart rate.

Reassess the patient's level of

Apply a sterile pressure dressing. consciousness (LOC) and orientation,
and offer reassurance.

Grab you r cha lk and

your sneakers and Check the patient's I.v. line and, if
fol low th ese steps t o ordered, increase the flow rate
avert serio us temporarily to compensate for
complications!
blood loss.
w~O\+- +-C

-::--...;-/
r '\. ,
.""
r. )'
1 1>-"'"/
y--"
) /~
Immediately apply direct pressure
at the insertion site, and have someone
SUll1ffion the doctor. Because arterial
blood flows under high intravascular
~C -PlVS+-

\ \ J~-;::'r7b-~ pressure, be certain to maintain flrm,

L~~
direct pressure for a minimum of
1 \{
Jr~J~
5 minutes to encourage clot
()I/'~ ....--,,1( ,~/a
j. \\/- formation at the insertion site.
k How to handle a displaced arterial line
~
O\\8<'l\\8 C()\Ve
Frequently assess the
patient's vital signs, LOC,
skin color and temperature,
and circulation at the
insertion site and beyond.
-
We get a little crazy when an
~
arterial line is displaced. We
Watch for further bleeding respond well to pressure,
though, so be firm and direct.
or hematoma formation at
Okay, everyone, let's get a good
the insertion site. count! One, two, three ...
When the patient's condition
stabilizes, reduce the LV.
flow rate to the previous
keep-vein-open level.

Minimizing complication6 of arterial pre66ure monitoring

For most critically ill patients, the advantages of arterial lines outweigh the disadvantages. However, because any invasive hemodynamic
monitoring procedure poses some risk, you'll need to watch your patient for complications that may result from an arterial line.
. . ... - . .
.Complications and Possible .causes
Possible. causes Nursing interventions · · ·
signs and symptoms

Thrombosis • Arterial damage • Notify the doctor. He may remove the • Check the patient's pulse
• Loss or weaken ing of during or after line. rate immediately after catheter
pulse below arterial line insertion • Docu ment the complication and insertion, then once hourly.
insertion site • Sluggish flush record yo ur interventions. • Reduce injury to the artery by
• Loss of warmth, solution flow rate splinting the limb holding the
sensation, color, and • Failure to line and by taping the catheter
mobility in limb below heparinize flush securely.
insertion site solution adequately • Check the flush solution's
• Damped or straight • Failure to flush flow rate hourly; maintain the
waveform on monitor catheter routinely rate at 3 to 4 ml/ hour.
display or printout and after withdraw- • Check the pressure infuser
ing blood samples bag to make sure that pressure
• Irrigation of clot- is maintained at 300 mm Hg.
ted catheter with a • Heparinize the flush solution
syringe according to facility policy.
• Flu sh the catheter once
hourly and after withdrawing
blood samples.
• Never irrigate an arterial
catheter. You may flush a
blood clot into the
bloodstream.
(iif ~l
I.~l
aifJ.J ~
r\ n.=:\fj
Continued ...
I , U"'NI \('f'I
h\ (\J
 Arterial pressure monitoring

Continued here.

Blood loss
• Bloody dressing;
blood flowing from
disconnected line
A dislodged • Stop the bleeding. • Check the line connections
catheter or • Check the patient's vital signs. and insertion site frequently.
disconnect ed • Notify the doctor if blood loss is great • Tape the catheter securely
or if the patient's vital signs change. and splint the patient's limb.
line could
• If the line is disconnected, avoid re- • Make sure that the monitor
cause blood
connecting it. Instead, immediately re- alarms are enabled.
loss. place contaminated equipment.
• If the catheter is pulled out of the
artery, remove it and apply direct pres-
sure to the site; then notify the doctor.
• When the bleeding stops, check the
patient's pulse and the insertion site
frequently for signs of thrombosis or
hematoma.
• Document the complication and your
interventions.

Air embolism or • Air in tubing • Place the patient on his left side and • Expel all air from the line
thromboembolism • Loose in Trendelenburg 's position. If air has before connecting it to the
• Drop in blood pressure connections entered the heart chambers, this posi- patient.
• Rise in central tion may keep the air on the heart's • Make sure that all connec-
venous pressure right side. The pulmonary artery can tions are secure; then check
• Weak, rapid pulse then absorb the small air bubbles. connections routinely.
• Cyanosis • Check the arterial line for leaks. • Change the flush solution
• Loss of • Notify the doctor immediately, and bag before it empties.
consciousness check the patient's vital signs. • Prevent thromboembolism by
• Damped waveform • Administer oxygen if ordered. keeping the arterial line patent
• Document the com plication and your with heparin flush solution.
interventions.

Systemic infection • Look for other sources of infection • Review care procedures and
• Sudden rise in Causes may first. Obtain urine, sputum, and blood ensure sterile technique.
tem perature and include poor specimens for cultures and other analy- • Take care not to contaminate
pulse rate aseptic technique, ses, as ordered. the arterial line insertion site
• Chills and shaking use of • Notify the doctor. He may discontinue when bathing the patient.
• Blood pressure contaminated the line and send the equipment to the • If any part of the line discon-
changes laboratory for study. nects accidentally, don 't rejoin
equipment, or
• Document the complication and it. Instead, replace the parts
irrigation of a
record your interventions. with sterile equipment.
clotted catheter. • Change system components
as recommended (I.v. flush
solution and pressure tubing
every 48 hours, transparent
dressing every 7 days, and
nontransparent dressing every
24 to 48 hours).
 How to handle a displaced arterial line e
Complications and Possible causes Nursing interventions Prevention
signs and symptoms

Arterial spasm
• Intermittent loss or
weakening of pulse
below insertion site
• Irregular waveform
on monitor screen or
printout
• Trauma to vessel • Notify the doctor. • Tape the catheter securely to
during catheter • Prepare lidocaine (Xylocaine) , w hich prevent it from moving in the
insertion the doctor may inject directly into the artery.
• Artery irritated by arterial catheter to relieve the spasm . • Splint the patient's limb to
catheter after inser- Caution: Make sure that a combination stabilize the catheter.
tion product containing lidocaine and epi-
nephrine (Xylocaine with Epinephrine)
isn't used ; the epinephrine in this
product could cause further arterial
constriction .
• Document the complication as well as
your interventions.

Hematoma
• Swelling at insertion
site and generalized
swelling of limb holding
arterial line
• Bleeding at site
• Blood leakage • Stop the bleeding. • Tape the catheter securely
around catheter • If the hematoma appears while the and splint the insertion area to
(resulting from catheter is in place, notify the doctor. prevent damage to the artery.
weakened or • If the hematoma appears within • After the catheter is removed,
damaged artery) 30 minutes after you remove the apply firm, manual pressure
• Failure to maintain catheter, apply ice to the site. Other- over the site for a minimum of
pressure at site wise, apply warm, moist compresses to 5 minutes or until bleeding
after removing help speed the hematoma's absorption. stops. ~-,
catheter • Document the complication and
record your interventions. ~W
,~C-\
1~1~~t?\
Make su re that you apply a pressu re IJ:-~-~-'
II L.----'
bandage over t he site. Of course, you don't
have t o get as carried away as this ... \l_:s;~
.....-' \..-.c..:
~S::J
\- ........ ~

Inaccurate pressure False-high values • Relevel and rezero the transducer • Make sure to zero and cali-
readings • Transducer system. brate the transducer system
positioned too low • Remove air bubbles. precisely.
~. .,,11"=
§.j. ~ i~J' • Small air bubbles • Properly level the transducer

1
t-~Q~;~~~~J
\ ,
"-t_~:-,-) ----~
in arterial line
False-low values
• Transducer
• Relevel and rezero the transducer
system .
at the level of the patient's right
atrium (the phlebostatic axis).
• Keep air from entering the
'-' I~'-">~ positioned too high • Remove air bubble. pressure tubing or system.
' ((~~1 • Large air bubble • Document the complication and • Check the arterial waveform
in arterial line record your interventions. configuration for abnormalities.

What's a sure sign of inaccurat e pressure

readings? Your patient's cl inica l appearance
is inconsistent with pressure values.
Question: Inaccurate pressure readings could be
caused by an air bubble in what line?
1. boimstrosh --0 -----0 -
2. loitershbombmom __ 0 ____ 0 ______ _
3. meathamo - - -O - - - O
4. ratelair mapss __ 0 ____ 0
Answer: __ _ __ __ _

1. Alternating high and

low waves in a regular
pattern _ _
A.
nrOOM_al
2. Flattened waveform _ _
3. Slightly rounded
B.
oo.nJtiWI
waveform with c.
consistent variations in
systolic height - - MIlilUIE
4. Slow upstroke - -
5. Diminished
amplitude on
D.
IUn.1
E.
inspiration _ _

6. Alteration in
m~m.fl {1
beat-to -beat amplitude
(in otherwise normal
rhythm)
F.
mlnll1l!
'~ " 'J 'S ~ 'v 'If '2-' <l '-z Is:! '\ A~",\"''-'1'1'::>-+'''W 'l"')A~-+A'" :"OHS~\1D
('-'1$",d$ l"')A~-+A'" 'v '''''-'10-+''''-'1 ~'1 '2- ''-'1$!lo,\'-'1~0,\'-'10A'1-+ '-z '$)$0,\'-'10 A'1-+ '\ i'fAON\ "-w :$A~N\$ Wr/
 • CVP monitoring 54
• Obtaining CVP
We here in the South
try to take it slow and measurements 66
not let our pressure get
out of control . CVP
press ure is best when
C Vision quest 66
under control, too.
(How's my drawl coming?
It's for a new part.)
 Central venous pressure monitoring

.~, ':;:~'
"I
- ..[ "'(

~
.1
.
,,-,:\.,
<[
',(':
'~~~
I ,..c
CVP monitoring
~ : c, ~)\
~ ~ ~\ //
/ =" ~' ,,/ CVP helps indi rectly
!
·\r ,~
"
: ,, ~
\
~
! [ ga uge how well I'm
pumping. I'd say I'm doing
A closer look at
L
eM !0 I.L.
,f ~.
.t Y'"""'-'l;-
prett y darn good!
If; }(~ a CV catheter
?,<, .... 3~:'
Central venous pressure monitoring Clamps

In central venous pressure (CVP) monitoring, Clam ps prevent the

the doctor inserts a catheter through a vein backflow of blood or
inadvert ent
and advances it until its tip lies in or near the
adm in istration of fluid
right atrium. Because no major valves lie at
throu gh lumens that
the junction of the vena cava and right atrium, aren't in use.
pressure at end diastole reflects back to the
catheter. When connected to a transducer or
manometer, the catheter measures CVP, an
index of right ventricular function.
Winged hub

What it does The win ged hub may be used

CVP monitoring helps to assess cardiac func~ to sut ure the catheter in
tion, evaluate venous return to the heart, and place and provide improved
indirectly gauge how well the heart is pump~ st abi lity when securing and
ing. The central venous (CV) line also provides dressing the insertion site.
access to a large vessel for rapid, high-volume
fluid administration and enables frequent
blood withdrawal for laboratory samples.

Intermittent or continuous? Measurement ma rkers along t he

catheter aid in catheter insertion.
CVP monitoring can be done intermittently or
continuously. Typically, a single lumen CVP
line is used for intermittent pressure readings
using a disposable plastic water manometer. Polyester cuff ~
CVP is recorded in centimeters of water So me catheters come with
(cm H20) or millimeters of mercury (mm Hg) a polyester tissue ingrowth
read from manometer markings. However, cuff. Healing tissue adheres
more commonly, a pressure transducer system to this cuff, providing more
is used to measure continuous CVP. catheter stability and
reducing the risk of
dislodgment.
 Obtaining GYP measurements e
Obtaining CVP
measurements
1 Make sure that the CV line or the
proximal lumen of a pulmonary artery
catheter is attached to the system. (If
the patient has a CV line with multiple
lumens, one lumen may be dedicated
to continuous CVP monitoring and
the other lumens used for fluid
administration. )

2 Set up a pressure transducer sys-

tem. Connect nonpliable pressure tub-
ing from the CVP catheter hub to the
transducer. Then connect the flush
solution container to a flush device.

:3 To obtain values, position the

patient flat. If he can't tolerate this
position, use semi-Fowler's position.
Locate the level of the right atrium by
identifying the phlebostatic axis. Zero
the transducer, leveling the transducer
air-fluid interface stopcock with the
right atrium, as shown in the photo
above right. Read the CVP value from
the digital display on the monitor, and
note the waveform. Make sure that the
patient is still when the reading is-tak-
en to prevent ctItifact. Use this posi-
tion for all subsequent readings.
Correlating CVP with
cardiac function
Essentially, CVP measurements reflect events in the
cardiac cycle, and thus depict cardiac function.
During ventricular diastole, the atrioventricular (AV) valves open.
........
As diastole ends, each open valve creates '{Vhat amounts to a
common heart chamber.
........
The pressure created by blood volume in the ventricles then extends back
into the atria so that pressure measured in the right atrium
indirectly mirrors the volume status of the right ventricle (called preload) .
........
During systole, the AV valves close and the semilunar valves open .
........
At this point, the pressure measured in the atria indicates atrial filling.
 CD C.ntral venouo pre50ure moo1itori,;!j
Ta ke a good look at these
cath et ers. Each has its own
advantages and
disadvantages as well as
specifi c nursing intervent ion s.
r~l-~
~-
Guide to CV catheters

~\-.'"

Groshong catheter • Silicone rubber • Long-term CVaccess

• About 35" (88.9 cm) long • Patient with heparin allergy
• Closed end with pressure-sensitive
two-way valve
• Dacron cuff
• Single or double lumen
• Tunneled

Short-term single-lumen catheter • Polyvinyl chloride (PVC) or • Short-term CV access

polyurethane • Emergency access
• About 8" (20.3 cm) long • Patient who needs only one
• Lumen gauge varies lumen
• Percutaneously placed

Short-term multilumen catheter • PVC or polyurethane • Short-term ·CV access

• Two, three, or four lumens exiting at • Patient with limited insertion
%" (2-cm) intervals sites who requires multiple
• Lumen gauges vary infusions
• Percutaneously placed

Hickman catheter • Silicone rubber • Long-term CV access

• About 35" long • Home therapy
• Open end with clamp
• Dacron cuff 11 %" (29.8 cm) from hub
• Single lumen or multilumen
• Tunneled

Broviac catheter • Identical to Hickman except smaller • Long-term CVaccess

========'~
inner lumen • Patient with small central ves-
OJ
sels (pediatric or geriatric)

Hickman-Broviac catheter • Hickman and Broviac catheters • Long-term CVaccess

combined • Patient who needs multiple
• Tunneled infusions

Peripherally inserted central catheter • Silicone rubber • Long-term CV access

= • 20" (50.8 cm) long • Patient with poor CV access
• Available in 16G, 18G, 20G, and 22G • Patient at risk for fatal complica-

~
• Can be used as midline catheter
• Percutaneously placed
tions from CV catheter insertion
• Patient who needs CV access
but is scheduled for or has had
head or neck surgery

~~~~~~~~~~~~-
iJ..~~;1:,
• Less thrombogenic
• Pressure-sensitive two-way valve
eliminates frequent heparin flushes
• Dacron cuff anchors catheter and
prevents bacterial migration
---
• Easily inserted at bedside
• Easily removed
• Stiffness aids CVP monitoring
• Same as single-lumen catheter
• Allows infusion of multiple (even in-
compatible) solutions through the
same catheter
• Less thrombogenic
• Dacron cuff prevents excess motion
and migration of bacteria
• Clamps eliminate need for Valsalva's
maneuver
• Smaller lumen
• Double-lumen Hickman catheter
allows sampling and administration
of blood
• Broviac lumen delivers IV fluids, in-
cluding total parenteral nutrition
.,.-.---------------- ---- -
• Peripherally inserted
• Easily inserted at bedside with mini-
mal complications
• May be inserted by a specially
trained nurse in some states
Ilf..-+:lo.·r~j.;
• Requires surgical insertion
• Tears and kinks easily
• Blunt end makes it difficult to
clear substances from its tip
• Limited functions
• PVC is thrombogenic and irri-
tates inner lumen of vessel
• Should be changed every 3 to
7 days (frequency may depend
on facility's CV line infection rate)
• Same as single-lumen catheter
• Requires surgical insertion
• Open end
• Requires doctor for removal
• Tears and kinks easily
• Small lumen may limit uses
• Single lumen
• Same as Hickman catheter
• Catheter may occlude smaller
peripheral vessels
• May be difficult to keep immo-
bile
• Long path to CV circulation
Obtaining CVP measurements
• Two surgical sites require dressing after insertion.
• Handle catheter gently.
• Check the external portion frequently for kinks
and leaks.
• Repair kit is available.
• Remember to flush with enough saljne solution
to clear the catheter, especially after drawing or
administering blood.
• Minimize patient movement.
• Assess frequently for signs of infection and clot
formation.
• Know gauge and purpose of each lumen .
• Use the same lumen for the same task.
• Two surgical sites require dressing after insertion.
• Handle catheter gently.
• Observe frequently for kinks and tears.
• Repair kit is available.
• Clamp catheter with a nonserrated clamp any
time it becomes disconnected or opens.
• Check facility policy before drawing blood or
administering blood or blood products.
• Know the purpose and function of each lumen .
• Label lumens to prevent confusion.
• Check frequently for signs of phlebitis and
thrombus formation .
• Insert catheter above the antecubital fossa.
• Basilic vein is preferable to cephalic vein .
• Use arm board if necessary.
• Length of catheter may alter CVP measurements.
e Cent",1 venou. pre••ure monitoring '"

A CV catheter
usually ends in the
CV catheter pathways superior vena cava.
These illustrations show several common However, it can also
Superior
pathways for CV catheter insertion. Typical ly, vena terminate in the
a CV catheter is inserted in the subclavian or cava ~ right atrium .
internal jugular vein.
Right
atrium~

) \/c
I '\j "\ ~'' ' -'>__
\l (r
) ~
, .~

1\'\~~fJJ
(" ~ ~ )
:1\
' \ ') I '

"\ \ "" / /
,

Catheter ((~1'
~ ~
~ ~ ~. ~ Insertion
. + ~"CA~~ ~~ • Subclavian vein
Ii';;' ..... 'it Termination
• Superior vena cava

F
~
1 2J$~7t~ "0'\ Insertion
• Subclavian vein

~ , ; Him Termination
• Right atrium

.£

1
)I
 Obtaining CVP measurements

Catheter

• Internal Subclavian vein

jugular vein

• Superior
vena cava

Catheter

Termination Ai
• Superior vena
cava

Insertion ~< "1'

• Basilic vein
(peripheral)

III f .~........... '

s~:· .
••

Subclavian
cava vein

re ~li Dacron
• Through a cuff
subcutaneous
tunnel to the Catheter
subclavian vein
(Dacron cuff
helps hold
catheter in
place)
CD Cent,..1 venau. pres.u ... manlto_ri_n_g==~____________________..........

ride the wave

Understanding the GVP waveform

When the CV catheter is attached to a pressure monitoring system, the bedside monitor can usually display digital
pressure values, CVP waveforms, and ECG tracings. Synchronizing the CVP waveform with the ECG helps you
identify components of the tracing. Keep in mind that cardiac electrical activity precedes the mechanical activities
of systole and diastole.

Comparing electrical activity Normal waveforms

The P wave on the ECG reflects atrial
depolarization, which is then followed by
atrial contraction and increased atrial
ECG
R
pressure. Corresponding to the PR
interval on the ECG, the a wave
sequence on the CVP waveform
represents atrial contraction.
The X descent on the CVP waveform
represents atrial relaxation and declining
pressure after systole, when the atrium
expels blood into the ventricle.
As the cardiac cycle progresses, the
tricuspid valve closes, producing a small
backward bulge known as the C wave.
The atrium filling w ith venous blood
during diastole produces another rise
;.-. pressure and a V wave, which
corresponds to the T wave of the ECG. eyp
After atrial filling, the tricuspid valve
opens. Most of the blood in the right
atrium passively empties into the right
.-entricle, causing atrial pressure to fall.
On the CVP waveform, this decline
aopears as the Y descent.
The a and V waves are almost
me same height, indicating that Synchronizing the
8iaJ systole and atrial diastole CVP waveform with
the ECG helps Whew!
oroduce about the same amount
identify components. I'm electric!
.f pressure. Consequently, right
Keep in mind that Do-do-do
8iaJ pressures are recorded as
cardiac electrical Do-do-do-
""'€afl values because they're
activity precedes do-do-do ...
~tthesame.
systole and diastole.
 Obtaining CVP measurements

I've been under a lot

of pressu re lately. I
think I need a vacation.
Maybe a cr uise t o
Bermuda ...

on the level .

CVP or right atrial pressure shows rig ht ventricular function and end-diastolic pressure.

Causes of increased pressure

• Right-sided heart failure
• Volume overload
• Tricuspi d valve stenosis or insufficiency
• Constrictive pericarditis
• Pulmonary hypertension
• Cardiac tamponade Normal values
• Right ventricular infarction
Normal mean pressure ranges from
2 to 6 mm Hg (3 to 8 cm H 2 0).

Causes of decreased pressure

• Reduced circulating blood vol ume
 CD Central venous pressure monitoring ....... ...'""""

ride the wave

Recognizing abnormal GVP waveforms

Elevated a wave Elevated v wave I Elevated a and v waves

ECG ECG CVP a a v
15- v

or
cVP a I cVP v I cVP v v
15-

y
0- PhY6i%gic caU6e6
PhY6i%gic caU6e6 PhY6i%gic caU6e • Increased resistance to ventricular filling ,
• Increased resistance to ventricular filling • Regurgitant flow w hich causes an elevated a wave
• Increased atrial contraction • Functional regurgitation, w hich causes
A660ciated condition6
an elevated v wave
A660ciated condition6 • Tricuspid insufficiency
• Heart failure • Inadequate closure of the tricuspid valve A660ciated condition6
• Tricuspid stenosis due to heart failure • Cardiac tamponade (smaller y descent
• Pulmonary hypertension than x descent)
• Constrictive pericardial disease
Absent a wave (y descent exceeds x descent)
Heart failure, ECG • Heart failure
arrhythmias, ca rdiac • Hypervolemia
tam ponade... Oh, horror! I • Atrial hypertrophy
can't bear to look at any
more abnormal wavef orm s.

\ '\ \.( l..

'\ /-.,,/
'I
A <:
PhY6i%gic caU6e
~ "';T
.I I • Decreased or absent atrial contraction

\ ! ?.......
", '\1) A660ciated condition6
\ \., ~(\~ /, ,,
" /(',.,,
" \...1: ~ v-.::. • Atrial fibrillation
\"
'/~-'7. . • Junctional arrhythmias
\ 'l'S'
1/11\> \ J -"" • Ventricular pacing

,\ a' ';;'~\
1/ ~I ......

.....
 Obtaining CVP measurements •
, ~.
Just what I need - more
math ! I suppose I shou ldn't
Measuring CVP with a water manometer complain . The fo rmulas are
written out for us!
To ensure accurate CVP readings, make sure that the
manometer base is aligned with the patient's right atrium
(the zero reference point). The manometer set usually /",
contains a leveling rod to allow you to determine this r'~~
1'(:' '17 ~
alignment quickly.
~I~ 1'('~ .
~/~~'~~~=-;R~
After adjusting the manometer's position, examine
the 3-way stopcock. By turning it to any position shown
below, you can control the direction of fluid flow. Four-
way stopcocks are also available. Converting pressu re val ues
Although most facilities today use the pressure trans-
All openings blocked ducer system to measure CVP, the water manome-
ter -the first device developed for monitoring CVP -
may still be in use in some facilities. Both methods
measure right atrial pressure-the pressure transducer
in mm Hg and the water manometer in cm H 2 0. If
your faci lity uses both pressure transducers and water
manometers, you may have t6 convert pressure
values.
Manometer to patient I.V. solution to manometer Use this formula to convert cm H20 to mm Hg:

em H20 7 1.36 = mm Hg
+ t
+ t Conversely, use this formula to change mm Hg to
+ t
cm H20 :
•
I.V. solution to patient
mm Hg X 1.36 = em H20
';:=
r-
fil
I.v. solution bOttle
9
0

• •j I~O .c! t··

~ Manometer

Zero point

3-way stopcock
 mO,mn~~i=tO~,r,",i=n~~~~=~===~="'=4
Ma ny
_ _ Central venou. pre••ure co mp lications of
CVP monit oring
ca n be
minim ized wit h
th e right
Minimizing complications nursing
interventions.
of CVP monitoring

• Redness, warmth, tenderness, swelling at insertion

or exit site insertion or care
• Possible exudate of purulent material • Wet or soiled dressing remaining on site
• Local rash or pustules • Immunosuppression
• Fever, chills, malaise • Contaminated catheter or solution
• Leukocytosis • Frequent opening of catheter or long-term use of
single I.v. access site

Pneumothorax, • Decreased breath sounds on affected side • Repeated or long-term use of same vein
hemothorax, • With hemothorax, decreased hemoglobin level • Preexisting cardiovascular disease
chylothorax, because of blood pooling • Lung puncture by catheter during insertion or ex-
hydrothorax • Abnormal chest X-ray change over a guide wire
• Large blood vessel puncture with bleeding inside or
outside the lung
• Lymph node puncture with leakage of lymph fluid
• Infusion of solution into chest area through infiltrat-
edcatheter

Air embolism • Respiratory distress • Intake of air into the CV system during catheter
• Unequal breath sounds insertion or tubing changes, or inadvertent opening,
• Weak pulse cutting, or breaking of catheter
• Increased CV pressure
• Decreased blood pressure
• Alteration or loss of consciousness

Thrombosis • Edema at puncture site • Sluggish flo w rate

• Erythema • Composition of catheter material (PVC catheters
• Ipsilateral swelling of arm, neck, and face are more thrombogenic.)
• Pain along vein • Hematopoietic status of patient
• Fever, malaise • Preexisting limb edema
• Chest pain • Infusion of irritating solutions
• Dyspnea
• Cyanosis
 , , -,.
~
I fee l
better
already!
Ol>talning CVP me•• urement. CD
! : ;j I
\ ,,Ie--

("" ...,,, '\J

~.

~ ~.
~

• Monitor vital signs closely.
• Culture the site.
• Re-dress the site using sterile technique.
• Possibly use antibiotic ointment locally.
• Treat systemically with antibiotics or antifungals, depending
on culture results and the doctor's order.
• Catheter may be removed.
• Draw central and peripheral blood cultures; if the same or-
ganism appears in both, then the catheter is the primary
source and should be removed.
• If cultures don 't match but are positive, the catheter may be
removed or the infection may be treated through the catheter.
• If the catheter is removed , culture its tip.
• Document interventions .
• Maintain sterile technique. Use sterile gloves, masks, and
gowns when appropriate.
• Observe dressing-change protocols.
• Teach about restrictions on sw imming, bathing , and so on .
(With adequate white blood cell count, the doctor may allow
these activities.)
• Change a wet or soiled dressing immediately.
• Change the dressing more frequently if catheter is located in
femoral area or near tracheostomy. Perform tracheostomy care
after catheter care.
• Examine solution for cloudiness and turbidity before infusing;
check the fluid container for leaks.
• The catheter may be changed frequently.
• Keep the system closed as much as possible.

• Notify the doctor.
• Remove the catheter or assist with removal.
• Administer oxygen as ordered .
• Set up and assist with chest tube insertion.
• Document interventions.
• Position the patient head dow n with a rolled towel between
hi;> scapulae to dilate and expose the internal jugular or sub-
clavian vein as much as possible during catheter insertion .
• Assess for early signs of fluid infiltration (swelling in the
shoulder, neck, chest, and arm).
• Make sure that the patient is immobilized and prepared for
insertion. An active patient may need to be sedated or taken to
the operating room .
• Minimize patient activity after insertion, especially with a
peripheral catheter.

• Clamp the GaUleter illllllediately' • PWBe ",II "ir· frum th e tubin g before hOOKUp.
• Turn the patient on his left side, head down, so that air • Teach the patient to perform Valsalva's maneuver during
can enter the right atrium. Maintain this position for 20 to catheter insertion and tubing changes.
30 minutes. • Use air-eliminating filters.
• Avoid Valsalva's maneuver because a large air intake • Use an infusion device w ith air detection capability.
worsens the condition. • Use luer-Iock tubing , tape the connections, or use locking
• Administer oxygen. devices for all connections.
• Notify the doctor.
• Document interventions.

• Notify the doctor.
• Possibly remove the catheter.
• Possibly infuse anticoagulant doses of heparin .
• Verify thrombosis with diagnostic studies.
• Apply warm , wet compresses locally.
• Don 't use the limb on the affected side for subsequent
venipuncture.
• Document interventions.
• Maintain a steady flow rate with the infusion pump, or flush
the catheter at regular intervals.
• Use catheters made of less thrombogenic materials or
catheters coated to prevent thrombosis.
• Dilute irritating solutions.
• Use a 0.22-micron filter for infusions.
 Understanding PAP and
PAWP monitoring 68
PAp, PAWp, • PA catheter
PA ... just like
these scripts, it's
insertion 71
all starting to
sound the same! I Understanding the
guess I'll have to
read on to get to
pulmonary artery
the heart of the waveform 74
story.

A closer look at
pulmonary artery
pressures 76
• Pulmonary artery
wedge pressure 77
_ • A. ,.

• Influence 0 '"
intrathoracic
pressure 80
• Vision quest 86
'II;) Pulmonary artery pressure m~nitoring

Understa nd ing
PAP and PAWP
monitoring
i
Continuous pulmonary artery
pressure (PAP) and intermittent
A closer look at
pulmonary artery wedge pres- a pulmonary
sure (PAWP) measurements artery
provide important information
about left ventricular function
catheter
and preload.
The original PAP monitoring
catheter, called a Swan-Ganz
catheter or, more commonly, a
pulmonary artery (PA) cath-
eter, had two lumens. Current
versions have up to six lumens,
allowing more hemodynamic
information to be gathered.
In addition to distal and
proximal lumens used to mea-
sure pressures, a PA catheter
has a balloon inflation lumen
that inflates the balloon for
PAWP measurement and a ther-
mistor connector lumen that
enables cardiac output measure-
ment. Some catheters also have
a pacemaker wire lumen that
The deflated catheter tip rests in
provides a port for pacemaker the pulmonary artery, allowing
electrodes and measures contin- diastolic and systolic pulmonary
uous mixed venous oxygen artery pressure readings.
saturation.

Inflated balloon

When inflated, the balloon wedges

in a branch of the pulmonary
artery during PAWP measurement.
 Understanding PAP and PAWP monitoring

access point for inflating

the distal tip of the catheter for
PAWP measurement.

Thermistor

The therm istor measures core body

temperature. When connected t o a
cardiac output monitor, it measu res
temperature changes related t o
cardiac output.

I'1roximal lumen

The proximal lumen, usually blue, typically

opens into the right atrium. In addition
to measuring right atrial pressure, it
delivers the bolus injection that's used
to measure cardiac output and
functions as a fluid infusion route.

Distal lumen

.~' ! The distal lumen, usually yel low, opens

I into the pulmonary artery. When
A PA catheter has attached to a transducer, it al lows
a balloon inflation you to measure PAWP This port ca n
lumen for PAWP also be used to measure mixed veno us
measurement and a oxygen saturation.
the(r-riistor connector ,-,,,.,","~.,,,.~"".,,.,,,,,,,,,

lumen to measure
ca rdiac output.
This lu men provides a portf6~':)R~Gema ker
electrodes or infusion of medications or
------- '-.. '\ other I.v. f lu ids.

/ \
/)
"
o Pulmona'Y a....'Y pre••ureemonitorlitg ~ . " . ~'_ _
Alook at the whole picture ...
Detecting pressure changes in the heart with a PA catheter involves the use of a fluid-filled monitoring
system as described in chapter 2, Understanding a pressure monitoring system. The components of this
system are shown in this illustration.

* T #"f #"h"" #f±###i¥¥¥¥§1::~~: ::-:;¥ 'g

Components of the PAP monitoring system

Superior
vena cava
Pressure bag Pulmonary
Electrocardiogram artery
Normal saline or
heparinized normal
saline IV. solution
(fl ush)

Monitor

Cables

Multilumen Distal
pulmonary artery lumen
catheter

Proximal (RA)
infusion port

Distal (PA)
infusion port

Balloon inflation
valve (port)

Thermistor
connector

..
 PA catheter lnoertlon e
fA catheter The
balloon-tipped, multilu-
men catheter is inserted into the

insertion patient's internal jugular or subclavian

When is PAP
monitoring used?
Nearly all acutely ill patients are candidates for
PAP monitoring - especially those who:
I t are her;99dyru;;;k;;;iiY~II~table
It need) luid management Ol-jOntinuous
vein. Fluoroscopy usually isn't required during
catheter insertion because the catheter is flow-
directed, following venous blood flow from the right
heart chambers into the pulmonary artery. Also, the pul-
monary artery, right atrium, and right ventricle produce
characteristic pressures and waveforms that can be ob-
served on the monitor to help track catheter-tip location.
Marks on the catheter shaft, with lO-cm graduations, assist
tracking by showing how far the catheter is inserted.
When the catheter reaches the right atrium, the balloon is
inflated to float the catheter through the right ventricle into
the pulmonary artery. PAWP measurement is then possible

d
through an opening at the catheter's tip. The catheter
card io ~ Imonary assessment
Cwith balloon tip deflated) rests in the pulmonary
I t are(receiving multiple or freqUJently administered
artery, allowing diastolic and systolic PAP read-
card ioactive drugs
k
I t are shock
ings. The balloon should be totally deflated
I t have\~erienced traum
except when taking a PAWP reading (pro-
I thave pulmQ~i ' c, or multisystem disease. longed wedging can cause pul-
monary infarction).

Cautions Fluoroscopy is n't

Some patients require special precautions during insertion and necessary with PA
use, including: catheter insertion
[j those with left bundle-branch heart block because the catheter
Think before
[J those for whom a systemic infection wou ld be life-threatening. fo llows venous blood flow
you act. While
into the pu lmonary
most patients
artery! Isn't that
are PAP
convenient?!
cand idates,
others are not!
PAP monitoring exist. However,
patients with:
(~

(\. - !
i>V ('v<
f\
-I ~~:---~/ 1 ~~ ~
.:::: ( I \\ ......,-._ ~_ (=. ".",""~""~"" _ :-::-.~ .- ~r---.,
c.:- ~ _..!" :;~_&,~:!!!"r~J,!~4~ .
\, ... (/.-::~) ':::''''~ (<<:. .\..."" ~.,
____ ~.,.....(...:~ - ;::, ---=,,==-:~- ..-..... ;J:?'
(~)/
~ r ~-.J.I
1
. -to'
L'~) C, -.....:..::- ...""':"'/
~:/~--'; ~ ~.,)

'jJ~!)
""'--: -"' \~
C--'
Q::-'
(~ :::Y
'J))~
., ~J
(%J'
uP
8 PUlmonary a ....ry pressure monito_rL_n_9________________________.........

ride the wave

Normal pulmonary artery waveforms

After insertion into a large vein (usually the subclavian, jugular, or femoral vein), a PA catheter is advanced through
the vena cava into the right atrium, through the right ventricle, and into a branch of the pulmonary artery, During
insertion, the monitor shows various waveforms as the catheter advances through the heart chambers,

When the
catheter tip enters

1
the right atrium, this
waveform appears
on the monitor,
representing right
atrial pressure,

The
catheter tip Watch the patient's
enters the right electrocard iogram
atrium ,
monitor closely.
Ventricu la r arrhythmias
can occur as the
cath eter passes throug h
the right ventricle.

v \ '-

--,~? (:" I-
I? I \~ 1 1)
Next, the
catheter tip
reaches the right
(\ \.~
- ~I!
]1~ I {
I
ventricle,

~ ~~~
~
~ ,-
-..\
I \1- t(
/-~L'
\I 'n" 'I'

~7 J
~ _ fl'-\) a .::y.,ol
'---_ _ _ __ -"v-.,"'--'-"'1.:"~
'"'~
.. ~-~t:~~~~
As the catheter tip reaches the
right ventricle, you' ll see a
C ~ ~S~~­
waveform with sharp systolic
upstrokes and lower diastolic dips,
 PA oathete, In.....lon e
As the catheter
reaches the ~
pulmonary artery, the
upstroke of the
waveform becomes
smoother than that of
the right ventricular
waveform.

The
catheter floats
into the
pulmonary
artery.
The dicrotic
notch indicates
closure of the
pulmonic valve.

The monitor now

shows a pulmonary artery
wedge pressure
The catheter's
waveform with two small
balloon floats into a
uprises. The balloon is
distal branch of the
then deflated and the
pulmonary artery.
catheter is left in the
The balloon
wedges where the ~ pulmonar; arter;. )
vessel becomes
too narrow for it
to pass.
e Pulmona"Y a ...."Y pre••ure .'t!~~ltot~".g _ . m,

Understanding the_~_~
pulmonary artery
As you ca n see, a low
pres sure syst em is going
t o head our way that
resembles an arterial

waveform I-ro-\ --v~~ I ~-----r::: ~ ~ ,'-t:5JL_

pres sure wa vef orm, ..

The waveform produced by PAP ! .~ r(r~",/ 1)1 -' '\

monitoring is similar to the arterial i ( .l} ( \
pressure waveform, except that
the pressures are lower (due to !ft-\~~\f-\~f)
the lower pressures in the pulmo-
I ~~~ ~~
-/i!~10
nary arteries when compared to
pressures in the systemic arteries).
~-- - ~

~\IVII"'~""
~1?Y K. ..';''''<::)
1

ride the wave

PAP waveform
In this example of a normal PAP waveform, note the lower pressure scale used, This waveform would be
interpreted as a PAP of 32/12 mm Hg ,

mmHg
35

30

25
fij~
20 1 Systolic ejection into
pulmonary artery

15 2 Closure of pulmonic
valve (dicrotic notch)

10 3 End diastole

1 2 :3
 Onaerstanaing the pulmonary artery waveform

Ii '!

IJI J~
on the level

Normal PAP parameters

(
l _
~~~
"' T ..~
.•• •
..- ~
~
-.:---
...'."',
PAP monitoring provides information on intracardiac pressures . To understand intracardiac pressures, picture the
heart and vascular system as a continuous loop with constantly changing pressure gradients that keep blood moving. PAP monitoring
records the gradients within some of the heart chambers and vessels.

Pressure and description Normal values Causes of increased pressure Causes of decreased pressure

Right ventricular pressure Normal systolic • Mitral stenosis or insufficiency

Typically, the doctor measures pressure ranges • Pulmonary disease
right ventricular pressure only from 20 to • Hypoxemia
when initially inserting a pul- 30 mm Hg; • Constrictive pericarditis
monary artery catheter. Right normal diastolic • Chronic heart failure
ventricular systolic pressure pressure, from • Atrial and ventricular
normally equals pulmonary o to 5 mm Hg. septal defects
artery systolic pressure. Right • Patent ductus arteriosus
ventricular end-diastolic pres-
sure reflects left ventricular
function.

PAP Systolic pressure • Left-sided heart failure

Pulmonary artery systolic pres- normally ranges • Increased pulmonary blood flow
sure shows right ventricular from 20 to (left or right shunting, as in atrial or
function and pulmonary circula- 30 mm Hg; nor- ventricular septal defects)
tion pressures. Pulmonary artery mal diastolic • Any condition causing increased
diastolic pressure reflects left pressure, from pulmonary arteriolar resistance,
ventricular pressures, specifical- 6 to 12 mm Hg. such as pulmonary hypertension,
ly left ventricular end-diastolic The mean pres- volume overload, mitral stenosis,
pressure, in a patient without sure usually acute respiratory distress syn-
significant pulmonary disease. ranges from drome, or hypoxia
10 to 15 mm Hg.

PAWP The mean pres- • Left-sided heart failure

PAWP reflects left atrial and sure normally • Mitral stenosis or insufficiency
left ventricular pressures, ranges from • Pericardial tamponade
unless the patient has mitral 4to 12 mm Hg.
stenosis. Changes in PAWP PAP monitoring record s
reflect changes in left ventricu-
the gra dients within some
lar filling pressure.
of my cha mbers and
vessels. Gee, I hope I make
t he "g rad e." Ha, hal Get
it ? Grad ient, grade? I
crack me up!
o Pulmonary a....ry pre550'" monito.ng

A closer look
at pulmonary
To remember the
difference between ... butyou
pulmonary artery close the door
pre ssures, (pulmonic valve)

artery remember: you get a

PAS(S) (Pulmonary
Artery Systolic) to
open the door
to your PAD
(Pulmonary
Artery Diastol ic).

pressures (pul mon ic valve) ...

After PA catheter insertion, pulmonary artery systolic

pressure and pulmonary artery diastolic pressure are
continuously measured. , <)
i
if,
'\ ~~ "",dll~:
4l/
-,.1[:" _
\
) =
~~ o il· _- ___
Understanding pulmonary artery pressures
PA systolic ~ressure PA diastolic pressure
PA systolic pressure measures right ventricular systolic ejection or, PA diastolic pressure represents the resistance of the pulmonary
simply put, the amount of pressure needed to open the pulmonic vascular bed as measured when the pulmonic valve is closed and
valve and eject blood into the pulmonary circulation. When the the tricuspid valve is open. To a limited degree (under absolutely
pulmonic valve is open, PA systolic pressure should be the same normal cond itions), PA diastolic pressure also reflects left
as rig ht ventricular pressure. ventricular end -diastolic pressure.

Bronchus )~ Alveolus Bronchus

)~ Alveolus
Pulmonary Pulmonary
artery artery

Pulmonary
circulation
 ......._ _ _ _ _ __ _ _ _ __________ ~_P_u~l_m_on.ry .rtery wedge pressure "

Looks li ke I'm headed for

Pulmonary artery t he dista l bra nch . I hope I

don't wedge my boat int o
a sa ndbar!

wedge pressure r ~<

hJ}f'l "1~
~~j.. \ ..J~
PAWP reflects left atrial and left ventricular pressures. PAWP is
\'n~ ~J~U~:fJ1~V~'I~\~ .
obtained by inflating the balloon on the PA catheter tip. The balloon
floats downstream with venous blood flow to a smaller, more distal
branch of the pulmonary artery. Here, the catheter lodges, or w edges,
-=-~~/ ",.Iii
~ c ____ ~
G7 \ f'~ -g ~
J
causing occlusion of right ventricular and pulmonary artery diastolic ~ c~'!"\
pressures. The resulting waveform resembles that of the right atrial '":'I \~. "

~l
) v'~ ~
~
waveform (obtained when the balloon is deflated), except that the
U~~!r,I~"",
J) I, "
.
;, ~~~
PAWP waveform reflects back pressure from the left side ofthe heart.
/ '
"" '''"",
"-
~ v-- . . )
r

A closer look at the wedged position '-':-;-~~

c:....::..co~
This illustration show s t he positioning of the pulmonary artery catheter and its inflated t ip
during pulmonary artery wedge pressure measurement.
>-
Bronchus
Balloon
inflated Alveolus
Pulmonary
artery
Pulmonary
vein
Pulmonary
artery
catheter Left

Right Pulmonic Mitral

atrium valve valve
closed open

Tricuspid Right Left

valve open ventricle ventricle
- Pulmonary artery pre66ure monitoring

Taking a PAWP reading

By inflating the balloon and letting it float in a distal artery,
Whi le trac ing
is a no-n o in the
art world, it's
absolutely
essent ial when
it comes t o
you can record PAWP. Extreme caution should be used PAWP read ings.
when taking a PAWP reading because of the risk ofpul- Trace away!
monary artery rupture - a rare but life-threatening compli-
cation. Make sure that you're thoroughly familiar with in-
tracardiac waveform interpretation and follow these steps:

To begin, verify that the transducer is properly lev-

eled and zeroed. Detach the syringe from the balloon
inflation hub. Draw 1.5 ml of air into the syringe, and
then reattach the syringe to the hub. Watching the
monitor, inject the air through the hub slowly and
smoothly. When you see a wedge tracing on the mon-
itor, immediately stop inflating the balloon. Note:
Never inflate the balloon beyond the volume needed
to obtain a wedge tracing; otherwise the pulmonary
artery could rupture.
Take the pressure reading at end expiration.
Note the amount of air needed to change the pul-
monary artery tracing to a wedge tracing (normally,
1.25 to 1.5 ml). If the wedge tracing appeared with
injection of less than 1.25 ml, suspect that the cath-
eter has migrated into a more distal branch and re-
quires repositioning. If the balloon is in a more distal
branch, the tracings may move up the oscilloscope,
indicating that the catheter tip is recording balloon
pressure rather than PAWP. This may lead to pulmo-
nary artery rupture.

ride the wave

Observing the PAWP waveform

Upon balloon inflation, you should see the normal PAP waveform flatten to the characteristic PAWP waveform .
Balloon inflation should be halted upon observation of this waveform. Upon balloon deflation , the PAP waveform
should immediately reappear.

PAP w aveform Wedged position PAP waveform reappears

20
10
o
 Pulmonary artery wedge pressure

Overwedging
~
rOIOnged wedging or hyperinflation of the balloon can produce falsely elevated PAWP measuremen
" that are useless. Prolonged wedging or hyperinflation create occlusion of the catheter tip

~_ -===-=\
and distort accurate measurements by either:
\ • lodging the sensing tip of the catheter into the vessel wall, causing measurement of /,
the pressure within the occluded catheter and high-pressure flush system
•
It causing the inflated balloon tip to become compressed by the surrounding
pulmonary artery, placing pressure on the sensing tip of the catheter. I /
\
Gently now \

---=1----- -
\ tL \ I
,::o·tI -
\I-,.:..:~waveform should reappear. Then rewedge with less air, and avoid
prolonged wedging.

'
Overwedgmg is visible in a
PAWP wavef orm that
continuously rises or declines
abruptly and then slowly rises
t .1 -'"'-= ~ -

\ ( again. Wheeee!

\/ ~(V<"
-=- ---
,

1 7f\ II flr~~~!~0; ~ 1\
\\
~
-..

71DUn\~l! ~ r\-u ,( ~'

l ,J \
ride the wave

Observing an overwedged waveform

PAP waveform Overwedging PAWP waveform PAP waveform

_ Pulmonary a....ry pre••ure monitoring .•

Influence of
intrathoracic pressure
Because the blood ves-
sels and heart are pli-
able and compressible, ride the wave
the respiratory pres-
sure changes that oc- Ventilatory effects on PAP
cur within the thorax and PAWP values
may influence hemo-
dynamic measure- These waveforms illustrate how cyclical respiratory pressure changes affect
ments. If possible, ob- PAP and PAWP measurements and highlight end-expiration points (the optimal
time to obtain a reading),
tain PAP and PAWP
values at end expira-
tion (when the patient Spontaneous breathing
completely exhales). Normal, unlabored, spontaneous respi rations have a minimal effect on PAP and PAWP values,
At this time, intratho- as shown below,
End
racic pressure ap-

+:s2 ifi gs
Expiration expiration
proaches atmospheric

~
pressure and has the
least effect on hemo-
dynamic measure- -3
ments. Inspiration
If you obtain a
reading during other Electrocardiogram
phases of the respira-
tory cycle, respiratory
interference may oc-
cur. For instance, dur-
ing inspiration, when
PAWP
intrathoracic pressure
drops, PAP may be 30 ------------------------------------------------------------
false-low because the
~
negative pressure is 20 ~
transmitted to the
10 --------------------
----------~=-~~~~~~--~~
---------------
-:--~~------~~
catheter. During expi-
ration, when intratho- o ----------~------------------------------------------------
racic pressure rises,
PAP may be false-high.
 Influence of intrathoracic pressure

t~
«I
Respiratory
~ ')
..,v--- '\(~ \
JJU" 1
I / rlfi; f,\ That's
pressure ( \
i ~ iJ " \ on ly

Le. ~J
changes in the i because
thorax may
\ '" you're so

~" "~ ~~~

influence pl iable!
hemodynamic
~,_~~.&-5)
-IL
monitoring. ",.
~--.>~~ "-;' 'OJ-.,
\~ \'\t? fr
~~JLJ .-.~ ~ v'

~.
~~ ..v
?:

Mechanical ventilation
When a patient is mechanically ventilated, his PAP and PAWP waveforms will follow the intrathoracic pressure changes
that occur upon delivery of ventilator breaths . This diagram illustrates the effects of control mode ventilation, in which
the venti lator delivers a preset tidal volume at a fixed rate, and synchronized intermittent mandatory ventilation (SIMV),
in which the ventilator delivers a preset number of breaths at a specific tidal volume, but the patient may supplement
these mechanical ventilations with his own breaths. The PAWP waveform baseline shows a combination of machine
breaths and spontaneous breaths when the patient is ventilated using SI MV.

Control mode
+25 cm H 0
2
Peak in:piration
..

o· >« '\« )"

PAWP Ventilator breath Ventilator breath Ventilator breath

End expiration End expiration

SIMV
+ 25 cm H20 A

0' , " I,
r c: >I" «

-3cm H20 ------------~----~~--~~~~~~~-------------------------

 Pulmonary artery pressure monitorit;l9

Minimizing complications of PAP monitoring

A patient who has a PA catheter in place is at risk for several complications. In addition to ob-
serving the patient's electrocardiogram, waveform pattern, and PAP values on the bedside
monitor, watch for these signs and symptoms of complications. Implement appropriate care
measures to resolve or prevent them.

Complication and causes

Bacteremia
• Introduction of bacteria into the ci rculatory
system

Bleedback
• Leaks in the PA catheter apparatus
• Pressure bag that's inflated below 300 mm Hg

Bleeding at the insertion site

• Inadequate application of pressure during and
-;
after catheter w ithdrawal

Pulmonary embolism
• Thrombus migration from the catheter into
pulmonary ci rculation
• Clotted catheter tip from inadequate flushing

Pulmonary infarction
• Catheter migration into a wedged position in
the blood vessel

Ruptured pulmonary artery

• Pulmonary hypertension
• Thrombus
• Catheter migration into the peripheral branch
of the artery
• Improper inflation or prolonged wedging of
the catheter's balloon
 Watch f or
Influence of intrathoracic pressure e
I
r~~
these signs and
symptoms of
c"".,1"'o,>! complications
from PAP
'/ monitoring.
to,
Ct['
G-
"-
................ ./

Signs and symptoms

~----------------------~
_i
v- ', '
(c-~)~
Prevention
_____________________________________________

• Fever c... \ - \~ •
Maintain strict sterile technique.
• Chills \''\ / - \ • Maintain and change the monitoring setup according to
• Warm skin \ \off=> 4J ~ " ..... facility policy.
• Headache 1\ \\')\/''" ~~
• Malaise v..i':!.,'~~'V
• Blood easily seen in the pressure • Tighten all connections in the monitoring setup.
tubing • Return stopcocks to their proper position after use.
• Keep the pressure bag adequately inflated .

• Prolonged oozing or frank bleeding • Maintain pressure on the site during catheter withdrawal
at the insertion site after catheter and for at least 10 minutes afterward.
withdrawal • Apply a pressure dressing over the site.
• At a femoral site, apply a sandbag for 1 to 2 hours. -..../""

• Be sure to assess distal circulation routinely to ensure I') 0." '\;

~ \ ,) \

L--------------------------~~~:=~~~==~::::~---------- (
that a hematoma isn't obstructing blood flow. I
)
I

• Sharp, stabbing chest pain • Administer anticoagulants as ordered.

• Anxiety • Use a continuous flush system.
"~~'\ "..,
.>- i~
I
·V\. ,J~
• Cyanosis • If clotting of the catheter is suspected, gently aspirate 4 /

• Dyspnea blood (with clots), and then gently irrigate the line with flush (c-');
(~ ~
• Tachypnea solution.
• Diaphoresis

• Chest pain • Never allow the balloon to be inflated for more than
• Hemoptysis 2 respiratory cycles or 15 seconds.
• Fever • After wedg ing, make sure that a clearly defined PA
• Pleural friction rub waveform returns on the monitor.
• Low arterial oxygen levels

• Restlessness • Slowly inflate the balloon only until the PAWP waveform
• Tachycardia appears on the monitor, and then let the balloon deflate
• Hypotension passively.
...)'v
• Hemoptysis • Never overinflate the balloon.
• Dyspnea
{
l\ \\. • Reposition a migrating catheter, if permitted.

\ (" '1 )
\ .:::,,1
fl -},
~f>''!nL /I\j'
6..,,,,,
e Pulmonary artery pre66ure monitoring
____________
Troubleshooting the PAP
monitoring system
When your patient has a PA catheter, do you know how to respond to an
uncharacteristic waveform on the monitor? For example, what action
should you take for an erratic waveform? How should you respond to a
concurrent arrhythmia on the electrocardiogram? How can you deal with
an obviously inaccurate pressure reading? Use this chart to help you
recognize and resolve com mon problems.
Problem Causes
No waveform on monitor • Transducer not open to catheter
• Transducer or monitor set up improperly
• Defective or cracked transducer
• Clotted catheter tip
• Large leak in the system ; loose connections
Overdamped waveform • Air bubble or blood clots within the catheter
or tubing
• Catheter tip lodged in the vessel wall
• Kinked or knotted catheter or tubing
• Small leak in the system due to a loose
connection
Changed waveform • Incorrectly positioned catheter
configuration (noisy or • Loose connections in the setup
erratic tracings) • Faulty electrical circuitry
Ventricular irritability • Irritation of the ventricular endocardium or
heart valves by the catheter
Right ventricular • Migration of the PA catheter into the right
w aveform ventricle
~m~W~ ____________~
What happen s
when the waveform
you see is n't
cha ra cteristic'? Do
~
you know what t o do'?
j'
Q
Nursing interventions
• Check the stopcock, calibration, and scale
mechanisms of the system.
• Tighten all connections.
• Rezero the setup.
• Replace the transducer.
• Remove air bubbles observed in the catheter tubing
and transducer.
• Restore patency to a clotted catheter by gently
aspirating the clot with a syringe. (Note: Never irrigate
the line as a first step.)
• Correct a lodged catheter by repositioning the
patient or by having him cough and breathe deeply.
• Reposition the patient.
• Assist with chest X-ray to verify catheter location.
• Check and tighten connections in the catheter and
transducer apparatus.
• Notify the doctor. (Note: The doctor may prevent this
problem during insertion by keeping the balloon in-
flated when advancing the catheter through the heart.)
• Administer antiarrhythmic drugs as ordered .
• Notify the doctor immediately. The catheter may
need to be repositioned.
 @"" Influence of Intrathoracic pre••ure e

Problem Causes Nursing interventions

Catheter fling • Excessive catheter movement that may re- • Notify the doctor for catheter repositioning.
sult from an arrhythmia, excessive respiratory
effort, hyperdynamic circulation, excessive
catheter length in the right ventricle, or loca-
tion of the catheter tip near the pulmonic valve

Falsely increased or • System not properly leveled or zeroed • Reposition the transducer level with the phlebostatic
decreased pressure • Patient's body or bed repositioned without axis.
readings releveling or rezeroing the system • Rezero the monitor.

Continuous PAWP • Catheter migration • Reposition the patient or have him coug h and
waveform • Balloon still inflated breathe deeply.
• Keep the balloon inflated for no longer than two
respiratory cycles or 15 seconds.

Missing PAWP • Malpositioned catheter • Reposition the patient. (Don't aspirate the balloon.)
waveform • Insufficient air in the balloon tip • Reinflate the balloon adequately. (Remove the
• Ruptured balloon syringe from the balloon lumen, wait for the balloon to
deflate passively, and then instill the correct volume of
air.)
• Assess the balloon 's competence. (Note resistance
during inflation , feel how the syringe 's plunger springs
back after the balloon inflates, and check for blood
leaking from the balloon lumen.)
• If the balloon has ruptured, turn the patient onto his
left side, tape the balloon-inflation port, and notify the
doctor.
 Cardiac
monitoring is • Underatandin{f
crucial. So is
monitoring how output monjtorin~
much film you're
shooting. Has
anyone seen
• Thermodilution
frame 8 157 method 93
• Vision quest
 Understa nd ing
cardiac outl?ut
mon itoring , The Fick method is
especially useful in
detecting low cardiac
output levels. The blood's
oxygen content is
Other methods measured before and
after it passes through
of measuring the lungs.
cardiac output
Measuring cardiac output (CO)- l~
the amount of blood ejected by the
heart over 1 minute - helps evalu-
flclt ~,
....J -.lv,
~\l
ate cardiac function. The most ~et~o~ ~ r'r-; 1. ( "
/'" ~ ..
(\ ~ f"'·i" ~V..J.A \~TI I
J(

widely used method for monitoring (

(~ J r)t ". ~) ( ~\
J. ...
CO is the bolus thermodilution I
technique. Performed at the bed-
side, the thermodilution technique
Ii'6 '\ \'V. 1!~
.... \ \ .
')') ) I\
is the most practical method of
evaluating the cardiac status of
~c~/l~(\ ~) ~I
critically ill patients and those sus-
pected of having cardiac disease,
and is the method focused on in
No, no. Tha t's a tie-dye, not a
this chapter. Other methods in- dye dilution test! Dye is injected
clude the Fick method and the dye into the pulmonary artery and
dilution test. measured by sampling the amount
of dye in the brachial artery.

----~TI
Dye
~thA.Ho\\ \~~
r:: -" I
tMet~o~ :~~
 ........A'." careliac output monitocing CD
on the level

What causes changes in cardiac output?

Normally, CO ranges from 4 to 8 Uminute. Values below this range may result from:
• decreased myocardial contracti lity caused by myocardial infarction, drug effects, acidosis, or hypoxia
• decreased left ventricular filling pressure resulting from hypovolemia
• increased systemic vascu lar resistance related to arteriosclerosis or hypertension
• decreased ventricular flow related to valvular heart disease.
High CO can occur with some arteriovenous shunts and from decreased vascular resistance (as in septic
shock). In some cases, an unusually high CO can be normal-for example, in well-conditioned athletes. OK, now it's
time to put your
thinking cap on!
First, blood is removed from the Then, a spirometer measures oxygen Use the formula
pulmonary and brachial arteries consumption, which is the amount of air below to
and analyzed for oxygen content. entering the lungs each minute. calculate CO.

I
i
1

----- --- _J
To calculate CO, CO (Llminute)
these values are
entered into a
formula or plotted Remember: Dye dilution
into a time and A computer, similar to the one measurements are particularly helpful in
dilution- used for the thermodilution test, detecting intraca rdiac shunts and
concentration curve. performs the computation. valvular insufficiency.

!
.-~~
.~

Groovy!
'\
e ea"'iac output monitorin~
Measuring cardiac function
To measure various aspects of cardiac function, combine CO values with other key values obtainable
when the patient has a pulmonary artery (PA) line and a separate arterial line in place. These values
include mean arterial pressure (MAP), central venous (or right atrial) pressure, mean pulmonary artery
pressure (MPAP), and pulmonary artery wedge pressure (PAWP).
Then calculate stroke volume (SV), stroke volume index (SVI), systemic vascular resistance (SVR),
or pulmonary vascular resistance (PVR) using these formulas. For continuity, the same values for CO,
heart rate (HR), and SV will be used throughout the equations. Keep in mind that some monitoring
sys~ks compute these values automatically.
~F~~

~ Stroke volume
_~-I

To d~termine SV - the volume of blood pumped by the ventricle in one Example

contraction - multiply the CO by 1,000 and divide by the HR. Normal Here, the patient's CO is 5.5 Uminute
SV ranges between 60 and 130 mllbeat. and his HR is 805eatslminute .

Use this \
-~
'\.1
...,~~
(f,'-
.\[ co X 1,000 SV
.
= 5.5 X
80
1,000
equation to (' r .:'l~\SV
determine my
stroke volume.
\
'/ ~.
\!--/
//
HR SV = 5,500
80
"r"'-
~) '(
~ /
J SV = 68.75 ml/beat
,1'/-,\
,; d
(/ ,.
/1

~ Stroke volume index

To assess whether the patient's SV is adequate for his body size, com- Example
pute the SVI. Do so by dividing the SV by the patient's body surface area As we determined in the example
(BSA) or dividing his cardiac index eCI) by his HR. Normally, the SVI above, the patient's SV is 68.75 mil
ranges between 30 to 65 mllbeat'm2 of BSA. beat. His BSA is 1.64 m 2 and his CI
(calculated by dividing his CO by his
BSA) is 3 .35 Umin/m2.
Tell me the
truth ... is my SV
adequate for my
SV SVI = 68.75
size'? SVI 1.64
BSA SVI = 42 ml/beat/m 2
IF ~~ f V,.,UL
L~/ r'r
k}\illI ("
J~q:l ~ \ ,;., ) ~
or or

[~/~;; ~l ~ /~
i!J
CI SVI = 3.35
80
~ -~ ~, SVI
HR SVI = 0 .042 Llbeat/m 2
 Understanding cardiac output monitoring

lW. SY6:f;el11icva6cul(irre6i5tanC;~
To assess SVR - the degree of left ventricular resistance known as Exa:mple
afterload-deduct the central venous pressure (CVP) from the MAP. Herej:hepatieflt's MAP is 9,
Divide this value by the CO value. Then multiply by a rounded conver- CVP is 6~ CO remains 5.5.
sion factor of 80 to compute the value into units of force (dynes/sec/ 80 is the conversion factor,
cm -5). Normal SVR ranges from 770 to 1,500 dynes/sec/cm -5.
SVR = 93 --: 6 X"80
SVR == MAP_~ CVP X 80
5.5
Ifthe SVR = 6,960
"pressure" is 5.5
getting to you,
use a "MAP" like SVR = 1,265 dynes/sec/cm- 5
this equation to
get the answer.
Heh! I'm too
funny!

~ •
To measure PVR-or right ventricular afterload-deduct the PAWP Example
from the MPAP. Then divide the product by the CO value. To compute Here, the patient's MPAP
the value into units of force (dynes/sec/cm -5), multiply the result by 80. his PAWP is 5; his CO
Normal PVR values range from 20 to 200 dynes/sec/cm- 5.

MPAP - PAWP X 80 ') PVR = 2~.~ 5 X 80

PVR
CO Ir PVR = 1,200
5.5
Let's get this stra ight: to , ~ Ve PVR = 218 dynes/sec/cm- 5
get the PVR, you take the PAWP I)
I)
from the MPAP and divide by the \
CO and multiply by 80 . .A.aargh! \\\ \( -.i1'l<)~~
Oh, the pressure! I think I need
an equation - like this one! I
~.l~
--=-----""'- . ' '.; I : l:~'\~\
,",,,or
~ <~ ~ ~
V~/
.1(1\...
- Cardiac output monitoring
_ ~<'" "'"F'i2i ,"i'B0Ji9i!E!!jffil1ZE'

Calculating the cardiac index

Because it takes into account the patient's size, the cr is a more accurate indicator of CO. To calculate the
cr, divide the CO value by the patient's BSA. Normally, the cr ranges from 2.5 to 4 Uminute/m2 (of BSA).

HEIGHT BODY SURFACE AREA WEIGHT

Body surface area nomogram
2.80m2 To use the nomogram, locate the patient's height
cm200 79 inch 2.70 in the left column of the nomogram and her
78 kg 150 330lb
195 77
2.60
145 320 weight in the right column and use a ruler to
76 2.50 140 310 draw a straight line connecting the two points.
190 75 135 300
74 2.40 290
The point where the line intersects the surface
130
185 73
125
280 area column indicates the patient's BSA in square
72 2.30
270 meters.
180 71 120
2.20 260
70 115
175 69 250
2.10 110
68 240
170 67 105 230
2.00
66 The nomogram
1.95 100 220
165 65
1.90 210
shown here lets you
64 95
1.85 plot the patient's
160 63 200
1.80 90
62 height and weight to
1.75 190
155 61 85 determine the BSA.
1.70
60 180
1.65 80
150 59
1.60
58 75
145 1.55 160
57
56 1.50 70
150
140 1.45 ~" r-~
~\.\,
55
65 '\1 \
54 1.40 140
_ I _ I · ... f
135 53 1.35 II ""'" c-, l~ ~
I '-.., V
60
52 1.30
130 « r~,
If - r\

TJ
130 51

,1 jI
1.25 55 120
50
125 1.20
49
50 110

!I
\ \ )J1\
48 1.15
105
120 47 1.10 100
45
46
1.05 95
III
115 45
1.00 90
44 40
110 85
43 0.95
80
42
0.90 35
105 75
41
0.86m2
40 70
cm100
39in kg 30 661b
 rhermodilution method

Let's see, if I No more

Thermodilution take the CO and

the fA and
multiply it by
the ... Hmm, wa it
formulas-
just one word:
thermodilution.

method a minute ... ???

To measure CO using the thermodilution method, a quantity of I L )VV,---

solution colder than the patient's blood is injected into the right I ff -
\ ~
atrium through a port on a PA catheter. This indicator solution
mixes with the blood as it travels through the right ventricle into
(
the pulmonary artery, and a thermistor on the catheter registers
the change in temperature of the flowing blood. A computer then
plots the temperature change over time as a curve and calculates
flow based on the area under the curve.

A closer look at the thermodilution method

This illustration shows the path of the injectate solution through the heart during thermodilution cardiac output monitoring.

PA
catheter

The cooled blood

then flows into the
pulmonary artery,
and a thermistor
on the catheter
registers the
change in temper-
ature of the blood.

The cold injectate is

introduced into the
right atrium through
the proximal injec-
tion port of the PA
catheter.

The injectate solu -

tion mixes com-
pletely with the Left ventricle
blood in the right
ventricle.
Right ventricle
e Cardiac output monitoring

Thermodilution setup
Equipment and supplies used for the thermodilution method include a thermodilution PA catheter in position, an output computer and
cables (or a module for the bedside cardiac monitor), a closed or open injectate delivery system, a 1O-ml syringe, a 500-ml bag of normal
saline solution, and crushed ice and water (if iced injectant is to be used) .
Some PA catheters contain a filament that permits continuous CO monitoring. With these catheters , an average in the CO value is
determined over a span of 3 minutes and updated every 30 to 60 seconds . This type of monitoring enables close scrutiny of the patient's
hemodynamic status and prompt intervention if problems arise.
The newer bedside card iac monitors measure CO continuously, using an invasive or a noninvasive method. If your bedside monitor
doesn't have this capability, you'll need a freestanding CO computer.
~~'-
~

PA catheter prepared for

CO monitoring

TemperatlJre probe
l-
-r:..
!.\
Proximal lumen 1 " '
Injectate syringe

In FA catheters that
permit continuous CO
monitoring, an average
CO value is determined
over a span of 3 minutes (;
and updated every 30 to
60 seconds. Very
efficient!
~
.......:_",./
r
,,-'>

'"
1
Thermistor connector 1.----:-:--

a
 ThermodllutJon method _

Ij ust
love to see
everyth ing
working
together!
["1\
,..-{O-"

~-::-----------~h( ~ \~/'_-------
The big picture
~-? \ ~
~~) ~I:~~~~ \)/
/ ,=:'.::::.;.~ \~
J ~..J~J".J \
Sterile
injectate
solution
(" )
-, (" (
\-\ '1'- J-J
- 'f (
Nonvented
l.v. spike
Three-way stopcock and Balloon
continuous flush device inflation
Snap valve
clamp Temperature
10·ml probe
syringe

lnjectate
delivery tubing

CO computer

Catheter Thermistor
connecting
cable ==~ /
Proximal injectate port
 Cardiac output monitoring

Measuring cardiac output

Room-temperature injectate with a closed delivery system
• Connect the primed system to the stopcock of • Tum the stopcock at the catheter injectate hub
the proximal injectate lumen of the PA catheter. to open a fluid path between the injectate lumen of
• Connect the temperature probe from the CO the PA catheter and the syringe.
computer to the closed injectate system's flow- • Press the START button on the CO computer or
through housing device. wait for the INJECT message to .flash. Then inject the
• Connect the CO computer cable to the thermis- solution smoothly within 4 seconds, making sure
tor connector on the PA catheter and verify the that it doesn't leak at the connectors.
blood temperature reading. • If available, analyze the contour of the thermodi-
• Tum on the CO computer and enter the correct lution washout curve on a strip chart recorder for a
computation constant as provided by the catheter's rapid upstroke and a gradual, smooth return to
manufacturer. The constant is determined by the baseline.
volume and temperature of the injectate as well as • Wait 1 minute between injections and repeat the
the size and type of catheter. procedure until three values are 10% to 15% of the
• Unclamp the I.v. tubing and withdraw 5 ml of median value. Compute the average and record the
solution into the syringe. patient's CO.
• Inject the solution to flow past the temperature • Return the stopcock to its original position and
sensor to obtain the injectate temperature. make sure that the injectate delivery system is
• Verify the presence of a pulmonary artery wave- clamped.
form on the cardiac monitor. • Verify the presence of a pulmonary artery wave-
• Withdraw exactly 10 ml of injectate before form on the cardiac monitor.
reclamping the tubing.
When measuring
cardiac output, inject the
specified amount of
The inj ection injectant into the
should take no proximal port of the
pulmonary artery
longer than
catheter during end
4 seconds to expiration.
complete.
 Thermodilution method _ .

Iced injectate with a closed delivery system

• Place the coiled segment of the tubing into
the Styrofoam container and add crushed ice
and water to cover the entire coil.
• Let the solution cool for 15 to 20 minutes.
• Proceed as for the room-temperature
injectate with a closed-delivery system.
;' -../~"l,

Add crushed ice I ~

and water to cover ('<;t·y.~r? 'Y;
the tubing and let
it cool for 15 to 20 (~~~?l
minutes. Brrrr!
!~~
\.,,-", ;
~~.,I
Check the thermodilution curve on the
patient's monitor to make sure that the injection
was properly performed. You should see a
smooth, sharp rise in the curve. Repeat the
injection procedure at least 3 times to obtain a
mean cardiac output value.
If you want to
remember the benefits
of injectate at room
temperature and iced,
picture lemonade ...
If you want it to taste
like the refreshing drink
it is (a more accurate
taste), take it iced . If
you don't have time to
chip away with the ice
pick, ta ke it the
convenient way - room
temperature.
e Card;•• output mon;torin~

ride the wave

Analyzing thermodilution curves

The thermodilution curve provides valuable information about CO,
injection technique, and equipment problems. When studying the The larger the
curve, keep in mind that the area under the curve is inversely pro- area under the
The smaller the
portionate to CO: The smaller the area under the curve, the higher curve, the lower my
area under the curve,
the CO; the larger the area under the curve, the lower the CO. output. Wait ... 1
the higher my output.
Besides providing a record of CO, the curve may indicate prob- shou ldn't be
Hey, at least you have
lems related to technique, such as erratic or slow injectate instilla- smiling, should I?
more room!
tions, or other problems, such as respiratory variations or electrical
interference. The curves below correspond to those typically seen
.)v'-
in clinical practice. / Ii "'"
~ ~ .!, ~ =
t ¥VV(> (" I \

Normal thermodilution curve

0-\ c'; I.......
I\ \ ~~ r:~

l-!'~
With an accurate monitoring system and a patient who has ade- (' f' ~
~

,?
quate CO, the thermodilution curve begins with a smooth, rapid '"
i f '\.. ~)~
upstroke and is followed by a smooth, gradual dow nslope. The
curve shown below indicates that the injectate instillation time was
within the recommended 4 seconds and that the temperature r;;""-.. . .
...-' " i:\' II \\
curve retumed to baseline blood temperature.
The height of the curve wi ll vary, depending on whether you use
a room-temperature or an iced injectate. Room -temperature InJec-
h-I
y
~,
'\..'\..
~
/1
J/
\\\\
tate produces an upstroke of lower amplitude. '-
~ ~
Low CO curve
Injection A thermodilution curve representing low CO shows a rapid, smooth
upstroke (from proper injection technique). However, because the
heart is ejecting blood less efficiently from the ventricles, the injec-
~ tate warms slowly and takes longer to be ejected from the ventri -
::>
'§ cle. Consequently, the curve takes longer to return to baseline. This
Q)
Co
slow return produces a larger area under the curve, correspond ing
E __ to low CO.

~ Time

Injection

~
::>
'§
Q)
0..
E
~
Time
 thermodilution met;hod _

High CO curve Curve associated with respiratory variations

Again, the curve has a rapid, smooth ,upstroke from proper injec-
tion technique. But because the ventricles are ejecting blood too
forcefully, the injectate moves through the heart quickly and the
curve returns to baseline more rapidly. The smaller area under the
curve suggests higher CO.
Injection
To obtain a reliable CO measurement, you need a steady baseline
pulmonary artery blood temperatu re. If the patient has rapi d or la-
bored resp irations or if he's receiving mechanical vent ilation, the
thermodilution curve may reflect inaccurate CO values. The curve
shown below from a patient receiving mechanical ventilation re-
flects fluctuating pulmonary artery blood temperatures. The ther-
mistor interprets the unsteady temperatu re as a return to baseline.
The result is a curve erroneously showing a high CO (small area un-
der the curve). (Note: In some cases, the equipment senses no re-
turn to baseline at all and produces a sinelike curve recorded by
the computer as Q.QQ.)

!I lJl
~ Time

~
Injection

:::l
~
I-
m
Curve reflecting poor technique Q.
E
This curve results from an uneven and too slow (taking more than ~
4 seconds) administration of injectate. The uneven and slower than Time Respiratory variation
normal upstroke and the larger area under the curve erroneously
indicate low CO. A kinked catheter, unsteady hands during the in-
jection, or improper placement of the injectate lumen in the intro-
C'mon, Bob.
ducer sheath may also cause this type of curve.
Those curves
aren't going to )--1
Injection
go away by
themselves ! 6JJ
ltte~h\
j~l~
~ ~~Y;v ~W
--= I'
:::l , __ (J( ,~
i
tv,\
II "-
..../(
') , 1'\ '\ Vj'" i~
((..- ""/ -.;'~'..r i ~>
v

r l '\ \ \ ""I { ilre

~ ~ r. ·. ·~ )\t
cl' ( \ ( \ 1(1\ " ( '\
(/, \ \ \. , f
Time
~r:- I, \ , ) I i'~. ~ I.1~- /IPiit
'" "" ".,l>,-.\ k:.· ~ ~~,,('J-9.
-/(~f~,_~2:,r:~/~ "
1...
~ V '" ~1::--- t1!.-" =-
),;,>~ ~I
'@' '>., •
" - 'OJ ',' - -
-
l I>
~~.. " lJ~:J.iiI ~P _L.\
~ -'~
e Cardiac output monltorlne

Troubleshooting the cardiac output monitoring system

~

Problem Causes Nursing interven; ions

CO values lower than Injectate volume greater o Be sure to instill only the injectate volume that's appropriate for the
expected than indicated for computation constant (CG).
computation constant

Erroneous computation o Before injection, verify that the CC setting and the injectate volume are
constant (set too low) compatible.
o To avoid repeating the injection procedure, correct the CO value and
the CC setting. To do so, use this formula: CO w rong x CC right -0- CC
wrong = CO right. Then reset the monitor for the next serial injection,
using the correct CC.

Injectate lumen exiting in oConfirm proper placement of the injectate lumen by observing the
right ventricle monitor for right atrial waveforms.

CO values higher Injectate volume smaller o Before injection, verify that the injectate volume is correct for the
than expected than indicated for determined CC.
computation constant o Look for and expel air bubbles from the injectate syringe.

Erroneous computation o Before injection, verify that the CC setting and the injectate volume are
constant (set too high) compatible.
o To avoid repeating the injection procedure, correct the CO value and
the CC setting. To do so, use this formula: CO wrong x CC right -0- CC
wrong = CO right. Then reset the monitor for the next serial injection ,
using the correct CC.

Catheter tip too far into o Check catheter placement by obtaining a PAWP tracing. If the catheter
pulmonary artery is placed correctly, 1.25 to 1.5 ml of air w ill be necessary to obtain a PAWP
tracing.
o Reposition the catheter if necessary.

Left to right ventricular o Observe the PAWP tracing. A giant "V" wave indicates a ventricular septal
septal defect defect and resultant incorrect CO values.
o Prepare to use another CO monitoring method such as the Fick method.

f?\~\ Cardiac output that

(.~. Jh~ fal ls below or above the

mean can signal trouble.
\. .:7 JJ{ Fo llow these
') C· · , , ~
\~r~n!j~
troubleshooti ng steps to
avoid inaccurate
measurements.
,I \/
')
lVt '
--1\ \
~j\ fn-
r-

~ Thermodilution method _

.-
Problem Causes Nursing interventions

CO values deviating _ Arrhythmias, such as • Observe the electrocardiogram monitor while monitoring CO, and try to
at least 10% from premature ventricular instill injectate during a period without arrhythmias.
the mean (no pattern) contractions and atrial • Increase the number of serial injections to five or six, and average the
fibrillation values.
• If the arrhythmias continue, notify the doctor.

Catheter fling (turbulent,
erratic waveform resulting
from turbulence of blood
circulating around intrusive
catheter)
• Observe the waveforms, and reposition the catheter if necessary.
• If catheter fling doesn't decrease spontaneously after the catheter is
inserted or repositioned, increase the number of serial CO determinations.

Varying pulmonary artery • Obtain CO values when respirations are steadier and less labored.
baseline temperature • Minimize temperature variations by administering injectate during the same
(which causes drift during phase of the respiratory cycle each time you measure CO.
respiration) • Increase the number of serial injections.

Variations in venous return
(for example, from rapid
bolus administration of
drugs or fluids or from the
patient shivering, coughing,
• Avoid giving bolus injections of drugs or fluids just before measuring CO.
• If shivering accompanies a fever, notify the doctor.
• Avoid measuring CO until coughing and restlessness subside.

h ~dl\
~~.~ I
or being restless)

Inadequate signal-to-noise • To strengthen the signal, increase the injectate volume or lower the
- ~J ~'I r-i'" ratio injectate temperature (for example, by using iced injectate for patients with
,I ~l )IJ:"~JJ £ (1' hypothermia).
~ " JI--.~ 7 1\('''-- .J"'...
J~ ' '> , \ f J::::::' (;'
,-'"If .~. ~~ ~\ P/";-\ J) Poor Injection technique • Observe the upstroke on the thermodilution curve to detect an error in
~ 1\ ;.- {-~ 1 ':" f \'. injection technique.

~ .c::(';, r(IJ ;iji. 'L'l J[~'1(''-'J~ -1'~C::J;"'"4'

~~IIJ"'~ ~~ __ . • Use two hands to deliver a bolus injection quickly and evenly.
N /- >1 i..
-1"--(,1
II.::::::. ('::""?' ,~~
('~ ~fi>\;"
..
1::
- - _ , I :>

r
~ ~~))) (~" ~ ,- . ~
(-'> .~ ~ ~ ilO "
r./
{ j .,]0
1(/'0;"'\/
'1r"i Quiet down, students. I'm sorry
that you thought the cu rve I was
~ ~ i~4
q '~B )\- ,~~ ) talking about was ~~~ading curve. I
~:t~ h ~t~~ff1~~ was actua lly talking about a
thermodilution cu rve. You should
- /1
-~-=--=~~I
really learn what that is!

:fr ~i~
A. . . swevs: C"l"v lNIy w"vld. "Tt.-.e c"ld. i'tied'o..t'e is i. . . h"d.LAced. i. . .t-" t-t.-.e vi:;)t.-.t- O\hilAlNI t-t.-.v"IA:;)t.-.
t-t.-.e pv,,)<ilNlO\li'tiecH". . . p"vt-. "Tt.-.e" it- -Pl"ws i"t-" t-t.-.e vi:;)t.-.t- ve . . . hicle wt.-.eve it- lNIi)<es C"INI-
ple+-ely wit-t.-. t-t.-.e 'ol""d.. LO\sHy it- -Pl"ws i. . . t-" t-t.-.e plAllNI""o\vy O\vt-evy. Pt.-."t-" -Pi. . .ist.-. \. Hi:;)t.-. Co
clAvve,2. L"w Co ClAvve, >. ClAvve O\ss"clO\t-ed. wit-t.-. vespivO\t-"vy vO\viO\H" . . . s, 4. N"vINIO\1 clAVVe,
5. ClAvve ve-PlecH . . . :;) P""v t-ect.-."iqlAe.
'£
'g 'z
aW! l
If
'17 'L
aWll aW ll
~
I l/ If
 • Understanding
oxygen supply and
tissue demand 104
Shooting
this tearjerker
scene is going
• A closer look
to require some at 5a0 2 106
tissues! You'l l
learn about a
diffe rent kind of
• A closer look
tissue demand at 5v02 110
in this chapter.

• Vision quest 116

"-...
,i66ue oxygenation monitoring

Understa nd ing
oxygens' uppIy _______________
a nd t ISS Ue OXt~~;~ ~~~~ct Most of the

hemoglobin to

demand ~\) <i!J\

form
oxyhemog lobin.

Most oxygen (0, ) collected ;n the

lungs binds with hemoglobin (Hb) to
f\l·! t:I \,.,
, ~~\ ~ 1""
form oxyhemoglobin. However, a small ~~-~ -)["
portion of it dissolves in the plasma. '"""
The portion of oxygen that dissolves in the plasma can be measured as the par-
tial pressure of arterial oxygen in the blood (Pao 2).
After oxygen binds to Hb, red blood cells (RECs) carry it by way of the circu-
latory system to tissues throughout the body. Internal respiration occurs by cel-
lular diffusion when RECs release oxygen and absorb the carbon dioxide (C0 2)
produced by cellular metabolism. The RECs then transport the carbon dioxide
back to the lungs for removal during expiration.

Oxygen and carbon dioxide transport

w'" Und....tanding oxygen supply and "ssu. dema nd e
~~~~t~1[@%T1J@lli.@~~~
Venous oxygen reserve (Rv0 2) is the The amount of oxygen transported
amount of oxygen left over (not used to the tissues, Da0 2 , depends on two
by body tissues) that returns to the factors :
heart in venous blood. Rv02 depends • arterial oxygen content - the total
on two factors: amount of oxygen in the blood that 's
• arterial oxygen delivery (Da0 2) available to tissue cells
• oxygen consumption . • cardiac output - the amount of
Normal Rvo 2 ranges from blood pumped out of the heart per
700 to 800 ml O/minute, or minute.
450 ml 0 2/minute/ m2 based on Normal Da0 2 ranges from
body surface area (BSA). 900 to 1,000 ml 0 2/minute, or
600 ml 0 2/minute/m2 based on
BSA.

Oxygen con6um
The amount of oxygen used by the tissues in the body is called oxygen consumption. Oxygen consumption is de-
termined by three factors :
• oxygen demand (the cells' requ irement for oxygen)
• oxygen delivery (the supply of oxygen delivered to the tissues)
• transport of oxygen from the blood for use by the cells.
Normal oxygen consumption ranges from 200 to 240 ml O/minute, or 150 ml 02/minute/m2 based on BSA.
CD 11 ••ue oxygenat;on mon;toring

A closer look at Sao2

Arterial oxygen saturation (Sao 2), expressed as a
percentage, represents the actual amount of oxygen
bound to Rb divided by the maximum amount of
oxygen that could possibly bind to Rb. Because Rb
carries most of the blood's oxygen, a normal Sao2
level is 95% to 100%. Pulse oximetry is a noninva-
sive, real-time estimation of the oxygen saturation
of Hb in arterial blood.

How the body responds

To maintain normal tissue

oxygenation and avoid hypoxia,
the body needs to compensate
for these conditions. Let's see
what can happen ... I increase my

_
output to
quickly deliver An increased
....... An increased amount
more blood to extraction of
of hemog lobin can help,
! . .. .~~ body t issues! oxygen from

~ill~.~I~
'E("
too. However, it might be
systemic capil laries
too slow of a process to
helps out!
benefit those who are
acutely ill.
,J ~ -, ",)~-

~
')'--
~l ~}f~~\ y"""'?
--
"I~

ri\
(-
' "'
) ,\ f\..
!L-~~ \I / ( \)(~\\
h~
/
i\j
(""
\ \ ",/"

/ ~' ,// I 'S \

\~)r"- ~ / ! ~(

~~
'\
(;--/"'\
)J
. )1 ~"

\ \ ~
 A closer look at 5a02 e
How pulse oximetry works
Performed intermittently or continuously, oximetry is a simple procedure used to monitor arterial oxygen saturation noninvasively.
Pulse oximeters usually indicate arterial oxygen saturation values with the symbol Sp02' whereas invasively measured arterial
oxygen saturation values are indicated by the symbol Sao2 ,
In pulse oximetry, two light-emitting diodes (LEOs) send red and infrared light through a pulsating arterial
vascular bed such as the one in the fingertip or the earlobe, A photodetector slipped over the finger or No bones about
earlobe measures the transmitted light as it passes through the vascular bed, detects the relative it, Pulse oximetry
amount of color absorbed by arterial blood, and calculates the exact arterial oxygen saturation, can calculate the
exact level of
arterial oxygen
LEOs
saturation
without
interference from
venous blood, skin,
tissue - or even
bone!

Photodetector
//'~
~ (., 0,;"',/
,,J
,
(\~ );7"'
Oximeter monitor
~\,
\. " ~~ "
~~'~

~:-. " ,i~~

..' r-Y "",. .~',.F"~~
'.:-,.--=~
..,." \. ""'-; -c::::::___ 1.

~\
~ ,j~. <:sf . . \ ." ,," ,' '"

~\:l; -,~.F . ~ff

.;JP
r: '-1;W~
\. . ·'" C'\."W':-"'f)
'~~'z&~J\
1~( !(
Photodetector
L'j
k
r
I, )

(flJ
\

r\ ~
Oximeter
connector

-~ ~~\~ ~'ll!;;j~'
20~/-
t;t
;ili;'W ,. '{!'$.' r :~" ";,;4j;;
~~,
±illi~<l"
~ 'liJ:m ~:.
e 1155ue oxygenation monitoring ~_ __
\
• ,1
~}I"
How to use pulse oximetry ') ,...-'
~"~\l
c::::r .~
,_ . I.{ ~ '\ ·;
~/.,/ ~:~\~~
I '/;'.. t~\· f
J /I
L
~
IRM~;;,z~.~~~
''''

\ ,~ ~
Finger probe !f
}
If
< '
(
I J 1
! Turn' on the power switch. If the
devi<5e is working proPerly, a.
beep will sound, a display will
light momentarily, and the pulse
neonate or a small
searchlight will flash. The 8p02
infant, wrap the
Select one finger for the test. Although the index finger is CGmmonly (indicating arterial oxygen satu-
probe around the
used, a smaller finger may be selected if the patient's fingers are too rcation by pulse oximetry) and
foot so that light
large for the equipment. Make sure the patient isn't wearing false fin- pulse rate displays will show
beams and detec-
gemails, and remove nail polish from the test finger. Place the trans- stationary zeros. After four to
tors oppose each
ducer (photodetector) probe over the patient's finger so that light six heartbeats, the 8p02 and
other. For a large
beams and sensors oppose each other. If the patient has long finger- pulse rate displays will supply
infant, use a probe
nails, position the probe perpendicular to the finger, if possible, or information with each beat, and
that fits on the
clip the fingernail. Always position the patient's hand at heart level to the pulse amplitude indicator
great toe and se-
eliminate venous pulsations and to promote accurate readings. will begin tracking the pulse.
cure it to the foot.

Ear probe prQGeQure,

remevethe
el;lr Rrobe,
place fGlr :3 or m6re min-
frum efland
utes until readinfjS sfabi-
Following the manufacturer's instructions, attach the ear probe to the patient's unplug the
lize at the highest point,
earlobe or pinna. Use the ear probe stabilizer for prolonged or exercise testing . unit, and
or take three separate
Be sure to establish good contact on the ear; an unstable probe may set off the clean the
readin\ls and average
low -perfusion alarm. After the probe has been attached for a few seconds, a probe by
them.
saturation reading and pulse waveform will appear on the oximeter's screen . gently ruobing
it with an
alcohol pad.
 A cl05er look at 5a02 e
Clean and dry! [f t he skin Obtai ning a
To maintain a becomes irritated signal can also be a
Troubleshooting continuous from adhesives used problem with pulse
the pulse disp[ayof to keep disposab le oximeters. [f this
arterial oxyg en probes in place, happens, first check
oximetry saturation levels, change the oximetry the patient's vita l
system the monitoring site. You can also Signs. [f they're
site must be replace disposable suffic ient enough to
When using pulse oximetry to
clean and dry. probes that irritate produce a signa l,
measure arterial oxygen
the skin with use the chart below
saturation, there are several
nondisposab[e to check f or
problems that can be avoided
models. pro blems and
~~~n
or fi xed following good clinical
intervene.
practice. , . '<. u
\ ",, 1
'"9 . '
~~rnm~ t' ~~,

rm mt441 !~~~ if" ;~"!-.

~h ;<' f j
l' / ' ./
tnmiAl4i4iit1!4 1/ ./
<,I ~ \ ~fl.~ \""' ~
Certain factors can interfere ~d !{
~ \ \
'-~~ ) rv.,
r"""; r~ _
'(r\I\\ I
with the accuracy of oximetry

if;fil
li£P.lil;
6 ~\ Vf"~-t\, ""g:i£.
t.~. \~
bilirubin levels (whicH \ '.
~I ?E9'~,,>,\
-!'~/. ,,,x.....
~ lower oxygen satura-
ilt.".i¥i.i',w;aI'i.ttiij.I#)I,I.#I
@!1!lIII!lJ1"t¥\!u¥1lu·wwm.e
IM,.lllImi¥J·tmd
» ~~
\ \" \

o Intravascular substances, sucli

m;Gi~';i,[lJI·];iOOi.t!IiP Problem Interventions

ibl-==
patient movement, o~ ear pigment
Poor connection • Check that the sensors are aligned properly.
• Make sure that wires are intact and fastened securely and that
the pulse oximeter is plugged into a power source.

Vasoconstriction
Some acrylic nails and certain
titi1i,'mmmrmOOQi'i¥Eli¥I§ij,
lijl$1iUW,.G]l!1ldAi$l!Il
Inadequate or • Check the patient 's pulse rate and capillary refill time, and
intermittent take corrective action if blood flow to the site is decreased .
blood flow to Such action may include loosening restraints, removing
the site tight-fitting clothes, taking off a blood pressure cuff, or
checking arterial and r.v. lines.
• If none of these interventions works, find an alternative site.
Finding a site with proper circulation may also prove
challenging when a patient is receiving vasoconstrictive drugs.

Equipment • Remove the pulse oximeter from the patient, set the alarm
malfunctions limits according to your facility's policies, and try the instrument
on yourself or another healthy person. Doing so will tell you
w hether the equipment is working correctly.
e T;55Ue oxygenat;on mon;toring

A closer look at S\i02

After oxygen is delivered to the tissues,
some remains attached to Hb and returns to
the heart in venous blood. Mixed venous
oxygen saturation (8v02) is the oxygen sat-
uration of Hb in venous blood that returns
to the heart from the tissues. Normal 8v02
levels are also expressed in percentages,
ranging from 60% to 80%. 8v02 levels are de-
termined by tissue oxygen consumption
and cardiac output (the amount of blood
pumped out of the heart per minute) .
.,..r.J?, Arterial blood with oxygen-saturated Hb
1CfI/\ (normally 96% to 100% saturated) is deliv-
~1o ~~'\ ered to body tissues, where cells extract

/(r~\Jt~\)
and use about 25% of this oxygen. Then the
blood passes into venous circulation, now
~ {~'\:.fty with Hb only 60% to 80% saturated with

I~..:·. j
.

(\~\ \
\
1\\'-. .; 1
oxygen because the cells have taken about
25%. This venous blood is returned to the
heart, where 8v02 mea-

\.{~ surements are made in

the pulmonary artery. OK, easy does

i>0- -[I 8v02 measures the oxy-

gen saturation of Hb in
the venous system that
it. I can give you
about 25%. The
rest goes back to
I i{ returns to the heart the heart.

I ~5{1
1
(after the cells have con-
sumed what they need).

( l.,r ........
,-~'-....~
C:.. _ _
---"}

"
 A clo..r look at 5Vo2 0
Factors affecting 5vo 2
The patient's 8v0 2 level alone isn't useful information. The balance between available oxygen and tissue consumption
depends on other factors, such as cardiac output, 8a0 2, and Hb levels on the supply side and tissue oxygen needs on
the demand side. Any change in the patient's 8v0 2 level typical ly reflects a change in one or more of these factors.

Increase SV0 2

Increased cardiac
output can increase
SV0 2 levels? I cou ld have ...NVl.J
..... ,'-
told you that! Now, ~-.... '. ~r
onto the next page ... I '\
\. ~. ~ .\
\: ~' :-" -::<•.•'
\~ ~\i,~4
_'\~ ~~/ .

( ~)'
~ ~~ ( ¢
?f~-' .... :./.d.~

j ·~ ~?)."
'!"I~i"c ,---",,)0 \. ,. '-
,,-,",../ (v-' r
 Tissue oxygenation monitoring

OK, I think I'm quite

0 2 monitoring satu rated now! But
what I th ink t hey're
Sm 2 monitoring uses a fiberoptic thermodilution pulmonary artery (PA) discussing here is
caIheter to continuously monitor oxygen delivery to tissues and oxygen con- oxygen saturation !
smnption by tissues. Monitoring of 8v02 allows rapid detection of impaired
oxygen delivery, as from decreased cardiac output, Hb level, or 8a02 . It also
helps evaluate a patient's response to drug therapy, endotracheal tube suction- F"\ g {----.
- g, \'entilator setting changes, positive end-expiratory pressure, and fraction I o.\~~ \
of inspired oxygen. "" / r. t J'--~ J \
J-I . \(~ " 1 0 \~ i?=
"'> ~..>.JJ~ j~~!~ \it
5v0 2 monitoring equipment ---.--r----- J--..... ~

......
 -
A closer look at 5;;0 2 e
Troubleshooting the system
If the intensity of the tracing is low:
• ensure that all connections between the catheter and oximeter are secure
• ensure that the catheter is patent and not kinked.
If the tracing is damped or erratic:
• try to aspirate blood from the catheter to check for patency (if allowed by your
facility)
• if you can't aspirate blood, notify the doctor so that he can replace the catheter
• check the PA waveform to determine whether the catheter has wedged; if the
catheter has wedged, tum the patient from side to side and instruct him to cough;
if the catheter remains wedged, notify the doctor immediately.

ride the wave

Normal Svo 2 waveform

Const ant lines
This traCing represents a stable, normal 8 v0 2 level: higher than 60% and are no good for
lower than 80%. Note the relatively constant line. surfing, but t hey're
great f or Si,i02
waveform s!
/:'~)i:\
k~~
l,J~~
""'-./', ( X)~, Il.~
~
7-
;::,'-.I.~ ."-
-'i'
~-( ~
-"'\\

11111 T4
/ .J
~/---l ?
'\ \,,,,~
\\ ') I tZ'~ ______ ----.
.)~-/-r
''- r-S
100%
,,----
.
~ ~
- -- .=-·" ---7
8 ~OI ~~ ....1/ItItItAA. .................. _~ ... _ _ .... . - .

UfO" .~r""'~-ttI\IIV-
...,....... •••••., .......
..". W-~Y--"'
z...r ... -
- ...

~
60% ··

40%

20%

o
o 15 30 45 60 75
Minutes
_ 11 ••ue °><Yeen.t;on .......' ... ,T- ~=':"=:.~~~~~~__~...:.-.....:...................................~~...................:.......IllIIIll11_

ride the wave

Abnormal waveforms

Knowing these
waveforms will Because a patient's Sli0 2 level may change almost immediately af-
make it easier to ter intervention, the subsequent levels can help you determine the
spot abnormal _J\I It intervention 's effectiveness. This tracing shows a rise in Sli0 2 levels

),;'
trends! and cardiac output (CO) after the patient has received IV nitro-
I
\ prusside (Nitropress).

100%
~ \
('; ~ l
,
. 90
.~~ ') ~
. ~/Il t~
"i.i,,~ / - " -
80
CO = 3.23 Uminute
ifi". / 70 Nitroprusside:
}} I
,- ' ) 0.5 mcg/kg/minute
((--'11 60
4 J~ 50

The first tracing shows a falling venous oxygen saturation (Sli0 2) 40

level in a patient returning from the operating room after coronary
artery bypass surgery. Notice the event marks that indicate atrial 30
pacing and the cardiac index (CI) at about 1 hour, 15 minutes;
20
administration of a vasoactive drug; the patient's plotted response;
and his subsequent return to the operating room. 10 f I I I I I 1
o 15 30 45 60 75 90
100%
From operating room Minutes
90

80
t Atrial CI = 1.7 Uminute/m'2:

70

60

50

40
CI = 1.5 Uminute/m 2 T
To operating room
30

20

10 f I
o 2
Hours

.-
 A closer look at 51'0 2 _

This tracing represents the patient's response to a muscle relaxant. i

tor settings. Note that increasing the positive end-expiratory pres-
100% sure (PEEP) causes an increase in S1I0 2; therefore, the fraction of
inspired oxygen (FI02 ) can be decreased .
90
100%
80 Flo? decreased

70
90
~~
I -
PEEP
~ Vecuronium (Norcuron) 6 mg
80
increased
~ . ~
60
-
50 . 70

60
40
50
30
40
20
30
10 I I
o 2 20
Hours
10 I I I I I I I
o 15 30 45 60 75 90
Minutes

This waveform shows typical changes in the SV0 2 level as a result

Boy, there's a lot
of various activities.
to learn about
100% abnormal waveforms.
I'm glad we had
90 these visuals!
80

70

60

50

40

30

20

10 r T T T T T 1
o 15 30 45 60 75 90
Minutes
% % %
100 100 100
90 90 90
m
80 80
m~ m~
80 r ~
60 v.......~~
50 ~
60
50
r
sr;: 60 %J
50 __~#-
f _____
...J.

40 40 40 --~V------
~ ~ ~
20 20 20
10 I I I 10 I i I 10 I i i i i i i
o 1 2 0 1 2 0 15 30 45 60 75 90
Hours Hours Minutes

1. 2. 3.

% % %
100 - - - - - - - - 100 - - - - - - - - 100 - - - - - - - - -
90 - - - - - - - - 90 - -- - - - - -
80 - -- - - - - -
70 - - - -- - - -
80~
70 -~-----~
~~
70 ~~------
T?':~
60,,-- ~ 60 - - - - - - - - 60 - - - - - - - - -
50 ......... ..... J" 50 - - - - - - - - 50 - - - - - - - -
40 v 40 - - - - - - - - 40 - - - - - - - -
30 - - - - - -- - 30 - - - - - - - - 30 - - - - - - - -
20 - - - - - - - - 20 - - - - - - - - 20 - - - - - - - -
10 I i i iii i 10 I i i iii 10 I Iii I i I
o 15 30 45 60 75 90 0 15 30 45 60 75 o 15 30 45 60 75 90
Minutes Minutes Minutes

4. 5. 6.

1. Dao 2 A. partial pressure of arterial oxygen

2. Sao 2 B. arterial oxygen delivery
3. Svo 2 C. venous oxygen reserve
4. Pao 2 D. arterial oxygen saturation
5. Rvo 2 E. mixed venous oxygen saturation

'J 's 'V 'v '~ 's I CI ..z 'g ' 1 Aa>O\"'WI'1.: :> -I"'W 'sG\\!-\-\a>S AI>-I
-"'l!-I"a>i'\ "! a>G"",'1':::> 1>-1 a>S"I>dSa>A -I"a>!-I"'d " 'WlAI>d"a>i'\"'1'<\ -Zo~> l"'WlAI>N 's '-IYid-lYil> ':::>"'!I"A"'':::> 1""'"
Sla>i'\a>l -Zo~> "! a>S!~ 'v 'Sa>!-I!i'\!-t.:::>'" SYil>!A"'i'\ d"I> -IlYiSa>A '" S'" la>i'\a>l -Zo~> a>'1-1 "! Sa>G"",'1':::> l"'.:::>!dA.L
's 'la>i'\a>l -Zo~> G"!ll"';j ..z '-I""'>/"'Ia>A a>eSYiWl '" 0-1 a>S"OdSa>A -I"a>!-l"'d "I lla>-I 1""'" 1'<\0'1> :SAa>I'<\S"V

..ill
 Understanding
• •
noninvaSive
Argh ... a hemodynamic
Doppler or
ultrasound will
monitoring 118
help you
track heart Esophageal Doppler
fun ctioning , but
neither wil l help hemodynamic
me find me pi rate
treasu re! (So am
monitoring 119
I in cha ract er, or
what ?!) • Impedance
cardiography 124
• Ultrasound cardiac
output
measurement 131
II Vi&i'9t1 qU86't ~2 ~ ====1
 Understa nd ing
• •
nonInvasIve
hemodynamic
monitoring
Although invasive hemodynamic monitoring using a
pulmonary artery (PA) catheter remains the gold
Did som eon e
standard for clinical practice, noninvasive monitoring say gold? Oh, you
techniques are proving to be reliable, safe options were referrin g to
that yield results that correlate with PA catheter th e gold standa rd
readings. of usi ng a PA
Noninvasive hemodynamic monitoring techniques cathete r for
don't involve puncturing the patient's skin or inserting hemody na mic
catheters. Current systems are easy to use, can be monit oring.
applied in many clinical settings, and
provide reproducible results.

~~'\\-~
.",--

\.
~

(
\

rc.- \1--____ _____=_

,~) ) .. --~
\ I
I I

). (/
- . -1

~-. ;--, ..... ~- . - Qt _ _011- ~)

(.-l!l:!@n""ItJA,-' tL- _ I!
'- 'Rr

.
....._ _ _ _ _ _ _ _ _ _ __ _ _ _ ~_ _E_6_0_p_h=a~g_e_a_1 D
_ oppler hemodynamic monltodng e
Esophageal Esophageal Doppler

Doppler hemodynamic monitoring can

keep track of five hemodynamic
values - not bad for a minimally
invasive monitoring system!

hemodynamic
monitoring
Esophageal Doppler hemodynamic monitoring is a minimally invasive
method of using ultrasound to measure heart function. It involves placement
of a probe into the esophagus. By measuring blood flow through the heart
valves or ventricular outflow tracts, this monitoring system can monitor:
• cardiac output
• stroke volume
• cardiac index
• systemic vascular resistance
• systemic vascular resistance index.

Indications and contraindications

This type of monitoring is appropriate for: It isn't recommended for patients:
It2l'sedated, critically ill patients with difficult fluid ~ undergoing intra-aortic balloon pump
management counterpulsation
It2l'use during and after cardiac surgery. ~ with severe coarctation of the aorta
~ with a disorder of the pharynx, esophagus, or
stomach
~ with a bleeding disorder.

Pros and cons of esophageal Doppler hemodynamic monitoring

Pros Cons
• It's minimally invasive. ~. .. It's difficult to-align the ultrasou nd' beam with the-flow of
• It allows for immediate evaluation of hemodynamic status in blood. (If the beam isn't properly angled , the results aren't
the doctor's office, emergency department, or operating room. - -reliable.) - '-
..- - ' - - - - .;;m"",,'
• It allows for periods of activity or exercise without the risk of _~•....!!5arries t ~sk~sophagea l da~ e"£!:'p erforati~
dislodging invasive lines. • The patient may require sedation because of the stiffness
__ofthepwbe. _ _ _ _ _ _ _ _ _ _ __
e Noninvasive homodyo"""c monitoring ~" . "

Transducer probe placement

Transducer probe placement for esophageal Doppler hemodynamic monitoring is similar to inserting a nasogastric or orogastric tube, and
typically can be performed by a nurse at the bedside. However, the patient usually requires sedation for this procedure because the probe
is rigid .
The stiff probe is lubricated and then inserted nasally or orally to a depth of 14" to 16" (35.5 cm to 40.5 cm). Each probe has depth
markers to demonstrate appropriate depth placement. The probe can be taped in place or left unsecured to allow for adjustments (if the
patient is sedated). When the probe is positioned properly, it's ready to measure blood flow in th e descending thoracic aorta.

First, the transducer

probe is lubricated . It can
then be inserted nasally or
orally. Oral placement is
shown here.

Depth markers on the

probe enable easy
insertion to a depth of
35.5 to 40.5 cm.
r

The nurse can typical ly

perform the insertion of a
E50phagea1PoI'PI "r hemodynamic monitoring 0
transducer probe. However, the
patient usual ly requires sedation.

The probe can then

~
- "'\'t' r~j _-;:;--_~'1Jf~
~,/<.J~.
be secured with tape or
left unsecured (if the

@~~ .. ))...:1) ~I\U!!

~~~l~
(O.:'·~l J tlI~
!?I.!)
patient is sedated).
"' . ~I
'.J'})--\~, .I........
'''- f'Ti ~~~_Jr' I
•

/4
I I
/ tq\.jr-,,_~_~
r}~~~ ,
) .( " "'-"""""-,
I ~-rI;
'->
I--~~~/~."'i)
I 'I'
~-:'. l

, - - - - - - - - - - - - - Tip of probe Depth markers at

35.5 cm and 40.5 cm
Esophagus
o Non;n...;ve hemodynam;c_ ~~~:~ '"

ride the wave

Esophageal Doppler
hemodynamic monitoring waveform
This normal waveform shows good capture of blood flow. Key aspects of the waveform include peak velocity and
systolic blood flow in seconds corrected for heart rate.

This waveform
is picture
perfect. It shows
good capture of
I ~, blood flow.
I} ! on the level ~-;':,

.»

1.1J:!l Normal values in esophageal Doppler

!~
hemodynamic monitoring
Parameter Normal values

Flow time, corrected (the time in seconds of systolic 330 to 360 milliseconds
blood flow, corrected to heart rate)

eak velocity (the velocity of the blood measured at the 20 years: 90 to 120 em/ second
peak of systole) 50 years: 60 to 90 em/second
70 years: 50 to 80 em/second
 Eoophageal Doppler hemodynamic monitoring 0
A closer look at the monitoring system
Th is monitor automatically measures such values as heart rate. peak velocity (PV). flow time corrected (FTc). and more. Other hemody-
namic monitoring parameters are then derived from these direct measurements. including cardiac output. cardiac index. stroke volume.
stroke volume index, and systemic vascular resistance.

Flow time
Peak velocity Cardiac output Cardiac index Stroke volume Heart rate
corrected

Th is sa mple
mon it or screen is an
example of one type
of esophagea l
Doppler hemodynam ic
mon itoring system.
fa
Impedance cardiography
Impedance cardiography provides a noninvasive alternative for tracking hemodynamic status. This
technique provides information about a patient's cardiac index, preload, afterload, contractility, cardiac
output, and blood flow by measuring low-level electricity that flows harmlessly through the body from
electrodes placed on the patient's thorax. These electrodes detect signals elicited from the changing
volume and velocity of blood flow through the aorta. The signals are interpreted by the impedance
monitor as a waveform. Cardiac output is computed from this waveform and the electrocardiogram.

Monitoring equipment for

impedance cardIography
To begin impedance cardiography, assemble the impedance cardio-
graphy monitor, printer, and disposable sensors .

Printer
.------~
IMonitor

Automatic blood
pressure cuff
'"'' Impedance caoJiogmphy 0
Impedance
card iography is
harmless and
noninvasive. So
there's nothing
to impede you
from using it.
Ach ach ach! I'm
a stitch!

-~/ r"
J~'<\"J /
~- l ' I ~. <-,\
( \ ) . , \{
:o '"o .
1
~(

v"
./ ",I.
> , ,..

.~~ *,..r'~~,
~
\ /
..r'
,-,

Indications for
impedance
cardiography
Impedance cardiography helps monitor
patients who wou ld have a high risk of
complications from thermodilution
monitoring. Because of its portability,
the impedance cardiography unit may
be used in the operating room , post-
anesthesia care unit, and intensive care
unit.
However, baseline impedance cardio-
graphy values may be reduced in
ati~itieFls-GAara
terized by increased fluid in the chest,
such as pulmonary edema and pulmo-
nary effusion. Also, impedance cardio-
graphy values may be lower than
thermodilution values in patients with
tachycardia and other arrhythmias.
 e Nonlnva.lve hemodynamic monitoring

Impedance
Impedance cardiography electrode placement cardiography uses a
low-voltage electric
This illustration shows proper placement of the four pairs of electrodes needed for impedance current to detect
cardiography. This system uses a low-voltage current to detect resistance (impedance) resistance, or
to the current between electrodes. impedance, to the
current between the
electrodes. Whoo! Okay,
no resistance here!

....
~
s.~~J( '"
~!
. &:;.4 )vC-r'\ ~
.' (V l, '-'i'-~J),
f ~' 1'~1 J. 7/.
Outer
~,p \(i?,
electrodes I( ( \ l3
transmit \\ ('j )'
current ~\ :::I)

\'<t/
(r-" ~
V' ~

•"
The outer The inner
waters move me waters are
along with the going to cause
current. me some
resistance!

- (

'<~~:<.r
~ :-. ~_...l\ (J, 'D...-"'~
" ""~
\' l ((!"\11~~~
~' ~~,,-

':c./~""
- .~'-~
.
\it
~ ~~~
 Noninva6ive hemodynamic monitoring
.G' ~

Using the impedance cardiography monitor

To use the impedance cardiography monitor, plug it in and tum on
the power. The welcome display screen should appear. If neces-
sary, enter the basic patient data as prompted by the monitor. The
START MONITORING screen should appear.
Before initiating monitoring, advise your patient to remain still. Then
press the START MONITOR key. Evaluate the signal strength on the
screen to make sure that at least three green lights appear on the
impedance cardiography and electrocardiogram (ECG) signal bars.
A beep should also be audible as each R wave appears on the
ECG screen.

i~
strength
indicators

Electrodes should
be replaced every
Lastly, note the waveforms and values on the monitor and document the values by printing a report.
24 hours during
continuous impedance
cardiography
monito ring.
 Imp••anc. cardlO<!raphy 0
Understanding hemodynamic indices
After you connect your patient to an impedance cardiography monitor, you can easily obtain
the hemodynamic data needed to determine his stability and plan treatment and care.
With an impedance cardiography monitoring unit, you can measure these values:
Loo k at all
cardiac index: cardiac output (CO) divided by body surface area, these indices!
Just shows how
which puts CO in perspective for the patient's size
va lua ble a tool
cardiac output: the volume of blood pumped through the heart impedance
(measured in Uminute) ca rdiography
is for
dZ/dt: indicator of peak flow hemodynamic
monitoring!
ejection fraction (EF): volume of blood ejected from the left
ventricle in a single myocardial contraction (expressed as a percentage)
end-diastolic volume (EDV): volume of blood in the left ventricle at
the end of diastole; also known as the preload volume (measured in
milliliters)
heart rate (HR): number of heartbeats in 1 minute
~ '/
left cardiac work index (LeWI): reflection of myocardial oxygen \.A
consumption
1(. / II
I ('(15
preejection period (PEP): time between the onset of ventricular
activity and the opening ofthe aortic valve (measured in seconds)
C;/ \ \
stroke volume (SV): amount of blood pumped from the ventricle with
each myocardial contraction (measured in milliliters) III I J
systemic vascular resistance (SVR): resistance against which the
)aff \
L1t~
left ventricle pumps
ventricular ejection time (VET): amount of time that blood is
flowing out of the ventricles
Zo: base impedance, or the amount of resistance met by the electric
current passing through the thorax. If'
\ l
i

~j-
.,/~..:;),,~
-.....~;
.... -~--
o Noninva.ive hemodynamic monitoring

ride the wave

Understanding the impedance cardiography waveform

A waveform produced by an arterial pressure monitoring system is based on pressure. Although a waveform
produced by impedance cardiography is similar, it's based on the volume and velocity of aortic blood flow.
It captures the electrical impedance of pulsatile flow that's generated by every heartbeat. The components
of an impedance cardiography waveform are shown below.

ECG

Delta Z

dZ/dt

Unl ike arteria l pressure I don't think

monitoring, wh ich is based it's supposed to
on pressure, impedance be that kind of
cardiography is al l about volume.
Key volume and velocity!
Q = Start of ventricular depolarization ,>\.)V'-
~ I ~,..

~
~~~. \/~
'{~~~
B = Opening of pulmonic and aortic
valve
C = Maximal deflection
\ '1!J (-
X = Closure of aortic valve J ~ ( :'I>. Iit\ ( \ ~ - ,::-
Y = Closure of pulmonic valve __I- M~\!~ \ J t.l }
~\r--~~,~ \ ,YW
1\'+·:( to.J'V1W
o b

~ t) '~~
= Mitral opening snap/rapid filling
of ventricles

~.;J.., ; f' ,,/ l(~

L
~' ~'J / _ tJ~

...
 Ultrasound cardiac 0

Ultrasound cardiac
output measurement
Ultrasound cardiac output measurement (USCOM), a new technology developed by USCOlr I "" "'->1.
continuous wave Doppler ultrasound to evaluate heart function. This entirely noninvash-e SJSf.
the Doppler ultrasound at two anatomic areas:

1 the suprasternal notch to evaluate the left side of the heart by looking at aortic valve blood fioK
2 the left sternal edge to evaluate the right side of the heart by looking at pulmonic valve bloodfiOK
Parameters measured by USCOM include cardiac output, cardiac index, stroke volume, heart rare. ~loc­
ity time integral, minute distance, ejection time percent, peak flow velocity, and mean pressure gradient.

USCOM monitor
This illustration displays the work FIl.E I MODE ;\CONTROl.s !1 VSCOM
screen of an ultrasound cardiac
output measurement (USCOM)
monitor. This monitoring system is
produced by USCOM Limited.

( )
~

@W
a:. .-. _--..I --.~
A.v..sweys: Coloy lMy woylJ. AH'e y llA'pYic",tlv..3 tl-\e \-lA'pe, lv..sey\- l\- el\-l-\ey v..",s",l1y Oy oy",l1y \-0
\-l-\e "'ppYOpYl",\-e J.ep\-l-\ lM",ykey. -rl-\e tip o{! \-l-\e pyo'pe sl-\olAIJ. lle lv.. tl-\e esopl-\"'3lAS, posteYl-
Oy \-0 \-l-\e l-\e",y\-. Pic\-lAye llMpey{!ec\- Coyyec\- e1ec\-YoJ.e pl",celMev..t lS sl-\owv.. lv.. #3.
'17
.~
 o Understanaing
circulatory assist
devices 134
. IABP
counterpulsation 135
Ventricular assist
Chapter 10:
Last take! Then
devices 145
it's a wrap!
• Vision quest 148
 devices

Understa nd ing
circulatory
assist devices
Circulatory assist devices support or aid the heart's pumping ability in
patients with heart failure. These devices improve blood flow to the myo-
cardium and the rest of the body, while reducing myocardial workload.
Such devices include intra-aortic balloon pump counterpulsation and
ventricular assist devices.

A treadmil l is a
circu latory assist
in my book ... it
really gets the
heart pumping!
)U
V v(,
( Q) (-\
I l,\
\ ~ l
(7"\r" 'tJ
'f:~__\~' ~D
\~
, 'j&Ji.~
IllL~~~h
~~ \~--:q
I , .-
0'--~~
., '-'~"'I. !-~-.~ -"..~o!.-(9)
'~t~~;L-- -m

IABP counterpulsation
Providing temporary support for the heart's left
ventricle, intra-aortic balloon pump (IABP) coun-
terpulsation mechanically displaces blood within
the aorta by means of an intra-aortic balloon at-
tached to an external pump console. The balloon
is usually inserted through the common femoral
artery and positioned with its tip just distal to the
left subclavian artery. It monitors myocardial per-
fusion and the effects of drugs on myocardial
function and perfusion. When used correctly,
IABP improves two key aspects of myocardial
physiology: It increases the supply of oxygen-rich
blood to the myocardium and decreases myocar-
dial oxygen demand.
The doctor may insert the
ba lloon percutaneously
through the femoral artery
IA6P counterpulsation e
Indication6 for IABP counterpul6ation
Intra-aortic balloon pump (IASP) counterpulsation is
recommended for patients with:
• refractory anginas
• ventricular arrhythmias associated with ischemia
• pump failure caused by cardiogenic shock, intraoperative
myocardial infarction (MI), or low cardiac output after bypass
surgery
• low cardiac output secondary to acute mechanical defects
after MI (such as ventricular septal defect, papillary muscle
rupture, or left ventricular aneurysm)
• a suspected high-grade lesion (used peri operatively for
those who are undergoing such procedures as angioplasty,
thrombolytic therapy, cardiac surgery, and cardiac
catheterization).
IASP counterpulsation is contraindicated in patients with:
• severe aortic insufficiency
• aortic aneurysm
• severe peripheral vascular disease.

"iF, into the descending thoracic

aorta, using a modified
( .;J Seldinger techn ique.
Insertion of the intra.. aortic balloon
'l(
fj ~*•.(~,
' ·' ffi, ,.,.~f.'l>\
=t;: \ ~
<•" ) t.c.
l"7!-l . ~.~ \

JII~~~
~ . '\
~~Irr·· . ~
the control
tl1@ballocJF1 over
system to
t8~iglJic;le wire
initiate

1 1/ f
intQ tFi!,) intro-
oounterpul-
l!!ue-er~fieath,
t
L , the doctor ad-
sation. The
balloon

(,~
over the guidewira
t2tnetI:Jr into
into the vessel tlnti( then unfurls.

b-~
dilator over the
passes the about 1" (2.5cr'h) em)
guide wire into
guide wire remains above the
the vessel, he elisfalto the left
First, the doctor insertion site. He
through the subclavian
accesses the ves- removes the
needle and then removeS tJ:le "ftl;l"" liIDrlAr flu-
sel with an 18G vessel dilator,
removes the inner dilator, leaving
angiography needle leaving the
needle. the introducer
and removes the guide wire in
sheath and, gUide
inner stylet. place.
wire in place.
__ Circulatory •••I.t device.
~

Surgical insertion sites for the intra-aortic balloon

If an intra-aortic balloon can't be inserted percutaneously, the doctor will insert it surgical ly, using a femoral or transthoracic approach .

--
-
-: ~!#]41
-::~5
'oach ~ ~~1t0
Insertion throug h the femoral artery req uires a cutdown and an If femoral insertion is
arteriotomy. The doctor passes the balloon throug h a Dacron graft unsuccessful , the doctor
that has been sewn to the artery. may use a transthoracic
approach . He inserts the
Dacron graft balloon in an antegrade
direction through the
Femoral artery
subclavian artery and then
positions it in the descend-
ing thoracic aorta.

Subclavian artery

Descending
thoracic aorta

How the intra-aortic balloon pump works

Made of polyurethane, the intra-aortic balloon is attached to an external pump console by means of a large-lumen catheter. The illustra-
tions here show the direction of blood flow when the pump inflates and deflates the balloon.

BaJloon deflation
The balloon inflates The balloon deflates
as the aortic valve before ventricular
closes and diastole ejection , when the
begins. Diastole aortic valve opens.
increases perfusion This deflation permits
to the coronary ejection of blood from
arteries. the left ventricle
against a lowered re-
sistance. As a result,
aortic end-diastolic
pressure and after-
load decrease and
cardiac output rises.
 ____.......___ ~........_ ______~ IABP counterpulsation
A ba lloon with A bal loon with
e
increased inflation decreased inflation
increases perfusion decreases aortic end-
to the coronary diastolic pressure and
arteries. afterload.

ride the wave

Interpreting IABP waveforms

During IABP counterpulsation, you can use electrocardiogram (ECG) and arterial pressure waveforms to
determine whether the balloon pump is functioning properly.

Normal inflation"deflation timing

Balloon inflation occurs
after aortic valve closure;
deflation occurs during
isovolumetric contraction,
just before the aortic valve
opens. In a properly timed
waveform such as this
one, the inflation point lies
at or slightly above the
dicrotic notch. Both infla-
tion and deflation cause a
sharp V. Peak diastolic
pressure exceeds peak
systolic pressure; peak
systolic pressure exceeds
assisted peak systolic
pressure.
Peak Inflation Peak Balloon aortic Dicrotic Assisted Patient aortic
systolic point diastolic end-diastolic notch peak systolic end-diastolic
pressure pressure pressure pressure pressure
 With IABp, t iming
is everyth ing. Early
Circulatory assist devices
or late inflation or
deflation can
endanger the
patient. Check out
these waveforms to
learn how to spot
IABP problems!

Early inflation
With early inflation, the
inflation point lies before
the dicrotic notch. Early
inflation dangerously
increases myocardial
stress and decreases ii.....

cardiac output.

Peak Inflation Assisted Dicrotic

systolic pOint peak systolic notch
pressure pressure

Early deflation
With early defiation,
a U shape appears and
peak systolic pressure is
less than or equal to
assisted peak systolic
pressure. Early deflation
won't decrease afterload
or myocardial oxygen
consumption.

Peak Balloon aortic Patient aortic Assisted

systolic end-diastolic end-diastolic peak systolic
pressure pressure pressure pressure

iIJ
 For some reason , after reading
this page, I fe lt the urge to hit the IABP counterpulsation _
amusement park and ride some
roller coasters. Now what would
have made me think of that ... ?

Late inflation
With late inflation, the
dicrotic notch precedes
the inflation point, and the
notch and the inflation
point create a W shape.
Late inflation can lead to a
reduction in peak diastolic
pressure, coronary and
systemic perfusion
augmentation time, and
augmented coronary
perfusion pressure.

Dicrotic Inflation Peak

notch point diastolic
pressure

Late deflation
With late deflation, peak
systolic pressure exceeds
assisted peak systolic
pressure. Late deflation
puts the patient at risk by
increasing afterload,
myocardial oxygen
consumption, cardiac
workload, and preload.

Peak Balloon aortic Assisted Patient aortic

systolic end-diastolic peak systolic end-diastolic
pressure pressure pressure pressure
o Circulatory •••I.t devl."",

ride the wave

Heart rate and blood pressure effects

on IABP waveforms
Changes in heart rate and blood pressure cause changes in the width and height of the balloon pressure plateau
of the IABP waveform, as shown in these illustrations.

~l1ange5 in heart rate

Variations in heart rate affect the width of the balloon pressure plateau. Note: If the w idth of the balloon pressure plateau isn't consistent
with the patient's heart rate, there may be a significant error in timing.
~--------------- r" --...
Bradycardia The balloon '\ Tachycardia I The balloon
pressure plateau is pressure plateau is
w ide in patients with narrow in patients
bradycardia. w ith tachycardia.

DI
I---+.------+------r--tj/
./ ],

1
t-------fI-~
~
i
~f-+---+-~

1
\
jI
~
, \ ~

...... ~
.........
~
.......
-- I
-
~
 Circulatory assist devices

ride the wave

Abnormal IABP / -",_/-' /;-::"V~-'.I"\ _ J

-"~ ' - / \. / \~ ) -/'
waveforms '\ -'\/

"""~ / /
'~£~~/
I su re don't
§ W
l4i"
like hearing ~ f..;q~
\ ~r~( } ~ But look at the
about low
ball oon press ure ( c~ )If~?' beautiful hi ll s, pastures,
,,..J,"'~f'-..;t2('1~\ and waveforms below!
at a moment
\, ! i~
like t his, ; \\1, Ill ' ~
~§.~)}i~

Abnormality Waveform Causes

Low balloon pressure plateau • Hypotension

• Hypovolemia
• Low systemic vascular resistance
• Balloon that's too small for the aorta or low balloon in-
flation volume
• Positioning of balloon too low in aorta

t 1(d a1100n pressure ba~e;ine -;~~r~sio~ - l('l"-Wl . Helium leak ------ ~ _~ L - -

/ "'l. • Inappropriate timing settings -----

~ • Mechanical defect

~
~i..§''''''''~
-(
~.r <
l.n r ~ ('t
" ~~' ~ ~"\.
 ~ ~~'=
IABP co unte~"
~ t ~

................~~==~~--
.
'~2&
,; ) u 05)
~. ~
Wondering 7.....z: -:;c
\...) V er }J ~ do if t here's .. ~-:::;;:.=­
Troubleshooting an IABP ~(' lltp with an lAB?? .. c:' ~

~~(J~r\ jJ.) we've got the c/5i:::-S

fo ryot..!
\~I \V/
\./\ .. ,J!"-J
Problem Possible causes Interventions

High gas leak Balloon leakage or abrasion • Check for blood in the tubing.
(automatic mode only) • Stop pumping.
• Notify the doctor to remove the balloon.

Condensation in extension • Remove condensate from the tubing and volume limiter
tubing , volume limiter disk, • Refill, autopurge, and resume pumping.
or both

Kink in balloon catheter or • Check the catheter and tubing for kinks and loose connections:; sbG.ljloial
tubing and tighten any found.
• Refill and resume pumping .

Tachycardia • Change wean control to 1:2 or operate on "manual" mode.

• Autopurge the balloon every 1 to 2 hours, and monitor the balloon
pressure waveform closely.

Malfunctioning or loose • Replace or tighten the disk.

volume limiter disk • Refill, autopurge, and resume pumping.

System leak • Perform a leak test.

Balloon line block (in Kink in balloon or catheter • Check the catheter and tubing for kinks and loose connections; straighten
automatic mode only) and tighten any found.
• Refill and resume pumping.

Balloon catheter not • Notify the doctor immediately to verify placement.

unfurled; sheath or balloon • Anticipate the need for repositioning or manual inflation of the balloon .
positioned too high

Condensation in tubing, • Remove condensate from the tubing and volume limiter disk.
volume limiter disk, or both • Refill , autopurge, and resume pumping.

Balloon too large for aorta • Decrease volume control percentage by one notch.

Malfunctioning volume • Replace the volume limiter disk.

limiter disk or incorrect • Refill, autopurge, and resume pumping. Continued . . .
volume limiter disk size

No electrocardiogram Inadequate signal • Adjust ECG gain, and change the lead or trigger mode.
(ECG) trigger
Lead disconnected • Replace the lead . t~- l
----------------------------------------------------------------~~> ~
Improper ECG input mode • Adjust ECG input to appropriate mode (skin or monitor). ~ !I', ~
(skin or monitor) selected (\,¥i=8 !
/
N ,
l~
t ('v !
 Circulatory assist devices

Continued here.

Problem Possible causes Interventions

o atri al pressure Arterial line damped • Flush the line.

bigger
Arterial line open to • Check connections on the arterial pressure line.
atmosphere

Trigger mode change Trigger mode changed • Resume pumping.

w hile pumping

Irregular heart rhythm Patient experiencing • Change to R or QRS sense (if necessary to accommodate irregular
arrhythmia, such as atrial rhythm).
fibrillation or ectopic beats • Notify the doctor of arrhythmia.

Erratic atrioventricular Demand for paced rhythm • Change to pacer reject trigger or QRS sense.
(AV) pacing occurring when in AV
sequential trigger mode

Noisy ECG signal Malfunctioning leads • Replace the leads.

• Check the ECG cable.

Electrocautery in use • Switch to atrial pressure trigger.

Internal trigger Trigger mode set on internal • Select an alternative trigger if the patient has a heartbeat or rhythm.
80 beats/ minute • Keep in mind that the internal trigger is used only during cardiopulmonary
bypass or cardiac arrest.

Pu rge incomplete OFF button pressed during • Initiate autopurging again , or initiate pumping.
autopurge; interrupted
purge cyc le

High fill pressure Malfunctioning volume • Replace the volume limiter disk.
limiter disk • Refill, autopurge, and resu me pumping.

Occluded vent line or valve • Attempt to resume pumping.

• If unsuccessfu l, notify the doctor and contact the manufacturer.

No balloon drive No volume limiter disk • Insert the volume limiter disk, and lock it securely in place.

Tubing disconnected • Reconnect the tubing.

• Refill , autopu rge , and pump.

Incorrect timing INFLATE and DEFLATE controls • Place the IN FLATE and DEFLATE controls at set midpoints.
set incorrectly • Reassess timing and readjust.

Low volume Volume control percentage • Assess the cause of decreased volume, and reset (if necessary).
percentage not 100%
r

Ventricula' a55;5t dev;ce5 0

A VAD is commonly

Ventricular assist used as a bridge to

heart transplantation.
It is a far, far better
place I go than I have

devices ever been ...

>vUl
A ventricular assist device (VAD) is implanted to provide support to a failing ~ l.J r"'-;Y<,
heart. The device consists of a blood pump, cannulas, and a pneumatic or \( ~ "' "\
electrical drive console. VAD can provide systemic and pulmonary support. \ ) )EfF )
VADs are designed to decrease the heart's workload and increase cardiac "'~l!:<1"=/.~
~
' . /. _~
...
output in patients with ventricular failure. They're commonly used as a bridge .. ~
m ,;.
~~ • ,\'1.
to cardiac transplantation. VADs are also indicated for use in patients with:
J
~0.,.-~
• cardiogenic shock that doesn't respond to maximal pharmacologic therapy ~~...~
.\, ,~~~
• inability to be weaned from cardiopulmonary bypass.
~~~~},\~'--­
/f)~("j~
/ ,
I
..... ;

Left VAD

Shoulder strap Aorta

Diaphragm

External battery pack

Blood pump

Access device ~~ J ~:r--

 Several options
Circulatory assist devices exist for how to
place the VAD.

Procedure A closer look

Insertion of a VAD involves a specific surgical proce-
dure, in which blood is diverted from a ventricle to at VADs
an artificial pump. The diversion is created by insert-
ing a cannula into either the atria or ventricles that
directs blood to the pump. This pump, which is syn-
chronized to the patient's electrocardiogram, then
functions as the ventricle.

Implantable VADs
The typical VAD is implanted in the upper abdominal Placing the VAD
wall. An inflow cannula drains blood from the left
VADs divert blood from failing ventricles to a pump that can
atrium or ventricle into a pump (part ofthe VAD),
effectively eject it. This diversion can occur by cannulation of
which then pushes the blood into the aorta through either the atria or the ventricles. These illustrations show
the outflow cannula. some of the cannulation options that exist.
A continuous
Pump options synchronized
flow ... it may not
LVAD
VADs are available as con- be as graceful
tinuous flow or pulsatile as ba llroom
pumps. A continuous flow dance, but it's
pump fills continuously beautiful just
and returns blood to the the same!
aorta at a constant rate. A
pulsatile pump may work

r'~.·
in one of two ways:
l\'~" r
1It may fill during systole -)·,r-~~
IU(J~0-'?~~ Blood

I~~
and pump blood into the flows
aorta during diastole. 'Z.~;: .~;:;< from left
\ atrium
\
aorta
to LVAD
2 It may pump regard-
less of the patient's car-
diac cycle.
I'

Potential !J
f~
complications
Despite the use of anticoagulants, the VAD may
cause thrombi formation, leading to pulmonary em-
bolism or stroke. Other complications include heart
failure, bleeding, cardiac tamponade, or infection.
 Ventricular a •• I.t d.~c.. _

There are three types of ventricu lar assist devices (VADs) :

A right VAD (RVAD) provides pulmonary
support by diverting blood from the right
atrium or failing right ventricle to the VAD,
which then pumps the blood to the pul -
monary circulation via the VAD connection
to the left pulmonary artery.
With a left VAD (LVAD), blood flows from When an RVAD and LVAD are used, it 's
the left atrium or ventricle to the VAD, referred to as biventricular (BiVAO)
which then pumps blood back to the body support.
via the VAD connection to the aorta.

BiVAD BiVAD

RVAD
pumps
blood to
pulmonary
rrrn '"-.
"
"
.
'.
.:

". '.
~~':sd
from left
atrium
to LVAD
RVAD .
pumps
artery" . Blood blood to
flows LVAD pulmonary
from left pumps artery
ventricle blood
to LVAD to aorta Blood
flows from
LVAD right
pumps atrium to
blood RVAD
to aorta
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N 0 31 ~ 1d ~ V0 d A3 ~~ V 1 11 V J 1 '17
--5 ---.- 5 -
N 10 J N 311 d '£
- 5 -----5 ----5 -
~ 3 d ~ n1 n NV~ 3 ~ 9 n A 0 J I ~ V1 'z
- 5 ----- ---5 --
3~vdl1n V~3H1 '~
id9VI U~ uo
>J~91 G~~ 4~!4 ~ JO 9Gn~Q 9ltJ!GGod ~ G,~~4M :UO!~G9nt>
.~
1---' ,-
\
.#-'

Selected references
Adams, K.L. "Hemodynamic Assessment: The Physiologic Basis for Turning Data
into Clinical Information," AACN Clinical Issues 15(4):534-46, October-
December 2004.
Albert, N.M. "A 'Current' Choice for Hemodynamic Monitoring, " Nursing2004
34(10):58-60, October 2004.
Alspach, J.G. (Ed.). Core Curriculum for Critical Care Nursing, 6th ed.
Philadelphia: w.E. Saunders Co., 2006.
Baird, M., et al. Manual of Critical Care Nursing, 5th ed. St. Louis: Mosby-Year
Book, Inc., 2005.
Cardiovascular Care Made Incredibly Easy. Philadelphia: Lippincott Williams &
Wilkins, 2005.
Critical Care Nursing Made Incredibly Easy. Philadelphia: Lippincott Williams
& Wilkins, 2004.
Darovic, G.O. Handbook of Hemodynamic Monitoring, 2nd ed. Philadelphia:
w.E. Saunders Co., 2004.
Dulak, S.B. "A PA Catheter Refresher Course," RN 66(4): 28-34, April 2003.
Dulak, S.B. "PA Catheters. What the Waveforms Reveal," RN 66(9):56-63,
September 2003.
Earsing, K.A. , et al. "Best-Practice Protocols: Preventing Central Line Infection,"
Nursing Management 36(10):18-24, October 2005.
Mastering A CLS, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2005.
McKnight, S. "Nurse's Guide to Understanding and Treating Thrombotic
Occlusion of Central Venous Access Devices," Medsurg Nursing 13(6): 377-82,
December 2004.
Morton, PG., et al. Critical Care Nursing: A Holistic Approach, 8th ed.
Philadelphia: Lippincott Williams & Wilkins, 2004.
Nursing Procedures, 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2004.
Stillwell, S.B. Mosby's Critical Care Nursing Reference, 4th ed. St. Louis:
Mosby-Year Book, Inc., 2006.
Turner, M.A. "Doppler-Based Hemodynru'1lic Monitoring: A Minimally Invasive
Alternative," AACN Clinical Issues 14(2):220-31, May 2003.
Woods, S.L. , et al. Cardiac Nursing, 5th ed. Philadelphia: Lippincott Williams &
Wilkins, 2005.

Chapter 4
Close look at an arterial pressure monitor-
ing system, pages 40 and 41. LifeART im-
age, Lippincott Williams & Wilkins.
Credits
Chapter 8
Oxygen and carbon dioxide transport,
pages 104 and 105. From Premkumar, K.
The Massage Connection Anatomy and
Physiology. Philadelphia: Lippincott
Williams & Wilkins, 2004.

Chapter 6
Components of the PAP monitoring sys-
tem, page 70. From Smeltzer, S.C., and
Bare, B.G. Brunner and Suddarth's Text-
book of Medical-Surgical Nursing, 9th ed.
Philadelphia: Lippincott Williams & Wil-
kins,2000.
A closer look at the wedged position, page
77. From Morton, PG., et al. Critical Care
Nursing: A Holistic Approach, 8th ed ..
Philadelphia: Lippincott Williams & Wil-
kins,2005.
Chapter 9
Monitoring equipment for impedance car-
diography, pages 124 and 125. Photos by
Gary Donnelly.
Preparing the patient for impedance car-
diography, page 127. Photos by Gary Don-
nelly.
Using the impedance cardiography moni-
tor, page 128. Photos by Gary Donnelly.

We gratefully acknowledge Anatomical

Chapter 7 Chart Company for the use of selected
Body surface area nomogram, page 92. images.
Reprinted with permission from Geigy
Scientific Tables, 8th ed., vol. 5, p. 105.
© Novartis, 1990.

A closer look at the thermodilution

method, page 93. LifeART image, Lippin-
cott Williams & Wilkins.

Thermodilution setup, page 95. From Mor-

ton, PG., et al. Critical Care Nursing: A
Holistic Approach, 8th ed. Philadelphia:
Lippincott Williams & Wilkins, 2005.

A indications for, 42
Afterload, 15
effects of, on heart, 15
Air embolism
as arterial pressure monitoring compli-
cation, 50
as central venous pressure monitoring
complication, 64-65
Allen's t est, 30
Alveolar-capillary membrane, diffusion
across, 6
Alveoli, 2, 5,6, 7
Anacrotic limb on arterial waveform, 43
Anaphylactic shock, systemic vascular
resistance and, 13
Anemia, systemic vascular resistance
and, 13
Anesthesia, mixed venous oxygen satura-
tion level and, III
Aorta, 8
normal pressure in, 9
Aortic arch, 8, 9
Aortic stenosis, arterial waveform and,
44-45
Aortic valve, 11
pulmonary artery wedge pressure
and, 77
Arterial catheter. See also Arterial line.
assessing insertion site of, 31
choosing insertion site for, 29
dressing insertion site of, 31
immobilizing, 31
Arterial diastolic pressure, 42
Arterial embolism as intra-aortic balloon
pump counterpulsation complication,
141
Arterial line. See also Arterial catheter.
Allen's test and, 30
displaced, how to handle, 48-49
immobilizing extremity for, 31
insertion sites for, 28
advantages and disadvantages of, 29
Arterial oxygen delivery, 105
Arterial oxygen saturation, 106
body's response to, 106
elevated, mixed venous oxygen satura-
tion level and, 111
factors that affect, 106
monitoring, 107-109
reduced, mixed venous oxygen satura-
tion level and, 111
Arterial pressure monitoring
abnormal waveforms in, 44-45
characteristic waveform in, 43
complications of, 49-51
contraindications for, 42
displaced arterial line in, 48-49
Index
Arterial pressure monitoring (continued)
normal parameters in, 42
system components for, 40-41
uses for, 42
zeroing system in, 46-47
Arterial spasm as arterial pressure moni-
toring complication, 51
Arterial systolic pressure, 42
Arterial waveform
abnormal, 44-45
normal, 43
Arterioles
blood circulation and, 12
pulmonary perfusion and, 5
Artifact, troubleshooting, 24-25
Atria, 8, 9
central venous catheter pathway and, 58
injectate pathway through, in cardiac
output monitoring, 93
normal pressures in, 9
phlebostatic axis and, 20
pulmonary artery catheter advancement
into, 72
pulmonary artery pressures and, 76
pulmonary artery wedge pressure
and, 77
Atrial kick as cardiac cycle event, 11
Atrial systole as cardiac cycle event, 11
Atrioventricular node, 10
a wave, 60, 62
Axillary artery as catheter insertion site,
28,29
B advantages and disadvantages of, 33
Bachmann's bundle, 10
Bacteremia as pulmonary artery pressure
monitoring complication, 82-83
Basilic vein as catheter insertion site, 32
advantages and disadvantages of, 33
central venous catheter pathway and, 59
Biventricular assis t device, 147
Bleedback as pulmonary artery pressure
monitoring complication, 82-83
Blood circulation, 12
Blood loss as arterial pressure monitoring
complication, 50
Body surface area nomogram, 92
Brachial artery as catheter insertion
site, 28
advantages and disadvantages of, 29
Bradycardia, effects of, on intra-aortic
balloon pump waveforms, 140
Breathlng, mechanics of, 4
Broviac catheter, 56-57
Bundle branches, 10
Bundle of His, 10
C
Capillaries. 2, 5, 6. 7, 12
Carbon dioxide rransport, 104-105
Cardiac conduction system, 10
Cardiac cycle. 11
Cardiac fimctiOD
correlating cenrral venous pressure
with.. 5-5
measuring, 90-91
Cardiac index.. calculating, 92
Cardiac Output. 1,1
causes of changes in, 89
decreased, mixed venous oxygen satura-
tion level and, 111
increased, mixed venous oxygen satura-
tion level and, 111
methods for measuring, 88-99
systemic vascular resistance and, 13
ultrasound measurement of, 131
Cardiac output monitoring, 88
dye dilution method of, 88-89
Fick method of. 88-89
thermodilution method of, 93-99
troubleshooting problems with, 100-lOl
Cardiac system. 8-15
Cardiac veins, 9
Cardiogenic shock. mixed venous oxygen
satunationleveland, III
Cardiovascular circuit, 12-13
Carotid artery, 9
Central venous catheter, 54
changing dressing for, 37
insertion sites for, 32
pathways for insertion of, 58-59
patient positioning for insertion of, 36
percutaneous technique for inserting, 34
surgical cutdown technique for inserting,
34
types of, 56-57
Central venous pressure measurements
correlating, with cardiac function, 55
measuring, with water manometer, 63
obtaining, with pressure monitoring
system, 55
Central venous pressw-e monitoring, 54
abnormal waveforms in, 62
catheter pathways for, 58-59
catheters used for, 54, 56-57
complications of, 64-65
intermittent versus continuous, 54
normal values in, 61
normal waveform in, 60
synchronizing, with electrocardiogram
tracings, 60
obtaining measurements with, 55
purpose of, 54
water manometer and, 63
 Index
Chemical paralysis, mixed venous oxygen
saturation level and, 111
Chordae tendineae, 8
Chylothorax as central venous pressure
monitoring complication, 64-65
Circulatory assist devices, 134-147
Cirrhosis, systemic vascular resistance
and, 13
Contractility, 15
Coronary arteries, 8, 9
Coronary vessels, 9
D blood circulation and, 12
Dead-space ventilation as cause of
ventilation-perfusion mismatch, 7
Diaphragm,4,5
Dicrotic limb on arterial waveform, 43
Dicrotic notch on arterial waveform, 43
Diffusion, 4, 6
Dorsalis pedis artery as catheter insertion
site, 28
advantages and disadvantages of, 29
Dye dilution method of measuring cardiac
output, 88-89
dZ/dt, 129
E Hickman-Broviac catheter, 56-57
Ear probe for pulse oxinletry, 107, 108
Ejection fraction, 129
Electrocardiogram tracings, synchronizing
central venous pressure waveform
with, 60, 62
End diastole on arterial waveform, 43
End-diastolic volume, 129
Esophageal Doppler hemodynamic moni-
toring, 119-123
contraindications for, 119
indications for, 119
normal values in, 122
pros and cons of, 119
system for, 123
transducer probe placement in, 120-121
values monitored by, 119
waveform in, 122
Expiration, 4, 104
External jugular vein as catheter insertion
site, 32
advantages and disadvantages of, 33
patient positioning for, 36
F electrode placement for, 126
False-high readings, troubleshooting, 24-25
False-low readings, troubleshooting, 24-25
Femoral artery as catheter insertion site,
28,29
Femoral vein as catheter insertion site, 32, 33
Fick method of measuring cardiac output,
88-89
Finger probe for pulse oximetry, 107, 108
Fluid volume, increased, preload and, 15
G cation, 50
Gas exchange
alveoli and, 2
respiration and, 4, 5, 6
Groshong catheter, 56-57
H Internal jugular vein as catheter insertion
Heart
afterload and, 15
anatomy of, 8
preload and, 15
Hematoma as arterial pressure monitoring
complication, 51
Hemodynamic measurements, effects of
position changes on, 21
Hemoglobin
decreased, mixed venous oxygen satura-
tion level and, 111
increased, mixed venous oxygen satura-
tion level and, 111
oxygen-saturated, 104-105, 106, 110, 111
Hemothorax as central venous pressure
monitoring complication, 64-65
Hickman catheter, 56-57
Hydrothorax as central venous pressure
monitoring complication, 64-65
Hypertension, effects of, on intra-aortic
balloon pump waveforms, 141
Hypotension, effects of, on intra-aortic bal-
loon pump waveforms, 141
Hypothernlia
mixed venous oxygen saturation level
and,111
systemic vascular resistance and, 13
Hypovolemia
afterload and, 15
preload and, 15
systemic vascular resistance and, 13
Hypovolemic shock as displaced arterial
line complication, 48, 50
UK
Impedance cardiography, 124-130
benefits of, 124
components of waveform produced by,
130
hemodynamic values measured with, 129
how to use monitor for, 128
indications for, 125
mechanics of, 124
monitoring equipment for, 124-125
preparing patient for, 127
Implantable ventricular assist device, 146
Infection
as arterial pressure monitoring compli-
as central venous pressure monitoring
complication, 64-65
Inferior vena cava, 5, 8, 9, 32
Inspiration, 4, 104
site, 32
advantages and disadvantages of, 33
central venous catheter pathway and, 59
patient positioning for, 36
Internodal tract, cardiac conduction and,
10
Intra-aortic balloon pump counterpulsa-
tion, 135-144
abnormal waveforms in, 142
balloon deflation in, 136, 137
balloon inflation in, 136, 137
complications of, 141
effects of blood pressure changes on
waveforms in, 141
effects of heart rate changes on wave-
forms in, 140
indications for, 135
inserting balloon for, 135, 136
interpreting waveforms in
for early deflation, 138
for early inflation, 138
for late deflation, 139
for late inflation, 139
for normal inflation-deflation tinling, 137
mechanics of, 136
purpose of, 135
troubleshooting problems with, 143-144
Intracardiac pressures, normal, 9
Intrapulmonary airways, structure of, 2
Intrathoracic pressure, influence of, on
pulmonary mtery pressure monitor-
ing,80-81
Isovolumetrics in cardiac cycle event, 11
l
Left cardiac work index, 129
Left ventricle, 5, 8, 9
normal pressure in, 9
systemic vascular resistance and, 13
Leveling the transducer, 20-21
Lungs, 2, 3, 12
M
Mean arterial pressure, 42
Mechanical ventilation, pulmonary artery
pressure values and, 81
Mitral valve, 8, 11
pulmonary artery wedge pressure and,
77
 Index

Mixed venous oxygen saturation, 110
abnormal waveforms for, 114-115
factors that affect, 111
levels of, 110
monitoring, 112
troubleshooting system for, 113
normal waveform for, 113
purpose of, 112
Multilumen catheter, short-term, 56-57
Multiple-pressure transducer systems, 18
N monitoring complication, 82-83
Neurogenic shock, systemic vascular
resistance and, 13
Noninvasive hemodynamic monitoring,
118-131
o
Optimally damped system, waveform
produced by, 23
Organs, delivery of blood to, 12
Overdamped system, waveform produced
by, 23, 84
Overwedging, 79
waveform in, 79
Oxygen consumption, 105
Oxygen transport, 104-105
Oxyhemoglobin, 104
PQ
Partial pressure of arterial oxygen in the
blood, 104
Patient positioning
for central venous or pulmonary artery
catheter insertion, 36
for subclavian vein access, 36
Percutaneous technique for catheter inser-
tion, 34, 35
Peripherally inserted central catheter,
56-57
Peripheral resistance, 42
Pheochromocytoma, systemic vascular
resistance and, 13
Phlebostatic axis, determining, 20
Pneumothorax as central venous pressure
monitoring complication, 64-65
Position changes, effects of, on hemo-
dynamic measurements, 21
Preejection period, 129
Preload, 15
effects of, on heart, 15
Preload volume, 129
Pressure monitoring system
components of, 18-19
leveling the transducer in, 20-21
multiple measurements and, 18
square wave testing in, 23
troubleshooting, 24-25
zeroing the transducer in, 22, 46-47
Pressure readings, inaccurate, as arterial
pressure monitoring complication, 51
PR interval, 60
Pulmonary arteries, 5, 6, 7, 8, 9
blood circulation and, 12
injectate pathway through, in cardiac
output monitoring, 93
normal pressures in, 9
pulmonary artery catheter advancement
into, 73
ruptured, as pulmonary artery pressure
Pulmonary artery catheter, 68-69
insertion sites for, 32, 71
advantages and disadvantages of, 33
mixed venous oxygen saturation moni-
toring and, 112
patient positioning for insertion of, 36
percutaneous technique for inserting,
34,35
surgical cutdown technique for
inserting, 34
thermodilution cardiac output monitor-
ing and, 93, 94, 95
wedged position for, 77
Pulmonary artery diastolic pressure, 76
Pulmonary artery pressure monitoring, 68
candidates for, 71
catheter insertion for, 71
catheter used for, 68-69
complications of, 82-83
contraindications for, 71
diastolic pressure in, 76
influence of intrathoracic pressure on,
80-81
mechanical ventilation and, 81
normal parameters in, 75
normal waveforms in, 74
during catheter advancement, 72-73
special precautions for, 71
spontaneous breathing and, 80
system components for, 70
systolic pressure in, 76
troubleshooting problems with, 84-85
Pulmonary artery systolic pressure, 76
Pulmonary artery wedge pressure monitor-
ing,77
influence of intrathoracic pressure on,
80-81
mechanical ventilation and, 81
overwedging in, 79
waveform in, 79
pulmonary artery catheter position
during, 77
spontaneous breathing and, 80
taking reading in, 78
waveform in, 78
Pulmonary embolism as pulmonary artery
pressure monitoring complication,
82-83
Pulmonary infarction as pulmonary artery
pressure monitoring complication,
82-83
Pulmonary perfusion, 4, 5
ventilation and, 6, 7
Pulmonary system, 2-7
Pulmonary vascular reSistance, 5
calculating, 91
Pulmonary veins, 5, 6, 7, 8, 9
blood circulation and, 12
Pulmonic valve, 11
pulmonary artery pressures and, 76
pulmonary artery wedge pressure
and, 77
Pulse oximetry
factors that interfere with accuracy
of, 109
mechanics of, 107
troubleshooting problems with, 109
using ear probe for, 107, 108
using finger probe for, 107, 108
Pulse pressure, 42
Pulsus altemans, arterial waveform and,
44-45
Pulsus paradoxus, arterial waveform and,
44-45
Purkinje fibers, 10
Pwave,60
R
Radial artery
Allen's test and, 30
as catheter insertion site, 28, 29
Respiration, 4-6
Right atrial pressure mOnitoring. See
Central venous pressure monitoring.
Right ventricle, 5, 8, 9
injectate pathway through, in cardiac
output monitoring, 93
pulmonary artery catheter advancement
through, 72
pulmonary artery pressures and, 76
S
Sedation, mixed venous oxygen saturation
level and, 111
Seizures, mixed venous oxygen saturation
level and, 111
Semilunar valve, 8
Septic shock, mixed venous oxygen satu-
ration level and, 111
Shivering, mixed venous oxygen satura-
tion level and, 111
Shunting as cause of ventilation-perfusion
mismatch, 7
Silent unit as cause of ventilation-
perfusion mismatch, 7
Single-lumen catheter, short-term, 56-57
Sinoatrial node, 10
Spontaneous breathing, pulmonary artery
pressure values and, 80
Square wave testing, 23
Starling's law, 15
Stress response, systemic vascular
resistance and, 13
Stroke volume, 14
calculating, 90
Stroke volume index, calculating, 90
Subclavian artery, 9
Subclavian vein
as catheter insertion site, 32
advantages and disadvantages of, 33
central venous catheter pathway and,
58,59
patient positioning for access to, 36
Superior vena cava, 5, 8, 9, 32
central venous catheter pathway and,
58,59
Surgical cutdown for catheter insertion, 34
Swan-Ganz catheter, 68
Systemic vascular resistance, 13
calculating, 13, 91
normal measurements of, 13
Systolic peak on arterial waveform, 43
T afterload and, 15
Tachycardia, effects of, on intra-aortic
balloon pump waveforms, 140
Thermodilution curves, analyzing, 98-99
Thermodilution method of measuring
cardiac output, 93-99
curve associated with respiration varia-
tions in, 99
curve reflecting poor technique in, 99
high cardiac output curve in, 99
injectate considerations for, 96
low cardiac output curve in, 98
normal curve in, 98
path of solution through heart during, 93
setup for, 94-95
using iced injectate with closed delivery
system for, 97
using room-temperature injectate with
closed delivery system for, 96
Thromboembolism as arterial pressure
monitoring complication, 50
Thrombosis
as arterial pressure monitoring compli-
cation, 49
as central venous pressure monitoring
complication, 64-65
Tissue oxygenation monitoring, 104-115
Tissues, delivery of blood to, 12 Venules
Transducer in pressure monitoring blood circulation and, 12
system, 18 pulmonary perfusion and, 5
leveling, 20-21 v wave, 60, 62
zeroing, 22
Tricuspid valve, 8, 11 w
Water manometer, measuring central
pulmonary artery pressures and, 76
pulmonary artery wedge pressure and, venous pressure with, 63
77 Waveform
Twave, 60 abnormal
in arterial pressure monitoring, 44-45
U in central venous pressure monitoring, 62
Ulnar artery, Allen's test and, 30 in intra-aortic balloon pump counter-
Ultrasound cardiac output measure- pulsation, 138-139, 142
ment, 131 in mixed venous oxygen saturation -e
mechanics of, 131 monitoring, 114-115
Underdamped system, waveform absent, troubleshooting, 24-25, 84
produced by, 23 changed configuration of, troubleshoot-
v
Vascular access
ing,84
continuous pulmonary artery wedge
pressure, troubleshooting, 85
Allen's test and, 30 damped, troubleshooting, 24-25
arterial line insertion for, 28
drifting, troubleshooting, 24-25
choosing site for, 29 heart rate and blood pressure effects on,
central venous and pulmonary artery
140-141
catheter insertion for, 34-35 interference with, troubleshooting, 24-25
patient positioning for, 36
missing pulmonary artery wedge
insertion sites for, 32, 33 pressure, troubleshooting, 85
changing central venous dressing for, 37
normal
Vasoconstriction in arterial pressure monitoring, 43
preload and, 15
in central venous pressure monitoring, 60
in esophageal Doppler monitoring,
Vasodilation 122, 123
afterload and, 15 in impedance cardiography, 130
preload and, 15 in intra-aortic balloon pump counter
systemic vascular resistance and, 13 pulsation, 137
Venous oxygen reserve, 105 in mixed venous oxygen saturation
Ventilation, 4 monitoring, 113
perfusion and, 6, 7 in pulmonary artery pressure monitor-
Ventilation-perfusion ratio, 6, 7 ing, 72-73, 74
Ventricular assist device, 145-147 in pulmonary artery wedge pressure
biventricular support and, 147 monitoring, 78
components of, 145 in optimally damped system, 23
implantable, 146 in overdamped system, 23
indications for, 145 overwedged, 79
left, 145, 146, 147 right ventricular, troubleshooting, 84
options for placing, 146-147 square wave testing and, 23
potential complications of, 146 in underdamped system, 23
procedure for inserting, 146 ventilatory effects on, 80-81
pump options for, 146
purpose of, 145 X
right, 147 x descent, 60
Ventricular bigeminy, arterial waveform
and,44-45
y
y descent, 60
Ventricular ejection as cardiac cycle
event, 11
Ventricular filling as cardiac cycle
Z
Zeroing the transducer, 22 Ol
event, 11 Zo, 129 o
Ol
o
en
a:
a: