Hemodynamic Monitoring 3.

Thermistor
- measures temperature changes in cardiac output
What is Hemodynamic Monitoring?
- Measures blood flowing into catheter (blood
- measures the pressure of cardiovascular and
surrounds catheter)
circulatory system
- Detects tissue perfusion
4. Proximal Lumen (Blue)
- Titrating therapy (inotropic agents to reach desire
- Opens into right atrium
blood pressure)
- Measures CVP and right atrial pressure
- Qualify severity of illness
- Avenue for drug administration (bolus or fluid
- differentiating system dysfunction (to locate
infusion)
anatomical dysfunction)
5. Distal Lumen (Yellow)
Note:
- Opens into pulmonary artery
- Central venous pressure great indicator for
- Measures pulmonary arterial wedge pressure
hypovolemic shock
-
- Aerobic respiration utilizes O2 in production of
ATP
- Anaerobic respiration DON’T utilize O2 (produces
Note:
lactate and ketones)
- Cold saline to flush catheter (to measure pressure
- Inotropic agents (dopamine, dobutamine, Nore)
left ventricle indirectly)
- NIBP (non-invasive blood pressure monitoing)
- Rapid dispersion of cold temperature indicates
high pressure (fast circulation rapid change in
What to Monitor?
temperature)
1. Direct Arterial BP Monitoring
- Blood flow disperse cold temperature into
- Pressure within arteries (pulmonary artery)
systemic circulation
2. CVP Monitoring
Key Parameters
1. Tissue Oxygenation
3. Indirect Measurement of left ventricular pressure
2. Cardiac Output
- Ideally Swan-Ganz Catheter (monitor pressures
3. Stroke Volume
within heart)
- Pulmonary artery catheter
Oxygenation and Hemodynamics
1. Mixed Venous Oxyhemoglobin (SvO2)
Swan-Ganz Catheter
Measurement
- Commonly used monitoring device
- Measures systemic circulation if sufficient in
- Balloon tip (to measure pulmonary arterial wedge
maintaining bodily function
pressure)
- Percentage of O2 bound hemoglobin returning to
- Inferior vena cava: femoral artery
right side of heart
- Superior vena cava: internal jugular vein or
- How much remnant O2 from the systemic
subclavian vein
circulation
- Turbulent of blood flow guides the catheter in
- If oxygen completely empty when returning to
place
right side of heart
- Balloon tip catheter occludes blood flow
- Amount of O2 returning to heart is accurate
- Indirectly measure the pressure in left ventricle
reflection of oxygenation
and left atrium
- Balloon NOT used to anchor
Note:
- (+) sepsis = high SvO2 (due to high cardiac
Basic Elements of Swanz-Ganz Catheter
output)
1. Balloon Tip
- Sepsis sx: tachycardia
2. Flush System
- used to inflate the balloon
2. Lactate Level
- Normal: 1-2 mmol 2. Afterload
- Increased with prolong anaerobic metabolism - Significant relation with systemic vascular
- Increased levels indicates increasing tissue resistance
damage - Pressure required for blood to be circulated
- LDH NOT specific to cardiac tissues - Resistance muscle faces in attempt to contraction
- S/sx metabolic acidosis (drowsiness to coma)
- Indication of poor O2 supply and blood circulation 3. Contractility
- NOT rapidly increase (NOT ideal) - Strength of muscle contraction
- Strength exerted by myocardial tissue in single
3. Cardiac Output and Index contraction
Cardiac output (CO) - Affected by infectious processes (myocarditis)
- Stroke volume x HR
- Normal: 4-8L/min Hemodynamic Pressures
1. Arterial Pressures
Cardiac Index (CI) Blood pressure
- Cardiac output in relation to body surface area - CO × SVR
- Body surface area (m2) - Pressure present within blood required for
- Normal: 2.5-4L/min/m2 maintenance of circulation
- <2.2L/min/m2 (threat to tissue oxygenation)
- Treat underlying cause 2. Pulmonary Artery Pressures
- Hemoglobin (carries O2) - Normal: 25/10 mmHg
- Hemoglobin high affinity to carbon monoxide
(Carboxy Hemoglobin) Pulmonary HPN
- Fluid forced out of vessels
4. Stroke Volume, Stroke Index & Ejection Fraction - Due to accumulation of blood in pulmonary
Stroke Volume (SV) circulation
- Normal: 50-100mL/beat - Fluid leaks from intravascular to interstitial spaces
- Blood ejected per beat (left ventricle) - lead to alveolar flooding (fluid deposits inside
alveoli)
Stroke Index (SI) - Interfere with gas exchange
- Blood pump of left ventricle in relation to body - Compensatory mechanism: Increased Pulmonary
surface area Arterial Pressure
- Normal: 25-45mL/m2 - Increased BP in pulmonary circulation for O2
penetration and exchange of gasses occurs
Ejection Fraction (EF) - damages pulmonary vessels (spontaneous
- Normal: >60% ruptures in pulmonary vessels and anatomical
- measured by 2D Echo (echocardiography) structures in respiratory system)
- Percentage of blood ejected in response to - Arterial Pressure: >35/20 mmHg
cardiac index - 2 Types: Primary & Secondary
- Amount of blood pumped with each contraction in
relation to amount of blood expected to be pumped Primary HPN
- UNKNOWN etiology/ idiopathic
Factors of Stroke Volume
1. Preload Secondary HPN
- Filling of blood (during relaxation) - Complication of other systemic diseases
- Atrial fibrillation and V. Tach (decreases preload)
- NO enough time for chambers to be filled with
blood
- “kinakargahan ng dugo”
- Amount of stretch in muscle before contraction
3. Central Venous Pressure (CVP) 2. NO Hypovolemia
- assess performance of right ventricle - PCWP normal and SI low
- Right Ventricular End-Diastolic Pressure (RVEDP)
- Pressure inside right ventricle during relaxation 3. Left Ventricular Dysfunction
- Normal: 2-6 mmHg - PCWP High and SI low

Low CVP 4. NO LV Dysfunction

- HYPOVOLEMIA (fluid status less than body - PCWP High and SI normal
requirement)
- Hypovolemic Shock (prolong hypovolemia) Parameters: Systemic and Pulmonary Resistance

Normovolemia- Normal fluid volume 1. Vascular Resistance

High CVP
- Right ventricular dysfunction
- Factor: accumulation of blood in right ventricle
- Heart Shape CXR: Boots (botas/sapatos)
4. Pulmonary Capillary Wedge Pressure (PCWP)
- Assessment of left ventricle preload
- Pressure in LV during filling of blood in state of
relaxation
- Left Ventricular End-Diastolic Pressure (LVDEP)
- Normal: 8-12 mmHg
- To measure using balloon port of Swan-Ganz
Catheter (indirect measurement)
Low PCWP
- Hypovolemia
Normovolemia- Normal fluid volume
- represent afterload (pressure required for blood to
be pumped into systemic circulation)
2. Systemic Vascular Resistance (SVR)
- Reflects LV afterload
- Normal: 900-1,300 dynes/sec/cm5
High SVR
- Primary or secondary systemic HPN
- To compensate for low cardiac output
Low SVR
- Pathologic response to inflammation
- Hepatic diseases
- Neurogenic-induced central
3. Pulmonary Vascular Resistance (PVR)
- Reflects RV afterload
- Normal: 40-150 dynes/sec/cm5

High PCWP High PVR

- Left ventricular dysfunction - Primary pulmonary HPN
- Left ventricle NOT fully emptied upon contraction - Secondary active or passive pulmonary HPN

Relationship of CVP and SI Nursing Consideration (Hemodynamic Monitoring)

1. Hypovolemia 1. Position
- CVP low and SI low - Flat to 40° upper body elevation (HOB)

2. NO Hypovolemia 2. Measurement of Cardiac Output

- CVP high and SI normal - CO 10% of each other (CO, PVR, SVR 10%
difference)
3. RV Dysfunction - Inconsistent measurement use “FLICK Equation”
- CVP high and SI low to measure CO

4. NO RV Dysfunction Flick Equation = ____O2 Consumption × 100

- CVP high and SI normal Arteriovenous O2 Difference

Relationship of PCWP and SI

1. Hypovolemia
- PCWP low and SI low
Nursing Care/ Management
- Catheter complication: Infection, thrombosis,
hemorrhage, pneumothorax
- Measured on supine or at <25° HOB elevation
(maximum 40° HOB elevation)
- PAP measurement = deflate balloon
- PCWP = inflate balloon
- CVP = supine or 45° if orthopneic
- Transducer attaches on machine at right atrium
level or midaxillary line at 4th ICS
- Measurements at end of expiration and client
should be relaxed
(Inhalation increases negative pressure and
increases intrathoracic pressure which affects
reading of results)
- Catheter connection checked frequently SHOULD
be secure to prevent AIR EMBOLISM (medical
emergency!!)
- Insertion site dressing changed as per policy
- Other complications: air and pulmonary emboli,
fluid overload, dysrhythmia, sepsis

Infection
- Foreign body insertion
- ASEPTIC Technique!!!

Thrombosis
- Damage in integrity of lumen of vessels lead to
thrombus formation

Hemorrhage
- puncture of subclavian or internal jugular vein

Pneumothorax
- Tip of catheter directly lodge into pulmonary
vessels
- Inflation of balloon can lead to rupture of vessels
result to pneumothorax or hemothorax

Dysrhythmia
- Insertion of catheter can stimulate sudden firing of
impulses