Hemodynamic Monitoring | Heart | Ventricle (Heart)

HEMODYNAMIC MONITORING

Martha Richter, MSN, CRNA

mlr/2007

OBJECTIVES 

The student will review   

cardiac and pulmonary considerations for invasive monitoring Procedural considerations for invasive monitoring Waveform identification related to invasive monitors

mlr/2007

EVALUATING THE PATIENT A REVIEW 

PULMONARY 
 

Breath sounds Level of mentation Oxygenation 

cyanosis 



Edema Chest circumference

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EVALUATING THE PATIENT CARDIOVASCULAR 
    

Pain issues Skin color/temp Weakness/fatigue Urinary output HR, rhythm, JVP
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EVALUATING THE PATIENT  JVP  supine  Sl distention No distention  Head up  mlr/2007 .

NONINVASIVE MONITORS  Routine      NIBP EKG Pulse ox Temperature Urine mlr/2007 .

CARDIAC FUNCTIONAL ANATOMY  Low pressure system   Right heart Pulmonary Left heart Systemic  High pressure system   mlr/2007 .

CARDIAC CONDUCTION  Atrial depolarization  SA node thru atria AV node bundles purkinjes  Ventricular depolarization    Atrial repolarization Ventricular repolarization mlr/2007 .

MECHANICS OF CARDIAC CYCLE  Isovolumetric phase  Active-requires energy     Ventricular ejection (rapid) Ventricular ejection (reduced) Isovolumetric relaxation Rapid ventricular filling  Beg when ventric pressure <atrial pressure  End diastole = atrial kick mlr/2007 .

WHAT ABOUT CARDIAC OUTPUT?  CO=HR X SV mlr/2007 .

CARDIAC OUTPUT  Determined by    Preload Afterload Contractility EF=SV/EDV X 100  mlr/2007 .

FRANK-STARLING     Described in early 1900s Relationship between myocardial muscle LENGTH and force of contraction More diastolic stretch = more ventricular vol = stronger contraction True to a limit (physiological) mlr/2007 .

FRANK-STARLING   Resting length affected by degree of preload CO begins to fall in CHF b/o inc preload mlr/2007 .

CARDIAC COMPENSATION     Contractility HR Arteriolar responses Venuole responses mlr/2007 .

INOTROPES      Sympathomimetic amines Phosphodiesterase inhibitors Calcium chloride Digitalis glycosides glucagon mlr/2007 .

SYMPATHOMIMETIC AMINES  Catecholamines     Epinephrine Norpinephrine Dopamine dobutamine mlr/2007 .

NONCATECHOLAMINES     Ephedrine Metaraminol Phenylephrine Methoxamine mlr/2007 .

PHOSPHODIESTERASE INHIBITORS   Amrinone Milrinone  20X more potent than amrinone  aminophylline mlr/2007 .

INOTROPES    Calcium Chloride Glucagon Digitalis   Slows HR. conduction Inc contractility mlr/2007 .

VASODILATORS      Nitroprusside NTG Phentolamine Hydralazine captopril mlr/2007 .

WHAT IS PRELOAD?      End diastolic length of myocardial fiber(wall stress) Amount of volume in ventricle at end diastole Muscle wall compliance important factor Normal ventricle:lge inc volume = small inc pressure Stiff ventricle: small inc in volume = large inc pressure mlr/2007 .

pressure SVR PVR Inc resistance dec contractility/SV mlr/2007 . impedance.WHAT IS AFTERLOAD?      Pressure that has to be overcome by LV for ejection of ventricular volume Resistance.

AFTERLOAD    Volume of blood ejected Size & thickness ventricular wall Impedance of vessels mlr/2007 .

DYNAMICS OF VENTRICULAR FUNCTION 
   

Rate Rhythm Preload Afterload Contractility 
  

Expressed as EF SV/EDV LVEF 60-70% RVEF 45-50% 

Heerdt, 2000

mlr/2007

WHAT ABOUT CONTRACTILITY? 
 

Inotropism Shortening of muscle fibers without altering fiber length or preload Effected by 
  

ANS Positive Inotropes Acidosis (dec) Negative inotropes (dec)
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ISSUES OF MYOCARDIAL O2 
  

Uses 65-80% No direct method of measurement Supply and demand Disease states 
 

May not be able to inc supply May have greater demand Poor reserve = ischemia/infarct risk
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CORONARY PERFUSION 


Occurs during diastole LV thick wall 

Endocardium flow influence during systole RCA and RV flow during systole 

RV wall less thick  

Diastolic pressure provides flow thru aortic root into coronaries
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WHAT ABOUT SVO2?     Mixed venous oxygen saturation Reflect O2 reserve Samples from PA catheter <60% (nl 60-80%)  Dec O2 delivery     Anemia Low CO states Hypovolemia Hypoxia mlr/2007 .

DECREASING SVO2  Also b/o O2 demand increase        Hyperthermia Seizures Pain Shivering/agitation Exercise Burns hyperthyroidism mlr/2007 .

HOW DO WE INCREASE SVO2?   Increase O2 delivery Decrease O2 demand mlr/2007 .

INCREASE O2 DELIVERY   Increase FIO2 Increase CO mlr/2007 .

HOW DO WE DECREASE O2 DEMAND?       Hypothermia Anesthesia Neuromuscular blockade Early stages of sepsis Hypothyroidism Shock states mlr/2007 .

INVASIVE CARDIAC MONITORING  Swan-Ganz catheter   Developed 1960 s Assess cardiopulmonary function  Cardiac disease    LV function Valves Issues of CHF. tamponade. cor pulmonale mlr/2007 .

SWAN GANZ MONITORING  Pulmonary issues   ARDS/respiratory failure Severe COPD Shock Sepsis ARF Burns mlr/2007  Complex fluid management     .

SWAN-GANZ ADDITIONAL INDICATIONS         CABG/RECENT MI AAA Sitting cranis Unstable sepsis Liver tx/shunts High risk OB PE Pts on IABP mlr/2007 .

SWAN-GANZ RELATIVE CONTRAINDICATIONS    LBBB WPW syndrome Ebstein s malformation  Tachyarrythmias   Hypercoagulation Sepsis  Site of infection mlr/2007 .

SWAN-GANZ CATHETER mlr/2007 .

PLACEMENT GUIDELINES  What s the distance to SVC/RA junction?      IJ SVC Femoral RAC LAC 15-20 cm 10-15 cm 30 cm 40 cm 50 cm mlr/2007 .

PLACEMENT mlr/2007 .

BALLOON PEARLS      1-1.5 cc used to wedge <1 cc=too far::pull back Wedge time <10-15 sec Never flush with inflated balloon PCWP = LVEDP (normal heart)   PCWP = LV function RA = RV function mlr/2007 .

PLACEMENT mlr/2007 .

PLACEMENT mlr/2007 .

PLACEMENT mlr/2007 .

WEDGE mlr/2007 .

PCWP WAVEFORM  A=contraction  After QRS May not see easily Late T-P interval  C=closure mitral valve   V=atrial filling (MV closed)  mlr/2007 .

PCWP>LVEDP     Mitral stenosis LA myxoma PE Mitral regurgitation mlr/2007 .

PCWP<LVEDP  Decreased LV compliance    Stiff ventricle LVEDP >25 mmHg Aortic regurg mlr/2007 .

PAD AND PCWP  If not = (1-4 mmHg)     Inc PVR Cor pulmonale PE CHD Causing Pul HTN  Eisenmengers mlr/2007 .

RA READING  High       RV failure Tamponade Pulmonary HTN COPD Chronic LV failure Volume overload mlr/2007 .

RA READING  Low readings     Hypovolemia Sepsis Cirrhosis anemia mlr/2007 .

RV   ESSENTIALLY SAME AS RA Additional high  VSD mlr/2007 .

PA SYSTOLIC  High       Shunts Constrictive pericarditis Hypoxemia ARDS LV failure overload mlr/2007 .

PA SYSTOLIC  Low     Hypovolemia Sepsis Cirrhosis anemia mlr/2007 .

PAD  High       Inc PVR PE COPD ARDS LV failure overload mlr/2007 .

PAD  Low     Hypovolemia Sepsis Cirrhosis anemia mlr/2007 .

PCWP  High        LV failure Overload Mitral v. issues Tamponade Pericardial effusion Stiff LV PPV mlr/2007 .

PCWP  Low     Hypovolemia Sepsis Cirrhosis anemia mlr/2007 .

PA COMPLICATIONS            Dysrhythmias RBBB/CHB in pt with LBBB PA/RA/RV rupture Knot/kink/coil catheter Infection Balloon rupture Thrombus Air embolus Pneumo Phrenic n. block Horner s   R/T stellate ganglion damage Eyelid ptosis mlr/2007 .

MORE PA COMPLICATIONS  Pulmonary infarct       Balloon overinflation Prolonged wedge Vigorous flushing Thrombus formation Catheter migration Pulmonary HTN Death mlr/2007  .

CENTRAL VENOUS PRESSURE MONITORING    Indirect measure of volume RAP reflects RVEDP CVP INDICATIONS      Cardiac disease Expected volume shifts Hypovolemia Shock states Massive trauma mlr/2007 .

CVP ACCESS      RIJ EJ Subclavian Antecubital Femoral mlr/2007 .

CVP PLACEMENT  RIJ benefits   Access Landmarks Carotid Brachial plexus trauma pneumothorax mlr/2007  Risks    .

CVP PLACEMENT  EJ benefits   Superficial Safe Low success rate Sheath kinking at SC v. Subclavian trauma mlr/2007  Risks    .

CVP PLACEMENT  Subclavian benefits   Accessible Good landmarks Pneumo Hemothorax Chylothorax Pleural effusion mlr/2007  Risks     .

CVP PLACEMENT  Antecubital benefits  Low complication rate Lowest success Thrombosis/thrombophlebitis Catheter shearing  Risks    mlr/2007 .

CVP PLACEMENT  Femoral advantages  High success Sepsis thrombophlebitis  Risks   mlr/2007 .

CVP PLACEMENT mlr/2007 .

CVP WAVEFORMS  A=RA contraction  After P wave of EKG Near end QRS Early T-P interval  C=closure tricuspid   V=atrial filling/tricuspid v closed  mlr/2007 .

COMPLICATIONS  Arterial puncture    Hematoma False aneurysm Fistula Wall perf/tamponade Dysrhythmias  Catheter position during placement      Catheter shear Brachial plexus injury Thoracic duct injury mlr/2007 .

mid axillary End expiration Supine PPV adds 8-12 cm to reading! mlr/2007 .READING THE CVP      5 cm below sternum 4 ICS.

HIGH READINGS        Ventricular failure (R/L) SVC obstruction Tricuspid regurg Tamponade Pulmonary HTN Overload glomerulonephritis mlr/2007 .

LOW READINGS         PERIPHERAL VASODILATION hemorrhage hypovolemia Addisonian crisis Sepsis Regional anesthesia Polyuria Sympathetic dysfunct mlr/2007 .

INVASIVE MONITORING READINGS  Normal    CVP/RAP 1-6 mm Hg PCWP 8-12 mm Hg PA 25/10 mm Hg mlr/2007 .

ARTERIAL LINE   Beat to beat measurement of B/P Upstroke of wave   Related to velocity of blood ejected Slowed upstroke   AS LV failure Anemia Hyperthermia Hyperthyroidism SNS Aortic regurg mlr/2007  Inc sharp vertical in hyperdynamic states      .

ARTERIAL LINE MONITORING SITES  Radial    Low complications Allen s test Poss median n damage b/o dorsiflexion Primary source hand flow Low complications Poss median n. damage mlr/2007  Ulnar    .

ARTERIAL LINE MONITORING SITES  Brachial   Medial to biceps tendon Potential median n damage At junction pectoralis major & deltoid Safer than brachial Low thromboembolic issues mlr/2007  Axillary    .

ARTERIAL LINE MONITORING SITES  Femoral    Easy access in shock states Potential hemorrhage (local/retroperitoneal) Requires longer catheter Post tibial collateral circ Estimates systolic higher Contraind in DM & PVD  Doralis Pedis    mlr/2007 .

ALLEN S TEST     OCCLUDE ulnar and radial arteries Have pt clench fist until hand blanches Release ulnar a with hand open Color return within 5 sec = adequate collateral circ mlr/2007 .

release ulnar a Color return within 7 sec = OK mlr/2007 . open fist.MODIFIED ALLEN S TEST       Elevate arm above heart Have pt open and close fist several times Tightly clench fist Occlude radial and ulnar a Lower hand.

RELATIVE CONTRAINDICATIONS    Inadequate circulation Infection at the site Recent cannulation same artery mlr/2007 .

COMPLICATIONS ARTERIAL LINE         Thrombosis/embolus Hematoma Infection Nerve damage/palsy Disconnect=blood loss Fistula Aneurysm Digital ischemia mlr/2007 .

ARTERIAL LINE   SV: systolic ejection area under waveform Seen from upsweep to dicrotic notch   End of systole Closure aortic valve mlr/2007 .

ARTERIAL LINES mlr/2007 .

delayed/lower dicrotic notch Dorsalis pedis/femoral = 20-40 mmHg higher than brachial/radial mlr/2007 .ARTERIAL LINE ISSUES  READINGS    May be 20-40 mmHg higher and cuffs More peripheral vessel = higher systolic. narrower waveform.

LOSS OF WAVEFORM       Stopcock Monitor not on correct scale Nonfunctioning monitor Nonfunctioning transducer Kinked/clotted catheter asystole mlr/2007 .

DAMPENED WAVEFORM       Air bubble/blood in line Clot Disconnect/loose tubing Underinflated pressure bag Catheter tip against wall Compliant tubing mlr/2007 .

UNDERDAMPED WAVEFORM     Too many stopcocks Long tubing Air bubbles Defective transducer mlr/2007 .

PULSUS PARDOXUS  Inspiration  Dec systolic >10 mmHg Inc systolic  Expiration  mlr/2007 .

PULSUS ALTERNANS   Regular alteration in amplitude radial pulse waveforms Seen in     LVD/cardiomyopathies HTN AS Normal hearts with SVT mlr/2007 .

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