HEMODYNAMIC

MONITORING
Amber Arsenault, MSN, FNP-BC, RN
WHAT IS THE PURPOSE OF HEMODYNAMIC
MONITORING?

• Goals of monitoring

• Variables monitored
CARDIAC
A&P REVIEW
CARDIAC
OUTPUT
CARDIAC
OUTPUT
CARDIAC OUTPUT VS CARDIAC INDEX
• CO = HR X SV

• Cardiac index accounts for body size

• CI = CO / BSA

• Stroke index (SI) accounts for body size

• SI = SV / BSA
PRELOAD
• Degree of stretch before systole

• LVEDV/LVEDP

• Increased stretch = Increased volume

• Increased stretch = Increased contractility

What conditions would decrease preload?

AFTERLOAD
• Pressure or resistance against flow

• Affected by:
– vascular tone
– blood viscosity
– flow pattern
– valve competency

• What conditions could alter afterload?

– Increase
– Decrease
HEMODYNAMIC MONITORING MODALITIES
• Noninvasive • Invasive
– Noninvasive blood pressure – Arterial line
– Jugular venous pressure – Central venous catheter
– Serum lactate levels (RAP/CVP)
– Pulmonary artery catheter
(PAOP/PCWP/PAWP)
JUGULAR
VENOUS
PRESSUR
E
INVASIVE
HEMODYNAMIC
MONITORING
EQUIPMENT
ZERO REFERENCING AND LEVELING

• Level = phlebostatic axis

– Fourth intercostal space, midaxillary line
– Approximate level of right atrium

• Zero reference
– Negate atmospheric pressure
– Zeroing stopcock is leveled at phlebostatic axis and “zeroed”
LEVELIN
G
ZEROING
 DYNAMIC RESPONSE TESTING
• Square wave test

Figure 8-13. A. Optimal dynamic response test. B. Overdamped dynamic response test. C.
Underdamped dynamic response test.
CLINICAL CONSIDERATIONS
• Nursing implications
– Positioning – supine or lateral; HOB flat or elevated 30 degrees

– Level the transducer

– Zero the transducer

– Square wave test

– Prevent infection
CLINICAL CONSIDERATIONS
• Nursing Implications
– Dressing changes

– Patency of system

– Tight connections

– Tubing free of kinks

– Alarms on and limits set

COMPLICATIONS
• Infection

• Thrombosis

• Embolism

• Hemorrhage
ARTERIAL PRESSURE MONITORING
• “arterial line or art line”
• Measures arterial blood pressure
• Sites
– Radial
– Brachial
– Femoral

• Allen’s Test
ARTERIAL PRESSURE MONITORING

ARTERIAL
WAVEFORM

Figure 8-14. A. Normal arterial pressure tracing; 1,

peak systolic pressure; 2, dicrotic notch; 3, diastolic
pressure; 4, anacrotic notch. B. Arterial pressure
waveform obtained from arterial line.
ARTERIAL PRESSURE MONITORING
• Clinical Considerations

– Assess for extremity perfusion

– Ensure hemostasis when catheter removed

– NEVER administer medications through arterial line

CENTRAL VENOUS PRESSURE MONITORING
• CVP or RAP (right atrial pressure)
CENTRAL VENOUS PRESSURE MONITORING
• Blood volume status

• Right heart function

• 2-6 mmHg

• Preload of right side

CENTRAL VENOUS PRESSURE MONITORING
• Measure RAP at end of expiration and ventricular diastole
CENTRAL VENOUS PRESSURE MONITORING
PULMONARY ARTERY PRESSURE
MONITORING

SWAN-GANZ
CATHETER
PULMONARY ARTERY CATHETER
• Proximal port – RAP, fluids, medications, intermittent thermodilution cardiac
output (CO)

• Distal port – pulmonary artery pressure (PAP), pulmonary artery occlusion

pressure (PAOP) “wedge”, mixed venous blood samples

• Thermistor port – temperature sensitive wire that allows for computer

calculation of cardiac output (CO)

• Balloon port – PAOP or left heart function

PULMONARY ARTERY CATHETER
• Additional functions
– Transvenous pacing

– Continuous cardiac output monitoring (COO)

– Continuous SvO2 monitoring (mixed venous oxygen saturation)

ASSISTING WITH INSERTION OF PA CATHETER

*See Quick Sheet

PULMONARY ARTERY CATHETER
• PAP – pulsatile pressure in pulmonary artery
– PAS 15-25 mm Hg
– PAD 8-15 mm Hg

• PAOP – “wedge”
– 8-12 mm Hg
– Reflects left atrial pressure and LVEDP
– Indicates left ventricular function
– Preload of left heart

What are possible causes of elevated or decreased PAOP?

THERMODILUTION CARDIAC OUTPUT
THERMODILUTION CARDIAC OUTPUT
THERMODILUTION CARDIAC OUTPUT
• CLINICAL CONSIDERATIONS
– CORRECT PA CATHETER POSITION

– CALIBRATION CONSTANT

– NO VASOACTIVE DRUGS THROUGH PORT

– END EXPIRATION

– 10 DEDREE DIFFERENCE BETWEEN PATIENT AND SOLUTION

– OBTAIN 3 MEASUREMENTS
CONTINUOUS CARDIAC OUTPUT

• COPPER FILAMENT DELIVERS PULSES OF ENERGY TO

WARM BLOOD

• TEMPERATURE DIFFERENCE IS MEASURED

CARDIAC OUTPUT/CARDIAC INDEX
• What are possible causes of:

– Low cardiac output/cardiac index?

– High cardiac output/cardiac index?

VENOUS SATURATION OF OXYGEN
• Oxygen delivery and Oxygen demand

• Percent oxygen saturation of hemoglobin returning to heart via venous system

• SvO2 – pulmonary artery

– Normal 60-75%

• ScvO2 – central venous system (SVC)

– Normal 65-80%