Transcript Blood Administration

Hemodynamic Monitoring
By
Nancy Jenkins RN,MSN
What is Hemodynamic
Monitoring and why do it?
It is measuring the pressures in the
heart
It allows us to see inside the heart and
adjust volume as needed
Comparing Hemodynamics to
IV pump
 Fluid =preload
 Pump= CO or
contractility (needs
electricity)
 Tubing =afterload
Nursing Management
Hemodynamic Monitoring- You
are already doing
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General appearance
Level of consciousness
Skin color/temperature
Vital signs
Peripheral pulses
Urine output
Lung sounds
Nursing Management
Hemodynamic Monitoring
 **Single hemodynamic values are rarely
significant.
 Monitor trends and evaluate whole clinical
picture
 Goals
– Recognize early clues
– Intervene before problems develop or escalate
Hemodynamic Monitoring
Components We Will Look at
Today
Heart Rate
Blood Pressure and MAP
CVP
Pulmonary Artery Pressures
Systemic Vascular Pressure (SVR)
Pulmonary Vascular Pressure (PVR)
Cardiac Output/ Cardiac Index
Stroke Volume
Important Equation
Hemodynamic Monitoring
General Principles
 CO: Volume of blood pumped by heart in 1
minute
 CI: CO adjusted for body size
 SV: Volume ejected with each heartbeat
 SVI: SV adjusted for body size
 Easier to adjust HR than SV
**Preload, afterload, and contractility determine
SV
Hemodynamics:
Normal value
Mean Arterial Pressure (MAP) 70 -90 mm Hg
Cardiac Index (CI)- 2.2-4.0 L/min/m2
Cardiac Output (CO)- 4-8 L/min
Central Venous Pressure (CVP) (also known as
Right Atrial Pressure (RA)) 2-8 mmHg
Pulmonary Artery Pressure (PA)
Systolic 20-30 mmHg (PAS)
Diastolic 4-12 mmHg (PAD)
Mean 15-25 mmHg
Pulmonary Capillary Wedge Pressure (PWCP)
4-12 mmHg
Systemic Vascular Resistance(SVR) 800-1200
Volume of blood within
ventricle at end of
diastole
–**Measured by CVP and
wedge pressure in ICU
Preload
 Def- the volume that stretches the LV just
before contraction
– Measured by CVP for RV and PAWP for LV
– Measures the preload of the LV or LVEDP=
wedge or PAW
– **The greater the preload the greater the
stroke volume and the greater the cardiac
output
Decreased Preload- leads to Dec.
SV and venous return
 Hypovolemia
 Tachycardia- why?
 Vasodilation/ dec. venous return
 Treatment- fluid
 **A goal for heart failure
Increased Preload
 Valvular disease
 Hypervolemia
 Heart failure
 Treatment- diuretics, vasodilators
 **Vascular system holding tankvasodilation, vasoconstriction depending
on need
–Measured by SVR and PVR in
the ICU
Afterload
 Resistance to ejection- arterial B/P
 Measured by PVR and SVR in the ER
 Decreased afterload
– Vasodilation (sepsis, hyperthermia)
– Hypotention
– Nitrates
Afterload
 Increased afterload
– Vasoconstriction (hypovolemia, hypothermia)
– Aortic stenosis
– Hypertension
– Fight or flight
– Pulmonary hypertension
– **The greater the afterload, the lower the
cardiac output
Cardiac Output
 CO=SVxHR; CI= CO/BSA
 Normal CO 4-8 L/min; CI 2.2-4
 Urine output- indirect measurement
 To compensate for dec. CO get tachycardia
 Decreased CO
– Poor ventricular filling- hypovolemia or SVT
– Poor emptying, dec. contractility (infarct,
ischemia, arrhythmias)
– Vasodilation- sepsis and drugs
– Increased afterload- hypertension,
vasoconstriction
Cardiac Output
 Increased
– Increased O2 demand- exercise
– SNS
– Drugs- positive inotropics (Continuous
infusions: Dobutamine, Dopamine, Primacor
– Digoxin- IVP
Stroke Volume
 Def- amount of blood ejected with each
heart beat
 Normal SV= 60-130
 Exercise can increase SV
 Factors that determine SV
– Preload
– Afterload
– Contractility
Contractility
 Starling’s law
 Increased contractility
– SNS
– Drugs- positive inotropics, epinephrine,
calcium
 Decreased contractility
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Loss of muscle (acute MI, cardiomyopathy)
Hypoxemia
Electrolyte imbalance
Drugs- (lidocaine, calcium channel blockers,
beta blockers
Contractility
 Determined by the SV and the EF%
 **Important to know the EF% of all heart failure
patients
 Measured by echo
 EF- how much blood is ejected during systole
compared to how much preload there is.
 **Normal EF%- 55-65%
 Ex 90/140= 64%EF
How and when do we measure
afterload?
Arterial B/P and SVR
– Continuous arterial pressure monitoring
– Acute hypertension/hypotension
– Respiratory failure- frequent ABG sampling
– Shock
– Coronary interventional procedures
– Continuous infusion of vasoactive drugs
Best indicator of tissue perfusion. Needs to be at
least 60-70 to perfuse organs
Arterial Line
Arterial Pressure Monitoring
 High- and low-pressure alarms based on
patient’s status
 Risks
– Hemorrhage, infection, thrombus formation,
neurovascular impairment, loss of limb
 Nursing- Check 5 P’s
Arterial Pressure Waveform
Dicrotic notch signifies the closure of the
aortic valve.
Pulmonary Artery Catheter
Fig. 66-7
PA Catheter Insertion
PPA catheter tells you everything you
want to know about the heart: (Snap,
Crackle, Pop)
1) how well the pump is pumping
(cardiac output, cardiac
index) (snap)
2)how full the right side of the
heart is (CVP), and how full the left
side is (wedge pressure) – that’s the
volume…(crackle)
3) and how well your patient’s
arteries can squeeze : that’s the SVR
– the “systemic vascular
resistance”… (pop)
PA Waveforms during Insertion
Fig. 66-9
Important Measurements Obtained
by PA Catheter
 Right Atrial Pressure (CVP)
 PAP
– Diastolic (PAD)
– PA Systolic (PAS)
– PA Wedge (Wedge, PAOP)
 Cardiac Output
 Cardiac Index
Pulmonary Artery Pressure
Monitoring- CVP
 Right atrium port- also know as proximal
– Measurement of CVP
– Injection of fluid for CO measurement
– Can you give meds through this port?
– Blood sampling
Central Venous Pressure
Waveforms
Fig. 66-11
CVP values
Right Heart Presssures
 Normal 2-8mmHg
 Dec.
– Hypovolemia
– Decreased venous return
 Inc.
– Hypervolemia
– Inc. venous return
– Right HF, pulmonary hypertension
– Tricuspid stenosis and regurgitation
PA pressure
 PAD- should be close to wedge
 PAS- tells RV pressure
 PAW- LVEDP or preload of LV
PA Pressures
 Normal 20-30 mmHg systolic, 4-12mmHg
diastolic
 PAS= RV pressure
 Inc PAS in pulmonary hypertension
 Inc. PAD in ventricular failure
 Dec. in hypovolemia
 Dec. in shock
PAW
 Normal 6-12mmHg
 Equals LVEDP or preload of LV
 Dec.in hypovolemia or low stroke volume
 Inc. in LV failure, mitral valve disorders
 Inc. in hypervolemia
 *** Fluids for dec. wedge and diuretics for
inc. wedge
Measuring Cardiac Output
Fig. 66-12
Cardiac Output
Cardiac Output Monitoring
Measuring Cardiac Output and SVR
 SVR can be calculated when CO is
measured
 SVR=(MAP-CVP) x80/ CO
– ↑ SVR
• Vasoconstriction from shock
• Hypertension
• ↑ Release or administration of epinephrine or other
vasoactive inotropes
• Left ventricular failure
– Dec. SVR
• Vasodilation
• sepsis
Cardiac Output
http://www.lidco.com/docs/Brochure.pdf
Complications with PA
Catheters
 Infection and sepsis
– Asepsis for insertion and maintenance of
catheter and tubing mandatory
– Change flush bag, pressure tubing, transducer,
and stopcock every 96 hours
 Air embolus (e.g., disconnection)
Complications with PA
Catheters
 Ventricular dysrhythmias
– During PA catheter insertion or removal
– If tip migrates back from PA to right ventricle
 PA catheter cannot be wedged
– May need repositioning
Complications with PA
Catheters
 Pulmonary infarction or PA rupture
– Balloon rupture (e.g., overinflation)
– Prolonged inflation
– Spontaneous wedging
– Thrombus/embolus formation
Noninvasive Hemodynamic
Monitoring
 Impedance cardiography (ICG)
 Def-Continuous or intermittent,
noninvasive method of obtaining CO and
assessing thoracic fluid status
• Impedance-based hemodynamic parameters (e.g.,
CO, SV, SVR) are calculated from Zo, dZ/dt, MAP,
CVP, and ECG
Noninvasive Hemodynamic
Monitoring
 Major indications
– Early signs and symptoms of pulmonary or
cardiac dysfunction
– Differentiation of cardiac or pulmonary cause
of shortness of breath
– Evaluation of etiology and management of
hypotension
Noninvasive Hemodynamic
Monitoring
 Major indications (cont’d)
– Monitoring after discontinuing a PA catheter
or justification for insertion of a PA catheter
– Evaluation of pharmacotherapy
– Diagnosis of rejection following cardiac
transplantation
hemodynamic cases (1 and 4)
Case Study