HEMODYNAMIC MONITORING

Martha Richter, MSN, CRNA

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OBJECTIVES
 The student will review
 cardiac and pulmonary considerations for
invasive monitoring
 Procedural considerations for invasive
monitoring
 Waveform identification related to invasive
monitors

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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
 Head up
 No distention

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NONINVASIVE MONITORS
 Routine
 NIBP
 EKG
 Pulse ox
 Temperature
 Urine

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CARDIAC FUNCTIONAL
ANATOMY
 Low pressure system
 Right heart
 Pulmonary
 High pressure system
 Left heart
 Systemic

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CARDIAC CONDUCTION
 Atrial depolarization
 SA nodethru atria
 Ventricular depolarization
 AV nodebundlespurkinjes
 Atrial repolarization
 Ventricular repolarization

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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

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WHAT ABOUT CARDIAC
OUTPUT?
 CO=HR X SV

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CARDIAC OUTPUT
 Determined by
 Preload
 Afterload
 Contractility

 EF=SV/EDV X 100

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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)

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

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CARDIAC COMPENSATION
 Contractility
 HR
 Arteriolar responses
 Venuole responses

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INOTROPES
 Sympathomimetic amines
 Phosphodiesterase inhibitors
 Calcium chloride
 Digitalis glycosides
 glucagon

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SYMPATHOMIMETIC AMINES
 Catecholamines
 Epinephrine
 Norpinephrine
 Dopamine
 dobutamine

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NONCATECHOLAMINES
 Ephedrine
 Metaraminol
 Phenylephrine
 Methoxamine

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PHOSPHODIESTERASE
INHIBITORS
 Amrinone
 Milrinone
 20X more potent than amrinone
 aminophylline

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INOTROPES
 Calcium Chloride
 Glucagon
 Digitalis
 Slows HR, conduction
 Inc contractility

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VASODILATORS
 Nitroprusside
 NTG
 Phentolamine
 Hydralazine
 captopril

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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

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

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AFTERLOAD
 Volume of blood ejected
 Size & thickness ventricular wall
 Impedance of vessels

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DYNAMICS OF VENTRICULAR
FUNCTION
 Rate
 Rhythm
 Preload
 Afterload
 Contractility
 Expressed as EF
 SV/EDV
 LVEF 60-70%
 RVEF 45-50%
 Heerdt, 2000

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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
 RV wall less thick
 RCA and RV flow during systole
 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

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

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HOW DO WE INCREASE
SVO2?
 Increase O2 delivery
 Decrease O2 demand

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INCREASE O2 DELIVERY
 Increase FIO2
 Increase CO

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HOW DO WE DECREASE O2
DEMAND?
 Hypothermia
 Anesthesia
 Neuromuscular blockade
 Early stages of sepsis
 Hypothyroidism
 Shock states

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INVASIVE CARDIAC
MONITORING
 Swan-Ganz catheter
 Developed 1960’s
 Assess cardiopulmonary function
 Cardiac disease
 LV function
 Valves
 Issues of CHF, tamponade, cor pulmonale

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

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SWAN-GANZ ADDITIONAL
INDICATIONS
 CABG/RECENT MI
 AAA
 Sitting cranis
 Unstable sepsis
 Liver tx/shunts
 High risk OB
 PE
 Pts on IABP
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SWAN-GANZ RELATIVE
CONTRAINDICATIONS
 LBBB
 WPW syndrome
 Ebstein’s malformation
 Tachyarrythmias
 Hypercoagulation
 Sepsis
 Site of infection

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SWAN-GANZ CATHETER

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

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PLACEMENT

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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

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PLACEMENT

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PLACEMENT

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PLACEMENT

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WEDGE

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

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PCWP>LVEDP
 Mitral stenosis
 LA myxoma
 PE
 Mitral regurgitation

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PCWP<LVEDP
 Decreased LV compliance
 Stiff ventricle
 LVEDP >25 mmHg
 Aortic regurg

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

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RA READING
 High
 RV failure
 Tamponade
 Pulmonary HTN
 COPD
 Chronic LV failure
 Volume overload

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RA READING
 Low readings
 Hypovolemia
 Sepsis
 Cirrhosis
 anemia

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RV
 ESSENTIALLY SAME AS RA
 Additional high
 VSD

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PA SYSTOLIC
 High
 Shunts
 Constrictive pericarditis
 Hypoxemia
 ARDS
 LV failure
 overload

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PA SYSTOLIC
 Low
 Hypovolemia
 Sepsis
 Cirrhosis
 anemia

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PAD
 High
 Inc PVR
 PE
 COPD
 ARDS
 LV failure
 overload

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PAD
 Low
 Hypovolemia
 Sepsis
 Cirrhosis
 anemia

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PCWP
 High
 LV failure
 Overload
 Mitral v. issues
 Tamponade
 Pericardial effusion
 Stiff LV
 PPV

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PCWP
 Low
 Hypovolemia
 Sepsis
 Cirrhosis
 anemia

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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

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MORE PA COMPLICATIONS
 Pulmonary infarct
 Balloon overinflation
 Prolonged wedge
 Vigorous flushing
 Thrombus formation
 Catheter migration
 Pulmonary HTN

 Death

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

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CVP ACCESS
 RIJ
 EJ
 Subclavian
 Antecubital
 Femoral

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CVP PLACEMENT
 RIJ benefits
 Access
 Landmarks
 Risks
 Carotid
 Brachial plexus trauma
 pneumothorax

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

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CVP PLACEMENT
 Subclavian benefits
 Accessible
 Good landmarks
 Risks
 Pneumo
 Hemothorax
 Chylothorax
 Pleural effusion

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CVP PLACEMENT
 Antecubital benefits
 Low complication rate
 Risks
 Lowest success
 Thrombosis/thrombophlebitis
 Catheter shearing

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CVP PLACEMENT
 Femoral advantages
 High success
 Risks
 Sepsis
 thrombophlebitis

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CVP PLACEMENT

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

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

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READING THE CVP
 5 cm below sternum
 4 ICS, mid axillary
 End expiration
 Supine
 PPV adds 8-12 cm to reading!

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HIGH READINGS
 Ventricular failure (R/L)
 SVC obstruction
 Tricuspid regurg
 Tamponade
 Pulmonary HTN
 Overload
 glomerulonephritis
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LOW READINGS
 PERIPHERAL VASODILATION
 hemorrhage
 hypovolemia
 Addisonian crisis
 Sepsis
 Regional anesthesia
 Polyuria
 Sympathetic dysfunct
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INVASIVE MONITORING
READINGS
 Normal
 CVP/RAP 1-6 mm Hg
 PCWP 8-12 mm Hg
 PA 25/10 mm Hg

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

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

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

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

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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

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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, open fist, release ulnar a
 Color return within 7 sec = OK
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RELATIVE
CONTRAINDICATIONS
 Inadequate circulation
 Infection at the site
 Recent cannulation same artery

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COMPLICATIONS ARTERIAL
LINE
 Thrombosis/embolus
 Hematoma
 Infection
 Nerve damage/palsy
 Disconnect=blood loss
 Fistula
 Aneurysm
 Digital ischemia
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ARTERIAL LINE
 SV: systolic ejection area under
waveform
 Seen from upsweep to dicrotic notch
 End of systole
 Closure aortic valve

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ARTERIAL LINES

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

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

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

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UNDERDAMPED WAVEFORM
 Too many stopcocks
 Long tubing
 Air bubbles
 Defective transducer

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PULSUS PARDOXUS
 Inspiration
 Dec systolic >10 mmHg
 Expiration
 Inc systolic

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

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