Invasive Hemodynamic for Prep and Recovery

8/3/2019 Invasive Hemodynamic for Prep and Recovery

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INVASIVEHEMODYNAMIC

MONITORING

Presentation by Donna Cohen, BSN, RN

Heart and Vascular CenterMedical University of South Carolina

February 2006


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INVASIVE HEMODYNAMIC

MONITORING


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Objectives Verbalizes purposes of Hemodynamic

Monitoring

Verbalize indications for HemodynamicMonitoring

Identify components of a Pulmonary Artery

Catheter[Swan-Gantz] Verbalize necessary equipment needed


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Objectives [cont] Identify the correct pressure waveforms

Identify the components of invasive

hemodynamic monitoring[RA,PA,PAM andPCWP]

Identify normal parameters for each

component of monitoring Verbalize how to troubleshoot abnormal

waveforms


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Objectives [cont] Verbalize definition of preload and afterload

Verbalize what and where to document data

collected Verbalize understanding of the Critical Care

Hemodynamic Monitoring Policy [C1]


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Introduction Swan-Ganz catheter has been in use for

almost 30 years

Initially developed for the management ofacute myocardial infarction

Now, widespread use in the management of a

variety of critical illnesses and surgicalprocedures


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Purposes of Invasive Hemodynamic

Monitoring Early detection, identification, and treatment

of life-threatening conditions such as heart

failure and cardiac tampanade Evaluate the patients immediate response to

treatment such as drugs and mechanical

support Evaluate the effectiveness of cardiovascular

function such as cardiac output and index


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Indications for Hemodynamic

Monitoring Any deficit or loss of cardiac function: such

as AMI,CHF,Cardiomyopathy

All types of shock;cardiogenic,neurogenic,oranaphylactic

Decreased urine output from dehydration,

hemorrhage,G.I. bleed,burns,or surgery


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Components of a Pulmonary Artery

Catheter


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Components of Swan-Ganz [cont]

Normally has four[4] ports

Proximal port[Blue] used to measure central

venous pressure/RAP and injectate port formeasurement of cardiac output

Distal port[Yellow] used to measure pulmonary

artery pressure

Balloon port[Red] used to determine pulmonarywedge pressure;1.5 special syringe is connected

Infusion port[White] used for fluid infusion


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Components of the Monitoring System

Bedside monitoramplifier is located inside.

The amplifier increases the size of signal

Transducerchanges the mechanical energyor pressures of pulse into electrical energy;

should be level with the phlebostatic axis[ you

can estimate this by intersecting lines fromthe 4th ICS,mid axillary line

Recorderplease record information


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Phlebostatic Axis


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Commonly used Terminology

Preload

Afterload

Cardiac Output Cardiac Index

Systemic Vascular

Resistance [SVR]

Pulmonary Vascular

Resistance [PVR]


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Preload

Is the degree of muscle fiber stretching

present in the ventricles right before systole

Is the amount of blood in a ventricle before itcontracts; also known as filling pressures

Left ventricular preload is reflected by the

PCWP Right ventricular preload is reflected by the

CVP [RA]


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Afterload

Any resistance against which the ventricles

must pump in order to eject its volume

How hard the heart [either side left or right]has to push to get the blood out

Also thought of as the resistance to flow or

how clamped the blood vessels are


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Cardiac Output/Index

Is the amount of blood ejected from the

ventricle in one minute

Two components multiply to make the cardiacoutput: heart rate and stroke volume [amount

of blood ejected with each contraction]

Cardiac index is the cardiac output adjustedfor body surface area (BSI)


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Computation Constant

Computation constant is based on the

1) type of catheter

2) temperature (iced or room temp) of theinjectate

3) the number of mLs (5mL vs 10mL) ---we

use 10 mL of room temperature injectate forour regular swanns, which requires a

computation constant of 0.592


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SVR / PVR

Systemic Vascular Resistancereflects left

ventricular afterload

Pulmonary Vascular Resistancereflectionof right ventricular afterload

Many of the drugs we administer will affect

Preload, Afterload, SVR/PVR, CardiacOutput


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Possible Complications Increased risk of infectionssame as with any central

venous linesuse occlusive dressing and Biopatch to prevent

Thrombosis and emboli-- air embolism may occur when the

balloon ruptures, clot on end of catheter can result inpulmonary embolism

Catheter wedges permanentlyconsidered an emergency,notify MD immediately, can occur when balloon is leftinflated or catheter migrates too far into pulmonary artery

(flat PA waveform)can cause pulmonary infarct after onlya few minutes!

Ventricular irritationoccurs when catheter migrates backinto RV or is looped through the ventricle, notify MDimmediatelycan cause VT


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Troubleshooting

Dampened waveformcan occur with physicaldefects of the heart or catheter; can be caused bykinks, air bubbles in the system, or clots

Solution: Check your line for kinks & airbubbles, aspirate (not flush) for clots, straightenout tubing or patient as much as possible

No waveformcan occur with non-perfusing

arrhythmias or line disconnection

Solution: Check your line for disconnection,check your patient for pulse, could also be wettransducer or broken cable or box


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Equipment NeededSET-UP FOR HEMODYNAMIC

PRESSURE MONITORING

1. Obtain Barrier Kit, sterile gloves, Cordis Kit and correct swan

catheter. Also need extra IV pole, transducer holder, boxes and cables.2. Check to make sure signed consent is in chart, and that patient and/or

family understand procedure.

3. Everyone in the room should be wearing a mask!

4. Position patient supine and flat if tolerated.

5. On the monitor, press Change Screen button, then select SwanGanz to allow physician to view catheter waveforms while inserting.

6. Assist physician (s) in sterile draping and sterile setup for cordis and

swan insertion.


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Equipment Needed

7. Set up pressure lines and transducers [see Critical Care Skills:

Clinical Handbook, Second Edition pages 293 -298]

Please level pressure flush monitoring system and transducers to the

phlebostastic axis. Zero the transducers. Also check to make sure

all connections are secure.8. Connect tubings to patient [PA port and CVP port] when physician

is ready to flush the swann. Flush all ports of swann before

inserting.

9. While floating the swann, observe for ventricular ectopy on the

monitor, and make physician aware of frequent PVCs or runs of

VT !

10. After swann is in place, assist with cleanup and let

patient know procedure is complete.


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Equipment Needed11. Obtain your RA [CVP], PAS/D, PAM, and wedge.

For Cardiac Outputs, inject 10 mLs of D5W after

pushing the start button, repeat X 3. Delete outputs

not within 1 point of the mean value. Can use .9NS

instead, but affects the accuracy of the output reading.12. Before obtaining the cardiac output, please check the

computation constant [should read 0.692 for regular

yellow swans; 0.692 for SVO2 or blue swanns]

13. Perform hemocalculations (enter todays height and weight).

14. Document findings on the ICU flowsheet.


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PA Insertion Waves


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Central Venous Pressure (CVP)

Zero transducer to the patients phlebostatic axis

Always read CVP at end expiration

CVP is a direct measurement of right ventricular enddiastolic pressure


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Right Ventricular Waveform If the swan falls or gets pulled back into the RV it is

considered a swan emergency.

If you see an RV waveform (looks like VT) pull the swanimmediately.

If the swan remains in the RV it may cause the patient to gointo VT.


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Pulmonary Capillary Wedge Pressure (PCWP)

Zero the transducer to the patients phlebostatic axis.

Measure the PCWP at end expiration

PCWP should not be higher than PA diastolic

PCWP is an indirect measurement of left ventricular enddiastolic pressure.


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Cardiac Output

It is the amount of blood pumped by the heart in one minute.

Calculated by multiplying heart rate times stroke volume.

Cardiac Index is the cardiac output adjusted for body surface

area.


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How to read a PA waveform

Measured at end expiration!

Dicrotic notch (closure of PulmonicValve) should always be on

Right side of wave (if notch on Left side find out if the tip in the RV)

Measure PAS at the top of the wave upslope (at end of QRS);

PAD is measured at the trough preceding the systolic peak(be careful not to measure whip in the wave)

How to read a PCWP (aka wedge) Measured at end expiration!

After balloon is inflated, compare waveform to respiratory waveform todetermine measurement at the end of expiration

(last clear wave before patient inspires)

Tip: if waveform is difficult to read, try resting hand on pts chest as youwedge; determine where the end of expiration occurs on the wedgewaveform, then measure across several waves for consistency


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Documentation

Document PAS, PAD, and PCWP on nursing flowsheet under

Hemodynamic Parameters

PCWP will rarely be > PAD (if so, means blood is flowing

backwards) If PCWP = PAD, look for tamponade Under circumstances where the catheter will not wedge (or

should not be), do not document any values in the PCWP

column on the flowsheet

If you use the PAD measurement for calculations, it isacceptable to write ONLY

PAD value used for calculations

at the top of your numbers


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Documents

Invasive Hemodynamic for Prep and Recovery