BYUMA

IIND YEAR MSC NURSING

SEMINAR ON HEMODYNAMIC

MONITORINGBY

UMAdevi.kIIND YEAR MSc NURSING

The oxford college of nursing

INTRODUCTION

Critically ill patients require continuos assessment of their

cardiovascular system to diagnose and manage their complex

medical conditions.This is most commonly achieved by the use

of direct pressure monitoring systems,often refered to as

hemodynamic monitoring.Heart function is the main focus of

hemodynamic studies. Hemodynamic pressure monitoring

provides information about blood volume , fluid balance and

how well the heart is pumping. Nurses are responsible for the

collection measurement and interpretation of these dynamic

patient status parameters.

HEMODYNAMIC MONITORING

HEMODYNAMICS

Hemodynamics are the forces which circulate blood through the body. Specifically, hemodynamics is the term used to describe the intravascular pressure and flow that occurs when the heart muscle contracts and pumps blood throughout the body.

DEFINITIONHemodynamic monitoring refers to measurement of pressure, flow and

oxygenation of blood within the cardiovascular system.

ORUsing invasive technology to provide

quantitative information about vascular capacity, blood volume, pump effectiveness

and tissue perfusion. 

OR Hemodynamic monitoring is the

measurement and interpretation of biological sytems that describes the performance of

cardiovascular system

PURPOSES

Early detection, identification and treatment of life threatening conditions such as heart failure and cardiac tamponade.

Evaluate the patient’s immediate response to treatment such as drugs and mechanical support.

Evaluate the effectiveness of cardiovascular function such as cardiac output and index.

INDICATIONS

Any deficits or loss of cardiac function: such as myocardial infarction, congestive heart failure, cardiomyopathy.

All types of shock; cardiogenic shock, neurogenic shock or anaphylactic shock.

Decreased urine output from dehydration, hemorrhage. G.I bleed, burns or surgery.

SPECIALISED EQUIPMENTS NEEDED FOR INVASIVE

MONITORING A CVP,pulmonary artery ,arterial catheter

A flush system composed of intravenous solution,tubing stop cocks and a flush device which provides for continous and manual flushing of system.

A pressure bag placed around the flush solution that is maintained at 300 mmhg pressure ;the pressurized flush system delivers 3-5ml of solution per hour through the catheter to prevent clotting and backflow of blood into the pressure monitoring system.

A tranducer to convert the pressure coming from artery or heart chamber into an electrical signal

An amplifier or moniter which increases the size of electrical signal for display on an occilloscope.

HEMODYNAMIC MONITER

SETUP FOR HEMODYNAMIC PRESSURE MONITORING

Obtain barrier kit, sterile gloves and correct swan catheter. Also need extra iv pole, transducer holder, boxes and cables.

Check to make sure signed consent is in chart , and that patient and or family understand procedure.

Everyone in the room should be wearing a mask.

Position patient supine and flat if tolerated. On the monitor , press “change screen” button , then

select “swan ganz” to allow physician to view catheter wave forms which inserting.

Assist physician in sterile draping and sterile setup for swan insertion.

Setup pressure lines and transducers. Level pressure flush monitoring system and transducers to the phlebostatic axis.

Connect tubings to patient when patient is ready to flush the swann.

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

After swann is in place, assist with cleanup and let patient know procedure is complete.

Obtain all the values. For cardiac output inject 10mls of D5w after pushing the start button.

Perform hemocalculations.

Document findings in ICU flow sheet.

PHLEBOSTATIC AXIS

DETERMINANTS OF CARDIAC PERFORMNACE

PRELOAD (estimated by end diastolic volume CVP for RVEDV ; PAOP (wedge) pressure for LVEDV

AFTERLOAD (SVR = [MAP-CVP]/CO*80)

CONTRACTILITY

METHODS OF HEMODYNAMIC MONITORING

1.ARTERIAL BLOOD PRESSURE a)Non Invasive b)Intra arterial blood pressure

measurement 2.CENTRAL VENOUS PRESSURE 3.PULMONARY ARTERY

CATHETER PRESSURE MONITORING

NON INVASIVE ARTERIAL BP MONITORING

With manual or automated devices Method of measurement

Oscillometry (most common) MAP most accurate DP least accurate

Auscultatory (korotkoff sounds)

Combination

NON INVASIVE

HEMODYNAMIC MONITORING

LIMITATIONS

Cuff must be placed correctly and must be appropriately sized

Auscultatory method is very inaccurate (Korotkoff sound is difficult to hear)

Significant underestimation in low flow (shock)

Oscillometric also mostly in accurate ( >5mmhg off directly recorded pressures)

DIRECT INTRA ARTERIAL BP MONITORING

Intra-arterial BP monitoring is used to obtain direct and continuous BP measurements in critically ill patients who have severe hypertension or hypotension

PROCEDURE  Once an arterial site is selected (radial,

brachial, femoral, or dorsalis pedis), collateral circulation to the area must be confirmed before the catheter is placed. This is a safety precaution to prevent compromised arterial perfusion to the area distal to the arterial catheter insertion site. If no collateral circulation exists and the cannulated artery became occluded, ischemia and infarction of the area distal to that artery could occur.

Collateral circulation to the hand can be checked by the Allen test

With the Allen test, the nurse compresses the radial and ulnar arteries simultaneously and asks the patient to make a fist, causing the hand to blanch.

After the patient opens the fist, the nurse releases the pressure on the ulnar artery while maintaining pressure on the radial artery. The patient’s hand will turn pink if the ulnar artery is patent.

 

COMPLICATIONS

Local destruction with distal ischemia external hemorrhage massive ecchymosis dissection air embolism blood loss pain arteriospasm and infection.

NURSING INTERVENTIONS Before insertion of a catheter, the site is

prepared by shaving if necessary and by cleansing with an antiseptic solution. A local anesthetic may be used.

Once the arterial catheter is inserted, it is secured and a dry, sterile dressing is applied.

The site is inspected daily for signs of

infection. The dressing and pressure monitoring system or water manometer are changed according to hospital policy.

In general, the dressing is to be kept dry and air occlusive.

Dressing changes are performed with the use of sterile technique.

Arterial catheters can be used for infusing intravenous fluids, administering intravenous medications, and drawing blood specimens in addition to monitoring pressure.

To measure the arterial pressure, the transducer (when a pressure monitoring system is used) or the zero mark on the manometer (when a water manometer is used) must be placed at a standard reference point, called the phlebostatic axis .

After locating this position, the nurse may make an ink mark on the chest

CENTRAL VENOUS PRESSURE MONITORING

The CVP, the pressure in the vena cava or right atrium, is used to assess right ventricular function and venous blood return to the right side of the heart. The CVP can be continuously measured by connecting either a catheter positioned in the vena cava or the proximal port of a pulmonary artery catheter to a pressure monitoring system

PROCEDURE

Before insertion of a CVP catheter, the site is prepared by shaving if necessary and by cleansing with an antiseptic solution.

A local anesthetic may be used. The physician threads a single lumen or multilumen catheter through the external jugular, antecubital, or femoral vein into the vena cava just above or within the right atrium

NURSING INTERVENTIONS

Once the CVP catheter is inserted, it is secured and a dry, sterile dressing is applied.

Catheter placement is confirmed by a chest x-ray, and the site is inspected daily for signs of infection. The dressing and pressure monitoring system or water manometer are changed according to hospital policy.

In general, the dressing is to be kept dry and air occlusive.

Dressing changes are performed with the use of sterile technique.

CVP catheters can be used for infusing intravenous fluids, administering intravenous medications, and drawing blood specimens in addition to monitoring pressure.

To measure the CVP, the transducer (when a pressure monitoring system is used) or the zero mark on the manometer (when a water manometer is used) must be placed at a standard reference point, called the phlebostatic axis .

After locating this position, the nurse may make an ink mark on the chest

PULMONARY ARTERY PRESSURE MONITORING

Pulmonary artery pressure monitoring is an

important tool used in critical care for assessing

left ventricular function, diagnosing the etiology of

shock, and evaluating the patient’s response to

medical interventions (eg, fluid administration,

vasoactive medications). Pulmonary artery

pressure monitoring is achieved by using a

pulmonary artery catheter and pressure

monitoring system.

PULMONARY ARTERY PRESSURE MONITORING

PULMONARY ARTERY CATHETER

Development of the balloon-tipped flow directed catheter has enabled continuous direct monitoring of PA pressure. Pulmonary artery catheter otherwise known as “swan- ganz catheter”.

COMPONENTS OF CATHETER

INSERTION OF PAC

PA monitoring must be carried out in a critical care unit under careful scrutiny of an experienced nursing staff.

Before insertion of the catheter , explain to the client that;

The procedure may be uncomfortable but not painful.

A local anesthetic will be given at the catheter insertion site. Support of the critically ill client at this time helps promote cooperation and lessen anxiety.

Procedure This procedure can be performed in the

operating room or cardiac catheterization laboratory or at the bedside in the critical care unit.Catheters vary in their number of lumens and their types of measurement (eg, cardiac output, oxygen saturation) or pacing capabilities.

All types require that a balloon-tipped, flow-directed catheter be inserted into a large vein (usually the subclavian, jugular, or femoral vein); the catheter is then passed into the vena cava and right atrium.

In the right atrium, the balloon tip is inflated, and the catheter is carried rapidly by the flow of blood through the tricuspid valve, into the right ventricle, through the pulmonic valve, and into a branch of the pulmonary artery.

(During insertion of the pulmonary artery catheter, the bedside monitor is observed for waveform andECG changes as the catheter is movedthrough the heart chambers on the right side and into the pulmonary Artery)

When the catheter reaches a small pulmonary artery, the balloon is deflated and the catheter is secured with sutures.

Fluoroscopy may be used during insertion to visualize the progression of the catheter through the heart chambers to the pulmonary artery.

After the catheter is correctly positioned, the following pressures can be measured:

CVP or right atrial pressure pulmonary artery systolic and diastolic pressures, mean pulmonary

artery pressure, and pulmonary artery wedge pressure).

NORMAL RESULTS

Normal pulmonary artery pressure is 25/9 mm Hg, with a mean pressure of 15 mm Hg.

Pulmonary capillary wedge pressure is a mean pressure and is normally 4.5 to 13 mm Hg.

NURSING INTERVENTIONS Catheter site care is essentially the same as for a CVP

catheter. As in measuring CVP, the transducer must be positioned at the phlebostatic axis to ensure accurate readings .

The nurse who obtains the wedge reading ensures that the catheter has returned to its normal position in the pulmonary artery by evaluating the pulmonary artery pressure waveform.

The pulmonary artery diastolic reading and the wedge pressure reflect the pressure in the ventricle at end-diastole and are particularly important to monitor in critically ill patients, because they are used to evaluate left ventricular filling pressures (preload)

At end-diastole, when the mitral valve is open, the wedge pressure is the same as the pressure in the left atrium and the left ventricle, unless the patient has mitral valve disease or pulmonary hypertension.

Critically ill patients usually require higher left ventricular filling pressures to optimize cardiac output. These patients may need to have their wedge pressure maintained as high as 18 mm Hg.

COMPLICATIONS Infection pulmonary artery rupture pulmonary thromboembolism pulmonary infarction catheter kinking, dysrhythmias, and air embolism.

TECHNIQUES WITH PULMONARY ARTERY CATHETER

CARDIAC OUTPUT MONITORING THERMODILUTION CONTINUOUS CARDIAC OUTPUT

MONITORING FICK'S CARDIAC OUTPUT MEASUREMENT

CO = VO2 --------- CA-CV

DERIVED PARAMETERS

Cardiac o/p measurements may be combined with systemic arterial, venous, and PAP determinations to calculate a number of variables useful in assessing the overall hemodynamic status of the patient.

They are, Cardiac index = Cardiac output / Body surface area Systemic vascular resistance = [(Mean arterial

pressure - resistance CVP or rt atrial pressure)/Cardiac output] x 80

Pulmonary vascular resistance = [(PAP - PAWP) / Cardiac vascular resistance output] x 80

Mixed venous oxygen saturation (SvO2)

(SvO2 = SaO2 - [VO2 / (1.36 x Hb x CO)] (6)

NURSING RESPONSIBILITIES Site Care and Catheter Safety: A sterile dressing is placed over the insertion

site and the catheter is taped in place. The insertionsite should be assessed for infection and the dressing changed every 72 hours and prn.

The placement of the catheter, stated in centimeters, should be documented and assessed every shift.

The integrity of the sterile sleeve must be maintained so the catheter can be advanced or pulled back without contamination.

The catheter tubing should be labeled and all the connections secure. The balloon should always bedeflated and the syringe closed and locked unless you are taking a PCWP measurement

Patient Activity and Positioning:

Many physicians allow stable patients who have PA catheters, such as post CABG patients, to getout of bed and sit. The nurse must position the patient in a manner that avoids dislodging thecatheter.

Proper positioning during hemodynamic readings will ensure accuracy.

Dysrhythmia Prevention:

Continuous EKG monitoring is essential while the PA catheter is in place.

Do not advance the catheter unless the balloon is inflated.

Antiarrhythmic medications should be readily available to treat lethal dysrhythmias.

Monitoring Waveforms for Proper Catheter Placement:

The nurse must be vigilant in assessing the patient for proper catheter placement. If the PA waveform suddenly looks like the RV or PCWP waveform, the catheter may have become misplaced. The nurse must implement the proper procedures for correcting the situation.

Monitoring Hemodynamic Values for Response to

Treatments:

The purpose of the PA catheter is to assist healthcare team members in assessing the patient’s condition and response to treatment. Therefore, accurate documentation of values before and after treatment changes is necessary.

Assessing the Patient for Complications Associated with the PA Catheter: Occluded ports Balloon rupture caused by overinflating the balloon

or frequent use of the balloon. Pneumothorax - may occur during initial placement. Dysrhythmias - caused by catheter migration Air embolism - caused by balloon rupture or air in

the infusion line. Pulmonary thromboembolism - improper flushing

technique, non-heparinized flush solution. Pulmonary artery rupture - perforation during

placement, overinflation of the balloon, overuse of the balloon.

Pulmonary infarction - caused by the catheter migrating into the wedge position, the balloon left inflated, or thrombus formation around the catheter which causes an occlusion.

CONCLUSION  Hemodynamics is the forces involved in blood

circulation. Hemodynamic monitoring started with the

estimation of heart rate using the simple skill of 'finger

on the pulse' and then moved on to more and more

sophisticated techniques like stethoscope,

sphygmomanometer, ECG etc. The status of critically ill

patients can be assessed either from non-invasive single

parameter indicators or various invasive techniques that

provide multi-parameter hemodynamic measurements.

As a result, comprehensive data can be provided for the

clinician to proactively address hemodynamic crisis and

safely manage the patient instead of reacting to late

indicators of hemodynamic instability

THANK UUUUUUUUU………………………….