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Hemodynamic Monitoring

Hemodynamic Monitoring Measurement of pressure, flow,

and oxygenation within the
and cardiovascular system
Circulatory Assist Devices Assesses heart function, fluid
balance, and effects of drugs on CO
Chapter 66

Copyright 2014 by Mosby, an imprint of Elsevier Inc. Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Hemodynamic Monitoring Hemodynamic Monitoring

Invasive and noninvasive Invasive and noninvasive

measurements measurements
Systemic and pulmonary arterial Stroke volume (SV)/stroke volume
pressures index (SVI)
Central venous pressure (CVP) Stroke volume variation (SVV)
Pulmonary artery wedge pressure O2 saturation of arterial blood (SaO2)
(PAWP) Mixed venous oxygenation saturation
Cardiac output (CO)/cardiac index (CI) (SvO2)
Copyright 2014 by Mosby, an imprint of Elsevier Inc. Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Hemodynamic Monitoring Hemodynamic Monitoring

Terminology Terminology
CO: volume of blood pumped by Systemic vascular resistance (SVR)
heart in 1 minute and pulmonary vascular resistance
CI: CO adjusted for body surface (PVR)
area (BSA) Opposition to blood flow by systemic
and pulmonary vasculature
SV: volume ejected with each
heartbeat Preload, afterload, and contractility
determine SV
SVI: SV adjusted for body size
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Hemodynamic Monitoring Hemodynamic Monitoring

Terminology Terminology
Preload Afterload
Volume of blood within ventricle at Forces opposing ventricular ejection
end of diastole SVR and arterial pressure indices of
PAWP: reflects left ventricular end- left ventricular afterload
diastolic pressure PVR and pulmonary arterial pressure
CVP: reflects right ventricular end- indices of right ventricular afterload
diastolic pressure

Copyright 2014 by Mosby, an imprint of Elsevier Inc. Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Hemodynamic Monitoring
Case Study
Terminology
iStockphoto/Thinkstock

Vascular resistance A.J., a 78-year-old male, is admitted

Systemic and pulmonary to the ICU in acute decompensated
Reflect afterload heart failure.
Contractility Health care provider decides to
Strength of ventricular contraction insert an arterial line and pulmonary
No direct clinical measure artery catheter to facilitate
treatment decisions.
Copyright 2014 by Mosby, an imprint of Elsevier Inc. Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Components of Pressure
Case Study
Monitoring System
iStockphoto/Thinkstock

What equipment will you collect in

preparation for insertion of these
lines?

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Principles of Invasive Pressure

Case Study
Monitoring
iStockphoto/Thinkstock

Why is it important to zero reference Equipment must be referenced and

the transducer and perform a zero balanced to environment and
dynamic response test during initial dynamic response characteristics
setup of the equipment for A.J.? optimized
Where is the phlebostatic axis Referencing: positioning transducer
located? so zero reference point is at level of
atria of heart or phlebostatic axis
Copyright 2014 by Mosby, an imprint of Elsevier Inc. Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Identification of the Principles of Invasive Pressure

Phlebostatic Axis Monitoring
Zeroing: confirms that when
pressure within system is zero,
monitor reads zero
Done by opening reference
stopcock to room air
With initial setup and periodically
thereafter
Copyright 2014 by Mosby, an imprint of Elsevier Inc. Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Dynamic Response Test

Types of Invasive Pressure
(Square Wave Test)
Monitoring
Arterial pressure monitoring
Various indications when continuous
BP measurements useful
20-gauge, 2-inch nontapered Teflon
catheter into peripheral artery
Suture in place
Immobilize insertion site
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Arterial Pressure Monitoring Case Study

iStockphoto/Thinkstock

When planning care for A.J., what

nursing interventions will you
perform to prevent complications
related to his arterial line?

Copyright 2014 by Mosby, an imprint of Elsevier Inc. Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Arterial Pressure Monitoring Arterial Pressure Monitoring

High- and low-pressure alarms Continuous flush irrigation system
Risks/complications Delivers 36 mL of saline/hour
Hemorrhage Maintains line patency
Infection Limits thrombus formation
Thrombus formation
Neurovascular impairment Assess neurovascular status distal to
arterial insertion site hourly
Loss of limb

Copyright 2014 by Mosby, an imprint of Elsevier Inc. Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Arterial Pressure-Based CO Arterial Pressure-Based CO

(APCO) Monitoring (APCO) Monitoring
Calculates continuous CO and CI
Used to assess patients ability to
respond to fluids
Uses arterial waveform characteristics
and patient demographic data to
calculate SVV, CCO/CCI, and SV/SVI
every 20 seconds

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Pulmonary Artery Pressure Pulmonary Artery Pressure

Monitoring Monitoring
PA flow-directed catheter (e.g.,
Guides management of patients
with complicated cardiopulmonary Swan-Ganz)
problems Distal lumen port in PA
PA diastolic (PAD) pressure and Balloon inflated to measure PAWP
PAWP cardiac function and fluid Two proximal lumens to measure CVP,
volume status inject fluid for CO, draw blood,
administer fluids or drugs
Allows for precise manipulation of
preload Thermistor port distally
Copyright 2014 by Mosby, an imprint of Elsevier Inc. Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Pulmonary Artery Pressure

PA Catheter
Monitoring
Specialized features
Atrial electrode
Fiberoptic sensor for mixed venous O2
saturation
Continuous measurement of right
ventricular volume and EF
Continuous CO monitoring
Additional ports for IV access
Copyright 2014 by Mosby, an imprint of Elsevier Inc. Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Pulmonary Artery Pressure PA Waveforms During

Monitoring Insertion

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Pulmonary Artery Pressure

Case Study
Monitoring
iStockphoto/Thinkstock

After insertion of the PA line, the When measurements are obtained:

health care provider orders PAWP PA: at end expiration
and CO measurement every 4 hours. PAWP: slowly inflate balloon with air
How will you obtain the PAWP until PA waveform changes to PAWP
measurement? waveform
Do not inflate for more than four
respiratory cycles or 815 seconds

Copyright 2014 by Mosby, an imprint of Elsevier Inc. Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Pulmonary Artery Pressure

Effect of Overinflated Balloon
Monitoring

Copyright 2014 by Mosby, an imprint of Elsevier Inc. Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Central Venous Pressure Central Venous Pressure

Monitoring Waveforms
Measurement of right ventricular
preload reflects fluid volume
Obtained from:
Central venous catheter
PA catheter
Similar to PAWP waveforms

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Measuring Cardiac Output Case Study

iStockphoto/Thinkstock

Continuous cardiac output (CCO) A.J.s pulmonary catheter does not

PA catheter with thermal filament have the capability to obtain
located in right atrium continuous CO measurements.
Senses change in temperature of blood
How will you perform an
as it passes through right ventricle
intermittent bolus thermodilution
Measures every 3060 seconds
CO assessment for A.J.?
Reflects average CO for past 36
minutes
Copyright 2014 by Mosby, an imprint of Elsevier Inc. Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Measuring Cardiac Output Measuring Cardiac Output

Intermittent bolus thermodilution

(TDCO)
Inject saline or D5W into proximal
lumen of PA catheter
Thermistor sensor detects differences
in blood temperature and calculates
CO
Uses average of three measurements
Copyright 2014 by Mosby, an imprint of Elsevier Inc. Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Measuring Cardiac Output Venous Oxygen Saturation

SVR, SVRI, SV, and SVI calculated PA and CVP catheters can be used
when CO is measured CVP measures central venous
SVR oxygen saturation (ScvO2)
Indicates vasoconstriction PA measures mixed venous oxygen
saturation (SvO2)
SVR
Determines adequacy of tissue
Indicates vasodilation
oxygenation
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Venous Oxygen Saturation Venous Oxygen Saturation

SvO2/ScvO2 reflect balance In SvO2/ScvO2

between oxygenation of arterial Arterial oxygenation
blood, tissue perfusion, and Low CO
tissue oxygen consumption. Low hemoglobin level
Oxygen consumption or extraction
Assess hemodynamic status and
response to treatment/activity
Normal 60%80%
Copyright 2014 by Mosby, an imprint of Elsevier Inc. Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Venous Oxygen Saturation Case Study

iStockphoto/Thinkstock

In SvO2/ScvO2 What nursing interventions will you

May indicate clinical improvement plan to prevent complications
(e.g., improved arterial oxygen related to A.J.s pulmonary artery
saturation) catheter?
Worsening clinical condition
(e.g., sepsis)

Copyright 2014 by Mosby, an imprint of Elsevier Inc. Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Complications with PA Complications with PA

Catheters
Infection and sepsis
Asepsis for insertion and maintenance
Change flush bag, pressure tubing,
transducer, and stopcock every 96
hours
Air embolus (e.g., disconnection)
Monitor for balloon integrity
Luer-Lok connections; alarms on
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Catheters
Pulmonary infarction or PA rupture
Do not inflate balloon with >1.5 ml
Monitor waveforms continuously
Maintain continuous flush system
Ventricular dysrhythmias
Monitor during insertion and removal
Also for migration of PA catheter
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Noninvasive Arterial Oxygenation

Case Study
Monitoring
iStockphoto/Thinkstock

A.J.s PA diastolic and PCWP are Pulse oximetry

elevated. Continuous method of determining
arterial oxygenation (SpO2)
Normal 95%100%
What does this mean?
Accurate measurements may be
difficultconsider forehead or earlobe
Used to evaluate effectiveness of O2
therapy
Copyright 2014 by Mosby, an imprint of Elsevier Inc. Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Noninvasive Hemodynamic Nursing Management

Monitoring
Impedance cardiography (ICG) Obtain baseline observational data
Noninvasive method of obtaining CO General appearance
and assessing thoracic fluid status Level of consciousness
Based on concept of impedance
Skin color/temperature
Uses four sets of external electrodes
Measures change in impedance in Vital signs
ascending aorta and left ventricle Peripheral pulses
Calculates CO, SV, and SVR Urine output
Copyright 2014 by Mosby, an imprint of Elsevier Inc. Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Circulatory Assist Devices

Nursing Management
(CADs)
Correlate baseline data with data Decrease cardiac work and improve
obtained from biotechnology organ perfusion when drug therapy
(e.g., ECG; arterial, CVP, PA, and fails
PAWP pressures; SvO2/ScvO2) Provide interim support when:
Monitor trends Recovering from acute injury
Stabilizing before surgical repair
Awaiting cardiac transplant

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Case Study Case Study

iStockphoto/Thinkstock iStockphoto/Thinkstock

Despite aggressive medical care, The health care provider decides to

A.J.s heart failure does not respond insert an intraaortic balloon pump
to medical treatment. (IABP).
What is the purpose of the IABP?
How does it work?

Copyright 2014 by Mosby, an imprint of Elsevier Inc. Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Intraaortic Balloon Pump Intraaortic Balloon Pump

(IABP) (IABP)
Most common CAD Consists of:
Benefits Sausage-shaped balloon
ventricular workload Pump that inflates and deflates
myocardial perfusion balloon
Augment circulation Control panel for synchronizing
balloon inflation to cardiac cycle
Temporary use only
Fail-safe features
Copyright 2014 by Mosby, an imprint of Elsevier Inc. Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Intraaortic Balloon Pump

IABP Machine
(IABP)
Balloon inserted into femoral artery
and placed in thoracic aorta
Confirm placement with x-ray
Inflate balloon with helium in
conjunction with ECG

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Intraaortic Balloon Pump

IABP Timing
(IABP)

Copyright 2014 by Mosby, an imprint of Elsevier Inc. Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Intraaortic Balloon Pump Intraaortic Balloon Pump

(IABP) (IABP)
Complications of IABP therapy Complications of IABP
Vascular injuries Mechanical complications
Thrombus and embolus formation Improper timing of balloon inflation
Thrombocytopenia Balloon leak
Peripheral nerve damage Malfunction of balloon or console
Ischemia to periphery, kidneys, bowel
Infection
Copyright 2014 by Mosby, an imprint of Elsevier Inc. Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Intraaortic Balloon Pump

Case Study
(IABP)
iStockphoto/Thinkstock

When updating the plan of care for To decrease risks of IABP therapy
A.J., what interventions will you Frequent assessments
include related to the IABP? Keep patient immobile and limited to
side-lying or supine positions with
HOB <45 degrees
Wean from IABP by gradually
reducing assist ratio
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Ventricular Assist Devices Ventricular Assist Devices

(VADs) (VADs)
Short- and long-term support VADs can
Allows more mobility than IABP Be implanted (e.g., peritoneum) or
positioned externally
Inserted into path of flowing blood
to augment or replace action of Provide biventricular support
ventricle
Internal or external
Left, right, or biventricular
Copyright 2014 by Mosby, an imprint of Elsevier Inc. Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Schematic Diagram of Ventricular Assist Devices

Biventricular Assist Device (VADs)
Indications for VAD therapy
Failure to wean from bypass
Failure after MI
Bridge while awaiting transplant
Cannula sites depend on type of
device used

Copyright 2014 by Mosby, an imprint of Elsevier Inc. Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Management Nursing Management

Ventricular Assist Devices Circulatory Assist Devices
Goal
Similar to care for patient with an Recovery through ventricular improvement
IABP Heart transplantation
Frequent assessments and observe for Artificial heart implantation
complications Many patients die or choose to terminate
Patient may be mobile and will require device, causing death
an activity plan Emotional support for patient and
In-depth teaching if discharged to caregiver essential
home
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Audience Response Question

The nurse is caring for a patient with a pulmonary

artery catheter. If the pulmonary artery
waveform is blunted, the nurse will suspect which
problem?
a. The catheter balloon is overinflated.
b. The catheter is occluded by a thrombus.
c. The catheter is wedged in a pulmonary artery.
d. The catheter has migrated to the right
ventricle.

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