hemodynamics

HEMODYNAMICS

In the CRITICAL CARE UNIT

Sherry L. Knowles, RN, CCRN, CRNI

OBJECTIVES

Define Basic Hemodynamics

Understand The Risks and Benefits

Identify PA Catheter Components

Analyze Cardiac Profiles

Interpret Shock States

Learn Appropriate Interventions

Describe How To Optimize Cardiac Output

Recognize Potential Complications

Upon completion of this program the student will be able to:

OBJECTIVES

Collect appropriate equipment/supplies necessary to set-up a transducer pressure system.

State the correct solutions/medications used at Kaiser Vallejo for the flush bags.

Correctly level and zero the transducer. Correctly identify the location and purpose of each port/ lumen of

the PA catheter Identify in sequence the normal waveforms observed during PA

catheter insertion, and state the corresponding pressure. Correctly obtain the following pressures:

Pulmonary artery systolic, diastolic and mean Pulmonary capillary wedge. Central venous pressure.

Briefly describe the indications, limitations and complications of PA catheterization, guidelines for accurate monitoring, and troubleshooting techniques.

Upon completion of this program the student will be able to:

INDICATIONS

To diagnose shock states

To determine fluid volume status

To measure cardiac output

To monitor and manage unstable patients

To assess hemodynamic response to

therapies

To diagnose primary pulmonary hypertension,

valvular disease, intracardiac shunts, cardiac

tamponade, and pulmonary embolus

CONTRAINDICATIONS

Tricuspid or pulmonary valve mechanical prosthesis

Right heart mass (thrombus and/or tumor)

Tricuspid or pulmonary valve endocarditis

SWAN-GANZ CATHETERS

The Cordis Offers A Large Bore Infusion Port There Are Ten Types Of Swan-Ganz Catheters VIP Catheter Has Three Other Infusion Ports Large Markers = 50cm, Small Markers = 10cm

SWAN GANZ CATHETER

SWAN GANZ COMPONENTS

SWAN GANZ PLACEMENT

Bleeding Infection Dysrhythmias Pulmonary Artery Rupture Pneumothorax Hemothorax Valvular Damage Embolization Balloon Rupture Catheter Migration

RISKS WITH SWAN GANZ

INSERTION EQUIPMENT

EQUIPMENT NECESSARY FOR INSERTION Flush solution for transducer system Flush solution for cardiac output system Arterial access line Disposable triple pressure transducer system Pulmonary artery catheter Monitor, module, electrodes, cables Central line kit Transducer holder, I.V. pole, pressure bag Emergency resuscitation equipment Prepackaged Introducer Kit; sutures Sterile gowns, gloves, and masks

RA WAVEFORM

Normal Value 0-8 mmHg RAP = CVP Wave Fluctuations Due To Contractions

RV WAVEFORM

Normal Value 15-25/0-8 mmHg Catheter In RV May Cause Ventricular Ectopy Swan Tip May Drift From PA to RV

PA WAVEFORM

Normal Value 15-25/8-15 mmHg Dicrotic Notch Represents PV Closure PAD Approximates PAWP (LVEDP)

(in absence of lung or MV disease)

PAWP WAVEFORM

Normal Value 8-12 mmHg Balloon Floats and Wedges in Pulmonary Artery PAWP = LAP = LVEDP Wedging Can Cause Capillary Rupture

PA INSERTION WAVEFORMS

A = RA (CVP) Waveform B = RV Waveform C = PA Waveform D = PAWP Waveform

B

C D

A

PA CATHETER WAVEFORMS

A wave - due to atrial contraction. Absent in atrial fibrillation. Enlarged in tricuspid stenosis, pulmonary stenosis and pulmonary hypertension.

C wave - due to bulging of tricuspid valve into the right atrium or possibly transmitted pulsations from the carotid artery.

X descent - due to atrial relaxation.

V wave - due to the rise in atrial pressure before the tricuspid valve opens. Enlarged in tricuspid regurgitation.

Y descent - due to atrial emptying as blood enters the ventricle.

Canon waves - large waves not corresponding to a, v or c waves. Due to complete heart block or junctional arrhythmias.

PA INSERTION SEQUENCE

POST INSERTION

1. Assess ECG for dysrhythmias.

2. Assess for signs and symptoms of respiratory distress.

3. Ascertain sterile dressing is in place.

4. Obtain PCXR to check placement.

5. Zero and level transducer(s) at the phlebostatic axis.

6. Assess quality of waveforms (i.e., proper configuration, dampening, catheter whip).

7. Obtain opening pressures and wave form tracings for each waveform.

8. Assess length at insertion site.

9. Ensure that all open ends of stopcocks are covered with sterile dead-end caps (red dead-end caps, injection caps, or male Luer lock caps).

10. Update physician of abnormalities.

ZEROING & REFERENCING

Zeroing is performed by opening the system to air to establish atmospheric pressure as zero.

Referencing is accomplished by placing the air-fluid interface of the catheter (the transducer) at the phlebostatic axis.

PHLEBOSTATIC AXIS

RESPIRATORY VARIATION

Intrathoracic pressure decreases during spontaneous inspiration (ventilation) This presents a negative () deflection on a PAWP tracing

Intrathoracic pressure increases during spontaneous expiration This present a positive () deflection on a PAWP tracing

SPONTANUOUS VENTILATION:


Intrathoracic pressure increases during positive pressure ventilation (ventilator breaths)This presents a positive () deflection on a PAWP tracing

Intrathoracic pressure decreases during positive pressure expiration This present a negative () deflection on a PAWP tracing

POSITIVE PRESSURE VENTILATION:


Spontaneous Breathing

END EXPIRATION

RAP WAVEFORM

RAP WAVEFORM

(CVP) RA WAVEFORM & ECG

(CVP) RA WAVEFORM

(CVP) RA WAVEFORM

WEDGING THE CATHETER

PAWP TRACING

PAWP WAVEFORM

PAWP WAVEFORM

PAWP WAVEFORM

PA vs PAWP WAVEFORM

PA vs PAWP WAVEFORM

PAWP WAVEFORM & ECG

PAWP WAVEFORM

PAWP WAVEFORM

PAWP WAVEFORM

V WAVES

PAWP WAVEFORM

PAWP WITH V WAVES

SVO2 MONITORING

SVO2 MONITORING

Normal Values: 60-75%

Decreased () SVO2 Values Indicate

Increased Extraction

From Decreased Oxygen Delivery

or

From Increased Oxygen Demands

POTENTIAL COMPLICATIONS

POTENTIAL COMPLICATIONSSame as arterial pressure monitoring plus the following:

Air emboli Cardiac tamponade

Thromboembolism Dysrhythmias

Catheter displacement Balloon rupture

Infection Lung ischemia

Inaccurate pressures Electromicroshock

Equipment malfunction Pulmonary artery rupture

Pneumothorax/Hemothorax Frank Hemorrhage

Loss of balloon integrity Altered skin integrity

Pulmonary artery extravasation

PA hemorrhage or infarction

Air emboli Cardiac arrest

Wedging Can Cause Capillary Rupture Catheter In RV Can Cause Ventricular Ectopy Swan Tip Can Drift From PA to RV

POTENTIAL COMPLICATIONS

PERICARDIAL TAMPONADE

Hemodynamic monitoring can diagnose tamponade:

Pericardial tamponade presents with equalization of the diastolic pressures on the left and right side of the heart

Other PAP signs of pericardial tamponade include:

Elevated right atrial pressure

Kussmaul sign (increase in right atrial pressure with inspiration)

Pulsus Paradoxus

Elevated right atrial pressure (RAP)

Pulmonary artery diastolic pressure (PAD) = mean right atrial pressure(RA) = right ventricular (RV) diastolic pressure = mean wedge pressure

PRECAUTIONS

1) Always set alarms, approximately 20 mmHg above and below the patient’s readings.

2) If balloon is down and you find PA catheter tracing in wedge position, you may ask the patient to deep breathe and cough, or reposition patient in bed to dislodge it.

3) If unable to dislodge catheter from wedge position by above measures notify physician immediately to reposition catheter by pulling back gently; then, get chest x-ray to confirm proper placement.

4) If patient coughs up blood or it is suctioned via endotracheal tube, suspect PA rupture and notify physician immediately.

TROUBLESHOOTING

= 0-8 mm Hg

= 15-25 / 8-15 mm Hg

= 8-12 mm Hg

= 8-12mm Hg

= 50-100 ml/beat

= 4-8 L/min

= 2.5-4.0 L/min M2

= 0.60-0.75

Right Atrial Pressure (CVP)

Pulmonary Artery Pressure

Pulmonary Artery Wedge Pressure

Left Ventricular Diastolic Pressure

Stroke Volume

Cardiac Output

Cardiac Index

SVO2

NORMAL VALUES

DAMPENED PA WAVEFORM

PAWP WAVEFORM

ALTERATIONS IN SVO2

Optimize HR and SV (Stroke Volume) Stroke Volume =

PRELOADAFTERLOAD

CONTRACTILITY Chronotropic Medications Diuretics / Volume Vasodilators / Vasoconstrictors Inotropic Medications (Positive or Negative) IABP

OPTIMIZING CARDIAC OUTPUT

Shock StatesCardiogenic ShockHypovolemic ShockSeptic ShockAnaphylactic Shock

Cardiac Tamponade Left Ventricular Failure Right Ventricular Failure Pulmonary Hypertension

CARDIAC PROFILES

SHOCK PARAMETERS

Cardiogenic Shock is the only shock with PAWP.

Early (Hyperdynamic) Shock is the only shock with CO and SVR.

Neurogenic Shock is the only shock with bradycardia.

Anaphylactic Shock has the definitive characteristic of wheezing due to bronchospasm.

Parameter Hypovolemic Cardiogenic Neurogenic Anaphylactic Early Septic Late Septic

CVP/RAP

PAWP or Norm

CO

BP

SVR

HR Normal

TREATMENTS

SAMPLE MEASUREMENTS

MEASUREMENTS

SAMPLE MEASUREMENTS

Hemodynamic monitoring measures factors that influence the force and flow of blood.

Hemodynamic monitoring aids in diagnosing, monitoring and managing critically ill patients.

SUMMARY

THE END

REFERENCES

AACN (American Association of Critical Care Nurses). Clinical Care References. 2002

SCCM (Society of Critical Care Medicine. PACEP (Pulmonary Artery Catheter Education Project). 701 Lee Street, Suite 200, Des Plaines, Illinoise 60016. 2000.

Bridges, EJ, and Woods, SL. Pulmonary artery pressure measurement: State of the art. Heart Lung 1993; 22:99.

Mirini, JJ. Pulmonary artery occlusion pressure: Clinical physiology, measurement and interpretation. Am Rev Respir Dis 1983; 128:319.

Putterman, C. The Swan-Ganz catheter: A decade of hemodynamic monitoring. J Crit Care 1989; 4:127.

Nemens, EJ, Woods, SL. Normal Fluctuations in pulmonary artery and pulmonary capillary wedge pressures in acutely ill patients. Heart Lung 1982; 11:393.

Darovic, G.O., (1995) Hemodynamic monitoring: invasive and noninvasive clinical application (2d ed), New York: W. B. Saunders