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Basic hemodynamic monitoring for nurses

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This is a very simple presentation prepared for nurses. It will help nurses to understand the need of monitoring and the available methods. The presentation has been constructed on a clinical case base scenario and gradually different methods of monitoring has been introduced.

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Basic hemodynamic monitoring for nurses

  1. 1. Basic Hemodynamic Monitoring (Nurses Concept) Muhammad Asim Rana BSc, MBBS, MRCP, MRCPS, EDIC, SF-CCM, FCCP Intensive Care Medicine King Saud Medical City
  2. 2. You said patient is the most important !
  3. 3. Objectives • Review: – purposes of Hemodynamic Monitoring – indications for Hemodynamic Monitoring – Biological sensors and monitoring – Pulse oximetry – Automated blood pressure devices – Arterial, central venous, and pulmonary artery catheters – Cardiac output and oxygen delivery variables
  4. 4. • Mrs. A. a 76 yrs old female with a previous history of congestive heart failure, is admitted with clinical and laboratory evidence of a urinary tract infection. Referred to ICU because of shock state.
  5. 5. ►Goals – Confirm diagnosis – Initiate treatment – Monitor for improvement or worsening in her condition • What is shock? • How to treat the shock? • How to monitor?
  6. 6. Shock and its types • Failure to deliver and/or utilize adequate amounts of Oxygen • Types – Hypovolemic Shock – Cardiogenic Shock – Distributive Shock – Obstructive Shock
  7. 7. Circulation & Oxygen transport
  8. 8. 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.
  9. 9. Hemodynamic monitoring refers to measurement of pressure, flow and oxygenation of blood within the cardiovascular system. OR Using 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
  10. 10. Purpose of monitoring • 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.
  11. 11. Indications All types of shock: – Cardiogenic shock – Distributive shock – Obstructive shock – Hypovolemic shock
  12. 12. Types of Hemodynamic Monitoring • Non-invasive = clinical assessment & NBP • Direct measurement of arterial pressure • Invasive hemodynamic monitoring ►Continuous vs. intermittent ►Invasive vs. noninvasive ►Never therapeutic but may be diagnostic 12
  13. 13. Noninvasive Hemodynamic Monitoring • Noninvasive BP • Heart Rate, pulses • Mental Status • Mottling 13 • Skin Temperature • Capillary Refill • Urine Output • Pulse Oxymetry
  14. 14. Pulse Oxymetry • Estimates Oxyhemoglobin as SpO2 • Target SpO2 > 92% • Heart rate displayed should be same as pulse rate captured by the probe
  15. 15. Oxyhemoglobin Saturation Curve
  16. 16. Oximeter Sensors
  17. 17. Pulse Oximetry Sources of error • Physiological/ anatomical • Vasoconstriction • Poor perfusion • Abnormal hemoglobin • Skin pigmentation • Cold extremities • External causes • Motion artifact • Excessive external light
  18. 18. Automated Blood Pressure measuring devices • Intermittent measurements • Appropriate cuff size necessary • Less accurate during hypotension, arrhythmias
  19. 19. 19 Proper Fit of a Blood Pressure Cuff • Width of bladder = 2/3 of upper arm • Length of bladder encircles 80% arm • Lower edge of cuff approximately 2.5 cm above the antecubital space
  20. 20. 20 Why A Properly Fitting Cuff? • Too small causes false-high reading • Too LARGEcauses false-low reading
  21. 21. Back to our patient • Patient was persistently hypoxic, hypotensive so electively intubated and ventilated. • What would you like to do for better monitoring of your patient ? • Inotropes requirement is increasing. • Oxygen requirement is varying.
  22. 22. Invasive BP monitoring
  23. 23. Invasive Arterial Blood Pressure Monitoring • Indications • Frequent titration of vasoactive drips • Unstable blood pressure • Frequent ABGs or labs • If unable to obtain Non- invasive BP • Sites – Radial artery – Brachial artery – Femoral – Dorsalis pedis artery • Complications – Hematoma/blood loss – Thrombosis – distal ischemia – Arterial injury – Infection 23 Tubing and transducer should be replaced every 96 hours.
  24. 24. Supplies to Gather • Arterial Catheter • Pressure Tubing • Pressure Cable • Pressure Bag • Flush – 500cc NS • Sterile Gown • Sterile Towels • Sterile Gloves • Suture (silk 2.0) • Chlorhexidine Swabs • Mask
  25. 25. Leveling and Zeroing • Leveling – Before/after insertion – If patient, bed or transducer move • Zeroing – Performed before insertion & readings • Level and zero at the insertion site 25 • Phlebostatic Axis
  26. 26. •Re-level the transducer with any change in the patient’s position •Referencing the system 1 cm above the left atrium decreases the pressure by 0.73 mm Hg •Referencing the system 1 cm below the left atrium increases  the pressure by 0.73 mm Hg Angles 45° 30° 0° Importance of zeroing
  27. 27. Arterial pressure measurement • The systolic pressure is measured at the peak of the waveform. • This pressure reflects the function of the left ventricle. • NORMAL value=100-130 mmHg • The LOWEST point on the waveform represents the end diastolic pressure. • This pressure reflects systemic resistance. • Normal diastolic pressure is 60-90 mmHg
  28. 28. Important Concepts Dicrotic notch • The small notch on the downstroke of the wave form. • It represents the closure of the aortic valve. • This is the reference point between the systolic and diastolic phases of the cardiac cycle. Mean Arterial Pressure/MAP • Is a calculated pressure that closely estimates the perfusion pressure in the aorta and its branches. • It represents the average systemic arterial pressure during the ENTIRE CARDIAC CYCLE. • Normal MAP = 70-100 mmHg • MAP MUST be maintained above 60 for the major organs to perfuse.
  29. 29. Dampening
  30. 30. Dampening
  31. 31. Dampening and Flush test Underdampening Normal Dampening
  32. 32. Invasive BP monitoring • Invasive monitoring is more accurate • Invasive BP should by higher than cuff BP • If cuff BP is higher look for equipment malfunction or technical error • A dampened wave form can indicate a move toward hypotension…an immediate cuff pressure should be obtained
  33. 33. 33 Documentation • Insertion procedure note • Arterial BP readings as ordered • Neurovascular checks every two hours (in musculoskeletal assessment of HED) • Pressure line flush amounts (3ml/hr) • Tubing and dressing changes
  34. 34. Nursing Implications • Prevent or reduce the potential for complications. • Maintain 300mmHg on bag • Maintain continuous flow through tubing • Aseptic dressing change • Sterile caps on openings • Change tubing q 96 hrs. • 5 min hold on discontinued site
  35. 35. Let’s see our patient • Arterial BP being monitored. • Fluid challenge given • Inotropes and vasopressors support augmented. • Physician asked for CVP & Mixed venous oxygen saturation…. • What is mixed venous oxygen saturation? • Difference between SVO2 and ScVO2 • How to measure them? • Concept of cardiac pressures and management strategies
  36. 36. Central Venous Pressure • Indications – Measure central venous pressure – Access for resuscitation – Selected drug administration – Placement of pulmonary artery catheter • Complications – Hematoma/vessel injury/blood loss – Pneumothorax/hemothorax – Cardiac arrhythmias – Infection
  37. 37. Central Venous catheter position
  38. 38. Central Venous catheter position
  39. 39. Central venous pressure measurement
  40. 40. Patient position & transducer level
  41. 41. Factors affecting CVP waves
  42. 42. CVP/ Right Atrial Pressure Monitoring • A direct measure of the right atrium pressure • Clinical significance: REFLECTS RIGHT VENTRICULAR DIASTOLIC PRESSURE • Abnormalities in RAP are caused by conditions that alter venous tone, blood volume, or right ventricular contractility • CVP is measured at end expiration
  43. 43. Right Atrial Pressure Monitoring Indications • Measure right atrial pressure (RAP) • Same as Central Venous Pressure (CVP) • Assess blood volume; reflects preload to the right side of the heart • Assess right ventricular function • Infusion site for large fluid volume • Infusion site for hypertonic solutions
  44. 44. Reasons for elevated RA pressure: • decreased right (or single) ventricle compliance • tricuspid valve disease • Intravascular volume overload • cardiac tamponade • tachyarrhythmia Right Atrial Pressure Mean: 1 to 7 mm Hg
  45. 45. Reasons for reduced RA pressure: • low intravascular volume status • inadequate preload Right Atrial Pressure Mean: 1 to 7 mm Hg
  46. 46. Right Atrial Pressure Monitoring Complications • Pneumothorax • Hemothorax • Hemorrhage • Cardiac tamponade • Vessel, RA, or RV perforation • Arrhythmias • Air embolism • Pulmonary embolism • Thromboembolism • Infection
  47. 47. Right Atrial Pressure Monitoring Waveform Analysis • a wave: rise in pressure due to atrial contraction • x decent: fall in pressure due to atrial relaxation • c wave: rise in pressure due to ventricular contraction and closure of the tricuspid valve • v wave: rise in pressure during atrial filling • y decent: fall in pressure due to opening of the tricuspid valve and onset of ventricular filling
  48. 48. Right Atrial Pressure Monitoring Waveform Analysis • Elevated RAP • RV failure • Tricuspid regurgitation • Tricuspid stenosis • Pulmonary hypertension • Hypervolemia • Cardiac tamponade • Chronic LV failure • Ventricular Septal Defect • Constrictive pericarditis • Decreased RAP • Hypovolemia • Increased contractility
  49. 49. Nursing HOURLY assessment: 1. Air in line or stopcocks 2. Precipitates 3. Leaking at site 4. Increasing resistance 5. Condition of entrance sites Dressing change policy at LPCH Arterial line prn (when seal is broken, wet, old blood, etc) Non-tunneled CVC Q 7 days & prn (Tegaderm & biopatch) Tunneled CVC Q7 days & prn (Tegaderm & biopatch) Intracardiac catheter Q 7 days & prn (Tegaderm & biopatch)
  50. 50. Our patient Mrs A. • The CVP > 12 • FiO2 requirement has increased. • ScVO2 < 50% • Physician has concern about cardiac status. • Need to distinguish between cardiogenic and septic shock… • Role of cardiac out put in oxygen delivery? • How to determine the cardiac status? • Non-invasive – Echo • Invasive – Swan-Ganz (PAC) – Picco
  51. 51. Some common terminologies… • Preload • Afterload • Cardiac Output • Cardiac Index • Systemic Vascular Resistance [SVR] • Pulmonary Vascular Resistance [PVR]
  52. 52. Understanding basic terms Preload • Is the degree of muscle fiber stretching present in the ventricles right before systole • Is the amount of blood in a ventricle before it contracts; also known as “filling pressures” • Left ventricular preload is reflected by the PCWP • Right ventricular preload is reflected by the CVP [RAP] 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
  53. 53. Understanding basic terms Cardiac output/Index • Is the amount of blood ejected from the ventricle in one minute • Two components multiply to make the cardiac output: heart rate and stroke volume [amount of blood ejected with each contraction] • Cardiac index is the cardiac output adjusted for body surface area (BSI) Vascular Resistance • Systemic Vascular Resistance – reflects left ventricular afterload • Pulmonary Vascular Resistance – reflection of right ventricular afterload • Many of the drugs we administer will affect Preload, Afterload, SVR/PVR, Cardiac Output
  54. 54. Normal Cardiac Pressures
  55. 55. Concept of right and left sides
  56. 56. Equipment Needed SET-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 “Swan Ganz” to allow physician to view catheter waveforms while inserting. 6. Assist physician (s) in sterile draping and sterile setup for cordis and swan insertion.
  57. 57. Equipment Needed 7. Set up pressure lines and transducers 8. Please level pressure flush monitoring system and transducers to the phlebostastic axis. Zero the transducers. Also check to make sure all connections are secure. 9. Connect tubings to patient [PA port and CVP port] when physician is ready to flush the swann. Flush all ports of swann before inserting. 10. While floating the swann, observe for ventricular ectopy on the monitor, and make physician aware of frequent PVC’s or runs of VT ! 11. After swann is in place, assist with cleanup and let patient know procedure is complete.
  58. 58. Measuring Cardiac output 11. 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 0.9% NS 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 today’s height and weight). 14. Document findings on the ICU flowsheet.
  59. 59. PA Insertion Waves
  60. 60. Pulmonary Capillary Wedge Pressure (PCWP) • Zero the transducer to the patient’s phlebostatic axis. • Measure the PCWP at end expiration • PCWP should not be higher than PA diastolic • PCWP is an indirect measurement of left ventricular end diastolic pressure.
  61. 61. Possible Complications • Increased risk of infections – same as with any central venous lines—use occlusive dressing and Biopatch to prevent • Thrombosis and emboli-- air embolism may occur when the balloon ruptures, clot on end of catheter can result in pulmonary embolism • Catheter wedges permanently—considered an emergency, notify MD immediately, can occur when balloon is left inflated or catheter migrates too far into pulmonary artery (flat PA waveform)…can cause pulmonary infarct after only a few minutes! • Ventricular irritation – occurs when catheter migrates back into RV or is looped through the ventricle, notify MD immediately…can cause VT
  62. 62. Troubleshooting • Dampened waveform –can occur with physical defects of the heart or catheter; can be caused by kinks, air bubbles in the system, or clots Solution: Check your line for kinks & air bubbles, aspirate (not flush) for clots, straighten out tubing or patient as much as possible • No waveform – can occur with non-perfusing arrhythmias or line disconnection Solution: Check your line for disconnection, check your patient for pulse, could also be wet transducer or broken cable or box
  63. 63. Back to our patient Mrs A. • A pulmonary artery catheter passed and following values obtained. RA LA RV LV CI and MAP Impression: Cardiac
  64. 64. • Cardiac Inotropic support added. • Hemoglobin raised to 10. • Mrs. A’s blood pressure responds to further Rx, urine output improves, mental status returns to normal, and she recovers uneventfully. Monitoring and therapy based upon information carefully obtained allowed appropriate responses to measured/calculated abnormalities and prevented other inappropriate treatment.
  65. 65. Thank you

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