2. OUTLINE
• Introduction
• Importance of hemodynamic monitoring
• Review of anatomy and physiology
• Hemodynamic monitoring techniques
• Parameters measured
• Clinical application
• Complications
• Challenges and considerations
• Nursing implication
• Conclusion
• References
3. INTRODUCTION
• Hemodynamic monitoring is a critical aspect of care in critically ill
patients.
• It involves the continuous assessment of various parameters related
to
• blood flow,
• pressure, and
• cardiac function to guide medical interventions and optimize patient
outcomes.
4. IMPORTANCE OF HEMODYNAMIC
MONITORING
• Hemodynamic monitoring provides vital information about the
cardiovascular system's function, allowing clinicians to assess tissue
perfusion, cardiac output, fluid status, and organ function.
• This data is essential for diagnosing and managing conditions such as
• shock,
• heart failure,
• sepsis, and
• major trauma.
5. REVIEW OF ANATOMY AND PHYSIOLOGY
• Heart;
• The heart is responsible for pumping
oxygenated blood forward through the
arterial vasculature and receiving
deoxygenated blood via the venous
vasculature
• Arteries
• Arteries are the tough, elastic vessels that
carry blood away from the heart.
• Veins
• Responsible for the flow of blood back to the
heart.
• Capillaries
• Exchange vessels, are composed of a
network of low-pressure, thin-walled
microscopic vessels.
6. REVIEW OF ANATOMY AND PHYSIOLOGY
• Cardiac Output:
• The volume of blood pumped by the heart per unit of time (usually measured in liters per minute). It's
determined by heart rate and stroke volume (the volume of blood ejected from the heart with each beat).
• Blood Pressure:
• The force exerted by the blood against the walls of blood vessels. Blood pressure gradient is a driving force for
blood flow. It's affected by factors like vascular resistance, blood volume, and cardiac output.
• Vascular Resistance:
• The resistance to blood flow offered by the blood vessels. It's primarily determined by the diameter of the
blood vessels (vasoconstriction and vasodilation), blood viscosity, and the length of the blood vessels.
• Blood Viscosity:
• The thickness or stickiness of the blood, mainly determined by the hematocrit (the proportion of red blood
cells to the total blood volume) and the presence of certain proteins and cells in the blood.
• Vessel Diameter:
• Changes in the diameter of blood vessels, through vasodilation (widening) or vasoconstriction (narrowing),
significantly affect blood flow.
7. REVIEW OF ANATOMY AND PHYSIOLOGY
• Autonomic Nervous System:
• Sympathetic and parasympathetic nervous systems regulate blood vessel diameter and cardiac output, affecting blood flow.
• Local Factors:
• These include metabolic factors (such as oxygen, carbon dioxide, pH levels), myogenic responses (automatic response of
blood vessels to changes in blood pressure), and local regulatory substances like nitric oxide.
• Gravity:
• Positional changes affect blood flow, with gravity influencing blood distribution in the body.
• Endocrine Factors:
• Hormones such as adrenaline, noradrenaline, angiotensin, and vasopressin can affect blood flow by influencing cardiac
output, vascular resistance, or both.
• Temperature:
• Blood flow can be influenced by temperature changes, with increased temperature often leading to vasodilation and
increased blood flow to dissipate heat.
• Poiseuille’s law
• the rate of fluid flow through a vessel is determined by the pressure difference between the two ends of the vessel and the
resistance within the lumen.
8. COMPONENTS OF CARDIAC OUTPUT
• Cardiac output (CO) is
determined by;
• heart rate and
• stroke volume.
10. NON INVASIVE MONITORING
TECHNIQUES
• Echocardiography
• 3D echocardiography provides
volumetric data of the heart,
which can be used to measure
stroke volume and cardiac
output.
12. NON INVASIVE MONITORING
TECHNIQUES
• Jugular venous pressure
• Assessment of the jugular veins
provides an estimate of
intravascular volume.
• it is an indirect measure of central
venous pressure (CVP).
• Normal is 7 to 9 cm
13. INVASIVE MONITORING TECHNIQUES
• Arterial line
• Central venous catheter
• Pulmonary artery catheter
By Privatarchiv Foto von MrArifnajafov - Own work, CC BY 3.0,
https://commons.wikimedia.org/w/index.php?curid=15166650
14.
15. PARAMETERS MEASURED
Arterial Pressure Monitoring
• It is the most accurate method of obtaining the systemic blood pressure.
• It allows for continuous, beat-to-beat analysis of the arterial pressure.
• Arterial pressure monitoring is the method of choice in assessing blood
pressure in the hemodynamically unstable patient
• Location; Radial, brachial and femoral
• Indications
• compromised tissue perfusion and volume status,
• Frequent arterial blood gas sampling,
• hypotension or hypertension, and
• patients whose treatment includes vasoactive agents
16. PARAMETERS MEASURED CONTD
• Complications
• thrombosis,
• embolism,
• blood loss, and
• infection.
• Considerations
• invasive blood pressure
generally higher than the
noninvasive value (10-
20mmHg)
• When NIBP value >invasive BP
value, one must suspect
equipment malfunction or
technical error
17. PARAMETERS MEASURED CONTD
Central Venous Pressure (CVP)
• Reflects right ventricular preload and provides information about
intravascular volume status.
• The pressure is obtained from the right atrial port of a pulmonary
artery catheter.
• It is also called the Right Atrial pressure (RAP).
• Normal CVP/RAP ranges from 2 to 6 mm Hg
18. PARAMETERS MEASURED CONTD
• Complications
• Infection
• carotid puncture,
• pneumothorax,
• hemothorax,
• perforation of the right atrium or ventricle, and
• cardiac dysrhythmias.
• Considerations
• a low RAP may be hypovolemic because of dehydration or
traumatic blood loss. Low pressures are also seen in relative
hypovolemia as a result of vasodilation from rewarming,
medications, or sepsis. In all of these conditions, RAP reflects
blood return to the heart that is insufficient to meet the body’s
requirements.
• Confounding the interpretation of a low RAP, is that the value
may be negative in an individual in the upright position, even if
cardiac function and volume status are normal.
• A high RAP measurement indicates conditions that reduce the
right ventricle’s ability to eject blood, thereby increasing right
ventricular pressure and RAP. Such conditions include
hypervolemia (seen with aggressive administration of
intravenous fluids), severe vasoconstriction, and mechanical
ventilation.
19. PARAMETERS MEASURED CONTD
Pulmonary Artery Pressure (PAP)
• Measured via a pulmonary artery catheter (PAC), PAP provides
information about left ventricular preload and can help assess cardiac
function.
• To determine PA pressure (PAP) a specialized catheter is placed
directly into the PA
20. PULMONARY ARTERY CATHETER
• The proximal port lies in the right atrium and
measures RAP; it is also used to administer fluids
and electrolytes and to obtain intermittent
thermodilution CO measurements.
• The distal port measures PAP and PA occlusion
pressure (PAOP); mixed venous blood samples are
also drawn from this port.
• The thermistor port incorporates a temperature
sensitive wire that allows computer calculation of
CO with the thermodilution method. Many catheters
have an additional proximal infusion port for fluid
and medication administration.
• The balloon inflation lumen provides the ability to
inflate and deflate the small-volume (approximately
1.5 mL) balloon at the distal tip of the catheter. The
balloon is inflated to facilitate insertion of the
catheter and to measure PAOP, which provides
information about the function of the left side of the
heart.
21. PARAMETERS MEASURED CONTD
Cardiac Output (CO):
• The volume of blood ejected by the heart per unit of time, typically
measured in liters per minute. CO reflects the heart's ability to meet
tissue oxygen demand.
• Cardiac index (CI) is the CO adjusted for an individual’s size or body
surface area.
• Cardiac output / BSA= Cardiac index
• (Body Surface Area= 0.007184 x (Height(cm)^0.725) x (Weight(kg)^0.425))
• Two methods are commonly used to evaluate CO via the PA catheter:
thermodilution cardiac output (TdCO) and CCO
22. Thermodilution Cardiac Output (TdCO)
Monitoring
• Attach the thermistor connector on the PA catheter to a CO module on the
cardiac monitor.
• Inject a set volume (5 to 10 mL) of 0.9% normal saline solution at room
temperature quickly and smoothly via the proximal port.
• As the fluid bolus passes into the right ventricle and subsequently the PA,
the difference in temperature is sensed by the thermistor located at the
distal portion of the catheter.
• The TdCO is calculated as the difference in temperature over time washout
curve.
• Normal CO is represented by a smooth curve with a rapid upstroke and
slow return to the baseline.
23. Continuous Cardiac Output Monitoring
• The CCO system uses a modified PA catheter and a CO computer specific to
the device.
• The specialized catheter has a copper filament near the distal end that
delivers pulses of energy at prescribed time intervals and warms the blood
in the right ventricle.
• This temperature change is detected by the thermistor at the tip of the
catheter about every 3 to 6 seconds.
• The computer interprets the temperature change and averages the CO
measurements over the last 60 seconds.
• Patients with a CCO device can be positioned supine with the HOB elevated
up to 45 degrees.
24. Continuous Cardiac Output Monitoring
• Advantages
• removes the potential for operator error,
• no extra fluid is administered to the patient,
• data are available for trending throughout the shift and
• there is no need to change the computation constant in the CO module.
• Disadvantages
• the device may not accurately sense the CCO in the patient whose body
temperature is greater than 40° C to 43° C, because the thermal filament
heats to a maximum of 44° C.
• CCO does not reflect acute changes in CO as the measurements provide an
average of CO over time.
25. COMPLICATIONS
• Invasive hemodynamic monitoring techniques carry risks of
complications such as ;
• infection,
• bleeding,
• thrombosis, and
• catheter-related injuries.
26. CLINICAL APPLICATION
• Shock Management
• Surgical Care
• Critical Care
• Titrating medications
• Detecting early signs of hemodynamic instability
27. CHALLENGES AND CONSIDERATIONS
• Interpretation: Accurate interpretation of hemodynamic data
requires clinical expertise and consideration of individual patient
factors, as well as integration with other clinical parameters.
• Technology Advancements: Ongoing advancements in monitoring
technologies, such as minimally invasive devices and hemodynamic
monitoring software, aim to improve accuracy, safety, and ease of use
28. STRATEGIES FOR NURSING MANAGEMENT IN
HEMODYNAMIC MONITORING
• Document insertion date
• Change dressings according to institutional policy
• Assess for signs of infection
• Date dressing changes
• Maintain patency of the flush system
• Flush the system after each use of a port
• Clear any blood from the tubing, ports, and/or stopcocks
• Maintain a pressure of 300 mm Hg on the flush solution using a pressure
bag
• Ensure adequate amount of flush solution in the intravenous bag
29. STRATEGIES FOR NURSING MANAGEMENT IN
HEMODYNAMIC MONITORING
• Ensure tightened connections in the tubing and flush system
• Keep tubing free of kinks
• Limit disconnecting or opening the system
• Ensure that alarm limits are set on the monitor and alarms are turned
on
• Assessment of the extremity every 2 hours for perfusion: color,
temperature, sensation, pulse, and capillary refill (normal time to
refill is less than 3 seconds).
• When the catheter is removed, ensure that adequate pressure is
applied to the site of insertion until hemostasis is obtained.
30. NURSING IMPLICATION
• Assessment and Monitoring
• Device management
• Interpretation of data
• Fluid management
• Medication administration
• Patient education
• Collaboration and
• Communication
• Documentation
31. CONCLUSION
• Nurses play a central role in hemodynamic monitoring. Their
expertise and diligence are essential for optimizing patient outcomes
in hemodynamically unstable situations.
32. REFERENCES
• Magder, Sheldon. "Central venous pressure: a useful but not so
simple measurement." Critical care medicine 44.3 (2016): 546-547.
• Monnet, Xavier, and Jean-Louis Teboul. "Passive leg raising: five rules,
not a drop of fluid!." Critical care 20.1 (2016): 55.
• Vincent, Jean-Louis, et al. "Ten big mistakes in intensive care
medicine." Intensive care medicine 42.3 (2016): 531-532.
• Rhodes, Andrew, et al. "Surviving sepsis campaign: international
guidelines for management of sepsis and septic shock: 2016."
Intensive care medicine 43.3 (2017): 304-377.
