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Hemodynamics

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HEMODYNAMICS In the CRITICAL CARE UNIT Sherry L. Knowles, RN, CCRN, CRNI DEFINITION PURPOSE DEFINITION HEMODYNAMIC MONITORING Measuring and monitoring the factors that influence the force and flow of blood.…
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  1. HEMODYNAMICS In the CRITICAL CARE UNIT Sherry L. Knowles, RN, CCRN, CRNI
  2. DEFINITION PURPOSE DEFINITION HEMODYNAMIC MONITORING
      • Measuring and monitoring the factors that influence the force and flow of blood.
      • To aid in diagnosing, monitoring and managing critically ill patients.
  3. 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:
  4. 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:
  5. 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
  6. CONTRAINDICATIONS
    • Tricuspid or pulmonary valve
    • mechanical prosthesis
    • Right heart mass
    • (thrombus and/or tumor)
    • Tricuspid or pulmonary
    • valve endocarditis
  7. 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
  8. SWAN GANZ CATHETER
  9. SWAN GANZ COMPONENTS
  10. SWAN GANZ PLACEMENT
  11. SWAN GANZ PLACEMENT
    • Bleeding
    • Infection
    • Dysrhythmias
    • Pulmonary Artery Rupture
    • Pneumothorax
    • Hemothorax
    • Valvular Damage
    • Embolization
    • Balloon Rupture
    • Catheter Migration
    RISKS WITH SWAN GANZ
  12. 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
  13. RA WAVEFORM
    • Normal Value 0-8 mmHg
    • RAP = CVP
    • Wave Fluctuations Due To Contractions
  14. RV WAVEFORM
    • Normal Value 15-25/0-8 mmHg
    • Catheter In RV May Cause Ventricular Ectopy
    • Swan Tip May Drift From PA to RV
  15. 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)
  16. PAWP WAVEFORM
    • Normal Value 8-12 mmHg
    • Balloon Floats and Wedges in Pulmonary Artery
    • PAWP = LAP = LVEDP
    • Wedging Can Cause Capillary Rupture
  17. PA INSERTION WAVEFORMS
    • A = RA (CVP) Waveform
    • B = RV Waveform
    • C = PA Waveform
    • D = PAWP Waveform
    B C D A
  18. 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.
  19. PA INSERTION SEQUENCE
  20. POST INSERTION
    • Assess ECG for dysrhythmias.
    • Assess for signs and symptoms of respiratory distress.
    • Ascertain sterile dressing is in place.
    • Obtain PCXR to check placement.
    • Zero and level transducer(s) at the phlebostatic axis.
    • Assess quality of waveforms (i.e., proper configuration, dampening, catheter whip).
    • Obtain opening pressures and wave form tracings for each waveform.
    • Assess length at insertion site.
    • 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).
    • Update physician of abnormalities.
  21. 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.
  22. PHLEBOSTATIC AXIS
  23. 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 :
  24. RESPIRATORY VARIATION
    • 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 :
  25. RESPIRATORY VARIATION Spontaneous Breathing
  26. RESPIRATORY VARIATION
  27. END EXPIRATION
  28. RAP WAVEFORM RAP WAVEFORM
  29. (CVP) RA WAVEFORM & ECG
  30. (CVP) RA WAVEFORM (CVP) RA WAVEFORM
  31. WEDGING THE CATHETER
  32. PAWP TRACING PAWP WAVEFORM
  33. PAWP WAVEFORM PAWP WAVEFORM
  34. PA vs PAWP WAVEFORM PA vs PAWP WAVEFORM
  35. PAWP WAVEFORM & ECG PAWP WAVEFORM
  36. PAWP WAVEFORM PAWP WAVEFORM
  37. V WAVES PAWP WAVEFORM
  38. PAWP WITH V WAVES
  39. SVO 2 MONITORING
  40. SVO2 MONITORING
    • Normal Values: 60-75%
    • Decreased ( ? ) SVO 2 Values Indicate
    • ? Increased ? Extraction
    • From Decreased Oxygen Delivery
    • or
    • From Increased Oxygen Demands
  41. POTENTIAL COMPLICATIONS POTENTIAL COMPLICATIONS Same as arterial pressure monitoring plus the following: Cardiac arrest Air emboli PA hemorrhage or infarction Pulmonary artery extravasation Altered skin integrity Loss of balloon integrity Frank Hemorrhage Pneumothorax/Hemothorax Pulmonary artery rupture Equipment malfunction Electromicroshock Inaccurate pressures Lung ischemia Infection Balloon rupture Catheter displacement Dysrhythmias Thromboembolism Cardiac tamponade Air emboli
    • Wedging Can Cause Capillary Rupture
    • Catheter In RV Can Cause Ventricular Ectopy
    • Swan Tip Can Drift From PA to RV
    POTENTIAL COMPLICATIONS
  42. 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
  43. PRECAUTIONS
    • Always set alarms, approximately 20 mmHg above and below the patient’s readings.
    • 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.
    • 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.
    • If patient coughs up blood or it is suctioned via endotracheal tube, suspect PA rupture and notify physician immediately.
  44. 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 M 2
    • = 0.60-0.75
    NORMAL VALUES
    • Right Atrial Pressure (CVP)
    • Pulmonary Artery Pressure
    • Pulmonary Artery Wedge Pressure
    • Left Ventricular Diastolic Pressure
    • Stroke Volume
    • Cardiac Output
    • Cardiac Index
    • SVO 2
  45. DAMPENED PA WAVEFORM PAWP WAVEFORM
  46. ALTERATIONS IN SVO 2
  47. ALTERATIONS IN SVO 2
    • Optimize HR and SV (Stroke Volume)
    • Stroke Volume =
    • PRELOAD
    • AFTERLOAD
    • CONTRACTILITY
    • Chronotropic Medications
    • Diuretics / Volume
    • Vasodilators / Vasoconstrictors
    • Inotropic Medications (Positive or Negative)
    • IABP
    OPTIMIZING CARDIAC OUTPUT
    • Shock States
      • Cardiogenic Shock
      • Hypovolemic Shock
      • Septic Shock
      • Anaphylactic Shock
    • Cardiac Tamponade
    • Left Ventricular Failure
    • Right Ventricular Failure
    • Pulmonary Hypertension
    CARDIAC PROFILES
  48. 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.
  49. TREATMENTS
  50. SAMPLE MEASUREMENTS
  51. MEASUREMENTS
  52. SAMPLE MEASUREMENTS
  53. SAMPLE MEASUREMENTS
  54. SAMPLE MEASUREMENTS
  55. SAMPLE MEASUREMENTS
  56. SAMPLE MEASUREMENTS
  57. SAMPLE MEASUREMENTS
  58. SAMPLE MEASUREMENTS
  59. SAMPLE MEASUREMENTS
  60. SAMPLE MEASUREMENTS
  61. SAMPLE MEASUREMENTS
  62. SAMPLE MEASUREMENTS
  63. SAMPLE MEASUREMENTS
  64. SAMPLE MEASUREMENTS
  65. 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
  66. THE END
  67. 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) H emodynamic monitoring: invasive and noninvasive clinical application (2d ed), New York: W. B. Saunders

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