NonInvasive Hemodynamics with a Small Overview of Invasive Hemodynamic Monitoring

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Non-Invasive Hemodynamicswith a Small Overview
of Invasive Hemodynamic Monitoring

• SVCCs Cardiopulmonary and Neurodiagnostic
  Sophomore Class

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Review of the Heart and Blood Circulation

• The cardiovascular system performs two major
  tasks
• Delivers oxygen and nutrients to the body organs
• Removes waste products of metabolism from tissue
  cells

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Major components of the cardiovascular system

• The heart- a hollow muscular pump with two sides
  pulmonary and systemic
• Circulatory system-consists of large and small
  elastic vessels that transport blood throughout
  the body
• The amount of blood pumped through the heart of a
  normal healthy adult could reach 2100 gallons per
  day!

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The Human Heart

• Central organ of the cardiovascular system,
  located between the two lungs in the middle of
  the chest
• The adult heart is about the size of two clinched
  fists. It is shaped like a cone and weighs about
  7 to 15 ounces, depending on the individual
• The heart pumps one-million barrels of blood in
  an average lifetime, with 3 million beats per
  year, for a healthy adult

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Chambers of the Heart

• The human heart is divided into four chambers
  the right atrium, right ventricle, left atrium
  and left ventricle
• There are special muscles that create the walls
  of the chambers, hence the myocardium, that
  contracts rhythmically under the stimulation of
  electrical currents

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Chambers of the Heart Cont.

• Both the left and right sides of the heart are
  separated medially by a muscle called the septum.
  (The septum may be termed as the atrial or
  ventricular septum, depending on its location.)
• Contained within the chambers are four one-way
  valves, closing off at appropriate times to keep
  a forward flow of blood in the cardiac cycle

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Valves of the Heart

• The heart contains four vital valves that allow
  the blood to flow through, then collapse
  preventing backflow
• The two valves that separate the ventricles to
  the circulatory system are the pulmonic and
  aortic valves, also known as the semilunar valves
  due to there crescent shape

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Valves of the Heart Cont.

• The two valves consist of three cusps. The
  pulmonic valve opens freely when the right
  ventricle contracts and then falls back as it
  relaxes. Where the aortic valve opens as the
  left ventricle pushes the blood into circulation,
  then shuts from the pressure of the aorta

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Valves of the Heart Cont.

• The two valves that separate the ventricle from
  the atria are the mitral valve and the tricuspid
  valve. The two valves consist of cusps, but in
  addition they have a strong fibrous cords called,
  chordae tendinae, which help keep the valves
  attached to the ventricular walls
• The mitral valve separates the left ventricle and
  left atrium, where the tricuspid valves separate
  the right ventricle and atrium. Both valves
  prevent backflow into the ventricles, in normal
  functioning hearts

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Circulation of Blood

• The poor oxygenated blood returns from the body,
  which is rich with carbon dioxide
• The blood first travels through the Superior and
  Inferior Vena Cava, along with the coronary
  sinuses into the right atrium
• The blood flows from the right atrium through the
  tricuspid valve into the right ventricle

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Circulation of Blood Cont.

• When the right ventricle contracts the tricuspid
  valve collapse, the right ventricle will then
  expel the blood through the pulmonic valve into
  the pulmonary trunk, which divides into a right
  and left pulmonary artery. Each of which carries
  blood to one lung. (The pulmonary circuit)

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Circulation of Blood Cont.

• The blood then flows through the pulmonary
  arteries into the lungs (where oxygen and carbon
  dioxide are exchanged in the pulmonary
  capillaries) and then to the pulmonary veins.
  The carbon dioxide is now exhaled, while the left
  atrium receives oxygenated blood from the lungs,
  via four pulmonary veins, two from each lung

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Circulation of Blood Cont.

• The blood will flow from the left atrium through
  the mitral valve, also known as the bicuspid
  valve, into the left ventricle, causing the
  bicuspid valve to close off
• As the blood leaves the left ventricle it travels
  through aortic valve into the aorta, which is a
  network of small branches, circulating the blood
  to the systemic circuit (the rest of the body)

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Circulation of Blood Cont.

• After the oxygenated blood travels through the
  whole body, the blood returning from the lower
  body empties into the inferior vena cava and the
  blood from the tissues of the head and neck
  region will empty into the superior vena cava.
  Back into the atrium

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What is Non-Invasive Hemodynamic Monitoring How
Does It Work?

• A device that provides hemodynamic parameters
  based on the measurement of thoracic electrical
  bioimpedance. This device works by transmitting
  an alternating current through the chest that
  seeks the path of least resistance and ends up in
  the blood filled aorta. It also measures the
  baseline impedance to this current and then with
  each heartbeat, as the blood volume and velocity
  in the aorta change, it measures the
  corresponding change in impedance. This
  information is then processed with statistics on
  blood pressure and heart rate to determine fluid
  levels and cardiac function.

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Indications for Non-Invasive Hemodynamic
Monitoring

• Suspected or known cardiovascular disease
• Patients with the need for fluid management
• Differentiation of cardiogenic from pulmonary
  causes of acute dyspnea
• Optimization of atrioventricular interval for a
  patient with A/V sequential cardiac pacemakers
• Patients with need of determination for
  intravenous inotropic therapy
• Post heart transplant myocardial biopsy patients

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It is used on patients with

• Heart Failure
• Hypertension/Hypotension
• Pacemaker Syndromes
• Coronary Artery Disease
• Pericardial Disease with Effusion
• Critical Multi-System Illness
• Acute/Chronic Renal Failure

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Warnings and Precautions of Hemodynamic
Monitoring, General Warnings

• The BioZ is not specifically intended to monitor
  variations in cardiac performance that could
  result in immediate danger to the patient
• Explosive Hazard Do not use in the presence of
  flammable anesthetics or gases.
• Sensors are to be placed externally on the skin
  only and are not for direct cardiac application
• The conductive gel of the sensors should not
  contact any other conductive materials during
  patient monitoring
• This device is to be connected to a grounded
  receptacle

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Warnings and Precautions of Hemodynamic
Monitoring, General Warnings Cont.

• The external Ferrite Core must remain attached to
  the patient cable at all times
• The patient cables specified and included with
  the BioZ are designed specifically for protection
  against the effects of cardiac defibrillators and
  radio-surgery equipment
• Do not use any other type of patient cable with
  this device
• Disposal of this product and/or any of its
  accessories shall be in accordance with any and
  all local regulations
• The BioZ should only be used with a
  Hospital/Medical grade power supply

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Conditions that May Limit the Accuracy of the Data

• Septic Shock
• Aortic valve regurgitation
• Severe hypertension (MAP gt 130 mmHg)
• Patient heights measuring below 48 (120 cm) or
  above 90 (230 cm)

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Conditions that May Limit the Accuracy of the
Data Cont.

• Patient weights measuring less that 67 lbs. (30
  kg) or greater than 341 lbs. (155 kg)
• Patient Movement
• Aortic Balloon Pump
• The BioZ should not be used concurrently on
  patients with Minute Ventilation pacemakers when
  the MV sensor is activated

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Procedure

• Skin preparation
• 1. Shave the hair over the sensor site if
  necessary.
• 2. Dry prep the sensor sites by mildly
  abrading the skin with the perforation on the
  sensor backing

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Sensor Application

• Check expiration date on sensor package before
  opening, after opening the sealed pouch and
  remove the four dual sensor patches
• Remove the four dual sensor patches from the
  backing material and apply each sensor, adhesive
  side down to the proper sites as in the diagram
  on the next page

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Diagram
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Sensor Application Cont.

• The rectangular shaped end should be positioned
  closest to the heart
• Depress the tab at the end of the connector,
  place the connector over the sensor stud and
  release the tab
• The blue left and right lead wire connectors to
  the respective circular shaped transmitting
  sensors on the neck
• The violet left and right lead wire connectors to
  the respective rectangular shaped detecting
  sensors on the neck

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Sensor Application Cont.

• The green left and right lead wire connectors to
  the respective rectangular shaped detecting
  sensors on the thorax
• The orange left and right lead wire connectors to
  the respective circular shaped transmitting
  sensors on the thorax
• The sensors must be positioned so that they are
  180 degrees opposite each other

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Sensor Application Cont.
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How Impedance Cardiography Works

• An alternating current is transmitted through the
  chest
• The current seeks the path of least resistance
  the blood filled aorta
• Baseline impedance to current is measured
• Blood volume and velocity in aorta change with
  each heartbeat
• Corresponding changes in impedance are used with
  ECG to provide hemodynamic parameters

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Non-Invasive Hemodynamic monitors the following

• Cardiac Output
• Stroke Volume
• Systemic Vascular Resistance
• Acceleration Index
• Thoracic Fluid Content

• Velocity Index
• Systolic Time Ratio
• Left Ventricular Ejection Time
• Pre-Ejection Period
• Left Cardiac Work/Index
• Heart Rate

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Brief Overview of Invasive Hemodynamic Monitoring
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Basic Indications of Invasive Hemodynamic
Monitoring

• Pulmonary arterial pressure monitoring
• For diagnosis, management, and treatment of
  cardiopulmonary insufficiency
• For management and treatment of cardiac shock
• For assessment of pulmonary vascular function

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Basic Indications of Invasive Hemodynamic
Monitoring

• For assessment of cardiac function
• For cardiac pacing
• In application of mechanical ventilation to
  assess patient status

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Indications of Invasive Hemodynamic Monitoring
Related to Arterial Pressure Monitoring

• During manifestations of hemodynamic instability
• For measurement of the hemodynamic response to
  therapeutic intervention
• Example Administration of vasoactive
  pharmacologic agents
• For repeated arterial blood gas sampling

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Indications of Invasive Hemodynamic Monitoring
Related to Central Venous Pressure Monitoring

• For assessment of intravascular volume status and
  venous return
• For administration of fluids and/or drugs
• For assessment of cardiac function
• Mixed venous saturation and sampling

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Application of Invasive Hemodynamic Monitoring
Related Disease Processes

• Hypotension/Hypertension
• Acute MI
• Mitral regurgitation
• Ventricular septal perforation
• Cardiac tamponade
• Congestive Heart Failure

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Application of Invasive Hemodynamic Monitoring
Related Disease Processes

• Pulmonary Edema
• Sepsis
• Respiratory failure
• Renal failure
• Dialysis with complications
• Drug overdose

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Precautions In Application of Invasive
Hemodynamic Monitoring

• Read patients chart carefully before applying
  Invasive Hemodynamic Monitoring
• Check documented vitals for any abnormalities
  such as hypotension, hypertension, tachypnea,
  bradypnea, etc.
• Check for recent arterial blood gas results
• Assess the patient
• Assess mechanical ventilation settings

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Contraindications of Invasive Hemodynamic
Monitoring

• Presence of Left Bundle Branch Block on EKG
• Placement of right heart catheter
• Severe hypothermia
• Inadequate monitoring equipment
• Patient refusal
• Poor collateral circulation
• Coagulopathies, systemic anticoagulation, and
  interventional thrombolysis

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Complications of Invasive Hemodynamic Monitoring

• Bleeding or bruising at the catheter insertion
  site
• Hemorrhage
• Infection
• Pneumothorax or hemothorax darning venipuncture
  for insertion of central venous catheters

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Complications of Invasive Hemodynamic Monitoring

• Dysrhythmias attributed to central venous or
  pulmonary artery catheter migration or irritation
  of the myocardium
• Pulmonary artery rupture with inflation of balloon

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Complications of Invasive Hemodynamic Monitoring

• Pulmonary infarction or ischemia from prolonged
  wedging of pulmonary artery catheter balloon or
  embolization of a thrombus from the tip of a
  catheter
• Obtaining inadequate or poor quality data or
  inappropriately interpreting data

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Please see your handout for an overview of
Swan-Ganz catherization
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References

• Online site www.cardiodynamics.com BioZ tect,
  ICG Sensor and Cable System
• BioZ.com Operators Manual
• Online site www.cardiodynamics.com BioZ CG
  Monitor Specifications
• Online site www.medobserver.com/may2002/hemodyna
  mics.html Noninvasive Hemodynamics
• Online site www.inpedancecardiography.com/icgove
  r10.html Overview of Impedance Cardiography

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References

• Matthew Acampora, M.D. Internal Medicine of
  Charlotte, P.A. Protocol for Use of BioZICG
  (Impedence Cariography).
• Non-Invasive Hemodynamics Monitoring
  www.fciheart.com/NonInvasive20CHF20Monitor.html
  accessed on 9/1/04.
• Gary A. Thibodequ and Kevin T. Patton. Anatomy
  Physiology, 4th Edition.
• St. Louis Mosby, 1999.
• Braunwald, Eugene and others. Harrisons
  Principles of Internal Medicine, 11th Edition.

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References

• New York McGraw-Hill Book Company, 1987
• Baum, Gerald L., J.D. Crapo, B.R. Celli, and J.B.
  Karlinsky.
• Pulmonary Diseases 6th Edition.
• Philadelphia Lippincott Raven, 1998

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References

• Pilbeam, Susan. Mechanical Ventilation
  Physiological and Clinical Applications, 3rd ed.
• White, Gary C. Basic Clinical Lab Competencies
  for Respiratory Care An Integrated Approach, 4th
  ed.
• Wilkens, Robert L. Egans Fundamentals of
  Respiratory Care, 8th ed.
• Miller-Keane Encyclopedia Dictionary of Medicine,
  Nursing, Allied Health, 6th ed.
• http//www.medscape.com/viewarticle/463474
• http//www.cyber-nurse.com/veetac.cham2.htm
• http//hemodynamicsociety.org/hemodyn.html