INVASIVE HEMODYNAMIC MONITORING

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INVASIVE HEMODYNAMIC
MONITORING

• Presentation by Donna Cohen, BSN, RN
• Heart and Vascular Center
• Medical University of South Carolina
• February 2006

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INVASIVE HEMODYNAMIC
MONITORING
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Objectives

• Verbalizes purposes of Hemodynamic Monitoring
• Verbalize indications for Hemodynamic Monitoring
• Identify components of a Pulmonary Artery
  CatheterSwan-Gantz
  
• Verbalize necessary equipment needed

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Objectives cont

• Identify the correct pressure waveforms
• Identify the components of invasive hemodynamic
  monitoringRA,PA,PAM and PCWP
  
• Identify normal parameters for each component
  of monitoring
  
• Verbalize how to troubleshoot abnormal waveforms

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Objectives cont

• Verbalize definition of preload and afterload
• Verbalize what and where to document data
  collected
  
• Verbalize understanding of the Critical Care
  Hemodynamic Monitoring Policy C1

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Introduction

• Swan-Ganz catheter has been in use for almost 30
  years
  
• Initially developed for the management of acute
  myocardial infarction
  
• Now, widespread use in the management of a
  variety of critical illnesses and surgical
  procedures

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Purposes of Invasive Hemodynamic
Monitoring

• Early detection, identification, and treatment of
  life-threatening conditions such as heart failure
  and cardiac tampanade
  
• Evaluate the patients immediate response to
  treatment such as drugs and mechanical support
  
• Evaluate the effectiveness of cardiovascular
  function such as cardiac output and index

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Indications for Hemodynamic
Monitoring

• Any deficit or loss of cardiac function such as
  AMI,CHF,Cardiomyopathy
  
• All types of shockcardiogenic,neurogenic,or
  anaphylactic
  
• Decreased urine output from dehydration,
  hemorrhage,G.I. bleed,burns,or surgery

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Components of a Pulmonary Artery
Catheter
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Components of Swan-Ganz cont

• Normally has four4 ports
• Proximal port Blue used to measure central
  venous pressure/RAP and injectate port for
  measurement of cardiac output
  
• Distal port Yellow used to measure pulmonary
  artery pressure
  
• Balloon port Red used to determine pulmonary
  wedge pressure1.5 special syringe is connected
  
• Infusion port White used for fluid infusion

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Components of the Monitoring System

• Bedside monitor amplifier is located inside.
  The amplifier increases the size of signal
  
• Transducer changes the mechanical energy or
  pressures of pulse into electrical energy should
  be level with the phlebostatic axis you can
  estimate this by intersecting lines from the 4th
  ICS,mid axillary line
• Recorder please record information

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Phlebostatic Axis
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Commonly used Terminology

• Preload
• Afterload
• Cardiac Output
• Cardiac Index

• Systemic Vascular Resistance SVR
• Pulmonary Vascular Resistance PVR

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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
  RA

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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

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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)

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Computation Constant

• Computation constant is based on the
• 1) type of catheter
• 2) temperature (iced or room temp) of the
  injectate
  
• 3) the number of mLs (5mL vs 10mL) ---we use 10
  mL of room temperature injectate for our regular
  swanns, which requires a computation constant of
  0.592

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SVR / PVR

• 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

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Possible Complications

• Increased risk of infections same as with any
  central venous linesuse 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 permanentlyconsidered 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 immediatelycan cause VT

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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

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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.

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Equipment Needed

• 7. Set up pressure lines and transducers see
  Critical Care Skills
  
• Clinical Handbook, Second Edition pages 293
  -298
  
• Please level pressure flush monitoring
  system and transducers to the
  
• phlebostastic axis. Zero the transducers.
  Also check to make sure
  
• all connections are secure.
• 8. Connect tubings to patient PA port and CVP
  port when physician
  
• is ready to flush the swann. Flush all
  ports of swann before
  
• inserting.
• 9. While floating the swann, observe for
  ventricular ectopy on the
  
• monitor, and make physician aware of
  frequent PVCs or runs of
  
• VT !
• 10. After swann is in place, assist with cleanup
  and let
  
• patient know procedure is complete.

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Equipment Needed

• 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 .9NS
  
• 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 todays
  height and weight).
  
• 14. Document findings on the ICU flowsheet.

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PA Insertion Waves
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Central Venous Pressure (CVP)

• Zero transducer to the patients phlebostatic
  axis
  
• Always read CVP at end expiration
• CVP is a direct measurement of right ventricular
  end diastolic pressure
  

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Right Ventricular Waveform

• If the swan falls or gets pulled back into the RV
  it is considered a swan emergency.
  
• If you see an RV waveform (looks like VT) pull
  the swan immediately.
  
• If the swan remains in the RV it may cause the
  patient to go into VT.
  

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Pulmonary Capillary Wedge Pressure (PCWP)

• Zero the transducer to the patients 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.
  

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Cardiac Output

• It is the amount of blood pumped by the heart in
  one minute.
  
• Calculated by multiplying heart rate times stroke
  volume.
  
• Cardiac Index is the cardiac output adjusted for
  body surface area.
  

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How to read a PA waveform

• Measured at end expiration!
• Dicrotic notch (closure of PulmonicValve) should
  always be on
  
• Right side of wave (if notch on Left side
  find out if the tip in the RV)
  
• Measure PAS at the top of the wave upslope (at
  end of QRS)
  
• PAD is measured at the trough preceding
  the systolic peak
  
• (be careful not to measure whip in the
  wave)
  
• How to read a PCWP (aka wedge)
• Measured at end expiration!
• After balloon is inflated, compare waveform to
  respiratory waveform to determine measurement at
  the end of expiration
  
• (last clear wave before patient inspires)
• Tip if waveform is difficult to read, try
  resting hand on pts chest as you wedge
  determine where the end of expiration occurs on
  the wedge waveform, then measure across several
  waves for consistency

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Documentation

• Document PAS, PAD, and PCWP on nursing flowsheet
  under Hemodynamic Parameters
  
• PCWP will rarely be PAD (if so, means blood is
  flowing backwards) If PCWP PAD, look for
  tamponade
  
• Under circumstances where the catheter will not
  wedge (or should not be), do not document any
  values in the PCWP column on the flowsheet
  
• If you use the PAD measurement for calculations,
  it is acceptable to write ONLY
  
• PAD value used for calculations
• at the top of your numbers

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