Hemodynamic Monitoring for the Respiratory Therapist

1
Hemodynamic Monitoring for the Respiratory
Therapist

• Jane Reynolds, MS, RN, RRT

2
Definition of terms

• Preload amount of blood in the ventricle before
  contraction End diastolic volume
• EDV determines the amount of stretch that is
  placed on the myocardial muscle
• That stretch determines the strength of the
  next contraction
• The strength of the contraction determines how
  much blood is pumped out of the ventricle during
  the next systole stroke volume
• The stroke volume determines the blood pressure
  and perfusing pressures

3
Definition of terms

• Afterload - resistance to blood flow from the
  ventricle work that must be done to pump blood
  from the ventricle to the circulation
• Resistance determined by size of valve opening,
  blood viscosity and blood pressure in pulmonary
  or systemic circulation
• Work is the oxygen consumed by the myocardium
  to overcome the resistance to flow

4
CirculatIon
5
Normal Circulatory Pressures

• Preload to RV
• Afterload to RV
• Preload to LV
• Preload to LV
• Afterload to LV

5
3
2
3
1
6
Circulation
7
Alveolar Capillary Membrane
8
(No Transcript)
9
Normal Alveolar Capillary Membrane
10
Begin Pulmonary Edema
11
Interstitial Edema
12
Pulmonary Edema - Late
13
Pulmonary Artery Catheter
14
(No Transcript)
15
Pulmonary Artery Catheter
16
Arterial Blood Gas Interpretation
17
Oxygenation
18
Oxyhemoglobin Dissociation Curve
19
Pulmonary Artery Catheter in Wedge Position
20
Case Study 1

• An 18 year old white male was brought to the ED
  by CFD after being rescued from his car following
  a high speed collision with a parked truck. He
  is conscious, c/o of chest pain and is anxious.
  He was wearing his seat belt but still hit his
  chest on the steering wheel. His vital signs
  are T 37, P 113, RR 23, B/P 100/ 70. CT scan of
  chest was unremarkable and he was brought to SICU
  for observation. He continued to have
  fluctuations in his blood pressure. A pulmonary
  artery catheter was placed.

21
Case Study 1
22
Cardiac Tamponade
23
Case Study 2

• A 72 year old white female was admitted to the
  MICU with an exacerbation of COPD. She has
  emphysema and chronic bronchitis and a 40 pack
  year history of cigarette smoking. Breath sounds
  are bilaterally diminished, crackles and rhonchi.
• She has JVD and pedal edema. A pulmonary
  artery catheter was placed as she had sustained
  hypotension and SOB. Her VS are T 37, P118, RR
  32, B/P 150/90, FiO2 .28, HB 22 Gm.

24
Case Study 2
25
Case Study 3

• A 25 year Hispanic male was admitted to the
  SICU after a thoracotomy for repair of his aorta
  following a gun shot wound to his chest. He has
  bilateral chest tubes. He is intubated and
  receiving full ventilatory support. His chest
  tube drainage for the last hour was 400 ml. He
  has bloody sputum and urine. His last CaO2 was
• 10.4 volumes with a PaO2 of 110 and
  saturation of 95. VS T 36, P148, RR 14, B/P
  65/44.

26
Case Study 3
27
Case Study 4

• A 52 year old white male with shortness of
  breath and chest pain was admitted to the ED.
  ECG showed ST elevation in 4 leads and his
  cardiac enzymes were markedly elevated. His
  vital signs were stable, SpO2 on NC at 2 LPM was
  95. He was taken to the cardiac cath lab and a
  diagnostic cardiac angiogram revealed 99
  occlusion of his LAD. A coronary stent was
  placed and 15 minutes post intervention he began
  complaining again of severe SOB and chest pain.
  He was taken back to the cath lab. A pulmonary
  artery catheter was placed. A left heart
  catheterization revealed progression of the MI.
  His LVEDP is 32 and an intra aortic balloon was
  placed and counter pulsation started at 11.

28
Case Study 4
29
Intra Aortic Balloon Counter Pulsation
30
Case Study 5

• A 55 year old AA male was admitted to the MICU
  with acute SOB, cough, HTN and hypoxemia. He is
  oliguric and has required hemodialysis for the
  past 2 years. He is depressed and has not been
  following his dietary and fluid restrictions and
  has skipped his last 2 dialysis appointments.
  His VS are now T 37, P118, RR 35, B/P 200/135.
  He is receiving oxygen via venturi mask, FiO2
  50. He has a pulmonary artery catheter in place
  to monitor his cardiac status.

31
Case Study 5
32
Case Study 6

• A 36 year old female was admitted to the ED with
  a CC of SOB and chest pain. She has no
  significant PMH, she does not smoke. She says
  that she hurt her ankle about two weeks ago and
  never went to the doctor about it. It is very
  painful and she has been almost immobilized for
  the past two weeks because it is just too painful
  to walk on. She has a cough and says her SOB
  came on rather suddenly after she went down to
  her basement to put some clothes in the laundry
  this morning. She is tachypneic, her MV is 12
  LPM.

33
Case Study 6
34
Saddle Pulmonary Embolism
35
(No Transcript)
36
Questions??

• Thank you!
• You were great!!

37
(No Transcript)
38
Thoraco-abdominal Pump
Mechanism
39
Small Vessels
40
(No Transcript)
41
Venous return
42
Oxygen carried in the blood
43
(No Transcript)
44
Chest x-ray of ARDS
45
Normal Chest x-ray
46
CT Scan of ARDS
47
(No Transcript)
48
Left-Sided Heart Failure

• Pulmonary congestion occurs when left ventricle
  cannot pump well
• Dyspnea upon exertion, orthopnea, and paroxysmal
  nocturnal dyspnea
• Oliguria

49
Right-Sided Heart Failure

• Congestion of viscera and peripheral tissues when
  right ventricle fails
• Jugular vein distention
• Dependent edema
• Hepatomegaly
• Ascites
• Weakness, anorexia, and nausea
• Weight gain

50
(No Transcript)
51
Sphincters Open
52
Sphincters Closed
53
Path of Blood
54
Major Blood Vessels