HEMODYNAMIC MONITORING

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HEMODYNAMIC MONITORING NUR 351/352 PROFESSOR
DIANE E. WHITE RN MS CCRN PhD (c)
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• Equipment Needed for Hemodynamic Monitoring
• Transducer an instrument that senses
  physiological events transforms them into
  electrical signs
• Amplifier connects to transducer and an
  electrical cablefilters out interference so
  signal can be displayed
• Monitors provides display of original signal
• Catheter, tubing flush system (single or double)
  pressure bag is 500cc Normal Saline with 10cc of
  100u/ml of heparin delivers continuous cc/hr to
  keep line open catheter may be arterial or
  venous

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• Monitoring Hemodynamic Measurements
• Arterial used for unstable BP or frequent ABGs
  or labs
• Controversial regarding accuracy
• Inserted by MD, RT, or Anesthesia
• Inserted into any artery
• Waveform peak represents SBP and Ventricular
  contraction, lowest point reflects peripheral
  resistance diacrotic notch is on the downward
  stroke results from aortic valve closure
• MAP mean arterial pressure represents perfusion
  pressure in aorta and branches SBP-DBP/3 DBP
  MAP
• Nursing considerations
• Complications

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• Central Venous Pressure represents blood return
  to the heart abnormalities usually secondary to
  altered venous tone and / or blood volume
• Inserted by MD under sterile conditions
• Normal value is 0-8 mm Hg
• Increase in blood volume increase in CVP (vice
  versa)
• Triple Lumen Catheter (TLC) distal port on TCL
  and proximal on Swan Ganz catheter
• Measured at end of expiration ventilated
  patients lowest part of waveform and vice versa
  for spontaneous breathing

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• Pulmonary Artery Catheter or Swan Ganz Catheter
  allows monitoring of Left Ventricular function
• Various ports proximal (cardiac output), distal
  (PA), balloon (wedge or PCWP), RV (pacer port)
  temp (core blood temp)
• Inserted by MD under sterile conditions at the
  brachial, subclavian, internal jugular or
  external jugular veins
• All measurements done at end of expiration

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• What can we monitor with the Swan Ganz Catheter?
• PAP pulmonary artery pressure _at_ 25/10 with
  average 15
• PCWP pulmonary catheter wedge pressure _at_ 6-12
  use of DPAP if balloon not working
• Cardiac Output can be measured intermittently
  or continuously
• -- injectate is D5W or NS _at_ 10cc
• --errors in CO
• -- 3 values averaged (within 10) of each other
• -- CO 4-8 L/min
• -- CI or cardiac index CO/BSA usually greater
  than 2

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• Mixed Venous Oxygenation (SVO2) allows
  clinician to look at overall picture of O2 used
  by the body organs
• CVP central venous pressure 0-8mmHg
• SVR systemic vascular resistance- measures the
  opposition to blood flow exerted by blood
  vessels 800-1200 normal value
• Formula SVR MAP-CVP x 80/ CO
• PVR pulmonary vascular resistance
• Formula PVR MAP-PCWP x 80/CO

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• Volume Effects on Hemodynamic Monitoring
• What is the difference between intracellular and
  extracellular volume?
• Arterial Pressure
• Central Venous Pressure
• PAP/PCWP
• Cardiac Output
• SVR

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• Pharmacological Agents Used in Hemodynamic
  Monitoring
• Arterial Pressure
• Dopamine gt or 5 mcg/kg/min up to 20mcg/kg
• Epinephrine mcg/min
• Neosenephrine mcg/min
• Levophed or norepinephrine mcg/min
• CVP
• Volume controlled
• PCWP/PAP increase CO by decreasing PAP and PCWP
• Dobutamine 5-20 mcg/kg/min
• Natrecor .001mcg/kg/min

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• Cardiac Output
• Dobutamine and Natrecor
• Must be sure enough volume on board to gain
  desired effect
• SVR
• Nipride mcg/kg/min used to decrease SVR and
  increase CO
• Cardene 5-10mg/hr

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Inotropic Agent Calculations

• Difference between positive and negative
  inotropic drugs?
• Dosing charts CONCENTRATION of drug must match
  in order to use charts
• Pharmacy directions for drug adminstration
  always DOUBLE-CHECK!
• Fudge Factors a way of calculating dosages and
  rates

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Fudge Factors

• Know the concentration of drug ordered
• Know the patients weight in kilograms
• Know the volume of dilution
• Know correct dosage administration for drug
  ordered
• Remember constants

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Fudge Factor Formula

• How is the drug run? mcg/min, mcg/kg/min,
  mcg/kg/hour, mg/min
• Fill in the necessary formula components
• mg x 1000 mg x 1000
• volume x kg x 60 volume x 60
• mg x 1000 mg
• volume x kg volume x 60