1. Hemodynamic Monitoring Part I (ABP, CVP, Ao)
MICU Competencies

2. What is Hemodynamic Monitoring?
Non-invasive = clinical assessment & NBP
Direct measurement of arterial pressure
Invasive hemodynamic monitoring

3. Noninvasive Hemodynamic Monitoring
Noninvasive BP
Heart Rate, pulses
Mental Status
Mottling (absent)
Skin Temperature
Capillary Refill
Urine Output

4. Proper Fit of a Blood Pressure Cuff
Width of bladder = 2/3 of upper arm
Length of bladder encircles 80% arm
Lower edge of cuff approximately 2.5 cm above the antecubital space

5. Why A Properly Fitting Cuff?
Too small causes false-high reading
Too LARGE causes false-low reading

6. Indications for Arterial Blood Pressure
Frequent titration of vasoactive drips
Unstable blood pressures
Frequent ABGs or labs
Unable to obtain Non-invasive BP

7. Supplies to Gather Arterial Catheter Pressure Tubing Pressure Bag
Pressure Cable
Pressure Bag
Flush – 500cc NS

8. Supplies to Gather Sterile Gown (2) Sterile Towels (3) Sterile Gloves
Suture (silk 2.0)
Chlorhexidine Swabs
Mask

9. Leveling and Zeroing Leveling Before/after insertion
If patient, bed or transducer move
Zeroing
Performed before insertion & readings
Level and zero at the insertion site

10. Potential Complications Associated With Arterial Lines
Hemorrhage
Air Emboli
Infection
Altered Skin Integrity
Impaired Circulation

11. Documentation Insertion procedure note ABP readings as ordered
Neurovascular checks every two hours
(in musculoskeletal assessment of HED)
Pressure line flush amounts (3ml/hr)
Tubing and dressing changes

12. Central Venous Pressure Assesses . . .
Intravascular volume status
Right ventricular function
Patient response to drugs &/or fluids

13. Central Venous Pressure (CVP)
Central line or pulmonary artery catheter
Normal values = 2 – 8 mm Hg
Low CVP = hypovolemia or ↓ venous return
High CVP = over hydration, ↑ venous return, or right-sided heart failure

14. Leveling and Zeroing Leveling Before/after insertion
After patient, bed or transducer move
Aligns transducer with catheter tip
Zeroing
Performed before insertion & readings
Level and zero transducer at the phlebostatic axis

15. Phlebostatic Axis 4th intercostal space, mid-axillary line
Level of the atria
(Edwards Lifesciences, n.d.)

16. More on Leveling and Zeroing
HOB 0 – 60 degrees
No lateral positioning
Phlebostatic axis with any position (dotted line)
(Edwards Lifesciences, n.d.)

17. Dynamic Flush
Dynamic flush ensures the integrity of the pressure tubing system. Notice how it ascends - forms a square pattern - and bounces below the baseline before returning to the original waveform.
Check dynamic flush after zeroing any pressure tubing system

18. System Maintenance Change tubing and fluid bag q 96hrs
No pressors through CVP port
Antibiotics, NS boluses, blood, & IV pushes are allowed through the CVP line

19. Troubleshooting
Improper set-up and equipment malfunction are the primary causes for hemodynamic monitoring problems
Retracing the set-up process or tubing (patient to monitor) may identify the problem and solution quickly
Use your staff resources: Help All, Charge Nurse, Educator, Preceptors, MICU experts

20. Troubleshooting Damped Waveforms Pressure bag inflated to 300 mmHg
Reposition extremity or patient
Verify appropriate scale
Flush or aspirate line
Check or replace module or cable

21. Troubleshooting Inability to obtain/zero waveform
Connections between cable & monitor
Position of stopcocks
Retry zeroing after above adjustments

22. Continuous Airway Pressure (Ao)
Also known as Paw, Ao
Purpose:
Improves accuracy of hemodynamic waveform measurements
Identification of end-expiration
Positive waveform deflections = positive pressure ventilation
Negative deflections = spontaneous inspiratory effort

23. Supplies to Gather Pressure Cable Pressure Tubing Connector
(Edwards Lifesciences, n.d.)

24. Setting up the Ao Discard infusion spike end & cap port
Connect pressure tubing to vent tubing
(using connector opposite heating cable)
Connect cables
Zero the tubing (leveling not necessary)

25. Troubleshooting Ao Do not prime tubing with fluids!
Damping will occur with fluid or secretions
To evacuate any fluids, disconnect pressure tubing from vent tubing and push air through the pressure tubing with a 10 ml syringe connected at one end until fluid-free

26. Pressure Measurement CVP=13 1) Record Ao and CVP on the same strip
2) Find end-expiration by drawing a vertical line with a straight edge 200 ms prior to the rise or dip in Ao (1 large box) associated with a breath.
3) Draw a horizontal line through the visually assessed average vascular pressure starting at end-expiration going backward 200 ms (1 large box).
4) Read the pressure at the horizontal line. 15 10 5 -5
CVP=13

27. Assist-Control
200 ms { Ao {
CVP
200 ms

28. CPAP with Pressure Support
200 ms { Ao {
200 ms
CVP

29. CPAP without Pressure Support
200 ms { Ao {
200 ms
CVP

30. Incorrect method!
This point was identified as end-expiration for a pt. who did not have an Ao set up. 40 30 20 10
-10
Correct method!
30 sec after the above tracing, Ao was added & true end-expiration clearly identified.

31. Same patient 20 minutes later40 30 20 10
-10 40 30 20 10
-10

32. 15 10 5 -5
CVP=13

33. Summary Record Ao with CVP
Read mean CVP at end-expiration as described. No need read vascular pressure at any particular time in the cardiac cycle

34. Documentation of CVP Include on waveform strip
Position of the HOB
Vasopressors and rates
Amount of PEEP
Scale
CVP measurement
Signature of the nurse
(post in green chart behind graphics tab)

35. References & Resources
Burns, S. M. (2004). Continuous airway pressure monitoring. Critical Care Nurse, 24(6),
Chulay, M., & Burns, S. M. (2006). AACN Essentials of critical care. McGraw-Hill: New York.
Edwards. (2006). Pulmonary Artery Catheter Educational Project.
Edwards Lifesciences. (n.d.) Educational videos.
MICU Routine Practice Guidelines.
MICU Bedside Resource Books
MICU Education Kits (Red cart in conference room)
MICU Preceptors, Help All Nurses, & Charge Nurses
VUMC policies.