1. 1 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

2. 2 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Chapter 9 Hemodynamic Monitoring

3. 3 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Pascal’s Law The pressure of a fluid in a closed container is equal at all points within the container. The pressure acts perpendicularly against the walls of the container. Pascal’s law is used to determine arterial, right atrial, and left ventricular end diastolic pressures using indwelling catheters.

4. 4 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Transducers A device that converts one form of energy into another A typical transducer consists of a diaphragm with a strain gauge. A change in electrical current is proportional to a change in pressure.

5. 5 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Central Venous Pressure Catheter Placed in the venous system with the distal tip resting in the vena cava –Outflow from the vena cava empties into the right atrium. –Pressure in the vena cava is the same as the pressure in the right atrium. (continues)

6. 6 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Central Venous Pressure Catheter (continued) Sites used for insertion of CVP catheters: –Antecubital fossa –Basilic –Internal jugular –Subclavian veins (continues)

7. 7 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Central Venous Pressure Catheter Wave Forms –a-wave: reflects the atrial contraction –x-wave descent: represents the fall in atrial pressure –c-wave: reflects closure of the tricuspid at the beginning of ventricular systole –v-wave: reflects the filling of the atrium during ventricular systole –y-wave descent: reflects the fall in pressure as the tricuspid opens (continues)

8. 8 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Central Venous Pressure Catheter (continued) Normal CVP Values –Range from 0 to 7 mm Hg (0 to 10 ‑ cm of H 2 O) –Vary with inspiration and expiration –Measured during resting exhalation

9. 9 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Clinical Applications of the Central Venous Pressure Catheter CVP provides useful clinical information pertaining to: –Hypervolemia –Hypovolemia –Right ventricular preload –Mixed venous blood sampling –Fluid administration

10. 10 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Pulmonary Artery Catheters or Swan-Ganz Catheters Provides: –CVP or right atrial pressures –Measurement of the pulmonary artery pressure –Measurement of the pulmonary artery wedge pressure (PAWP) (continues)

11. 11 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Pulmonary Artery Catheters or Swan-Ganz Catheters (continued) Multilumen catheter, with each lumen or port having a specific function –Proximal lumen –Distal lumen –Thermistor lumen –Inflation lumen and balloon

12. 12 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Preferred Routes of Access Antecubital fossa Basilic Internal jugular Subclavian veins

13. 13 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Pulmonary Artery Pressure and PAWP Wave Form Morphology Morphology of pressure tracings is a result of: –Physiologic events –Pathophysiologic events –Cardiac cycle events Pressure changes are a reflection of changes in: –Fluid volume –Ventricular compliance –Vascular resistance

14. 14 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Normal Pressure Ranges MEANSYSTOLICDIASTOLIC Right Atrium0–8 mm Hg 0–11 cm H 2 O Right Ventricle 10–22 mm Hg 13–30 cm H 2 O 15–28 mm Hg 20–36 cm H 2 O 0–8 mm Hg 0–11 cm H 2 O Pulmonary Artery 10–22 mm Hg 13–18 cm H 2 O 15–28 mm Hg 20–36 cm H 2 O 5–16 MM Hg 7–22 mm H 2 O Pulmonary Artery Wedge 6-12 mm Hg 8–16 cm H 2 O

15. 15 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Clinical Applications of the Pulmonary Artery Catheter Fluid volume and venous return Assessment of right ventricular function Assessment of left ventricular preload Assessment of cardiac output Determination of mixed venous oxygen saturation Determination of pulmonary vascular resistance

16. 16 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Arterial Lines Provides several types of data helpful in the management of critically ill patients Convenient site for: –Arterial blood sampling –Real-time measurement of systemic blood pressure (continues)

17. 17 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Arterial Lines (continued) Preferred Routes of Insertion –Radial Preferred due to collateral circulation –Femoral Increased risk of complications

18. 18 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Parts of an Arterial Pressure Wave Form Lowest point –End-diastolic pressure Highest point –Systolic pressure Normal values –100 to 140 ‑ mm Hg systolic –60 to 90 ‑ mm Hg diastolic

19. 19 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Hazards with Indwelling Vascular Catheters –Ischemia –Infection –Hemorrhage Hazards with Pulmonary Artery Catheters –Cardiac arrhythmias –Pulmonary artery rupture with inflation of the balloon (rare)

20. 20 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Equipment Set-up and Preparation Use aseptic technique Remove air bubbles from tubing, transducer and connections

21. 21 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Medication Preparation Preparing equipment to monitor hemodynamic pressures –500 units of heparin to the 500 ml normal saline bag –Affix medication and dosage label to bag

22. 22 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Spiking the Bag and Priming the Tubing Aseptically spike the solution bag. Ensure that all air is removed from bag. Prime the tubing. Close the stopcock. Insert the solution bag into the pressure bag. Increase pressure to 300 mm Hg using the hand bulb.

23. 23 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Transducer Preparation Insert the disposable transducer into the holder. Attach the monitoring cable to its connection on the transducer and to the pressure monitor or patient monitoring system. (continues)

24. 24 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Transducer Preparation (continued) Attach the infusion IV line to the transducer. Place a three-way stopcock on the other port of the transducer and connect the patient catheter to it.

25. 25 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Zeroing the Transducer Zero at initial prep and beginning of each shift –Turn off system to the patient –Open reference stopcock to air –Allow a few seconds and depress the zero button or switch on the monitor Transducer should be at patient’s phlebostatic axis

26. 26 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Identification of the Phlebostatic Axis Position patient supine and level Identify phlebostatic axis on patient’s axilla –Midaxillary line at junction of fourth rib Position transducer in the same plane –Use carpenter’s level

27. 27 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Wave Form Damping Caused by –Air in the system –Improper zeroing of transducer –Blood clots in system –Catheter occlusion –Leaks in system –Inadequate pressure in the bag –Kinks in the tubing

28. 28 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Obtaining a Pulmonary Artery Wedge Pressure Pulmonary artery wedge pressure is measured when the balloon on the pulmonary artery catheter is inflated and wedged in the pulmonary artery.

29. 29 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Overwedging of the Balloon Do not inject more than 1 to 1.5 cc of air into the inflation lumen. If overwedged, withdraw all air. Verify the correct wave form morphology is being viewed. Inject only enough air for desired pulmonary artery wedge wave form morphology.

30. 30 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Cardiac Output Determination Change the function to cardiac output determination – check supply of cold injectate. Draw 10ml of injectate and attach syringe to port – trigger the monitor. When instructed, push contents of syringe into proximal port’s lumen. Obtain 3 values within 10% of each other and average.

31. 31 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Arterial Line Maintenance Use heparinized solution in the pressure bag. Flush the catheter periodically with a syringe and herparinized solution. Check frequently for loose connections. Check pulses proximal and distal to catheter.

32. 32 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Zeroing an Arterial Line Turn off system to patient by rotating stopcock Open reference stopcock to atmospheric pressure Allow for equilibration. Zero the monitor.