1. Basics of Hemodynamics Christian Sonnier MD

2. Learning Objectives Review basic cardiac anatomy Review cardiac output and its variables Discuss non-invasive and invasive monitoring Discuss strategies to manipulate cardiac output

4. Coronary Arteries RCA- RA, RV&LV Inf, Inf Septum SA node 65% AV node 80% PDA 80-90% CX- LA,LV ( side/back) SA node 40% AV node 20% LAD – LV (front/bottom) Septum Bundle branches Left Main

6. Cardiac Cycle Diastole Phase Early DiastoleVentricles relax. Semilunar valves close.valves Atrioventricular valves open.valves Ventricles fill with blood. Mid DiastoleAtria and Ventricles are relaxed. Semilunar valves are closed. Atrioventricular valves are open. Ventricles continue to fill with blood. Late DiastoleSA nodeSA node contracts. Atria contract. Ventricles fill with more blood. Contraction reaches AV node.AV node Cardiac Cycle Systole Phase SystoleContraction passes from AV node to Purkinje fibers and ventricular cells.AV node Purkinje fibers Ventricles contract. Atrioventricular valves close. valves Semilunar valves open. valves Blood is pumped from the ventricles to the arteries.

7. Cardiac Cycle

8. Electrical Conduction system SA node  Atrial muscle  Internodal fibers  AV node  AV bundle  right and left bundle branches  Ventricular muscle

9. Autonomic Nervous System The autonomic nervous system stimulates the heart through a balance of sympathetic nervous system and parasympathetic nervous system innervations. – The sympathetic nervous system plays a role in speeding up impulse formation, thus increasing the heart rate – The parasympathetic nervous system slows the heart rate.

10. The Cardiac Cycle

11. Coronary Arteries Fill The Cardiac Cycle

14. Normal CO 4-8 liters Normal Cardiac Index is 2.5 to 4.5 liters

15. Heart Rate  Works with Stroke Volume  Compensatory  Tachycardia  Bradycardia  Dysrhythmias

18. Factors Causing Low Cardiac Output Inadequate Left Ventricular Filling – Tachycardia – Rhythm disturbance – Hypovolemia – Mitral or tricuspid stenosis – Pulmonic stenosis – Constrictive pericarditis or tamponade – Restrictive cardiomyopathy Inadequate Left Ventricular Ejection – Coronary artery disease causing LV ischemia or infarction – Myocarditis, cardiomyopathy – Hypertension – Aortic stenosis – Mitral regurgitation – Drugs that are negative inotropes – Metabolic disorders

20. Hemodynamic terms Preload- Stretch of ventricular wall. Usually related to volume. (how full is the tank?) – Frank Starling ’ s Law

21. Hemodynamic terms Increased preload seen in – Increased circulating volume (too much volume) – Mitral insufficiency – Aortic insufficiency – Heart Failure – Vasoconstrictor use- (dopamine) Decreased Preload seen in – Decreased circulating volume (bleeding,3 rd spacing) – Mitral stenosis – Vasodilator use ( NTG) – Asynchrony of atria and ventricles

22. Normal Value - 2-8 mm Hg

23. Or LVEDP PAOP = 8-12 mm Hg PAD = 10-15 mm Hg

25. Hemodynamic terms Contractility - – How well does the ventricular walls move? How good is the pump? –  Decreased due to Drugs – certain drugs will decrease contractility – Lido, Barbiturates, CCB, Beta-blockers Infarction, Cardiomyopathy Vagal stimulation Hypoxia

26. Hemodynamic terms Contractility- –  Increased Positive inotropic drugs – Dobutamine, Digoxin, Epinephrine Sympathetic stimulation – Fear, anxiety Hypercalcemia ( high calcium)

27. CONTRACTILITY - PRECAUTIONS Do Not use Inotropes until volume deficiency is corrected Correct Hypoxemia and electrolyte imbalance.

29. Hemodynamic terms Afterload – resistance the blood in the ventricle must overcome to force the valves open and eject contents to circulation.

30. X Y

31. Hemodynamic terms Factors that  increase afterload are – Systemic resistance or High Blood pressure – Aortic stenosis – Myocardial Infarcts / Cardiomyopathy – Polycythemia – Increased blood viscosity

32. Hemodynamic terms Factors that  decrease Afterload – Decreased volume – Septic shock- warm phase – End stage cirrhosis – Vasodilators

33. Normal PVR is 120 to 200 dynes

34. Normal SVR - 800-1200 dynes

37. Mean Arterial Pressure organs MAP is considered to be the perfusion pressure seen by organs in the body. 60 mmHg It is believed that a MAP of greater than 60 mmHg is enough to sustain the organs of the average person under most conditions. If the MAP falls significantly below this number for an appreciable time, the end organ will not get enough blood flow, and will become ischemic. Calculated MAP = 2x diastolic + systolic 3

40. EKG

46. 1. PRELOAD- venous blood return to the heart Controlled by; ♥.Blood Volume  PRBC’s Albumin Normal Saline  Diuretics- lasix,bumex Thiazides  Ace inhibitors ♥. Venous Dilation  Nitroglycerine  Ca+ channel blockers clonidine (Catapress) methyldopa trimethaphan (arfonad) ↓ Dobutamine  Morphine 2. CONTRACTILITY- forcefulness of contractility  Ca+ channel blockers  Digoxin  Dopamine/Dobutamine  Milrinone/amrinone 3. AFTERLOAD – work required to open aortic valve and eject blood – resistance to flow in arteries °  Dopamine (at higher doses)  Ace inhibitors  Nipride/lesser extent Nitro  Calcium channel blockers  Labetalol Drugs of Hemodynamics 4. HEART RATE – 1.  Beta blockers 2.  Calcium channel blockers 3.  Atropine 4.  Dopamine 5.  Dobutamine

51. O2 To BODY From Body

52. O2

53. Factors that make up SVO 2 are Cardiac output SaO 2 VO 2 (oxygen consumption) Hemoglobin

55. Causative Factors Clinical Conditions  O2 Delivery  Hb concentration - Anemia - Hemorrhage  Oxygen saturation (SaO2) (SaO2) - Hypoxemia - Lung disease - Low FIO2  Cardiac Output - LV dysfunction (cardiac disease, drugs) - Shock – cardiac/septic (late) - Hypovolemia - Cardiac Dysrhythmias  Oxygen consumption - Fever, infection - Seizures, agitation - Shivering -  Work of Breathing - Suctioning, bathing, repositioning

56. Increased SVO 2 Most common cause is - Sepsis Or Wedged PA catheter

57. Functions of PA Catheter Allows for continuous bedside monitoring of the following – Vascular tone, myocardial contractility, and fluid balance can be correctly assessed and managed. – Measures Pulmonary Artery Pressures, CVP, and allows for hemodynamic calculated values. – Measures Cardiac Output. (Thermodilution) – SvO2 monitoring (Fiber optic). – Transvenous pacing. – Fluid administration.

58. PA Catheter KEEP COVERED KEEP LOCKED YELLOW Clear BLUE RED Markings on catheter. 1. Each thin line= 10 cm. 2. Each thick line= 50 cm.

59. Description of PA Catheter Ports/lumens. CVP Proximal (pressure line - injectate port for CO)-BLUE PA Distal (Pressure line hook up)- Yellow Extra port - usually- Clear Thermistor – Red Cap

60. Continuous Cardiac Output and SVO 2 monitoring

61. Indications for PA catheter The pulmonary artery catheter is indicated in patients whose cardiopulmonary pressures, flows, and circulating volume require precise, intensive management. MI – cardiogenic shock - CHF MI – cardiogenic shock - CHF Shock - all types Shock - all types Valvular dysfunction Valvular dysfunction Preoperative, Intraoperative, and Postoperative Monitoring Preoperative, Intraoperative, and Postoperative Monitoring ARDS, Burns, Trauma, Renal Failure ARDS, Burns, Trauma, Renal Failure

62. PRESSURE TRANSDUCER SYSTEMS SET UP

65. RN magazine April, 2003 - PA catheter refresher course.

68. a, c,& v Waves and their Timing to the ECG tracing

71. RA WAVEFORM

73. RV WAVEFORM 22 4

78. COMPLICATIONS OF PA CATHETER Infection ☹ Infection ☹ Electrocution (Microshock) ☹ Ventricular Arrhythmias (Vtach.,Vfib., Cardiac Arrest) ☹ Atrial Dysrhythmias, RBBB ☹ Knotting and misplacement ☹ Hemo or Pneumothorax ☹ Cardiac valve trauma

79. COMPLICATIONS OF PA CATHETER ☹ Catheter thromboembolism or air embolism ☹ Dissection or Laceration of subclavian artery or vein ☹ Cardiac Tamponade ☹ Pulmonary infarction ☹ Pulmonary artery injury or rupture ☹ Balloon rupture ☹ Hematoma

80. Arterial line Indicated in patient’s with – Hypotension – Pressors – Need for recurrent/frequent abg’s – LHC

81. ARTERIAL WAVEFORM

82. Strategies to manipulate cardiac output

83. Increased Preload

84. Decreased preload

85. Hemodynamic terms Contractility- –  Increased Positive inotropic drugs – Dobutamine, Digoxin, Epinephrine

86. CONTRACTILITY - PRECAUTIONS Do Not use Inotropes until volume deficiency is corrected Correct Hypoxemia and electrolyte imbalance.

88. Hemodynamic terms Afterload – resistance the blood in the ventricle must overcome to force the valves open and eject contents to circulation.

92. 1. PRELOAD- venous blood return to the heart Controlled by; ♥.Blood Volume  PRBC’s Albumin Normal Saline  Diuretics- lasix,bumex Thiazides  Ace inhibitors ♥. Venous Dilation  Nitroglycerine  Ca+ channel blockers clonidine (Catapress) methyldopa trimethaphan (arfonad) ↓ Dobutamine  Morphine 2. CONTRACTILITY- forcefulness of contractility  Ca+ channel blockers  Digoxin  Dopamine/Dobutamine  Milrinone/amrinone 3. AFTERLOAD – work required to open aortic valve and eject blood – resistance to flow in arteries °  Dopamine (at higher doses)  Ace inhibitors  Nipride/lesser extent Nitro  Calcium channel blockers  Labetalol Drugs of Hemodynamics 4. HEART RATE – 1.  Beta blockers 2.  Calcium channel blockers 3.  Atropine 4.  Dopamine 5.  Dobutamine

93. References Pulmonary Artery Catheter Education Project @ www.pacep.org sponsored bywww.pacep.org – American Association of Critical Care Nurses American Association of Nurse Anesthetists American College of Chest Physicians American Society of Anesthesiologists American Thoracic Society National Heart Lung Blood Institute Society of Cardiovascular Anesthesiologists Society of Critical Care Medicine Hemodynamics Made Incredibly Visual – LWW publishing 2007 AACN practice alert – Pulmonary Artery Pressure Monitoring - Issued 5/2004 Handbook of Hemodynamic Monitoring – G Darovic 2 nd ed. TCHP Education Consortium 2005 – A Primer for Cardiovascular Surgery and Hemodynamic Monitoring Uptodate.com