Chapter 9 Hemodynamic Monitoring Copyright 2013 Wolters Kluwer

Indications for Hemodynamic Monitoring • Assesses cardiac function and evaluates effectiveness of therapy –

System Components Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Square-Wave Test Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Leveling and Zeroing Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question • To ensure accurate arterial pressures, the nurse must level the transducer to

Answer • B. Phlebostatic axis • Rationale: The phlebostatic axis is between the fourth

Arterial Pressure Monitoring • Continuous monitoring of arterial blood pressure • Vascular access for

Nursing Interventions for Arterial Lines • Ensure insertion site is visible at all times.

Data Interpretation Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question • Is the following question True or False? • It is acceptable to

Answer • False • Rationale: An arterial pressure line is used for monitoring purposes

Complications of Arterial Lines • Accidental blood loss – Secure and tighten connections. –

Central Venous Pressure Monitoring • Normal values 2 to 8 mm Hg • Measures

Complications of Central Venous Catheters • Infection – Assess the site. – Observe a

Question • Is the following statement True or False? • A central venous catheter

Answer • True • Rationale: Central venous catheter terminates in the superior vena cava

Pulmonary Artery Catheter • Four lumens – Distal lumen – Proximal lumen – Thermistor

Nursing Interventions for Pulmonary Artery Catheters • Assist with insertion. • Monitor waveform. •

Data Interpretation • Right atrial pressure 2 to 6 mm Hg – Measures pressure

Data Interpretation (cont. ) • Pulmonary artery pressure – Systolic pressure equals right ventricular

Complications of Pulmonary Artery Catheters • Ventricular dysrhythmias • Pulmonary artery rupture or perforation

Cardiac Output • Cardiac output (CO)—the amount of blood ejected from the heart per

Stroke Volume • Preload – Amount of stretch on the myocardial muscle fibers at

Methods of Evaluating Cardiac Output • Thermodilution • Arterial pressure and waveform-based methods •

Question • Determinants of stroke volume includes all of the following except what? –

Answer • B. Cardiac output • Rationale: Stroke volume is the volume of blood

Thermodilution Technique • Gold standard for evaluating cardiac output – Intermittent • Measures change

Thermodilution Technique (cont. ) Copyright © 2013 Wolters Kluwer Health | Lippincott Williams &

Cardiac Output Curves Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Thermodilution Technique (cont. ) • Ensure volume of injectate in the syringe is correct.

Arterial Pressure and Waveform-Based Method • Proportional relationship between pulse pressure and stroke volume

Impedance Cardiography • Electrodes placed on the base of the neck and lower thorax

Esophageal Doppler Monitoring • Doppler transducer in nasogastric tube • Placed in esophagus and

Question • What is the most widely used method to determine cardiac output? –

Answer • D. Thermodilution • Rationale: Thermodilution is the most common method used to

Evaluation of Oxygen Delivery and Demand Balance • Oxygen delivery (Da. O 2) –

Balance Between Supply and Demand • Oxygen consumption—the amount of oxygen used by the

Evaluation of Global Tissue Oxygenation Status • Metabolic indicators – Lactate levels, serum p.

Question • Is the following statement True or False? • Oxygen extraction is the

Answer • True • Rationale: Oxygen extraction—the amount of oxygen removed from Hgb to

Factors Affecting Oxygen Supply Versus Demand • Surgery • Sepsis • Infection • Anesthesia

Evaluation of Regional Tissue Oxygenation Status • Gastric tonometry – Specialized nasogastric tube measures

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Indications for Hemodynamic Monitoring • Assesses cardiac function and evaluates effectiveness of therapy – Cardiogenic shock – Severe heart failure – Sepsis or septic shock – Multiple organ system dysfunction (MODS) – Acute respiratory distress syndrome (ARDS) – Cardiac surgery Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question • To ensure accurate arterial pressures, the nurse must level the transducer to what landmark? – A. Nipple line – B. Phlebostatic axis – C. Sternal notch – D. Apical impulse Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer • B. Phlebostatic axis • Rationale: The phlebostatic axis is between the fourth intercostal space and midaxillary line; this is the approximate location of the right atrium. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Arterial Pressure Monitoring • Continuous monitoring of arterial blood pressure • Vascular access for obtaining blood samples • Guides therapy Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Interventions for Arterial Lines • Ensure insertion site is visible at all times. • Ensure monitor alarms are visible and audible. • Set parameters according to the facility protocol. – Typically 10 to 20 mm Hg of the patient’s trended blood pressure • DO NOT infuse IV solution or medication through the arterial pressure monitoring system. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer • False • Rationale: An arterial pressure line is used for monitoring purposes only. NEVER infuse any medications or IV solutions via this line. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Complications of Arterial Lines • Accidental blood loss – Secure and tighten connections. – Immobilize extremity. – Expose extremity. • Infection – Observe a sterile technique. – Maintain a closed system. • Impaired circulation – Assess color, sensation, temperature, and movement of extremity. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Central Venous Pressure Monitoring • Normal values 2 to 8 mm Hg • Measures right atrial pressure • Left ventricular end-diastolic pressure • Reflects intravascular blood volume Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Complications of Central Venous Catheters • Infection – Assess the site. – Observe a sterile technique with any catheter manipulation. • Thrombosis – Monitor waveform, ability to flush, blood return. • Pneumothorax – CXR postinsertion • Air embolism – Ensure tight connections. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question • Is the following statement True or False? • A central venous catheter measures right atrial pressure, left ventricular end-diastolic pressure, and intravascular blood volume. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer • True • Rationale: Central venous catheter terminates in the superior vena cava near the right atrium; it measures right atrial pressures, left ventricular end-diastolic pressure, and intravascular blood volume. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Pulmonary Artery Catheter • Four lumens – Distal lumen – Proximal lumen – Thermistor lumen – Balloon inflation lumen *Some PACs may have additional lumens. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Interventions for Pulmonary Artery Catheters • Assist with insertion. • Monitor waveform. • Observe for dysrhythmias. • Observe for accidental wedging of the catheter. • Maintain sterile dressing. *Central catheter placement must be confirmed by CXR before accessing the device. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Data Interpretation • Right atrial pressure 2 to 6 mm Hg – Measures pressure in the right ventricle during diastole, equals CVP • Right ventricular pressure 20 to 30 mm Hg – Equals the pulmonary artery systolic pressure Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Data Interpretation (cont. ) • Pulmonary artery pressure – Systolic pressure equals right ventricular systolic function 20 to 30 mm Hg. – Diastolic pressure equals the left ventricular enddiastolic pressure (LVEDP) 8 to 15 mm Hg. • Pulmonary artery wedge pressure 8 to 12 mm Hg – More accurate measure of LVEDP Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Complications of Pulmonary Artery Catheters • Ventricular dysrhythmias • Pulmonary artery rupture or perforation • Pulmonary infarction Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Cardiac Output • Cardiac output (CO)—the amount of blood ejected from the heart per minute • Stroke volume (SV)—the milliliters of blood ejected from the ventricle with each contraction • HR x SV=CO • 4 to 8 L/minute at rest • Cardiac index (CI)—relates cardiac output to body size; normal is 2. 5 to 4 L/minute/m 2. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Stroke Volume • Preload – Amount of stretch on the myocardial muscle fibers at end diastole • Afterload – The resistance to ejection of blood from the ventricles • Contractility – Ability of the heart to contract independent of preload and afterload Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Methods of Evaluating Cardiac Output • Thermodilution • Arterial pressure and waveform-based methods • Electrical bioimpedance cardiography • Esophageal Doppler monitoring Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question • Determinants of stroke volume includes all of the following except what? – A. Preload – B. Cardiac output – C. Afterload – D. Contractility Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer • B. Cardiac output • Rationale: Stroke volume is the volume of blood ejected from the ventricle with each contraction. Preload, afterload, and contractility determine stroke volume. Stroke volume X heart rate = cardiac output Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Thermodilution Technique • Gold standard for evaluating cardiac output – Intermittent • Measures change in blood temperature following injection of indicator solution – Continuous • Specialized PACs with thermal filaments Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Thermodilution Technique (cont. ) • Ensure volume of injectate in the syringe is correct. • Inject the volume smoothly and rapidly, less than 4 seconds. • Wait approximately 1 minute between injections to allow the catheter thermistor to return to baseline. • Obtain three or more consecutive measurements. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Arterial Pressure and Waveform-Based Method • Proportional relationship between pulse pressure and stroke volume • Inverse relationship between pulse pressure and aortic compliance • Measures using an arterial line, special sensor, and a monitor that uses an algorithm for SV and CO Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Impedance Cardiography • Electrodes placed on the base of the neck and lower thorax • Measures impedance over time and is mathematically converted into SV and CO values using an algorithm Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Esophageal Doppler Monitoring • Doppler transducer in nasogastric tube • Placed in esophagus and monitors blood flow velocity through the descending aorta • Continuous CO and SV are calculated using an algorithm. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question • What is the most widely used method to determine cardiac output? – A. Arterial pressure and waveform method – B. Impedance cardiography – C. Esophageal Doppler monitoring – D. Thermodilution Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer • D. Thermodilution • Rationale: Thermodilution is the most common method used to measure cardiac output and is considered the clinical gold standard. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Evaluation of Oxygen Delivery and Demand Balance • Oxygen delivery (Da. O 2) – Amount of oxygen transported to tissues – Depends on cardiac output, hemoglobin levels, and arterial oxygen saturation Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Balance Between Supply and Demand • Oxygen consumption—the amount of oxygen used by the cells of the body • Primary determinants: – Oxygen demand—the cells requirement for oxygen – Oxygen delivery—need adequate supply of oxygen to deliver to the cells – Oxygen extraction—the amount of oxygen removed from Hgb to be used by the cells Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Evaluation of Global Tissue Oxygenation Status • Metabolic indicators – Lactate levels, serum p. H, and base excess/base deficit • Venous oxygen saturation – Evaluates oxygen supply versus oxygen demand – Mixed venous oxygen saturation Sv. O 2 – Venous oxygen saturation Scv. O 2 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question • Is the following statement True or False? • Oxygen extraction is the amount of oxygen removed from Hgb to be used by the cells. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer • True • Rationale: Oxygen extraction—the amount of oxygen removed from Hgb to be used by the cells; oxygen demand is the cells’ requirement for oxygen, oxygen delivery the need for adequate supply of oxygen to deliver to the cells. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Factors Affecting Oxygen Supply Versus Demand • Surgery • Sepsis • Infection • Anesthesia • Pain • Suctioning • Hypothermia • Pharmacological paralysis • Sedation • Anxiety Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Evaluation of Regional Tissue Oxygenation Status • Gastric tonometry – Specialized nasogastric tube measures partial pressure of carbon dioxide (PCO 2) • Sublingual capnometry – Measures PCO 2 under the tongue Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins