Boot Camp Hemodynamic Monitoring

NTI 2010
Cardiovascular Boot Camp:

Hemodynamic Monitoring
Carol Jacobson RN, MN

Cardiovascular Nursing Education Associates
www.cardionursing.com
Function of CV
system is to deliver
O2 to tissues
Heart
Arteries
Veins
Volume
Hemodynamic monitoring
evaluates the ability of CV system
to deliver blood flow to tissues:
Determinants of CO
Blood volume
Vascular tone
Carol Jacobson RN, MN 2010

Cardiovascular Nursing Education Associates: www.cardionursing.com
Lungs job:
oxygenate
blood
Tissues job:
extract and use O2
Hemodynamic Data:
What do we need to know?
CO = HR X SV
BP = CO X SVR
TISSUE OXYGENATION
Most important piece of hemodynamic

information is STROKE VOLUME
Amount of blood ejected with each beat
- Normal = 60 130 ml/beat
Cant measure directly invasively or

noninvasively
Heart Rate and BP easy to obtain but

dont tell us anything about whats
wrong with the patient

So What We Really Want to Know

From Hemodynamic Monitoring is:
What is the stroke volume?
Must assess determinants of SV to get that
information:
Preload
Afterload
Contractility
Pulmonary artery catheter is an invasive way

to get some of this information
There are some newer noninvasive methods
of obtaining CO that can give us SV but are
not widely used at present
Invasive Methods of Obtaining

Hemodynamic Data

Pulmonary Artery Catheter

Cardiac output
connection
Distal (PA) tail
Distal port
Proximal (CVP) tail
Proximal port
Balloon port

CVP measures right atrial
pressure and is used as a
clinical indicator of RV
preload
- Normal CVP = 2-6 mmHg
PWP reflects left atrial

pressure and is used as a
clinical indicator of LV
preload
PWP
CVP
- Normal PWP = 8-12 mmHg

PA Catheter
PVR is a calculated value
based on mean PA pressure
and PWP and is used as a
clinical indicator of RV
afterload
PVR
- Normal PVR = < 250 dynes
SVR is a calculated value

based on mean arterial
pressure and CVP and is
used as a clinical indicator of
LV afterload
SVR
- Normal SVR = 900-1200 dynes

In order for these calculated values to be accurate, the parameters
they are based on need to be accurate: CVP & PWP
Cardiac Output
Can be measured by intermittent injection or
continuously
Normal CO = 4-8 liters/minute
CO should be indexed to patients size by
dividing CO by BSA
- Normal CI = 2.5 -4.5 L/min/M2
Stroke Volume can be estimated by

dividing CO by HR
Normal SV = 60-130 ml/beat

Newer Noninvasive Methods

Aortic Doppler
Bioimpedance
LidCo (lithium injection, requires arterial
line and venous line)

PiCCO (pulse contour analysis, requires
arterial line and venous line)
Flotrac (uses arterial waveform and
works only in ventilated patients with no
arrhythmias)
Hemodynamic
Monitoring:
Getting Accurate Data From a

Pressure Monitoring System

Fluid System
Fluid source: IV bag of 500 cc of NS
Caution: if patient has history of or suspected
heparin induced thrombocytopenia (HIT) DO NOT
use heparin in flush solution!
A continuous fluid filled line from the IV bag to the
transducer and from the transducer to the catheter
tip is needed in order to monitor pressures.
Pressure bag: IV bag must be pressurized at

300 mmHg to overcome the resistance of the
flush device in the transducer and to deliver
3ml per hour through the catheter to keep the
line from clotting off.
Tubing: high pressure rigid tubing is

necessary to accurately transmit
vascular pressures to the transducer.
Transducer with flush device:
contains a one-way valve that allows
3ml/hr of fluid to pass through unless
the resistance is released by pulling
the tail or pushing the lever on the
device which allows the line to run
wide open.
PA Catheter

Electrical System
Transducer: contains fine wires that move
back and forth with pressure changes and
convert the pressure to an electrical signal
that is sent to the monitor. Must be filled with
fluid and be bubble-free to accurately transmit
pressure.
Connecting cable: connects the transducer
to the bedside monitor and transmits the
electrical signal to the monitor.
Monitor: converts electrical signal to a
waveform and displays it on the screen.

AACN Practice Alert for Pulmonary

Artery Pressure Monitoring - 2004
Perform square waveform test each shift
Position patient supine with HOB between
0 60
Level stopcock air-fluid interface to
phlebostatic axis
Use graphic tracing that includes the ECG
Take measurements at end expiration
Square Waveform Test

Fast Flush
Determines ability of transducer to
correctly reflect pressures in PA
Identifies system problems
Air bubbles
Tubing too long
Loose connections
Loss of pressure on bag
Catheter patency

Square Waveform Test

Perform the test
Once each shift
After opening system
- Zeroing
- Blood draws
- Tubing changes
Whenever PAP waveform appears damped or

distorted
Method of Performing Test

Verify 300 mmHg pressure on bag
Pull pigtail and release - watch response of
system on monitor
If abnormal
Tighten connections
Pump up bag
Flush system
Change transducer and tubing to patient if

unable to correct

10
Normal Square Waveform Test
Abnormal Fast Flush Tests

Over damped
Results in erroneously low SBP and high DBP

Caused by:
- Large air bubbles
- Loose/open connections
- Low fluid level in flush bag

11
Abnormal Fast Flush Tests

Under damped
Results in erroneously high SBP and low DBP

Caused by:
- Small air bubbles
- Tubing too long
- Defective transducer
Marking the Phlebostatic Axis

Phlebostatic axis is 4th intercostal space at mid
anterior-posterior chest level (left atrial level)
System needs to be zeroed and leveled at the
phlebostatic axis
Measure accurately and mark on chest

12
Zeroing and Leveling

Zeroing tells the monitoring system that
atmospheric pressure is zero
It removes the effect of hydrostatic pressure in
the tubing system and establishes a baseline
of zero so all pressure recorded by the
system is patient pressure
Leveling means that the stopcock that

was used to zero must be at the
phlebostatic axis for all pressure readings
Keep the transducer at the phlebostatic axis
while monitoring pressure
To Zero the System

Place the stopcock located on top of the
transducer at the level of the phlebostatic axis
Open the stopcock to air (turn it off to the
patient)
Push the Zero button on the monitor.
This tells the transducer that atmospheric pressure
is Zero and sets a baseline for pressure
measurements.
Close the stopcock to air (turn back to neutral

position)
This opens the line between the patient and the
transducer and allows the transducer to see the
patients pressure

13
Leveling
Stopcock used to zero must remain at
phlebostatic level regardless of patient position.
Leveling must occur with every reading
For every cm deviation from true phlebostatic
axis, pressures can change 1.86 mmHg

14
Obtain measurements from graphic

tracing that includes the ECG
Read at end expiration
Right Atrial Waveforms
2-6 mmHg
a wave = atrial contraction

and follows P wave
c wave = closure of
tricuspid valve
v wave = atrial filling and
follows QRS
Record the mean of the a wave for the CVP

15
Normal CVP
ac v
CVP
a
v
Identify a and v waves

What is the CVP measurement?

16
Swan Insertion RA to RV
RV
RA
Right Ventricular Waveforms

The monitor is never
right on the RV
diastolic pressure!
It reads the lowest point
We want to record the
plateau (true RVEDP)
15-30
2-6
30- Systolic
20100-

Diastolic
17
Normal RV Waveform
Identify RV systolic and diastolic pressure.
RV Pressure = 38/10
RV Pressure
Identify RV Systolic and Diastolic Pressure
3020100RV Pressure = 22/7

18
Swan Insertion RV to PA
PA
RV
Pulmonary Artery Waveforms

15-30
8-12
The monitor is usually

right about PA pressures
No false lows
Ignore the pre-systolic
bump
Systolic
Diastolic

19
PA Waveform
Identify PA Systolic and Diastolic pressure

What is the pressure?
PAP = 54/20
Swan Insertion PA to PWP
PA

PWP
20
Wedge Pressure Waveform

Same a, c, and v
waves as CVP
Further removed from the
ECG waves
a wave near end of QRS
v wave after T wave
8-12 mmHg
Record the mean of the a wave

for the PWP
PWP Waveform
Identify a and v waves and state the value of the PWP
1050-
PWP = 6 mmHg

21
Normal PAW
20-
a
100-
Identify a and v waves and state the PWP measurement

PAW = 10 11 mmHg
Large v Waves in PAW Waveform
v
a
Identify two problems this patient has.

LV failure: elevated PAWP (mean of a wave)
Mitral regurgitation: large v wave

22
End Expiration in
Spontaneous Breathing
Inspiration is a negative dip in waveform.

23
Find end-expiration.
Where would you read the PA and the PAW pressure?
PA to PAW
a v
PA pressure = 58/32
PAW pressure = 25

24
End Expiration in
Ventilator Breath
Inspiration is a rise the in waveform
Ventilator Breaths
a v
Find the ventilator breath.

Where would you read this PAW pressure?
PWP = 16

25
Goals of Hemodynamic
Monitoring
Determine magnitude of pulmonary
congestion (LV preload)
Assess peripheral perfusion
(forwards flow)
Determine LV function based on

preload and forwards flow

26
Forwards flow:
CI/SV, skin temp (warm or cold)
Left Ventricular Function Curves

5
4
3
2
1
0
2
10 12 14 16 18 20 22 24 26 28 30 32 34 36
Preload: PWP, lung sounds (dry or wet)
Forwards flow:
Changing Preload: moves patient along the curve they are on.
5
4
3
2
1
0
2
10 12 14 16 18 20 22 24 26 28 30 32 34 36

27
Forwards flow:
Changing Contractility: moves patient to a higher curve

5
4
3
2
1
0
2
10 12 14 16 18 20 22 24 26 28 30 32 34 36
Changing Afterload: moves patient up and to the left

Forwards flow:
(improves forwards flow and reduces preload)

5
4
3
2
1
0
2
10 12 14 16 18 20 22 24 26 28 30 32 34 36

28
Relationship of PWP to Clinical

Signs of Pulmonary Congestion
Clinical State
PWP
18 20 mmHg
20 25 mmHg
25 30 mmHg
> 30 mmHg
Pulmonary Congestion
Moderate Congestion
Severe Congestion
Pulmonary Edema
The value for PWP that best separates patients with and
without pulmonary congestion is 18 mmHg
Physical assessment: lung sounds dry or wet.
Relationship of CI to Clinical
Signs of Hypoperfusion
CI
2.7 4.7
2.2 2.7
1.8 2.2
< 1.8
Clinical State
Normal
Subclinical depression
Clinical hypoperfusion
Cardiogenic shock
The value for CI that best separates patients with and

without hypoperfusion is 2.2 L/min/M2
Physical assessment: skin temperature warm or cold

29
Forwards flow:
Hemodynamic and Clinical Subsets

5
4
3
Normal Hemodynamics (I)
Backwards Failure (II)
No pulmonary congestion:
PWP < 18; Dry lungs
No hypoperfusion:
CI > 2.2; Warm skin
Pulmonary congestion
PWP > 18; Wet lungs
No hypoperfusion
CI > 2.2; Warm skin
Warm & Dry
Warm & Wet
2
1
Forwards Failure (III)
The Shock Box (IV)
No pulmonary congestion
PWP < 18; Dry lungs
Hypoperfusion
CI < 2.2; Cold skin
Pulmonary congestion
PWP > 18; Wet lungs
Hypoperfusion
CI < 2.2; Cold skin
Cold & Dry
0
2
Cold & Wet
10 12 14 16 18 20 22 24 26 28 30 32 34 36
Mini Case #1
Forwards flow:
CI/SV skin temp (warm or cold)
A patient returns to the ICU after a AAA repair with a PA catheter

in place. This is the first set of data: HR = 96, BP = 114/72,
CO = 4.2, CI = 2.2, CVP = 3, PWP = 8, SVR = 1580.
5
0
2
10 12 14 16 18 20 22 24 26 28 30 32 34 36

30
Mini Case #2
Forwards flow:
A patient with acute anterior MI returns from the cath lab with a
PA catheter in place following two stents to the LAD coronary
artery. The first set of numbers looks like this: BP 100/60, HR =
106, CO = 3.0, CI = 1.8, CVP = 10, PWP = 30, SVR = 1680.
5
0
2
10 12 14 16 18 20 22 24 26 28 30 32 34 36
Mini Case #3
Forwards flow:
A 20 year old motor cycle accident victim with multiple trauma is on the
ventilator in the ICU and becomes hypotensive and febrile. His BP is 80/45, HR
120 in sinus tachycardia, skin is hot and dry. A PA catheter is inserted and these
are the numbers: CO = 10.4, CI = 5, CVP = 4, PWP = 10, SVR = 404.
5
0
2
8 10 12 14 16 18 20 22 24 26 28 30 32 34 36

31
Mini Case #4
Forwards flow:
A 65 year old woman with a history of HF returns from CABG

with the following data: BP 136/76, HR = 84, CO = 5.5,
CI = 3.1, CVP = 8, PWP = 26, SVR = 1280.
5
0
2
10 12 14 16 18 20 22 24 26 28 30 32 34 36

32
Forwards flow:
Preload changes: move patient along the current curve

5
4
3
2
1
0
2
10 12 14 16 18 20 22 24 26 28 30 32 34 36
Afterload changes: move patient up and to the left:
Forwards flow:
improves forwards flow and reduces preload

5
4
3
2
Must have adequate BP
SVR must be elevated
1
0
2
10 12 14 16 18 20 22 24 26 28 30 32 34 36

33
Contractility changes: move patient to a higher curve

Forwards flow:
5
4
3
2
1
0
2
10 12 14 16 18 20 22 24 26 28 30 32 34 36
Forwards flow:
Summary of the Effects of Therapies
V+I
D = Diuresis (preload reduction)

F = Fluids (increase preload)
I = Inotropes (increase contractility)
V = Vasodilators ( reduce afterload)
V + I = Vasodilator + Inotrope
3
2
0
2
10 12 14 16 18 20 22 24 26 28 30 32 34 36

34
Potential Therapies by Subset

Forwards Flow: Cardiac Index
Skin temp (warm or cold)
Normal Hemodynamics
Backwards Failure
In sepsis or trauma:
? Inotropes
3
2
1
Forwards Failure
Volume (if PWP low)
Inotropes (if PWP adequate)
Pacing (if HR low)
IABP
0
2
Diuretics
Venous Dilators
Shock Box
Afterload reduction (if BP adequate
and SVR high)
Preload reduction (diuretics, venous

dilators)
Inotropes, Vasopressors, IABP
10 12 14 16 18 20 22 24 26 28 30 32 34 36
Mini Case #2
Forwards flow:
A patient with acute anterior MI returns from the cath lab with a
PA catheter in place following two stents to the LAD coronary
artery. The first set of numbers looks like this: BP 100/60, HR =
106, CO = 3.0, CI = 1.8, CVP = 10, PWP = 30, SVR = 1680.
5
0
2
10 12 14 16 18 20 22 24 26 28 30 32 34 36

35
Mini Case #2
Where do you want him to go?
Where would he go with preload reduction?

Where would he go with an inotrope?
Where should he go with afterload reduction?
Forwards flow:
What drugs could you use?
Is he a candidate for
afterload reduction?
Yes: BP is reasonable
and SVR is high
0
2
10 12 14 16 18 20 22 24 26 28 30 32 34 36
Forwards flow:
More than one way to accomplish a goal
Diuretic
Inotrope
0
2
10 12 14 16 18 20 22 24 26 28 30 32 34 36

36
Hemodynamic Profiles in Shock

Preload Afterload
Pump
Tissue
(PWP)
(SVR)
Function Perfusion
(CI/SV)
(SVO2)
Hypovolemic
Therapy
Volume
(Subset III)
Cardiogenic
Inotropes
Preload
reduction
Afterload
reduction
(Subset IV)
Vasodilated
Volume
Vasopressors
(Subset I early)
(Subset IV late)
Handout available at:

www.cardionursing.com

37

Boot Camp Hemodynamic Monitoring

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Boot Camp Hemodynamic Monitoring

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NTI 2010

Cardiovascular Boot Camp:

Carol Jacobson RN, MN

Carol Jacobson RN, MN 2010

Most important piece of hemodynamic

Cant measure directly invasively or

Heart Rate and BP easy to obtain but

Carol Jacobson RN, MN 2010

So What We Really Want to Know

Pulmonary artery catheter is an invasive way

Invasive Methods of Obtaining

Carol Jacobson RN, MN 2010

Pulmonary Artery Catheter

Pulmonary Artery Catheter

PWP reflects left atrial

- Normal PWP = 8-12 mmHg

Carol Jacobson RN, MN 2010

- Normal PVR = < 250 dynes

SVR is a calculated value

- Normal SVR = 900-1200 dynes

Stroke Volume can be estimated by

Carol Jacobson RN, MN 2010

Newer Noninvasive Methods

line and venous line)

Carol Jacobson RN, MN 2010

Pressure Monitoring System

Pressure bag: IV bag must be pressurized at

Tubing: high pressure rigid tubing is

Carol Jacobson RN, MN 2010

Carol Jacobson RN, MN 2010

AACN Practice Alert for Pulmonary

Square Waveform Test

Carol Jacobson RN, MN 2010

Square Waveform Test

Whenever PAP waveform appears damped or

Method of Performing Test

Change transducer and tubing to patient if

Carol Jacobson RN, MN 2010

Normal Square Waveform Test

Abnormal Fast Flush Tests

Results in erroneously low SBP and high DBP

Carol Jacobson RN, MN 2010

Abnormal Fast Flush Tests

Results in erroneously high SBP and low DBP

Marking the Phlebostatic Axis

Carol Jacobson RN, MN 2010

Zeroing and Leveling

Leveling means that the stopcock that

To Zero the System

Close the stopcock to air (turn back to neutral

Carol Jacobson RN, MN 2010

Carol Jacobson RN, MN 2010

Obtain measurements from graphic

Right Atrial Waveforms

a wave = atrial contraction

Record the mean of the a wave for the CVP

Carol Jacobson RN, MN 2010

Identify a and v waves

Carol Jacobson RN, MN 2010

Right Ventricular Waveforms

Carol Jacobson RN, MN 2010

Carol Jacobson RN, MN 2010

Pulmonary Artery Waveforms

The monitor is usually