INVASIVE

HEMODYNAMIC
MONITORING
INVASIVE HEMODYNAMIC
MONITORING
 Introduction
o  Swan-Ganz catheter has been in use for
almost 30 years
o  Initially developed for the management of
acute myocardial infarction
o  Now, widespread use in the management of a
variety of critical illnesses and surgical
procedures
Purposes of Invasive Hemodynamic
Monitoring
o  Early detection, identification, and treatment
of life-threatening conditions such as heart
failure and cardiac tamponade
o  Evaluate the patient’s immediate response to
treatment such as drugs and mechanical
support
o  Evaluate the effectiveness of cardiovascular
function such as cardiac output and index
 Indications for Hemodynamic
Monitoring
o  Any deficit or loss of cardiac function: such
as AMI,CHF,Cardiomyopathy
o  All types of shock;cardiogenic,neurogenic,or
anaphylactic
o  Decreased urine output from dehydration,
hemorrhage,G.I. bleed,burns,or surgery
Components of a Pulmonary Artery
Catheter
Components of Swan-Ganz [con’t]
o  Normally has four[4] ports
o  Proximal port – [Blue] used to measure central
venous pressure/RAP and injectate port for
measurement of cardiac output
o  Distal port – [Yellow] used to measure pulmonary
artery pressure
o  Balloon port – [Red] used to determine pulmonary
wedge pressure;1.5 special syringe is connected
o  Infusion port – [White] used for fluid infusion
Components of the Monitoring System
o  Bedside monitor – amplifier is located inside.
The amplifier increases the size of signal
o  Transducer – changes the mechanical energy
or pressures of pulse into electrical energy;
should be level with the phlebostatic axis /
you can estimate this by intersecting lines
from the 4th ICS,mid axillary line
o  Recorder – record information
Phlebostatic Axis
 Commonly used Terminology
o  Preload o  Systemic Vascular
o  Afterload Resistance [SVR]
o  Cardiac Output o  Pulmonary Vascular
o  Cardiac Index Resistance [PVR]
 Preload
o  Is the degree of muscle fiber stretching
present in the ventricles right before systole
o  Is the amount of blood in a ventricle before it
contracts; also known as “filling pressures”
o  Left ventricular preload is reflected by the
PCWP
o  Right ventricular preload is reflected by the
CVP [RA]
 Afterload
o  Any resistance against which the ventricles
must pump in order to eject its volume
o  How hard the heart [either side left or right]
has to push to get the blood out
o  Also thought of as the “ resistance to flow” or
how “clamped” the blood vessels are
 Cardiac Output
o  Is the amount of blood ejected from the
ventricle in one minute
o  Two components multiply to make the cardiac
output: heart rate and stroke volume [amount
of blood ejected with each contraction]
 CARDIAC INDEX
o  Cardiac index is the cardiac output divided by
body surface area (BSI)
o  The CI is a useful marker of how well the
heart is functioning as a pump by directly
correlating the volume of blood pumped by
the heart with an individual's body surface
area.
o  If the CI falls below 2.2 L/min/m2, the patient
may be in cardiogenic shock.
 SVR / PVR
o  Systemic Vascular Resistance – reflects left
ventricular afterload
o  Pulmonary Vascular Resistance – reflection
of right ventricular afterload
o  Many of the drugs we administer will affect
Preload, Afterload, SVR/PVR, Cardiac
Output
 Possible Complications
o  Increased risk of infections – same as with any central
venous lines—use occlusive dressing and Biopatch to prevent
o  Thrombosis and emboli-- air embolism may occur when the
balloon ruptures, clot on end of catheter can result in
pulmonary embolism
o  Catheter wedges permanently—considered an emergency,
notify MD immediately, can occur when balloon is left
inflated or catheter migrates too far into pulmonary artery
(flat PA waveform)…can cause pulmonary infarct after only
a few minutes!
o  Ventricular irritation – occurs when catheter migrates back
into RV or is looped through the ventricle, notify MD
immediately…can cause VT
 Central Venous Pressure (CVP)
o  Zero transducer to the patient’s phlebostatic axis
o  Always read CVP at end expiration
o  CVP is a direct measurement of right ventricular end
diastolic pressure
 Right Ventricular Waveform
o  If the swan falls or gets pulled back into the RV it is
considered a swan emergency.
o  If you see an RV waveform (looks like VT) pull the swan
immediately.
o  If the swan remains in the RV it may cause the patient to go
into VT.
 Pulmonary Capillary Wedge Pressure (PCWP)

o  Zero the transducer to the patient’s phlebostatic axis.

o  Measure the PCWP at end expiration
o  PCWP should not be higher than PA diastolic
o  PCWP is an indirect measurement of left ventricular end
diastolic pressure.
 Cardiac Output
o  It is the amount of blood pumped by the heart in one minute.
o  Calculated by multiplying heart rate times stroke volume.
o  Cardiac Index is the cardiac output adjusted for body surface
area.
Normal Pressures
o  When a catheter is passed through the venous
system into the heart and pulmonary artery,
certain pressure readings and wave forms are
measurable
o  During each individual section to follow, we
will be looking at normal waveforms displayed
depending on type of hemodynamic monitoring
being used eg. arterial waveforms, CVP
waveforms and PA waveforms
 Hemodynamic Pressures
o  Central Venous Pressure (CVP)
Ø  0 – 6 mm Hg
o  Right Arterial Pressures (RAP)
Ø  0 – 6 mm Hg
o  Right Ventricular Pressures (RVP)
Ø  Systolic 20 – 30 mm Hg
Ø  Diastolic 2 – 8 mm Hg
Ø  RV End Diastolic 2 – 6 mm Hg
o  Pulmonary Artery Pressures (PAP)
Ø  Systolic 20 – 30 mm Hg
Ø  End diastolic 8 – 15 mm Hg
o  Pulmonary Artery Wedge Pressures
Ø  (PAWP) ~ (PAOP) ~ (PCWP) = 5 – 12 mm Hg