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Leanna R. Miller, RN, MN, CCRN-CMC, PCCN-CSC, CEN, CNRN, NP Education Specialist LRM Consulting

Hemodynamic Case Studies. Leanna R. Miller, RN, MN, CCRN-CMC, PCCN-CSC, CEN, CNRN, NP Education Specialist LRM Consulting Nashville, TN. Case Studies in Hemodynamics. Objectives Analyze the hemodynamic data of a patient with sepsis.

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Leanna R. Miller, RN, MN, CCRN-CMC, PCCN-CSC, CEN, CNRN, NP Education Specialist LRM Consulting

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  1. Hemodynamic Case Studies Leanna R. Miller, RN, MN, CCRN-CMC, PCCN-CSC, CEN, CNRN, NP Education Specialist LRM Consulting Nashville, TN

  2. Case Studies in Hemodynamics • Objectives • Analyze the hemodynamic data of a patient with sepsis. • Identify key hemodynanic abnormalities seen in patients with cardiogenic shock. • Describe the priorities in the management of a patient with acute respiratory distress syndrome (ARDS).

  3. Case Studies in Hemodynamics Case Study 1 • 45 - year old woman • stab wounds to the abdomen x 2, multiple lacerations, probable aspiration • 3 days post - op became restless • T 40.3 C (104.6 F)

  4. Case Study 1 HR 106 BP 78 / 44 / 55 Case Studies in Hemodynamics

  5. Case Studies in Hemodynamics Case Study 1 HR 106 RAP / PAOP 1 / 4 BP 78 / 44 / 55 CI 4.5 PAP 17 / 7 / 11

  6. Case Studies in Hemodynamics Case Study 1 PVRI 119 SVRI 858 SV 70.2 LVSWI / RVSWI 26.5 / 8.0

  7. Case Studies in Hemodynamics Case Study 1 ABGs (.40 FiO2) pH 7.26 pCO2 35 pO2 55 SaO2 .88 HCO3 12 SvO2 82% P/F ratio 138

  8. Case Studies in Hemodynamics Case Study 1 PaO2 / FiO2 Ratio (P/F) • 55 / .40 • 138 Normal = > 300 ALI = < 250 ARDS = < 200

  9. Case Studies in Hemodynamics Case Study 1 • Laboratory Values Sodium 150 Chloride 98 Hgb / Hct 8.8 / 26.4

  10. Case Studies in Hemodynamics Sepsis •  O2 demand 55% • peripheral shunting & delivery-limited VO2 • sudden  in VO2 = early warning • VO2 remains low = poor outcome

  11. Case Studies in Hemodynamics • CI > 5.5 • DO2I 250 - 500 • VO2I 70 - 90

  12. Case Studies in Hemodynamics Case Study 1 DOI2 = CI ( 1.38 x Hgb x SaO2) 10 4.5 X 1.38 X 8.8 X 0.88 x 10 481 mL/min/m2 (normal = 360 - 600 mL/min/m2)

  13. Case Studies in Hemodynamics Case Study 1 VOI2 = CO X 1.38 X Hgb X (SaO2 - SvO2) X 10 4.5 x 1.38 x 8.8 x (.88 - .82) x 10 33 mL/min/m2 (Normal 220 - 290 mL/min/m2)

  14. Case Studies in Hemodynamics Case Study 2 • 54 - year old male with large anterioseptal MI • new episode pain • restless, dusky, new systolic murmur LLSB • 12 – lead: ST elevation, T wave inversion & Q wave in V2 - 4

  15. Case Study 2 HR 118 BP 80 / 42 / 55 Case Studies in Hemodynamics

  16. Case Studies in Hemodynamics Case Study 2 HR 118 BP 80 / 42 / 55 CO / CI 3.2 / 1.56 PAP 58 / 32 / 40 PAOP / CVP 29 / 15

  17. Case Studies in Hemodynamics Case Study 2 PVRI 564 SVRI 2051 LVSWI / RVSWI 8.84 / 5.78

  18. Case Studies in Hemodynamics Case Study 2 ABGs (.40 FiO2) pH 7.49 pCO2 25 pO2 56 SaO2 .88 HCO3 21 SvO2 60%

  19. Case Studies in Hemodynamics Case Study 2 PaO2 / FiO2 Ratio (P/F) • 56 / .40 • 140 Normal = > 300 ALI = < 250 ARDS = < 200

  20. Case Studies in Hemodynamics Case Study 2 • Laboratory Values Sodium 144 Chloride 98 Hgb / Hct 12.1 / 36.3 CO2 21

  21. Case Studies in Hemodynamics •  CO threatens DOI2 levels • O2 demands are seldom except when catecholamines are used

  22. Case Studies in Hemodynamics • DOI2 300 - 400 • VOI2 > 125 • SvO2 > 60% • O2ER < 30%

  23. Case Studies in Hemodynamics Case Study 2 SIMV 8 FiO2 / TV .60 /800 PaO2 / SaO2 65 / .92 pH 7.29 PaCO2 / HCO3 30 /16 Hgb / Temp 9.0 / 102 oF

  24. Case Studies in Hemodynamics Case Study 2 DOI2 = CI ( 1.38 x Hgb x SaO2) 10 1.56 X 1.38 X 12.1 X 0.88 x 10 229 mL/min/m2 (normal = 360 - 600 mL/min/m2)

  25. Case Studies in Hemodynamics Case Study 2 VOI2 = CI X 1.38 X Hgb X (SaO2 - SvO2) X 10 1.56 x 1.38 x 12.1 x (.88 - .60) x 10 73 mL/min/m2 (Normal 220 - 290 mL/min/m2)

  26. Case Studies in Hemodynamics Case Study 2 • Anion Gap • Na – (CO2 + Cl) • 144 – (98 + 21) • 25 (Normal = 12 – 15)

  27. Case Studies in Hemodynamics Case Study 3 • 62 - year old male • 2 ppd smoking history • acute bacterial pneumonia • intubated & mechanically ventilated

  28. Case Study 3 BP 100/90/93 HR 122 Case Studies in Hemodynamics

  29. Case Study 3 BP 100/90/93 HR 122 RAP / PAOP 6/8 PAP 38/18/25 C0 4.0 SvO2 .30 Case Studies in Hemodynamics

  30. Case Studies in Hemodynamics Case Study 3 PaO2 / FiO2 Ratio (P/F) • 65 / .65 • 108 Normal = > 300 ALI = < 250 ARDS = < 200

  31. Case Studies in Hemodynamics • PEEP can  DOI2 • WOB  VOI2 • triggers inflammatory response • maldistributed blood flow   VOI2 • ideal Hgb is 12

  32. Case Studies in Hemodynamics  DOI2 until VOI2 plateaus

  33. Case Studies in Hemodynamics Case Study 3 DO2= CO ( 1.34 x Hgb x SaO2) 10 4.0 X 1.34 X 9.0 X 0.92 x 10 457 mL/min (normal = 900 - 1100 mL/min)

  34. Case Studies in Hemodynamics Case Study 3 VO2= CO X 1.34 X Hgb X (SaO2 - SvO2) X 10 4.0 x 1.34 x 9.0 x (.92 - .30) x 10 308 mL/min (Normal 220 - 290 mL/min)

  35. Case Studies in Hemodynamics IN CONCLUSION

  36. Case Studies in Hemodynamics

  37. THE END

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