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Chapter 9 Hemodynamic Monitoring

Chapter 9 Hemodynamic Monitoring. 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)

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Chapter 9 Hemodynamic Monitoring

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  1. Chapter 9Hemodynamic Monitoring

  2. 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

  3. System Components

  4. Square-Wave Test

  5. Leveling and Zeroing

  6. 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

  7. 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.

  8. Arterial Pressure Monitoring • Continuous monitoring of arterial blood pressure • Vascular access for obtaining blood samples • Guides therapy

  9. 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.

  10. Data Interpretation

  11. Question • Is the following question True or False? • It is acceptable to infuse medications via an arterial line.

  12. Answer • False • Rationale: An arterial pressure line is used for monitoring purposes only. NEVER infuse any medications or IV solutions via this line.

  13. 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.

  14. Central Venous Pressure Monitoring • Normal values 2 to 8 mm Hg • Measures right atrial pressure • Left ventricular end-diastolic pressure • Reflects intravascular blood volume

  15. 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.

  16. 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.

  17. 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.

  18. Pulmonary Artery Catheter • Four lumens • Distal lumen • Proximal lumen • Thermistor lumen • Balloon inflation lumen *Some PACs may have additional lumens.

  19. 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.

  20. 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

  21. Data Interpretation (cont.) • Pulmonary artery pressure • Systolic pressure equals right ventricular systolic function 20 to 30 mm Hg. • Diastolic pressure equals the left ventricular end-diastolic pressure (LVEDP) 8 to 15 mm Hg. • Pulmonary artery wedge pressure 8 to 12 mm Hg • More accurate measure of LVEDP

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

  23. 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 8L/minute at rest • Cardiac index (CI)—relates cardiac output to body size; normal is 2.5 to 4L/minute/m2.

  24. 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

  25. Methods of Evaluating Cardiac Output • Thermodilution • Arterial pressure and waveform-based methods • Electrical bioimpedance cardiography • Esophageal Doppler monitoring

  26. Question • Determinants of stroke volume includes all of the following except what? • A. Preload • B. Cardiac output • C. Afterload • D. Contractility

  27. 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

  28. 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

  29. Thermodilution Technique (cont.)

  30. Cardiac Output Curves

  31. 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.

  32. 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

  33. 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

  34. 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.

  35. 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

  36. Answer • D. Thermodilution • Rationale: Thermodilution is the most common method used to measure cardiac output and is considered the clinical gold standard.

  37. Evaluation of Oxygen Delivery and Demand Balance • Oxygen delivery (DaO2) • Amount of oxygen transported to tissues • Depends on cardiac output, hemoglobin levels, and arterial oxygen saturation

  38. 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

  39. Evaluation of Global Tissue Oxygenation Status • Metabolic indicators • Lactate levels, serum pH, and base excess/base deficit • Venous oxygen saturation • Evaluates oxygen supply versus oxygen demand • Mixed venous oxygen saturation SvO2 • Venous oxygen saturation ScvO2

  40. Question • Is the following statement True or False? • Oxygen extraction is the amount of oxygen removed from Hgb to be used by the cells.

  41. 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.

  42. Factors Affecting Oxygen Supply Versus Demand Sepsis Anesthesia Suctioning Pharmacological paralysis Anxiety • Surgery • Infection • Pain • Hypothermia • Sedation

  43. Evaluation of Regional Tissue Oxygenation Status • Gastric tonometry • Specialized nasogastric tube measures partial pressure of carbon dioxide (PCO2) • Sublingual capnometry • Measures PCO2 under the tongue

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