Purpose The primary purpose of invasive hemodynamic monitoring is the early detection, identification, and treatment of life-threatening conditions such as heart failure and cardiac tamponade. By using invasive hemodynamic monitoring the nurse is able to evaluate the patient's immediate response to treatment such as drugs and mechanical support. The nurse can evaluate the effectiveness of cardiovascular function such as cardiac output, and cardiac index.
Objectives Understands basic cardiac anatomy Verbalizes determinates of Cardiac Output and their relationships to each other List indications for hemodynamic monitoring Demonstrates monitor system and set up Describe pharmacologic strategies that manipulate the determinates of cardiac output
Indications for Hemodynamic Monitoring: One of the obvious indications for hemodynamic monitoring is decreased cardiac output. This could be from dehydration, hemorrhage, G. I. bleed, Burns, or surgery. All types of shock, septic, cardiogenic, neurogenic, or anaphylactic may require invasive hemodynamic monitoring. Any deficit or loss of cardiac function: such as acute MI, cardiomyopathy and congestive heart failure may require invasive hemodynamic monitoring.
Cardiac Cycle Diastole Phase Early DiastoleVentricles relax. Semilunar valves close.valves Atrioventricular valves open.valves Ventricles fill with blood. Mid DiastoleAtria and Ventricles are relaxed. Semilunar valves are closed. Atrioventricular valves are open. Ventricles continue to fill with blood. Late DiastoleSA nodeSA node contracts. Atria contract. Ventricles fill with more blood. Contraction reaches AV node.AV node Cardiac Cycle Systole Phase SystoleContraction passes from AV node to Purkinje fibers and ventricular cells.AV node Purkinje fibers Ventricles contract. Atrioventricular valves close. valves Semilunar valves open. valves Blood is pumped from the ventricles to the arteries.
Electrical Conduction system SA node Atrial muscle Internodal fibers AV node AV bundle right and left bundle branches Ventricular muscle
Autonomic Nervous System The autonomic nervous system stimulates the heart through a balance of sympathetic nervous system and parasympathetic nervous system innervations. –The sympathetic nervous system plays a role in speeding up impulse formation, thus increasing the heart rate –The parasympathetic nervous system slows the heart rate.
Hemodynamic terms Contractility - –How well does the ventricular walls move? How good is the pump? – Decreased due to Drugs – certain drugs will decrease contractility –Lido, Barbiturates, CCB, Beta- blockers Infarction, Cardiomyopathy Vagal stimulation Hypoxia
Mean Arterial Pressure MAP is considered to be the perfusion pressure seen by organs in the body. It is believed that a MAP of greater than 60 mmHg is enough to sustain the organs of the average person under most conditions. If the MAP falls significantly below this number for an appreciable time, the end organ will not get enough blood flow, and will become ischemic. Calculated MAP = 2x diastolic + systolic 3
♥ Re-level the transducer with any change in the patient’s position ♥ Referencing the system 1 cm above the left atrium decreases the pressure by 0.73 mm Hg ♥ Referencing the system 1 cm below the left atrium increases the pressure by 0.73 mm Hg Angles 45° 30° 0°
SQUARE WAVE TEST - Determines the ability of the transducer to correctly reflect pressures. - Perform at the beginning of each shift A B C
Thermodilution Cardiac Outputs Thermodilution Cardiac Outputs Cardiac Outputs reading should be within.5 of each other for averaging purposes. Except in patients with atrial fibrillation- just average 3 to 4 readings. (due to loss of atrial kick output changes from minute to minute) Cardiac Outputs should be obtained at the end of respiration - at the same point each time
PAP DOCUMENTATION Measure at end expiration Measure pressures from a graphic tracing Measure pulmonary capillary wedge pressure at end-expiration using the mean of the a wave a wave indicates atrial contraction and falls within the P – QRS interval of the corresponding ECG complex
PAOP/PAWP Pressure Safety Points Watch monitor during inflation and stop when you see PAOP waveform Never inject more than 1.5 ml of air or any fluid into PA port Don’t keep balloon inflated longer than 15 seconds When completed - Allow air to passively exit the balloon
COMPLICATIONS OF PA CATHETER Infection ☹ Infection ☹ Electrocution (Microshock) ☹ Ventricular Arrhythmias (Vtach.,Vfib., Cardiac Arrest) ☹ Atrial Dysrhythmias, RBBB ☹ Knotting and misplacement ☹ Hemo or Pneumothorax ☹ Cardiac valve trauma
COMPLICATIONS OF PA CATHETER ☹ Catheter thromboembolism or air embolism ☹ Dissection or Laceration of subclavian artery or vein ☹ Cardiac Tamponade ☹ Pulmonary infarction ☹ Pulmonary artery injury or rupture ☹ Balloon rupture ☹ Hematoma
Trouble Shooting Dampened Waveform –Flush catheter –Check transducer system for air bubbles Blood in Tubing –Look for open Stopcock –Put 300mgHg pressure in pressure bag Stuck in Wedge /PWP –Very slowly and gently pull back catheter until you see PA waveform
References Pulmonary Artery Catheter Education Project @ www.pacep.org sponsored by www.pacep.org – American Association of Critical Care Nurses American Association of Nurse Anesthetists American College of Chest Physicians American Society of Anesthesiologists American Thoracic Society National Heart Lung Blood Institute Society of Cardiovascular Anesthesiologists Society of Critical Care Medicine Hemodynamics Made Incredibly Visual – LWW publishing 2007 AACN practice alert – Pulmonary Artery Pressure Monitoring - Issued 5/2004 Handbook of Hemodynamic Monitoring – G Darovic 2 nd ed. TCHP Education Consortium 2005 – A Primer for Cardiovascular Surgery and Hemodynamic Monitoring Nursebob's MICU/CCU Survival Guide-Hemodynamics in Critical Care -Hemodynamic Monitoring Overview 12/04/00