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1 Hemodynamic Monitoring Part 2 PAC insertion & measurements: PAP, wedge, & cardiac output MICU Competencies 2006 - 2007.

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Presentation on theme: "1 Hemodynamic Monitoring Part 2 PAC insertion & measurements: PAP, wedge, & cardiac output MICU Competencies 2006 - 2007."— Presentation transcript:

1 1 Hemodynamic Monitoring Part 2 PAC insertion & measurements: PAP, wedge, & cardiac output MICU Competencies 2006 - 2007

2 2 Pulmonary Artery Pressure Monitoring Balloon tip, indwelling catheter with several lumens & thermistor placed in the PA The PA (distal) & CVP (proximal) ports are connected to a hemodynamic monitoring system Provides monitoring & measurement of the pulmonary artery wedge pressures (PAWP), cardiac outputs, & cardiopulmonary function

3 3 Indications for PA Monitoring Alterations in cardiac output (CO) Shock [cardiogenic, hypovolemic, septic] Alteration in fluid volume [preload] Alteration in tissue perfusion Differentiate cardiac &/or pulmonary disease Cardiac output measurements

4 4 Cardiac Output Volume pumped by ventricles each minute; normal = 4 - 8 liters/minute Cardiac Output = Heart Rate x Stroke Volume (CO = HR X SV) SV = amount of blood ejected from each ventricle with each contraction; normal SV = 50 - 100 ml per contraction

5 5 Cardiac Index Cardiac output (CO) adjusted to body size Cardiac index (CI) = CO / body surface area Normal CI range = 2.5 to 4.3 L/min/m2

6 6 Low Cardiac Output Inadequate ventricular filling dysrhythmias hypovolemia cardiac tamponade mitral or tricuspid stenosis constrictive pericarditis restrictive cardiomyopathy

7 7 Low Cardiac Output Inadequate ventricular emptying mitral/tricuspid insufficiency myocardial infarction &/or disease increased afterload (hypertension) metabolic disorders (acidosis, hypoxia) negative inotropic drugs (beta-blockers, calcium channel blockers)

8 8 High Cardiac Output Increased HR and/or contractility and/or decreased afterload –Sepsis –Anemia –Pregnancy –Hyperthyroid crisis

9 9 Determinants of Cardiac Output & Stroke Volume Preload - Volume or pressure generated in the ventricles at end diastole Afterload – Resistance to ejection of blood from the ventricles Contractility – Force of ventricular ejection; difficult to measure clinically

10 10 Clinical Measurement of Preload Left ventricular end diastolic pressure = LVEDP; measures preload in left ventricle –Pulmonary artery wedge pressure (PAWP) reflects LVEDP; normal = 8 - 12 mmHg –If unable to wedge PAC, use PA diastolic –PA diastolic (PAD); normal = 10 - 15 mmHg –PAD indirectly reflects left atrial pressure, which indirectly reflects LVEDP

11 11 Clinical Measurement of Preload Central venous pressure = CVP; measures preload in the right ventricle – Normal CVP = 2 – 8 mmHg

12 12 Factors that Affect Preload Anything that alters → –Circulating blood volume –Blood returning to the heart –Ventricular filling time

13 13 Factors that Decrease Preload Affect right & left ventricles (CVP & Wedge) Hypovolemia Patient position reducing venous return Vasodilatation causing blood to pool Reduced venous return due to mechanical ventilation - high PIP, high levels of PEEP Tension pneumothorax Blood is not returning to the heart to fill the ventricles.

14 14 Factors that Increase Preload Intravascular volume overload Cardiac tamponade Restrictive cardiomyopathies Left ventricular dysfunction (↑ PCWP & CVP) Right ventricular dysfunction (↑ CVP)

15 15 Afterload Afterload is any resistance against which the ventricle must pump in order to eject its volume –Systemic Vascular Resistance (SVR) reflects LV afterload Normal Range = 800-1200 dynes/sec/cm-5 –Pulmonary Vascular Resistance (PVR) reflects RV afterload Normal Range =100-250 dynes/sec/cm-5

16 16 Factors that Affect Afterload Volume & mass of blood ejected from the ventricle –Inverse relationship between afterload and CO (↑CO = ↓afterload; ↓CO = ↑afterload) Compliance & diameter of the vessels into which the blood is ejected Aortic impedance, peripheral vascular resistance, and blood viscosity

17 17 Decreased Afterload (↓ SVR) Arterial dilatation from drugs such as nitroprusside, nitroglycerin, calcium channel blockers, beta blockers Shock (septic, anaphylactic, neurogenic) Hyperthermia (fever)

18 18 Increased Afterload (↑SVR) Accomplished by vasoconstriction –Hypothermia –Hypertension –Alpha agonists (pressors) Levophed, Dopamine, Phenylephrine, Epinephrine –Low CO with hypovolemic or cardiogenic shock An effect of obstruction –Aortic/pulmonic stenosis

19 19 Increased Afterload (↑ PVR) Conditions exhibiting increased PVR –Pulmonary hypertension –Hypoxia –End-stage COPD (Cor pulmonale) –Pulmonary emboli

20 20 Contractility = Inotropy Inherent ability of cardiac muscle to contract Reflected indirectly by stroke volume index (SVI) and the stroke work index for each ventricle (LVSWI & RVSWI) Influenced by myocardial oxygenation & functionality; electrolyte balance; +/- inotropes; amounts of preload and afterload

21 21 Factors/Meds Increasing Contractility Positive Inotropes Sympathic stimulation – “fight or flight” Dobutamine Epinephrine (Adrenalin) Norepinephrine (Levophed) Amrinone (Inocor) Dopamine (5 – 10 mcg/kg/min) Calcium; glucagon; caffeine Digoxin (only oral inotrope)

22 22 Factors Decreasing Contractility Negative inotropes Acidemia Hypoxia Beta blockers Anti-arrhythmics

23 23 PACs in the MICU In 2006, Dr. Wheeler presented the findings from the Fluid and Catheter Treatment Trial (FACTT) to nurses in our MICU. Data from this study indicates a preference for using the CVP to monitor fluid status and conservative fluid management of the patient. Therefore, we do not frequently see or manage patients with PAC’s in our MICU.

24 24 PA Catheter Insertion Strict sterile technique; threaded through an introducer Common sites are subclavian & jugular (occasionally femoral) PA balloon is inflated & floated through the RA → tricuspid valve → RV → the pulmonic valve → PA → the wedged position Record a continuous strip of the insertion hemodynamic waveforms at the bedside

25 25 PAC Insertion Waveforms PAWP=PAOP=PCWP=wedge

26 26 Manual CVP Measurement Zero/level CVP stopcock at the phlebostatic axis Record duel channel strip with CVP and Ao waveforms Measure all waveforms at end-expiration (See slides #30 & 31)

27 27 Manual PA/PCWP Measurement Zero/level PA stopcock at phlebostatic axis Record duel channel strip with PA and Ao PA systolic = 20-30; PA diastolic = 10-15 Slowly inflate balloon with 1.0 – 1.5 ml air KEEP EYES ON MONITOR Keep inflated 5 – 10 seconds Passively deflate Record the return of PA waveform

28 28 Cardiac Output Measurements 10ml syringe of room temperature D5W injected quickly & smoothly via the proximal port Thermistor at the tip of the catheter senses the change in temperature Rate of change in blood temperature generates a cardiac output value Minimum of 3 measurements within 10% of each other averaged for a mean cardiac output Confirm on the monitor

29 29 Maintenance, Care & Measurement Sterile technique during tubing & dressing changes Consistent leveling & measurement techniques Measure CVP, PAP, and PCWP at end-expiration Do not over-inflate balloon (only 1.5 ml) Allow balloon to deflate passively Only MDs advance PAC when necessary (i.e. PAC not wedging)

30 30 Using End-expiration Reference Draw at least 2 vertical lines First line = Ao tracing deviates from baseline Back up 200 msec (one large box) to draw second vertical line Draw a horizontal line to the left of the second line indicating –Systolic and diastolic values for PAP –Mean of the CVP; mean of the PAWP See next slide for example

31 31 The first vertical line would be drawn where the Ao tracing deviates from baseline Second vertical line would be drawn where the ↑ is located See the horizontal line to the left of the arrow indicating the PAOP (PAOP = PAWP; Paw = Ao)

32 32 Keys to Excellent Measurements Use only the Ao as a reference for end- expiration. The respiratory waveform is not accurate! To help determine end-expiration for a non-ventilated patient, remember: –“Vent = valley” (lower portion of waveform) –“Patient = peak” (higher portion of waveform) PA mean = PAS + 2(PAD)/3

33 33 Complications from PA catheters ProblemDescription/Treatment PneumothoraxSubclavian insertion/chest tube InfectionCommon complication/antibiotics ThrombophlebitisSite red, tender/remove PAC Air embolusWith insertion; loose connections/ prevention; L lateral T-berg position Ventricular dysrhythmiasCath tip in RV/remove; defib Catheter knotting/kinkingDuring insertion/pull back; may repeat attempt to float PA perforation or infarction Prolonged or frequent wedging/watch for bright red blood return/surgical or no treatment

34 34 Documentation for PAC Record on hemocalculations sheet: HOB; PEEP; drips; position of PAC (in cm); scale; interpretation of CVP, PAP, & PCWP; sign Stamp sheet “Permanent Chart Document” Computation constant in HED as annotation Zero calibration every four hours in HED See additional data to chart on next slide

35 35 Documentation for PAC

36 36 References & Resources Burns, S. M. (2004). Continuous airway pressure monitoring. Critical Care Nurse, 24(6), 70-74. Chulay, M., & Burns, S. M. (2006). AACN Essentials of critical care. McGraw-Hill: New York. Edwards. (2006). Pulmonary Artery Catheter Educational Project. http://www.pacep.org Edwards Lifesciences. (n.d.) Educational videos. MICU Routine Practice Guidelines. MICU Bedside Resource Books MICU Education Kits – Pulmonary Artery Catheter (Red cart in conference room) MICU Preceptors, Help All Nurses, & Charge Nurses VUMC policies.

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