1. Hemodynamic Monitoring for the Respiratory Therapist
Jane Reynolds, MS, RN, RRT

2. Definition of terms
Preload – amount of blood in the ventricle before contraction – End diastolic volume
EDV determines the amount of ‘stretch’ that is placed on the myocardial muscle
That ‘stretch’ determines the strength of the next contraction
The strength of the contraction determines how much blood is pumped out of the ventricle during the next systole ‘stroke volume’
The stroke volume determines the blood pressure and perfusing pressures

3. Definition of terms
Afterload - resistance to blood flow from the ventricle; work that must be done to pump blood from the ventricle to the circulation
Resistance determined by size of valve opening, blood viscosity and blood pressure in pulmonary or systemic circulation
Work – is the oxygen consumed by the myocardium to overcome the resistance to flow

4. C i r c u l a t I o n

5. Normal Circulatory Pressures
Preload to RV
Afterload to RV
Preload to LV
Afterload to LV 5 3 2 3 1

6.                                                             
                                   
Circulation

7. Alveolar Capillary Membrane

9. Normal Alveolar Capillary Membrane

10. Begin Pulmonary Edema

11. Interstitial Edema

12. Pulmonary Edema - Late

13. Pulmonary Artery Catheter

15. Pulmonary Artery Catheter

16. Arterial Blood Gas Interpretation

17. Oxygenation Saturation PO2 27 mmHg 50% 40 mmHg 75% 60 mmHg 90% 95 mmHg
97%
150 mmHg
100%

18. Oxyhemoglobin Dissociation Curve

19. Pulmonary Artery Catheter in Wedge Position

20. Case Study 1
An 18 year old white male was brought to the ED by CFD after being rescued from his car following a high speed collision with a parked truck. He is conscious, c/o of chest pain and is anxious. He was wearing his seat belt but still hit his chest on the steering wheel. His vital signs are: T 37, P 113, RR 23, B/P 100/ 70. CT scan of chest was unremarkable and he was brought to SICU for observation. He continued to have fluctuations in his blood pressure. A pulmonary artery catheter was placed.

21. Case Study 1 Area Normal 8 am 10:30 11:00 CVP 10 4 8 PAP 28 6 22 PWP
0 to 8 10 4 8
PAP
10 to 22 28 6 22
PWP
5 to 12 15 7
MAP
70 to 105 85 40 70 CO
4 to 8 LPM
5.9
2.5
5.7 HR
60 to 100
110
160 95 pH
7.35 to 45
7.37
7.22
7.39
PCO2
35 to 45 45 52 41
PaO2
80 to 100 65 50 88
PvO2
39 to 42 39 21 38

22. Cardiac Tamponade

23. Case Study 2
A 72 year old white female was admitted to the MICU with an exacerbation of COPD. She has emphysema and chronic bronchitis and a 40 pack year history of cigarette smoking. Breath sounds are bilaterally diminished, crackles and rhonchi.
She has JVD and pedal edema. A pulmonary artery catheter was placed as she had sustained hypotension and SOB. Her VS are: T 37, P118, RR 32, B/P 150/90, FiO2 .28, HB 22 Gm%.

24. Case Study 2
Normal
Noon
1600
1800
CVP
0 to 8 25 20 18
PAP
10 to 22 50 35 32
PWP
5 to 12 15 12 10
MAP
70 to 105 60 72 75 CO
4 to 8 LPM
3.9
4.5
4.7 HR
60 to 100
110 90 88 pH
7.35 to 45
7.35
7.39
7.38
PCO2
35 to 45 69 55 51
PaO2
80 to 100 46 85 78
PvO2
39 to 42 38 39

25. Case Study 3
A 25 year Hispanic male was admitted to the SICU after a thoracotomy for repair of his aorta following a gun shot wound to his chest. He has bilateral chest tubes. He is intubated and receiving full ventilatory support. His chest tube drainage for the last hour was 400 ml. He has bloody sputum and urine. His last CaO2 was
10.4 volumes% with a PaO2 of 110 and saturation of 95%. VS T 36, P148, RR 14, B/P 65/44.

26. Case Study 3
Normal
3 am
5:30
11:00
CVP
0 to 8 2 4 8
PAP
10 to 22 10 15
PWP
5 to 12 6 5
MAP
70 to 105 48 40 60 CO
4 to 8 LPM
2.94
3.5
5.7 HR
60 to 100
150
160
140 pH
7.35 to 45
7.22
7.20
7.32
PCO2
35 to 45 55 49
PaO2
80 to 100
110 94
PvO2
39 to 42 29 27 39

27. Case Study 4
A 52 year old white male with shortness of breath and chest pain was admitted to the ED. ECG showed ST elevation in 4 leads and his cardiac enzymes were markedly elevated. His vital signs were stable, SpO2 on NC at 2 LPM was 95%. He was taken to the cardiac cath lab and a diagnostic cardiac angiogram revealed 99% occlusion of his LAD. A coronary stent was placed and 15 minutes post intervention he began complaining again of severe SOB and chest pain. He was taken back to the cath lab. A pulmonary artery catheter was placed. A left heart catheterization revealed progression of the MI. His LVEDP is 32 and an intra aortic balloon was placed and counter pulsation started at 1:1.

28. Case Study 4
Normal
9 am
10:30
1600
CVP
0 to 8 10 8
PAP
10 to 22 28 20
PWP
5 to 12 35 15
MAP
70 to 105 72 47 65 CO
4 to 8 LPM
4.9
2.5
4.4 HR
60 to 100
110 80 pH
7.35 to 45
7.39
7.26
7.32
PCO2
35 to 45 40 50 38
PaO2
80 to 100 48 75
PvO2
39 to 42 36

29. Intra Aortic Balloon Counter Pulsation

30. Case Study 5
A 55 year old AA male was admitted to the MICU with acute SOB, cough, HTN and hypoxemia. He is oliguric and has required hemodialysis for the past 2 years. He is depressed and has not been following his dietary and fluid restrictions and has skipped his last 2 dialysis appointments. His VS are now T 37, P118, RR 35, B/P 200/135. He is receiving oxygen via venturi mask, FiO2 50%. He has a pulmonary artery catheter in place to monitor his cardiac status.

31. Case Study 5
Normal
8 am
10:30
11:00
CVP
0 to 8 25 19 12
PAP
10 to 22 40 32 28
PWP
5 to 12 22 18 15
MAP
70 to 105
150
110
100 CO
4 to 8 LPM
3.4
4.1
5.7 HR
60 to 100 95 86 pH
7.35 to 45
7.32
7.39
PCO2
35 to 45 49 38
PaO2
80 to 100 60 79
PvO2
39 to 42 34

32. Case Study 6
A 36 year old female was admitted to the ED with a CC of SOB and chest pain. She has no significant PMH, she does not smoke. She says that she hurt her ankle about two weeks ago and never went to the doctor about it. It is very painful and she has been almost immobilized for the past two weeks because it is just too painful to walk on. She has a cough and says her SOB came on rather suddenly after she went down to her basement to put some clothes in the laundry this morning. She is tachypneic, her MV is 12 LPM.

33. Case Study 6
Normal
5 am
24 hours later
CVP
0 to 8 25 12
PAP
10 to 22 40 29
PWP
5 to 12 10 9
MAP
70 to 105 65 75 CO
4 to 8 LPM
6.4
5.1 HR
60 to 100
110 84 pH
7.35 to 45
7.36
7.39
PCO2
35 to 45 45 38
PaO2
80 to 100 85
PvO2
39 to 42 41

34. Saddle Pulmonary Embolism

36. Questions??
Thank you!
You were great!!

38. Thoraco-abdominal Pump Mechanism

39. Small Vessels

41. Venous return
                                                     

42. Oxygen carried in the blood

44. Chest x-ray of ARDS

45. Normal Chest x-ray

46. CT Scan of ARDS
35-year-old bone marrow transplant patient with respiratory failure from noncardiogenic pulmonary edema. The chest x-ray (left) shows a right sided pnbeumothorax, and bilateral ground glass density in the lungs. The HRCT scan (right) demonstrates relatively "airless" lungs despite high positive end expiratory pressure. The bronchovascular bundles are normal (A) suggesting that the hydrostatic pressure within the pulmonary capillaries is normal.

48. Left-Sided Heart Failure
Pulmonary congestion occurs when left ventricle cannot pump well
Dyspnea upon exertion, orthopnea, and paroxysmal nocturnal dyspnea
Oliguria

49. Right-Sided Heart Failure
Congestion of viscera and peripheral tissues when right ventricle fails
Jugular vein distention
Dependent edema
Hepatomegaly
Ascites
Weakness, anorexia, and nausea
Weight gain

51. Sphincters Open

52. Sphincters Closed

53. Path of Blood

54. Major Blood Vessels