1. HEMODYNAMIC MONITORING NUR 351/352 PROFESSOR DIANE E. WHITE RN MS CCRN PhD (c)

2. Equipment Needed for Hemodynamic Monitoring Transducer: an instrument that senses physiological events & transforms them into electrical signs Amplifier: connects to transducer and an electrical cable;filters out interference so signal can be displayed Monitors: provides display of original signal Catheter, tubing flush system (single or double): pressure bag is 500cc Normal Saline with 10cc of 100u/ml of heparin; delivers continuous cc/hr to keep line open; catheter may be arterial or venous

3. Monitoring Hemodynamic Measurements Arterial – used for unstable BP or frequent ABG’s or labs Controversial regarding accuracy Inserted by MD, RT, or Anesthesia Inserted into any artery Waveform: peak represents SBP and Ventricular contraction, lowest point reflects peripheral resistance & diacrotic notch is on the downward stroke & results from aortic valve closure MAP – mean arterial pressure represents perfusion pressure in aorta and branches; SBP-DBP/3 + DBP = MAP Nursing considerations Complications

4. Central Venous Pressure – represents blood return to the heart; abnormalities usually secondary to altered venous tone and / or blood volume Inserted by MD under sterile conditions Normal value is 0-8 mm Hg Increase in blood volume = increase in CVP (vice versa) Triple Lumen Catheter (TLC); distal port on TCL and proximal on Swan Ganz catheter Measured at end of expiration: ventilated patients lowest part of waveform and vice versa for spontaneous breathing

5. Pulmonary Artery Catheter or Swan Ganz Catheter – allows monitoring of Left Ventricular function Various ports – proximal (cardiac output), distal (PA), balloon (wedge or PCWP), RV (pacer port) & temp (core blood temp) Inserted by MD under sterile conditions at the brachial, subclavian, internal jugular or external jugular veins All measurements done at end of expiration

6. What can we monitor with the Swan Ganz Catheter? PAP – pulmonary artery pressure; @ 25/10 with average 15 PCWP – pulmonary catheter wedge pressure; @ 6-12; use of DPAP if balloon not working Cardiac Output – can be measured intermittently or continuously -- injectate is D5W or NS @ 10cc --errors in CO -- 3 values averaged (within 10%) of each other -- CO = 4-8 L/min -- CI or cardiac index = CO/BSA usually greater than 2

7. Mixed Venous Oxygenation (SVO2) – allows clinician to look at overall picture of O2 used by the body organs CVP – central venous pressure 0-8mmHg SVR – systemic vascular resistance- measures the opposition to blood flow exerted by blood vessels; 800-1200 normal value Formula: SVR= MAP-CVP x 80/ CO PVR – pulmonary vascular resistance Formula: PVR= MAP-PCWP x 80/CO

8. Volume Effects on Hemodynamic Monitoring What is the difference between intracellular and extracellular volume? 1.Arterial Pressure 2.Central Venous Pressure 3.PAP/PCWP 4.Cardiac Output 5.SVR

9. Pharmacological Agents Used in Hemodynamic Monitoring 1.Arterial Pressure Dopamine > or= 5 mcg/kg/min up to 20mcg/kg Epinephrine mcg/min Neosenephrine mcg/min Levophed or norepinephrine mcg/min 2.CVP Volume controlled 3.PCWP/PAP –increase CO by decreasing PAP and PCWP Dobutamine 5-20 mcg/kg/min Natrecor.001mcg/kg/min

10. 5.Cardiac Output Dobutamine and Natrecor Must be sure enough volume on board to gain desired effect 6.SVR Nipride mcg/kg/min used to decrease SVR and increase CO Cardene 5-10mg/hr

11. Inotropic Agent Calculations  Difference between positive and negative inotropic drugs?  Dosing charts: CONCENTRATION of drug must match in order to use charts  Pharmacy directions for drug adminstration: always DOUBLE-CHECK!  Fudge Factors: a way of calculating dosages and rates

12. Fudge Factors  Know the concentration of drug ordered  Know the patient’s weight in kilograms  Know the volume of dilution  Know correct dosage administration for drug ordered  Remember constants

13. Fudge Factor Formula  How is the drug run? mcg/min, mcg/kg/min, mcg/kg/hour, mg/min  Fill in the necessary formula componentsmg x 1000 volume x kg x 60 volume x 60 mg x 1000 mg volume x kgvolume x 60