1. Hemodynamic Monitoring and Transthoracic Lines
Deb Updegraff RN, CNS
Lucille Packard Children’s Hospital
Pat Hock RN, Nurse Educator
Winnie Yung , CNS

2. Infants and children undergoing open heart surgery may require intracardiac monitoring.
The hemodynamic data can assist in the assessment of contractility, preload and afterload.
As the patient stabilizes post cardiac by-pass, intracardiac catheters (RA) may be left in place for vascular access reasons.

3. “Percutaneous” vs “Transthoracic”
What’s the difference ??
“Percutaneous” vs “Transthoracic”
Percutaneous – Insertion site is through the skin.
Transthoracic- Insertion is done while the chest is open and directly through
the myocardium.

4. Examples of Percutaneous lines:
PICCs
Tunneled lines
Non-tunneled lines
Swan-Ganz thermodilutional catheters
Dialysis/CRRT catheters

5. Examples of Transthoracic Lines

6. LA PA RA Percutaneous Central Venous Catheter Pulmonary Artery
Left Atrial
Transthoracic
Catheter RA
Right Atrial
Transthoracic
Catheter
Roth, S. 1998

7. Hemodynamic Waveforms- Normal Heart
(CVP)

8. Right Atrial Pressure Monitoring Indications
Measure right atrial pressure (RAP)
Same as Central Venous Pressure (CVP)
Assess blood volume; reflects preload to the right side of the heart
Assess right ventricular function
Infusion site for large fluid volume
Infusion site for hypertonic solutions

9. Reasons for elevated RA pressure:
decreased right (or single) ventricle compliance
tricuspid valve disease
Intravascular volume overload
cardiac tamponade
tachyarrhythmia
Right Atrial Pressure
Mean: 1 to 7 mm Hg

10. Reasons for reduced RA pressure:
low intravascular volume status
inadequate preload
Right Atrial Pressure
Mean: 1 to 7 mm Hg

11. Right Atrial Pressure Monitoring Complications
Arrhythmias
Air embolism
Pulmonary embolism
Thromboembolism
Infection
Pneumothorax
Hemothorax
Hemorrhage
Cardiac tamponade
Vessel, RA, or RV perforation

12. Right Atrial Pressure Monitoring Waveform Analysis
a wave: rise in pressure due to atrial contraction
x decent: fall in pressure due to atrial relaxation
c wave: rise in pressure due to ventricular contraction and closure of the tricuspid valve
v wave: rise in pressure during atrial filling
y decent: fall in pressure due to opening of the tricuspid valve and onset of ventricular filling

13. Right Atrial Pressure Monitoring Waveform Analysis
Elevated RAP
RV failure
Tricuspid regurgitation
Tricuspid stenosis
Pulmonary hypertension
Hypervolemia
Cardiac tamponade
Chronic LV failure
Ventricular Septal Defect
Constrictive pericarditis
Decreased RAP
Hypovolemia
Increased contractility

14. Reasons for elevated LA pressure:
Elevated systemic ventricular end diastolic pressure
mitral valve disease
Large left-to-right shunt
intravascular volume overload
cardiac tamponade
tachyarrhythmia
Artifactual

15. Reasons for reduced LA pressure:
low intravascular fluid status
Inadequate preload
Artifactual

16. Reasons for elevated PA pressure:
mechanical obstruction of pul. circulation
pul. arteriolar smooth muscle hypertrophy
inflammatory response to CPB
mechanical obstruction of the airways (for examples…)
acidosis and hypoxia
elevated LA pressure
unrestrictive VSD or large PDA
pul. hypertension

17. Dressing change policy at LPCH
Nursing HOURLY assessment:
Air in line or stopcocks
Precipitates
Leaking at site
Increasing resistance
Condition of entrance sites
Dressing change policy at LPCH
Arterial line
prn (when seal is broken, wet, old blood, etc)
Non-tunneled CVC
Q 7 days & prn (Tegaderm & biopatch)
Tunneled CVC
Q7 days & prn (Tegaderm & biopatch)
Intracardiac catheter

18. BEFORE REMOVAL Transthoracic Line
Check coagulation labs (pt, ptt, INR, platelets)
Transfuse if Platelets < than 70 and INR > 1.5
Ensure Packed Red Blood Cells in cooler at bedside
(Remember two RN check for PRBCs. Instructions
for blood in cooler, taped to cooler)
Ensure good vascular access
Ensure chest tube patency
Evaluate need for sedation. (if too active ↑ BP may → bleeding)

19. After Removal of Transthoracic Line
Keep PRBCs for a minimum of 1 hour
Continuous hemodynamic monitoring for a minimum of 1 hour
(assess for signs of tamponade-dampening arterial wave form
narrowing pulse pressure and bleeding- blood in chest tubes,
decrease blood pressure, pallor
altered LOC)
Document vitial signs every 15 minutes
Check HCT if bleeding suspected
Ensure patency of chest tubes
Do not transfer patient for at least 2 hours

20. Pressure Line Safety What is air vigilance and why is it so important?
Why is it unsafe to draw back or flush fluid into a line infusing vasoactive medications?
What precautions should be taken when discontinuing any pressure line?
Is it safe to get a patient out of bed to be held or to sit in a chair if they have a transthoracic pressure line?
What additional safety measures should be followed for transthoracic pressure lines?

21. References
Alspach. AACN’s Core Curriculum for Critical Care Nursing. Saunders.
Berne and Levy. Physiology. Mosby.
Hazinski. Manual of Pediatric Critical Care. Mosby.
Kinney, Packa, and Dunbar. AACN’s Clinical Reference for Critical Care Nursing. Saunders.
Kumm. Hemodynamic Monitoring. University of Kansas School of Nursing.
Kumm. Intra-arterial Pressure Monitoring. University of Kansas School of Nursing.
Slota. AACN’s Core Curriculum for Pediatric Critical Care Nursing. Saunders.
Taleghani, Fred. Invasive lines, hemodynamic monitoring, and waveforms. LPCH, PICU.