HEMODYNAMIC MONITORING

INTRODUCTION
Critically ill patients require continues assessment of their cardiovascular system to diagnose and
manage their complex medical conditions. This is most commonly achieved by the use of direct
pressure monitoring systems, often referred to as hemodynamic monitoring Heart function is the
main focus of hemodynamic studies. Hemodynamic pressure monitoring provides information
about blood volume, fluid balance and how well the heart is pumping Nurses are responsible for
the collection measurement and interpretation of these dynamic patient status parameters.
HEMODYNAMICS
Hemodynamics are the forces which circulate blood through the body. Specifically.
hemodynamics is the term used to describe the intravascular pressure and flow that occurs when
the heart muscle contracts and pumps blood throughout the body. Hemo -Blood Dynamics-
Movement Hemo Dynamics Movement of blood flow
DEFINITION
Hemodynamic monitoring refers to measurement of pressure, flow and oxygenation of blood
within the cardiovascular system.
WIKIPEDIA
METHODS OF HAEMODYNAMIC MONITORING
 Noninvasive hemodynamic assessment
 Arterial Blood Pressure
 Central Venous Pressure
 The Pulmonary Artery Catheter
 Cardiac Output Measurement
NON INVASIVE HAEMODYNAMIC ASSESSMENT
 Take vital signs
 Precordium Inspect anterior chest for heaves and an increase in visible pulsations
 Palpate the PMI
 Ausultate the aortic, pulmonic, mitral and tricuspid areas of the precordium
 Inspect and palpate the skin for colour, texture, moisture and targor
 Palpate the peripheral pulses and check nail bed capillary refill
 Inspect the neck for jugular venous distension
 Auscultate and palpate the carotid arteries
PURPOSES
 Early detection, identification and treatment of life threatening conditions such as heart
failure and cardiac tamponade
  Evaluate the patient's immediate response to treatment such as drugs and mechanical
support
 Evaluate the effectiveness of cardiovascular function such as cardiac output and index
INDICATIONS
 Any deficits or loss of cardiac function: such as myocardial infarction, congestive heart
failure, and cardiomyopathy
 All types of shock, cardiogenic shock, neurogenic shock or anaphylactic shock.
 Decreased urine output from dehydration, hemorrhage. G. I bleed, burns or surgery
SPECIALISED EQUIPMENTS NEEDED FOR INVASIVE MONITORING
 A CVP, pulmonary artery arterial catheter
 A flush system composed of intravenous solution, tubing stop cocks and a flush device
which provides for continuous and manual flushing of system.
 A pressure bag placed around the flush solution that is maintained at 300 mmhg pressure,
 the pressurized flush system delivers 3-5ml of solution per hour through the catheter to
 prevent clotting and backflow of blood into the pressure monitoring system A transducer
to convert the pressure coming from artery or heart chamber into an electrical signal
 An amplifier or monitor which increases the size of electrical signal for display on an
oscilloscope
HEMODYNAMIC MONITER SETUP FOR HEMODYNAMIC PRESSURE
MONITORING
 Obtain barrier kit, sterile gloves and correct swan catheter Also need extra iv pole,
transducer holder, boxes and cables.
 Check to make sure signed consent is in chart, and that patient and or family understand
procedure
 Everyone in the room should be wearing a mask.
 Position patient supine and flat if tolerated
 On the monitor, press "change screen" button, then select "swan ganz" to allow physician
to view catheter wave forms which inserting
 Assist physician in sterile draping and sterile setup for swan insertion.
 Setup pressure lines and transducers
 Level pressure flush monitoring system and transducers to the phlebostatic axis
 Connect tunings to patient when patient is ready to flush the swann
 While floating the Swann, observe for ventricular ectopic on the monitor
 After Swann is in place, assist with cleanup and let patient know procedure is complete
Obtain all the values. For cardiac output inject 10mls of D5w after pushing the start
button
 Document findings in ICU flow sheet
METHODS OF HEMODYNAMIC MONITORING
I ARTERIAL BLOOD PRESSURE
a)Non Invasive
b)Intra arterial blood pressure measurement
2.CENTRAL VENOUS PRESSURE
3. PULMONARY ARTERY CATHETER PRESSURE MONITORING
NON INVASIVE ARTERIAL BP MONITORING
 With manual or automated device
 Method of measurement
 Oscillometry (most common) | MAP most accurate DP least accurate
 Auscultatory (korotkoff sounds)
 Combination
NON INVASIVE HEMODYNAMIC MONITORINGLIMITATIONS
 Cuff must be placed correctly and must be appropriately sized
 Auscultatory method is very inaccurate (Korotkoff sound is difficult to hear)
 Significant underestimation in low flow (shock)
 Oscillometric also mostly in accurate (>5mmhg off directly recorded pressures)
DIRECT INTRA ARTERIAL BP MONITORING
Intra-arterial BP monitoring is used to obtain direct and continuous BP measurements in
critically ill patients who have severe hypertension or hypotension
PROCEDURE
 Once an arterial site (radial, brachial, femoral, is selected or dorsalis pedis), collateral
circulation to the area must be confirmed before the catheter is placed.
 This is a safety precaution to prevent compromised arterial perfusion to the area distal to
the arterial catheter insertion site. If no collateral circulation exists and the cannulated
artery became occluded, ischemia and infarction of the area distal to that artery could
occur.
 Collateral circulation to the hand can be checked by the Allen test
 With the Allen test, the nurse compresses the radial and ulnar arteries simultaneously and
asks the patient to make a fist, causing the hand to blanch
 After the patient opens the fist, the nurse releases the pressure on the ulnar artery while
maintaining pressure on the radial artery The patient's hand will turn pink if the ulnar
artery is patent
COMPLICATIONS
Local destruction with distal ischemia external hemorrhage massive ecchymosis dissection air
embolism blood loss pain arteriospasm and infection
NURSING INTERVENTIONS
 Before insertion of a catheter, the site is prepared by shaving if necessary and by
cleansing with an antiseptic solution. A local anesthetic may be used
 Once the arterial catheter is inserted, it is secured and a dry, sterile dressing is applied
 The site is inspected daily for signs of infection. The dressing and pressure monitoring
system or water manometer are changed according to hospital policy
 In general, the dressing is to be kept dry and air occlusive
 Dressing changes are performed with the use of sterile technique
 Arterial catheters can be used for infusing intravenous fluids, administering intravenous
medications, and drawing blood specimens in addition to monitoring pressure.
 To measure me arterial pressure, the transducer (when a pressure monitoring system is
used) or the zero mark on the manometer (when a water manometer is used) must be
placed at a standard reference point, called the phlebostatic axis
 After locating this position, the nurse may make an ink mark on the chest
CENTRAL VENOUS PRESSURE
The CVP, the pressure in the vena cava or right atrium, is used to assess right ventricular
function and venous blood return to the right side of the heart. The CVP can be continuously
measured by connecting either a catheter positioned in the vena cava or the proximal port of a
pulmonary artery catheter to a pressure monitoring system
PROCEDURE
 Before insertion of a CVP catheter, the site is prepared by shaving if necessary and by
cleansing with an antiseptic solution
 A local anestetic may be used
 The physician threads a single lumen or multilumen catheter through the external jugular,
antecubital, or femoral vein into the vena cava just above or within the right atrum
NURSING INTERVENTIONS
 Once the CVP catheter is inserted, it is secured and a dry, sterile dressing is applied
Catheter placement is confirmed by a chest x-ray, and the site is inspected daily for signs
of infection.
 The dressing and pressure monitoring system or water manometer are changed according
to hospital policy. In general , the dressing is to be kept dry and air occlusive
 Dressing changes are performed with the use of sterile technique CVP catheters can be
used for infusing intravenous fluids, administering intravenous medications, and drawing
blood specimens in addition to monitoring pressure
  To measure the CVP, the transducer (when a pressure monitoring system is used) or the
zero mark on the manometer (when a water manometer is used) must be placed at a
standard reference phlebostatic axis. Point, called the
 After locating this position, the nurse may make an ink mark on the chest

PULMONARY ARTERY PRESSURE MONITORING

Pulmonary artery pressure monitoring is an important tool used in critical care for assessing left
ventricular function, diagnosing the etiology of shock, and evaluating the patient's response to
medical interventions (eg, fluid administration, vasoactive medications) Pulmonary artery
pressure monitoring is achieved by using a pulmonary artery catheter and pressure monitoring
system.
PULMONARY ARTERY CATHETER
Development of the balloon-tipped flow directed catheter has enabled continuous direct
monitoring of PA pressure. Pulmonary artery catheter otherwise known as "swan- ganz catheter
COMPONENTS OF CATHETER
INSERTION OF PAC
 PA monitoring njust be carried out in a critical care unit under careful scrutiny of an
experienced nursing staff
 Before insertion of the catheter, explain to the client that
 The procedure may be uncomfortable but not painful
 A local anesthetic will be given at the catheter insertion site. Support of the critically ill
client at this time helps promote cooperation and lessen anxiety.
PROCEDURE
This procedure can be performed in the operating room or cardiac catheterization laboratory or at
the bedside in the critical care unit. Catheters vary in their number of lumens and their types of
measurement (eg, cardiac output, oxygen saturation) or pacing capabilities. All types require that
a balloon-tipped, flow directed catheter be inserted into a large vein (usually the subclavian,
jugular, or femoral vein), the catheter is then passed into the vena cava and right atrium. In the
right atrium, the balloon tip is inflated, and the catheter is carried rapidly by the flow of blood
through the tricuspid valve, into the right ventricle, through the pulmonic valve, and into a
branch of the pulmonary artery
(During insertion of the pulmonary artery catheter, the bedside monitor is observed for waveform
and ECG changes as the catheter is moved through the heart chambers on the right side and into
the pulmonary Artery)
When the catheter reaches a small pulmonary artery, the balloon is deflated and the catheter is
secured with sutures
Fluoroscopy may be used during insertion to visualize the progression of the catheter through the
heart chambers to the pulmonary artery
After the catheter is correctly positioned, the following pressures can be measured:
CVP or right atrial pressure Pulmonary artery systolic and diastolic pressures, mean pulmonary
artery pressure, and pulmonary artery wedge pressure).
NORMAL RESULTS
 Normal pulmonary artery pressure is 25/9 mm Hg, with a mean pressure of 15 mm Hg.
 Pulmonary capillary wedge pressure is a mean pressure and is normally 4.5 to 13 mm Hg
NURSING INTERVENTIONS
 Catheter site care is essentially the same as for a CVP catheter As in measuring CVP, the
transducer must be positioned at the phlebostatic axis to ensure accurate readings
 The nurse who obtains the wedge reading ensures that the catheter has returned to its
normal position in the pulmonary artery by evaluating the pulmonary artery pressure
waveform
 The pulmonary artery diastolic reading and the wedge pressure reflect the pressure in the
ventricle at end diastole and are particularly important to monitor in critically ill patients,
because they are used to evaluate left ventricular filling pressures (preload) At end-
diastole, when the mitral valve is open, the wedge pressure is the same as the pressure in
the left atrium and the left ventricle, unless the patient has mitral valve disease or
pulmonary hypertension
 Critically ill patients usually require higher left ventricular filling pressures to optimize
cardiac output These patients may need to have their wedge pressure maintained as high
as 18 mm Hg
COMPLICATIONS
Infection pulmonary artery ruptures pulmonary thromboembolism pulmonary infarction catheter
kinking, dysrhythmias, and air embolism.
TECHNIQUES WITH PULMONARY ARTERY CATHETER
CARDIAC OUTPUT MONITORING THERMODILUTION CONTINUOUS CARDIAC
OUTPUT MONITORING FICK'S CARDIAC OUTPUT MEASUREMENT
DERIVED PARAMETERS
 Cardiac o/p measurements may be combined with systemic arterial, venous, and PAP
determinations to calculate a number of vanables useful in assessing the overall
hemodynamic status of the patient.
  They are, Cardiac index-Cardiac output/Body surface area Systemic vascully resistance
[(Mean arterial pressure-resistance CVP or it atrial pressure) Cardiac output) x 80
 Pulmonary vascular resistance [(PAP-PAWP)/Cardiac vascular resistance output) x 80
 Mixed venous oxygen saturation (SvO2) (SvO2-SaO2-[VO2/(136 x Hb x CO)] (6
NURSING RESPONSIBILITIES
SITE CARE AND CATHETER SAFETY:
 A sterile dressing is placed over the insertion site and the catheter is taped in place. The
insertion site should be assessed for infection and the dressing changed every 72 hours
and prm. The placement of the catheter, stated in centimeters, should be documented and
assessed every shift
 The integrity of the sterile sleeve must be maintained so the catheter can be advanced or
pulled back without contamination.
 The catheter tubing should be labeled and all the connections secure The balloon should
always be deflated and the syringe closed and locked unless you are taking a PCWP
measurement
PATIENT ACTIVITY AND POSITIONING
 Many physicians allow stable patients who have PA catheters, such as post CABG
patients, to get out of bed and sit. The nurse must position the patient in a manner that
avoids dislodging the catheter
 Proper positioning during hemodynamic readings will ensure accuracy
DYSRHYTHMIA PREVENTION:
 Continuous EKG monitoring is essential while the PA catheter is in place
 Do not advance the catheter unless the balloon is inflated
 Antiarrhythmic medications should be readily available to treat lethal dysrhythmias
MONITORING WAVEFORMS FOR PROPER CATHETER PLACEMENT:
The nurse must be vigilant in assessing the patient for proper catheter placement. If the PA
waveform suddenly looks like the RV or PCWP waveform, the catheter may have become
misplaced. The nurse must implement the proper procedures for correcting the situation.
MONITORING HEMODYNAMIC VALUES FOR RESPONSE TO TREATMENTS:
 The purpose of the PA catheter is to assist healthcare team members in assessing the
patient's condition and response to treatment. Therefore, accurate documentation of
values before and after treatment changes is necessary.
 Assessing the Patient for Complications Associated with the PA Catheter Occluded ports
 Balloon rupture caused by overinflating the balloon or frequent use of the balloon.
 Pneumothorax may occur during initial placement. Dysrhythmias caused by catheter
migration
 Air embolism-caused by balloon rupture or air in the infusion line
  Pulmonary thromboembolism improper flushing technique, non-heparinized flush
solution Pulmonary artery rupture perforation during placement, overinflation of the
balloon, overuse of the balloon. Pulmonary infarction caused by the catheter migrating
into the wedge position, the balloon left inflated, or thrombus formation around the
catheter which causes an occlusion
CONCLUSION
Hemodynamics is the forces involved in blood circulation. Hemodynamic monitoring started
with the estimation of heart rate using the simple skill of finger on the pulse' and then moved on
to more and more sophisticated techniques like stethoscope, sphygmomanometer, ECG etc. The
status of critically ill patients can be assessed either from non-invasive single parameter
indicators or various invasive techniques that provide multiparameter hemodynamic
measurements. As a result, comprehensive data can be provided for the clinician to proactively
address hemodynamic crisis and safely manage the patient instead of reacting to late indicators
of hemodynamic instability
BIBILOGRAPHY
Black MJ,Hawks HJ “.Medical Surgical Nursing” Elseiver publication 8 th edition, publications
2014 page no. 1532-37
Lewis Ls; "Medical Surgical Nursing", Elseiver publication 7 edition page no: 597-618

NET REFFERENCE:

 https://www.scribed.com
 https://tnpcb.gov.in