This is a very simple presentation prepared for nurses. It will help nurses to understand the need of monitoring and the available methods. The presentation has been constructed on a clinical case base scenario and gradually different methods of monitoring has been introduced.

1. Basic Hemodynamic Monitoring
(Nurses Concept)
Muhammad Asim Rana
BSc, MBBS, MRCP, MRCPS, EDIC, SF-CCM, FCCP
Intensive Care Medicine
King Saud Medical City

2. You said patient is the most important !

3. Objectives
• Review:
– purposes of Hemodynamic Monitoring
– indications for Hemodynamic Monitoring
– Biological sensors and monitoring
– Pulse oximetry
– Automated blood pressure devices
– Arterial, central venous, and pulmonary artery
catheters
– Cardiac output and oxygen delivery variables

4. • Mrs. A. a 76 yrs old
female with a previous
history of congestive
heart failure, is
admitted with clinical
and laboratory evidence
of a urinary tract
infection. Referred to
ICU because of shock
state.

5. ►Goals
– Confirm diagnosis
– Initiate treatment
– Monitor for
improvement
or worsening in her
condition
• What is shock?
• How to treat the shock?
• How to monitor?

6. Shock and its types
• Failure to deliver and/or
utilize adequate
amounts of Oxygen
• Types
– Hypovolemic Shock
– Cardiogenic Shock
– Distributive Shock
– Obstructive Shock

7. Circulation & Oxygen transport

8. 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.

9. Hemodynamic monitoring
refers to measurement of pressure, flow and
oxygenation of blood within the cardiovascular system.
OR
Using invasive technology to provide quantitative
information about vascular capacity, blood volume,
pump effectiveness and tissue perfusion.
OR
Hemodynamic monitoring is the measurement and
interpretation of biological sytems that describes the
performance of cardiovascular system

10. Purpose of monitoring
• 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.

11. Indications
All types of shock:
– Cardiogenic shock
– Distributive shock
– Obstructive shock
– Hypovolemic shock

12. Types of Hemodynamic Monitoring
• Non-invasive = clinical assessment & NBP
• Direct measurement of arterial pressure
• Invasive hemodynamic monitoring
►Continuous vs. intermittent
►Invasive vs. noninvasive
►Never therapeutic but may be diagnostic
12

13. Noninvasive Hemodynamic Monitoring
• Noninvasive BP
• Heart Rate, pulses
• Mental Status
• Mottling
13
• Skin Temperature
• Capillary Refill
• Urine Output
• Pulse Oxymetry

14. Pulse Oxymetry
• Estimates Oxyhemoglobin as SpO2
• Target SpO2 > 92%
• Heart rate displayed should be same as pulse
rate captured by the probe

15. Oxyhemoglobin Saturation Curve

16. Oximeter Sensors

17. Pulse Oximetry
Sources of error
• Physiological/ anatomical
• Vasoconstriction
• Poor perfusion
• Abnormal hemoglobin
• Skin pigmentation
• Cold extremities
• External causes
• Motion artifact
• Excessive external light

18. Automated Blood Pressure
measuring devices
• Intermittent measurements
• Appropriate cuff size necessary
• Less accurate during hypotension, arrhythmias

19. 19
Proper Fit of a Blood Pressure Cuff
• Width of bladder = 2/3 of upper arm
• Length of bladder encircles 80% arm
• Lower edge of cuff approximately 2.5 cm above the
antecubital space

20. 20
Why A Properly Fitting Cuff?
• Too small causes false-high reading
• Too LARGEcauses false-low reading

21. Back to our patient
• Patient was persistently
hypoxic, hypotensive so
electively intubated and
ventilated.
• What would you like to
do for better
monitoring of your
patient ?
• Inotropes requirement
is increasing.
• Oxygen requirement is
varying.

22. Invasive BP monitoring

23. Invasive Arterial Blood Pressure Monitoring
• Indications
• Frequent titration of
vasoactive drips
• Unstable blood pressure
• Frequent ABGs or labs
• If unable to obtain Non-
invasive BP
• Sites
– Radial artery
– Brachial artery
– Femoral
– Dorsalis pedis artery
• Complications
– Hematoma/blood loss
– Thrombosis
– distal ischemia
– Arterial injury
– Infection
23
Tubing and transducer should be replaced every 96 hours.

24. Supplies to Gather
• Arterial Catheter
• Pressure Tubing
• Pressure Cable
• Pressure Bag
• Flush – 500cc NS
• Sterile Gown
• Sterile Towels
• Sterile Gloves
• Suture (silk 2.0)
• Chlorhexidine Swabs
• Mask

25. Leveling and Zeroing
• Leveling
– Before/after insertion
– If patient, bed or
transducer move
• Zeroing
– Performed before
insertion & readings
• Level and zero at the
insertion site
25
• Phlebostatic Axis

26. •Re-level the transducer with any
change in the patient’s position
•Referencing the system 1 cm above
the left atrium decreases the
pressure by 0.73 mm Hg
•Referencing the system 1 cm below
the left atrium increases  the
pressure by 0.73 mm Hg
Angles 45°
30°
0°
Importance of zeroing

27. Arterial pressure measurement
• The systolic pressure is
measured at the peak of the
waveform.
• This pressure reflects the
function of the left
ventricle.
• NORMAL value=100-130
mmHg
• The LOWEST point on the
waveform represents the
end diastolic pressure.
• This pressure reflects
systemic resistance.
• Normal diastolic pressure is
60-90 mmHg

28. Important Concepts
Dicrotic notch
• The small notch on the
downstroke of the wave
form.
• It represents the closure of
the aortic valve.
• This is the reference point
between the systolic and
diastolic phases of the
cardiac cycle.
Mean Arterial Pressure/MAP
• Is a calculated pressure that
closely estimates the
perfusion pressure in the aorta
and its branches.
• It represents the average
systemic arterial pressure
during the ENTIRE CARDIAC
CYCLE.
• Normal MAP = 70-100 mmHg
• MAP MUST be maintained
above 60 for the major organs
to perfuse.

29. Dampening

30. Dampening

31. Dampening and Flush test
Underdampening
Normal Dampening

32. Invasive BP monitoring
• Invasive monitoring is more accurate
• Invasive BP should by higher than cuff BP
• If cuff BP is higher look for equipment malfunction or
technical error
• A dampened wave form can indicate a move toward
hypotension…an immediate cuff pressure should be
obtained

33. 33
Documentation
• Insertion procedure note
• Arterial BP readings as ordered
• Neurovascular checks every two hours
(in musculoskeletal assessment of HED)
• Pressure line flush amounts (3ml/hr)
• Tubing and dressing changes

34. Nursing Implications
• Prevent or reduce the potential for complications.
• Maintain 300mmHg on bag
• Maintain continuous flow through tubing
• Aseptic dressing change
• Sterile caps on openings
• Change tubing q 96 hrs.
• 5 min hold on discontinued site

35. Let’s see our patient
• Arterial BP being
monitored.
• Fluid challenge given
• Inotropes and
vasopressors support
augmented.
• Physician asked for CVP
& Mixed venous oxygen
saturation….
• What is mixed venous
oxygen saturation?
• Difference between
SVO2 and ScVO2
• How to measure them?
• Concept of cardiac
pressures and
management strategies

36. Central Venous Pressure
• Indications
– Measure central venous pressure
– Access for resuscitation
– Selected drug administration
– Placement of pulmonary artery catheter
• Complications
– Hematoma/vessel injury/blood loss
– Pneumothorax/hemothorax
– Cardiac arrhythmias
– Infection

37. Central Venous catheter position

38. Central Venous catheter position

39. Central venous pressure measurement

40. Patient position & transducer level

41. Factors affecting CVP waves

42. CVP/ Right Atrial Pressure Monitoring
• A direct measure of the right atrium pressure
• Clinical significance: REFLECTS RIGHT
VENTRICULAR DIASTOLIC PRESSURE
• Abnormalities in RAP are caused by
conditions that alter venous tone, blood
volume, or right ventricular contractility
• CVP is measured at end expiration

43. 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

44. 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

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

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

47. 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

48. 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

49. Nursing HOURLY assessment:
1. Air in line or stopcocks
2. Precipitates
3. Leaking at site
4. Increasing resistance
5. 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 Q 7 days & prn (Tegaderm & biopatch)

50. Our patient Mrs A.
• The CVP > 12
• FiO2 requirement has
increased.
• ScVO2 < 50%
• Physician has concern
about cardiac status.
• Need to distinguish
between cardiogenic
and septic shock…
• Role of cardiac out put
in oxygen delivery?
• How to determine the
cardiac status?
• Non-invasive
– Echo
• Invasive
– Swan-Ganz (PAC)
– Picco

51. Some common terminologies…
• Preload
• Afterload
• Cardiac Output
• Cardiac Index
• Systemic Vascular
Resistance [SVR]
• Pulmonary Vascular
Resistance [PVR]

52. Understanding basic terms
Preload
• Is the degree of muscle fiber
stretching present in the
ventricles right before systole
• Is the amount of blood in a
ventricle before it contracts;
also known as “filling
pressures”
• Left ventricular preload is
reflected by the PCWP
• Right ventricular preload is
reflected by the CVP [RAP]
Afterload
• Any resistance against
which the ventricles must
pump in order to eject its
volume
• How hard the heart [either
side left or right] has to
push to get the blood out
• Also thought of as the “
resistance to flow” or how
“clamped” the blood vessels
are

53. Understanding basic terms
Cardiac output/Index
• Is the amount of blood
ejected from the ventricle in
one minute
• Two components multiply to
make the cardiac output: heart
rate and stroke volume
[amount of blood ejected with
each contraction]
• Cardiac index is the cardiac
output adjusted for body
surface area (BSI)
Vascular Resistance
• Systemic Vascular
Resistance – reflects left
ventricular afterload
• Pulmonary Vascular
Resistance – reflection of
right ventricular afterload
• Many of the drugs we
administer will affect
Preload, Afterload,
SVR/PVR, Cardiac Output

54. Normal Cardiac Pressures

55. Concept of right and left sides

56. Equipment Needed
SET-UP FOR HEMODYNAMIC
PRESSURE MONITORING
1. Obtain Barrier Kit, sterile gloves, Cordis Kit and correct swan
catheter. Also need extra IV pole, transducer holder, boxes and
cables.
2. Check to make sure signed consent is in chart, and that patient
and/or
family understand procedure.
3. Everyone in the room should be wearing a mask!
4. Position patient supine and flat if tolerated.
5. On the monitor, press “Change Screen” button, then select “Swan
Ganz” to allow physician to view catheter waveforms while inserting.
6. Assist physician (s) in sterile draping and sterile setup for cordis and
swan insertion.

57. Equipment Needed
7. Set up pressure lines and transducers
8. Please level pressure flush monitoring system and transducers to
the
phlebostastic axis. Zero the transducers. Also check to make sure
all connections are secure.
9. Connect tubings to patient [PA port and CVP port] when
physician
is ready to flush the swann. Flush all ports of swann before
inserting.
10. While floating the swann, observe for ventricular ectopy on the
monitor, and make physician aware of frequent PVC’s or runs of
VT !
11. After swann is in place, assist with cleanup and let patient know
procedure is complete.

58. Measuring Cardiac output
11. Obtain your RA [CVP], PAS/D, PAM, and
wedge.
For Cardiac Outputs, inject 10 mLs of D5W
after pushing the start button, repeat X 3.
Delete outputs not within 1 point of the
mean value.
Can use 0.9% NS instead, but affects the
accuracy of the output reading.
12. Before obtaining the cardiac output, please
check the computation constant [should
read 0.692 for regular yellow swans; 0.692
for SVO2 or blue swanns]
13. Perform hemocalculations
(enter today’s height and weight).
14. Document findings on the ICU flowsheet.

59. PA Insertion Waves

61. Pulmonary Capillary Wedge Pressure (PCWP)
• Zero the transducer to the patient’s phlebostatic axis.
• Measure the PCWP at end expiration
• PCWP should not be higher than PA diastolic
• PCWP is an indirect measurement of left ventricular end
diastolic pressure.

62. Possible Complications
• Increased risk of infections – same as with any central venous
lines—use occlusive dressing and Biopatch to prevent
• Thrombosis and emboli-- air embolism may occur when the
balloon ruptures, clot on end of catheter can result in
pulmonary embolism
• Catheter wedges permanently—considered an emergency,
notify MD immediately, can occur when balloon is left inflated
or catheter migrates too far into pulmonary artery (flat PA
waveform)…can cause pulmonary infarct after only a few
minutes!
• Ventricular irritation – occurs when catheter migrates back
into RV or is looped through the ventricle, notify MD
immediately…can cause VT

63. Troubleshooting
• Dampened waveform –can occur with physical
defects of the heart or catheter; can be caused by
kinks, air bubbles in the system, or clots
Solution: Check your line for kinks & air bubbles,
aspirate (not flush) for clots, straighten out tubing
or patient as much as possible
• No waveform – can occur with non-perfusing
arrhythmias or line disconnection
Solution: Check your line for disconnection, check
your patient for pulse, could also be wet transducer
or broken cable or box

64. Back to our patient Mrs A.
• A pulmonary artery catheter passed and
following values obtained.
RA LA
RV LV
CI and MAP
Impression: Cardiac

65. • Cardiac Inotropic support added.
• Hemoglobin raised to 10.
• Mrs. A’s blood pressure responds to further Rx,
urine output improves, mental status returns to
normal, and she recovers uneventfully.
Monitoring and therapy based upon information
carefully obtained allowed appropriate responses
to measured/calculated abnormalities and
prevented other inappropriate treatment.

66. Thank you