Lesson 3 Hemodynamic Monitoring Semi Finals 3
Lesson 3 Hemodynamic Monitoring Semi Finals 3
Lesson 3 Hemodynamic Monitoring Semi Finals 3
BASIC NURSING SKILLS FOR CLIENTS WITH LIFE-THREATENING CONDITIONS, ACUTELY ILL/ MULTI-
ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY SITUATION
Hemodynamics, by definition, is the study of the motion of blood through the body. In a simple
patient assessment this may include the observation of a patient’s heart rate, pulse quality,
blood pressure, capillary refill, skin color, or skin temperature, ECG, CVP, ABG, pulse oximetry, etc).
As a patient's condition worsens, invasive approach such as invasive hemodynamic monitoring and
invasive blood pressure monitoring (arterial line) may be utilized to provide a more advanced
assessment and guide therapeutic interventions.
Invasive monitoring is used routinely in many critical care units to assist in the assessment of both single
and multi-system disorders and their treatment
Goals of Monitoring:
To assure the adequacy of perfusion.
Early detection of an inadequacy of perfusion
To titrate therapy to specific hemodynamic endpoints in unstable patients.
To differentiate among various organ system dysfunction.
It is also known as The Swan-Ganz Catheter in honor of its inventors Jeremy Swanz and
William Ganz.
PA catheters may be used for both diagnosis and therapy. Clinical indications include:
Postmyocardial infarction: to assess hemodynamic status and monitor and
guide therapy.
Cardiac surgery: to monitor cardiac function.
Major surgery: in the presence of myocardial dysfunction or for preoperative
optimization of hemodynamics.
Resuscitation: in case of hemodynamic instability during fluid replacement:
to assess left ventricular function.
Septic shock: assessment of LV function and fluid status.
Diagnosis of high and low pressure pulmonary edema.
Measurement of oxygen transport, enabling optimization of ventilation and
perfusion.
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Pre-eclampsia and eclampsia: to monitor fluid status and assess intravascular
volume.
As depicted in the photo above, the catheter is introduced through a large vein—
often the internal jugular, subclavian, or femoral veins. From this entry site, it is
threaded through the right atrium of the heart, the right ventricle, and subsequently
into the pulmonary artery. The passage of the catheter may be monitored by dynamic
pressure readings from the catheter tip or with the aid of fluoroscopy.
The standard pulmonary artery catheter has two lumens (Swan-Ganz) and is
equipped with an inflatable balloon at the tip, which facilitates its placement into the
pulmonary artery through the flow of blood. The balloon, when inflated, causes the
catheter to "wedge" in a small pulmonary blood vessel.
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TERMINOLOGIES OF HEMODYNAMIC MONITORING:
Cardiac output/cardiac index are used to assess the heart’s ability to meet the body’s
oxygen demands.
Cardiac index is a more precise measurement of heart function since body size affects
overall cardiac output.
The cardiac index is a calculation of cardiac output per square meter of body surface area.
The normal cardiac index is 2.8-4.2 L/min/m2.
CO = SV x HR.
Normal resting CO is 4-8 L/min and varies with body size.
b. Stroke volume is the volume of blood pumped out of the heart with each heartbeat. If
the stroke volume drops, the body will compensate by increasing the heart rate to
maintain cardiac output. This is known as compensatory tachycardia. Tachycardia is an
effective compensatory mechanism at a certain point. At heart rates greater than 150
bpm, diastolic filling time becomes so short that the tachycardia itself produces a drop
in stroke volume, and cardiac output can no longer be maintained. Stroke volume is
affected by three factors, preload, afterload, and contractility:
1. PRELOAD –
Preload is the force that stretches the muscle fibers of a resting heart – how much
they are stretched just prior to contraction. It is the degree of muscle fiber
stretching present in the ventricles right before systole
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It is the amount of blood in a ventricle before it contracts; also known as “filling
pressures”
The amount of blood present within the right and left atria and ventricles prior to
contraction and the condition of the myocardium determine the stretch or preload
of the heart muscle
The greater the volume of blood in a heart chamber, the greater the preload
Ideally, an adequately filled and stretched left ventricle should briskly contract, snap
like a rubber band, to send blood on its way
2. AFTERLOAD
Afterload is defined as the resistance that the ventricle must overcome to eject its
volume of blood.
It refers to 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
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e. Too little preload and the cardiac output cannot propel enough blood
forward, too much and the heart will become overwhelmed leading to
failure.
f. Just the right amount of preload produces the best possible cardiac output;
finding this level of preload is called “preload optimization
3. CONTRACTILITY
The inherent ability of the cardiac muscle to contract regardless of preload or
afterload status.
QUICK RECALL:
PRE-LOAD: Filling & Stretching (Diastole)
AFTER-LOAD: Pressure to pump (Systole)
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In the setting of marked vasoconstriction or hypotension, the arterial line gives more
accurate pressure values than a blood pressure cuff; however, in case of strong
centralization of circulation, blood pressure measurements done with peripheral arterial
lines may considerably differ from the core hemodynamics.
The arterial line gives an accurate representation of MAP or mean arterial pressure
Indications include:
a. Continuous blood pressure measurement in a rapidly changing clinical circumstances in
critically ill patients (e.g. hemorrhage, sepsis).
b. Frequent blood gas measurement
c. Monitoring and guiding the use of vasoactive drugs with rapid cardiovascular effects.
d. Monitoring and guiding acute interventions (e.g. major surgery, resuscitation).
e. Blood sampling.
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5.Zero and calibrate equipment every 4 to 12 hours, as appropriate, with
transducer at the level of the right atrium to ensure accuracy of waveform.
6.Monitor blood pressure (systolic, diastolic, and mean), central venous/right
atrial pressure, pulmonary artery pressure (systolic, diastolic, and mean), and
pulmonary capillary/artery wedge pressure.
7.Monitor hemodynamic waveforms for changes in cardiovascular function.
8.Compare hemodynamic parameters with other clinical signs and symptoms.
9.Monitor pulmonary artery and systemic arterial waveforms; if dampening
occurs, check tubing for kinks or air bubbles, check connections.
10.Document pulmonary artery and systemic arterial waveforms.
11.Monitor peripheral perfusion distal to catheter insertion site every 4 hours or
as appropriate.
12.Refrain from inflating balloon more frequently than every 1 to 2 hours, or as
appropriate.
13.Maintain sterility of ports.
14.Perform sterile dressing changes and site care, as appropriate.
15.Inspect insertion site for signs of bleeding or infection.
16.Change IV solution and tubing every 24 to 96 hours, based on protocol.
17.Keep hemodynamic monitoring alarms ON.
The right atrium and ventricle transfer deoxygenated blood to the lungs via
the pulmonary arteries. Blood is oxygenated and returned to the left artium
via the pulmonary veins. The left ventricle then pumps the oxygenated blood
to the body, exiting the heart through the aorta. Systemic circulation flows
through arteries, then arterioles, then capillaries where gas exchange occurs
to tissues. Blood is then returned to the heart through venules and veins,
which merge into the superior and inferior vena cavae and empty into the
right atrium to complete the circuit.
Systemic circulation is ordered from the left ventricle to the aorta, through the
structures of the body, to the superior or inferior vena cava, and reenters the
heart in the right atrium.
The aorta carries blood from the left ventricle to the body for systemic
circulation. The vena cavae return the blood from systemic circulation to the
right atrium. The superior vena cava returns blood from the head upper
extremities, while the inferior vena cava returns blood from the abdomen and
lower extremities.
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PRE-SELECTED VIDEO FOR LEARNING REINFORCEMENT:
POST-TASK ACTIVITY
1. Quizzes
Quiz 1 – PULMONARY ARTERY CATHETERIZATION (PAC): INVASIVE
HEMODYNAMIC MONITORING
Quiz 2 – PERIPHERAL ARTERIAL LINE: INVASIVE BLOOD PRESSURE MONITORING
2. Oral Revalida - equivalent to Major Exam
References:
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SKILLS LABORATORY MODULE
BASIC NURSING SKILLS FOR CLIENTS WITH LIFE-THREATENING CONDITIONS, ACUTELY ILL/ MULTI-
ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY SITUATION
Circulatory assist devices are mechanical and artificial devices that perform some or all of the functions
of the heart. They vary significantly in design and indication but are typically used to provide either
partial or full support for a heart that is unable to function adequately. Those used for temporary
support include the Intraaortic Balloon Pump or IABP, Left and Right Ventricular Assist Device (LVAD /
RVAD). Those used for full support include Biventricular Assist Device (BiVAD) and Total Artificial Heart
(TAH).
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Nursing care has dual roles. It involves care of the Mechanical Circulatory Assist Devices as well as the
care of the patient by assessing patient from a cardiovascular and hemodynamic perspective, keeping
them safe, comfortable and free from complications.
b. Site and Placement: The femoral artery is the most common insertion site of IABP.
Alternative insertion sites include the iliac, axillary, and subclavian arteries.
IABP placement may even be accomplished via the ascending aorta, as is
occasionally done after cardiac surgery.
The ideal location for the tip of the balloon is just distal to the aortic arch, 1 to 2
cm beyond the left subclavian artery. The other end of the balloon should sit
proximal to the takeoff of the celiac axis. Correct positioning of the balloon may
be confirmed at the time of placement with either transesophageal
echocardiography or fluoroscopy.
Alternatively, confirmation may be performed after placement by chest
radiograph.
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Intra-aortic balloon pump (IABP) catheter insertion using a novel left
external iliac artery approach and a subcutaneous channel in a 67-year-
old woman with chronic heart failure due to dilated cardiomyopathy.
The catheter was removed subcutaneously from the left retroperitoneal
space to the right lower quadrant of the abdomen. 1. The insertion of
the intra-aortic balloon pump (IABP) catheter in the external iliac artery.
2. The subcutaneous pocket from left retroperitoneal space to the right
lower quadrant of the abdomen. 3. The external part of the IABP device.
Yellow indicates the Dacron conduit. The dressing on the patient's left
side indicates the retroperitoneal surgical access. The dressing on the
patient's right side indicates the external approach and exit of the IABP
device.
c. Mechanism of Action: The IABP is designed to inflate during diastole and deflate during
systole.
It is beneficial in both phases of the cardiac cycle.
During diastole, inflation of the balloon displaces blood proximally, increasing
perfusion pressure to the coronary arteries and the critical vessels branching off
the aortic arch. Perfusion and blood flow are equally improved in the aorta
distal to the balloon through the vessels supplying blood to the mesentery and
the lower extremities.
In systole, deflation of the balloon creates a relative negative space within the
aorta, which reduces afterload.
As a consequence, not only is cardiac function improved because of lower
systemic resistance, but the duration of isovolumic contraction, the most
energy-demanding phase of the cardiac cycle, is also reduced.
AIM / GOAL:
Increase coronary artery perfusion by improving myocardial oxygen
supply
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Reduction in afterload by reducing myocardial oxygen demand
After Insertion – Maintaining the patency of the IABP and safety and
comfort of the patient through the following nursing actions:
a. Assess cardiovascular hourly, or more frequently depending on
clinical acuity, noting mean arterial pressure, augmented
pressure heart rate, oxygen saturation and perfusion state
(lower and upper limb perfusion assessment)
b. Assess and observe for any alteration in neurological status
c. Confirm timing, ratio and trigger of intra-aortic balloon pump
hourly
d. Strict intake and output record – aim for output 0.5ml/kg/hr –
report any sudden decrease in urinary output (signs of
decreased renal perfusion due to low cardiac output or
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migration of the catheter to the renal arteries obstructing blood
flow)
e. Ensure the transducer is level with the phlebostatic axis, flushed
hourly and zeroed four hourly or on change of patient position.
Always flush with the pump on standby
f. Check all connections, observe the balloon catheter for
presence of blood which may indicate balloon puncture/rupture
hourly
g. Monitor for signs of pulmonary edema or ischemia
h. Monitor temperature two-to-four-hourly, observing for signs of
infection such as erythema/inflammation and pain at the
insertion site and a raised white cell count
i. Observe for bleeding at cannulation sites, venipuncture sites,
urinary catheter, and insertion site as a complication of
anticoagulation therapy
j. Educate the patient re importance of passive limb exercises,
keeping the affected leg straight
k. Encourage deep breathing exercises to promote adequate
ventilation and lung expansion preventing the development of
chest infections
l. Provide skin care and pressure area care – may need a pressure
relieving mattress and if needed two-hourly turns
m. Assist with nutrition and hydration as patient should be no
higher than 30° which is challenging when eating or drinking
n. Provide ongoing psychological support and education as
required
II. VENTRICULAR ASSIST DEVICE (VAD) and TOTAL ARTIFICIAL HEART (TAH)
Although a VAD can be placed in the left, right or both ventricles of your heart, it is most
frequently used in the left ventricle. When placed in the left ventricle it is called a left
ventricular assist device (LVAD).
Donors for heart is not always immediately available, making it more difficult for those
with end-stage heart failure to improve quality and longer life. Besides the scarcity of
heart donor, there are certain patients who are not a good candidate to receive live
heart for transplant.
An alternative now made available for heart replacement is in the form of Total
Artificial Heart.
A total artificial heart (TAH) is a pump that is surgically installed to provide circulation
and replace heart ventricles that are diseased or damaged. The ventricles pump blood
out of the heart to the lungs and other parts of the body. Machines outside the body
control the implanted pumps, helping blood flow to and from the heart.
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As with any surgery, TAH surgery can lead to serious complications such as blood clots
or infection.
Mechanism of TAH
The TAH is an FDA approved device that weighs 14 pounds and can be recharged at
home or in a car. It replaces the function of the ventricles of the heart. Tubes connect
the TAH to a power source that is outside the body. The TAH then pumps blood through
the heart’s major artery to the lungs and the rest of the body.
The TAH has four mechanical valves that work like the heart’s own valves to control
blood flow. These valves connect the TAH to your heart’s atrium, and to the major
arteries, the pulmonary artery, and the aorta. Once the TAH is connected, it duplicates
the action of a normal heart, providing mechanical circulatory support and restoring
normal blood flow through the body.
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For patients with End-Stage-Heart Failure who were not candidates for
heart transplant surgery. It is considered only for patients when all
other treatment options, such as medications, lifestyle changes and
heart procedures, have been tried and not effectively managed heart
failure. DT support the patient’s heart to function and improve quality
of life for the rest of the patient’s life.
Patients with VAD or TAH generally are in a home setting. HEALTH TEACHINGs, therefore
are the most essential for the nurses to render for patients living with these devices,
including the maintenance of the device, the signs and symptoms of its major
complications such as:
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Dysrhythmias. Patients with an LVAD / TAH are at high risk for atrial and
ventricular dysrhythmias. Alterations in cardiac rate and rhythm are
sometimes poorly tolerated because right and left ventricular filling and
function are compromised, which can lead to decompensated HF,
syncope, and sometimes death. Management of atrial dysrhythmias in
patients with devices is similar to patients without an LVAD / TAH. For
rate control, beta-blockers are preferred over calcium channel blockers
because calcium channel blockers provide no functional or mortality
benefit and may worsen outcomes. If beta-blockers aren't well
tolerated, amiodarone is preferred for atrial dysrhythmias. To treat
ventricular dysrhythmias, amiodarone, lidocaine, are often prescribed
Neurologic events. Patients with an LVAD / TAH are at increased risk for
ischemic and hemorrhagic strokes. Head CT scan is needed to identify
the type of stroke. Acute ischemic strokes result from thromboembolic
events due to pump thrombosis, subtherapeutic anticoagulation, or a
prothrombotic state associated with activation of the immune system.
Ischemic strokes occur in 8% to 10% of patients with an LVAD / TAH.
Causes of hemorrhagic stroke in these patients include hemorrhagic
transformation of an ischemic stroke, over anticoagulation, or infection.
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