Hemodynamic Monitoring

MODULE F HEMODYNAMIC MONITORING
Topics to be Covered
Cardiac Output Determinants of Stroke Volume Hemodynamic Measurements Pulmonary Artery Catheterization Control of Blood Pressure Heart Failure
Cardiac Measurements
Stroke Volume: Volume of blood ejected from the ventricle with each contraction.
60-130 mL per beat
Cardiac Output: Volume of blood pumped by the ventricles per minute

CO = SV x HR Normal Value is 4-8 L/min 5,040 mL/min = 70 mL x 72/min Cardiac Output directly influences blood pressure (both HR and SV).
Distribution of Blood Volume

Blood Volume is normally 5 L (varies with age, sex, body size)
75% is found in the systemic circulation
60% in the systemic veins 10% in systemic arteries
15% is found in the heart 10% is found in the pulmonary circulation

Usual volume is 75 mL with capacity of 200 mL.
Distribution of Pulmonary Ventilation & Blood Flow

Blood flow is gravity dependent
Sitting/standing position o blood goes to the lung bases. Lying flat, blood flow preferentially will go to posterior lung.

Ventilation is also gravity dependent, BUT
At FRC, the alveoli are larger at the apices. Once the FRC is established, the majority of the tidal volume goes to the bases

Net effect is that there is both perfusion and ventilation are greatest at the bases, but not in equal proportions. Wests Lung Zones
Zone 1
Least Gravity Dependent. PA > Pa > Pv NO BLOOD FLOW
Zone 2
Some Gravity Dependency Pa > PA > Pv SOME BLOOD FLOW o AS YOU GO DOWN THE LUNG
Zone 3
Most Gravity Dependent Pa > Pv > PA
Changing Body Position to Improve Oxygenation

Unilateral Lung Disease
Examples: Pneumonia only in right lung; fractured ribs with pulmonary contusion only on left.
Bad lung up & Good lung down (GOOD TO GROUND)
Improved ventilation will match greater area of perfusion
Ventilate each lung separately (Independent Lung Ventilation)
Determinants of Cardiac Output

The amount of blood pumped each minute is determined by the number of beats (Heart Rate) and the amount pumped each beat (Stroke Volume). The Stroke Volume is dependent on three factors:
Preload Afterload Contractility
http://www.manbit.com/PAC/chapters/PAC.cfm (look under physiology)
Pulmonary Artery Catheterization

Initially devised by Swan and Ganz. Allows for view of Left Ventricular function by using extrapolation of right heart measurements. Catheter is floated into right side of the heart and into a small pulmonary arteriole. Catheter is then wedged and a pressure is measured.
Pulmonary Capillary Wedge Pressure (PCWP) or Pulmonary Occlusion Pressure (POP)
PCWP reflects Left Atrial Pressure (LAP) which reflects Left Ventricular End Diastolic Pressure (LVEDP) which reflects Left Ventricular End Diastolic Volume (LVEDV)
Pulmonary Artery Catheter
Preload
Definition
The degree that the myocardial fiber is stretched prior to contraction at end diastole The more the fiber is stretched, the more it will contract. However, if it is overstretched the amount of contraction goes down.
(Think rubber band)
On right side of heart Right Ventricular End Diastolic Volume which is reflected by Right Atrial Pressure or Central Venous Pressure (CVP) On left side, the LVEDV is reflected by the PCWP.
Pulmonary Artery Catheterization

Catheter is inserted into the right side of the heart and advanced into the pulmonary artery. The physician knows the position of the catheter by watching the waveforms and noting the change in pressures.
http://rnceus.com/hemo/pacath.htm CVP= 2-6 mm Hg
RVP= 25/0 mm Hg
PAP= 25/8 mm Hg (MPAP: 10-20 mm Hg)
PCWP= 4-12 mm Hg
Afterload
Definition
The force against which the ventricles must work to pump blood The ventricular wall tension generated during systole Determined by:
Volume and viscosity of blood Vascular resistance Heart valves
Vascular Resistance
Derivation of Ohms Law
The resistance in a circuit is determined by the voltage difference across the circuit and the current flowing through the circuit.
Resistance = (Pressure Flow Vascular Resistance = (Blood Pressure (mmHg) Cardiac Output (L/min)
Where (Blood Pressure is the highest pressure in the

circuit minus the lowest pressure in the circuit.
Pulmonary Vascular Resistance (PVR)

Key Components:
Highest Pressure MPAP Lowest Pressure LAP or PCWP Flow Cardiac Output
Formula
PVR = (MPAP-PCWP)/CO x 80
Systemic Vascular Resistance (SVR)

Key Components
Highest Pressure MAP Lowest Pressure RAP or CVP Flow Cardiac Output
Formula
SVR = (MAP-CVP)/CO x 80
Contractility
Definition
The force generated by the myocardium when the ventricular muscle fibers shorten.
Positive Inotropic effect (o force of contraction) Negative Inotropic effect ( force of contraction)
Contractility is affected by:

Drugs Oxygen levels within the myocardium Cardiac muscle damage Electrolyte imbalances
Heart Failure
Right Heart Failure vs. Cor Pulmonale
Right ventricular hypertrophy Peripheral edema Pitting edema, swollen ankles, palpable liver (hepatomegaly), ascites, engorged neck veins (JVD)
Left Heart Failure

Left ventricular hypertrophy Pulmonary edema and pleural effusions
Types of Invasive Catheters

Arterial Line (A-line)
Inserted into an artery
Central Venous Catheter (CVP)

Inserted into a vein
Pulmonary Artery Catheter (PAP)

Inserted into a vein
Blood Pressure
Low Blood Pressure is hypotension
Prevents the tissues from receiving the O2 and nutrients it needs to survive
High Blood Pressure is hypertension

This strains the heart and over time may lead to heart failure
25/8 (10-20) PAP (MPAP)
4-12 PCWP
CVP 2-6
BP(MAP) 120/80 (80-100)
Heart/Vascular Pressures
Left Ventricle: 120/0 mm Hg Arterial Blood Pressure: 120/80 mm Hg Mean Arterial Pressure: 93 mm Hg (80 - 100) Arterioles: 30 mm Hg Capillaries: 20 mm Hg Veins: 10 mm Hg Right Atrium (CVP): 2-6 mm Hg (4-12 cm H20) Right Ventricle 25/0 mm Hg Pulmonary Artery 25/8 mm Hg Mean Pulmonary Artery Pressure: 14-15 mm Hg (10-20 cm H2O) Pulmonary Capillary Wedge Pressure (PCWP): 4-12 mm Hg Pulmonary capillaries 12 mm Hg Pulmonary veins 8-10 mm Hg Page 7 of Left Atrium 5 mm Hg Formulae Left Ventricle - 120/0
Factors that Control Blood Pressure

Heart
oHR and Stroke Volume, o BP q HR and Stroke Volume, q BP
Blood
Hypervolemia: Increased BP Hypovolemia: Reduced BP
Blood Vessels
Vasoconstriction: Increased BP Vasodilation: Reduced BP
Mean Blood Pressure

Mean = 2 (diastolic pressure) + systolic pressure 3
Mean arterial blood pressure is 90100 mm Hg Mean pulmonary artery pressure is 9-18 mm Hg
Indexed Values
Relates values to body size
Allows for better correlation between patients
Calculated by using Dubois nomogram

Appendix IV, p 513
Cardiac Index
CO/BSA
Stroke Volume Index

SV/BSA
Pulmonary & Systemic Vascular Resistance Index

Divide by CI instead of CO

Hemodynamic Monitoring

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MODULE F HEMODYNAMIC MONITORING

Cardiac Output: Volume of blood pumped by the ventricles per minute

Distribution of Blood Volume

15% is found in the heart 10% is found in the pulmonary circulation

Distribution of Pulmonary Ventilation & Blood Flow

Distribution of Pulmonary Ventilation & Blood Flow

Distribution of Pulmonary Ventilation & Blood Flow

Changing Body Position to Improve Oxygenation

Ventilate each lung separately (Independent Lung Ventilation)

Determinants of Cardiac Output

Pulmonary Artery Catheterization

Pulmonary Artery Catheter

Pulmonary Artery Catheterization

http://rnceus.com/hemo/pacath.htm CVP= 2-6 mm Hg

PAP= 25/8 mm Hg (MPAP: 10-20 mm Hg)

Where (Blood Pressure is the highest pressure in the

Pulmonary Vascular Resistance (PVR)

Systemic Vascular Resistance (SVR)

Contractility is affected by:

Left Heart Failure

Types of Invasive Catheters

Central Venous Catheter (CVP)

Pulmonary Artery Catheter (PAP)

High Blood Pressure is hypertension

25/8 (10-20) PAP (MPAP)

BP(MAP) 120/80 (80-100)

Factors that Control Blood Pressure

Mean Blood Pressure

Calculated by using Dubois nomogram

Stroke Volume Index

Pulmonary & Systemic Vascular Resistance Index

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