HEMODYNAMIC

MONITORING

Presented by:
Rowena R. Tosoc RN, PhD
 INTENDED LEARNING OUTCOME

AT THE END OF THE SESSION THE STUDENT WILL BE ABLE TO:

• DIFFERENTIATE THE DIFFERENT SKILLS IOF MONITORING
HEMODYNAMICS OF A CLIENT IN CRITICAL CONDITION.
• APPLY THE PRINCIPLES OF HEMODYNAMICS IN THE
ASSESSMENT OF A CLIENT
Hemodynamics

describe the intravascular pressure and flow

that occurs when the heart muscle contracts
and pumps blood throughout the body.
 HEMODYNAMIC MONITORING
1. Central Venous Pressure

2. Pulmonary Artery Pressure

3. Pulmonary Capillary Wedge Pressure

4. Cardiac Output

5. Cardiac Index

6. ECG - non invasive

7. Systemic Vascular Resistance

 MAIN FOCUS

Heart function is the main focus of hemodynamic studies but

the heart is not the only factor influencing pressure and flow.
There are four factors which influence hemodynamic. They
are the three hemodynamic components to the circulation of
blood in the body plus chronotropy
 HEMODYNAMIC COMPONENTS
• Intravascular volume: the amount of fluid circulating in the
vasculature. This can be affected by dehydration, diuresis, and
volume overload due to heart or kidney failure.

• Intropy: the strength of myocardial contractions. Myocytes are the

only muscle cells which are able to vary the strength of contraction.
Intropy can be affected by exercise, stress and pharmaceutical
agents, which increase the strength of myocardial contractions, or
by cardiac diseases such as heart failure, which decrease the
strength of contractions.
• Vasoactivity: the expanding and contracting of blood vessels to
accommodate the variation in blood flow, regulate arterial pressure,
and meet the metabolic demands of the organs and body tissues.

• Hormones also affect vasoactivity. They are angiotenson II,

epinephrine, norepinephrine, and vasopressin.

• The fourth factor is chronotropy - involves the timing, or rate of

heart contraction. This affects tissue perfusion and is not considered
a hemodynamic component. However, a person needs to have all
four components functioning normally to remain hemodynamically
stable.
 PARAMETER NORMAL VALUES
Blood Pressure
• Systolic 90-140 mm Hg
• Diastolic 60-90 mm Hg
Mean Arterial Pressure (MAP) 70-100 mm Hg
Cardiac Index (CI) 2.5-4 L/min/m2
Cardiac Output (CO) 4-8 L/min
Central Venous Pressure (CVP) 2-6 mm Hg
Pulmonary Artery Pressure (PA)
• Systolic 20-30 mm Hg (PAS)
• Diastolic 8-12 mm Hg (PAD)
• Mean 25 mm Hg (PAM)
Pulmonary Capillary Wedge Pressure (PWCP) 4-12 mm Hg
Pulmonary Vascular Resistance (PVR) 37-250 dynes/sec/cm5
Right Ventricular Pressure (RV)
• Systolic 20-30 mm Hg
• Diastolic 0-5 mm Hg
Stroke Index (SI) 25-45 ml/m2
Stroke Volume (SV) 50-100 ml
Systemic Vascular Resistance (SVR) 800-1200 dynes/sec/cm5
 DEFINITION
Afterload: describes the resistance that the heart has to overcome,
during every beat, to send blood into the aorta. These resistive forces
include vasoactivity and blood viscosity.

Cardiac Index (CI): The amount of blood pumped by the heart, per
minute, per meter square of body surface area.

Cardiac Output (CO): The volume of blood pumped by the heart in one
minute.
o Increased cardiac output may indicate a high circulating volume.
o Decreased cardiac output indicates a decrease in circulating
volume or a decrease in the strength of ventricular contraction.
Central Venous Pressure CVP readings are used to approximate the
Right Ventricular End Diastolic Pressure (RVEDP). assesses right
ventricular function and general fluid status.
o Low CVP values typically reflect hypovolemia or decreased
venous return.
o High CVP values reflect overhydration, increased venous return or
right sided cardiac failure.

Mean Arterial Pressure (MAP): Reflects changes in the relationship

between cardiac output (CO) and systemic vascular resistance (SVR) ,
reflects the arterial pressure in the vessels perfusing the organs.
o A low MAP indicates decreased blood flow through the organs.
o A high MAP indicates an increased cardiac workload.
Preload occurs during diastole. It is the combination of pulmonary
blood filling the atria and the stretching of myocardial fibers. Preload is
regulated by the variability in intravascular volume.
o Volume reduction decreases preload
o Volume increase will increase preload, mean arterial pressure
(MAP) and stroke index (SI).

Pulmonary Artery Pressure (PA Pressure): Blood pressure in the

pulmonary artery.
o Increased pulmonary artery pressure may indicate: a left-to-right
cardiac shunt, pulmonary artery hypertension, COPD or
emphysema, pulmonary embolus, pulmonary edema, left
ventricular failure.
Pulmonary Capillary Wedge Pressure: PCWP pressures are used to
approximate LVEDP (left ventricular end diastolic pressure).
o High PCWP may indicate left ventricle failure, mitral valve
pathology, cardiac insufficiency, cardiac compression post
hemorrhage.

Pulmonary Vascular Resistance (PVR): The measurement of resistance

or the impediment of the pulmonary vascular bed to blood flow.
o An increased PVR or "Pulmonary Hypertension" is caused by
pulmonary vascular disease, pulmonary embolism, or pulmonary
vasculitis, or hypoxia.
o A decreased PVR is caused by medications such as Calcium channel
blockers, Aminophylline, or Isoproterenol or by the delivery of O2.
Right Ventricular Pressure (RV Pressure): A direct measurement that
indicates right ventricular function and general fluid status.
o High RV pressure may indicate: pulmonary hypertension, right
ventricle failure, congestive heart failure.

Stroke Index or Stroke Volume Index: (SI or SVI): The amount of blood
ejected from the heart in one cardiac cycle, relative to Body Surface
Area (BSA). It is measured in ml per meter square per beat.
o An increased SVI may be indicative of early septic shock,
hyperthermia, hypervolemia or be caused by medications such as
Dopamine, Dobutamine, or Digitalis.
o A decreased SVI may be caused by CHF, late septic shock, beta
blockers, or an MI.
Stroke Volume (SV): The amount of blood pumped by the heart per cardiac
cycle. It is measured in ml/beat.
o A decreased SV may indicate impaired cardiac contractility or valve
dysfunction and may result in heart failure.
o An increased SV may be caused by an increase in circulating volume or an
increase in inotropy.

Systemic Vascular Resistance (SVR): The measurement of resistance or

impediment of the systemic vascular bed to blood flow.
o An increased SVR can be caused by vasoconstrictors, hypovolemia, or late
septic shock.
o A decreased SVR can be caused by early septic shock, vasodilators,
morphine, nitrates, or hypercarbia
Arterial Blood Pressure
Monitoring
Intra-arterial catheters ("art lines") offer clinicians a low risk and reliable
method to continuously monitor systemic blood pressure. Critically ill
patients, with unstable cardiopulmonary status, often benefit from such
continuous monitoring. Clinicians are better able to promptly manage
changes in blood pressure which may signal perfusion deficits.

A secondary benefit of an art line is the ability to do serial blood sampling.

Arterial blood gas evaluations can be performed without the need for
repeated painful needle sticks. Arterial blood gas monitoring is vital to the
successful treatment of respiratory failure, whatever the cause.
Arterial pressure monitoring begins with an accurate patient history and
assessment. A history of peripheral vascular disease could raise the risk of
complications from arterial line insertion. Skin changes, scars, sores,
discoloration, swelling, excess warmth or swelling etc., could indicate the
presence of peripheral vascular disease.

Palpation, capillary refill and the Allen test are necessary steps to determine
the suitability of a limb for insertion of an arterial line. The Allen test
determines the patency of the arm's radial and ulnar arteries. The Allen test
must be done prior to arterial line insertion, in order to reduce the risk of
ischemia due to arterial occlusion.
Central Venous Pressure
Monitoring
Central venous pressure is considered a direct measurement of the blood
pressure in the right atrium and vena cava. It is acquired by threading a central
venous catheter (subclavian double lumen central line shown) into any of
several large veins. It is threaded so that the tip of the catheter rests in the
lower third of the superior vena cava. The pressure monitoring assembly is
attached to the distal port of a multi-lumen central vein catheter.
➢ The CVP catheter is an important tool used to assess right ventricular
function and systemic fluid status.

➢ Normal CVP is 2-6 mm Hg.

➢ CVP reading is elevated by :

❑ over hydration which increases venous return
❑ heart failure or PA stenosis which limit venous outflow and lead to
venous congestion
❑ positive pressure breathing, straining,
➢ CVP decreases with:
❑ hypovolemic shock from hemorrhage, fluid shift, dehydration
❑ negative pressure breathing which occurs when the patient
demonstrates retractions or mechanical negative pressure which is
sometimes used for high spinal cord injuries.

➢ The CVP catheter is also an important treatment tool which allows for:
❑ Rapid infusion
❑ Infusion of hypertonic solutions and medications that could damage
veins
❑ Serial venous blood assessment
Primary Factors Affecting
CVP
✓ Circulating blood volume
✓ Right-sided pump function
✓ Degree of peripheral vasoconstriction

The normal values for CVP vary with the use of different
equipment, a range of 5-15 cm of water is acceptable it is
important to note the changes rather than the numerical values.
 Pulmonary Artery Catheter

The purpose of this catheter is to:

❖ Indirectly measure the left ventricular end-diastolic pressure.
❖ Evaluate the hemodynamic treatments and measure the
patient’s hemodynamic status.
❖ Draw mixed venous blood samples.
❖ Obtain central vascular pressures measurements.
❖ Measure cardiac output.
PULMONARY ARTERY PRESSURE

▪ These pressure are measured with a special balloon tipped catheter (Swan-
Ganz catheter). The catheter is inserted into a vein like the subclavian.
▪ The balloon is inflated & carried by the blood flow into right ventricle then to
the pulmonary artery. The balloon is then deflated and the tip of the catheter
is left floating in the pulmonary artery.
▪ The other end of the catheter is connected to to a low compliance tubing
attached to a transducer. The transducer converts the pressure that it senses
through the catheter to an electrical signals that are displayed into the
monitor
PULMONARY ARTERY WEDGE PRESSURE

A patient without lungs or with pulmonary vascular disease PAP does not
accurately reflect ventricular failure so in this case PCWP should be obtain.
Done by inflating the balloon which is near the tip of the catheter, the
pulmonary artery then is occluded. This then blocks the communication
between the pulmonary artery and the lumen of catheter allowing the
pressure that is ahead of the occluded artery to be transmitted through
the catheter, this now become the PCWP because it is identical to the left-
atrial pressure.
There are certain indications for using a PA catheter.
o Shock such as septic and hypovolemic shock.
o Evaluation of fluid volume status.
o Evaluation of cardiac output in complex medical situations.
o Prophylactic insertion for high-risk surgeries
Components of the Pulmonary Artery
Catheter
CARDIAC OUTPUT AND CARDIAC
INDEX MONITORING
Pulmonary artery catheter allows too to measure cardiac output and
cardiac index. A thermistor (sensor to measure temperature) is located at
the tip of the catheter and attached to a wire that runs through a catheter
is attached to cardiac output computer. Iced or room-temperature saline
solution is injected into the right atrium, the solution travels with the
blood into the pulmonary artery. The thermistor senses the changes in the
temperature and the data are calculated by the computer to calculate the
CO and cardiac index. This thermistor can also measure the core body
temperature.
The proximal port, commonly termed the CVP port, is used to measure right
atrial or central venous pressure. It is also used for medication infusion and fluid
boluses for cardiac output measurement.

The distal port is used for PA pressure measurements and PCWP measurements
when the balloon is inflated. Mixed venous blood gases can also be drawn from
this port. The balloon port which is located at the tip of the catheter is inflated
with a small amount of air (less than 1.5cc). When inflated, this balloon allows
the catheter to float into a pulmonary artery branch vessel. This is referred to as
a wedge position. This position allows pressure measurements to be made that
indirectly reflect left ventricular end diastolic pressure.
The thermistor port is connected to the patient’s monitor via a cable
and allows the display of continuous temperature readings. These
temperature readings are essential to calculate cardiac output
measurements. The actual thermistor is located just proximal to the
balloon. In order to determine the cardiac output value, cool injectate is
delivered rapidly through the proximal port of the PA catheter. A
temperature curve is plotted over time as the cool inject causes the
pulmonary artery temperature to fall. It then rises back to the previous
core temperature as warm blood continues in circulation.
CVP MONITORING
PROCEDURE
CVP CAN BE MEASURED
1. a transducer
2. use of manometer attached to the intravenous fluid
Phlebostatic Axis
• Phlebostatic axis – located at the right atrium at the
mid axillary line about one-third of the distance from
the anterior to the posterior chest wall in the fourth
intercostals space.
Special Consideration:
• CVP reading the patient must always be positioned in the same
place, relative to the right atrium when measurement is
performed.
• Patient lie in supine position without a pillow
• Position should be documented to ensure that all nurses caring
for the patient perform measurement in the same manner.
Complication:
• Infection
• Air embolism
Equipment
• Sterile gloves
• Manometer set/transducer
• Marking pen indelible ink
• Mask
• Normal Saline
• Tape
• IV tubing
• Stopcock
PROCEDURE:
ACTION RATIONALE
1. Wash hands Reduces transmission of
microorganism

2. Wear gloves and mask. Practice aseptic technique

3. Gather equipment needed. Maximizes efficiency and

minimizing the chance of
breaking sterility once started.
 PROCEDURE:
ACTION RATIONALE
4. Position the client in a supine or flat The manometer should always be zeroed
position if this is not tolerated and the at the “X: to minimize variance in
client is place in semi-fowlers position. measurements.
Take all measurements at the same angle.
Mark the right atrium with an “X” using
indelible ink pen(phlebostatic axis) to
identify the level of the atrium
5. Connect the IV fluid to a three-way Forces air out of the stopcock. Fluids with
stopcock and flush the other two glucose are sticker and should be avoided.
ports.(Normal Saline)
PROCEDURE:
ACTION RATIONALE
7.Connect the CVP tubing from Establishes IV line from Normal
the client to the second side Saline to CVP catheter.
port of the stopcock
8.Allow Normal Saline to drip Establishes that CVP line is
rapidly into client for a few patent. Fluids must flow freely
seconds, with stopcock close to for reading to be accurate.
manometer
 PROCEDURE:
ACTION RATIONALE
9.Turn stopcock off to client and The normal CVP reading varies
fill manometer with Normal from 5 to 12 cm of water.
Saline to the 20-cm mark or
above the anticipated reading.
10.Hold manometer at the System is open from the
phlebostatic axis and turn the manometer to the patient.
stopcock off to the Normal
Saline
PROCEDURE:
ACTION RATIONALE

11.Watch as the fluid falls in the The fluid stabilizes at a level

manometer. Take the CVP equal to the pressure in the
reading when the fluid central veins or right atrium. If
stabilizes. the fluid level fluctuates with
the client’s respirations, take the
reading at the end of client’s
respiration.
12.Turn the stopcock off to the Re-establishes fluid flow from
manometer. the IV to the client.
 PROCEDURE:
ACTION RATIONALE
13.Store the manometer in an The top of the manometer is
upright position(usually hanging open to the air. If the manometer
from the IV pole) to prevent air is not properly stored
bubbles from entering the fluid contaminations or air can enter
column or the client and to the manometer and be flushed
prevent contamination of the into the client.
manometer.
14.Wash hands Prevents the spread of
microorganism.
15.Document reading Provides continuity of care.
THANK
YOU