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HEMODYNAMIC MONITORING

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  1. HEMODYNAMIC MONITORING Martha Richter, MSN, CRNA mlr/2007

  2. OBJECTIVES • The student will review • cardiac and pulmonary considerations for invasive monitoring • Procedural considerations for invasive monitoring • Waveform identification related to invasive monitors mlr/2007

  3. EVALUATING THE PATIENT – A REVIEW • PULMONARY • Breath sounds • Level of mentation • Oxygenation • cyanosis • Edema • Chest circumference mlr/2007

  4. EVALUATING THE PATIENT - CARDIOVASCULAR • Pain issues • Skin color/temp • Weakness/fatigue • Urinary output • HR, rhythm, • JVP mlr/2007

  5. EVALUATING THE PATIENT • JVP • supine • Sl distention • Head up • No distention mlr/2007

  6. NONINVASIVE MONITORS • Routine • NIBP • EKG • Pulse ox • Temperature • Urine mlr/2007

  7. CARDIAC FUNCTIONAL ANATOMY • Low pressure system • Right heart • Pulmonary • High pressure system • Left heart • Systemic mlr/2007

  8. CARDIAC CONDUCTION • Atrial depolarization • SA nodethru atria • Ventricular depolarization • AV nodebundlespurkinjes • Atrial repolarization • Ventricular repolarization mlr/2007

  9. MECHANICS OF CARDIAC CYCLE • Isovolumetric phase • Active-requires energy • Ventricular ejection (rapid) • Ventricular ejection (reduced) • Isovolumetric relaxation • Rapid ventricular filling • Beg when ventric pressure <atrial pressure • End diastole = atrial kick mlr/2007

  10. WHAT ABOUT CARDIAC OUTPUT? • CO=HR X SV mlr/2007

  11. CARDIAC OUTPUT • Determined by • Preload • Afterload • Contractility • EF=SV/EDV X 100 mlr/2007

  12. FRANK-STARLING • Described in early 1900s • Relationship between myocardial muscle LENGTH and force of contraction • More diastolic stretch = more ventricular vol = stronger contraction • True to a limit (physiological) mlr/2007

  13. FRANK-STARLING • Resting length affected by degree of preload • CO begins to fall in CHF b/o inc preload mlr/2007

  14. CARDIAC COMPENSATION • Contractility • HR • Arteriolar responses • Venuole responses mlr/2007

  15. INOTROPES • Sympathomimetic amines • Phosphodiesterase inhibitors • Calcium chloride • Digitalis glycosides • glucagon mlr/2007

  16. SYMPATHOMIMETIC AMINES • Catecholamines • Epinephrine • Norpinephrine • Dopamine • dobutamine mlr/2007

  17. NONCATECHOLAMINES • Ephedrine • Metaraminol • Phenylephrine • Methoxamine mlr/2007

  18. PHOSPHODIESTERASE INHIBITORS • Amrinone • Milrinone • 20X more potent than amrinone • aminophylline mlr/2007

  19. INOTROPES • Calcium Chloride • Glucagon • Digitalis • Slows HR, conduction • Inc contractility mlr/2007

  20. VASODILATORS • Nitroprusside • NTG • Phentolamine • Hydralazine • captopril mlr/2007

  21. WHAT IS PRELOAD? • End diastolic length of myocardial fiber(wall stress) • Amount of volume in ventricle at end diastole • Muscle wall compliance important factor • Normal ventricle:lge inc volume = small inc pressure • Stiff ventricle: small inc in volume = large inc pressure mlr/2007

  22. WHAT IS AFTERLOAD? • Pressure that has to be overcome by LV for ejection of ventricular volume • Resistance, impedance, pressure • SVR • PVR • Inc resistancedec contractility/SV mlr/2007

  23. AFTERLOAD • Volume of blood ejected • Size & thickness ventricular wall • Impedance of vessels mlr/2007

  24. DYNAMICS OF VENTRICULAR FUNCTION • Rate • Rhythm • Preload • Afterload • Contractility • Expressed as EF • SV/EDV • LVEF 60-70% • RVEF 45-50% • Heerdt, 2000 mlr/2007

  25. WHAT ABOUT CONTRACTILITY? • Inotropism • Shortening of muscle fibers without altering fiber length or preload • Effected by • ANS • Positive Inotropes • Acidosis (dec) • Negative inotropes (dec) mlr/2007

  26. ISSUES OF MYOCARDIAL O2 • Uses 65-80% • No direct method of measurement • Supply and demand • Disease states • May not be able to inc supply • May have greater demand • Poor reserve = ischemia/infarct risk mlr/2007

  27. CORONARY PERFUSION • Occurs during diastole • LV thick wall • Endocardium flow influence during systole • RV wall less thick • RCA and RV flow during systole • Diastolic pressure provides flow thru aortic root into coronaries mlr/2007

  28. WHAT ABOUT SVO2? • Mixed venous oxygen saturation • Reflect O2 reserve • Samples from PA catheter • <60% (nl 60-80%) • Dec O2 delivery • Anemia • Low CO states • Hypovolemia • Hypoxia mlr/2007

  29. DECREASING SVO2 • Also b/o O2 demand increase • Hyperthermia • Seizures • Pain • Shivering/agitation • Exercise • Burns • hyperthyroidism mlr/2007

  30. HOW DO WE INCREASE SVO2? • Increase O2 delivery • Decrease O2 demand mlr/2007

  31. INCREASE O2 DELIVERY • Increase FIO2 • Increase CO mlr/2007

  32. HOW DO WE DECREASE O2 DEMAND? • Hypothermia • Anesthesia • Neuromuscular blockade • Early stages of sepsis • Hypothyroidism • Shock states mlr/2007

  33. INVASIVE CARDIAC MONITORING • Swan-Ganz catheter • Developed 1960’s • Assess cardiopulmonary function • Cardiac disease • LV function • Valves • Issues of CHF, tamponade, cor pulmonale mlr/2007

  34. SWAN GANZ MONITORING • Pulmonary issues • ARDS/respiratory failure • Severe COPD • Complex fluid management • Shock • Sepsis • ARF • Burns mlr/2007

  35. SWAN-GANZ ADDITIONAL INDICATIONS • CABG/RECENT MI • AAA • Sitting cranis • Unstable sepsis • Liver tx/shunts • High risk OB • PE • Pts on IABP mlr/2007

  36. SWAN-GANZ RELATIVE CONTRAINDICATIONS • LBBB • WPW syndrome • Ebstein’s malformation • Tachyarrythmias • Hypercoagulation • Sepsis • Site of infection mlr/2007

  37. SWAN-GANZ CATHETER mlr/2007

  38. PLACEMENT GUIDELINES • What’s the distance to SVC/RA junction? • IJ 15-20 cm • SVC 10-15 cm • Femoral 30 cm • RAC 40 cm • LAC 50 cm mlr/2007

  39. PLACEMENT mlr/2007

  40. BALLOON PEARLS • 1-1.5 cc used to wedge • <1 cc=too far::pull back • Wedge time <10-15 sec • Never flush with inflated balloon • PCWP = LVEDP (normal heart) • PCWP = LV function • RA = RV function mlr/2007

  41. PLACEMENT mlr/2007

  42. PLACEMENT mlr/2007

  43. PLACEMENT mlr/2007

  44. WEDGE mlr/2007

  45. PCWP WAVEFORM • A=contraction • After QRS • C=closure mitral valve • May not see easily • V=atrial filling (MV closed) • Late T-P interval mlr/2007

  46. PCWP>LVEDP • Mitral stenosis • LA myxoma • PE • Mitral regurgitation mlr/2007

  47. PCWP<LVEDP • Decreased LV compliance • Stiff ventricle • LVEDP >25 mmHg • Aortic regurg mlr/2007

  48. PAD AND PCWP • If not = (1-4 mmHg) • Inc PVR • Cor pulmonale • PE • CHD Causing Pul HTN • Eisenmengers mlr/2007

  49. RA READING • High • RV failure • Tamponade • Pulmonary HTN • COPD • Chronic LV failure • Volume overload mlr/2007

  50. RA READING • Low readings • Hypovolemia • Sepsis • Cirrhosis • anemia mlr/2007