Professional Documents
Culture Documents
Function of CV
system is to deliver
O2 to tissues
Heart
Arteries
Veins
Volume
Hemodynamic monitoring
evaluates the ability of CV system
to deliver blood flow to tissues:
Determinants of CO
Blood volume
Vascular tone
Lungs job:
oxygenate
blood
Tissues job:
extract and use O2
Hemodynamic Data:
What do we need to know?
CO = HR X SV
BP = CO X SVR
TISSUE OXYGENATION
Distal port
Proximal (CVP) tail
Proximal port
Balloon port
PWP
CVP
PA Catheter
PVR is a calculated value
based on mean PA pressure
and PWP and is used as a
clinical indicator of RV
afterload
PVR
SVR
Cardiac Output
Can be measured by intermittent injection or
continuously
Normal CO = 4-8 liters/minute
CO should be indexed to patients size by
dividing CO by BSA
- Normal CI = 2.5 -4.5 L/min/M2
Hemodynamic
Monitoring:
Getting Accurate Data From a
Pulmonary Artery Catheter
Electrical System
Transducer: contains fine wires that move
back and forth with pressure changes and
convert the pressure to an electrical signal
that is sent to the monitor. Must be filled with
fluid and be bubble-free to accurately transmit
pressure.
Connecting cable: connects the transducer
to the bedside monitor and transmits the
electrical signal to the monitor.
Monitor: converts electrical signal to a
waveform and displays it on the screen.
Air bubbles
Tubing too long
Loose connections
Loss of pressure on bag
Catheter patency
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Leveling
Stopcock used to zero must remain at
phlebostatic level regardless of patient position.
Leveling must occur with every reading
For every cm deviation from true phlebostatic
axis, pressures can change 1.86 mmHg
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2-6 mmHg
15
Normal CVP
ac v
CVP
a
v
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Swan Insertion RA to RV
RV
RA
30- Systolic
20100-
Diastolic
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Normal RV Waveform
Identify RV systolic and diastolic pressure.
RV Pressure = 38/10
RV Pressure
Identify RV Systolic and Diastolic Pressure
3020100RV Pressure = 22/7
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Swan Insertion RV to PA
PA
RV
Systolic
Diastolic
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PA Waveform
PA
PWP
20
8-12 mmHg
PWP Waveform
Identify a and v waves and state the value of the PWP
1050-
PWP = 6 mmHg
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Normal PAW
20-
a
100-
v
a
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End Expiration in
Spontaneous Breathing
Inspiration is a negative dip in waveform.
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Spontaneous Breathing
Find end-expiration.
Where would you read the PA and the PAW pressure?
PA to PAW
Spontaneous Breathing
a v
PA pressure = 58/32
PAW pressure = 25
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End Expiration in
Ventilator Breath
Inspiration is a rise the in waveform
Ventilator Breaths
a v
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Goals of Hemodynamic
Monitoring
Determine magnitude of pulmonary
congestion (LV preload)
Assess peripheral perfusion
(forwards flow)
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Forwards flow:
CI/SV, skin temp (warm or cold)
10 12 14 16 18 20 22 24 26 28 30 32 34 36
Forwards flow:
CI/SV, skin temp (warm or cold)
Changing Preload: moves patient along the curve they are on.
5
4
3
2
1
0
2
10 12 14 16 18 20 22 24 26 28 30 32 34 36
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Forwards flow:
CI/SV, skin temp (warm or cold)
10 12 14 16 18 20 22 24 26 28 30 32 34 36
10 12 14 16 18 20 22 24 26 28 30 32 34 36
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PWP
18 20 mmHg
20 25 mmHg
25 30 mmHg
> 30 mmHg
Pulmonary Congestion
Moderate Congestion
Severe Congestion
Pulmonary Edema
The value for PWP that best separates patients with and
without pulmonary congestion is 18 mmHg
Physical assessment: lung sounds dry or wet.
Relationship of CI to Clinical
Signs of Hypoperfusion
CI
2.7 4.7
2.2 2.7
1.8 2.2
< 1.8
Clinical State
Normal
Subclinical depression
Clinical hypoperfusion
Cardiogenic shock
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Forwards flow:
CI/SV, skin temp (warm or cold)
No pulmonary congestion:
PWP < 18; Dry lungs
No hypoperfusion:
CI > 2.2; Warm skin
Pulmonary congestion
PWP > 18; Wet lungs
No hypoperfusion
CI > 2.2; Warm skin
2
1
No pulmonary congestion
PWP < 18; Dry lungs
Hypoperfusion
CI < 2.2; Cold skin
Pulmonary congestion
PWP > 18; Wet lungs
Hypoperfusion
CI < 2.2; Cold skin
0
2
10 12 14 16 18 20 22 24 26 28 30 32 34 36
Mini Case #1
Forwards flow:
CI/SV skin temp (warm or cold)
0
2
10 12 14 16 18 20 22 24 26 28 30 32 34 36
30
Mini Case #2
Forwards flow:
CI/SV skin temp (warm or cold)
A patient with acute anterior MI returns from the cath lab with a
PA catheter in place following two stents to the LAD coronary
artery. The first set of numbers looks like this: BP 100/60, HR =
106, CO = 3.0, CI = 1.8, CVP = 10, PWP = 30, SVR = 1680.
5
0
2
10 12 14 16 18 20 22 24 26 28 30 32 34 36
Mini Case #3
Forwards flow:
CI/SV skin temp (warm or cold)
A 20 year old motor cycle accident victim with multiple trauma is on the
ventilator in the ICU and becomes hypotensive and febrile. His BP is 80/45, HR
120 in sinus tachycardia, skin is hot and dry. A PA catheter is inserted and these
are the numbers: CO = 10.4, CI = 5, CVP = 4, PWP = 10, SVR = 404.
5
0
2
8 10 12 14 16 18 20 22 24 26 28 30 32 34 36
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Mini Case #4
Forwards flow:
CI/SV skin temp (warm or cold)
0
2
10 12 14 16 18 20 22 24 26 28 30 32 34 36
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Forwards flow:
CI/SV skin temp (warm or cold)
10 12 14 16 18 20 22 24 26 28 30 32 34 36
Forwards flow:
CI/SV skin temp (warm or cold)
1
0
2
10 12 14 16 18 20 22 24 26 28 30 32 34 36
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5
4
3
2
1
0
2
10 12 14 16 18 20 22 24 26 28 30 32 34 36
Forwards flow:
CI/SV skin temp (warm or cold)
V+I
3
2
0
2
10 12 14 16 18 20 22 24 26 28 30 32 34 36
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Normal Hemodynamics
Backwards Failure
In sepsis or trauma:
? Inotropes
3
2
1
Forwards Failure
Volume (if PWP low)
Inotropes (if PWP adequate)
Pacing (if HR low)
IABP
0
2
Diuretics
Venous Dilators
Shock Box
Afterload reduction (if BP adequate
and SVR high)
10 12 14 16 18 20 22 24 26 28 30 32 34 36
Mini Case #2
Forwards flow:
CI/SV skin temp (warm or cold)
A patient with acute anterior MI returns from the cath lab with a
PA catheter in place following two stents to the LAD coronary
artery. The first set of numbers looks like this: BP 100/60, HR =
106, CO = 3.0, CI = 1.8, CVP = 10, PWP = 30, SVR = 1680.
5
0
2
10 12 14 16 18 20 22 24 26 28 30 32 34 36
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Mini Case #2
Is he a candidate for
afterload reduction?
Yes: BP is reasonable
and SVR is high
0
2
10 12 14 16 18 20 22 24 26 28 30 32 34 36
Forwards flow:
CI/SV skin temp (warm or cold)
Diuretic
Inotrope
0
2
10 12 14 16 18 20 22 24 26 28 30 32 34 36
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Therapy
Volume
(Subset III)
Cardiogenic
Inotropes
Preload
reduction
Afterload
reduction
(Subset IV)
Vasodilated
Volume
Vasopressors
(Subset I early)
(Subset IV late)
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