Basic Hemodynamic Monitoring Notebook

Notebook
Basic Hemodynamic Monitoring

Lesson 1: Basics of Hemodynamic Monitoring Systems
Lesson 2: Arterial Pressure Monitoring
Lesson 3: Central Venous Catheters
Lesson 4: Pulmonary Artery Catheters
Lesson 5: Cardiac Output Monitoring
Lesson 6: Oxygenation and Transport
Lesson 7: Pharmacological Management of Hemodynamics
Last Updated: November 2013
Inside:
• Module Outline
• Lesson Objectives
• Lesson Summary
• Lesson Resource Files
• Lesson Practice Pearls
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Module Outline
Module 4 - Basic Hemodynamic Monitoring
Lesson 1 - Basics of Hemodynamic Monitoring Systems

Topic 1: Basic Components Of The Hemodynamic Pressure Monitoring Systems
Topic 2: Obtaining Accurate Hemodynamic Values
Lesson 2 - Arterial Pressure Monitoring

Topic 1: Catheter Types And Insertion Techniques
Topic 2: Complications Or Arterial Monitoring
Topic 3: Waveforms And Clinical Applications
Topic 4: Direct Vs. Indirect Measurement Of Arterial Pressure
Topic 5: Obtaining Blood Samples
Topic 6: Arterial Catheter Removal
Lesson 3 - Central Venous Catheters

Topic 1: Catheter Types
Topic 2: Insertion Of Central Catheters – Sites And Techniques
Topic 3: Managing Central Venous Catheters
Topic 4: Waveform Analysis And Clinical Applications
Topic 5: Complications
Topic 6: Water Vs. Pressure Transducer Monitoring
Lesson 4 - Pulmonary Artery Catheters

Topic 1: Indications For PA Catheter
Topic 2: Catheter Types
Topic 3: Insertion
Topic 4: Managing And Troubleshooting PA Catheters
Topic 5: Waveform Analysis
Topic 6: Complications And Associated Problems
Topic 7: Clinical Applications
Lesson 5 - Cardiac Output Monitoring

Lesson 1: Factors Affecting Cardiac Output
Lesson 2: Methods Of Calculating CO
Lesson 3: Clinical Application Of CO
Lesson 4: Non-Invasive CO Monitoring
Lesson 6 - Oxygenation And Transport

Topic 1: Oxygen Supply And Demand
Topic 2: Types Of Catheters (SVO2, Scvo2)
Topic 3: Conditions Affecting Oxygen Monitoring
Topic 4: Clinical Applications
Lesson 7 - Pharmacological Management Of Hemodynamics

Topic 1: Managing Preload
Topic 2: Managing Afterload
Topic 3: Managing Contractility
Lesson 1
Basic Components of Hemodynamic
Systems
Included in this Lesson:
• Basic Components Of The Hemodynamic Pressure
Monitoring Systems
• Obtaining Accurate Hemodynamic Values
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Lesson Objectives Module: Hemodynamic Monitoring

Lesson: Basics of Hemodynamic Monitoring
Systems
Upon completion of this lesson you will be able to:
• Identify and describe the components of a hemodynamic monitoring

system
- Describe the basic elements of hemodynamic pressure monitoring

equipment.
- Identify mechanisms used to ensure accurate pressure measurements.

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Lesson Takeaway - Basics of Hemodynamic Monitoring Systems
Topic One: Basic Components of Hemodynamic Pressure Monitoring Systems
Introduction
In this lesson we look at the hemodynamic monitoring system itself which offers the clinician a relatively simple way of
measuring the dynamic conditions of the cardiovascular system at the bedside. We learn how to set up a hemodynamic
pressure monitoring system and explore the fact that with advances in electronics and computer systems, there have also
been advances in the monitoring of cardiovascular hemodynamics.
Blood Pressure
• Monitoring blood pressure is the most basic way to monitor a patient’s hemodynamic status.
• Can be done noninvasively using a sphygmomanometer and stethoscope or invasively using an arterial catheter and
electronic monitor
• If system is set up correctly, these BP values are highly reliable and valid:
• When measured noninvasively via a cuff, BP values depend on the detection of pulsations within the artery to
determine the systolic and diastolic values.
• When measured directly via a catheter placed inside the artery, BP values are taken directly from pressures detected
inside the vessel itself.
Pressure Monitoring Systems

• 2 basic types:
• Fluid filled monitoring systems (most common)
• Have become obsolete in the critical care unit because are easily contaminated (because of their open
nature) and only allow for intermittent readings
• Fiberoptic monitoring systems (newer)
Closed Fluid Filled Monitoring System

• The most commonly used form of hemodynamic monitoring system
• Is coupled with a transducer and connected to an amplifier/monitor for continuous readout of pressures in mmHg
Catheter for Pressure Monitoring

• Catheter is the device used to access the body cavity or vessel where pressures will be measured
• Different types are used based on hemodynamic parameter being measured.
• For measuring arterial pressure
• For measuring CVP
• While fluid filled pressure monitoring systems are usually used for measuring hemodynamic pressures, they can also
measure pressures from other parts of the body.
© 2008 American Association of Critical-Care Nurses (AACN). All rights reserved.

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• Note: Different standards exist for using the fluid filled pressure monitoring system to measure nonhemodynamic
pressures.
Hemodynamic Monitoring Kit

• Commercially available hemodynamic monitoring kits used by most facilities.
• Are an improvement from the non-disposable systems of the past
• Contain items needed for set-up:
• Low compliance • Transducer • Stopcocks
tubing • Flush device
Flushing to Maintain Patency of the Catheter

• Purpose of flush system and solution: Maintain patency of the catheter to which the hemodynamic monitoring system is
connected
• How accomplished: The flush solution bag is surrounded by an inflatable pressure bag maintained at 300 mmHg.
• Size of bag must match the size capacity of the inflatable pressure bag.
• All transducer flush systems are calibrated to deliver continuous flow at 3-5 ml/hr when pressure bag is properly
maintained (at 300 mmHg.) This constant pressure:
• Maintains continuous rate of flow through catheter, preventing occlusion
• Provides means of intermittent, rapid manual flushing of the catheter
• Provides way to test the waveform’s dynamic response (called “square wave testing.”)
Transducer Cable, Amplifier and Monitor

• The amplifier/monitor and cable transfer electrical signal from transducer to the over bed monitor display.
• The monitor can only interpret (and display) the signals it gets
• If proper setup/maintenance is absent, monitor’s readings may be wrong.
Strip Recorder
• Allows user to document the waveform on paper for further analysis
• Especially important when waveform has significant movement from baseline
• Most can record in single channel (one waveform per strip) or dual channel (2 waveforms per strip) - When analyzing
hemodynamic waves, select dual channel when available.

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Topic Two: Obtaining Accurate Hemodynamic Values
Introduction
Here we explore how to ensure that the hemodynamic values you get are accurate and that your monitoring system is
accurate.
Obtaining Accurate Hemodynamic Values

• Fluid in motion exerts “hydrodynamic” pressure. Pressures within the cardiovascular system do as well, except that due to
inertia, there is a lag between the actual force/pressure occurring and the recording of that force on the EKG.
• Therefore: Keep the tubing as short as possible. The shorter the tubing, the less the lag.
Hydrodynamic Pressure and Principles of Fluid in Motion

• Hemodynamic pressure waves: Complex waves of differing amplitude and frequency which, when combined, produce the
waveform ultimately viewed on the monitor.
• Essential to understand the factors affecting frequency response and to know how to correct it because when a
hemodynamic monitoring system is not functioning optimally, the waveform’s shape and amplitude will be distorted
and end result could be inaccurate treatment of patient.
Factor Affecting Frequency Response

• Factors that can have an effect on this frequency response:
• Excess tubing length
• Keep as short as possible.
• Never exceed 3-4 feet in length.
• An improperly-flushed transducer and monitoring system
• The transducer and monitoring system are fluid-filled and it is the fluid column within the tubing that transmits the
signal from patient to transducer. If improperly-flushed, there will be excess dampening and inaccurate results.
• Preventing/avoiding bubbles and compliant loose/flabby tubing since both can result in excess harmonics and an
overshoot or undershoot of hemodynamic values
• Do the priming of the tubing (to reduce bubbles) prior to inflating the pressure bag and examine stopcock
intersections to ensure that all air has been removed from the stopcock.
• Keep in mind that patients with hyperdynamic circulation produce waveforms that are an overshoot of actual
values.
• Keep in mind that patients with tachycardia also produce waveforms that overshoot values since tachycardia
increases the number of signals per minute being transmitted to the monitor.
• Be sure monitoring system’s dynamic response is accurate.

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Dynamic Response Testing

• Dynamic response test (“square wave test”) helps you evaluate whether your monitoring system’s dynamic response is
accurate.
• Should be done:
• Whenever assessing a patient • Anytime you suspect your values are not accurate
• Easy to do. Done by activating the fast flush device on the transducer for 1-2 seconds. Evaluate the “bounce back.”
• Actions of an optimally-damped system
• Actions of an over-damped system
• Actions of an under-damped system
Leveling the Transducer

• Required in order for hemodynamic measures to be accurate
• Transducer is leveled with patient’s right atria to a point at the patient’s fourth intercostal space, at the midaxillary point.
(This point is called the phlebostatic axis.)
Transducer Placement
• Using a leveling device, place transducer at a level horizontal with the phlebostatic axis.
• Any type of level fine, electric, laser or even simple carpenter’s level
• Never eyeball or estimate. Can result in large variation in your numbers.
• Transducer placed by positioning the air-reference stopcock at the same horizontal level as the phlebostatic axis.
• Some institutions place transducers directly on bed or on patient’s chest at phlebostatic axis.
• Many institutions mount transducer in a manifold on an IV pole at the bedside (instead of directly on bed or
patient’s chest.)
• In IV pole approach, important to relevel transducer whenever the head of the bed position is changed.
Effects of Position Changes on Hemodynamic Monitoring

• Being only one inch off from the correct level can change pressure readings by 2 mmHg! This can be difference between
treating and not treating a patient.
• A too-high transducer level produces too-low values.
• A too-low transducer level produces too-high values.
• Re-level the transducer every time you change a patient’s position.

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Zero Referencing
• After leveling transducer, we zero the transducer. This is done to ensure that pressures being measured are result of
patient’s hemodynamic system and not of atmosphere or fluid.
• Zeroing basically tells transducer to ignore the effects of:
• Weight of the atmosphere
• Weight of the fluid in the system
• 5 basic steps for zeroing a transducer:
• Level transducer.
• Turn stopcock nearest transducer off to patient and open to the capped stopcock port.
• Remove cap to stopcock port, opening it to air.
• Activate zero function key on monitoring device.
• When monitor indicates that system is properly zeroed, replace cap to stopcock port. Then turn stopcock back so
that it’s off to the cap and open to the patient.

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Troubleshooting Fluid-Filled Lesson: Basics of Hemodynamic Monitoring Systems

Monitory Systems Topic: Obtaining Accurate Hemodynamic Values
Hemodynamic Monitoring Troubleshooting Guide

Problem Cause Prevention Intervention
No waveform Stop cocks not open to Check stop cocks for proper Correct stop cock position.
on monitor patient monitoring position.
position.
Inappropriate zero. Zero the transducer Re-zero the transducer.

periodically per hospital
policy.
Scale for pressure Set pressure monitoring scale Check monitor to assure
being measured to appropriate level for appropriate level has been
incorrect. pressure being measured. set.
Clotted catheter. Keep flush bag inflated to Check flush bag to assure it
300mmHg is inflated properly.
Aspirate catheter if possible.
Follow hospital policy
regarding clearing of clotted
catheters. DO NOT
ATTEMPT TO FLUSH
FORWARD.
Faulty transducer. Change transducer.
No cable, cable not Check cable connections. Change cable, refer to

connected, monitor biomedical engineering.
malfunction.
Dampened Air bubbles in tubing / Flush system with gravity Flush bubbles from system.
waveform (over stopcocks. only. Check tubing and stop
damped) cocks carefully for air bubbles
prior to connecting.
Improper scale Utilize appropriate scale for Place scale at appropriate

selection the pressure being measured. level.
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Partial occlusion of Maintain pressure bag at ASPIRATE catheter
catheter &/or catheter 300mmHg, maintain adequate (NEVER FORWARD
tip. flush solution, follow hospital FLUSH before aspirating,
policy regarding the use of could dislodge clot material
anticoagulants in the flush into circulation). Reinflate
solution. pressure bag or replace
flush solution. Have patient
cough. Reposition catheter
(follow hospital policy.)
Leak in tubing / set. Tighten all connections. Check to assure all

connections are tight.
Readout values Transducer level too ALWAYS check level with Confirm level at phlebostatic
too high or too high (readouts too leveling device. axis.
low. low).
Transducer level too ALWAYS check level with Confirm level at phlebostatic
low (readouts too leveling device. axis.
high).
Improper zero. Periodically re zero the Check zero, rezero as

transducer. necessary.
Ringing / fling Excess tubing length Use non compliant tubing. Change tubing, shorten
or whip in or use of compliant Make sure tubing is less than length.
catheter. (under tubing. 4 feet from the catheter
damped) connection to the transducer.
Excess catheter Catheter may require

movement. repositioning, follow hospital
policy &/or consult MD.
Excessive stop cocks Keep inline stop cocks to a Remove excess stop cocks.
in system minimum.
Change in Catheter migration to a Reposition the patient.

waveform different location. Obtain a Chest x-ray.
configuration. Follow hospital procedure to
reposition the catheter if
necessary.
Loose connections in Tighten connections.

system.
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Electrical interference. Tighten all connections
between the transducer and
the monitoring system.
Move electrical equipment
with moving parts away
from the transducer.
Bleed back into Loose connections in NOTE: If blood gets into the Check & tighten all
tubing system. transducer, the transducer will connections.
need to be changed.
Stop cock turned off to Turn stop cocks off to

transducer (instead of patient when zeroing
to patient) when transducer.
opening to air.
Pressure bag deflated Check pressure bag

frequently to assure
300mmHg is maintained.
High Risk for Breaks in sterile ALWAYS maintain sterile If infection is suspected,
infection from technique technique. Keep stop cock contact MD to review
invasive lines. ports sterile and always antibiotic coverage, When
maintain sterility of stopcock discontinuing catheter,
ports. culture catheter tip.
Prolonged therapy Discontinue invasive catheters

when no longer needed.
Contaminated flush Change flush bags and

solution solutions per hospital policy.
Monitor for signs and

symptoms of infection
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The Essentials of Lesson: Basics of Hemodynamic Monitoring Systems

Hemodynamic Monitoring Topic: Basic Components of Hemodynamic
Practice Pearls

We will discuss the water manometer system briefly in the section on central venous
pressure monitoring. This system is used on occasion in areas where electronic
hemodynamic monitors are not available.
Catheter for Pressure Monitoring

You are measuring the pressures where the line TERMINATES! For example, a central
line may originate at the right internal jugular vein, but the catheter terminates at the
superior vena cava. Thus, any hemodynamic pressures obtained from that catheter
would be measuring the pressure in the superior vena cava or central veins (CVP).
Flushing to Maintain Patency of the Catheter

Once the tubing and all stopcock ports are flushed and fluid filled without air bubbles,
replace all the vented stopcock caps with the nonvented stopcock caps. This will
prevent any possibility of air entering the system.
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The Essentials of Lesson: Basics of Hemodynamic Monitoring Systems

Hemodynamic Monitoring Topic: Obtaining Accurate Hemodynamic Values
Dynamic Response Testing

Remember, when flushing a catheter, if you in anyway suspect clotting of the catheter
you must ALWAYS ASPIRATE the catheter prior to using the fast forward flush device.
Transducer Placement
Remember, the phlebostatic axis is on the patient’s chest. Every time you raise or lower
the head of the patient’s bed, the transducer will need to be releveled.
Zero Referencing
When removing the cap from the stopcock, care must be taken not to contaminate the
cap. You can do so by placing it on a piece of sterile gauze while zeroing, or you can
replace the cap with a new sterile one.
Lesson 2
Arterial Pressure Monitoring

• Catheter Types And Insertion Techniques
• Complications Or Arterial Monitoring
• Waveforms And Clinical Applications
• Direct Vs. Indirect Measurement Of Arterial Pressure
• Obtaining Blood Samples
• Arterial Catheter Removal

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Lesson: Arterial Pressure Monitoring
• Describe the elements of and nursing considerations for arterial pressure

monitoring
- Discuss indications and contraindications for Arterial Catheters
- Identify arterial pressure catheter types and nursing considerations for

insertion.
- Identify arterial pressure catheter types and nursing considerations for

insertion
- Discuss nursing care of patients with an arterial pressure catheter
- Describe complications and troubleshooting measures of arterial

pressure catheters.
- Identify the components of the arterial pressure waveform
- Discuss difference between direct and indirect arterial pressure

monitoring and nursing implications.
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Lesson Take-away – Arterial Pressure Monitoring
Topic One: Catheter Types and Insertion Techniques
Introduction
In this lesson we explore arterial pressure monitoring, one of the most common forms of invasive pressure monitoring and a
common invasive procedure among the critically ill. We learn about commonly used arterial catheter insertion sites and look
at different arterial catheter types and the insertion techniques. We also explore the complications you may encounter with
an arterial line. We analyze and discuss some different arterial waveforms and review arterial line blood sampling removal.
We also briefly discuss the difference between direct and indirect blood pressure monitoring.
Direct Arterial Pressure Measurement

• The type of blood pressure monitoring used when a procedure or the patient’s condition requires that blood pressure be
monitored with the greatest of accuracy.
• Following cardiac surgery or other high-risk surgeries
• When patient is hypotensive (systolic blood pressure less than 90 mmHg) and requires medications such as
vasopressors to support and maintain the blood pressure
• When ready access to blood samples (for lab tests or for arterial blood gases) is needed
Arterial Catheter
• Catheter inserted into an artery • Arterial sites used
Informed Consent must be obtained

• Informed consent must first be obtained.
• Physician/nurse needs to be experienced inserting catheter and familiar with catheter and associated equipment
• 90% of all arterial catheters inserted in either radial or femoral artery
Radial Artery Placement

• Circulation of hand by radial and ulnar arteries
• Some have poor flow through ulnar artery
• If radial artery becomes cannulated, dramatic loss of blood flow, tissue ischemia, an loss of hand possible.
• If inserting catheter into the radial artery, use Allen’s Test.

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Allen’s Test
• Assesses the adequacy of blood flow and perfusion through ulnar artery
• Performed by compressing both the radial and ulnar arteries at wrist
• Use nondominant hand
• 2 Steps
Pressure Monitoring System Setup
• Needs to be done prior to catheter insertion
• Includes setting up transducer system, flush solution and pressure bag should be set up at the bedside.
• Process of set-up
Arterial Catheter Insertion

• Usually an arterial catheter kit is used but sometimes individual components are gathered at bedside.
• Steps of insertion same for both:
• Sterile gloves and catheter kit
• Locate artery and insert
• Connect to pressure monitoring system
• Suture catheter in place
• Sealing and applying sterile dressing
Referencing Catheter to the Phlebostatic Axis

• Next step is to reference the catheter to the phlebostatic axis and zero the system according to the procedure for the
bedside monitor.
• Verify integrity of waveform and print hard copy.
• Record the systolic, diastolic, and mean arterial pressures.
Advantages vs. Disadvantages of Using the Radial Artery

• Advantages
• Easy to locate • Accessible during most types of • Immobilization of the site fairly
• Cannulated surgery easy and comfortable for patient

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• Disadvantages
• Complications can result from prolonged use
• Thrombus formation possible
• Cannulation of artery requires smaller catheter which can cause waveforms that “over-shoot” giving inaccurate/overly
large results
• Potential injury to adjacent nerves with hematoma formation
Femoral Artery Catheter

• Done when radial artery may not be accessible or if a large bore catheter needs to be used.
• Done most often in cardiac catheterization lab or in surgery. If done in ICU, the steps followed include:
• Site preparation by physician
• Catheter insertion into femoral artery
• Nurse immediately connects catheter to pressure monitoring system and flushes catheter. After catheter sutured
into place and sterile dressings applied, nurse writes write date, time, and initials on dressing.
Advantages vs. Disadvantages of Using the Femoral Artery

• Advantages:
• Pressure line remains patent longer with fewer complications.
• Less distortion of waveform
• Because larger than radial artery, can accommodate a larger catheter
• Disadvantages:
• Requires patient remain supine • Cannot be used if intra-aortic balloon pump is to be
• Difficult to immobilize if patient agitated or restless used
Brachial Artery an Alternative to the Radial Artery

• Larger than radial artery and easier to locate and cannulate
• May be artery of choice if radial artery cannot be cannulated
• Disadvantages:
• Creates difficulty immobilizing arm and discomfort for patient since it’s located at elbow
• The possibility for thrombus material from the catheter to dislodge and impair blood flow to the lower arm/hand.

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Axillary Artery Catheter

• Arterial catheter inserted into the axillary artery only when/if:
• Other arterial access may cannot be used • Severe peripheral vascular disease present
• Produces waveform similar to aortic waveform; pressure closely correlates with central aortic pressure.
• Must be careful to avoid introducing air or thrombus material into the system when flushing catheter or obtaining blood
samples.
• Main disadvantage: Cannulation technically difficult; requires arm to be rotated, abducted, and extended upward to level
of shoulder.
Topic Two: Complications of Arterial Pressure Monitoring
Introduction
Here we look at the infrequent, but possible complications that can occur with arterial pressure monitoring.

• Common complications of arterial pressure monitoring:
• Peripheral embolization • Retroperitoneal bleeding
• Air embolus • Thrombosis of effected artery
• Bleeding around catheter insertion site • Vascular insufficiency
• In cases where femoral artery used, bleeding in
surrounding tissues
Patient Safety
• Patient safety issues related to arterial pressure monitoring:
• The chance for accidental administration of medication through arterial line
• Blood loss due to stopcock turned wrong way
Topic Three: Waveforms and Clinical Applications
Here we examine waveforms in detail.

Systemic Arterial Waveform
• A rapid upstroke and rounded peak followed by a rapid downstroke
• Notch observed on the rapid downstroke is called the “dicrotic notch.”

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• After dicrotic arch, the fall in waveform pressure is smooth and progressive (called the reflection wave) during diastole until
the next systolic upstroke.
Measuring the Systemic Arterial Waveform

• To measure the systemic arterial waveform, locate and measure the peak systolic and end-diastolic values using the
measurement scale to the left of the waveform.
Using the ECG as a Reference

• Arterial peak systole and end-diastole can be identified using the ECG.
• End-diastole occurs simultaneously with the end of the QRS complex.
• Peak systole occurs after the QRS.
• Then, as before, measure the systolic and diastolic pressure using the scale.
Waveform Morphology Considerations

• The arterial pressure waveform shape and value changes depending on measurement site.
• The farther away the site from the aorta:
• The more peaked the systolic portion of waveform and the higher amplitude
• The less distinct the dicrotic notch (often absent in femoral artery waveforms)
• The greater the delay following the QRS complex
Normal Variations in Pressure Waveform Contour and Value

• Radial artery pressure values are higher than aortic pressure values, and femoral artery values are higher than both radial
and aortic.
• Therefore, getting a low pressure reading is more worrisome in some cases than in others.
• Example: A femoral artery pressure of 100/50 mmHg would be more worrisome than a radial artery pressure of
the same amount.

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Pressure at the Tip of the Catheter

• Important to remember that the pressures recorded here (at tip of catheter) do not change based on site of monitoring.
They (the mean arterial pressure) are actual and will remain same, regardless of site of monitoring.
Atrial Fibrillation
• Often associated with variation in amplitude of the arterial systolic waveform
• The longer the R to R interval, the more time the ventricle has to fill, and therefore the larger stroke volume it ejects.
• Therefore, peak systolic pressure is higher in the beat terminating the longer R to R interval.
Topic Four: Direct vs. Indirect Measurement of Arterial Pressure
Introduction
Here we explore the fact that noninvasive (cuff) blood pressure and direct arterial pressure are not the same.
Indirect vs. Direct Arterial Pressure Measurement

• The two are often assumed to be the same, but they don’t always match up.
• Reasons they are not the same
• Reasons why they don’t always match up.
• The amount they differ:
• In normal patients, direct arterial pressure usually 2-8 mmHg higher than cuff pressure.
• In critically ill patients, direct arterial pressure is often 10-30 mmHg higher than the cuff pressure, and differences
of 50-60 mmHg between the two have been reported.
Variations in Configuration of Arterial Waveform

• Variation in the arterial waveform often due to changes in physiologic processes rather than to system error. However, if
you question accuracy, be sure that:
• Blood can blood be drawn from the catheter
• The system can be zeroed
• There is a mechanism to keep the catheter clear between the pressure source and the transducer
• The waveform is dependable

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Topic Five: Obtaining Blood Samples
Introduction
Here we look at both open and closed systems for drawing blood for lab tests.
Ready Access to Draw Blood

• Provided by arterial catheter
• Two types of systems for blood sampling from an arterial line:
• Open
• Closed
• Procedure for using Open system
Closed System
• Highly recommended because:
• Reduces likelihood of contamination or introduction of bacteria into system
• Contributes to blood conservation since no need to discard aspirated solution/blood
• Procedures for using closed system
Topic Six: Arterial Catheter Removal
Here we look at the timing and steps of removing the arterial catheter.
Arterial Catheter Removal
• Done when it is no longer required for continuous arterial pressure monitoring or frequent blood gas samples
• Steps:
• Remove dressing
• Aspiration of blood
• Apply pressure
• Pressure dressing

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Catheter Placement Lesson: Arterial Pressure Monitoring

Topic: Catheter Types and Insertion Techniques
Catheter
Placement Advantages Disadvantages
Radial Artery • The artery is easy to locate • Prolonged use may lead to
and cannulated. complications such as vascular
• The artery is accessible occlusion.
during most types of • Thrombus formation may occur
surgery. occluding the catheter.
• Immobilization of the site is • Cannulation of the artery
fairly easy and comfortable requires a smaller catheter
for the patient. which can contribute to “over-
shoot” of the waveform giving
an “over estimation” of the
systolic pressure.
• Potential injury to the adjacent
nerves with hematoma
formation.
Femoral Artery • Pressure line tends to • Increased risk of bleeding
remain patent longer with (larger artery) and
fewer complications. retroperitoneal bleeding.
• Waveform tends to be more • Requires the patient to remain
reflective of the actual supine to prevent bending the
aortic waveform, i.e., less catheter.
distortion. • Difficult to immobilize if patient
• Femoral artery is larger is agitated or restless.
accommodating a larger • Cannot use if an intra-aortic
catheter. balloon pump is to be used.
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Brachial Artery • The brachial arteries is • Location at the elbow creates

larger than the radial artery difficulty with immobilization of
and may be the artery of the arm and discomfort for the
choice if the radial artery patient.
cannot be cannulated. • Thrombus material from the
• Larger vessel and easier catheter could dislodge and
for the clinician to locate impair blood flow to the lower
and cannulate. arm and hand.
Axillary Artery • Occurs infrequently in • Care must be taken when
situations where other flushing the catheter or
arterial access may not be obtaining blood samples to
accessible or severe avoid introducing air or
peripheral vascular disease thrombus material into the
is present (example: system. This could potentially
Raynaud’s Disease). travel to the cerebral
• The artery is large and circulation.
closer to the aorta providing • Cannulation is technically
a waveform similar to the difficult requiring the arm be
aortic waveform. rotated, abducted and
• The pressure closely extended upward to the level of
correlates with the central the shoulder.
aortic pressure.
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Arterial Pressure Measurement Lesson: Arterial Pressure Monitoring

Topic: Direct vs. Indirect Measurement
Many clinicians will compare the noninvasive (cuff) blood pressure with the direct
arterial pressure assuming both are equal. A common practice is to state the arterial line
pressure correlates with the cuff pressure. Of interest is which set of numbers to accept
if they do not correlate.
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The Essentials of Lesson: Arterial Pressure Monitoring

Hemodynamic Monitoring Topic: Complications of Arterial Pressure
Monitoring
Practice Pearls

Factors Increasing the Risk for Complications Associated with Arterial Pressure
Monitoring
1. Large bore catheters (greater than 20 gauge unless placed in a femoral artery)
2. Inserted via Cutdown
3. Multiple puncture attempts
4. Frequent non-invasive blood pressure measurements on the same arm as the
arterial line
5. “Flush” system not working properly
6. Hypercoagulable states
7. Low cardiac output associated with markedly impaired peripheral blood flow
8. Failure to label the line as arterial
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Hemodynamic Monitoring Topic: Direct vs. Indirect Measurement of Arterial
Pressure
Indirect vs. Direct Arterial Pressure Measurement

The mean arterial pressure (MAP) will remain the same regardless of which technique
is used.
Variations in Configuration of Arterial Waveform

Important thoughts:
1. If the system is questioned, we should fix it!
2. We are monitoring trends and not treating an absolute number!
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Hemodynamic Monitoring Topic: Obtaining Blood Samples
Ready Access to Draw Blood

If an arterial blood gas blood sample is to be obtained, use a heparinized syringe. Pull
back on the plunger of the syringe very slowly being sure that there are no air bubbles
in the syringe. Air bubbles will distort the blood gas measurement. Fill the syringe with
approximately 4 to 5 mL of blood. Turn the stopcock off to the patient and disconnect
the syringe. Immediately cap off the syringe taking care to be sure no air has entered
into the blood sample. Immediately place the syringe on ice. Placing the syringe on ice
will extend the amount of time (up to 30 minutes) for the blood gas analysis to be
obtained otherwise the gas analysis should be run within 10 minutes. Most recommend
icing the sample.
Lesson 3
Central Venous Catheters

• Catheter Types
• Insertion Of Central Catheters – Sites And Techniques
• Managing Central Venous Catheters
• Waveform Analysis And Clinical Applications
• Complications
• Water Vs. Pressure Transducer Monitoring

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Lesson: Central Venous Catheters
• Discuss the indications for, contraindications of, and general management

principles for central venous catheters.
• Identify the characteristics of normal and abnormal central venous

pressure waveforms.
- Identify Central Venous Catheter types
- Identify Central venous catheter insertion sites and procedure
- Describe management and nursing implications of central venous

catheters
- Identify complications of central venous catheters
- Identify the components of the central venous pressure waveform
- Discuss the possible causes and management of increased and

decreased central venous pressures
- Interpret and discuss the difference between central venous pressures

obtained via water manometer and pressure transducer
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Lesson Takeaway – Central Venous Pressure Monitoring
Topic One: Catheter Types
Introduction
In this lesson we learn about various different central venous catheter types, insertion techniques, and sites. We also
explore how to manage CVP lines, analyze CVP waveforms, and handle some of the more common complications
encountered with CVPs. We also briefly discuss the use of water manometers to obtain a CVP reading and compare that
with values obtained using the pressure transducer.
Central Venous Pressure Monitoring First Used

• Central Venous Pressure (CVP) an important indicator of cardiac preload (venous return) and the intravascular volume
• CVP monitoring: Hemodynamic monitoring using central venous catheters
• Not routinely accepted until 1960s
• Considered first step in bedside invasive cardiac monitoring
• Because CVP was discovered to be unreliable for use in measuring left heart function, pulmonary artery catheter was
introduced 1970.
• Inflation of small balloon on tip of catheter allowed for indirect assessment of left heart pressures and function.
• Ultimately came to measure not just pulmonary artery pressure but CVP too
Central Venous
• Term “central venous” generally considered to be within the thoracic cavity
• CV pressure often used interchangeably with right atrial pressure (RAP) since the difference between the two is generally
insignificant clinically
• Indications:
• Fluid resuscitation
• Hemodynamic monitoring
• Medication administration
• Inability to access peripheral veins
• Dialysis
• Plasmapheresis
• Transvenous pacemaker placement
• Contraindications:
• Infection
• Trauma
• Venous thrombosis at the selected site

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Types of Central Venous Catheters
• A large-gauge single lumen catheter

•For rapid administration (often 1 liter per minute) of large volumes of fluid
• A multilumen catheter
• Can have 2, 3, or 4 ports; most commonly 3 (called a “triple lumen” catheter)
• Allows for simultaneous medication/fluid infusions as well as one port to be used for continuous CVP monitoring
• Each lumen must be flushed and capped prior to insertion.
• Use distal port to guide catheter into blood vessel.
Topic Two: Insertion of Central Catheters Sites and Techniques
Introduction
Here we discuss insertion points for a central venous catheter.
Catheter Insertion Points

• 3 possibilities:
• Subclavian vein
• Internal jugular vein
• Femoral vein.
• Consider patient’s individual circumstances to decide.
Accessing a Vein
• Done by performing one or the other of these:
• Cutdown
• An incision directly over the target vein
• Used only if/when the vein is undetectable
• Percutaneous insertion
• Into the vessel, introducing a needle attached to a syringe
• Blood is aspirated into the syringe.
• Can use either of two access systems or insertion techniques: -
• Seldinger technique
• Catheter-Over-Needle technique

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Venous Catheter Insertion Techniques

• Percutaneous insertion uses either of two access systems or insertion techniques: Seldinger technique (most common) or
Catheter-Over-Needle
• Details of Seldinger technique
Evidence Based Interventions

• When inserting a central venous catheter, use these evidence-based interventions for decreasing the possibility of
catheter-related blood stream infection:
• Pay diligent attention to hand hygiene.
• Use chlorhexadine skin antiseptic prep solution on insertion site.
• Use a large drape over patient in sterile fashion.
• Practitioner inserting catheter wears hat, mask, sterile gown, and gloves.
• Assisting practitioner wears the same.
• All staff in the room wear mask during insertion.
• Select the most optimal insertion site. Preferred insertion site for nontunneled catheters is subclavian vein.
• Review line necessity daily and promptly remove unnecessary lines.
Most Common Insertion Sites for Central Venous Catheters

• In the critically ill patient, most commonly used insertion sites for central venous catheters are:
• Subclavian vein
• Advantages
• Disadvantages
• Internal jugular vein
• Advantages
• Disadvantages
• Femoral vein
• Advantages
• Disadvantages

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Topic Three: Managing Central Venous Catheters
Introduction
Here we look at the management of the central venous catheter once it has been inserted.
After Insertion Catheter Procedures

• Management means taking steps to:
• Maintain catheter patency
• Aspirate
• Flush
• Secure catheter in place
• Verify catheter placement
• Prevent infection by daily assessing the need to continue using the catheter (since one way to prevent infection is
to remove it as soon as possible.)
Catheter Removal
• Proper technique crucial since during this procedure, patient at a very high risk for developing air embolus.
• Patient should remain in bed for at least 30 minutes following the removal of a central venous catheter from the internal
jugular vein or the subclavian vein.
• Removal of a femoral vein catheter involves a different procedure and requires placing the patient at bed rest for a longer
period time.
• Steps of removal
Topic Four: Waveform Analysis and Clinical Applications
Introduction
Here we look at how to analyze the waveform and obtain values.
CVP/RAP Waveform
• Components of a CVP/RAP waveform:
• Waveform • V Wave
• A Wave • X Descent
• C Wave • Y Descent

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Correlation of CVP/RAP Waveform with ECG

• Correct identification of the waves in the CVP/RAP waveform requires correlation with the patient's ECG.
• A wave (representing atrial systole) occurs approximately 0.08 seconds after the P wave of the ECG.
• C wave, if present, occurs at the end of the QRS complex and at the point where the QRS complex joins the ST-
segment.
• V wave occurs approximately 0.08 seconds after the T wave of the ECG.
Practice CVP/RAP to ECG

• To do this comparison/correlation of the CVP/RAP waveform and the ECG complex, you will need to:
• Print a dual channel strip (a hard copy of the ECG and CVP/RAP waveform on the same strip of paper)
• Follow these steps to mark the respective areas:
• On ECG, find P wave and draw straight line down towards the waveform. The A wave will follow the P
wave in about 0.08 seconds.
• On ECG, find the end of the QRS complex and, again, draw straight line down towards the waveform.
That point on the waveform will mark the onset of the C wave.
• On the ECG, find T wave and draw straight line down towards waveform. The V wave will follow the T
wave.
Elevated and Decreased CVP/RAP

• Normal right atrial pressure: 2-6 mmHg
• Causes of elevated CVP/RAP:
• Right ventricular failure
• Tricuspid valve disease: Stenosis or insufficiency
• Right ventricular failure
• Increased preload/Hypervolemia
• Pulmonary hypertension
• Cardiac tamponade
• Positive-pressure ventilatory support
• Adding positive end-expiratory pressure (PEEP) of 5 cm or more to the ventilator
• Causes of decreased CVP/RAP:
• Decreased preload/Hypovolemia
Mean Pressure of the A Wave

• The very final filling of the ventricle from the atrium occurs during atrial contraction (the A wave of the CVP/RAP
waveform). Therefore, to measure the final ventricular filling pressure indirectly using the CVP/RAP waveform, it is best to
use the mean pressure of the A wave.

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Measuring the Mean CVP/RAP Value

• Steps for measuring the mean CVP/RAP value:
• Locate the A wave within PR interval.
• Measure the top and bottom of the A wave, and average these two values. (Or draw horizontal line midway
through the A wave and measure this value as done on the latter part of the waveform.)
Topic Five: Complications
Introduction
Here we explore some of the complications associated with insertion of central venous catheters and with central venous
pressure monitoring.
Complication with Central Venous Catheters & Pressure Monitoring

• Bleeding
• Vascular erosions
• Arrhythmias
• Infections
• Fluid overload
• Thromboembolic complications
• Air embolism
• Perforation of right atrium or right ventricle
• Pneumothorax
Bleeding
• Is usually occult (not visible) Instead blood is in either the tissue or a body cavity.
• The reason that a chest x-ray following insertion is so important.
Vascular Erosion
• Rare but can occur any time after insertion of the catheter
• Patients at increased risk if hypertonic solutions being infused or if endothelial lining is friable.
• More common with Internal Jugular (IJ) or subclavian insertions

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Arrhythmias
• Occur when catheter tip is introduced into the right atrium or right ventricle.
• A central venous catheter inserted into subclavian vein or IJ may spontaneously advance into the right ventricle. The
arrhythmia occurs from the tip of the catheter touching the endocardial wall.
Nosocomial Infection
• All central venous catheters increase patient’s risk of developing a nosocomial infection and severe sepsis.
• Possible reasons for infection:
• Poor technique during catheter insertion
• Introduction/migration of the skin flora into the insertion site
• Contaminated tubing and pressure transducer/flush system.
• Use strict sterile technique when changing dressings, replacing tubing and flush solutions, or accessing the line for a blood
sample.
Thromboembolic Complications
• Occur with kink in catheter or when fluid flow through system is poor
• A blood clot can form at tip of the catheter. This blood clot could become dislodged during catheter repositioning or with
flushing.
• Most thrombi clinically silent
• Risk Factors for thromboembolic complications
• Hypercoagulability associated with:
• Myocardial infarction • Antithrombin
• Fever • Cancer
• Polycythemia • Estrogen therapy
• Vessel wall trauma (during insertion)
Topic Six: Water vs. Pressure Transducer Monitoring
Introduction
Here we explore the taking of pressure measurements via different methods-pressure transducer and water manometer.

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Central Venous Pressure Measurement Using a Pressure Transducer

• Pressure transducer takes pressure measurements.
• CVP/RAP measurement may be taken from proximal port of any of these:
• Pulmonary artery catheter
• Single lumen catheter or multilumen catheter CVP/RAP
• Lumen will be attached to a transducer-pressure monitoring system.
• The pressure monitoring system is referenced to the phlebostatic axis (fourth intercostal space and midchest.)
• Pressure readings taken at end-expiration
Water Manometer
• Before the advent of electronic pressure monitoring systems, water manometer systems were used to take pressure
measurements.
• Today, rarely used in critical care but sometimes used outside ICU for patients experiencing fluid shifts.
• Measurements are taken in centimeters of water pressure (cm H20).
Zero Point of Water Manometer

• When using water manometer, the water manometer is placed level with the phlebostatic axis (fourth intercostal space and
midchest.)
• Measurements are taken from the height of the water column in the manometer.
• Use this formula to convert a “cm H20” reading to mmHg:
• 1 cm H20 ÷ 1.36 = mmHg

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Preventing Catheter Related Lesson: Central Venous Pressure Monitoring

Bloodstream Infection Topic: Insertion of Central Catheters-Sites and
Techniques
Practice Alerts
The goal of the practice alerts is to help nurses and other health care practitioners carry their bold
voices to the bedside to directly impact patient care. Practice alerts are succinct, dynamic directives
from AACN that are supported by authoritative evidence to ensure excellence in practice and a safe and
humane work environment. Practice Alerts are short directives designed for easy reference.
AACN will issue practice alerts to:
• Close research/practice gap

• Provide guidance
• Standardize practice
• Identify/inform about new advances/trends
Recognizing that practice is dynamic, the Practice Alerts will be reviewed and updated as needed, and
can be accessed by going to: http://www.aacn.org/aacn/practicealert.nsf/vwdoc/pa2
Following is the current Practice Alert for Preventing Catheter Related Bloodstream Infection, but be
sure to check the link for the most up-to-date information.
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PREVENTING CATHETER RELATED BLOODSTREAM

INFECTION
Expected Practice:
; Cleanse hands with waterless cleaning solution or, if visibly soiled, with soap and water before
and after patient contact.
; Disinfect clean skin utilizing friction with an appropriate antiseptic (preferably 2% chlorhexadine)
before catheter insertion and during site care.
; Utilize full barrier precautions when inserting central venous access devices.
; Educate all staff inserting and caring for intravascular catheters, assess competency of same at
regular intervals, advocate adherence to standards of care.
; Replace peripheral IV sites in the adult patient population at least every 96 hours but no more
frequently than every 72 hours. Leave peripheral venous catheters in children until IV therapy
is completed, unless complications (e.g., phlebitis and infiltration) occur.
; Replace IV tubing at least every 96 hours but no more frequently than every 72 hours.
; When adherence to aseptic technique during intravascular catheter insertion cannot be
ensured (i.e. prehospital, code situation), replace the catheter soon as possible, but within 48
hours.
Supporting Evidence:
A substantial proportion of hospital-acquired infections result from cross-contamination from the
hands of healthcare workers. Alcohol-based hand rub, compared with traditional handwashing
with unmedicated soap and water or medicated hand antiseptic agents, may offer better results
because it requires less time, acts faster, and is less likely to irritate skin. Thus, the CDC
recommends the use of alcohol-based hand rubs between patient contacts as an adjunct to
traditional handwashing alone.
Chlorhexidine gluconate solutions utilized for vascular catheter site care reduce catheter related
bloodstream infections and catheter colonization more effectively than povidone-iodine solutions.
Moreover, 80% of resident and transient skin flora are found in the first five epidermal layers of
the skin. There is clinical evidence to support the efficacy of applying antiseptics with sufficient
friction to assure that the solution reaches into the cracks and fissures of the skin. There is no
evidence that supports use of traditional concentric prepping technique. Although a 2%
chlorhexidine-based preparation is preferred, tincture of iodine, an iodophor, or 70% alcohol can
be used. Allow any solution used to dry before the catheter is inserted.
Compared with peripheral venous catheters, CVCs carry a substantially greater risk for infection;
therefore, the level of barrier precautions needed to prevent infection during insertion of CVCs
should be more stringent. Maximal sterile barrier precautions (e.g., cap, mask, sterile gown,
sterile gloves, and full body sterile drapes) during the insertion of CVCs substantially reduce the
incidence of CRBSI compared with standard precautions (e.g., sterile gloves and small
drapes)1,3,2,10 There are some studies that demonstrate infection rates are lower when the
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subclavian site is used. Selection of central line insertion site, however, is based on patient risk
factors.
Healthcare workers who insert and care for intravascular devices should receive formalized
education and training in indications for intravascular catheterization, proper placement,
maintenance, and infection control. Educational programs focusing on central venous catheter
insertion and care have lead to a substantial decrease in cost, morbidity, and mortality
attributable to central venous catheterization. Ongoing education and reinforcement of
appropriate technique serve as a reminder of current best practices, and studies demonstrate
that consistent reinforcement of aseptic technique leads to decreased CRBSI.
Studies of peripheral intravenous catheters show that there is not a substantial difference in
phleblitis rates between catheters left in place 72 hours and those left in place 96 hours. There is
no evidence to support that routine replacement of central venous catheters is more effective in
decreasing blood stream infections than replacing central venous catheters as needed.
Studies show that IV tubing containing crystalloids can be replaced every 72 – 96 hours. If
monitoring using a transducer system, replace the transducer, tubing, flush device and flush
solution every 96 hours.
What You Should Do:

Ensure that your units have written practice documents such as a policy, procedure or standard
of care that include use sterile technique with full barrier precautions when central venous access
devices are inserted.
Ensure that your units have written practice documents such as policy, procedure or standard of
care that address frequency of peripheral IV site rotation and tubing change.
Establish a process for education and routine evaluation of all staff inserting and caring for
intravascular devices.
Review your unit’s rate of catheter related blood stream infection rate and if needed establish an
interdisciplinary team, including but not limited to staff nurse, advance practice nurse, infection
control nurse (officer), and a physician.
Develop a process for daily evaluation for need of any central venous catheters.
Need More Information or Help?

• Talk with a clinical practice specialist for additional information / assistance at www.aacn.org then
select PRN.
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Rhythm Strip and ECG Lesson: Central Venous Pressure Monitoring

Topic: Waveform Analysis and Clinical Applications
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Checklist Sample Lesson: Central Venous Pressure Monitoring

Topic: Complications
Central Line Procedural Checklist

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The Essentials of Lesson: Central Venous Pressure Monitoring

Hemodynamic Monitoring Topic: Catheter Types
Practice Pearls
Types of Central Venous Catheters

Central venous catheters can be used to obtain blood samples, administer different
medications simultaneously, administer total parenteral nutrition (TPN) and obtain CVP
measurements.
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Hemodynamic Monitoring Topic: Insertion of Central Catheters Sites and
Techniques
Evidence Based Interventions

Prior to insertion of any central venous catheter, including a pulmonary artery catheter,
collect all supplies including the sterile tray holding the catheter as well as sterile gown,
gloves and mask for the person inserting the catheter. Usually the tray containing the
catheter will contain a large sterile drape, the prep solution for cleansing the area as
well as a local anesthetic, syringes, needles, gauze dressings, and other supplies.
Most Common Insertion Sites for Central Venous Catheters

The subclavian approach should be avoided in any patient with a coagulopathy or
thrombocytopenia due to the inability to apply compression if the Subclavian artery is
punctured. One should never allow the system to be open. If the patient inhales, a large
amount of air could be “sucked” into the catheter and the vein resulting in an air
embolus.
The left IJ and left subclavian are often avoided because of the risk of puncturing the
thoracic duct, located at the junction of the left IJ and left subclavian vein. Puncturing
the duct can result in lymph fluid leaking into the pleural space causing a hydrothorax.
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Hemodynamic Monitoring Topic: Managing Central Venous Catheters
After Insertion Catheter Procedures

In many multilumen central venous catheters the brown port is the distal port. The distal
port should be used for CVP monitoring, blood administration, high-volume fluids and
medication administration. The blue port is the medial port and should be used for TPN
administration or medication administration. When inserting a central venous catheter, if
TPN administration is anticipated, the distal port should be used for medication
administration. The white port is the proximal port. This port should be used for blood
sampling, medication administration and blood administration. You will need to validate
these with the product used in your facility.
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Hemodynamic Monitoring Topic: Waveform Analysis and Clinical Applications
Elevated and Decreased CVP/RAP

In the critically ill patient, a low CVP/RAP may indicate hypovolemia. The physician may
order volume to be administered by IV to achieve a target CVP of 10 to 14 mmHg.
The reliability of the CVP/RAP reading to accurately reflect the intravascular volume is
limited by the compliance of the right ventricle. If the right ventricle becomes less
compliant (occurs with right ventricular failure and ischemia), the CVP/RAP will be
increased because more pressure is required to eject the RA volume into the RV. One
must always assess the patient’s entire clinical picture to determine the reliability of the
pressure measurement and intravascular volume.
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Hemodynamic Monitoring Topic: Complications
Bleeding
Always assess the abdominal girth as well as the softness of the abdomen. If
retroperitoneal bleeding is present, the abdomen will become very taught and the girth
will increase. Patients often will complain of severe back pain.
Nosocomial Infection
Most facilities have a central line “bundle” which consists of mandatory steps/processes
to be used during insertion of a central line. The purpose is to prevent a central line
infection. Ask about your hospital’s “central line bundle.”
Thromboembolic Complications
Avoid forceful flushing with a syringe which may cause the thrombus to become
dislodged.
Lesson 4
Pulmonary Artery Catheters

• Indications For PA Catheter
• Catheter Types
• Insertion
• Managing And Troubleshooting PA Catheters
• Waveform Analysis
• Complications And Associated Problems
• Clinical Applications
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Lesson: Pulmonary Artery Catheters

principles for pulmonary artery catheters.
• Identify the characteristics of normal and abnormal pulmonary artery

pressure waveforms.
- Identify various types of PA catheters, indications and

contraindications
- Describe PA catheter insertion procedure and nursing considerations
- Describe PA catheter insertion procedure and nursing considerations
- Describe management and nursing implications of PA catheters
- Identify complications of PA catheters and how to troubleshoot them
- Identify the components of the pulmonary arterial and pulmonary

capillary wedge pressure waveform
- Discuss the clinical applications of pulmonary artery pressure

monitoring
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Lesson Takeaway - Pulmonary Artery Catheters
Topic One: Indications for PA Catheter
Introduction
In this lesson we focus on the pulmonary artery catheter (PA catheter) and discuss types, insertion responsibilities, and
indications for use. For patients with a PA catheter, interpreting waveforms and documenting values, troubleshooting the
system, and assessing for complications are priorities.
Value of Pulmonary Artery Catheters

• The value of a PA catheter: A single catheter placed in the right heart can:
• Measure pressures directly in the right heart
• Measure pressures indirectly from the left heart.
• A continuous chamber is result of the opening of valves during diastole.
• In patients with normal pulmonary vasculature, mitral valve, and left ventricular function, the PAD and PAOP reflect the left
ventricular end-diastolic pressure.
• Left ventricular end-diastolic pressure important for evaluating left ventricular function/prognosis.
Challenges to Widespread Use

• History of pulmonary artery catheter
• Steady decline in use and a search for new methods of obtaining cardiac output have occurred since 1986 when a multisite
study denounced their use.
• Some of these newer and minimally to noninvasive methods for obtaining information to assist in management of critically
ill are looked at in next lesson.
Assessment of Cardiovascular Status

• Today, PA catheter generally used:
• In patients not responding well to traditional therapy
• For assessing cardiovascular status and response to therapeutic interventions in complicated myocardial
infarction cases like those where patient:
• Develops cardiogenic shock
• Develops congestive heart failure
• Has structural defects
-Acute ventricular septal defect
-Valvular abnormalities
-A right ventricular infarction
• Use in Cardiovascular context
• Use in Pulmonary context
• Use in Obstetric context
• Use in Monitoring

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• Fluid
• Perioperative
• Use in preventing/treating Shock
Topic Two: Catheter Types
Introduction
Here we explore different types of PA catheters.
Triple-Lumen Thermodilution Catheter

• First type of PA catheter available
• Thermistor near its tip to measure changes in core temperature
• 3 Lumens:
• One is at level of the right atrium and measures RAP and CO
• Second one terminates in the pulmonary artery and measures PAP
• Third one is also in the pulmonary artery and measures PAOP or wedge
PAOP obtained using the attached syringe to inflate balloon-tipped port with up to 1.5 mL of air.
Other Types of PA Catheters

• Four-lumen Thermodilution • Mixed Venous Oxygen Saturation • Pacing Thermodilution Catheter
Catheter Catheter
Topic Three: Insertion
Introduction
Here we look at insertion methods for a PA catheter.
Relative Contraindications
• No known absolute ones but relative ones are:
• Presence of fever, mechanical tricuspid valve, and anticoagulated state
• Patients with Wolff, Parkinson, White syndrome, and Ebstein malformation
• Have risk for tachydysrhythmias
• Closely monitor the ECG in patients with left bundle branch block.
• Have increased risk of complete heart block
• In case that heart block develops, emergent pacemaker insertion may be necessary.

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Equipment Preparation
• Nurse responsibility to prepare equipment including the pressure tubing system, transducer, and monitoring system
• To ensure accuracy, setting the scales for pressure tracing is important.
• Procedure for setting the scales
PA Catheter Insertion
• Gather and prepare supplies and equipment (steps):
• Infection prevention
• Gather supplies
• Connect
• Calibrate fiberoptics
• Check balloon
• Also vital to determine patient’s baseline cardiovascular, peripheral vascular and neurovascular status.
Assisting With PA Catheter Insertion

• May be inserted through subclavian, internal jugular, femoral, external jugular, or antecubital vein.
• Subclavian (instead of jugular or femoral) best for infection prevention
• Validation of PA catheter placement
• Done by waveform analysis
•Correct if a PAOP tracing exists when balloon is inflated and a PA tracing exists when balloon is deflated.
• Verified by chest x-ray.
• PA Catheter Specs
• Procedure
• Saline IV
• Steps of PA catheter insertion:

• Advance Catheter
• Inflate Balloon
• Distinct Waveforms
• Pressure Monitored
• Dual-channel Strip

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• Advance Catheter
Continuous PAP Waveform Monitoring

• PAP waveform requires continuous monitoring because catheter may become wedged in pulmonary artery or slip back into
right ventricle, leaving patient at risk for pulmonary infarction or ventricular dysrhythmias.
• Procedure for attempting a dislodge
• Bedside nurse should not advance a PA catheter.
Daily Inspection of the Catheter Insertion Site

• Catheter insertion site needs daily inspecting erythema, drainage, or swelling.
• Clean insertion site and apply an occlusive dressing.
Fluoroscopy or Chest x-ray to Confirm Catheter Position

• Catheter position requires confirmation by fluoroscopy or chest x-ray. (Chest x-ray also rules out pneumothorax and
kinking of the catheter.)
• Use a lateral chest film.
Topic Four: Managing and Troubleshooting PA Catheters
Introduction
Here we look at ways to get accurate readings, manage the PA catheter, and troubleshoot it when it’s not accurate or
functioning properly.
Patient Positioning
• Helps get accurate PA pressure measurements
• Position patient in supine position with the head of bed elevated from 0 to 60 degrees.
• Ensure air/fluid interface is level with phlebostatic axis.
• Reposition transducer.
• When patient in a side-lying or prone position, phlebostatic axis is not at the fourth ICS, midclavicular.
• For patient in right lateral position, reference point is intersection of the fourth intercostal space and the
midsternum.

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• For patient in left lateral position, reference point is intersection of the fourth intercostal space and the left
parasternal border.
Inaccurate Pressure Interpretations

• Factors that can cause distortion:
• Catheter obstruction (clots, air • Excessive tubing or connectors • Transducer damage
or blood, catheter bending) • Loose connections
• To ensure accuracy, perform the dynamic response testing (square wave test) on regular basis.
End-expiration Hemodynamic Values

• Hemodynamic values taken end-expiration since that is when:
• Atmospheric and alveolar pressures are approximately equal
• Pulmonary pressures have minimal effect on intracardiac pressures (thereby allowing for a more accurate value)
• In a patient breathing spontaneously, pleural pressure decreases during inspiration.
• The pressure waveform elevates during expiratory phase. Readings should be documented at the peak pressure.
Pressure Readings in the Mechanically Ventilated Patient

• In a mechanically ventilated patient, pleural pressure increases as the breath is delivered by the ventilator.
• Therefore, in this case, it is the intracardiac pressures that are more consistent and accurate. Readings should be
documented at the lowest point in the tracing.
PA Pressure Accuracy vs. Location of Catheter Tip

• Properly locating the catheter tip also helps accuracy.
• Place catheter tip below left atrium in lung zone 3.
• Aspects of proper catheter tip placement:
• Pulmonary Zone • Tip Migration • Validation by Waveform
• Tip Placement

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Positive End Expiratory Pressure (PEEP) Greater than 10 cm H2O

• A PEEP greater than 10 cm H2O increases alveolar and intrathoracic pressure, compresses pulmonary vasculature, and
affects PAOP measurement accuracy.
• Question accuracy of PA measurements if/when:
• Significant respiratory variation present with the PAOP waveform
• PAOP > PAD
• Gradient between PAD and PAOP is greater than 4 mmHg
Evidence-Based Practice: Pulmonary Artery Pressure Measurement:

• AACN’s 2004 Practice Alert on PA pressure measurement provides guidelines for improving accuracy of PA catheter
measurements:
• Perform square wave test at beginning of each shift.
• Position patient supine with HOB elevation from 0 to 60 degrees.
• Use phlebostatic axis as reference point for leveling.
• Obtain measurements from a graphic tracing at end-diastole.
Troubleshooting
• Important for maintaining catheter patency, ensuring that data from PA catheter is accurate, and preventing occurrence of
catheter-related and patient-related complications.
• Possible reasons why waveform may not be displaying on the monitor:
• Catheter has kink.
• Stopcock not correctly positioned.
• An incorrect scale size was chosen.
• Flush bag is empty or there is less than 300 mmHg of pressure on the pressure bag.
• Catheter is clotted.
• Cable may be fractured and need replacing. (rare)
Other Issues
• Other possible reasons for an inaccurate or absent PA reading on the monitor:
• Artifact • Blood back-up in line
• Inability to flush catheter • Ruptured balloon
• Continuous wedge waveform (a medical emergency)

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Topic Five: Waveform Analysis
Introduction
Here we explore the process of interpreting waveforms.
Pressure Waveform Changes in Relation to Catheter Location

• Changes as catheter floats through right ventricle, across pulmonic valve, and out to pulmonary artery
• Obvious change in diastolic pressure
• Monitoring of systolic pressure values will not alert nurse if PA catheter is in the right ventricle.
• Monitoring of diastolic pressure values will alert nurse if PA catheter is in the right ventricle.
Pulmonary Artery Pressure (PAP)

• Components: Peak systolic pressure, dicrotic notch, and end diastole.
• PAD (PA Diastolic)
• PAS (PA Systolic)
• Normal range: 15 to 25 mmHg • Is generally equal to the right ventricular systolic pressure
• Dicrotic Notch
• PAOP (PA Occlusion Pressure)
• PVR (Pulmonary Vascular Resistance)
• LVEDP (Left Ventricular End-Diastolic Pressure)
Identifying PA Peak Using the ECG

• Locate peak systole within the T wave and measure this value.
• Then locate end-diastole at the end of the QRS complex and measure this value.
Pulmonary Artery Occlusion Pressure (PAOP)

• An indirect measure of left atrium pressure
• The waveform has characteristics similar to that of the RAP/CVP.
Balloon Inflation Causes Waveform Change

• Causes waveform to change from a PA waveform to an atrial waveform with characteristic A and V waves.

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• Components of the PA waveform:

• Mean Value PAOP • A Wave • V Wave • Left Atrial Pressure
Measuring Mean PAOP

• Locate the A wave near or after the QRS complex.
• Measure the top and bottom of the A wave and average the values.
Topic Six: Complications and Associated Problems
Introduction
Here we explore some of the complications that can arise with PA catheters either during insertion or during maintenance.
Complications Associated with PA Catheters

• Complications can occur during insertion or during maintenance.
• Potential complications:
• Arterial Puncture • Pneumothorax • Kinking or Knotting
• Air Embolus • Ventricular Ectopy
Complications of PA Catheter Monitoring

• Potential complications during maintenance:
• Pulmonary Rupture • Pulmonary Infarction • Infection • Thrombosis
Topic Seven: Clinical Applications
Introduction
Here we look at how monitoring the waveforms not only helps ensure that the catheter is still properly placed, but also aid in
the diagnosis of cardiac and pulmonary diseases. We look at the implication of both PA pressures and elevations in certain
wave types can mean to for diagnosing a patient.
RAP, PAP, and PAOP Waveforms

• Some diseases cause abnormal waveform morphology.

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PA Pressure vs. Systemic Pressure

• PA pressures are critical for assessing whether there is adequate gas exchange in the lungs.
• PA pressures are low in comparison to systemic pressures.
• Normal pulmonary artery systolic pressure: 15 -25 mmHg • Normal pulmonary artery diastolic pressure: 8 -15 mmHg
• If pressure in pulmonary vasculature elevates, capillary hydrostatic pressure exceeds capillary osmotic pressure and forces
fluid out of vessels.
PAD vs PAOP
• For blood flow through lungs to occur, mean PA pressure must always be higher than left atrial pressure.
• PAD pressure should be higher than left atrial pressure (PAOP) and if it isn’t, it usually means either a very low pulmonary
blood flow state or the waveform has been misinterpreted.
• Reduce possible pulmonary complications by using the PAD to depict PAOP.
• Conditions that make PAD not equal to PAOP:
• Pulmonary diseases that increase the PVR • Rapid heart rates that decrease filling time causing
• Mitral valve diseases PAD to elevate with no change in PAOP
Analyzing Elevated PA Pressures

• Measuring PA pressures can help diagnose conditions.
• Elevated PA pressures occur in:
• Pulmonary hypertension • Mitral valve disease • Hypoxia
• Chronic pulmonary disease • LV failure • Pulmonary emboli
• Waveform analysis, too, can help diagnose conditions.
• Large A waves seen in patients with:
• Mitral stenosis • Ventricular demand pacing
• Severe LV failure • PVCs
• Large V waves seen in patients with mitral insufficiency.
• Elevated A and V waves seen in patients with:
• Cardiac tamponade • Constrictive pericardial disease • Hypervolemia

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Supply Checklist Lesson: Pulmonary Artery Catheters

Topic: Insertion
As the critical care nurse, you will need to gather all the supplies and equipment for the
insertion of the PA catheter. Below is a sample supply checklist.
PA catheter (nonheparin-coated PA catheters are available)

Percutaneous sheath introducer kit and sterile catheter sleeve
Pressure modules and cables for interface with the monitor
Cardiac output cable with a thermistor/injectate sensor
Pressure transducer system, including flush solution recommended according to
institution standard, a pressure bag or device, pressure tubing with flush device,
and transducers
Dual-channel recorder
Sterile normal saline intravenous fluid for flushing the introducer and catheter
infusion ports
Antiseptic solution (e.g., 2% chlorhexidine-based preparation)
Caps, fluid-shield masks, sterile gowns, sterile gloves, nonsterile gloves and
sterile drapes
1% lidocaine without epinephrine
Sterile basin or cup
Sterile water or normal saline
Sterile dressing supplies
Stopcocks (may be included in some pressure tubing systems)
Nonvented caps for stopcocks
Additional equipment as needed includes the following:
Fluoroscope
Emergency equipment
Temporary pacing equipment
Indelible marker
Transducer holder
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Pulmonary Artery Pressure Lesson: Pulmonary Artery Catheters

Measurement Topic: Managing and Troubleshooting PA
Catheters
Practice Alerts
The goal of the practice alerts is to help nurses and other health care practitioners carry their bold
voices to the bedside to directly impact patient care. Practice alerts are succinct, dynamic directives
from AACN that are supported by authoritative evidence to ensure excellence in practice and a safe and
humane work environment. Practice Alerts are short directives designed for easy reference.
AACN will issue practice alerts to:
• Close research/practice gap

• Provide guidance
• Standardize practice
• Identify/inform about new advances/trends
Recognizing that practice is dynamic, the Practice Alerts will be reviewed and updated as needed, and
can be accessed by going to: http://www.aacn.org/aacn/practicealert.nsf/vwdoc/pa2
Following is the current Practice Alert for Pulmonary Artery Pressure Measurement, but be sure to
check the link for the most up-to-date information.
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PULMONARY ARTERY PRESSURE MEASUREMENT
Expected Practice:
; Verify the accuracy of the transducer-patient interface by performing a square waveform test at
the beginning of each shift.
; Position the patient supine prior to PAP/RAP (CVP) measurements. Head of the bed (HOB)
elevation can be at any angle from 0° (flat) to 60°.
; Level the transducer air-fluid interface to the phlebostatic axis (4th ICS/½ AP diameter of the
chest) with the patient in a supine position prior to PAP/RAP measurements.
; Obtain PAP/RAP measurements from a graphic (analog) tracing at end-expiration.
; Use a simultaneous ECG tracing to assist with proper PAP/RAP waveform identification.
; PA catheters can be safely withdrawn and removed by competent registered nurses.
Supporting Evidence:

The square waveform test, or dynamic response test, determines the ability of the transducer
system to correctly reflect pressures in the pulmonary artery.1-5 This test can identify system
problems, such as air bubbles in the tubing, excessive tubing length, loose fitting equipment,
and/or patient problems, such as catheter patency. Any of these problems may affect accuracy of
PAP/RAP measurements and should be corrected prior to pressure measurement. Experts
recommend the following situations as appropriate to perform the square waveform test: on the
initial system setup, at least once each shift, after opening the catheter system (e.g. for rezeroing,
drawing blood, or changing tubing), and whenever the PAP waveform appears to be damped or
distorted. 1-4,6
Consider the following changes in PA pressures as clinically significant (i.e., not reflective of the
normal variability in PA pressures): UPAS > 4-7 mm Hg; UPAEDP > 4-7 mm Hg; UPAWP > 4
mm HG.7,8
Studies in a variety of patient populations have found that PAP/RAP measurements are accurate
when the head of the bed is elevated to any angle between 0o and 60o, as long as the patient is in
the supine position.9-11 Two studies have also shown that PAP/RAP readings are accurate with
the patient in a lateral position if the angle of rotation is exactly 30° or 90° with the head of the bed
flat, and the location of the transducer air-fluid interface changed to the appropriate external
landmarks for lateral positioning (30o lateral: ½ distance from surface of bed to the left sternal
border; 90o right lateral: 4th ICS/midsternum; 90o left parasternal border).1,12-14 When utilizing a
30o side lying angle a method of ensuring an accurate angle is needed and should be readily
available to the bedside practitioner.13
Leveling the transducer air-fluid interface to the left atrium corrects for changes in hydrostatic
pressure in vessels above and below the heart.1,3 In the supine position, the external landmark for
the left atrium is the phlebostatic axis (4th ICS/½ AP diameter of the chest).15,16 Studies have
found that improper positioning of the air-fluid interface can lead to significantly different PAP/RAP
reading.17,18 Once the correct location for the phlebostatic axis is identified, a mark should be
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placed on the chest wall and a laser pointer level or a carpenter’s level should be used to properly
level the transducer air-fluid interface anytime the patient is repositioned.1,2.,18 Changes in patient
position, even slight HOB m or n, require releveling of the transducer air-fluid interface before
obtaining PAP/RAP measurements.
Changes in intrathoracic pressure during respiration significantly alter hemodynamic pressures.
Obtaining accurate PAP/RAP measurements requires reading pressure waveforms during end
expiration only.1-4,9,19 Digital readouts on pressure monitors reflect pressures obtained throughout
respiration and are significantly different from end expiratory pressures, requiring pressure to be
read from graphic waveform tracings. 6,20,21
Levels of evidence supporting validation of PAP/RAP waveform measurement with simultaneous
ECG tracings include clinical literature, expert opinion and sound theoretical principles of
hemodynamic measurement. 1-4
Studies and surveys show that after education and clinical monitoring to assess competency,
registered nurses can safely withdraw and/or remove PA catheters.22,23,24 Before incorporating
withdrawing and/or removing PA catheters into nursing practice, verify that it is within your state’s
scope of practice for registered nurses.
What You Should Do:

Always identify and mark the phlebostatic axis, obtain PAP/RAP with the patient in the supine
position and the head of the bed elevated between 0 and 60 degrees, read pressures from a
graphic (analog) recording at end expiration, and periodically perform a square waveform test.
Assure that your critical care unit has written practice documents such as a policy, procedure or
standard of care, that include these expected practice alert standards.
Determine your unit’s rate of compliance with these Practice Alert standards.
If compliance is < 90%, develop a plan to improve compliance13:
⇒ Consider forming a unit task force to address the need for changes in PAP/RAP
measurement practices.
⇒ Educate staff about the inaccuracies which can occur in PAP/RAP measurements with
improper techniques (Education Toolbox)
⇒ Incorporate content into orientation programs, initial and annual competency verifications.
⇒ Develop a variety of communication strategies to alert and remind staff of the importance of
these PAP/RAP practices.
⇒ Create an audit tool for measuring compliance with PAP/RAP expected practice standards
Need More Information or Help?

A web based educational program on pulmonary artery pressure measurement is available at
www.pacep.org
PAP/RAP Practice Alert information at www.aacn.org
⇒ Test of PA catheter knowledge
⇒ Square waveform test information
⇒ Identifying correct PAP/RAP waveforms from simultaneous pressure and ECG tracings
⇒ Identifying correct phlebostatic axis location for leveling transducers in the supine position
⇒ Power Point slide program for PAP/RAP measurement education sessions
Talk with a clinical practice specialist for additional information / assistance (www.aacn.org) then
select PRN.
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REFERENCES:
1. Keckeisen M, Chulay M, Gawlinski A, eds. Pulmonary and artery pressure monitoring. In
AACN’s Protocols for Practice: Hemodynamic Monitoring Series. Aliso Viejo, Calif: AACN;
1998.
2. Quaal S. Quality assurance in hemodynamic monitoring. AACN Clin Issues. 1993;4:197-206.
3. Daily E, Schroeder J. Techniques in Bedside Hemodynamic Monitoring. St Louis, Mo: Mosby-
Year Book; 1994.
4. Quaal S. Ask the experts. Crit Care Nurse. 1995;10:92-93.
5. Gardner R. Direct blood pressure measurement: Dynamic response requirements.
Anesthesiology. 1981;54:227-236.
6. Ahrens T, Penick J, Tucker M. Frequency requirements for zeroing transducers in
hemodynamic monitoring. Am J Crit Care. 1995;4:466-471.
7. Moser D, Woo M. Normal fluctuation in pulmonary artery pressure and cardiac output in
patients with severe left ventricular dysfunction abstract. Am J Crit Care. 1996;5:236.
8. Nemens EJ, Woods SL. Normal fluctuations in pulmonary artery and pulmonary capillary
wedge pressure in acutely ill patients. Heart Lung. 1982;11:393-398.
9. Dobbin K, Wallace S, Ahlberg J, et al. Pulmonary artery pressure measurement in patients
with elevated pressures: effect of backrest elevation and method of measurement. Am J Crit
Care. 1992;1:61-69.
10. Wilson A, Bermingham-Mitchell K, Wells N, et al. Effect of back position on hemodynamic and
right ventricular measurements in critically ill adults. Am J Crit Care. 1996;5:264-270.
11. Woods S, Mansfield L. Effect of body position upon pulmonary artery and pulmonary capillary
wedge pressures in noncritically ill patients. Heart Lung. 1976;5:83-90.
12. VanEtta D, Gibbons E, Woods S. Estimation of left atrial location in supine and 30° lateral
position abstract. Am J Crit Care. 1993;2:264.
13. Bridges EJ, Woods SL, Brengelmann GL, et al. Effect of the 30 degree lateral recumbent
position on pulmonary artery and pulmonary artery wedge pressures in critically ill adult
cardiac surgery patients. Am J Crit Care. 2000;9:262-275.
14. Kennedy GT, Bryant A, Crawford MK. The effects of lateral body positioning on
measurements of pulmonary artery and pulmonary wedge pressures. Heart Lung.
1984;13:155-158.
15. Paolella L, Dortman G, Cronan J, et al. Topographic location of the left atrium by computed
tomography: reducing pulmonary artery catheter calibration errors. Crit Care Med.
1988;16:1154-1156.
16. Courtois M, Fattal P, Kovacs S, Tiefenbrunn A, Ludbrook P. Anatomically and physiologically
based reference level for measurement of intracardiac pressures. Circulation. 1995;92:1994-
2000.
17. Kee L, Simonson J, Stotts N, Skov P, Schiller N. Echocardiographic determination of valid
zero reference levels in supine and lateral positions. Am J Crit Care. 1993;2:72-80.
18. Bartz B, Maroun C, Underhill S. Differences in midanteroposterior level and midaxillary level of
patients with a range of chest configurations. Heart Lung. 1988;17:309.
19. Ahrens T. The effects of mechanical ventilation on hemodynamic waveforms. Crit Care Clin
North Am. 1991;3:629-639.
20. Ahrens T, Schallom L. Comparison of pulmonary atery and central venous pressure waveform
measurements via digital and graphic measurement methods. Heart Lung. 2001;30:26-38.
21. Lipp-Ziff E, Kawanishi D. A technique for improving the accuracy of the pulmonary artery
diastolic pressure as an estimate of left ventricular end-diastolic pressure. Heart Lung.
1991;20:107-115.
22. Wadas TM. Pulmonary artery catheter removal. Crit Care Nurse. 1994;14;62-72.
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23. Roundtree WD. Removal of pulmonary artery catheters by registered nurses: a study in safety
and complications.
Focu s Crit Care. 1999;18:313-318.
24. Zevola, DR, Maier B. Improving the care of cardiothoracic surgery patients through advanced
nursing skills. Crit Care Nurse. 1999;19:34-44.
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The Essentials of Lesson: Pulmonary Artery Catheters

Hemodynamic Monitoring Topic: Insertion
Practice Pearls
Relative Contraindications
When the decision to insert a PA catheter has been made, the physician will need to
speak to the patient and family regarding the reason for insertion, overview of the
procedure and possible complications. A signed informed consent is the ideal. In most
instances the insertion is emergent and the preparation of the patient and family may be
inadequate. It is important to take the time after the patient has stabilized to discuss the
information with the family.
68

Hemodynamic Monitoring Topic: Managing and Troubleshooting PA
Catheters
Inaccurate Pressure Interpretations

Check tubing from arterial line and PA catheter for extensions when the patient returns
from OR. Anesthesia usually adds extension tubing allowing access during surgery.
Remove any extensions, tighten connections and perform square wave test during
postoperative assessment.
Positive End Expiratory Pressure (PEEP) Greater than 10 cm H2O

A corrected wedge should be calculated for all patients on PEEP greater than 10 cm
H2O. Corrected PAOP = measured PAOP–(PEEP)(.75)/2.
If the measured PAOP = 22 mmHg and the PEEP = 25 cm H2O, what is corrected
wedge?
(25 x .75)/2 = 9; then 22–9 = 13 mmHg
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Hemodynamic Monitoring Topic: Complications and Associated Problems
Complications of PA Catheter Monitoring

The pressure waveform from the distal tip should be monitored continuously and
promptly withdrawn if a spontaneous PAOP waveform appears. Overinflation of the
balloon should be avoided by carefully observing the PA waveform and only inflating the
balloon with enough air to change the PA waveform to the PAOP waveform. If a PAOP
waveform is seen with inflation of <1.25 mL of air, withdraw the catheter tip slightly.
Limit inflation time to 10 to 15 seconds. Prolonged inflation and excessive balloon
volume put too much tension on the vessel wall.
Lesson 5
Cardiac Output Monitoring

• Factors Affecting Cardiac Output
• Methods Of Calculating CO
• Clinical Application Of CO
• Non-Invasive CO Monitoring
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Lesson Takeaway - Cardiac Output Monitoring
Topic One: Factors Affecting Cardiac Output

Introduction
In this lesson we learn that the most widely utilized pieces of information from the PA catheter are cardiac output (CO) and
stroke volume (SV.) We look at the factors affecting CO, methods of calculating CO, and the clinical application of this
information. We also briefly discuss the several newer methods for assessing cardiac function which arose out of a desire
for a method that was safer and less invasive.
Cardiac Output
• Cardiac Output (CO) one the two most widely utilized pieces of information from the PA catheter
• Understanding CO critical to assessing if cardiac function adequate
• CO is the amount of blood ejected by the ventricle each minute.
• Equals HR x SV
• Is measured in L/min.
• Normal CO: 4 - 8 L/min.
Output Relative to Body Size

• The CO value should be assessed keeping body size in mind.
• Example: A CO of 4.0 L/min. might not be enough for an NFL football player to maintain tissue perfusion.
Cardiac Index
• Cardiac Index (CI) is a better measure of cardiac function than CO and is the value that should be used to trend cardiac
function.
• CI is CO adjusted to individual body size
• You divide CO by the individual’s BSA (which you get from the Dubois’ Surface Area chart on the cardiac monitor.)
• CI is displayed on most monitors either continuously or at the time that CO is obtained.
• This value only accurate if person’s height and weight were entered into the database to ensure accuracy of this
value.
• Normal value for CI: 2.5 -4.3 L/min/m2
Stroke Volume
• Stroke Volume (SV) one of the two most widely utilized pieces of information from the PA catheter
• Understanding SV critical to assessing if cardiac function adequate

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• SV is the amount of blood ejected with each contraction of the ventricle.

• Normal SV: 50 - 100 mL/beat
• Is best to index it. Do so by dividing it by BSA.
• Normal SVI (SV indexed): 35 - 60 mL/beat/m2
• SVI is another indexed parameter that will be displayed on the monitor.
• Possible causes for a low SV or SVI:
• Inadequate blood volume (hemorrhage)
• Impaired ventricular contractility (myocardial ischemia or infarction)
• Increased systemic vascular resistance or cardiac valve dysfunction (mitral insufficiency).
• Possible cause for an elevated SV or SVI:
• A low systemic vascular resistance
Cardiac Output Represents Oxygen Delivery to Cells

• SV depends on preload, afterload, and contractility.
• Since CO is SV x HR, CO is determined by preload, afterload, contractility, and heart rate.
• CO offers a global representation of oxygen delivery to the cells.
• If CO abnormal, selecting the right intervention requires a look at each of its component parameters: Preload, afterload,
contractility, and heart rate.
Ventricular Filling vs. Ventricular Ejection

• Causes of low CO can be broken into 2 groups:
• Conditions causing inadequate ventricular filling
• Similar characteristic of all these conditions is diminished preload resulting in inadequate forward blood
flow
• Rapid rate dysrhythmias • Constrictive pericardial disease
• Hypovolemia • Cardiac tamponad
• Mitral/tricuspid valve stenosis • Restrictive cardiomyopathy
• Conditions causing inadequate ventricular ejection
• Myocardial infarction • Mitral/ tricuspid insufficiency
• Metabolic disorders • Conditions causing high resistance to
• Use of negative inotropic drugs ejection
• Myocardial diseases such as
myocarditis or cardiomyopathy
Increased Cardiac Output

• Causes of high CO (the two most likely) are increased heart rate and decreased afterload.
• Conditions that can cause higher CO are:
• Fever • Sepsis • Anemia • Pregnancy • Hyperthyroidism

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Heart Rate and Rhythm

• Normal HR 60 -100 bpm. • Dysfunction
• In a healthy individual, increased HR causes increased CO. • Bradycardia
• In individuals with impaired cardiac function, the great • Tachycardia
reduction in atrial contribution to ventricular filling that comes
with increased HR can have detrimental effects.
Components of Cardiac Output

• Preload
• The force that stretches the ventricles during diastole
• The filling pressure of the ventricles at the end of diastole
• The amount of blood that fills the ventricles during diastole
• Afterload
• Vascular resistance; the resistance to ventricular emptying during systole
• The pressure/resistance that the ventricles must overcome in order for them to be able to open the aortic and
pulmonic valves and pump blood into the systemic and pulmonary vasculature.
• Contractility
• The strength of the myocardial contraction • The degree of myocardial fiber shortening
Preload
• Clinical indicators for right and left ventricular preload • Reasons for reduced preload
• Influences on preload • Reasons for increased preload
Afterload
• Influences on afterload • Reasons for reduced afterload • Reasons for increased afterload
Calculating Afterload
• Afterload cannot be measured directly; it must be calculated using values from the PA catheter.

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Lesson: Cardiac Output Monitoring

principles for cardiac output testing
- Describe factors affecting Cardiac Output
- Describe the methods for obtaining and calculating cardiac output
- Discuss the clinical application of cardiac output
- Describe non-invasive means of obtaining cardiac output

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• Clinical indicator of RV afterload is the PVR

• Both PAM and PAOP affect (correlate positively with both) PVR
• CO affects (correlates negatively with PVR
• Besides PAM, PAOP, and CO, another factor influencing afterload is hypoxia.
Contractility
• Affected by many factors including:
• Preload and afterload • Functioning of myocardium
• Vasodilators, vasoconstrictors, and intropes • Myocardial oxygenation
• Electrolyte levels
• Factors increasing contractility:

• Fluid resuscitation • Positive inotropic drugs • Tachycardia • Decreased afterload
• Factors decreasing contractility:

• Hypovolemia • Hypoxemia • Intraabdominal hypertension
• Negative inotropic drugs • PEEP • Cardiac diseases
• Myocardial ischemia • Electrolyte and acid–base imbalances
• Another method for identifying altered contractility in each ventricle:

• Right Ventricular Stroke Work Index (RVSWI)
• RVSWI = (PAD-RAP/CVP) SV/BSA (0.0136)
• Normal range: 7-12 g/m2/beat
• Left Ventricular Stroke Work Index (LVSWI)
• LVSWI = (MAP-PAD) SV/BSA (0.0136)
• Normal range: 35 -85 g/m2/beat

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Topic Two: Methods of Calculating Cardiac Output

Introduction
Here we explore the different clinical methods for measuring cardiac output including Direct Fick, Dye Dilution, and
Thermodilution.
Clinical Methods for Measurement of Cardiac Output

• Different methods, each with strengths/weaknesses
• Direct Fick • Dye Dilution • Thermodilution (most commonly used)
Direct Fick Method

• Requires calculating the oxygen consumed over a given period and measuring the oxygen concentration in venous and
arterial blood.
• Most accurate method for CO measurement but not practical for routine use
• Use in situations where the thermodilution CO method cannot be used or when values obtained are suspect.
• Downsides:
• Invasive • Accurate samples are sometimes difficult to obtain.
• Requires time for sample analysis
• Usually performed in cardiac catheterization suite
Dye Dilution Method

• Involves injection of known quantity and concentration of indocyanine green or lithium into bloodstream then measuring the
dye concentration at selected time intervals in order to calculate flow and volume
• CO is equal to the area under the indicator dilution curve.
• Though less cumbersome than Fick, has the problem that dye may recirculate and cause inaccuracies in subsequent
measurements.
Thermodilution Method
• At bedside, CO measurements obtained through PA catheter via one of these methods:
• Intermittent Bolus Thermodilution (TDCO)
• Continuous CO (C CO)
• Steps:
• TDCO injection
• Thermistor detects temperature change
• CO curve interpreted

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• If area under curve is large, indicates a low CO

• If area under curve is small, indicates a high CO.
Controlling Variables Alleviates Erroneous Measurements

• In thermodilution method, you will want to take these measures in order to avoid erroneous results:
• Ensure forward flow of blood and adequate mixing of blood and injectate.
• Ensure that catheter is properly placed with the proximal port in the right atrium and the distal port in the
pulmonary artery.
TDCO Technique
• Xx
• A closed injectate delivery system is most often used for reasons of reducing multiple entries into the system and
controlling infections.
• Iced injectate verses room temperature injectate
• A 10+ degree gradient between temperature of injectate and of patient’s blood
• Cardiac output computer
Proper Technique
• Use of proper technique and observing of CO curve will bolster accuracy.
• End-expiration • Rapid injection • Interpretation • Abnormal curves
• Factors that can cause irregular cardiac output curves:

• Poor injectate mixing • Changes in heart rate or blood • Faulty technique
• Thermistor-vessel wall contact pressure • Abnormal respiratory patterns
Continuous Cardiac Output (CCO)

• Some PA catheters have continuous CCO capability (the ability to measure cardiac output continuously.)

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• Catheters with continuous CCO capability have a 10 cm thermal filament that emits a pulsed, low heat energy signal in a
30 to 60 second sequence.
• Proper placement: The thermal filament section of catheter is located in RV
• Bedside computer constructs thermodilution curves and measures CO automatically.
Factors Affecting Accuracy of CO Values

• Adequate mixing • Hyperthermia • Infusions • Ten-minute delay
Topic Three: Clinical Application of Cardiac Output

Introduction
Here we look at the clinical application of CO and other values in assessing the hemodynamic status of the critically ill
patient.
Keys to Hemodynamic Assessment

• CO and CI: Assess blood flow
• SV and SVI: Help in assessment of pump performance
• RAP/CVP and PAOP: Assess cardiac filling pressures and give estimates of ventricular volume prior to preload or systolic
ejection
Hemodynamic Instability
• Presents as either a high blood flow state or a low blood flow state
• Body’s efforts to compensate work only for a while.
• Low CO states occur due to hypovolemia or left ventricular dysfunction.
• Early warning of decreasing CO is a drop in the SV/SVI. CO will still appear normal even if this is dropped, so
paying attention to this can help you anticipate and ward off a low CO or low-flow state.
Low-flow State
• To treat a low CO state you must first determine whether it’s hypovolemia or a problem of LV dysfunction. This is done by a
combination of clinical and hemodynamic assessments:
• Patient’s physical assessment

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• Patient’s history
• Use of intracardiac pressures such as RAP, PAP and PAOP
Abnormal PAOP Values

• Should be assessed with SV/SVI values to determine the clinical significance of the abnormality
• PAOP > 18 mmHg, especially if SV/SVI are low, usually reflects left ventricular impairment (and therefore something like
congestive heart failure, myocardial infarction, cardiac tamponade, or cardiomyopathy)
Elevated CO Values
• In healthy people, CO values elevate in response to increased oxygen demand.
• In critically ill patients, an elevated CO is always an indicator of some other problem.
• Elevated CO values can mean systemic inflammation, anaphylaxis, or neurogenic-mediated vasodilation, all of
which result in a decreased SVR (afterload.)
• The increase in CO might be minimal or marked. The key to remember is that the CO elevation is a sign of a problem
rather than the problem.
Topic Four: Minimally Invasive and Noninvasive CO Monitoring

Introduction
Here we look at some of the more newly-developed and less invasive techniques for CO monitoring. However, despite these
newer devices, CO monitoring using the PA catheter remains the standard, especially when data about cardiac filling
pressures (RAP, PAP, PAOP) and mixed venous oxygen saturation are needed.
Continuous Monitoring of the Central Circulation

• Can provide improved insights into normal physiology, pathophysiology and treatments for diseases.
• While invasive methods are well accepted, there is increasing evidence that these methods are neither accurate nor
effective in guiding therapy. Hence the drive for other methods.
Esophageal Doppler Cardiac Output

• The Esophageal Doppler uses sound to measure aortic blood flow velocity
• How it works (Doppler, transducer probe, and beam)

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• Contraindications:
• Coarctation of the aorta • Esophageal pathology • Coagulopathy • IABP
Pulse Contour Analysis

• SV is derived from the arterial pressure or the pulse waveform.
• Patients with poorly defined arterial waveforms or with arrhythmias that alter the waveform will not achieve reliable CO
results with this method.
• Various types: • PiCCO system • LiDCO method • Pulse Contour Wave
Thoracic Bioimpedance
• Determines SV using a current that flows from an outer electrode to an inner sensor
• Thoracic bioimpedance: the relationship between impedance and SV
• The resistance of current flow (impedance) across the chest is inversely related to the thoracic fluid.
• A useful method for trend analysis, but not accurate enough for diagnostic interpretation
• Major application has been outside the critical care setting.
• Management of acutely ill patients in the outpatient setting may be the most important contribution of this technology.
Gastric Tonometry
• Provides CO information based on adequacy of gastric mucosal perfusion.
• Gastric very sensitive to altered mucosal perfusion.
• Carbon dioxide partial pressure PCO2 measured in the stomach or intestine.
Sublingual Capnometry (PSLCO2)

• An increase in PSLCO2 directly and inversely correlates with a decrease in sublingual blood flow.
• Noninvasive method of identifying regional abnormalities in blood flow
• Only limitation: Its noncontinuous data collection
• Has been used to:
• Diagnose and quantify severity of circulatory shock, with predictive value of 100%
• Validate end-points of resuscitation.
• Predict hemodynamic stability: A PSLCO2 measurement < 45 mmHg accurately predicts hemodynamic stability.

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The Essentials of Lesson: Cardiac Output Monitoring

Hemodynamic Monitoring Topic: Methods of Calculating CO
Practice Pearls
Thermodilution Method
The specific gravity of D5W is used in the formula to derive CO by the TDCO method.
The use of saline can result in a 2% decrease in the TDCO measurement. Saline
should be substituted if the patient’s medical condition warrants it.
TDCO Technique
Iced injectate may be preferable to room temperature injectate in patients with poor
forward blood flow, such as those with right ventricular failure, tricuspid stenosis or
tricuspid insufficiency. These conditions make it difficult to get accurate cardiac output
measurements, but the larger signal-to-noise ratio obtained with iced injectate may
improve the estimates obtained with the thermodilution method. Hypothermic patients
(cardiac surgery, trauma) may also require iced injectate to achieve greater accuracy
and precision of measurement.
The computation constant for the size and type of catheter used can be found in the
package insert of the PA catheter.
Factors Affecting Accuracy of CO Values

Continuous CO monitoring does not reflect acute changes in the CO value since the
updated value on the monitor display is an average of three to six minutes of data.
Expect a delay of approximately 10 or more minutes to detect a change of 1 L/min in
CO.
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The Essentials of Lesson: Cardiac Output Monitoring

Hemodynamic Monitoring Topic: Minimally Invasive and Noninvasive CO
monitoring
Esophageal Doppler Cardiac Output

Sedation is required for the entire time the probe is in place.
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Lesson 6
Oxygenation And Transport

• Oxygen Supply And Demand
• Types Of Catheters (SVO2, Scvo2)
• Conditions Affecting Oxygen Monitoring
• Clinical Applications
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Lesson: Oxygen and Transportation

principles for mixed venous oxygenation monitoring
- Describe oxygen supply, demand and consumption
- Identify the types of catheters and equipment required for monitoring

systemic oxygenation
- Discuss conditions that affect oxygenation and the body’s

compensatory mechanisms
- Identify the clinical application of mixed venous oxygen monitoring
- Describe the use of SVO2 and ScVO2 monitoring in the critically ill
patient.
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Lesson Take-away - Oxygen and Transport
Topic One: Oxygen Supply and Demand

Introduction
In this lesson we learn that all the hemodynamic parameters we’ve discussed are all part of a bigger picture-a balance, at
the tissue level, between oxygen delivery and oxygen demand. We look here at types of catheters used to monitor mixed
venous oxygen saturation, conditions affecting oxygen monitoring, and clinical
applications of SVO2 monitoring.
Oxygen Delivery
• Goal of hemodynamic monitoring: Evaluate whether oxygen delivery to tissues is enough to meet their metabolic demands.
If oxygen delivery not adequate, we must determine steps for enhancing this delivery.
• Adequate Oxygen Delivery
• Inadequate Oxygen Delivery
Oxygen Demand
• Oxygen demand: Amount of oxygen cells require to meet their metabolic process
• Oxygen consumption: Amount of oxygen cells actually use
Determinants of Oxygen Supply

• Diffused oxygen • Blood oxygen content • Oxygen transport • Oxygen extraction
Topic Two: Types of Catheters (SvO2, ScVo2)

Introduction
Here we review the clinical applications of SvO2 and ScvO2 monitoring.
Oxygen Saturation of Blood

• Traditionally, a pulmonary artery catheter is used.
• Referred to as “mixed venous oxygen saturation.”
• A continuous measure possible by using a fiberoptic pulmonary artery catheter.
• An intermittent measure possible by obtaining mixed venous blood samples.

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• More recently, central venous oxygen saturation has been reintroduced as a less invasive alternative to mixed
venous oxygen saturation.
Monitoring Mixed Venous Oxygen Saturation (SvO2)

• The oxygen saturation of the “mixed venous” blood (blood in the pulmonary artery)
• Varies as blood returns to right side of heart from various parts of body but gets mixed in the RV by the trabeculae so that
the oxygen content uniform by time blood is ejected from the RV into the pulmonary artery.
Tissue Oxygen Delivery vs. Oxygen Consumption

• Oxygen delivery/consumption similar to a train, the hemoglobin molecules as the boxcars that get loaded and offloaded
over and over again.
• Venous oxygen: Amount of oxygen left after blood has passed through the tissues
• Oxygen Delivery (DO2): Amount of oxygen delivered to tissues in 1 minute
• Important components
-Hemoglobin (Hgb)
-Arterial oxygen saturation (SaO2)
-Cardiac Output (CO)
• Formula is Hgb x 1.38 x SaO2 x CO x 10
• Venous oxygen transport: Amount of oxygen remaining after the blood has passed through the tissues
• Important components:
-Hemoglobin (Hgb)
-Venous oxygen saturation (SvO2)
-Cardiac Output (CO)
• Formula is Hgb x 1.38 x SvO2 x CO x 10
• Normal = 750 mL/min. • Oxygen consumption (VO2): Amount of oxygen extracted (consumed) at the tissue level.
• Is the difference between DO2 and venous oxygen transport
• Formula is Hgb x 1.38 (SaO2-SvO2) x CO x 10
• Normal = 25% of DO2 or 250 mL/min.
• VO2I is 125 mL/min/m2
• Mixed venous oxygen saturation (SvO2): The difference between oxygen delivery and oxygen consumption.
• Provides information about the balance between oxygen delivery and consumption in tissue
• Represents the end result of tissue oxygen delivery and consumption
• Provides information about the oxygen reserve for the body
• Formula is DO2-VO2

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SvO2: Global Indicator of Oxygen Utilization

• SvO2 a global indicator of oxygen utilization by body
• Rather than offering specific info about oxygen utilization by an organ, it tells the percentage of oxygen used by the body
used and how much is left over.
Changes in SvO2
• Can be due to changes in oxygen delivery or to changes in oxygen consumption
Normal SvO2 Range

• Is 60-80%
• Patient within normal range can still be in trouble. Better indicator: A 5 - 10% increase or decrease in the SvO2 that lasts
over 3-5 minutes.
Body Compensation for Low Oxygen Supply

• In the event oxygen supply is inadequate to meet oxygen demands, body tries to compensate in these ways:
• Increasing cardiac output • Autoregulation • Anaerobic metabolism
Monitoring Central Venous Oxygen Saturation (ScvO2)

• ScvO2 can be used as a surrogate for SvO2
• Is the incorporation of fiberoptics into continuous monitoring of the oxygen saturation of the superior vena cava
ScvO2 vs. SvO2: What is the difference between the two?

• SvO2 measured using a pulmonary artery catheter • ScvO2 measured using a central venous catheter
• Normally the ScvO2 and SvO2 measures are the same, but in a critically ill patient with severe sepsis or shock,

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ScvO2 runs 5-13% (and an average of 7.5%) higher than SvO2

• ScvO2 has been shown to track with SvO2.
ScvO2 Tracks SvO2

• A ScvO2 of 70% implies that SvO2 is likely to be 60-65%.
Fiberoptic Technology
• Used in both fiberoptic pulmonary artery catheter and fiberoptic central venous triple lumen catheter
• How the technology works:
• Fiberoptic network travels length of catheter.
• An optical module transmits light down length of the catheter. Hemoglobin absorbs a certain amount of light
relative to oxygen saturation.
• The light is then reflected back to optical module where it is converted into an electrical signal and transmitted to
the monitor.
Insertion Guidelines
• Insertion guidelines for SvO2 and ScvO2 monitoring similar.
• In Vitro calibration • Signal strength • Transport
• In Vivo calibration considerations
Topic Three: Causes of DO2/VO2 Imbalance

Introduction
Here we look at the conditions that can affect oxygen delivery and tissue oxygen demand, causing DO2/VO2 imbalances.
DO2/VO2 Imbalances
• Oxygen delivery can fall with any of these occurrences:
• Decreased hemoglobin • Leftward shift of • Loss of autoregulation
• Decreased CO Oxyhemoglobin Saturation
• Decreased SaO2 Curve

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Increased Tissue Oxygen Demand

• Tissue oxygen demand can increase with certain patient conditions:
• Surgical trauma (oxygen demand increases 10-30%)
• Multisystem organ dysfunction (oxygen demand increases 20-80%)
• Severe sepsis (oxygen demand increases 50-100%)
• Critically ill in the ED (oxygen demand increases 60%)
• Head injury-not sedated (oxygen demand increases 138%)
• Head injury-sedated (oxygen demand increases 89%)
• Large, full thickness burns (oxygen demand increases 100%)
Oxygen Demand Factors

• Tissue oxygen demand can also increase with these general ICU factors:
• Dressing change (oxygen demand increases 10%)
• Bed bath (oxygen demand increases 23%)
• Each position change (oxygen demand increases 31%)
• Increased work of breathing (oxygen demand increases 40%)
• Shivering (oxygen demand increases 50-100%)
• Visitor (oxygen demand increases 22%)
• Chest X-ray (oxygen demand increases 25%)
• ET suctioning (oxygen demand increases 27-70%)
• Getting out of bed (oxygen demand increases 39%)
• Weight on a sling scale (oxygen demand increases 36%)
• Rise in body temperature (For every 1 degree centigrade body temperature is elevated there is a 10-13%
increase in oxygen demand.)
• Inotropic infusions (oxygen demand increases 6-20%)
Causes of Increased or Decreased SvO2

• Decreased SvO2
• Indicates that more oxygen is being extracted
• Possible causes of the decrease:
• Decreased delivery
- Falling hemoglobin - Falling cardiac output - Falling SaO2
• Increased demand
- Seizures, shivering - Pain - Increased activity - Hyperthermia
•Increased SvO2
• Indicates that less oxygen is being extracted

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• Possible causes of the increase:

• Increased delivery
-Increased CO -Administration of blood products -Increased FiO2
• Decreased demand
-Hypothermia -Relief of pain -Anesthesia
-Sepsis: • Demand increased • Oxygen extraction inhibited
-Wedging a pulmonary artery catheter
• SvO2 will increase by 10-20%
• Mixed venous blood no longer flowing by the catheter. The light source is now reflected off
arterialized blood. When the balloon is deflated, SvO2 value will return to previous setting.
Effects of SvO2 While Suctioning a Patient

• Very important to hyperoxygenate patient before and after suctioning (so that SvO2 doesn’t fall so low that patient becomes
very high risk for developing a lethal arrhythmia.)
Effects of SvO2 While Turning Patient

• SvO2 declines with turning. Patient’s efforts to compensate (return to prior SvO2 level within 3-5 minutes) may fail.
• Important to hyperoxygenate the patient prior to turning and again immediately after turning since with turning comes
increased oxygen demand.
• Hyperoxygenating also helps promote better gas exchange.
Topic Four: Clinical Applications
Introduction
Here we look at the impact of the components of oxygen delivery.
Prompt Restoration of Tissue Oxygen Delivery

• Prompt restoration of tissue oxygen delivery is only factor that’s enjoyed improved outcomes in last 30 years, so important
to incorporate this info into our clinical practice.

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Normal Patient
• How to calculate oxygen delivery for a patient:
• Given:
- CO = 5.0 l/min - SaO2 = 98% - Hgb = 15 g/dl - SvO2 = 75%
• Calculate these values:

•Oxygen Consumption (VO2)
•Oxygen Delivery (DO2)
•O2 Extraction (the percentage of the oxygen being delivered that is being consumed)
•VO2 = CO x Hgb x 13.8 (SaO2 - SvO2), so VO2 = 5 x 15 x 13.8 x (.98-.75)
•DO2 = CO x Hgb x 13.8 x SaO2, so DO2 = 5 x 15 x 13.8 x .98
•O2 Extraction = VO2 / DaO2, so O2 Extraction = 238 / 1014
• Note, this is a normal patient since the components of oxygen delivery are within normal limits since
• All of the “Given” values are within normal range
• All of the calculated values are within normal range:
VO2 is 238 ml O2/min DO2 is 1014 mL O2/min O2 Extraction is 23%
Oxygen Extraction Ratio

• We extract 22-30% of the oxygen delivered to the tissues.
• To get an actual estimate of this percentage, calculate the Oxygen Extraction Ratio (O2ER).
• O2ER = the difference between patient’s SaO2 or pulse oximetry (if a good reading present) and his/her
SvO2 value
-SaO2 represents the supply side.
-SvO2 represents the remaining amount of oxygen after blood passes through the tissues.
Continuous SvO2 Monitoring

• Critical care nurses must always be assessing patient for threats to oxygen delivery and cellular oxygen consumption.
• Continuous SvO2 monitoring helpful in variety of situations:
• Management of patients with pulmonary disease
• Ventilator weaning
• Accidental disconnection from an oxygen source
• Development of a spontaneous pneumothorax
• Hypoxemia
• Suctioning
• Post cardiac surgery patients
• Trauma and high risk surgical patients.

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Obtaining a Mixed Venous Lesson: Oxygenation and Transport

Blood Gas Sample Topic: Types of Catheters (SVO2, ScVo2)
Steps for obtaining a mixed venous blood gas sample:

1. Attach a 5 mL syringe to the stopcock connected to the distal port of the PA
catheter.
2. Turn the stopcock to “off” to the flush solution.
3. Begin withdrawing the blood sample very slowly. Aspirating quickly may result in
arterialized blood being withdrawn into the catheter as well as air bubbles,
causing an overestimation of the blood gas sample.
4. Once the “discard” volume is obtained and discarded, attach a heparinized
syringe and withdraw 4-5 mL per hospital policy.
5. Turn the stopcock off to the sideport (open to the flush solution) and flush the
catheter until free of blood.
6. Immediately cap the blood gas sample and place on ice.
7. Send to the laboratory.
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Increased Tissue Oxygen Lesson: Oxygenation and Transport

Demand Topic: Causes of DO2/VO2 Imbalance
Situations That Cause an Increased Tissue Oxygen Demand

Increased oxygen demand can be caused by specific patient conditions or by some
general ICU factors.
Patient conditions associated with an increased oxygen demand and the percent of
increase include:
1. Surgical trauma 10-30%
2. Multisystem organ dysfunction 20-80%
3. Severe sepsis 50-100%
4. Critically ill in the Emergency Dept. 60%
5. Head injury-not sedated 138%
6. Head injury-sedated 89%
7. Large, full thickness burns 100%
General ICU factors that increase oxygen demand and the percent of increase include:
1. Dressing change 10%
2. Bed bath 23%
3. Each position change 31%
4. Increased work of breathing 40%
5. Shivering 50-100%
6. Visitor 22%
7. Chest X-ray 25%
8. ET suctioning 27-70%
9. Getting out of bed 39%
10. Weight on a sling scale 36%
11. For every 1 degree centigrade the body temperature is elevated, there is a 10-13%
increase in demand
12. Inotropic infusions 6-20%
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Practice Exercise Lesson: Oxygenation and Transport

Topic: Causes of DO2/VO2 Imbalance
Calculate the total percent increase in oxygen demand for this patient:
Consider that you are caring for an abdominal surgery patient. He is intubated and on a
ventilator. You are preparing to bathe the patient at 0400. The following sequence of
events occurs.
1. Bath is given and the patient is turned twice during the bath.
2. Three sets of dressings are changed.
3. Bed linens are changed and the patient is turned three times during the process.
4. The patient required suctioning after being turned and repositioned.
5. The patient’s body temperature is 38 degrees centigrade.
6. At 5:30 am radiology is at the bedside to obtain the portable upright chest x-ray. In
the process of positioning the plate behind the patient’s back, his position is
changed a total of three times. Upon completion of the x-ray, the plate is removed
and the patient is repositioned.
Event Percent Change
Bed Bath 23%
Position Change (x2) 31%
Dressing Change (3 sets) 10%
ET Suctioning 27-70%
Body Temp. For every 1 degree centigrade the body temperature is
elevated, there is a 10-13% increase in demand.
Chest X-Ray 25%
Getting Out of Bed 39%
This patient’s tissue oxygen demand increased by a total of 468%.

General ICU nursing routines often follow this clinical scenario. The clinical issue that
we must think about is related to the patient’s ability to tolerate this increase in demand.
Very often a patient will experience a cardiac arrest shortly after being turned, at change
of shift in the morning after the bath has been given, or after the upright portable chest
x-ray is taken and lab work drawn. The advantage of monitoring SvO2 or ScvO2
continuously is that we have the ability to immediately see the impact of our nursing
interventions on the patient.
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Calculating Oxygen Delivery Lesson: Oxygenation and Transport

Topic: Clinical Applications
Let’s take a look at how to calculate oxygen delivery for a patient.

Note that the components of oxygen delivery are within normal limits.
The SvO2 is at 75%.
Calculation of oxygen delivery reveals a DO2 of 1000 mL O2/min and oxygen
consumption (VO2) of 250 mL/min. This individual is consuming 23% of the oxygen that
is being delivered which is normal.
CO = 5.0 l/min
SaO2 = 98%
Hgb = 15 g/dl
SvO2 = 75%
Oxygen Consumption
VO2 = CO x Hgb x 13.8 (SaO2 - SvO2)
5 x 15 x 13.8 x (.98-.75) = 238 ml O2/min
Oxygen Delivery
DaO2 = CO x Hgb x 13.8 x SaO2
45 x 15 x 13.8 x .98 = 1014ml O2/min
O2 Extraction
VO2 / DaO2 = % of O2 extracted
238 / 1014 = 23%
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The Essentials of Lesson: Oxygenation and Transport

Hemodynamic Monitoring Topic: Oxygen Supply and Demand
Practice Pearls
Oxygen Demand
Measuring oxygen consumption in the critically ill patient may be difficult unless the
patient is on a ventilator. In this case a “metabolic assessment" cart is used. In clinical
practice, we can use indirect methods to assess the amount of oxygen that is extracted
at the cellular level. We assume that oxygen extracted is actually consumed. Therefore,
we often use the terms interchangeably.
Determinants of Oxygen Supply

The formula for arterial oxygen content (CaO2) is:
Oxyhemoglobin = Hgb x 1.38 x SaO2
PLUS
Dissolved Oxygen = PaO2 x 0.0031
Hgb = hemoglobin
1.38 = 1 gram of hemoglobin when fully saturated carries 1.38 mLs of oxygen
SaO2 = arterial oxygen saturation
PaO2 = partial pressure of oxygen in the arterial blood
0.0031 = conversion factor for measuring the dissolved oxygen
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Oxygen Delivery
It is important to remember the formula for cardiac output as well as the determinants of
stroke volume.
CO – Cardiac Output
CO – HR x SV
CaOa – Arterial Oxygen Content
CaO2 – (Hgb x 1.38 x SaO2) + (PaO2 x 0.0031)
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Hemodynamic Monitoring Topic: Types of Catheters (SvO2, ScvO2)
Normal SvO2 Range

We always monitor trends rather than a single value. When monitoring SvO2, we want
to notice an upward or downward trend, as well as what the change in SvO2 is in
response to patient interventions.
Insertion Guidelines
If you do not have time to perform the “in vitro” calibration prior to insertion, you can
perform a calibration once the catheter is inserted. The catheter will still provide
necessary information to care for the patient.
The optical signal may be impaired if the tip of the catheter is against the wall of the vein
or artery, or if a small piece of fibrin covers the tip of the catheter. Kinking of the
catheter can interrupt the light emission as well.
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Hemodynamic Monitoring Topic: Causes of DO2/VO2 Imbalance
Causes of Increased or Decreased SvO2

If you note an abrupt increase in the SvO2 value without any warning, check the
pulmonary artery waveform to determine if the catheter has spontaneously “wedged.” If
the value abruptly increased 10-20%, and nothing has changed with the patient, this is
an early warning sign of a wedged catheter. Immediately follow your hospital protocol to
withdraw the catheter slightly.
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Hemodynamic Monitoring Topic: Clinical Applications
Practice Exercise
If it is greater than 30%, the metabolic demands of the tissues are not being met
indicating the tissues are trying to maximize oxygen extraction. On the other hand, if the
O2ER is less than 22%, the metabolic demands are being met or the patient is unable to
extract oxygen as in the case of severe sepsis.
Lesson 7
Pharmacological Management Of
Hemodynamics
• Managing Preload
• Managing Afterload
• Managing Contractility
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Lesson: Pharmocological Management of
Hemodynamics
• Discuss the pharmacological management of hemodynamics
- Identify the indications, contraindications, side effects and

administration guidelines of interventions used to effect preload

administration guidelines of interventions used to effect afterload

administration guidelines of interventions used to effect contractility
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Lesson Take-away - Pharmaceutical Management of Hemodynamics
Topic One: Managing Preload

Introduction
In this lesson we discuss the pharmacological management of hemodynamics and explore the different drugs that can
increase or decrease preload, afterload, and contractility, thereby improving cardiac output and improving the body’s ability
to perfuse vital organs.
Preload
• The force that stretches ventricles during diastole • Is measured on the right side by RAP/CVP and on the
• The amount of blood that fills ventricles during diastole left by the PAOP.
Increasing Preload
• Low PAOP (PAOP <8 mmHg) may be due to:
• Dehydration • Excessive diuresis • Third-spacing • Bleeding
• Preload increased by increasing circulating blood volume.
• Done by administering crystalloid or colloid
Crystalloids
• Crystalloids commonly used to enhance preload:
• Normal saline (NS) • Lactated ringers (LR)
• Hypotonic solutions (D5W, 0.45 NS) are not for use in rapid fluid resuscitation.
• Possible contraindications of LR
• Possible complications of normal saline in large volumes
• Monitor electrolytes closely in patients receiving aggressive fluid resuscitation.
Colloids Expand Intravascular Volume

• Colloids also used to increase preload and expand intravascular volume
• Colloid infusions
• Colloids should be used with caution when patient has altered capillary permeability (cardiopulmonary bypass patients and
patients with septic shock.)
• Dextran and Hetastarch may be counterproductive in hypovolemic patients.
• Guidelines for use of blood products

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Fluid Challenge to Assess and Guide Therapy

• Assessing the response of the PAOP to a “fluid challenge” can help guide therapy.
• Administer fluid rapidly (over 10 to 15 minutes) in predetermined increments (50-250 mL) and monitor the change in PAOP.
• Patient’s individual ventricular compliance curve determines the magnitude of the change in PAOP.
• Implication of:
• Large (>7 mmHg) increase in PAOP • Moderate increases in PAOP • No increase in PAOP
• What to do when fluid ineffective
Pulmonary Dysfunction
• A fluid challenge in patients with severe pulmonary dysfunction often results in increased CO and left ventricular stroke
work index without a significant increase in PAOP
• Indicates that further fluid administration may be beneficial.
• A PAOP of 15 -18 mmHg generally indicates adequate preload and warrants consideration for an afterload reduction with a
vasodilator (for purposes of improving SVI and CI.)
Preload Reducers
• Diuretics (Furosemide) • Nitroglycerin • Morphine sulfate
• Milrinone (a phosphodiesterase inhibitor, Type III) • Nitroprusside (Nipride)
Classification for Estimating Short-term Mortality

• A classification for estimating short-term mortality in patients with acute myocardial infarction was developed to help
provide guidance in medical and nursing decisions about therapy and in providing patient/family support.
• The underlying pathophysiology of subsets II, III, and IV: Increasing severity of left ventricular failure
• 4 Clinical subsets:
• Subset I: CI and PAOP within normal range (PAOP <18 mmHg and CI >2.2 L/min/m2)
• Subset II: CI is maintained >2.2 L/min/m2 but PAOP >18 mmHg
• Subset III: Classic hypovolemia; PAOP <18 mmHg and CI <2.2 L/min/m2
• Subset IV: Cardiogenic shock

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Topic Two: Managing Afterload

Introduction
Here we explore techniques for managing afterload.
Afterload
• The resistance ventricle must overcome to eject blood in the forward direction.
• Two determinants of afterload:
• Volume and mass of blood ejected from ventricle • Compliance of vascular space into which the blood is ejected.
• Right ventricular afterload measured by PVR; left ventricular afterload measured by SVR.
• Pulmonary hypertension reflects in an elevated PVR.
• Cardiac diseases that may cause elevated PVR.
• Pulmonary diseases that may cause an elevated PVR.
Reducing PVR
• Developing an effective therapy for pulmonary hypertension is difficult since pulmonary vasculature reacts less to neural
and pharmacologic stimulation than systemic vasculature does.
• Ways to manage pulmonary hypertension (lower PVR):
• First ensure adequate oxygenation
• If PVR not improving and patient shows signs of right-sided failure, a more aggressive therapy is warranted.
SVR Indications
• High SVR (>1200 dynes/sec/cm5) may reflect physiologic stress or left ventricular failure
• Medications that decrease SVR: nitroprusside, hydralazine, captopril, and to a lesser extent nitroglycerin
• Low SVR (<800 dynes/sec/cm5) may reflect septic shock or excessive administration of afterload reduction medications.
• Medications that increase SVR: dopamine, epinephrine, norepinephrine, phenylephrine, and vasopressin
High PAOP and Low CO

• In patients with high PAOP and low cardiac output, vasodilators such as nitroprusside can improve ventricular function and
reduce abnormally high SVR.
• In patients with a failing heart, either dobutamine or dopamine and nitroprusside can improve cardiac output
• The rationale for combining dopamine/dobutamine and nitroprusside

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Increasing SVR
• Drugs most commonly used to increase SVR:
• Dopamine • Norepinephrine • Vasopressin
• Epinephrine • Phenylephrine
Topic Three: Managing Contractility

Introduction
Here we look at the different factors influencing contractility and explore methods for managing contractility.
Contractility
• The ability to shorten and develop tension within the myocardial cells
• Not possible to directly measure; instead use these indirect measures of contractility:
• SVI • RVSWI • LVSWI
• Patients with poor contractility may also have decreased CI, elevated filling pressures (RAP and PAOP,) and a low SvO2.
• Blood pressure not a reliable indicator of low contractility.
• Conditions generally present with low contractility:
• Myocardial ischemia or infarction • Cardiomyopathy
• Congestive heart failure • Early stages of septic shock
Increasing the Strength of Cardiac Contractions

• Inotropic Agents
• Dobutamine (Dobutrex) • Dopamine • Milrinone (Primacor)
Negative Inotropic Effect

• Seen with hypoxia, acidosis, and hypercapnia so it is important to monitor patient for these conditions and correct promptly.
• A negative inotropic action can be produced by drugs. Closely monitor for hemodynamic stability patients taking these
drugs:
• Beta blockers • Calcium channel • Class I • Barbiturates
inhibitors Antidysrhythmics

Medication Calculation Pocket Lesson: Pharmacological Management of
Card Hemodynamics
Topic: Managing Preload
IV Drip Rate:
gtts/min = Volume to be infused (mL) x drip factor of tubing

Time (min) to be infused
Drug Concentration:
Amount of drug in solution (g, mg, mcg)
Amount of solution (mL)
Information required to calculate IV infusion rates to deliver specific

medication doses:
1. Dose to be infused (e.g. mcg/kg/min, mg/min, mg/h)
2. Concentration of solution (Ex: Dopamine 400 mg/250 D5W = 1.6 mg/mL)
3. Patient’s weight in kilograms
Calculation of mcg/kg/min:
Examples: dopamine, dobutamine, nitroprusside
To calculate dose with infusion already in progress:
_______ mcg/mL x ______mL/h ÷ 60min/h ÷ _____kg = ______mcg/kg/min
concentration pump setting pt weight dosage
To calculate pump setting in mL/h if a given dose is ordered:

_______ mcg/kg/min x _______kg x 60 min/h ÷ _______ mcg/mL = ______ mL/h
dosage pt weight concentration pump setting
Example: Calculate the intravenous infusion rate in mL/h for a 70-kg patient
requiring dobutamine, 5 mcg/kg /min, using a dobutamine drip of
500 mg in 250 mL D5W.
Dosage to be administered: 5 mcg/kg/min

Dobutamine concentration: 500 mg/250 mL = 2 mg/ml or 2000 mcg/mL
Patient weight: 70 kg
Calculation: 5 mg/kg/min x 70 kg x 60 min/h ÷ 2000 mcg/mL = 10.5 mL/h
Answer: Setting infusion pump at 10 mL/h will deliver approximately
5 mcg/kg/min of dobutamine.
Calculation of mcg/min:
Examples: Nitroglycerine, norepinephrine, isoproterenol, epinephrine
To calculate dose with infusion in progress:

_________ mcg/mL x _________ mL/h ÷ 60 min/h = ________ mcg/min
concentration pump setting dosage
To calculate pump setting in mL/h if a given dose is ordered:

_______ mcg/min x 60 min/h ÷ _________mcg/mL = _______ mL/h
dosage concentration pump setting
Example: Calculate the IV infusion rate in mL/hour for a 70-kg patient

requiring nitroglycerine, 50 mcg/min, using a nitroglycerine
admixture of 50 mg in 250 mL D5W.
Dosage to be administered: 50 mcg/min

Nitroglycerine concentration: 50mg/250mL = 0.2 mg/mL or 200 mcg/mL
Calculation: 50mcg/min x 60 min/h ÷ 200 mcg/mL = 15 mL/h
Answer: Setting the infusion pump at 15mL/h results in the delivery of
nitroglycerine at a dose of 50 mcg/min
Calculation of mg/min
Example: lidocaine, procainamide, bretylium

_________mg/mL x ________ mL/h ÷ 60 min/h = ______mg/min
To calculate pump setting in mL/h if a specific dose is ordered:

______mg/min x 60 min/h ÷ _______ mg/mL = ________mL/h
Example: Calculate the IV infusion rate in mL/h for a 70-kg patient requiring a
procainamide, maintenance drip at 2 mg/min.
Maintenance Dose to be infused: 2 mg/min
Procainamide Concentration: 2000 mg/500 mL = 4 mg/mL
Calculation: 2mg/min x 60 min/h ÷ 4 mg/mL = 30 mL/h
Answer: Setting the infusion pump to 30 mL/h will deliver procainamide at 2 mg/min.
Calculation of mg/h
Examples: Theophylline, versed, diazepam, morphine, diltiazem
_________mg/mL x _______mL/h = ______mg/h
To calculate pump setting in mL/h if specific dose ordered:

_______ mg/h ÷ ___________mg/mL = _________mL/h
Example: Calculate the IV infusion rate in mL/h for a 70-kg patient requiring
morphine 5mg/h.
Concentration: 20 mg/100 mL = 0.2 mg/mL.
Calculation: 5 mg/h ÷ 0.2 mg/mL = 25 mL/h
Answer: Setting the infusion pump to 5 mL/h will result in final infustion rate
of 5 mg/h.
Conversion Factors:
1 mg = 1000mcg 1m = 100 cm
1 kg = 2.2 lb 1/150 gr = 0.4 mg
1 gr = 60 mg 1 tsp = 5 ml
1/100 gr = 0.6 mg 1 Tbsp = 15 ml
1 inch = 2.5 cm 1 oz = 30 ml
1 cm = 10 mm 1 mm Hg = 1.36 cm H20
Temperature conversion Table
F C
89.6 32
91.4 33
93.2 34
95. 35
96.8 36
98.6 37
100.4 38
102.2 39
104.2 40
105.8 41
To convert Fahrenheit to Celsius: (F - 32) x 0.5555

To convert Celsius to Fahrenheit: (C x 1.8) - 32
114
The Essentials of Lesson: Pharmacological Management of

Hemodynamic Monitoring Hemodynamics
Topic: Managing Preload
Practice Pearls
Colloids Expand Intravascular Volume

Hetastarch may alter coagulation and result in transient prolongation of prothrombin
time (PT), partial thromboplastin time (PTT), bleeding and clotting times, decreased Hct
and excessive plasma protein dilution. It also increases indirect bilirubin concentrations.
115

Topic: Managing Afterload
Increasing SVR
Epinephrine should not be used as the initial vasopressor for management of
hypotension in the septic patient. It will improve the BP, but decrease mesenteric blood
flow and increase the production of lactate.
Many vasopressor agents can cause an extravasation if there is an infiltration of the IV
catheter and the drug leaks into the surrounding tissue. There are several mechanisms
for treating an extravastation from phentolamine administration to application of
nitroglycerine paste. Check your pharmacy policies to determine the procedure for
managing and extravasation.
116

Topic: Managing Contractility
Increasing the Strength of Cardiac Contractions

Amrinone (Inocor) is another phosphodiesterase inhibitor that may be encountered in
the critical care unit. The properties of amrinone are similar to milrinone. One of the
main considerations when using amrinone is that its half-life is approximately 12 hours.
This means the effects of any infusion rate changes won’t be seen for approximately 12
hours.
117
The Essentials of
Hemodynamic Monitoring Glossary
Afterload The force against which a ventricle contracts that is contributed to

by the vascular resistance especially of the arteries and by the
physical characteristics (as mass and viscosity) of the blood
(Merriam Webster's Medical Dictionary, 2005)
Air embolus Air entering the venous or arterial system inadvertently through an
arterial or venous line. (GE Healthcare - Medcyclopaedia, 2008)
Allen's test (for occlusion of ulnar or radial arteries) The patient makes a tight
fist so as to express the blood from the skin of the palm and fingers;
the examiner digitally compresses either the radial or the ulnar
artery. When the patient unclenches the fist, if blood fails to return
to the palm and fingers, there is indicated obstruction to blood flow
in the artery that has not been compressed. (Dorland's Illustrated
Medical Dictionary, 30th ed., 2003)
Arterial blood The pressure in the larger arteries, arteries being the blood vessels
pressure which take blood away from the heart (Wikipedia, 2008)
Artifact An electrocardiographic wave that arises from sources other than

the heart (Merriam Webster's Medical Dictionary, 2005)
Body surface The measured or calculated surface of a human body. A commonly

area (BSA) used formula is the Mosteller formula, published in 1987: BSA = the
square root of (Weight (lbs) x Height (in.)/ 3131) (Wikipedia, 2008)
Cardiac index A formula used to achieve an accurate estimate of blood flow in

(CI) proportion to body surface area (BSA). CI = cardiac output/BSA.
(Moser & Riegel, Cardiac Nursing, 2008)
Cardiac output The volume of blood ejected from the left side of the heart in one
minute (Merriam Webster's Medical Dictionary, 2005)
118
Cardiac Mechanical compression of the heart by large amounts of fluid or

tamponade blood within the pericardial space that limits the normal range of
motion and function of the heart (Merriam Webster's Medical
Dictionary, 2005)
Cardiogenic Shock resulting from failure of the heart to pump an adequate

shock amount of blood as a result of heart disease and especially heart
attack (Merriam Webster's Medical Dictionary, 2005)
Central Venous The oxygen saturation of venous blood as it is measured at the

Oxygen superior vena cava. Unlike SvO2, which is measured using a
Saturation pulmonary artery catheter, ScvO2 is measured using a central
(ScvO2) venous catheter. Normally the ScvO2 and SvO2 are the same.
However in the critically ill patient who may have severe sepsis or in
shock, the ScvO2 tends to run higher than the SvO2 by 5% to 13%
with an average of 7.5%.
Central Venous The venous pressure of the right atrium of the heart obtained by
Pressure (CVP) inserting a catheter into the median cubital vein and advancing it to
the right atrium through the superior vena cava (Merriam Webster's
Medical Dictionary, 2005)
Computation A correction factor determined by the Cardiac output computer

constant manufacturer, selected based on the catheter size and model, the
type of injectate delivery system, and the volume and temperature
of the injectate
Congestive heart Heart failure in which the heart is unable to maintain adequate
failure (CHF) circulation of blood in the tissues of the body or to pump out the
venous blood returned to it by the venous circulation (Merriam
Webster's Medical Dictionary, 2005)
Contractility The capability or quality of shrinking or contracting; especially : the

power of muscle fibers of shortening into a more compact form
Deadender cap A terminal cap that does not allow air into the line or blood to leak
out of the port.
119
Diastole The passive rhythmical expansion or dilation of the cavities of the

heart during which they fill with blood (Merriam Webster's Medical
Dictionary, 2005)
Dye dilution A method of measurement of cardiac output in which an injection of

a known quantity and concentration of indocyanine green or lithium
is made into the bloodstream. Flow and volume are calculated by
measuring the dye concentration at selected time intervals
Fast flush The pressure in the arterial line is rapidly increased to 300 mmHg by
flushing the system with the continuous flow mechanism and the
resulting waveform was analyzed to determine the response of the
system; ideally, one large and one small oscillation should occur,
after which the waveform should be returned to the baseline (Critical
Care. 2006;10(2):R43. ©2006 BioMed Central, Ltd.)
Fick method A generalization in physiology which states that blood flow is

proportional to the difference in concentration of a substance in the
blood as it enters and leaves an organ and which is used to
determine cardiac output from the difference in oxygen
concentration in blood before it enters and after it leaves the lungs
and from the rate at which oxygen is consumed. Fick, Adolf Eugen
(1829-1901), German physiologist. A professor of physiology, Fick
was an advocate of the school of physiology that sought to
determine quantitatively the fundamental capabilities of the
organism's components and then explain these on the basis of
general physicochemical laws of nature. Fick did research in fields of
notable diversity: molecular physics, including the diffusion of water
and gases, porous diffusion, endosmosis, and filtration;
hydrodynamics as applied to the motion of fluids in rigid and/or
elastic vessels; the origin and measurement of bioelectric
phenomena; optics; the theory of heat in physics and physiology;
and sound. In 1856 he published a work that is often considered to
be the first textbook of biophysics. In it he stated the fundamental
laws governing diffusion, one of which is now known as Fick's law.
Fick made outstanding contributions in hemodynamics, and in 1870
he stated the Fick principle for the measurement of cardiac output.
120
Hemodynamic Related to the forces or mechanisms involved in circulation (Merriam

Hemothorax The blood in the pleural cavity (Merriam Webster's Medical

Dictionary, 2005)
Hydrodynamic Related to a branch of physics that deals with the motion of fluids
and the forces acting on solid bodies immersed in fluids and in
motion relative to them (Merriam Webster's Medical Dictionary,
2005)
Hypercoaguable The state of being more readily coagualated than normal (Dorland's
state Illustrated Medical Dictionary, 30th ed., 2003)
Hyperdynamic Marked by abnormally increased muscular activity especially when of

organic origin (Merriam Webster's Medical Dictionary, 2005)
Hypotension Abnormally low pressure of the blood (Merriam Webster's Medical

Dictionary, 2005)
Hypovolemic A state of decreased blood volume; more specifically, decrease in

shock volume of blood plasma. (Wikipedia, 2008)
Ischemic Deficient supply of blood to a body part (as the heart or brain) that
is due to obstruction of the inflow of arterial blood (as by the
narrowing of arteries by spasm or disease) (Merriam Webster's
Korotkoff sounds Arterial sounds heard through a stethoscope applied to the brachial
artery distal to the cuff of a sphygmomanometer that change with
varying cuff pressure and that are used to determine systolic and
diastolic blood pressure. Korotkoff, Nikolai Sergeievich (1874-
1920), Russian physician. Korotkoff introduced the auscultation
method of determining blood pressure in 1905. (Merriam Webster's
121
Low compliance Stiff tubing that is used in hemodynamic monitoring. The rigidity of
tubing the tubing will not “absorb the wave” of pressure and create
inaccurate readings. With stiff tubing, the “wave” travels all the way
to the transducer so that accurate values are obtained.
Mean arterial The average pressure within an artery over a complete cycle of one
pressure (MAP) heartbeat; in the brachial artery, MAP = diastolic pressure +
((Systolic Pressure - Diastolic Pressure)/ 3) (Dorland's Illustrated
Mixed venous The oxygen saturation of venous blood as it returns to the heart as
oxygen measured at the vena cava. SvO2 represents the difference between
saturation oxygen delivery and oxygen consumption. SvO2 = DO2 - VO2.
(SvO2)
Multi-lumen A type of central venous catheter that may have two, three or four
catheter ports. The most common configuration is the triple lumen (3
lumens) catheter. This catheter allows for simultaneous medication/
fluid infusions as well as one port to be used for continuous CVP
monitoring.
Overdamped An oscillatory system, in which damping or the effect that to reduces

system the amplitude of oscillations, is excessive. For hemodynamic
monitoring, in an overdamped system, there will be slurring or
sluggishness in the readout when the flush device is released. There
will be a sluggish oscillation if any at all.
Oxygen The amount of oxygen extracted (consumed) at the tissue level.

Consumption VO2 = Hgb x 1.38 (SaO2 - SvO2) x CO x 10. Normal VO2 is 25% of
(VO2) DO2 or 250 mL/min.
Oxygen delivery The amount of oxygen delivered to the tissues in one minutes. DO2
(DO2) = Hgb x 1.38 x SaO2 x CO x 10. Normal DO2 = 1000 mL/min.
Oxygen demand The amount of oxygen the cells require to meet their metabolic
process.
122
Oxygen A measure of the degree to which oxygen is bound to hemoglobin,

Saturation usually measured by a pulse oximeter, given as a percentage
(SaO2) calculated by dividing the maximum oxygen capacity into the actual
oxygen content and multiplying by 100. (Dorland's Illustrated
Phlebostatic axis An anatomic landmark located near the midaxillary line and fourth
intercostal space. (Wikipedia, 2008)
Pneumothorax A condition in which air or other gas is present in the pleural cavity
and which occurs spontaneously as a result of disease or injury of
lung tissue, rupture of air-filled pulmonary cysts, or puncture of the
chest wall or is induced as a therapeutic measure to collapse the
lung (Merriam Webster's Medical Dictionary, 2005)
Positive end- A technique of assisting breathing by increasing the air pressure in

expiratory the lungs and air passages near the end of expiration so that an
pressure (PEEP) increased amount of air remains in the lungs following expiration
Preload The stretched condition of the heart muscle at the end of diastole
just before contraction (Merriam Webster's Medical Dictionary,
2005)
Pressure An electronic device that converts pressure (such as blood

transducer pressure) into electrical signals that can be recorded graphically and
monitored. (Dorland's Illustrated Medical Dictionary, 30th ed., 2003)
Pulmonary Pulmonary artery catheterization is the insertion of a catheter into a

artery catheter pulmonary artery. Its purpose is diagnostic; it is used to detect
heart failure or sepsis, monitor therapy, and evaluate the effects of
drugs. The pulmonary artery catheter allows direct, simultaneous
measurement of pressures in the right atrium, right ventricle,
pulmonary artery, and the filling pressure ("wedge" pressure) of the
left atrium. The pulmonary artery catheter is frequently referred to
as a Swan-Ganz catheter, in honor of its inventors Jeremy Swan and
William Ganz, from Cedars-Sinai Medical Center. (Wikipedia, 2008)
123
Pulmonary Increased pressure (above 30 mm Hg systolic and 12 mm Hg

hypertension diastolic) within the pulmonary arterial circulation. (Dorland's
Illustrated Medical Dictionary, 30th ed., 2003)
Pulmonary The vascular resistance of the systemic circulation: the difference

vascular between the mean arterial pressure and central venous pressure
resistance (PVR) divided by the cardiac output. (Dorland's Illustrated Medical
Dictionary, 30th ed., 2003)
Retroperitoneal Bleeding in the anatomical space behind (retro) the abdominal

bleeding cavity. Retroperitoneal bleeding, such as from a ruptured aortic
aneurysm shows as Grey Turner's sign (flank bruising). Causes
include: blunt abdominal trauma, ruptured abdominal aortic
aneurysm, ruptured/ hemorrhagic ectopic pregnancy, spontaneous
bleeding secondary to coagulopathy (congenital or acquired).
(Wikipedia, 2008)
Seldinger A method for introducing a catheter into a hollow lumen structure or

technique body cavity; a narrow needle is used to enter the structure, a
guidewire is passed through the needle, the needle is removed, and
the catheter is advanced over the wire. Used in angiography,
cardiac catheterization, and cannulation of the central venous
system. (Dorland's Illustrated Medical Dictionary, 30th ed., 2003)
Septic shock A life-threatening severe form of sepsis that usually results from the
presence of bacteria and their toxins in the bloodstream and is
characterized especially by persistent hypotension with reduced
blood flow to organs and tissues and often organ dysfunction
Square wave Activation of the fast flush device on the transducer for 1 to 2
test seconds, which causes the monitor wave form peak out at maximum
pressure. The waveform will “bounce” back from the peaked level
and oscillate back and forth before resuming the readout of the
pressure waveform. The evaluation of this “bounce back” reflects
the dynamic response of the system. An optimally damped system
will drop straight to the bottom when the flush device is released, it
will then bounce no more than twice before returning to the
waveform. (aka: dynamic response testing)
124
Strip recorder A feature of the hemodynamic monitor that allows the user to
document the waveform on paper for further analysis
Stroke Volume The volume of blood pumped from a ventricle of the heart in one
beat (Merriam Webster's Medical Dictionary, 2005)
Stroke Volume The stroke volume per heartbeat corrected for body surface area;
Index usually expressed in mL per beat per square meter. (Dorland's
Illustrated Medical Dictionary, 30th ed., 2003)
Systemic The resistance, offered by the peripheral circulation, to flow that

Vascular must be overcome to push blood through the circulatory system
Resistance (Wikipedia, 2008)
(SVR)
Systole The contraction of the heart by which the blood is forced onward and
the circulation kept up (Merriam Webster's Medical Dictionary,
2005)
Thermodilution Relating to or being a method of determining cardiac output by

measurement of the change in temperature in the bloodstream after
injecting a measured amount of cool fluid (as saline) (Merriam
Thermodilution A catheter used in thermodilution for introduction of the cold liquid

catheter indicator into the cardiovascular system. (Dorland's Illustrated
Transducer A device that is actuated by power from one system and supplies
power usually in another form to a second system (Merriam
Underdamped An oscillatory system, in which damping or the effect that to reduces

system the amplitude of oscillations, is insufficient. For hemodynamic
monitoring, in an underdamped system, there will be extreme
oscillations (more than 2-3) when releasing the fast forward flush
device. Waveforms will appear spiked and sharp.
125
Vasopressors Agents that cause a rise in blood pressure by exerting a

vasoconstrictor effect (Merriam Webster's Medical Dictionary, 2005)
Venous Oxygen The amount of oxygen remaining after the blood has passed through
Transport the tissues. This represents the oxygen reserve for the body.
Venous Oxygen Transport = Hgb x 1.38 x SvO2 x CO x 10. Normal
Venous Oxygen Transport = 750 mL/min.
Water An instrument for measuring the pressure or tension of liquids or

manometer gases, as of the blood, that uses changes of height of a column of
water to measure pressure. (Dorland's Illustrated Medical Dictionary,
30th ed., 2003)

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Notebook

Basic Hemodynamic Monitoring

Lesson 1 - Basics of Hemodynamic Monitoring Systems

Lesson 2 - Arterial Pressure Monitoring

Lesson 3 - Central Venous Catheters

Lesson 4 - Pulmonary Artery Catheters

Lesson 5 - Cardiac Output Monitoring

Lesson 6 - Oxygenation And Transport

Lesson 7 - Pharmacological Management Of Hemodynamics

Lesson Objectives Module: Hemodynamic Monitoring

Upon completion of this lesson you will be able to:

• Identify and describe the components of a hemodynamic monitoring

- Describe the basic elements of hemodynamic pressure monitoring

- Identify mechanisms used to ensure accurate pressure measurements.

Lesson Takeaway - Basics of Hemodynamic Monitoring Systems

Topic One: Basic Components of Hemodynamic Pressure Monitoring Systems

Pressure Monitoring Systems

Closed Fluid Filled Monitoring System

Catheter for Pressure Monitoring

© 2008 American Association of Critical-Care Nurses (AACN). All rights reserved.

Hemodynamic Monitoring Kit

Flushing to Maintain Patency of the Catheter

Transducer Cable, Amplifier and Monitor

© 2008 American Association of Critical-Care Nurses (AACN). All rights reserved.

Topic Two: Obtaining Accurate Hemodynamic Values

Obtaining Accurate Hemodynamic Values

Hydrodynamic Pressure and Principles of Fluid in Motion

Factor Affecting Frequency Response

© 2008 American Association of Critical-Care Nurses (AACN). All rights reserved.

Dynamic Response Testing

Leveling the Transducer

Effects of Position Changes on Hemodynamic Monitoring

© 2008 American Association of Critical-Care Nurses (AACN). All rights reserved.

© 2008 American Association of Critical-Care Nurses (AACN). All rights reserved.

Troubleshooting Fluid-Filled Lesson: Basics of Hemodynamic Monitoring Systems

Hemodynamic Monitoring Troubleshooting Guide

Inappropriate zero. Zero the transducer Re-zero the transducer.

Faulty transducer. Change transducer.

No cable, cable not Check cable connections. Change cable, refer to

Improper scale Utilize appropriate scale for Place scale at appropriate

Problem Cause Prevention Intervention

Leak in tubing / set. Tighten all connections. Check to assure all

Improper zero. Periodically re zero the Check zero, rezero as

Excess catheter Catheter may require

Change in Catheter migration to a Reposition the patient.

Loose connections in Tighten connections.

Problem Cause Prevention Intervention

Stop cock turned off to Turn stop cocks off to

Pressure bag deflated Check pressure bag

Prolonged therapy Discontinue invasive catheters

Contaminated flush Change flush bags and

Monitor for signs and

The Essentials of Lesson: Basics of Hemodynamic Monitoring Systems

Pressure Monitoring Systems

Catheter for Pressure Monitoring

Flushing to Maintain Patency of the Catheter

The Essentials of Lesson: Basics of Hemodynamic Monitoring Systems

Dynamic Response Testing

Included in this Lesson:

• Complications Or Arterial Monitoring

• Waveforms And Clinical Applications

• Direct Vs. Indirect Measurement Of Arterial Pressure

• Obtaining Blood Samples

• Arterial Catheter Removal