Bedside Hemodynamic

Monitoring

Khaldon Hamdan
Bedside Hemodynamic Monitoring
Definition

• The use of an indwelling catheter to measure

– pulmonary artery pressure

– pulmonary capillary wedge pressure

– right atrial pressure

– pulmonary artery oxygen saturation

– thermodilution cardiac output in the intensive care unit.

Indications:

processes that alter preload, afterload,

contractility and heart rate
and lead to:
• Decreased cardiac output
• Deficient fluid volume or excess fluid volume
• Ineffective tissue perfusion
Levels of Bedside Hemodynamic
Monitoring Based on the Needs of the
Patient

• Simplest: monitor heart rhythm, CVP

and arterial pressure

• Thermodilution pulmonary artery catheter

• Various measurements of cardiac output and

continuous measurement of pulmonary artery
oxygen saturation
Purpose of monitoring
• Evaluate cardiovascular system
– Pressure, flow, resistance
• Establish baseline values and evaluate trends
– Determine presence and degree of dysfunction
• Implement and guide interventions
– Provides criteria for determination of CV efficacy
Hemodynamic Monitoring Terms and Definitions

• Preload: the volume of blood either in the right atrium

or in the left ventricle at the end of diastole or the
beginning of systole. Preload is quantified with central
venous pressure (CVP) and pulmonary artery occlusive
pressure (PAOP), respectively; these parameters reflect a
patient’s volume status. The end-diastolic volume (EDV)
is related to the amount of stretch of the sarcomeres.
Preload is a reflection of all of the elements that affect
tension of the chamber wall at the end of filling (diastole).
 • Afterload: the amount of work the heart must do
to eject blood; the impedance or resistance to
ventricular contraction. Afterload reflects all of the
elements that affect tension of the myocardial wall
during systole.

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• Contractility: the ability of the myocardial muscle
to shorten itself or the amount of strength
produced by the myocardium when it ejects blood. It
is influenced by neural factors and certain metabolic
states (e.g., hypoxia, hypercarbia, or decrease in
pH).

• Cardiac output: the amount of blood ejected by

the heart each minute.
Equipment for Bedside Hemodynamic
Monitoring

• Invasive catheter
• High pressure tubing with flush solution
• Transducer to convert information to
electrical energy signal
• Bedside monitor
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Principles
– Unobstructed fluid filled system will reflect
change in pressure at distal tip of system
(catheter) throughout the system

– Pressure change may be detected at

proximal end of system, transformed into
electrical signal and displayed as a
waveform
Accuracy of Readings

• Calibration of equipment to
atmospheric pressure (zeroing)

• Determination of a consistent point of reference, the phlebostatic axis,

for baseline reference point at the level of the atria (4th ICS, mid
axillary line ) (leveling)

• Leveling at the phlebostatic axis is performed to eradicate the effects of

hydrostatic forces on the hemodynamic pressures

• Positioning

Majority of patients don’t need head of bed to be decreased to (0) level.

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Square Wave Test

• A square wave test (also referred to as a fast flush or

dynamic response test) is performed to assure that the
waveforms that appear on the monitoring screen
accurately reflect pulmonary artery pressures (AACN,
2004). It is accomplished by pulling and releasing the
pigtail or squeezing the button of the flush device so that
the flow through the tubing is increased (from 3 mL/hr
obtained with a pressure bag inflated to 300 mm Hg).
• This causes a sudden rise in pressure in the system,
such that a square wave is generated on the monitor
oscilloscope. An acceptable response is the pressure
waveform reverting to baseline within one to two
oscillations. If the response is lacking in shape,
amplitude, or time to return to baseline, the ICU
nurse should troubleshoot the system until an
acceptable response is achieved.
 Square Wave Test

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• If an underdamped or overdamped waveform is
present, hemodynamic measurements will not be
accurate. It is recommended that a square waveform
test be performed when the system is being initially
set up, at least once a shift, after opening the
catheter system (e.g., for rezeroing, blood sampling,
or changing tubing), and whenever the pressure
waveform appears to be damped or distorted
• An overdamped waveform is sluggish and has an
exaggerated or falsely widened and blunt tracing. It
will cause the patient’s systolic blood pressure (SBP)
to be recorded as falsely low and the diastolic blood
pressure (DBP) to be recorded as falsely high.
Causes of an overdamped waveform include the
presence of large bubbles in the system, loose
connections, no or low fluid in the flush bag, low
pressure of the flush solution pressure bag, or a kink
in the catheter.
Square Wave Test
• An underdamped waveform consists of an over-
response, which is seen as an exaggerated, narrow,
artificially peaked tracing. In this case, the waveform
overestimates the patient’s SBP and underestimates
the DBP. Causes of an underdamped waveform
include the presence of small bubbles in the system,
the pressure tubing being too long, or a defective
transducer
Square Wave Test
Hemodynamic Parameters and Normal Values
Derived Hemodynamic Parameters
Oxygenation Parameters
Intraarterial BP Monitoring

• Indications: conditions that compromise cardiac output, tissue

perfusion or fluid volume status

• Continuous pressure evaluation

– Tissue perfusion status

• Trends in blood pressure

• Efficacy of drugs, interventions

• Frequent blood samples required

Arterial pressure
• Placement of catheter
– Radial
– Brachial
– Axillary
– Femoral
– Dorsalis pedis
• Evaluate distal circulation prior to placement
– Allen’s test for radial catheter
• May be incorrect as many as 14% of patients
• Requires continued evaluation of distal
circulation!
 Catheter insertion

– Typically catheter over needle

– Catheter size based on size of artery
– For adults:
• Radial 20 gauge maximum
• Brachial, femoral 18 gauge maximum
• Posterior tibial 22 gauge maximum

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Arterial waveform
• Morphology (shape) of waveform
– Depends on force generated by ventricle
– Speed of ejection
– Volume of blood ejected
– Compliance of arterial vessels
– Rate of forward blood runoff – dependent on resistance to
forward flow or systemic vascular resistance
 Arterial Line Wave

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• Dicrotic notch: An area on the downstroke of the

arterial waveform that results from the slight

pressure increase created by closure of the aortic

valve.
Measures
• Systolic pressure
– Reflects volume and speed of ejection,
compliance of aorta

• Diastolic pressure
– Reflects vascular resistance and competence of
aortic valve
Pulse pressure

– Reflects difference in volume ejected from LV

into arterial vessels and volume that exits
simultaneously
– Function of SV and SVR
– Wide PP – increase in SV and decrease in SVR
– Narrow PP – Decreased SV and increased SVR
Mean Arterial Pressure (MAP)

– Best indicator of tissue perfusion

– Average driving pressure of blood during cardiac

cycle

– MAP is the driving force for peripheral blood flow and

the preferred pressure to be evaluated in unstable
patients.

– Time weighted – diastole is longer

 MAP
 MAP = DBP + pulse pressure/3

• BP = 90/70 mmhg --- MAP = 77 mmhg

• BP = 150/40 mmhg --- MAP = 77 mmhg

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Assessment of Arterial Waveforms
• Damped waveform
• Underdamped waveform
(overshoot or fling)
• Evaluate mean arterial pressure
Pulsus alternans

• Is believed to be a sign of decreased myocardial

contractility. A paradoxical pulse is an exaggeration
of the normal variation in the pulse during the
inspiratory phase of respiration, in which the pulse
becomes weaker as the person inhales and stronger
as the person exhales.
 • Pulsus alternans is an indicator of the presence of

severe ventricular systolic failure and can be a sign

of several conditions, including cardiac tamponade,

which is a concern following cardiac surgery.

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Complications

• ischemia or thrombosis of the affected extremity

• Infection

• bleeding.

• Prolonged hyperextension of the wrist can cause

nerve conduction deficits.
 Complications

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Nursing care
• Preparation and maintenance of fluid filled system
• Collection and evaluation of data
• Care of catheter and site
• Neurovascular evaluation
• Prevention of complications
Central Venous Pressure Monitoring
• Indications
– Preload of RV
– Indication of fluid volume state
• Catheters
• Single lumen
– Rapid, high volume fluid resuscitation, pressure monitoring
• Multi-lumen
– Simultaneous blood and fluid administration, drug therapy,
nutritional support or pressure monitoring
 CVC

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 • Insertion techniques and sites
Seldinger technique
• Exploring needle, guide or J wire, dilator, catheter
system

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 • Most common sites
– Internal jugular vein
– Subclavian vein

• Monitoring CVP
– Water vs. mercury CVP
– High and low readings

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Central venous waveform
• Actually 3 separate waves
– a wave – atrial contraction
– c wave – ventricular stroke.
– v wave – atrial filling
Values
• CVP values
– Adult 2-5 mmHg (3-8 cmH2O)
Nursing care
• Preparation and maintenance of fluid filled system
• Collection and evaluation of data
• Care of catheter and site
• Prevention of complications
 Complications

• Pneumothorax
– Incidence 0.5 to 6%
– Intervention
• None
• Needle decompression
• Tube thoracostomy

– Sudden dyspnea, chest pain, absent breath sounds,

tachycardia, asymmetrical chest wall movement
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• Infection
– Nosocomial infection
• From skin
• From stopcocks
• Catheter migration
– Forward migration into RA or RV
• Endocardial irritation – PVCs, VT
• May be intermittent if catheter floats freely in ventricle,
disrupt rhythm with movement or cough
• Vessel erosion or perforation
– Central vessels
– RA or RV wall
• Cardiac tamponade
• ~ 95% mortality tamponade from chamber perforation
– New pleural effusion or pericardial effusion soon after
placement
• Hemorrhage
– Carotid artery puncture during insertion (internal
jugular vein)
– Remove catheter and apply direct pressure for
minimum of 10 minutes
– Monitor airway for patency and observe for
hematoma formation
• Venous air embolus
– ITP lower than atmospheric during inspiration, ITP is
reflected on thoracic vessels
– Venous circulation open to atmosphere (needle or catheter)
• Pressure gradient between vessel and atmosphere
• Gas will enter circulation as a bolus and enter R heart
and PA
• Acute dyspnea, tachypnea, tachycardia, hypotension,
chest pain, arrest, death
Pulmonary artery pressures
• Means to evaluate fluid status
– Indicator of preload
• LV function
– PAOP, PCWP, wedge
• CO measurement
– Thermodilution technique
– Intermittent or continuous
 Pulmonary Artery
Pressure Monitoring
Indications
• Hypovolemic shock
• Early septic shock
• Advanced septic shock or multisystem failure
• Cardiogenic shock
• Acute respiratory distress syndrome
(non-cardiogenic shock)

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PA catheters
• Multi-lumen, polyvinylchloride catheters with balloon
at the tip
– Flow directed catheter
– Inflation of balloon ensures that blood flow will
move the catheter forward in the direction of blood
flow
• Typically bonded with heparin
• Lumens from 2-7
• Length from 60-110 cm
• Size from 4-8 French
• Most commonly 4 lumens
– Balloon lumen for
inflation
– Distal lumen in PA
– Proximal lumen in RA –
drug infusion, CVP
monitoring
– Thermistor to measure
blood temperature
• Other lumens may be used for
– Temporary transvenous
pacing
– Measurement of RVEDV and
RVEF
– Continuous measurement of
SvO2 (mixed venous oxygen saturation)
Insertion of catheter
• Right heart catheterization
– Typically place via subclavian or internal jugular
veins
– Introducer placed in the vessel
• Seldinger technique

– Catheter through introducer into vein

• Prior to insertion
– Flush all lumens with solution
– Check integrity of balloon
– Always deflate passively!
– Prepare fluid filled system that has been leveled
and zeroed
• PA catheter inserted
– Waveform at distal tip visualized continuously
– Balloon fully inflated when CVP wave is visualized
– Catheter advanced with balloon inflated – blood
flow will carry or “float” the catheter through RA, RV
and into PA
• Waveforms used to determine location of catheter
– RA – a, c and v waves
– RV – 25/0
– PA – see change in diastolic pressure due to
closure of pulmonic valve
– PAOP – wedge position
• PAOP should only be visualized when balloon is
inflated
– Indicates blood flow obstructed in the vessel
– Reflects LA pressure/volume
• High – LV failure
• Low - hypovolemia

– PA waveform should return when balloon deflated

Pulmonary artery occlusion pressure (PAOP)
Pulmonary capillary wedge pressure (PCWP)
Pulmonary artery wedge pressure (PAWP)
Measures
• During insertion
– RA, RV and PA pressure, PAOP
• Post insertion
– PA pressures - continuously
– PAOP – intermittently
– Thermodilution CO
Normal values
• PA systolic pressure – 15-30 mmHg
• PA diastolic pressure – 5-15 mmHg
• PAOP 4-12 mmHg
• Collection and evaluation of data
– Respiratory variation in pressure
– Measure all values at end-expiration
• Care of catheter and site
– Similar to CVC
• Prevention of complications
Complications
• Similar to CVC
– Pneumothorax
– Infection
– Vessel erosion or perforation
– Venous air embolus
– Hemorrhage
Other complications
• Cardiac dysrhythmias
– Up to 68% during insertion
– Irritation of endocardium
– Ventricular or atrial
– May occur if catheter migrates
back to RV
• Bundle branch blocks
– Conduction slowed due to irritation of Bundle of
HIS
– Usually RBBB
– Problem if pre-existing LBBB
• Produces complete heart block
• Pulmonary ischemia or infarction
– Catheter migrates to occlusion position for long periods
– Must be re-positioned ASAP!
• Rupture of pulmonary artery
– Rare - < 0.2% of patients
– Mild to massive hemoptysis
• May require emergent thoracotomy
Thermodilution CO
• Cardiac Output (CO
– Volume of blood ejected by heart in 1 minute
– SV x HR = CO
–
• Thermodilution technique
– Uses PA blood temperature change to calculate
CO
– Inject iced, cool or room temp solution into RA
– Thermistor detects temp changes in blood and
produces thermal curve
– Injection at end-expiration
– Use average of at least 3 values
– CO inversely proportion to size of curve
• Low CO – large curve
– Takes longer for blood temp to return to baseline

• High CO – small curve

– Takes less time for blood temp to return to baseline
Normal values
• CO norms
– Newborn 0.7-0.8 L/minute
– 1 year 1.3-1.5 L/minute
– 5 years 2.5-3.0 L/minute
– 10 years 3.8-4.0 L/minute
– 15 years 5.0-6.0 L/minute
– Adult 4-8 L/minute
• Cardiac index
– CO divided by body surface area
• The DuBois and DuBois formula:
• BSA = 0.007184 x (Weight (kg) 0.425 x Height (cm) 0.725)

– Normal 2.5-4 L/min/m2

– Individualizes CO values based on body size
DuBois Body
Surface Area
Nomogram
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