DEFINITION

Hemodynamic monitoring refers to measurement of pressure, flow and oxygenation of blood

within the cardiovascular system. OR Using invasive technology to provide quantitative
information about vascular capacity, blood volume, pump effectiveness and tissue perfusion.
OR Hemodynamic monitoring is the measurement and interpretation of biological sytems
that describes the performance of cardiovascular system

Purpose of monitoring
• Early detection, identification and treatment of life threatening conditions such as heart
failure and cardiac tamponade
• Evaluate the patient’s immediate response to treatment such as drugs and mechanical
support.
• Evaluate the effectiveness of cardiovascular function such as cardiac output and index.

Indications
All types of shock:
– Cardiogenic shock
– Distributive shock
– Obstructive shock
– Hypovolemic shock

Types of Hemodynamic Monitoring

• Non-invasive = clinical assessment & NBP
• Direct measurement of arterial pressure
• Invasive hemodynamic monitoring
►Continuous vs. intermittent
►Invasive vs. noninvasive
►Never therapeutic but may be diagnostic 12

Noninvasive Hemodynamic Monitoring

• Noninvasive BP
• Heart Rate, pulses
• Mental Status
• Mottling 13
• Skin Temperature
• Capillary Refill
• Urine Output
• Pulse Oxymetry

Pulse Oxymetry
• Estimates Oxyhemoglobin as SpO2
• Target SpO2 > 92%
• Heart rate displayed should be same as pulse rate captured by the probe.
Oxyhemoglobin Saturation Curve
Oximeter Sensors
Pulse Oximetry Sources of error
• Physiological/ anatomical
• Vasoconstriction
• Poor perfusion
• Abnormal hemoglobin
• Skin pigmentation
• Cold extremities
• External causes
• Motion artifact
• Excessive external light

Automated Blood Pressure measuring devices

• Intermittent measurements
• Appropriate cuff size necessary
• Less accurate during hypotension, arrhythmias

Proper Fit of a Blood Pressure Cuff

• Width of bladder = 2/3 of upper arm
• Length of bladder encircles 80% arm
• Lower edge of cuff approximately 2.5 cm above the antecubital space

Invasive Arterial Blood Pressure Monitoring

Indications

• Frequent titration of vasoactive drips

• Unstable blood pressure
• Frequent ABGs or labs
• If unable to obtain Non- invasive BP
Sites
– Radial artery
– Brachial artery
– Femoral
– Dorsalis pedis artery
Complications
– Hematoma/blood loss
– Thrombosis
– distal ischemia
– Arterial injury
– Infection
Tubing and transducer should be replaced every 96 hours.

ARTICLES
• Arterial Catheter
• Pressure Tubing
• Pressure Cable
• Pressure Bag
• Flush – 500cc NS
• Sterile Gown
• Sterile Towels
• Sterile Gloves
• Suture (silk 2.0)
• Chlorhexidine Swabs
• Mask

Leveling and Zeroing

• Leveling – Before/after insertion – If patient, bed or transducer move
• Zeroing – Performed before insertion & readings
• Level and zero at the insertion site
• Phlebostatic Axis
•Re-level the transducer with any change in the patient’s position
•Referencing the system 1 cm above the left atrium decreases the pressure by 0.73 mm Hg
•Referencing the system 1 cm below the left atrium increases  the pressure by 0.73 mm Hg
Angles 45° 30° 0° Importance of zeroin.

Arterial pressure measurement

• The systolic pressure is measured at the peak of the waveform.
• This pressure reflects the function of the left ventricle.
• NORMAL value=100-130 mmHg
• The LOWEST point on the waveform represents the end diastolic pressure
. • This pressure reflects systemic resistance.
• Normal diastolic pressure is 60-90 mmHg

Important Concepts
Dicrotic notch
• The small notch on the downstroke of the wave form.
• It represents the closure of the aortic valve.
• This is the reference point between the systolic and diastolic phases of the cardiac cycle.
Mean Arterial Pressure/MAP
• Is a calculated pressure that closely estimates the perfusion pressure in the aorta and its
branches
• It represents the average systemic arterial pressure during the ENTIRE CARDIAC
CYCLE. • Normal MAP = 70-100 mmHg • MAP MUST be maintained above 60 for the
major organs to perfuse.

Invasive BP monitoring
• Invasive monitoring is more accurate
• Invasive BP should by higher than cuff BP
• If cuff BP is higher look for equipment malfunction or technical error
• A dampened wave form can indicate a move toward hypotension…an immediate cuff
pressure should be obtained

Documentation
• Insertion procedure note
• Arterial BP readings as ordered
• Neurovascular checks every two hours (in musculoskeletal assessment of HED)
• Pressure line flush amounts (3ml/hr)
• Tubing and dressing changes
 Nursing Implications
• Prevent or reduce the potential for complications.
• Maintain 300mmHg on bag
• Maintain continuous flow through tubing
• Aseptic dressing change
• Sterile caps on openings
• Change tubing 96 hrs.
• 5 min hold on discontinued site

Equipment Needed SET-UP FOR HEMODYNAMIC PRESSURE MONITORING

1.Obtain Barrier Kit, sterile gloves, Cordis Kit and correct swan catheter. Also need extra IV
pole, transducer holder, boxes and cables
2. Check to make sure signed consent is in chart, and that patient and/or family understand
procedure.
3. Everyone in the room should be wearing a mask!
4. Position patient supine and flat if tolerated.
5. On the monitor, press “Change Screen” button, then select “Swan Ganz” to allow
physician to view catheter waveforms while inserting.
6. Assist physician (s) in sterile draping and sterile setup for cordis and swan insertion.
7. Set up pressure lines and transducers
8. Please level pressure flush monitoring system and transducers to the phlebostastic axis.
Zero the transducers. Also check to make sure all connections are secure.
9. Connect tubings to patient [PA port and CVP port] when physician is ready to flush the
swann. Flush all ports of swann before inserting.
10. While floating the swann, observe for ventricular ectopy on the monitor, and make
physician aware of frequent PVC’s or runs of VT !
11. After swann is in place, assist with cleanup and let patient know procedure is complete.
Complications
• Increased risk of infections – same as with any central venous lines—use occlusive
dressing and Biopatch to prevent
• Thrombosis and emboli-- air embolism may occur when the balloon ruptures, clot on
end of catheter can result in pulmonary embolism