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Cc 8 hemodynamic
Critical Care (408)
Loma Linda University
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Arterial Line (A-Line) BP, serial ABGs, hemo
Pulmonary Artery Line PA Catheter Components proximal injectate port (up to 492 mL/hr. no titratable meds) measure CO (4-6 L/min) measure CVP (2-5) PA distal port (NO MEDS) measure PAP (20- 30mmHg/5-10mmHg) balloon inflation port inflate balloon obtain PAOP (5-12) thermistor wire connector measure CO (4-6) & blood temperature CCO connector measure continuous CCO SvO2 sensor measures continuous SvO
for continuous BP reading & more Dicrotic Notch small dip in graph of aortic pressure throughout cardiac cycle aortic valve closure Pulsus Paradoxus diminished amplitude on inspiration SBP drop > 10 mmHg (small box) suggestive of cardiac tamponade, pericarditis, or lung disease Pulsus Alternans regular pattern of amplitude changes alternate between stronger & weaker beats suggestive of end stage left ventricular heart failure (not with breathe like paradoxus)
AKA: PA Line, Swan-Ganz, Right Heart Catheter PA Catheter Indications monitor cardiac function (MI, CHF) monitor fluid status assess hemodynamic response to fluids, diuretics, vasoactive agents, & inotropes manage hemodynamic instability after cardiac surgery guide treatment of shocks Gets: How well pump is pumping, how full right and left side of heart is, how well patient’s arteries can squeeze
Hemodynamic Terms & normal values
CO – cardiac output BV pumped by heart in 1min how well pump is pumping 4-6L/min CI – cardiac index CO adjust for body size how well pump is pumping 2 - 4 SV – stroke volume volume ejected w/ each heartbeat 60-70mL SVI – stroke volume index stroke volume adjusted for body size 40- SVR – systemic vascular resistance measures left ventricular resistance (afterload) index of arteriolar compliance or constriction throughout body how well pt’s arteries can squeeze 800-1400 dynes sec/cm PVR – pulmonary vascular resistance measures right ventricular resistance (afterload) 100-
CVP: important to remember that CVP in isolation is meaningless must be interpreted in conjunction w/ other clinical data (v/s, heart/lung sounds, & assessment findings) Possible cause of increased CVP: vasoconstriction ↑ blood volume right ventricular failure tricuspid insufficiency pericardial tamponade pulmonary embolism obstructive pulmonary disease positive pressure ventilation Decreased CVP may indicate hypovolemia sepsis or vasodilator meds vasodilation ↑myocardial contractility
CVP – central venous pressure BP in thoracic vena cava near the right atrium of heart CVP reflects amount of blood returning to heart right ventricular preload how full right side of heart is 2-5 mmHg on ventilator: 7-10 mmHg PAP – pulmonary artery pressure BP in pulmonary artery 20-30mmHg/5-10mmHg PAOP – pulmonary artery wedge pressure left ventricular preload how full left side of the heart is 5-12 mmHg SvO2 – mixed venous oxygen saturation measures balance between O supply & demand at tissue level O2 supply: Hgb, CO, SaO O2 demand: VO2 tissue metabolism 60-75% ScvO2 – central venous oxygen saturation 70-80% sustained ScvO2 <70% ↑mortality
PA Catheter – Snapshot of Heart Function CO & CI – how well pump is pumping CVP – how full right side of heart is PAOP – how full left side of heart is SVR – how well pt’s arteries can squeeze Math Formulas Primary Assessment w/ Lines Level & Zero - Prior to Measurement level transducer & zero at phlebostatic axis
CO – cardiac output CO = SV x HR
is patient stable? check catheter/line position
SVR – systemic vascular resistance SVR = [ (BP-CVP)/CO] x 80 MAP – mean arterial pressure MAP = [ 2(DBP) + SBP] ÷ 3 CI – cardiac index CO / BSA SVI – stroke volume index SV / BSA BSA – body surface area m 2 = sqrt [ (weight x height) / 3600] index calculations are more accurate because it’s specific to patient’s measurements
has it changed from insertion? note markings at hub of catheter ensure each port is used properly check for connections need to be tight & use dead- end cap check tubing for kinks & air bubbles check balloon deflated level & zero transducer assure appropriate scale is used for PA catheter & no other forms of pressure maintain pressure bag & continuous flush at 300mmHg
4 th ICS, midaxillary line level at atria or middle of chest HOB 0-60 degrees no lateral positioning phlebostatic axis w/ any position Square Wave Testing test system accuracy w/ reflecting pressure & waveform from the patients fast flush observe square wave count oscillation after square wave do square wave testing q- shift & prn Overdamped Waveform air, blood, clots in tubing remove air, blood, clots tubing too long or kinked remove tubing extensions unkink tubing connections are loose tighten connections or get new transducer Underdamped Waveform air bubbles remove air bubbles from system or get new transducer
PA Port – Proper Usage Do’s & Don’ts of Wedging never wedge (keep balloon inflated) for more than 15 seconds never leave catheter in permanent wedge position (balloon inflated) always allow for passive deflation of the balloon the pulmonary artery distal pressure can be used in place of wedging never inflate balloon w/ more than 1 of air only use 1 syringe supplied w/ the catheter
proximal injectate port used for infusions up to 492 mL/hr do NOT put titrated meds in proximal injectate port PA distal port mixed venous blood do NOT infuse meds in PA distal port RA port can be used for high volume infusions RV port can only use low volume infusions less than 50mL/hr recommended Measuring CO - How to do CO Reading
PA Catheter (Swan) Complications
Using Values to Effectively Treat Patients Position pt. to Supine HOB 0-20 degrees if HOB higher than 30 CO measure will be lower d/t postural effect of venous return Verify Correct Computation Constant computation constant included in PA line packet perform & average 3 measurements set up tubing for CO spike 500mL D5W bag. inject 10mL smoothly & in less than 4 sec if patient not intubated injection starts at end- expiration (extubated - expiration) if patient intubated injection starts at end- inspiration
air embolus disconnection pulmonary infarction (PA rupture) balloon rupture (over-inflation) prolonged inflation (>15sec) spontaneous wedging ventricular irritation occurs when catheter migrates back to right ventricle or looped through ventricle notify MD ASAP can cause V-tach risk for infections use occlusive dressing (biopatch) thrombosis & emboli when balloon ruptures air embolism may occur clot (thrombosis) on end of catheter pulmonary embolism
ALWAYS TX
HEMODYNAMICS IN THIS
ORDER
preload filling volume of ventricle (CVP, PAOP) CVP – central venous pressure (2-5) PAOP – pulmonary artery wedge pressure (5-12) Delta SV (CHEETAH) - <10% afterload pressure that ventricles must generate to overcome higher pressure in aorta to get blood out of the heart (SVR) SVR – systemic vascular resistance (800-1400) PVR – peripheral vascular resistance (100- 250)
dilates pulmonary arteries diuretics Lasix, Aldactone removes extra fluid from tissues & bloodstream reduces swelling make breathing easier
Cc 8 hemodynamic
Course: Critical Care (408)
University: Loma Linda University
