Hemodynamic Monitoring

Riding the Waves in California

Renee Smith DNP, EdD(c), ACNP

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 Purposes
Aid diagnosis of various cardiovascular
disorders

Guide therapies to minimize cardiovascular

dysfunction
Evaluate the patient’s response to the
therapy

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A & P of the Heart

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 Hemodynamic Monitoring System
• Basic components of the
monitoring system
• Noncompliant pressure tubing
• Transducer
• Amplifier
• Recorder

• Flush system
• Flush solution
• Infusion system
• Pressure bag

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Swan Ganz in Heart

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Hemodynamic Monitoring System (cont.)
• Zeroing and Leveling
• To avoid erroneous readings
• Position of the transducer
• The Phlebostatic axis
• If above---falsely low reading
• If below---erroneous elevated readings
• 2-mmHg change in pressure reading
• Zeroing the system
• 3-way stopcock off patient and open to air

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Hemodynamic Monitoring System (cont.)

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Swan Ganz Setup

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Swan in Patient

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Pulmonary Artery (PA)
Pressure Monitoring

• Pulmonary artery catheter (Swan Ganz is a brand

name) 1970- Dr. Swan and Dr. Ganz
• Early detection, Identification & treatment of life
threatening conditions, e.g Heart Failure, Cardiac
Tamponade
• Evaluate response to treatment e.g drugs,
mechanical support
• Allows assessment of left ventricular function
• Evaluates CO & CI
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PA Monitoring Indications

• Any deficit or loss of cardiac function, AMI, CHF, Cardiomyopathy

• All types of shock
• Decreased UOP from dehydration, hemorrhage, GI bleeding, burns or
surgery

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 Pulmonary Artery (PA) Pressure Monitoring (cont.)

• Types of Catheters
• Thermodilution Paceport
for pacing probe (no ballon).
• VIP– additional proximal
lumen and port
• Thermodilution
7-7.1/2 French lumen

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Swan Ports

• Normally has 4 -5 ports each port are color coded

• Proximal (Blue) used to measure central venous pressure/RAP ( &
injection port for cardiac output
• Distal (Yellow) used to measure PAP (pulmonary Artery Pressure
• Balloon (Red) used to measure PAWP (Pulmonary Artery wedge
Pressure.
• Infusion (White) used for fluid infusion

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Swan Ganz Waveforms

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Pulmonary Artery (PA) Pressure Monitoring (cont.)

• Right Atrial Pressure (2-6mmHg)

• Right Ventricular Pressure (20-30/0-8)
• Pulmonary Artery Pressure PA Sysolic pressure =Right VSP
• PA systolic pressure, (20-30 mmHg), equal to right ventricular systolic pressure
• PA diastolic pressure, (8-15 mmHg)
• Reflects the resistance of the pulmonary vascular bed and left ventricular end-diastolic
pressure

Important ****

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Pulmonary Artery (PA) Pressure Monitoring (cont.)

• Pulmonary Artery Wedge Pressure (PAWP)

• Inflating balloon at the catheter tip (1ml of air)
• Occludes forward flow in the branch of the PA
• Reflects LV end-diastolic pressure
• Normal 8-12 mmHg
• If meet resistance do not force the balloon inflation, it may
have ruptured or it is out of place and could cause infarct.
• Use the PAD reading & notify MD during rounds
***Pulmonary Infract due to inflated balloon don’t force to
pump the ballon so take out the pressure form diastolic
pressure.

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Pulmonary Artery (PA) Pressure Monitoring (cont.)

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Pulmonary Artery (PA) Pressure Monitoring (cont.)

• Complications
• Pneumothorax
• Infection
• Ventricular dysrhythmias- if catheter slip out of its place an fall to far
back in the R ventricles cause ventricular Dysthymias.

• Pulmonary artery rupture or perforation-

• Pulmonary artery infarct-

• Embolism -

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 Cardiac Output
Review concepts related to Cardiac Function
• Cardiac output (CO) 48 L per Min if no exercise if exercise
• The amount of blood, in liters, ejected from the left ventricle each minute
• CO = HR x SV ( Heart rate x stroke volume)
• Normal CO for an adult: 4-8 L/min.

• Cardiac Index (CI) **more accurate for the pt than CO

• The amount of blood, in liters, ejected each minute from the left
ventricle per square meter of body surface area
• 2.8 to 4.2 L/min/m2, average 3.0 ± 0.2L/min/m2
• CI = CO (liters/min) ÷ body surface area (m2)

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Cardiac Output
• Stroke Volume
• Amount of blood ejected by the ventricle during systole, 60-100 ml/beat
•Three factors
• 1. Contractility-
• 2. Preload Fill
• Starling’s Law of the heart
• 3. Afterload push
• systemic vascular resistance
• pulmonary vascular resistance

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Cardiac Output cont.) Not important
• 10 ml of normal saline or D5W
• Room temperature (or Iced solution-old)
• A closed system: 10-ml syringe attached to the RA port by a stopcock
• Quick and smoothly inject in less than 4 seconds
• Three or more consecutive measurements
• See schematic representation (slope)

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Central Venous Pressure (CVP)

• Reflects the pressure of blood in the right atrium or vena cava

• Provides information about intravascular blood volume, right
ventricular end-diastolic pressure, and right ventricular
function
• Water manometer -
• Pressure Transducer (hemodynamic monitoring system)
• Acceptable pressure: 5-15 cm H2O

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Arterial Pressure Monitoring
• Uses
• Continuous monitoring of blood pressure
• Provides access for obtaining blood samples, relatively
closed setup, needleless
• Common sites
• Radial artery --- Allen’s test before putting radial arterial catheter.
Releasing and looking for circulation in that hand 7 second (ulnar
and radial arterial hold at the same time for 7 second and release
then check hand for flush of blood to make sure it’s blood
circulation).
Allen’s test: to test collateral blood flow, compress radial &
ulnar artery, while patient has hand elevated
opening/closing fist, then ulnar is released, should see
good color return to hand w/in 10 secs.
• Femoral artery
• Brachial artery

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Arterial Line Monitoring

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Arterial Line Setup

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Arterial Monitor Reading

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Arterial Pressure Monitoring (cont.)

• Waveform
• Rapid upstroke
• Ejection from the ventricle into the aorta
• Peak = systolic pressure
• Clear dicrotic notch
• Sudden closure of the aortic valve
• The end of ventricular systole or the beginning of diastole
• Definite end-diastole
• The lowest point

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Arterial Pressure Monitoring (cont.)

• Mean Arterial Pressure (MAP) use opposite arm check MAP and
compare with arterial line.
• Evaluate perfusion of vital body organs
• The average pressure in the peripheral arterial system during the entire
cardiac cycle
• Normal: 70 to 105 mmHg
• Need to maintain more than 60 mmHg to perfuse vital organs automatically
calculated & continuously displayed
• [Systolic BP + (2 x Diastolic BP)] ÷ 3

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Arterial Pressure Monitoring (cont.)
• Complications
• Infection
• Accidental blood loss
• Impaired circulation to extremity
• Embolism
• Nursing Considerations
• Ensure reading obtained are accurate (AL & SG)
• Level transducer and zeroing system
• Catheter patency (blood clot in tip, kinking of tubing, air bubbles)
• Long tubing (>4ft)
• Too many stopcocks, loose or open stopcocks
• Compare to manual cuff pressure, proper size cuff, proper placement
• Dampened waveform? Check stopcocks, tighten system, flush line, aspirate for air
or clots, change patient position, pt cough
• Monitor complications

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