Hemodynamics

Hemodynamics in the ICU

1. HEMODYNAMICS
In the CRITICAL CARE UNIT
Sherry L. Knowles, RN, CCRN, CRNI

2. DEFINITION
PURPOSE
DEFINITION
HEMODYNAMIC MONITORING
Measuring and
monitoring the
factors that
influence the force
and flow of blood.
To aid in diagnosing, monitoring and
managing critically ill patients.

3. OBJECTIVES
Define Basic Hemodynamics
Understand The Risks and Benefits
Identify PA Catheter Components
Analyze Cardiac Profiles
Interpret Shock States
Learn Appropriate Interventions
Describe How To Optimize Cardiac Output
Recognize Potential Complications
Upon completion of this program the student will be able to:

4. OBJECTIVES
Collect appropriate equipment/supplies necessary to set-up a
transducer pressure system.
State the correct solutions/medications used at Kaiser Vallejo for
the flush bags.
Correctly level and zero the transducer.
Correctly identify the location and purpose of each port/ lumen of
the PA catheter
Identify in sequence the normal waveforms observed during PA
catheter insertion, and state the corresponding pressure.
Correctly obtain the following pressures:
Pulmonary artery systolic, diastolic and mean
Pulmonary capillary wedge.
Central venous pressure.
Briefly describe the indications, limitations and complications of
PA catheterization, guidelines for accurate monitoring, and
troubleshooting techniques.
Upon completion of this program the student will be able to:

5. INDICATIONS
To diagnose shock states
To determine fluid volume status
To measure cardiac output
To monitor and manage unstable patients
To assess hemodynamic response to
therapies
To diagnose primary pulmonary hypertension,
valvular disease, intracardiac shunts, cardiac
tamponade, and pulmonary embolus

6. CONTRAINDICATIONS
Tricuspid or pulmonary valve
mechanical prosthesis
Right heart mass
(thrombus and/or tumor)
Tricuspid or pulmonary
valve endocarditis

7. SWAN-GANZ CATHETERS
The Cordis Offers A Large Bore Infusion Port
There Are Ten Types Of Swan-Ganz Catheters
VIP Catheter Has Three Other Infusion Ports
Large Markers = 50cm, Small Markers = 10cm

8. SWAN GANZ CATHETER

9. SWAN GANZ COMPONENTS

10. SWAN GANZ PLACEMENT

11. SWAN GANZ PLACEMENT

12. Bleeding
Infection
Dysrhythmias
Pulmonary Artery Rupture
Pneumothorax
Hemothorax
Valvular Damage
Embolization
Balloon Rupture
Catheter Migration
RISKS WITH SWAN GANZ

13. INSERTION EQUIPMENT
EQUIPMENT NECESSARY FOR INSERTION
 Flush solution for transducer system
 Flush solution for cardiac output system
 Arterial access line
 Disposable triple pressure transducer system
 Pulmonary artery catheter

 Monitor, module, electrodes, cables
 Central line kit
 Transducer holder, I.V. pole, pressure bag
 Emergency resuscitation equipment
 Prepackaged Introducer Kit; sutures
 Sterile gowns, gloves, and masks

14. RA WAVEFORM
Normal Value 0-8 mmHg
RAP = CVP
Wave Fluctuations Due To Contractions

15. RV WAVEFORM
Normal Value 15-25/0-8 mmHg
Catheter In RV May Cause Ventricular Ectopy
Swan Tip May Drift From PA to RV

16. PA WAVEFORM
Normal Value 15-25/8-15 mmHg
Dicrotic Notch Represents PV Closure
PAD Approximates PAWP (LVEDP)
(in absence of lung or MV disease)

17. PAWP WAVEFORM
Normal Value 8-12 mmHg
Balloon Floats and Wedges in Pulmonary Artery
PAWP = LAP = LVEDP
Wedging Can Cause Capillary Rupture

18. PA INSERTION WAVEFORMS
A = RA (CVP) Waveform
B = RV Waveform
C = PA Waveform
D = PAWP Waveform
B
C D
A

19. PA CATHETER WAVEFORMS
A wave - due to atrial contraction. Absent in atrial fibrillation. Enlarged in
tricuspid stenosis, pulmonary stenosis and pulmonary hypertension.
C wave - due to bulging of tricuspid valve into the right atrium or possibly
transmitted pulsations from the carotid artery.
X descent - due to atrial relaxation.
V wave - due to the rise in atrial pressure before the tricuspid valve opens.
Enlarged in tricuspid regurgitation.
Y descent - due to atrial emptying as blood enters the ventricle.
Canon waves - large waves not corresponding to a, v or c waves. Due to
complete heart block or junctional arrhythmias.

20. PA INSERTION SEQUENCE

21. POST INSERTION
1.Assess ECG for dysrhythmias.
2.Assess for signs and symptoms of respiratory distress.
3.Ascertain sterile dressing is in place.
4.Obtain PCXR to check placement.
5.Zero and level transducer(s) at the phlebostatic axis.
6.Assess quality of waveforms (i.e., proper configuration,
dampening, catheter whip).
7.Obtain opening pressures and wave form tracings for each
waveform.
8.Assess length at insertion site.
9.Ensure that all open ends of stopcocks are covered with
sterile dead-end caps (red dead-end caps, injection caps, or
male Luer lock caps).
10.Update physician of abnormalities.

22. ZEROING & REFERENCING
Zeroing is performed by opening the
system to air to establish atmospheric
pressure as zero.
Referencing is accomplished by placing
the air-fluid interface of the catheter
(the transducer) at the phlebostatic
axis.

23. PHLEBOSTATIC AXIS

24. RESPIRATORY VARIATION
Intrathoracic pressure  decreases
during spontaneous inspiration 
(ventilation)
This presents a negative () deflection
on a PAWP tracing
Intrathoracic pressure  increases
during spontaneous expiration 
This present a positive () deflection on
a PAWP tracing
SPONTANUOUS VENTILATION :

25. RESPIRATORY VARIATION
Intrathoracic pressure  increases
during positive pressure ventilation
 (ventilator breaths)
This presents a positive () deflection
on a PAWP tracing
Intrathoracic pressure  decreases
during positive pressure expiration

This present a negative () deflection
on a PAWP tracing
POSITIVE PRESSURE VENTILATION :

26. RESPIRATORY VARIATION
Spontaneous Breathing

27. RESPIRATORY VARIATION

28. END EXPIRATION

29. RAP WAVEFORM
RAP WAVEFORM

30. (CVP) RA WAVEFORM & ECG

31. (CVP) RA WAVEFORM
(CVP) RA WAVEFORM

32. WEDGING THE CATHETER

33. PAWP TRACING
PAWP WAVEFORM

34. PAWP WAVEFORM
PAWP WAVEFORM

35. PA vs PAWP WAVEFORM
PA vs PAWP WAVEFORM

36. PAWP WAVEFORM & ECG
PAWP WAVEFORM

37. PAWP WAVEFORM
PAWP WAVEFORM

38. V WAVES
PAWP WAVEFORM

39. PAWP WITH V WAVES

40. SVO
2
MONITORING

41. SVO2 MONITORING
Normal Values: 60-75%
Decreased () SVO
2
Values Indicate
 Increased  Extraction
From Decreased Oxygen Delivery
or
From Increased Oxygen Demands

42. POTENTIAL COMPLICATIONS
POTENTIAL COMPLICATIONS
Same as arterial pressure monitoring plus the following:
Cardiac arrestAir emboli
PA hemorrhage or infarctionPulmonary artery
extravasation
Altered skin integrityLoss of balloon integrity
Frank HemorrhagePneumothorax/Hemothorax
Pulmonary artery ruptureEquipment malfunction
ElectromicroshockInaccurate pressures
Lung ischemiaInfection
Balloon ruptureCatheter displacement
DysrhythmiasThromboembolism
Cardiac tamponadeAir emboli

43. Wedging Can Cause Capillary Rupture
Catheter In RV Can Cause Ventricular Ectopy
Swan Tip Can Drift From PA to RV
POTENTIAL COMPLICATIONS

44. PERICARDIAL TAMPONADE
Hemodynamic monitoring can diagnose tamponade:
Pericardial tamponade presents with equalization of the
diastolic pressures on the left and right side of the heart
Other PAP signs of pericardial tamponade include:
Elevated right atrial pressure
Kussmaul sign (increase in right atrial pressure with
inspiration)
Pulsus Paradoxus
Elevated right atrial pressure (RAP)
Pulmonary artery diastolic pressure (PAD) = mean right
atrial pressure(RA) = right ventricular (RV) diastolic
pressure = mean wedge pressure

45. PRECAUTIONS
Always set alarms, approximately 20 mmHg
above and below the patient’s readings.
If balloon is down and you find PA catheter
tracing in wedge position, you may ask the
patient to deep breathe and cough, or
reposition patient in bed to dislodge it.
If unable to dislodge catheter from wedge
position by above measures notify physician
immediately to reposition catheter by pulling
back gently; then, get chest x-ray to confirm
proper placement.
If patient coughs up blood or it is suctioned via
endotracheal tube, suspect PA rupture and
notify physician immediately.

46. TROUBLESHOOTING

47.  = 0-8 mm Hg
 = 15-25 / 8-15 mm Hg
 = 8-12 mm Hg
 = 8-12mm Hg
 = 50-100 ml/beat
 = 4-8 L/min
 = 2.5-4.0 L/min M
2


= 0.60-0.75
Right Atrial Pressure (CVP)
Pulmonary Artery Pressure
Pulmonary Artery Wedge Pressure
Left Ventricular Diastolic Pressure
Stroke Volume
Cardiac Output
Cardiac Index
SVO
2
NORMAL VALUES

48. DAMPENED PA WAVEFORM
PAWP WAVEFORM

49. ALTERATIONS IN SVO
2

50. ALTERATIONS IN SVO
2

51. Optimize HR and SV (Stroke Volume)
Stroke Volume =
PRELOAD
AFTERLOAD
CONTRACTILITY
Chronotropic Medications
Diuretics / Volume
Vasodilators / Vasoconstrictors
Inotropic Medications (Positive or Negative)
IABP
OPTIMIZING CARDIAC OUTPUT

52. Shock States
Cardiogenic Shock
Hypovolemic Shock
Septic Shock
Anaphylactic Shock
Cardiac Tamponade
Left Ventricular Failure
Right Ventricular Failure
Pulmonary Hypertension
CARDIAC PROFILES

53. SHOCK PARAMETERS
Cardiogenic Shock is the only shock with  PAWP.
kEarly (Hyperdynamic) Shock is the only shock with  CO and  SVR.
mNeurogenic Shock is the only shock with  bradycardia.
Anaphylactic Shock has the definitive characteristic of wheezing due to
bronchospasm.
Parameter Hypovolemic Cardiogenic Neurogenic Anaphylactic Early Septic Late Septic

CVP/RAP      
PAWP      or Norm 
CO      
BP      
SVR      
HR     Normal 

54. TREATMENTS

55. SAMPLE MEASUREMENTS

56. MEASUREMENTS

57. SAMPLE MEASUREMENTS

58. SAMPLE MEASUREMENTS

59. SAMPLE MEASUREMENTS

60. SAMPLE MEASUREMENTS

61. SAMPLE MEASUREMENTS

62. SAMPLE MEASUREMENTS

63. SAMPLE MEASUREMENTS

64. SAMPLE MEASUREMENTS

65. SAMPLE MEASUREMENTS

66. SAMPLE MEASUREMENTS

67. SAMPLE MEASUREMENTS

68. SAMPLE MEASUREMENTS

69. SAMPLE MEASUREMENTS

70. SAMPLE MEASUREMENTS

71. Hemodynamic monitoring measures factors that
influence the force and flow of blood.
Hemodynamic monitoring aids in diagnosing,
monitoring and managing critically ill patients.
SUMMARY

72. THE END

73. REFERENCES
AACN (American Association of Critical Care Nurses).
Clinical Care References. 2002
SCCM (Society of Critical Care Medicine. PACEP (Pulmonary
Artery Catheter Education Project). 701 Lee Street, Suite
200, Des Plaines, Illinoise 60016. 2000.
Bridges, EJ, and Woods, SL. Pulmonary artery pressure
measurement: State of the art. Heart Lung 1993; 22:99.
Mirini, JJ. Pulmonary artery occlusion pressure: Clinical
physiology, measurement and interpretation. Am Rev
Respir Dis 1983; 128:319.
Putterman, C. The Swan-Ganz catheter: A decade of
hemodynamic monitoring. J Crit Care 1989; 4:127.
Nemens, EJ, Woods, SL. Normal Fluctuations in pulmonary
artery and pulmonary capillary wedge pressures in acutely
ill patients. Heart Lung 1982; 11:393.
Darovic, G.O., (1995) Hemodynamic monitoring: invasive
and noninvasive clinical application (2d ed), New York: W.
B. Saunders