HEMODYNAMIC MONITORING

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

Tricuspid or pulmonary valve mechanical prosthesis

Right heart mass (thrombus and/or tumor)

Tricuspid or pulmonary valve endocarditis

Management of complicated MI

Assessment of respiratory distress

Severe LVF/RMI (precise management of heart failure)

Cardiogenic vs non-cardiogenic pulmonary edema

Assessment/Diagnosis of shock/ cardiac dysfunction

Cardiogenic/hypovolemic/septic
Tamponade
Pulmonary embolism
Severe dilated cardiomyopathy

Management of Pulmonary Hypertension

Management of high-risk surgical patients

CABG, vascular, valvular, aneurysm repair

Management of volume requirements in the critically ill

ARF, GI bleed, trauma, sepsis (precise management)

CO / CI
SV / SVI or SI
SVO2
RVEDVI or EDVI
SVR / SVRI
PVR / PVRI
RVEF
VO2 / VO2I
DO2 / DO2I
PAOP
CVP
PAP

Cardiac Output/Cardiac Index

Stroke Volume/Stroke Volume Index
Mixed Venous Saturation
RV End-Diastolic Volume
Systemic Vascular Resistance
Pulmonary Vascular Resistance
RV Ejection Fraction
Oxygen Consumption
Oxygen Delivery
Pulmonary Artery Occlusive Pressure
Central Venous Pressure
Pulmonary Artery Pressure

Values normalized for body size (BSA)

CI is 2.5 4.5 L/min/m2

SVRI is 1970 2390 dynes/sec/cm5/m2

SVI or SI is 35 60 mL/beat/m2

EDVI is 60 100 mL/m2

Mr. Smith
47

y/o male
60 kg
CO = 4.5
6 ft tall (72 inches)
BSA = 1.8
CI = 2.5 L/min/m2

Mr. Jones
47

y/o male
120 kg
CO = 4.5
6 ft tall (72 inches)
BSA = 2.4
CI = 1.9 L/min/m2

Cardiac Output - amount of blood pumped out

of the ventricles each minute

Stroke Volume - amount of blood ejected by

the ventricle with each contraction
CO = HR x SV

Decreased SV usually produces compensatory

tachycardia..
So. . .changes in HR can signal changes in CO

Systemic Vascular Resistance

Measurement

of the resistance (afterload) of blood

flow through systemic vasculature
*Increased SVR/narrowing PP = vasoconstriction
*Decreased SVR/widening PP = vasodilation

Blood Pressure

BP = CO x SVR

** SVR can increase to maintain BP despite

inadequate CO
Remember CO = HR x SV

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BP = CO x SVR
CO and SVR are inversely related
CO and SVR will change before BP changes
* Changes in BP are a late sign of hemodynamic
alterations

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Stroke Volume

Components Stroke Volume

Preload: the volume of blood in the
ventricles at end diastole and the
stretch placed on the muscle fibers
Afterload: the resistance the ventricles
must overcome to eject its volume of
blood
Contractility: the force with which the
heart muscle contracts (myocardial
compliance)
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Stroke Volume
Preload

Afterload

Contractilit
y

Filling Pressures
& Volumes
CVP
PAOP (PAD may
be used to
estimate PAOP)

Resistance to
Outflow
PVR, MPAP
SVR, MAP

Strength of
Contraction
RVSV
LVSV

Fluids, Volume
Expanders
Diuretics

Vasoconstrictor
s
Vasodilators

Inotropic
Medications

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Right Side: CVP/RAP * filling pressures

Left Side: PAOP/LAP

PAD may be used to estimate PAOP in the

absence of pulmonary disease/HTN

The pulmonary vasculature is a low pressure

system in the absence of pulmonary disease

These pressures are accurate estimations of

preload only with perfect compliance of heart
and lungs
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RV Afterload
MPAP
PVR

= 150-250 dynes/sec/cm-5
PVRI = 255-285 dynes/sec/cm-5/m2

LV Afterload
MAP
SVR

= 8001300 dynes/sec/cm-5
SVRI = 1970-2390 dynes/sec/cm-5/m2

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Cardiac Output

* flow

Normal = 4-8 L/min

Cardiac Index
Normal = 2.5-4.5 L/min/m2

Stroke Volume

Stroke volume Index

*pump performance
Normal = 50-100 ml/beat

Normal = 30-50 ml/beat/m2

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Ability of the ventricle to stretch

Decreased with LV hypertrophy, MI, fibrosis,

HOCM

*If compliance is decreased, small changes in

volume produce large changes in

pressure

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Large Markers = 50cm

Small Markers = 10cm
10 cm between small black markers on
catheter
Several types
Thermodilutional
CCO
Precep
NICCO

CO

Multiple lumens

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Bleeding
Infection
Dysrhythmias
Pulmonary Artery Rupture
Pneumothorax
Hemothorax
Valvular Damage
Embolization
Balloon Rupture
Catheter Migration

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Right
Atrium

Pulmonary
Pulmonary
Right
Artery
Ventricle Artery
Occlusion
Pressure
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Assess ECG for dysrhythmias.

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

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Measure all pressures at End-Expiration

Patient Peak

Vent Valley

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4th ICS Mid-chest, regardless of head elevation

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4th ICS Mid-chest, regardless of head elevation

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Measure all pressures at end-expiration

At top curve with spontaneous respiration

patient-peak

Intrathoracic pressure decreases during

spontaneous inspiration

Negative deflection on waveforms

Intrathoracic pressure increases during

spontaneous expiration

Positive deflection on waveforms

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Measure all pressures at end-expiration

At bottom curve with mechanical ventilator

vent-valley

Intrathoracic pressure increases during positive

pressure ventilations (inspiration)

Positive deflection on waveforms

Intrathoracic pressure decreases during

positive pressure expiration

Negative deflection on waveforms

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Measure all pressures with the HOB at a

consistent level of elevation
Level the transducer at the phlebostatic axis

4th intercostal space, mid-chest

Print strips with one ECG and one pressure channel

adequate

scale
allows accurate waveform analysis

Confirm monitor pressures with pressures obtained

by waveform analysis
**

correct waveform analysis is more accurate than pressures from

the monitor
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RAP (CVP)

0-8 mmHg

RVP

PAP

15-30/0-8
mmHg

PAOP

15-30/6-12
mmHg
8 - 12 mmHg
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A=
B=
C=
D=

RA (CVP) Waveform
RV Waveform
PA Waveform
PAWP Waveform
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Normal Value 0-8 mmHg

RAP = CVP
Wave Fluctuations Due To
Contractions
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a-wave
atrial

contraction (systole)
begins in the PR interval and QRS on the ECG
correct location for measurement of CVP/RAP

* average the peak & trough of the a-wave

* (a-Peak + a-trough)/2 = CVP

May

not see if no atrial contractions as with. . .

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Absent a waves
Atrial

fibrillation

Paced

rhythm

Junctional

rhythm

Measure at the end of the QRS

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* Measure at end of QRS!

*PACEP.ORG 2007
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c-wave
tricuspid

valve closure
Between ST segment
Between a and v waves
*may or may not be present

v-wave
Atrial

filling
begins at the end of the QRS to the beginning of the T
wave (QT interval)

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Reading the RA CVP) Waveform

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Vented Patient
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a wave

Vented Patient Vent Valley

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Normal Value 15-25/0-8 mmHg

Catheter In RV May Cause Ectopy
Swan Tip May Drift From PA to RV
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Usually only seen with insertion

Systole

measured at the peak

peak occurs after the QRS

Diastole
measured

just prior to the the onset of systole

No dicrotic notch

Dicrotic notch indicates valve closure

*** Aids in differentiation from the PA tracing

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After PA catheter is correctly placed, RV

waveform should not be seen. If it is, then
interventions are necessary:
Check

for specific unit protocol first

Inflate balloon with patient lying on their left side
(catheter may float back into PA)
With deflated balloon, pull catheter into RA
placement or remove completely
Document your actions and notify physician

** An RN should NEVER advance the

catheter!
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Normal Value 15-25/8-15 mmHg

Dicrotic Notch Represents PV Closure
PAD Approximates PAWP (LVEDP)
(in absence of58 lung or MV

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Systole
measured

at the peak of the wave

Diastole
measured

just prior to the upstroke of systole (end of

QRS)
Higher

than RV diastolic pressure

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Dicrotic notch
indicates

pulmonic valve closure

aids in differentiation from RV waveform
aids in determining waveform quality

Anachrotic Notch
Before

upsweep to systole
Opening of pulmonic valve

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Dicrotic notch

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10/20/30

Identify that it is the PA tracing

Look at the scale
What is the PAP?
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Look for dichrotic notch

Look at scale
What is the PAP?
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Normal Value 8-12 mmHg

Balloon Floats and Wedges in Pulmonary
Artery
PAWP = LAP = LVEDP
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a-wave
atrial

contraction

correct

location for measurement of PAOP

average the peak & trough of the a-wave

begins

near the end of QRS or the QT

segment

* Delayed ECG correlation from CVP since PA

catheter is further away from left atrium

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c-wave
rarely

present
represents mitral valve closure

v-wave
represents

left atrial filling

begins at about the end of the T wave

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Begins within
the QRS or the
QT segment
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Wedging Can Cause

Pulmonary Artery Rupture
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Assess ECG for dysrythmias

Assess for S/S of respiratory distress

Be sure sterile dressing is applied

Order CXR for placement

Get MD order before infusing through ports

Zero and level all transducers

Assess quality of waveforms

Dampening, proper configuration, scale

Obtain opening pressures and waveform tracings for each

waveform

Note length at insertion site

Place proper luer-lock connectors to lumens and cap all ports

Notify MD of any abnormalities

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Always set alarms on monitor

20mmHg

above and below pt baseline

If in PAOP with balloon down, have pt cough,

deep breath, change position

If unable to dislodge from PAOP, notify MD

immediately to reposition catheter
CXR

to reconfirm placement

If pt coughs up blood or it is suctioned via ETT,

suspect PA rupture and notify MD immediately
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Based on measuring blood temperature changes

Must know the following:
Computation
Volume

of injectate

Temperature

constant
of injectate

Iced or room temperature

Inject rapidly and smoothly over 4 seconds max

Thermister at end of PA catheter detects change
in temperature and creates CO curve
At least 3 measurements and average results
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*PACEP.ORG 2007

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*PACEP.ORG 2007
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A heat signal is produced by the thermal

filament of the PA catheter

The signal is detected by the thermistor on the

PA catheter and is converted into a
time/temperature curve

The CCO computer produces a time-averaged

calculation
Over

3 minutes

Updates

every 30-60 seconds

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Mixed Venous Oxygen Saturation

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Measures the amount of O2 in the blood (on the Hgb

molecule) returned to the heart

Helps to demonstrate the balance between O2

supply & demand in the body (tissue oxygenation)

Helps to interpret hemodynamic dysfunction when

used with other measurements

Normal: 70% (60-80)

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Mixed Venous Oxygen Saturation

End result of O2 delivery and

consumption

Measured in the pulmonary artery

An average estimate of venous

saturation for the whole body.

**Does not reflect separate tissue

perfusion or oxygenation
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Mixed Venous Oxygen Saturation

Continuous measurement

Early warning signal to detect

oxygen transport imbalances

Evaluates the effect of the

therapeutic interventions

Identify potential patient care

consequences (turning, suctioning)
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There are four factors that affect SVO2:

1. Hemoglobin
2. Cardiac output
3. Arterial oxygen saturation (SaO2)
4. Oxygen consumption (VO2)

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SvO2 Application

In a case of increased SVR with decreased CO. Nitroprusside was

started. The increase in SvO2 and increase in CO reflects the
appropriateness of therapy.
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Ways To Increase O2 Delivery

Increase CO

increase HR, optimize preload, decrease

afterload, add positive inotropes

Increase Hgb, increase SaO2

Improve pulmonary function

pulmonary toilet, prevent atelectasis

ventilation strategies

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Ways To Decrease O2 Demand

Decrease muscle activity

sedatives, (paralytics)

prevent/control seizures

prevent/control shivering

space care activities

Decrease temperature

prevent/control fever

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Usually performed by the nurse with

an MD order

Place patient supine with HOB flat

(reduces chance of air embolus)

85

Make sure balloon is down, have

patient inhale and hold breath, pull
PA catheter out smoothly
monitor

for ventricular ectopy

stop immediately & notify MD if resistance is met

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If patient is unable to perform breath

hold:
Pull

PA catheter during period of positive intrathoracic

pressure to minimize chance of venous air embolus

Mechanically

ventilated patient

pull PA catheter during delivery of vent breath

Spontaneously
pull

breathing patient

PA catheter during exhalation

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If introducer sheath (cordis) is to remain in

place, it must be capped.

If introducer sheath (cordis) is to be removed,

repeat the steps used for PA catheter removal.

Hold pressure on the site (5-10 min.), keep

patient flat until hemostasis is achieved.

Apply sterile dressing or band-aid.

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The PA diastolic pressure is

measured at which part of the
waveform?

Just prior to the

upstroke of systole
108

Which part of the CVP and

PAOP waveforms is used to
calculate pressures?

The a wave

109

The RV waveform can be

distinguished from the PA
waveform by:

RV has lower
diastolic pressure
and no dicrotic notch
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The v wave of the CVP & PAOP

waveforms represents:

Atrial filling

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The a wave of the CVP

waveform correlates with
which electrical event?

The PR interval on the ECG

112

The a wave of the PAOP

waveform correlates with which
electrical event?

The QRS on the ECG

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