3. 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
3
4. CONTRAINDICATIONS
for an invasive PA Catheter
Tricuspid or pulmonary valve mechanical
prosthesis
Right heart mass (thrombus and/or tumor)
Tricuspid or pulmonary valve endocarditis
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5. Clinical Scenario Use of PAC
Management of complicated MI
Assessment of respiratory distress
Cardiogenic/hypovolemic/septic
Tamponade
Pulmonary embolism
Severe dilated cardiomyopathy
Management of Pulmonary Hypertension
Management of high-risk surgical patients
Cardiogenic vs non-cardiogenic pulmonary edema
Assessment/Diagnosis of shock/ cardiac dysfunction
Severe LVF/RMI (precise management of heart failure)
CABG, vascular, valvular, aneurysm repair
Management of volume requirements in the critically
ill
ARF, GI bleed, trauma, sepsis (precise management)
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6. Hemodynamic Values
CO / CI
SV / SVI or SI
SVO 2
Cardiac Output/Cardiac Index
VO 2 / VO 2 I
DO 2 / DO 2 I
Oxygen Consumption
Oxygen Delivery
Stroke Volume/Stroke Volume Index
Mixed Venous Saturation
RVEDVI or EDVI RV End-Diastolic Volume
Systemic Vascular Resistance
SVR / SVRI
Pulmonary Vascular Resistance
PVR / PVRI
RV Ejection Fraction
RVEF
PAOP
CVP
PAP
Pulmonary Artery Occlusive
Pressure
Central Venous Pressure
Pulmonary Artery Pressure
6
7. Index Values
Values normalized for body size (BSA)
CI is 2.5 – 4.5 L/min/m2
SVRI is 1970 – 2390 dynes/sec/cm-5/m2
SVI or SI is 35 – 60 mL/beat/m2
EDVI is 60 – 100 mL/m2
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8. Importance of Index Values
Mr. Smith
47 y/o male
60 kg
CO = 4.5
6 ft tall (72 inches)
BSA = 1.8
CI = 2.5 L/min/m 2
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
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9. Basic Concepts
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
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10. Basic Concepts
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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11. Basic Concepts
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
11
12. 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 it’s volume of blood
Contractility: the force with which the heart
muscle contracts (myocardial compliance)
12
13. Stroke Volume
Preload
Afterload
Contractility
Filling Pressures
& Volumes
Resistance to
Outflow
Strength of
Contraction
CVP
PVR, MPAP
RVSV
PAOP (PAD may
be used to
estimate PAOP)
Fluids, Volume
Expanders
SVR, MAP
LVSV
Vasoconstrictors
Inotropic
Vasodilators
Medications
Diuretics
13
14. Clinical Measurements of Preload
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
14
16. Clinical Estimation of Contractility
Cardiac Output
* flow
Normal = 4-8 L/min
Cardiac Index
Normal = 2.5-4.5 L/min/m2
Stroke Volume
*pump performance
Normal = 50-100 ml/beat
Stroke volume Index
Normal = 30-50 ml/beat/m2
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17. Ventricular Compliance
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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21. “Swan-Ganz” PA Catheter
Large Markers = 50cm
Small Markers = 10cm
10 cm between small black markers on
catheter
Several types
Thermodilutional CO
CCO
Precep
NICCO
Multiple lumens
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29. Post PA Catheter Insertion
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.
29
30. General Rules for Hemodynamic
Measurements
Measure all pressures at End-Expiration
“ Patient
“ Vent
Peak”
Valley”
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33. Spontaneous Respirations
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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38. General Rules for
Hemodynamic Measurements
Measure all pressures with the HOB at a …
consistent level of elevation
Level the transducer at the phlebostatic axis
Print strips with one ECG and one pressure
channel
4th intercostal space, mid-chest
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
38
39. Review of Normal Values
RAP
(CVP)
0-8 mmHg
RVP
15-30/0-8 mmHg
PAP
15-30/6-12 mmHg
PAOP
8 - 12 mmHg
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43. Components of the RA
(CVP) Waveform
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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44. Components of the RA
(CVP) Waveform
Absent a waves
Paced rhythm
Atrial fibrillation
Junctional rhythm
Measure at the end of the QRS
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46. Components of the RA
(CVP) Waveform
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)
46
52. Components of the RV
Waveform
Usually only seen with insertion
Systole
Diastole
measured at the peak
peak occurs after the QRS
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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54. RV Waveform Interventions
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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55. Pulmonary Artery
Normal Value 15-25/8-15 mmHg
Dicrotic Notch Represents PV Closure
PAD Approximates PAWP (LVEDP)
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(in absence of lung or MV disease)
57. Components of the PA Waveform
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
60
58. Components of the PA Waveform
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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62. PAOP / Wedge
Normal Value 8-12 mmHg
Balloon Floats and Wedges in Pulmonary
Artery
PAWP = LAP = LVEDP
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63. Components of the PA Waveform
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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64. Components of the PA Waveform
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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65. Reading the PAOP Waveform
Begins within
the QRS or the
QT segment
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68. Post PAC Insertion
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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69. Precautions
Always set alarms on monitor
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
20mmHg above and below pt baseline
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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70. Intermittent Thermodilution CO
Based on measuring blood temperature changes
Must know the following:
Computation constant
Volume of injectate
Temperature 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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73. Continuous Cardiac Output
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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75. Mixed Venous Oxygenation Monitoring
(SvO2)
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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76. 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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77. 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)
80
78. Mixed Venous Oxygen Saturation
There are four factors that affect SVO 2:
1. Hemoglobin
2. Cardiac output
3. Arterial oxygen saturation (SaO2)
4. Oxygen consumption (VO2)
81
79. 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.
82
81. Ways To Decrease O2 Demand
Decrease muscle activity
prevent/control seizures
prevent/control shivering
sedatives, (paralytics)
space care activities
Decrease temperature
prevent/control fever
84
82. Removal of the PA Catheter
Usually performed by the nurse with
an MD order
Place patient supine with HOB flat
(reduces chance of air embolus)
85
83. Removal of the PA Catheter
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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85. Removal of the PA Catheter
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 breathing patient
pull PA catheter during exhalation
88
86. Removal of the PA Catheter
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.
89
The CO and the SVR will modulate to maintain blood pressure even if CO is very low. Because of this phenomenon, the BP is not a good measure of cardiac output
The pulse pressure tells you more about afterload than the BP does
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
Components:
1. Proximal port – approximately 30 cm from tip of catheter.
Also known as the CVP port (central venous pressure). It lies in the right atrium and measures CVP. It can be used for infusion of IV solutions or medications, for drawing blood and for injecting cardiac output boluses. It is usually color coded blue.
2. Distal port – opening is at the tip (end) of the catheter.
Also known as the PA port. It lies directly in the pulmonary artery and measures the pulmonary artery pressures (PAP), systolic (PAS), and diastolic (PAD). It also measures the pulmonary capillary wedge pressure (PCWP) when the balloon is inflated. The PA pressures should always be monitored continuously. NEVER USE the PA port for medication infusion. It can be used for drawing "mixed venous" blood gas samples. It is usually color coded yellow.
3. Thermistor and connector port
The thermistor connector connects the pulmonary catheter to the cardiac output computer. The connector is at the end of a separate catheter lumen outside the patient thermistor wire. Blood temperature is transmitted within the lumen (the core temperature is the most accurate reflection of the body temperature). It is used in determining cardiac output. The connector tip should always have a protective covering to protect patient from microshock. It is usually color coded yellow with a red connector.
4. Balloon port
The balloon port is located < 1 cm from the tip of the catheter. When the balloon is inflated with approximately 0.8 to 1.5 cc of air, the catheter will become lodged (wedged) in the pulmonary artery and gives a wedge tracing. It reflects the pressures that are in the left side of the heart when inflated. DO NOT INFLATE WITH LIQUID---- ALWAYS INFLATE WITH AIR. When deflated, turn stopcock to off position and leave syringe connect to the port. It is usually color coded red.
5. A 5 - lumen Swan Ganz catheter has either an infusion port or a pacing port
A pacing port allows for insertion of a transvenous pacing wire. The infusion port allows for infusion of IV solutions or medications. It is usually color coded white.
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
Correct the students about the location of the phlebostatic axis
1) Normal Pressures:
RA = 1-7
RV = 15-25/1-7
PA = 15-25/8-15
PAD = 8-15
PAWP = 6-12
It is essential that you be able to recognize the RV waveform – If the tip migrates to the RV during monitorin it can cause dysrhythmias. The proper intervention is to have an MD or qualified PA/CRNA advance the catheter or you can pull the tip back to the RA. Check your unit’s protocols.
Action taken will depend on unit protocols and availability of an MD or advanced practitioner to reposition the catheter. Know your unit’s protocols before you do anything
Looks like a CVP waveform, but the timing is different