Hemodynamic Monitoring and Hemodynamic Monitoring ...
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1 Hemodynamic Monitoring and Circulatory Assist Devices (Relates to Chapter 66, “Nursing Management: Critical Care,” in the textbook) Hemodynamic Monitoring • Measurement of pressure, flow, and oxygenation within the cardiovascular system • Includes invasive and noninvasive measurements – Systemic and pulmonary arterial pressures Hemodynamic Monitoring • Invasive and noninvasive measurements (cont’d) – Central venous pressure (CVP) – Pulmonary artery wedge pressure (PAWP) – Cardiac output (CO)/cardiac index (CI) Hemodynamic Monitoring • Invasive and noninvasive measurements (cont’d) – Stroke volume (SV)/stroke volume index (SVI) – O 2 saturation of arterial blood (SaO 2 ) – O 2 saturation of mixed venous blood (SvO 2 ) Hemodynamic Monitoring General Principles • Preload: Volume of blood within ventricle at end of diastole • Afterload: Forces opposing ventricular ejection – Systemic arterial pressure – Resistance offered by aortic valve – Mass and density of blood to be moved Hemodynamic Monitoring General Principles • Contractility: Strength of ventricular contraction • PAWP: Measurement of pulmonary capillary pressure; reflects left ventricular end‐diastolic pressure under normal conditions
Transcript of Hemodynamic Monitoring and Hemodynamic Monitoring ...
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HemodynamicMonitoringandCirculatoryAssistDevices
(RelatestoChapter66,“NursingManagement:CriticalCare,”
inthetextbook)
HemodynamicMonitoring
• Measurementofpressure,flow,andoxygenationwithinthecardiovascularsystem
• Includesinvasiveandnoninvasivemeasurements
– Systemicandpulmonaryarterialpressures
HemodynamicMonitoring
• Invasiveandnoninvasivemeasurements(cont’d)– Centralvenouspressure(CVP)– Pulmonaryarterywedgepressure(PAWP)– Cardiacoutput(CO)/cardiacindex(CI)
HemodynamicMonitoring
• Invasiveandnoninvasivemeasurements(cont’d)– Strokevolume(SV)/strokevolumeindex(SVI)– O2saturationofarterialblood(SaO2)– O2saturationofmixedvenousblood(SvO2)
HemodynamicMonitoringGeneralPrinciples
• Preload:Volumeofbloodwithinventricleatendofdiastole
• Afterload:Forcesopposingventricularejection– Systemicarterialpressure
– Resistanceofferedbyaorticvalve– Massanddensityofbloodtobemoved
HemodynamicMonitoringGeneralPrinciples
• Contractility:Strengthofventricularcontraction
• PAWP:Measurementofpulmonarycapillarypressure;reflectsleftventricularend‐diastolicpressureundernormalconditions
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HemodynamicMonitoringGeneralPrinciples
• CVP:Rightventricularpreloadorrightventricularend‐diastolicpressureundernormalconditions,measuredinrightatriumorinvenacavaclosetoheart
PrinciplesofInvasivePressureMonitoring
• Equipmentmustbereferencedandzerobalancetoenvironmentanddynamicresponsecharacteristicsoptimized
• Referencing:Positioningtransducersozeroreferencepointisatlevelofatriaofheartorphlebostaticaxis
IdentificationofPhlebostaticAxis
Fig. 66-4
PrinciplesofInvasivePressureMonitoring
• Zeroing:Confirmsthatwhenpressurewithinsystemiszero,monitorreadszero– Duringinitialsetupofarterialline– Immediatelyafterinsertionofarterialline
PrinciplesofInvasivePressureMonitoring
• Zeroing(cont’d)– Whentransducerhasbeendisconnectedfrompressurecableorpressurecablehasbeendisconnectedfrommonitor
– Whenaccuracyofvaluesisquestioned
TypesofInvasivePressureMonitoring
• Continuousarterialpressuremonitoring– Acutehypertension/hypotension– Respiratoryfailure– Shock– Neurologicshock
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TypesofInvasivePressureMonitoring
• Continuousarterialpressuremonitoring(cont’d)– Coronaryinterventionalprocedures– Continuousinfusionofvasoactivedrugs– FrequentABGsampling
ComponentsofanArterialPressureMonitoringSystem
Fig. 66-3
ArterialPressureMonitoring
• High‐andlow‐pressurealarmsbasedonpatient’sstatus
• Measureatendofexpiration
• Risks– Hemorrhage,infection,thrombusformation,neurovascularimpairment,lossoflimb
ArterialPressureTracing
Fig. 66-6
ArterialPressureMonitoring
• Continuousflushirrigationsystem– Delivers3to6mlofheparinizedsalineperhour
• Maintainslinepatency• Limitsthrombusformation
– Assessneurovascularstatusdistaltoarterialinsertionsitehourly
PulmonaryArteryPressureMonitoring
• Guidesmanagementofpatientswithcomplicatedcardiac,pulmonary,andintravascularvolumeproblems– PAdiastolic(PAD)pressureandPAWP:Indicatorsofcardiacfunctionandfluidvolumestatus
– MonitoringPApressuresallowsfortherapeuticmanipulationofpreload
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PulmonaryArteryCatheter
Fig. 66-7
InsertionofPulmonaryArteryCatheter
Fig. 66-8
PulmonaryArteryPressureMonitoring
• Whenmeasurementsareobtained– PA:Atendexpiration– PAWP:ByinflatingballoonwithairuntilPAwaveformchangestoaPAWPwaveform• Balloonshouldbeinflatedslowlyandfornomorethanfourrespiratorycyclesor8to15seconds
PAWaveformsduringInsertion
Fig. 66-9
CentralVenousPressureMonitoring
• Measurementofrightventricularpreload– Obtainedfrom
• PAcatheterusingoneoftheproximallumens• Centralvenouscatheterplacedininternaljugularorsubclavianvein
MeasuringCardiacOutput
• Intermittentbolusthermodilutionmethod• Continuouscardiacoutputmethod
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MeasuringCardiacOutput
Fig. 66-12
ComplicationswithPACatheters
• Infectionandsepsis– Asepsisforinsertionandmaintenanceofcatheterandtubingmandatory
– Changeflushbag,pressuretubing,transducer,andstopcockevery96hours
• Airembolus(e.g.,disconnection)
ComplicationswithPACatheters
• Ventriculardysrhythmias– DuringPAcatheterinsertionorremoval
– IftipmigratesbackfromPAtorightventricle
• PAcathetercannotbewedged– Mayneedrepositioning
PulmonaryArteryWaveforms
Fig. 66-10
PreventingPARuptureandPulmonaryInfarction
• Neverinflateballoonbeyondballoon’scapacity– Usually1to1.5mlofair
• CheckPApressurewaveformsoftenforsignsofcatheterocclusion,dislocation,orspontaneouswedging
NursingManagementHemodynamicMonitoring
• Baselinedataobtained– Generalappearance– Levelofconsciousness– Skincolor/temperature– Vitalsigns– Peripheralpulses– Urineoutput
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NursingManagementHemodynamicMonitoring
• Baselinedatacorrelatedwithdataobtainedfrombiotechnology(e.g.,ECG;arterial,CVP,PA,andPAWPpressures;SvO2/ScvO2)
• Singlehemodynamicvaluesarerarelysignificant
NursingManagementHemodynamicMonitoring
• Monitortrendsandevaluatewholeclinicalpicture
• Goals– Recognizeearlyclues– Intervenebeforeproblemsdeveloporescalate
CirculatoryAssistDevices(CADs)
• Decreasecardiacworkandimproveorganperfusionwhendrugtherapyfails
• Provideinterimsupportwhen– Left,right,orbothventriclesrequiresupportwhilerecoveringfrominjury(MI)
– Heartrequiressurgicalrepairandpatientmustbestabilized(e.g.,rupturedseptum)
– Hearthasfailedandpatientneedscardiactransplantation
IntraaorticBalloonPump(IABP)
• Providestemporarycirculatoryassistance
– ↓Afterload
– Augmentsaorticdiastolicpressure
• Outcomes
– Improvedcoronarybloodflow– Improvedperfusionofvitalorgans
IABPMachine
Fig. 66-13
IABP
Fig. 66-14
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VentricularAssistDevices(VADs)
• Provideslonger‐termsupportforfailingheart• AllowsmoremobilitythanIABP
• Insertedintopathofflowingbloodtoaugmentorreplaceactionofventricle
SchematicDiagramofLeftVAD
Fig. 66-16
VentricularAssistDevices(VADs)
• IndicationsforVADtherapy– Extensionofcardiopulmonarybypass
• Failuretowean• Postcardiotomycardiogenicshock
– Bridgetorecoveryorcardiactransplantation
NursingManagementCirculatoryAssistDevices
– Observepatientfor:Bleeding,cardiactamponade,ventricularfailure,infection,dysrhythmias,renalfailure,hemolysis,andthromboembolism
– Patientmaybemobileandwillrequireanactivityplan
SIRSandMODS
(RelatestoChapter67,“NursingManagement:Shock,
SystemicInflammatoryResponseSyndrome,andMultipleOrganDysfunctionSyndrome,”
inthetextbook)
SIRS
• Systemicinflammatoryresponsesyndrome(SIRS)isasystemicinflammatoryresponsetoavarietyofinsults
• Generalizedinflammationinorgansremotefromtheinitialinsult
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SIRS
• Triggers– Mechanicaltissuetrauma:burns,crushinjuries,surgicalprocedures
– Abscessformation:intra‐abdominal,extremities– Ischemicornecrotictissue:pancreatitis,vasculardisease,myocardialinfarction
SIRS
• Triggers– Microbialinvasion:Bacteria,viruses,fungi– Endotoxinrelease:Gram‐negativebacteria– Globalperfusiondeficits:Post–cardiacresuscitation,shockstates
– Regionalperfusiondeficits:Distalperfusiondeficits
MODS
• Multipleorgandysfunctionsyndrome(MODS)isthefailureoftwoormoreorgansystems– Homeostasiscannotbemaintainedwithoutintervention
– ResultsfromSIRS
MODS
– SIRSandMODSrepresenttheendsofacontinuum
– TransitionfromSIRStoMODSdoesnotoccurinaclear‐cutmanner
RelationshipofShock,SIRS,andMODS
Fig. 67-1
SIRSandMODS
• Consequencesofinflammatoryresponse– Releaseofmediators
– Directdamagetotheendothelium– Hypermetabolism– VasodilationleadingtodecreasedSVR– Increaseinvascularpermeability– Activationofcoagulationcascade
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SIRSandMODSPathophysiology
• Organandmetabolicdysfunction
– Hypotension– Decreasedperfusion– Formationofmicroemboli
– Redistributionorshuntingofblood
SIRSandMODSPathophysiology
• Respiratorysystem– Alveolaredema
– Decreaseinsurfactant– Increaseinshunt– V/Qmismatch
– Endresult:ARDS
SIRSandMODSPathophysiology
• Cardiovascularsystem– Myocardialdepressionandmassivevasodilation
SIRSandMODSPathophysiology
• Neurologicsystem– Mentalstatuschangesduetohypoxemia,inflammatorymediators,orimpairedperfusion
– OftenearlysignofMODS
SIRSandMODSPathophysiology
• Renalsystem
– Acuterenalfailure• Hypoperfusion• Releaseofmediators
• Activationofrenin–angiotensin–aldosteronesystem
• Nephrotoxicdrugs,especiallyantibiotics
SIRSandMODSPathophysiology
• GIsystem– Motilitydecreased:Abdominaldistentionandparalyticileus
– Decreasedperfusion:RiskforulcerationandGIbleeding
– Potentialforbacterialtranslocation
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SIRSandMODSPathophysiology
• Hypermetabolicstate– Hyperglycemia–hypoglycemia
– Insulinresistance– Catabolicstate– Liverdysfunction– Lacticacidosis
SIRSandMODSPathophysiology
• Hematologicsystem
– DIC• Electrolyteimbalances
• Metabolicacidosis
SIRSandMODSCollaborativeCare
• PrognosisforMODSispoor• Goal:PreventtheprogressionofSIRStoMODS
• Vigilantassessmentandongoingmonitoringtodetectearlysignsofdeteriorationororgandysfunctioniscritical
SIRSandMODSCollaborativeCare
• Preventionandtreatmentofinfection– Aggressiveinfectioncontrolstrategiestodecreaseriskfornosocomialinfections
– Onceaninfectionissuspected,instituteinterventionstocontrolthesource
SIRSandMODSCollaborativeCare
• Maintenanceoftissueoxygenation– DecreaseO2demand
• Sedation• Mechanicalventilation
• Paralysis• Analgesia
SIRSandMODSCollaborativeCare
• Maintenanceoftissueoxygenation– OptimizeO2delivery
• Maintainnormalhemoglobinlevel• MaintainnormalPaO2
– IndividualizetidalvolumeswithPEEP
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SIRSandMODSCollaborativeCare
• Maintenanceoftissueoxygenation
– EnhanceCO– Increasepreloadormyocardialcontractility
– Reduceafterload
SIRSandMODSCollaborativeCare
• Nutritionalandmetabolicneeds– Goalofnutritionalsupport:Preserveorganfunction
– Totalenergyexpenditureisoftenincreased1.5to2.0times
SIRSandMODSCollaborativeCare
• Nutritionalandmetabolicneeds– Useoftheenteralrouteispreferredtoparenteralnutrition
– Monitorplasmatransferrinandprealbuminlevelstoassesshepaticproteinsynthesis
SIRSandMODSCollaborativeCare
• Supportoffailingorgans– ARDS:AggressiveO2therapyandmechanicalventilation
– DIC:Appropriatebloodproducts– Renalfailure:Continuousrenalreplacementtherapyordialysis
