1. HEMODYNAMIC
MONITORING
By
Yasmeen Rahim

2. OBJECTIVES
By the end of this session, learners will be
able to:
 Define what is hemodynamic monitoring.
 List down the importance of hemodynamic
monitoring in hospital.
 Discuss about pressure monitoring system.
 Identify troubleshooting in the pressure
monitoring system.

3. CONT.
 Explain in detail about arterial pressure
monitoring, central venous pressure
monitoring and pulmonary artery pressure
monitoring.
 Evaluate oxygen delivery and demand.

4. HEMODYNAMIC MONOTORING
 It is the study of interrelationship of blood
pressure, blood flow, vascular volumes,
heart rate, ventricular function and the
physical properties of blood at bedside
 Is an integral part of critical care nursing

5. Cont..
 CCN should have knowledge of how to
obtain accurate data, analyze waveforms
and interpret and integrate the data.
 The information provided by invasive
catheters can give us accurate and timely
information to clinicians so that appropriate
interventions can be taken.

6. IMPORTANCE OF HDM
 Early detection, identification, and treatment
of life-threatening conditions such as heart
failure and cardiac temponade.
 Evaluate the patient’s immediate response to
treatment such as drugs and mechanical
support.
 Evaluate the effectiveness of cardiovascular
function such as cardiac output and index.

7. PURPOSE OF HDM:
 The purpose of HDM is to:
 Early detection, identification, and treatment of
life-threatening conditions
 Aid in the diagnosis of various cardiovascular
disorders
 Guide therapies to optimize cardiac functions
 Minimize cardiovascular dysfunctions
 Evaluate the patient’s immediate response to
treatment modalities

8. INDICATION OF HDM
 It is essential in conditions when cardiac output is
insufficient to deliver oxygen to the cells (altered
preload, afterload and contractility).
 Any deficit or loss of cardiac function: such as AMI,
CHF, Cardiomyopathy.
 All types of shock; cardiogenic, septic, neurogenic or
anaphylactic.
 Dehydration, hemorrhage, G.I. bleed, severe burn,
ARDS or any major surgery.
 Severe sepsis or multiple organ failure.
 It aids in assessing body oxygen supply and demand.

9. HDM PARAMETERS:
 Cardiac output.
 Heart rate
 Rhythm
 Cardiac index.
 Stroke volume.
 Preload
 Afterload
 Contractility

10. PRESSURE MONITORING
SYSTEM
 Catheter (hollow tube).
 Central venous catheter for CVP
 Arterial catheter for Arterial pressure monitoring
 Pulmonary catheter / SWAN Ganz for PAP monitoring.
 Pressure tubing.
 Flush solution (N/S or D5W, heparinized)
 IV tubing with drip chamber
 Pressure bag (pressure of 300 mmHg) and stopcock
 Pressure transducer.
 Pressure amplifier.
 Cardiac monitor

11. SQUARE WAVE TEST:
 Square wave test is performed to quickly assess
the response of the system.
 Flush device is released rapidly which will
increase fluid flow through the system.
 Record the square wave formed on the monitor.

12. LEVELING & ZEROING:
 A fundamental step in obtaining accurate
hemodynamic values is to zero the transducer
amplifier system.
 This step is performed at least once before
obtaining the first hemodynamic reading after
catheter insertion.
 The pressure monitoring system is leveled to an
external landmark and then zeroed to
atmospheric pressure.
 Zeroing is done to eliminate the effect of
atmospheric and hydrostatic pressure.

13. Cont..
 The phlebostatic axis is used as the reference
point for leveling and zeroing.
 The site of the phlebostatic axis is at the
intersection of the fourth intercostal space and
mid axillary line (approx level of right atrium and
pulmonary artery.
 Leveling (referencing) and zeroing ensures that
hemodynamic values obtained with the catheter
are accurate.

14. STEPS FOR ZEROING AND
LEVELING:
 Position patient on their back
 Patient may be positioned with the head of the bed elevated
between 0-60°
 Flush the system
 Level transducer to phlebostatic axis (may mark this with an x
on patient)
 Turn stop-cock on transducer so that it is off to the patient.
 Remove cap
 Press zero on the module
 Ensure that zero appears on screen replace cap and turn
stop-cock so that it is open to monitoring and patient.

15. ARTERIAL PRESSURE
MONITORING:
 Arterial blood pressure is a basic
hemodynamic index often utilized to guide
therapeutic interventions
 Continuous monitoring of blood pressure is
indicated for patients with hemodynamic
instability that requires inotropic or
vasopressor medication

16. Cont.
 An arterial line is a cannula usually
positioned in a peripheral artery such as
 Radial artery (most commonly used site)
 Brachial artery (rarely used)
 Dorsalis pedis artery (rarely used)
 Femoral artery (second option other than radial
artery, more chances of getting contaminated)

17. Cont..
 An arterial line allows for consistent and
continuous monitoring of blood pressure to
facilitate the reliable titration of supportive
medications
 In addition, arterial lines allow for reliable
access to the arterial circulation for the
measurement of arterial oxygenation and
for frequent blood sampling

18. ARTERIAL LINE INSERTION:
 http://content.nejm.org/cgi/video/354/15/e13/

19. ARTERIAL PRESSURE
 Arterial pressure waveform has three parts:
 Rapid upstroke wave (systolic pressure)
 Dicrotic notch
 Diastolic pressure waveform
 Normal systolic BP is 90 – 140 mm Hg.
 Normal diastolic BP is 60 – 90 mm Hg.
 Dicrotic notch is small downward deflection
following the closure of semilunar valve, indicate
the end of systole and beginning of diastole.

20. MEAN ARTERIAL PRESSURE:
 Mean arterial pressure (MAP) is used to
evaluate perfusion of vital body organs.
 Normal MAP is 70 to 105 mm Hg.
 MAP can be calculated by:
Systolic BP + (Diastolic *2) / 3

21. EJECTION FRACTION
 Ejection Fraction (EF) is the fraction of
blood ejected by the ventricle relative to its
end-diastolic volume.
 EF is calculated from:
EF = (SV / EDV) * 100
 For example if SV is 75 and EDV is 120
then EF would be 63%.

22. POTENTIAL COMPLICATIONS
 HAEMORRHAGE:
PREVENTION:
 Keep limb visible at all times
 Ensure alarm is on so that any accidental disconnection
can be dealt quickly
 Ensure that arm is immobile with arm board
 Ensure all connections are tight
SOLUTION
 Apply pressure to limb
 Assess leak
 If hemorrhage persists notify medical officer

23. CONT..
 INFECTION
PREVENTION
 Assess area regularly for redness or swelling
 Avoid interrupting circuit as much as possible
 Use gloves when touching arterial line
SOLUTION
 Remove arterial Line
 Ensure proper hand washing when handling
arterial line or transducer

24. CONT..
 BLOCKAGE, CLOTTING & AIR EMBOLI
PREVENTION
 Keep pressure bag inflated to 300 mmHg
 ensure 3-5ml auto flush is continuous.
 Attempt to aspirate blood
 Use fast flush device to clear line to prevent clot
formation
SOLUTION
 Attempt to aspirate blood to remove clot
 Ensure all connections are secure

25. CONT..
 INTERUPTION TO PERIPHERAL
CIRCULATION
PREVENTION
 Regularly check distal pulses and capillary refill.
SOLUTION
 Notify MO and consider removing arterial line

26. NURSING CONSIDERATIONS
 Nursing care mainly directed to preventing
complications
 Ensure that the insertion site is visible at all
times for early detection of disconnection
 All connections must be secured
 Ensure that the cannula site is covered with
an appropriate dressing to maintain asepsis

27. Cont.
 Never inject anything into an arterial cannula
or arterial line
 Ensure that the flush bag has adequate fluid.
 Use only heparinized 0.9% sodium chloride
 Ensure that the pressure in the pressure bag
is maintained at 300mmHg.
 Always set and keep the alarms on.

28. Cont.
 Do not allow the flush bag to empty
 To maintain patency of arterial cannula.
 To prevent air embolism
 To maintain accuracy of blood pressure reading
 To maintain accuracy of fluid balance chart
 To prevent backflow of blood

29. Cont.
 Monitor color & temperature of limb distal to
arterial line & compare to other limb
 To confirm that circulation to the limb is
adequate.
 To ensure the early detection of impaired
circulation

30. Cont.
 Monitor and display the arterial waveform at
all times
 To detect cannula disconnection.
 Level and zero transducer once per shift
 To ensure accuracy in measuring blood pressure
 Maintain the transducer level with the
patient’s phlebostatic axis (fourth intercostal
space midaxillary line)

31. Cont.
 On removal of arterial cannula maintain
pressure over puncture site for at least 5
minutes until bleeding has stopped
 To prevent bleeding and haematoma formation
 Send cannula tip to microbiology
 Only if suspected infection
 To detect infection

32. CENTRAL VENOUS PRESSURE
 Is the pressure within the superior vena cava or
the right atrium
 It serve as a guide to fluid balance in critically ill
patients
 It give estimation of the circulating blood volume
 It also assist in monitoring of rt ventricular function
 Route for delivery of medications

33. Cont.
 CVP is a helpful tool in the assessment of
cardiac function, circulating blood volume, and
patient’s response to treatment
 CVP should not be interpreted solely but in
conjunction with other systemic measurements,
as isolated CVP measurements can be
misleading
 Normal CVP is less than 8 mm Hg
 CVP is raised in mechanical ventilation.

34. CVP INSERTION:
 http://content.nejm.org/cgi/video/356/21/e21/

35. METHODS OF CVP
MONITORING
 There are two methods of CVP monitoring
 manometer system: enables intermittent
readings and is less accurate than the
transducer system
 transducer system: enables continuous readings
which are displayed on a monitor.

36. MONITORING WITH
TRANSDUCERS
 Transducers enable the pressure readings
from invasive monitoring to be displayed on
a monitor
 To maintain patency of the cannula a bag
of normal saline or heparinized saline
should be connected to the transducer
tubing and kept under continuous pressure
of 300mmHg. (autoflush 3ml/hr)

37. PROCEDURE FOR CVP MEASUREMENT
USING A TRANSDUCER
 Explain the procedure to the patient
 Ensure that central line is patent
 Position the patient supine (if possible) and
align the transducer with the phlebostatic axis
 Zero the monitor
 Observe the CVP tracing
 Document the reading and report any changes
or abnormalities

38. COMPLICATIONS
 Infection
 Arterial puncture
 Hematoma
 Pneumothorax
 Hemothorax
 Arrhythmias
 Thrombosis
 Air embolism

39. MANAGEMENT OF A PATIENT
WITH A CVP LINE
 Monitor patient for signs of complications
 Label CVP lines with drugs/fluids etc. being infused
in order to minimise the risk of accidental bolus
injection
 Ensure all connections are secure to prevent
infection and introduction of air emboli
 Observe the insertion site frequently for signs of
infection.
 CVP lines should be removed when clinically
indicated

40. REMOVAL OF CENTRAL LINES
 This is an aseptic procedure
 The patient should be supine with head tilted down
 Ensure no drugs are attached and running via the
central line
 Remove dressing
 Cut the stitches
 Slowly remove the catheter
 If there is resistance then call for assistance
 Apply digital pressure with gauze until bleeding stops
 Dress with gauze and do clear dressing eg tegaderm

41. PA PRESSURE MONITORING
 Pulmonary artery pressure monitoring is
measuring the pressure in the pulmonary
artery leading to the lungs
 It also allows for indirect measurement of
left heart pressures since the pulmonary
veins have no valves in them and collects
the information needed to calculate cardiac
output and resistance

42. Cont.
 The PA catheter assesses right ventricular
function, pulmonary vascular status,
indirectly left ventricular function and all 3
components of stroke volume
 PAC aids in diagnosis of cardiovascular
and cardiopulmonary dysfunction, therapy
needed, and evaluate effectiveness of
interventions.

43. PULMONARY ARTERY CATHETER
 A Pulmonary artery catheter is a multi
lumen catheter inserted into pulmonary
artery.
 Each lumen or port has specific functions.
 Veins used for PA catheter insertion include
the internal jugular, subclavian, femoral and
very less commonly brachial.

44. Components of Swan-Ganz [con’t]
 Proximal port – [Blue] used to measure
central venous pressure/RAP and
injectate port for measurement of cardiac
output
 Distal port – [Yellow] used to measure
pulmonary artery pressure and for
withdrawal of mixed venous saturation.
Medication administration from this port
is not recommended.

45. Cont..
 Balloon port – [Red] used to determine
pulmonary wedge pressure;1.5 ml air is
injected via special syringe already
attached with the catheter.
 Thermister port- [White] it measures
patients temperature in the pulmonary
artery and reflect the temperature change
when fluid is injected for cardiac output.

46. PA CATHETER INSERTION
 http://www.edwards.com/products/pacatheters/c
 http://www.edwards.com/Products/PACathe
ters/HDMTroubleshooting.htm

47. INDICATIONS:
 To assess volume status and myocardial function.
 To assist in making a differential diagnosis
 To guide the management of the patient with heart/lung
disease/shock of all types
 To monitor hemodynamic pressures during fluid resuscitation
 Inotropic/vasoconstrictor/vasodilator drug infusion therapy
 To assess complications of MI and heart failure
 To monitor hemodyanamics with complicated surgical
procedures
 Sepsis and multi system organ failure
 Complex surgery, complicated myocardial infarction

48. CONTRAINDICATION:
 Severe coagulopathy.
 Patient receiving thrombolytics (e.g-TPA).
 Prosthetic right heart valve - catheter may cause the valve to
malfunction.
 Endocardial pacemaker - catheter may dislodge or knot around
the electrode.
 Severe pulmonary hypertension - increased risk of PA rupture.
 Severe vascular disease - catheter may puncture an abnormal
vessel.
 Significant immunodeficiency.
 If there are no skilled physicians/staff.
 If the patient's disease or injury can't be modified or corrected by
therapy.

49. COMPLICATIONS DURING
INSERTION:
 Pneumothorax
 Venous air embolism
 Dysrhythmias
 Dislodgement of the catheter guide wire
 Excessive bleeding

50. COMPLICATIONS AFTER
INSERTION:
 Dysrhythmias
 Infection
 Catheter dislodgement
 Thrombophlebitis
 Pulmonary artery rupture
 Tension Pnuemothorax

51. Cont..
 Catheter wedges permanently—considered an
emergency, notify MD immediately, can occur
when balloon is left inflated or catheter migrates
too far into pulmonary artery (flat PA waveform)…
can cause pulmonary infarct after only a few
minutes!
 Ventricular irritation – occurs when catheter
migrates back into RV or is looped through the
ventricle, notify MD immediately…can cause VT

52. • Check coagulation labs (pt, ptt, INR, platelets)
• Transfuse if Platelets < than 70 and INR > 1.5
• Ensure Packed Red Blood Cells in cooler at bedside
(Remember two RN check for PRBCs. Instructions
for blood in cooler, taped to cooler)
• Ensure good vascular access
• Evaluate need for sedation. (if too active
↑ BP may → bleeding)
NURSING CARE BEFORE REMOVAL OF PAC

53. • Keep PRBCs for a minimum of 1 hour
• Continuous hemodynamic monitoring for minimum 1hour
• Assess for signs of tamponade-dampening arterial wave
form, narrowing pulse pressure and bleeding- blood in
chest tubes, decrease blood pressure, pallor altered LOC)
• Document vital signs every 15 minutes
• Check HCT if bleeding suspected
• Ensure patency of chest tubes
• Do not transfer patient for at least 2 hours
NURSING CARE AFTER REMOVAL OF PAC

54. TROUBLESHOOTING:
 Remove multiple stopcocks, multiple injection
ports, and long lengths of tubing whenever
possible
 The optimal length of pressure tubing is 4 feet
 Overly compliant tubing leads to over damping
 Avoid large diameter tubing
 Remove all air bubbles from the system
 Ensure that all connections are tight and
periodically flush all tubing and stopcocks to
remove air bubbles

55. Cont…
 Whenever you are evaluating a patient’s changing
hemodyanamics check all transducers, stopcocks,
tubing, and injection ports for air
 Gently tap the tubing and stopcocks as the
continuous flush valve is opened to dislodge any
bubbles.
 This will usually clear the system and restore
measurement accuracy
 Flushing a few small bubbles through the catheter
is OK; if more air is present, aspirate it from the
tubing

56. Cont…
 Changes in bed positioning generally
require re zeroing the pressure transducer
 If the transducer is below the phlebostatic
axis, the resulting arterial pressure will be
erroneously high
 If the transducer is above the phlebostatic
axis, the resulting arterial pressure will be
erroneously low

57. Documentation
 Document PAS, PAD, and PCWP on nursing flowsheet
under Hemodynamic Parameters
 PCWP will rarely be > PAD (if so, means blood is flowing
backwards) If PCWP = PAD, look for tamponade
 Under circumstances where the catheter will not wedge (or
should not be), do not document any values in the PCWP
column on the flowsheet.