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Perfusion and Hemodynamics

This document discusses hemodynamic monitoring, including: - Perfusion is blood flow through arteries and capillaries delivering oxygen and nutrients to cells and removing waste. Hemodynamics refers to forces of the heart and circulating blood. - Hemodynamics can be affected by factors of the heart like contractility and filling ability, resistance the heart must pump against, and fluid return. Arteries, capillaries, and veins also impact hemodynamics through properties like elasticity and diameter. - Hemodynamic parameters that can be measured include cardiac output, ejection fraction, stroke volume, right atrial pressure, and systemic/pulmonary vascular resistances. These provide information on how well the heart is

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Krisianne Mae Lorenzo Francisco
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214 views21 pages

Perfusion and Hemodynamics

This document discusses hemodynamic monitoring, including: - Perfusion is blood flow through arteries and capillaries delivering oxygen and nutrients to cells and removing waste. Hemodynamics refers to forces of the heart and circulating blood. - Hemodynamics can be affected by factors of the heart like contractility and filling ability, resistance the heart must pump against, and fluid return. Arteries, capillaries, and veins also impact hemodynamics through properties like elasticity and diameter. - Hemodynamic parameters that can be measured include cardiac output, ejection fraction, stroke volume, right atrial pressure, and systemic/pulmonary vascular resistances. These provide information on how well the heart is

Uploaded by

Krisianne Mae Lorenzo Francisco
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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PERFUSION AND HEMODYNAMICS

• Perfusion: flow of blood through arteries and capillaries delivering nutrients and oxygen to cells
and removing cellular waste products.
- Hemodynamics: Forces of the heart and circulating blood throughout the
cardiovascular system.
- Different pressures/volumes of blood
- Where are those pressure? Why are they high? Low?

What affects hemodynamics?

Heart

✓ Contractility, filling ability, heart rate


✓ Resistance that the heart has to pump against
✓ Amount of fluid coming back to the heart to pump out

Arteries

✓ High pressure, low volume, high resistance system


✓ Elasticity, constriction/dilation?

Capillaries

✓ Low pressure, thin walls, receive metabolic waves

Veins:

✓ Low pressure, high capacity


✓ Thin walled, less elastic, larger diameter; constriction/dilation?

Blood
✓ Volume
✓ Viscosity, RBCs/oxygen delivery

What kinds of things can we measure?

• How well is the heart pumping?


- How is the squeeze?
- Measure it by: How much blood got pumped out of the left ventricle

How well is the heart pumping?

How is the “squeeze”? reflect CONTRACTILITY

How much blood is getting pumped out of the ventricle each beat?

• Ejection FRACTION
- Fraction (percentage) of blood ejected from the left ventricle with each beat
- What percentage of the blood in the ventricle was pumped out?
- Echocardiogram measures this
• Stroke VOLUME
- Amount of blood ejected with each beat
- How much of the blood in the ventricle (in milliliters) was pumped out?
- Measured by invasive arterial lines, pulmonary artery catheters, echocardiogram

What kinds of things can we measure?

• How well is the heart pumping?


o How much blood is getting pumped out of the heart over a minute?
- Measure it by: the volume of blood getting pumped out of the left ventricle over a
minute.
o How much blood is getting left behind?
(Bad pumps don’t pump a lot of blood out, they leave more blood behind)
- Measure it by: How much pressure is in or around the atria
- The blood left behind will back up from the ventricle into the atria

CONTRACTILITY

How much blood is getting pumped out of the ventricle each minute?

• CO: Cardiac Output


- Actual volume (in mL or Liters) of blood ejected by the heart each minute
- How many milliliters total will the ventricle pump out over a minute?
- Stroke Volume x heart rate = CO
- Measured by invasive lines (intra arterial lines, pulmonary artery catheters)
• CI: Cardiac Index
- Volume (in mL or Liters) of blood ejected by the heart each minute in relation to the
size of the person (body surface area)
- A “more specific CO” – related to person’s body size
- CO / Body Surface Area = CI
How much blood is getting left behind? How much fluid is coming in?

RIGHT SIDE

• Right Atrial Pressure (RAP) – Aka Central Venous Pressure


• How much pressure (caused by fluid) is in the right atrium?
• Measured in mmHg

Right Atrial Pressure/ Central Venous Pressure

- How much pressure (caused by fluid) is in the right atrium?


- Measured in mmHg
- High pressure caused by
✓ too much fluid systemically
✓ fluid backing up from a bad ventricle
- Low pressure caused by
✓ Not enough fluid from the system being returned to the heart

Following related to the concept of contractility?

- Ejection fraction
- Cardiac index
- Stroke volume

Following relates to the concept of preload?

- Right atrial pressure


- Central venous pressure
- Ventricular stretch before systole

AFTERLOAD: how much work does the ventricle have to do

- How much resistance is there up against the ventricle?


- Have to think about what is on the other side of each ventricle:
SYSTEMIC CIRCULATION and PULMONARY CIRCULATION
- Measured by: How much pressure is in the systemic or pulmonary circulation

Left Side: Systemic Vascular Resistance

Right side: Pulmonary vascular resistance


Which cause a decrease in SVR?

- Administration of nitrates
Monitoring and Related Nursing
Care: Part 3 [Hemodynamic
Monitoring Set-up and
Management]
Hemodynamic Monitoring Set-up and
Management
Once you have the hemodynamic monitoring vascular access device (eg. arterial line,
central line, PAC), then the line needs to be appropriately connected to the ICU monitor
or other monitor to trend a signal with the hemodynamic parameter. In most cases, you
will be setting up an arterial line or central line and connecting it to the ICU monitor. This
image shows the basic components of setting up hemodynamic monitoring:

Setting up hemodynamic monitoring: What will


you need?
Always review your institutional policies and procedures.
Equipment will vary, but in general, this is the equipment you will need to initially set up
basic hemodynamic monitoring.
Access device (eg. arterial line)

Transducer kit
500mL 0.9%NaCl

Pressure bag
Transducer holder/way to secure transducer

Pressure cable

General considerations when setting up the monitoring


system:
• Be sure to tighten all caps and connectors before removing the kit from the sterile
packaging to prevent contamination
• The soft tubing part of the kit (feels like regular IV tubing) will be connected to the
bag of NS and the hard tubing will be connected to the patient's access device
o Typically NS is used, sometimes the provider may order heparinized saline
• Close roller clamps initially before priming or setting up
• Use the flush device (often requires pulling) to flush the tubing that will connect to
the patient. Flush until there are no bubbles
• Pressurize the bag of saline by slipping it into the pressure bag and pumping up the
bag until it reaches 300mmHg
• Connect the system to the ICU monitor using the pressure cable (involves "plugging
in" to the monitor and inputting data into the ICU monitor "telling the monitor" what
hemodynamic parameter information is being connected-- eg. "ABP" for arterial
blood pressure)
• "Zero" the line (turning the stopcock off to the patient and open to atmospheric
pressure, pushing "Zero" on the monitor, waiting for the "(0)" on the monitor
waveform, and then reopening the stopcock to the patient)
• Place the transducer at the "phlebostatic axis" (4th intercostal space and midaxillary
line): this is critically important in ensuring that the hemodynamic value is accurate
Working with an existing hemodynamic pressure
system: Key considerations
If you are assuming care for a patient who already has hemodynamic monitoring set up,
there are still important nursing considerations related to managing and maintaining this
system.
Consider potential complications and key considerations for each component:

Is the waveform accurate?


• Verify values
o ABP: check a non-invasive pressure-- should not be more than 20mmHg
difference and should trend up and down with the ABP on the monitor
(done initially, if concerned values on monitor are incorrect, and per
facility protocol
o CVP: can verify by using a centimeter ruler to measure the vertical
distance between the angle of Louis (manubrio sternal joint) and the
highest level of jugular vein pulsation and add 5cm- this is a rough
estimate of CVP (not often done routinely)
o Be sure that the waveform showing on the ICU monitor is "optimally
dampened" this means that the waveform appears appropriate (not
overdamped or underdamped). If a waveform is over or underdamped, the
line may need to be flushed, the bag of normal saline may be empty and
needs to be replaced, there may be bubbles in the system that need to be
removed, or the patient's hand or wrist may need to be repositioned.

An example of arterial line waveforms: normal, underdamped, and overdamped:

Ensure that the waveforms are accurate. Here you can see ABP and CVP waveforms and
how they may look in an ICU monitor:
What do these waveforms mean? What is happening in
the heart?
See these two diagrams that show you the ABP and CVP waveforms and what each part
of the waveform means:

Arterial Blood Pressure Waveform


The dicrotic notch represents closure of the aortic valve

Central Venous Pressure Waveform:


Supplemental Resources
[Hemodynamic Monitoring and
Nursing Care]
What other hemodynamic parameters can be monitored?
Here is a more comprehensive list of hemodynamic values that can be monitored in the
ICU using arterial lines, central lines, and pulmonary artery catheters
How do you set up the FloTrac or Vigileo Monitor?
Different facilities have different types of monitors, but this is an example of how to set
up a FloTrac to use an arterial line to trend hemodynamic values other than ABP (eg. CO,
CI, SVR, etc)

Hemodynamic Monitoring and


Related Nursing Care: Part 2
[Hemodynamic Monitoring
Devices]
Hemodynamic Monitoring Devices
To monitor hemodynamics, invasive vascular access devices are often used. Depending
on the hemodynamic parameter we want to monitor, different vascular access devices
may be indicated.
Common invasive hemodynamic monitoring devices:

• Arterial lines
• Central lines
• Pulmonary Artery Catheters

In the case of arterial lines, that line can be connected to the regular ICU monitor to
monitor arterial blood pressure or the same arterial line could be connected to a FloTrac
or Vigileo monitor to monitor more complex hemodynamics (eg. cardiac output, cardiac
index, stroke volume, and many more)
Pulmonary Artery Catheters are a specialized therapy and are not discussed in this
introductory course

General considerations related to access devices


Arterial lines:

• Used to trend arterial blood pressure (ABP) when connected to the ICU monitor
• Used to trend CO, CI, SV, SVV, and other hemodynamics when connected to the
FloTrac or Vigileo monitor
• Label transducer accordingly
• Directly connected to the hemodynamic monitoring system set up, nothing should be
infusing into the arterial line. This is a CLOSED system and all tubing should be
primed with normal saline without any bubbles.
• Consider risks related to these lines: infection, neurovascular compromise, increased
risk for bleeding, thrombosis, air or thromboembolism, arterial vessel damage
o Needs to be secured and closely monitored
o Frequent assessment of neurovascular status (for a radial arterial line
assess for pain, swelling, coolness, poor capillary refill, paresthesia in the
hand)
o Frequent assessment of insertion site, reduce risk for inadvertent d/c of
line (by patient or due to other equipment/restraints near the area)
o May need to use an arm board or other device to keep the wrist straight
to ensure a clear waveform
o Nurses can d/c arterial lines- review your facility protocol and procedure.
You will need to apply firm pressure for 5 minutes and closely monitor the
site for bleeding

Evidence of neurovascular compromise- this line needs to be removed!


Arm board to help with appropriate positioning for radial arterial line

Central lines:

• Also a CLOSED system. Existing central lines that were initially placed for intravenous
infusion of medications are often used to trend a CVP to the ICU monitor.
• The hemodynamic monitoring system should be connected to the distal port (closest
to the heart gives us the most accurate number- many times this is the brown port).
• Monitor insertion site for signs of infection, bleeding, thrombosis
• Label transducer accordingly

Labels for different transducers


nitrari

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