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    HEMODYNAMICS

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    aries0411
    This patient is a 65-year-old woman with a history of hip surgery who presented with chest pain, shortness of breath, and hypoxemia. A pulmonary artery (PA) catheter was placed to help diagnose and guide therapy. The PA catheter measurements indicate elevated right atrial pressure (RAP), mean pulmonary artery pressure (mPA), and pulmonary capillary wedge pressure (PCWP), consistent with pulmonary edema from left heart failure. Systemic vascular resistance (SVR) is also elevated, likely due to vasoconstriction as a compensatory mechanism. Goals for this patient include diuresis to reduce pulmonary congestion and afterload reduction to improve cardiac output.

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    HEMODYNAMICS

    Uploaded by

    aries0411
    323 views28 pages
    This patient is a 65-year-old woman with a history of hip surgery who presented with chest pain, shortness of breath, and hypoxemia. A pulmonary artery (PA) catheter was placed to help diagnose and guide therapy. The PA catheter measurements indicate elevated right atrial pressure (RAP), mean pulmonary artery pressure (mPA), and pulmonary capillary wedge pressure (PCWP), consistent with pulmonary edema from left heart failure. Systemic vascular resistance (SVR) is also elevated, likely due to vasoconstriction as a compensatory mechanism. Goals for this patient include diuresis to reduce pulmonary congestion and afterload reduction to improve cardiac output.

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    This patient is a 65-year-old woman with a history of hip surgery who presented with chest pain, shortness of breath, and hypoxemia. A pulmonary artery (PA) catheter was placed to help diagnose and guide therapy. The PA catheter measurements indicate elevated right atrial pressure (RAP), mean pulmonary artery pressure (mPA), and pulmonary capillary wedge pressure (PCWP), consistent with pulmonary edema from left heart failure. Systemic vascular resistance (SVR) is also elevated, likely due to vasoconstriction as a compensatory mechanism. Goals for this patient include diuresis to reduce pulmonary congestion and afterload reduction to improve cardiac output.

    Copyright:

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    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    323 views28 pages

    HEMODYNAMICS

    Uploaded by

    aries0411
    This patient is a 65-year-old woman with a history of hip surgery who presented with chest pain, shortness of breath, and hypoxemia. A pulmonary artery (PA) catheter was placed to help diagnose and guide therapy. The PA catheter measurements indicate elevated right atrial pressure (RAP), mean pulmonary artery pressure (mPA), and pulmonary capillary wedge pressure (PCWP), consistent with pulmonary edema from left heart failure. Systemic vascular resistance (SVR) is also elevated, likely due to vasoconstriction as a compensatory mechanism. Goals for this patient include diuresis to reduce pulmonary congestion and afterload reduction to improve cardiac output.

    Copyright:

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    Download as PDF, TXT or read online from Scribd
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    of 28

    HEMODYNAMICS

    Carol Peyton Bryant, RN, MSN, ACNP, CCRN Priority Care, St. Marys

    Objectives:
    The participant will be able to discuss hemodynamic definitons (cvp,pa,pcwp,co,ci,svr and pvr) and how they relate to the respiratory patient. The participant will use critical thinking skills in assessing changes in respiratory status/ventilation with changes in hemodynamic status.

    INDICATIONS FOR HEMODYNAMIC MONITORING


    Shock Pulmonary edema of uncertain etiology Postcardiac surgery Cardiac tamponade Acute respiratory failure Need to evaluate for fluid status/guideline for fluid resuscitation Need to evaluate hemodynamic response to potent pharmacologic agents MI
    especially with an acute right or left ventricular failure Refractory pain Significant hypotension or hypertension

    Blood pressure
    Blood pressure=CO X SVR
    Changes in blood pressure are caused by either a change in cardiac output or by systemic vascular resistance MAP Mean arterial pressure= SBP + (DBP x 2) = 70-105 mm Hg 3 The average blood pressure occurring in the aorta and its major branches during the cardiac cycle

    Stroke volume: CO HR
    The amount of blood ejected by the left ventricle during systole. N= 60-120 ml/beat Stroke Index: SV BSA The SV indexed for differences in body size by dividing by BSA. N= 30-65 ml/m2/beat Ejection Fraction: % of blood in the ventricle that is ejected during systole. Normally, greater than 50%.

    Right Atrial Pressure-RAP


    Normal Value 2-8 mm Hg Clinical Significance: Equivalent to central venous pressure. Abnormalities: Increased
    Right ventricular failure, tricuspid valve abnormalities (stenosis or regurgitation), cardiac tamponade, right ventricular infarct, VSD with a left to right shunt. Pulmonary stenosis, Postive Pressure ventilation Pulmonary Hypertension
    Active: hypoxemic pulmonary vasoconstriction Pa02 < 60 mm Hg.
    Pulmonary Embolus COPD ARDS

    Passive:
    Mitral valve dysfunction either stenosis or regurgitation

    Right Atrial Pressure-RAP


    Decreased:
    Hypovolemia Anything that vasodilates the body;
    Endogendous systemic vasodilation
    Septic Shock, Neurogenic Shock, Anaphylactic Shock

    Venous vasodilation
    Nitroglycerin or Morphine

    Pulmonary Artery Pressure PAP or PAS/D


    Systolic: 15-30 mm Hg Diastolic: 5-12 mm Hg Mean: 10-20 mm Hg Clinical Significance: PAP is equal to right ventricular pressure during systole while the pulmonary valve is open. IF the pulmonary vascular resistance is normal, the PADP is 1-4 mm Hg greater than PCWP and can be substituted for it in following the patients hemodynamic measurements.

    Abnormalities: Increased:
    Hypervolemia, VSD with left to right shunt, Pulmonary HTN, Positive pressure ventilation, Mitral valve dysfunction (both), Tamponade, Left ventricular failure

    Decreased: Hypovolemia Excessive vasodilation If the PADP is 5mm Hg > PCWP, consider acute respiratory distress syndrome, pulmonary emboli, or chronic obstructive pulmonary disease.

    Pulmonary capillary wedge pressure PCWP or PAOP


    Normal value 5-12 mm Hg Clinical Significance: pcwp is normally equal to left atrial presure; ~sensitive indicator of pulmonary congestion or left sided CHF.

    PCWP is not equal to LVEDP in the following situations: PCWP >LVEDP: Mitral Stenosis, patients receiving PEEP, Left atrial myxoma, pulmonary venous obstruction

    PCWP< LVEDP:Stiff ventricle or Increased LVEDP (>25 mm Hg).

    Abnormalities: Increased
    Left ventricular failure with resultant pulmonary congestions, acute mitral insufficiency, tamponade, decreased left ventricular compliance (hypertropy, infarction).

    Decreased
    Hypovolemia Vasodilation

    Cardiac Output CO
    Normal Value 4-8 L/min. Clinical Significance: CO=SV x heart rate/1000 Abnormalities: Increased
    Sympathetic nervous system innervation (endogenous catecholamines ie. stress/exercise) Exogenous catecholamines (ie. epinephrine, dobutrex, dopamine, isuprel) Other positive inotropes ie. digitalis Infection, early sepsis Hyperthyroidism Anemia

    Cardiac Output-CO
    Decreased
    Cardiac dysrhythmias, decreased contracting muscle mass (myocardial infarction, ischemia) mitral insufficiency, VSD. Increased SVR (afterload)- systemic or Pulmonary HTN, Aortic or Pulmonic stenosis or polycythemia Significantly increased or decreased heart rate. Either hyper or hypovolemia

    Cardiac Index CI
    Normal Value: 2.5-4 L/min. Clinical Significance: CI= CO/BSA Abnormalities: Increased: high output failure secondary to fluid overload, hepatocellular failure, renal disease, septic shock Decreased: hypovolemia, cardiogenic shock, pulmonary embolism, hypothyroidism, CHF with failing ventricle.

    Normal Value 900-1300 dyne/sec/cm-5. SVR= (MAP-RAP) x 80 /CO

    Systemic Vascular resistance SVR

    Clinical Significance: Resistance against which the left ventricle must work to eject its stroke volume. Abnormalities: Increased: hypervolemic vasoconstrictive states (hypertension, cardiogenic shock, traumatic shock). Decreased: septic shock, acute renal failure, pregnancy.

    Remember
    There is a inverse relationship with CI and SVR. If the CI is UP, the SVR will be DOWN. If the CI is DOWN, the SVR will be UP.

    Pulmonary Vascular Resistance PVR


    Normal Value: 150-250 dyne/sec/cm-5.
    Clinical Significance: PVR=(mPAP-PCWP) x 80/CO. Abnormalities: Increased: cor pulmonale, pulmonary embolism, valvular heart disease, CHF. Decreased: hypervolemic states, pregnancy.

    Scenario
    65 year old woman admitted with a fractured hip. She had surgery 2 weeks ago. Earlier today she complained about chest pain, shortness of breath, and a feeling of doom. ABGs revealed respiratory alkalosis and hypoxemia. A RRT was called and she was transferred to ICU, the physician inserted a PA catheter into her right subclavian vein. He told the nurse it was placed so he could better diagnose and evaluate her thearpy. Her body surface area (BSA) is 1.6 m2.

    Parameter Bp:112/84 MAP: 93 mm Hg HR: 110 RAP: 18 PAS/D: 55/32 mPA: 40 PAOP: 6 CO: 4.4 CI: 2.75

    or normal

    Why?

    Parameter SaO2: 85% SV: 40 SVR: 1356 PVR: 618 Svo2: 58%

    or normal

    Why?

    Dx: ______________ _________________ Considering her history, you would suspect ____________. You know that means we gotta travel to have _____________________(test) done. Goals for this patient ____________________ ____________________ ____________________

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