Review of Hemodynamics

By: Maria Lourdes B. Galima

and determine
What is
Hemodynamics?
The study of forces involved in
the flow of blood through the
cardiovascular and
circulatory systems.

 What are the components

of hemodynamics?
- Blood Pressure (BP)
- Central Venous Pressure (CVP),
- Right and Left Heart Pressures.

 What are the physiologic

principles of
Hemodynamics?
Factors that :
- affect myocardial function,
- regulate BP
- determine cardiac performance
and cardiac output (CO).

 Review of the Circulatory

System
Veins and Arteries
Heart as a pump
Balance of oxygen delivery and
oxygen demand
Mechanisms that regulate the flow
of blood through the system

 Instant Feedback
Ms. Gallego,
When the bodys metabolic
demands increase, the blood
vessels (Dilate/Constrict?) in an
attempt to force blood back to
the heart.

 When the bodys metabolic

demands increase, the blood
vessels Constrict in an
attempt to force blood back to
the heart.

Instant Feedback
Ms. Estrada,
When the bodys metabolic
demand decreases, the veins
dilate, thus, pooling blood in the
periphery and reducing venous
return to the heart.

True or False

When the bodys metabolic

demand decreases, the veins
dilate, thus, pooling blood in
the periphery and reducing
venous return to the heart.

True

 How does the Heart

work?
- cardiac cycle
- the electrical conduction
system

 How does the Heart

work?
a. Depolarization
- electrical activation of muscle
cells of the heart and stimulates
cellular contraction.

b. Repolarization
- return of the depolarized muscle
cells to its original state of
electrolyte balance.

 Instant Feedback
Ms. Butawan,
During systole, the __________
valves are open and the
__________ are closed.
Ms. Tagalog
During diastole, the __________
valves are open and the
__________ are closed.

 During systole, the

semilunar valves are open
and the AV valves are
closed.
During diastole, the AV
valves are open and the
semilunar valves are closed.

 Cardiac Cycle
- Right atrium receives venous
blood from the systemic
circulation.
- Left atrium receives
reoxygenated blood from the
lungs.

 Cardiac Cycle
- While both atria are filling,
the SA node fires and starts
the process of depolarization.
- After atrial depolarization,
the atria contracts forcing the
remaining blood into the
ventricles (Atrial Kick).

 Common terms:
1. Stroke Volume (SV)
2. Left Ventricular End-Diastolic
Volume (LVEDV)
3. Left Ventricular End-Systolic
Volume (LVESD)
4. Ejection Fraction (EF)
5. Blood Pressure (BP)
6. Cardiac Output (CO)
7. Systemic Vascular Resistance (SVR)

 Stroke Volume
- the volume of blood that is
ejected during systole.
Left Ventricular End Systolic
Volume (LVESV) or Afterload
the amount of blood that
remains in the left ventricle at
the end of systole.

 Left Ventricular End Diastolic

Volume (LVEDV) or Preload
- the amount of blood that is in
the ventricle just before ejection
occurs.
Ejection Fraction
- the portion of the volume the
left ventricle ejects (70%).

 BP = CO x SVR
The tension exerted by blood on
the arterial walls

Cardiac output and

peripheral vascular
resistance directly affects
BP.

Factors affecting Arterial Blood Pressure

Mean Arterial Pressure

Peripheral Resistance

Blood Viscosity
(influenced by
hematocrit)

Autonomic Control

Arteriolar lumen size

(influenced by SNS)

Cardiac Output

Heart rate

Stroke volume

Sympathetic &
Parasympathetic
System

Preload
Intraventricular
pressure

Autonomic control

Atrial pressure

Blood volume

Venous pressure

Venous return

Renin angiotensin
system

 Instant Feedback
Ms. Baptista,
If a patients BP decreases,
then either the flow (CO) or
the resistance (SVR) will
change.

True or False

Cardiac Output and peripheral

vascular resistance directly
affects BP.
If a patients BP decreases,
then either the flow (CO) or
the resistance (SVR) will
change.
True

 Pressure = flow x
resistance
If flow or resistance is
altered, then pressure is
affected.

 Instant Feedback
Ms. Alcabasa,
Narrowed vessels decrease
resistance and decrease
pressure. Conversely, dilated
vessels increase resistance and
increase pressure.
True or False

False
Narrowed vessels increase
resistance and increase
pressure.
Conversely, dilated vessels
decrease
resistance and decrease
pressure.

 SVR = Mean Arterial Pressure MAP

CVP x 80
Cardiac Output (CO)
SVR is a reflection of peripheral vascular
resistance and is the opposition to blood
flow from the blood vessels.
It is affected by the tone of the blood
vessels, blood viscosity and resistance
from the inner lining of the blood
vessels.

 The resistance against which

the left ventricle pumps
(inverse relationship with
CO)
The diameter of the blood
vessel is one of the major
factor that influence SVR.

 Vasoactive drugs are often

used in the critical care
setting to change the size of
the arterioles to decrease or
increase blood pressure.

 Instant Feedback
Mr. Valles,
SVR decreases when the
blood vessels constrict and it
increases when blood vessels
dilate.
True or False

False
SVR decreases when the
blood vessels relax and it
increases when blood
vessels constrict.

Instant Feedback

Ms. Reyes,
If the SVR decreases, then
cardiac output increases.
SVR increases to maintain BP
when the cardiac output
decreases.
True or False

 If the SVR decreases, then

cardiac output increases.
SVR increases to maintain
BP when the cardiac output
decreases.
True

Elevations of Systemic
Vascular Resistance
Two (2) primary reasons for
elevation:
1. Vascular disturbances
(vasoconstriction caused by HPN
or excessive cathecholamine
release)
2. Compensatory responses to
maintain BP in decreased CO.

 Instant Feedback
Ms. Arciaga,
Elevations of SVR increases the
workload of the heart and
myocardial O2 consumption.
True or False

Elevations of SVR, increases

the workload of the heart
and myocardial oxygen
consumption.
True

Decreases in Systemic
Vascular Resistance
Potential causes are sepsis,
neurologically mediated
vasomotor tone loss.

 Instant Feedback
Ms. Gallego,
Thus, when SVR increases,
CO increases in an attempt
to maintain BP.
True or False

True
Thus, when SVR
decreases, CO increases
in an attempt to
maintain BP.

 Common Medications and Habits

that Affect SVR
Smoking and stress can cause
vasoconstriction
Vasodilators enlarge (dilate) the size of the
arterioles in an attempt to decrease BP.
Vasoconstrictors constrict the size of the
arterioles in an attempt to increase BP

 CO = SV x HR
Normal Value: 4-8 liters /min
Cardiac output is the amount of blood
ejected from the heart in one full
minute.
It has two components: the SV and HR
A major goal in assessing CO is
ensuring adequate oxygenation.

 Stroke Volume
The amount of blood ejected from
the heart with each beat.
Three (3) factors that influence
SV:
1. Preload
2. Afterload
3. Contractility

 Preload
The filling volume of the
ventricle at the end of diastole.
Reflects the amount of cardiac
muscle stretch at end diastole
just before contraction.

 Preload
It is dependent on the volume of
blood returning to the heart.
Measured by Pulmonary artery
wedge pressure (PAWP)

 Instant Feedback

Ms. Estrada,
Increase fluid volume and venous
constriction increases Preload.
WHILE
Hypovolemia and vasodilation
decreases Preload.

True or False

True
Increase fluid volume and
venous constriction increases
Preload. WHILE
Hypovolemia and vasodilation
decreases Preload.

 Preload is directly related to

the force of myocardial
contraction.
An enlarged heart will
increase preload and is
measured by an elevated
PAWP.

 Afterload
The amount of resistance against
which the left ventricle pumps.
Primarily influenced by the blood
vessels, blood viscosity, flow
patterns and condition of the
valves.
It is determined by BP and
arterial tone.

 Afterload
The greater the resistance, the
more the myocardium has to
work to overcome the
resistance.
Left ventricular afterload is measured
by the assessment of the systemic
vascular resistance (SVR).
Pulmonary vascular resistance (PVR)
measures the resistance against
which the right ventricle works.

 Instant Feedback
Ms. Butawan,
Vasoconstriction results from an
increase systemic arterial tone
which increases BP and causes
an increase in Afterload.
True or False

True
Vasoconstriction results
from an increase systemic
arterial tone which
increases BP and causes
an increase in Afterload.

 Contractility
The strength of myocardial fiber
shortening during systole.
Allows the heart to work
independently regardless of
changes in preload, afterload or
fiber length.

 Contractility
It is a determinant of stroke
volume and affects ventricular
function.
Preload directly influences
contractility.

 Instant Feedback
Ms. Tagalog,
As resistance to ventricular
ejection (afterload) decreases,
Left ventricular work increases
and stroke volume may
decrease.

True or False

False
As resistance to
ventricular ejection
(afterload) decreases,
Left ventricular work
increases and stroke
volume may increase.

 Heart Rate
The number of heartbeats per
minute
Important in maintaining CO and
included in the CO formula.

 Instant Feedback
Ms. Baptista,
When contractility is depressed or
if Cardiac Output is decreased,
HR will increase to maintain
blood flow for metabolic
demand.

True or False

True
When contractility is
depressed or if Cardiac
Output is decreased, HR
will increase to maintain
blood flow for metabolic
demand.

 Manipulation of Cardiac Output

STROKE VOLUME
PRELOAD

AFTERLOAD

HEART RATE
Contractility

Increased

Decreased

Increased

Decreased

Decreased

Increased

Decreased

Mgt:

Mgt:

Mgt:

Mgt:

Mgt:

Mgt:

Mgt:

Diuretics &
Vasodilators

Fluids &
Vaso
constrictors

Arterial
Vaso
-dilators

Vaso
-constrictors

Positive
Inotropes

Beta
Blockers &
Ca
Channel
Blockers

Sympathomimetics &
Cardiac
pacing

 Physiologic Principles that Affect

Cardiac Performance
1. Frank-Starling Law of the Heart
. Augmenting ventricular filling during
diastole before the onset of a
contraction will increase the force of
contraction during systole.
. The greater the stretch, the
greater the force of the next
contraction.

 Physiologic Principles that Affect

Cardiac Performance
2. Inotropism
The ability to influence contractility
of muscle fibers.
A positive inotrope enhances
contractility and a negative inotrope
depresses contractility.

Instant Feedback
Ms. Alcabasa,
Diastolic Filling time is shortened
when heat rate is <60 beats/min
(bradycardia) and diastolic filling
time is lengthened when heart
rate is >100 beats/min
(tachycardia).
True or False

False
Diastolic Filling time is
lengthened when heat rate is
<60 beats/min (bradycardia)
and diastolic filling time is
shortened when heart rate is
>100 beats/min
(tachycardia).

 Physiologic Principles that Affect

Cardiac Performance
3. Force-Frequency Ratio
Any changes in HR or rhythm can
change diastolic filling time of the
ventricles therefore altering fiber
stretch and the force of the next
contraction.
This ratio influences the SV and CO.

 Instant Feedback
Mr. Valles,
When HR increases, myocardial O2
demand increases so when diastolic
filling time is shortened, coronary
artery filling increases.
True or False

False
When HR increases, myocardial
O2 demand increases so when
diastolic filling time is
shortened, coronary artery
filling decreases.

 Physiologic Principles that

Affect Cardiac Performance
4. Miscellaneous Influences
Hyperkalemia, hyponatremia, hypoxia,
hypercarbia & myocardial scar tissue
decreases myocardial contractility.

 Instant Feedback
Ms. Reyes,
Sympathetic stimulation increases
myocardial contractility and
Parasympathetic stimulation (via the
vagus nerve) depresses the SA node,
atrial myocardium and AV junctional
tissue.

True or False

True
Sympathetic stimulation
increases myocardial
contractility and
Parasympathetic stimulation
(via the vagus nerve) depresses
the SA node, atrial myocardium
and AV junctional tissue.

Hemodynamic
Monitoring

 What is Hemodynamic
Monitoring?
- Hemodynamics or pressures of the
cardiovascular and circulatory systems
can be measured by invasive methods:
a. direct arterial BP monitoring
b. CVP monitoring
c. indirect measurements of left
ventricular
pressures via a flow-directed
balloon-tipped

 Goals of Hemodynamic
Monitoring:

1. Ensuring adequate perfusion

2. Detecting inadequate perfusion
3. Titrating therapy to specific end point
4. Qualifying the severity of illness
5. differentiating system dysfunction like:
- differentiating between cardiogenic and
noncardiogenic pulmonary edema

 Direct Arterial
Blood Pressure
Monitoring

- allows for accurate,

continuous monitoring
of arterial BPs.
- it provides a system
of continuous
sampling of blood for
arterial gases without
repeated arterial
punctures.

Clinical Considerations for

Direct Arterial BP
Monitoring:

- Potential complications
of thrombosis, embolism,
blood loss and infection.

 Right Atrial Pressure

Monitoring
- can be referred to as RAP
or CVP
- this is a direct method
- Any condition that
changes venous tone,
blood volume, or
contractility of the right
ventricle can cause
abnormality in RAP values.
- Normal Value = 06mmHg

Instant Feeedback
Ms. Arciaga,
Low RAP or CVP
measurements can reflect
hypervolemia or extreme
vasoconstriction. AND
High RAP measurements
can reflect hypovolemia or
severe vasodilation.

True or False

True
Low RAP or CVP measurements
can reflect hypervolemia or
extreme vasoconstriction. AND
High RAP measurements can
reflect hypovolemia or severe
vasodilation.

 Low RAP or CVP

measurements
can reflect
hypovolemia or
extreme
vasodilation.

 High RAP
measurements can
reflect
hypervolemia or
severe
vasoconstriction
OR conditions that
reduce the ability of
the right ventricle to
contract like
pulmonary

 Left trial
Pressure
Monitoring
- A direct method

used only in cardiac

surgical procedures,
cardiac
catheterization and
after open heart
surgeries.

 Left trial Pressure Monitoring

-A catheter is inserted with the
distal end tunneled through an
incision in the chest wall.
- LAP provides the ability to
observe the pressures in the left
atrium.
- Normal Value = 6-12mmHg

 Complications of
LAP Monitoring
- Major
complications are air
embolism and
system debris which
can obstruct a
coronary or cerebral
artery.

Prevention of
Complications
- Connections
must be tight and
caps should be on
stopcocks to avoid
air entering or
administering
medications and
fluids through this
line.

Chest x-ray (A) and intracardiac echocardiogram (B) at the time of implantation
demonstrating orthogonal fixation of the LAP monitoring device in the interatrial septum
(arrows).

 Instant Feedback
Ms. Gallego,
Patients who have compliant left
ventricles can have large volume
changes without large changes in
pressure; conversely, patients with
noncompliant ventricles may have
extreme volume changes without
PCWP increase.

True or False

 It is important to remember that

changes in PCWP are not always
equal to volume changes
because the PCWP is not the only
parameter involved in muscle
stretch.

 Therefore, Patients who have

compliant left ventricles can
have large volume changes
without large changes in
pressure; conversely, patients
with noncompliant ventricles
may have extreme volume
changes without PCWP increase.

 Pulmonary Artery
Monitoring
- The catheter is a
multi-lumen, balloon
tipped that is
inserted through the
venous system into
the right side of the
heart and into the
pulmonary artery.

- May be inserted
from an antecubital
vein, external jugular
vein, subclavian
artery or any other
peripheral vein into
the PA through a
percutaneous
introducer.
- Normal Value
(PAP) = 1015mmHg
- Normal Value

- The catheter is inserted

with the balloon
deflated.
- When the catheter
enters the right atrium,
the balloon is inflated
allowing it to float with
the flow of blood into
the PA.
- When the balloon is
deflated, the catheter
directly measures the PA
pressures.

- With balloon
inflated, the
catheter floats into
a pulmonary
arteriole and
wedges itself in a
smaller lumen.
- The opening of the
catheter beyond
the inflated balloon
reflects pressures

 The PA catheter is used to

monitor high-risk, critically ill
patients with goals that
include detection of
adequate perfusion and the
diagnosis and evaluation
of the effects of therapy.

 This high-risk patient group

include:
- Acute MI
- Severe angina
- Cardiomayopathy
- Right & Left ventricular
failure
-Pulmonary diseases

 Pulmonary Arterial
monitoring is a valuable tool
for observing fluid balance in
the critically ill patient at risk
for other cardiopulmonary
problems.

 To monitor hemodynamics, the equipment

must include:
- a transducer
- amplifier
- display monitor
- catheter system
- tubing filled with fluid
The system provides the ability to monitor
a pressure waveform that is displayed as a
digital readout on the oscilloscope.

 Nursing Interventions for

Hemodynamic Monitoring:
1. Provide patient education about the
procedure.
2. Ensure that the appropriate
procedure consent forms are signed.
3. Setting up the equipment and
preparing the lines properly.

Nursing Interventions for

Hemodynamic Monitoring:

4. Assisting the physician with

catheter insertion.
5. carefully monitoring the
pressures.
6. Making clinical decisions per
institutional policy
7. Must be alert to potential
complications.