week 2; #1 Hemodynamic Monitoring

Hemodynamic Monitoring: cardiac Index

- Calculation: CO/ BSA - Normal value: 2.2-4.0 L/min/m²

Hemodynamic Monitoring: CO

- Calculation: HR x SV - Normal value: 4-8 L/min

Measurements of Afterload (Left Ventricle): Systemic vascular resistance (SVR)

- Calculation: MAP-CVP x 80/CO - Normal range: 800-1200 dynes/s/cm¯⁵

Measurements of Afterload (Left Ventricle): Mean arterial pressure (MAP)

- Calculation: SBP + 2(DBP)/3 - Normal range: 70-92 mm Hg

Measurements of Preload: CVP (RAP)

- Normal value: 2-6 mm Hg

Measurements of Preload: Pulmonary artery diastolic pressure (PAD)

- Normal value: 4-12 mm Hg

Measurements of Preload: LVEDP

- Normal value: 6-12 mm Hg

Measurements of Preload: PAWP

- Normal value: 6-12 mm Hg

Determinants of Stroke Volume: Afterload

Afterload: resistance to ejection of blood from ventricle •Resistance provided by vaso-activity and blood viscosity •Affected by systemic vascular resistance BP, aortic valve (left side of heart); pulmonary vascular resistance (right side of heart)

Determinants of Stroke Volume: contractility

Contractility: ability of cardiac muscle to shorten in response to electrical impulse •Increased by catecholamines, sympathetic nervous system, some medications •Decreased by hypoxemia, acidosis, some medications •Measured indirectly by ejection fraction •If heart rate, preload, and afterload remain constant, but CO changes, then probably contractility is changed

Pulmonary Artery Pressure

Pulmonary artery pressure (PAP): Reflects left ventricular function •Indicated for: -Assessing left ventricular function (preload/afterload) -Diagnosing the etiology of shock -Evaluating the client's response to interventions such as fluids or meds •Measurement: -Requires insertion of PA catheter -Monitored continuously using a transducer

Mean Arterial Pressure (MAP) equation

SBP + (2 x DBP) ______________________ 3

Determinants of Stroke Volume

Stroke volume (SV): amount of blood ejected with each heartbeat (normal 60-100 mL/beat) -Preload -Afterload -Contractility

Arterial Pressure Monitoring nursing management

Watch for potential complications: •Hemorrhage •Infection •Thrombus formation •Neurovascular impairment •Loss of limb

Measurements of Contractility: Ejection Fraction (EF)

normal range : 55-60%

Measurements of Afterload (Left Ventricle): Systolic blood pressure (SBP)

normal range: 100-130 mm Hg

Measurements of Afterload (Right Ventricle): Pulmonary artery systolic pressure

normal value : 15-30 mm Hg

Cardiac Index

§Cardiac Index: •More accurate indicator of cardiac output •Relates cardiac output to client's body size •CI = CO ÷ Body Surface Area •Normal CI: 2.2 to 4.0 (4.5)L/min/m² (- cardiac index is a number that's really a more accurate indicator of your cardiac output because it's related to the patient's body size - the formula for cardiac index is your cardiac output divided by body surface area because that's measures for your body size and normal is 2.2 to 4.0)

Determinants of Stroke Volume: preload

§Preload: degree of stretch of cardiac muscle fibers at end of diastole (filling) •Amount of blood in ventricles at end of diastole •Affected by *venous return* to the heart •Can measure Preload in both ventricles (LV→PAWP; RV→CVP)

Signs of Hemodynamic Compromise notes

· Can become confused or dizzy or even lose consciousness altogether bc they're not getting enough blood flow to brain so think about the blood flow to all the different organs · With the lungs if the lungs don't get enough blood flow the patient SOB · If all the organs aren't getting enough blood flow the BP will drop · HR will speed up so they become tachycardic to kind of get some blood flow around to all organs · Skin is not getting enough blood flow so they become cold and clammy, they may look a little dusky bc they're high hypoxic · Then over time they would have a decrease in their urine output bc the kidneys aren't getting enough blood flow to the kidneys can compensate for a little while but not forever

Pressure Monitoring System notes

· Cath usually it's inserted into subclavian vein that goes to right side of heart, right up in the right chest area · It could also be inserted in the right brachial vein or the right femoral vein and threaded up to the heart but generally it's in the subclavian or maybe the jugular vein on that right side of the heart · It threads its way through Ratrium through Rventricle and into pulmonary artery where it kind of rests in pulmonary artery and this cath is called a pulmonary artery catheter or a swan-Ganz catheter · Then down at the bottom is the transducer so you have the cath in and then it connects to this transducer that kind of sits on a pole close to the pt's bedside and then that connects to the monitor there and that creates the waveform and a digital number from what the readings the transducer is sending it

Parasympathetic Response story

· Dog owner comes out he gets the dog takes it away the stimulus is gone and you just feel like this little guy here like a wet noodle like · your pupils constrict back because you don't need them to get away anymore · you have increased salivation · your bronchioles constrict and increase your respiratory secretions · your pulse goes down, your blood vessels dilate so your blood pressure goes down · you have increased peristalsis so you may feel like you need to throw up · your bladder constricts so all of a sudden you realized ok I need to go to the bathroom

Ejection Fraction notes

· Ejection fraction is % of the blood that's ejected with each heartbeat from the LV. · SV is the amount that's in there right when the ventricle is ready to contract and that's the amount that goes out but it's not all of the blood that's in the ventricle with each heartbeat is ejected · Normally 55 to 60% goes out so then you still have 40%- 45% that's still in the ventricle you add more to it with the next heartbeat and so on · As long as the heart is pumping appropriately and everything's moving forward then you're never going to have too much in there, it won't back up but when we start to have problems with the heart and the pump system then that's when you start to have a backup of and become fluid overloaded

Potential Complications of Pulmonary Artery Catheters notes

· Infection and sepsis is always a worry so you need to make sure you maintain aseptic technique · Getting an air embolism is worry so have good tight connections to make sure that there's no air getting into the system · When the catheter goes through Rventricle, if that catheter and it will kind of touch up against the sides of the Rventricle and it can cause some ventricular ectopy, PVC, little runs of vtac · Once it's in that pulmonary artery, it stays there and it doesn't affect the electrical conduction system of the heart just kind of floats along in that pulmonary artery · It can get wedged all the way out into a small capillary and of the pulmonary vasculature and if that happens, you notice a change in the wave form, you don't want to leave it that way bc it can cause a rupture of that vessel so just had to be very careful and watch the waveforms closely

Elevated Pulmonary Artery Pressure: notes

· with systolic any condition that acutely or chronically · whatever increases the afterload of the right ventricle so things in the lungs mostly pulmonary HTN, chronic lung disease, PE, and hypoxemia will cause an elevation in the pulmonary artery systolic · they don't use that measurement as much for measuring for shock type states but more for measuring the function of the right side of the ventricle in pts who have lung problems and symptoms vary depends on how bad their lung problems are

Pulmonary Artery Pressure notes

· Know: pulmonary artery pressure and reflects the left ventricular function even though the catheter is in the pulmonary artery, they can put a catheter in the left side of the heart, because the force of contraction is so strong it wouldn't stay in place like it will in the pulmonary artery · when the valves are open on that left side of the heart this is a direct reading of the left ventricle of the heart · they would use this for somebody who has problem with their left ventricular function whether it's preload or afterload · if they need to figure out what type of shock a patient's in they might put in a pulmonary artery catheter · to evaluate their response to interventions such as giving fluids or the vasopressive medication · patients that commonly have a pulmonary artery catheter in our patients who've had bypass surgery or valve replacement surgery or somebody that's in cardiogenic shock · this requires insertion of the PA catheter, and it is measured continuously using that transducer

Central Venous Pressure notes 2

· PA catheter even though the tip of it is all the way into the pulmonary artery there is a point there that where the catheter is still in the right atrium that can measure that right atrial pressure, CVP pressure · you can measure it with just a catheter in the right atrium or you can measure it that pulmonary artery catheter because it also measures it there in the right atrium · what you need to understand is what causes it to be elevated and what causes it to be too low or decrease · so elevated CVP would be fluid volume excess so what you could do to treat that is to either decrease or discontinue your IV fluids if you have too much volume coming back into the right side of the heart or you could give diuretics to pull that fluid off and get it out of the patient system · it's also caused by poor right ventricular contraction, there are some medications that might affect that but nothing really much that we can do about that · if you have a decrease in your CVP that means you have a fluid volume deficit so what you do to treat that would be increase your the fluids or if they had lost blood you would give blood products something like that and · normal is two to six it's always red as the mean it's not read as a systolic and diastolic

Thermodilution Catheter (Pulmonary Artery [PA] Catheter)

· PA catheter have multiple ports which is a good thing because these people are so sick so it gives you a little bit of extra IV space to have different IV drips and everything running through it · at the very tip of it down there you'll see like where numbers 2-3-4 so there'll be a little balloon on the end of it, the balloon doesn't stay inflated at all times but that tip can measure the temp of the blood and that's how they measure the CO · just know that this actually goes right into the heart, goes through the right ventricle and just sits in the pulmonary artery so that's a direct reflection of pressures on the left side of the heart

Pulmonary Artery Wedge Pressure symptoms notes

· Pulmonary artery wedge pressure what can cause it to be elevated could be fluid overload, if your left ventricle is not pumping effectively so you've got too much fluid in there, end of diastole so the most fluid that can be in the ventricle at any point in that cardiac cycle so if you've got fluid volume overload or the left ventricle is not pumping that's when there's too much fluid in there and that will cause elevation in your wedge pressure · MI because the heart's not getting blood flow so it's not going to pump appropriately · mitral valve stenosis and cardiac tamponade · you will have those lung type of symptoms because the fluid is backing up into the lungs, it can't go it's not going forward so it's going to back up into the lungs

Determinants of Stroke Volume notes 1

· SV is the amount of blood that is injected with each heartbeat so each time Lventricle contract, what goes out is SV and that's normally about 60 to 100 ml per beat · Preload is the amount of blood that is in ventricles at the end of diastole so systole is ejection, diastole is filling so it's the amount of blood that's in there when it's completely full or as full as it's going to get · Amount of stretch is the amount of recoil that you're going to have so preload is kind of based on that so it is affected by the venous return to the heart so if you have a pt who has is holding fluid down in their ankles and their legs then they're not going to have as much blood coming back into the heart so they're going to have a decrease in preload so that eventually works its way over to the left side of the heart so if you don't have as much coming to Rside of the heart you're not going to have any more going to Lside of the heart either · you could also have decreased preload on the left side bc fluid is staying in the lungs sometimes with some pts · Pulmonary artery wedge pressure that's the measurement of preload for the left ventricle · Right ventricle the central venous pressure is the measurement of preload · Afterload is the resistance to the ejection of the blood from the ventricles and that's created by the vasoactivity so the constriction and dilation of the arteries of the body and then how thick the blood is and then it can also be affected by the aortic valve

Effects of Sympathomimetics at Receptors notes

· Sympathomimetics which have a sympathetic response. · Alpha receptors are located in the blood vessels and in your eyes, your bladder, the prostate · so all of those things that we just talked about with the sympathetic response would happen · the alpha two receptors are the presynaptic neurons and cells and they inhibit the norepinephrine so that promotes the vasodilation and decreased blood pressure and decrease GI

Leveling and Zeroing notes

· They have be zeroed and leveled to make sure that you have an accurate reading · in order to do that the patient needs to be flat, you have to level it at what it's called the Phelbostatic axis or it's mid axillary line generally you use that right side of the heart because closer to the where the catheter goes in · one important thing to understand about zeroing and leveling if you're getting numbers that don't fit with your patient's clinical fixed picture so the patient looks fine but your numbers are crazy like the patient should be in cardiogenic shock or something like that then you need to go back and level and zero to make sure that you're that the pressures are appropriate

Body Surface Area Review (slide 8)

· you find the patient's height in centimeters and their weight in kilograms and you draw a line between the two of them and where it falls on the BSA index there that's what their body surface area is

Arterial Pressure Monitoring

•Intra-arterial BP monitoring (arterial line): •Uses: continuous monitoring of BP and blood sampling •Insertion sites: -Most common is radial artery -Other sites: femoral and brachial arteries -Immobilize site •*Allen's test* -Mean Arterial Pressure (MAP): an approximation of average pressure in systemic circulation throughout cardiac cycle - *Normally titrate vasoactive drugs to keep MAP >60-65*

Cardiac Output Monitoring notes

· To measure CO they use this pulmonary artery or thermodilution catheter · way it works is if you look at the diagram there you inject fluids normal saline usually either at room temperature or cold · because room temp is cooler than body temperature is and so when you inject got into that catheter it travels through the catheter and there's a little hole that it comes out and then at the tip of the cath it measures when that cooled fluid mixed with the blood by this time it's mixed with the blood because you've injected it and it's come out of the catheter that it would measure it how long it takes to pass that thermister point · so the temperature changes detected when the blood flows from one point past that thermistor point in the distal tip and then that relates it to computer there are some of CO machines that are measured continuously so like patients who've had bypass surgery or valve replacement surgery will have can have a continuous cardiac output machine but usually they'll you inject the saline and then you watch on the monitor and it gives you a readout of what your CO is

Vasoactive Medication Therapy notes

· Vasoactive medications are used in all forms of shock to help improve hemodynamic stability of the patient when IV fluids by themselves cannot maintain an adequate mean arterial pressure · they don't treat the underlying cause of the shock they're just treating the complication of hypotension in the shot glide state so you always have to address that underlying problem and make sure that there are fluid status is adequate even though you use these when you know that just the fluids haven't been affected but you still want to make sure that they get out adequate fluid

Pulmonary Artery Wedge Pressure notes

· Wedge pressure is when you inflate the balloon and it floats on out and kind of wedges itself into a pulmonary artery, its also called the pulmonary artery occlusion pressure because it's occluding blood flow past it so and reflecting what's going on in the left side of the heart or the pulmonary capillary wedge pressure · artery and capillary same thing is just the capillary is just smaller part of the artery · this does reflect that end diastolic pressure in the left ventricle so right when the ventricle is most full that's when the highest pressure would be and that's the measurement of preload in the left ventricle · the wedge pressure and the pulmonary artery diastolic pressure are measuring the same thing, measuring the fluid volume in the left ventricle at the same point in time · sometimes the doctors will not have you wedge the catheter just to keep from rupturing that capillary but sometimes they will · if you do you inflate the balloon you watch your waveform so it goes from that systolic diastolic type of a waveform in the pulmonary artery and then it wedges down to where it's just a little waveform and you capture that on your screen and then you let the air back out you let it come back out passively, you just take off little strange and let the air come back out you don't want to suck it back because you could cause damage then and just watch for it to go back to the wave form so this is a picture of that what the wave form would look like · you never want to leave it wedged because it can rupture the vessel and normally 6 to 12 , it's the same measurement as your pulmonary artery diastolic

Arterial Pressure Monitoring notes

· a patient can have a catheter put into an artery that measures continuous blood pressure inside the artery, so this is the most accurate blood pressure · you can also use it to draw blood from so it's an arterial line · usually, they use the radial artery they can also use the femoral and their brachial arteries make sure that if the patient has arterial line in that this site is immobilized · we try to avoid the femoral artery bc it especially in patients who are bedridden which they'd have to be if they had one of these in because of the proximity to their perineum so they might pee on it or poop on it or whatever and get infected so they try to avoid the femoral lines · the alliance test is something that you would do before you put in a arterial line where you would press on the patients both their radial and their ulnar artery and watch. They press on it and you actually look watch their fingers go pale and then you let up on the ulnar side and keep pressure on the radial side because you want to make sure that they have blood flow down into their fingers, you're going to put that catheter into the radial artery and you're going to pretty much occlude that radial artery with that catheter so you want to make sure that they actually have blood flow to their hand through their ulnar artery so that's why you do the Allen's test · the mean arterial pressure we've already talked about that and you do use the mean arterial pressure to titrate your vasoactive medications keep the mean arterial pressure 60 to 65 normal is 70 to 92 but sometimes with these really sick patients you're happy with 60 to 65

Determinants of Stroke Volume contractility notes

· contractility is the ability of the cardiac muscle to respond to that electrical stimulus and cause a contraction so you can increase this by catecholamines the sympathetic nervous system so if you remember the flight or fight that can change the contractility of your heart and there are medications that can do that as well · it can be decreased by hypoxemia so lack of oxygen in the blood, acidosis which comes from lack of oxygen and then there are medications as well · you measure that it's more of an indirect measurement by the ejection fraction · you can measure CO with a special cath and everything's normal but CO is dropping then it's the contractility so that's important to remember bc sometimes some pts are able to compensate for those changes in preload and afterload but they can't compensate for that contractility

Pulmonary Artery Wedge Pressure management notes

· give diuretics, draw off some fluid, decrease that preload get fluid off of the patient, vasodilators out in the peripheral system to allow the blood to flow out of the heart easier, · decreasing sodium because we're sodium goes water goes, having fluid restriction · nitrates dilate the venous beds so also the arterial system as well so those can be used to optimize your preload, reducing that venous return to the heart · reducing your afterload so you reducing preload is reducing the amount that's coming into that left ventricle to allow the left ventricle to work better and easier and then reducing preload is reducing that resistance to the blood going out of the heart and you use vasodilator so nitroglycerin dilates both the venous and the arterial system so it helps the heart to pump more effectively · nitroprusside is another vasodilator and then ace inhibitors (vasodilator) · enhancing that contractility so on the inotropic medications like digoxin, dobutamine and milrinone will help the heart to contract more forcefully and then the intraaortic balloon pump

elevated Pulmonary Artery Wedge Pressure management

•Optimize preload: Diuretics, vasodilators, sodium restriction, fluid restriction. Nitrates dilate venous bed, displacing fluid and reducing venous return to heart. •Reduce afterload: Arterial vasodilators (nitroglycerin, nitroprusside, ACE inhibitors) •Enhance contractility: Inotropic meds (digoxin, dobutamine, milrinone); intra-aortic balloon pump

PAD (diastolic) elevation: notes

· if they have mitral valve stenosis where the blood can't get through that mitral valve · if they have a shunt from left to right like a septal defect or even an atrial defect those aren't very common in adults especially · symptoms everything would back up into the lungs so they would be short of breath or heart rate would speed up to get the fluid around out of the heart, they might develop an S3 or S4 gallop and they would have crackles in their lungs because things are backing up into the lungs · low pulmonary artery diastolic is a low preload so there's not as much blood coming into that left side of the ventricle so inadequate venus return so symptoms would be symptoms of fluid volume deficit so flat neck veins, still tachycardiac the body's not getting blood flow so it's trying to speed up the heart rate to get perfusion to the lungs, the lungs would be clear so with an elevated pulmonary artery diastolic blood's backing up into the lungs so you would have fluid then but if the pulmonary artery diastolic is too low then your lungs are clear · you have other signs of dehydration and decreased fluid volume excess like dry mucous membranes, poor skin turgor, hypotension and then overtime decrease urine output and can lead to a shock like state if it's if it's allowed to continue

Hemodynamic Monitoring Waveforms notes

· if you're putting in a PA catheter you hook it up to the monitor, you'll see the waveform change as it goes through the different chambers · it comes into the right atrium first so that would be your central venous pressure in the right atrium and notice that the pressure is kind of low not a lot of variation between the top of the waveform and the bottom of the waveform · the right atrial pressure is measured not as a systolic and diastolic but just as a mean number so two - six · so then as the catheter goes through into the right ventricle notice that the wave form is much bigger much wider variation this is measured as the systolic and diastolic · systolic would be at the highest pressure and the diastolic is at the lowest pressure · the diastolic is pretty similar to what the waveform was in the right atrium then as the catheter moves into the pulmonary artery your systolic stays the same but the diastolic is much higher the pressure is higher you're getting closer to reflecting those pressures on the left side of the heart · if you inflate that little balloon and you let that catheter float on out and wedge into a capillary then you notice that the wave form kind of dampens back down into something that looks very similar to the right atrium because this is a direct measurement of the left side of the heart the left atrium the pressure there in the left atrium higher than it was in the right atrium but still a similar type of pressure not measured with systolic and diastolic but measured as a mean pressure

Sympathetic Response story

· imagine you're outside it's a dark night and you're walking in your neighborhood and all of a sudden you hear this dog barking it starts chasing you and you look back it's this vicious dog that's coming after you said your body goes into that sympathetic response where your pupils dilate so you can see where you're going, · your bronchioles dilate so you can breathe easier · you have decreased mucus secretion so you're able to breathe so you're able to run get away · your blood vessels constrict so that raises your blood pressure and increase your heart rate so your heart's pumping better so you can use it to get away from this dog, · your the muscles of your GI tract relax because you don't want to vomit right now or you don't want to have to poop right now so that you have decreased GI motility · your blood sugar increases Glucagon turn into glucose so you have glucose for energy that you need run and get away · your bladder muscle relaxes so that you don't feel like you need to pee right then because you've got to get away from this dog · you have increased urinary retention for the same reason

Hemodynamic Monitoring notes

· right atrium it's the CVP · pulmonary artery diastolic pressure that's the measurement of preload for the left side of the heart · the wedge the left ventricular end diastolic pressure so the PAD and the wedge pressure the PAWP very similar. PAWP is 6 to 12 · the measurement of your afterload for the right ventricle is your pulmonary artery systolic pressure we don't measure that unless the patient has pulmonary issues and then measurement of the afterload is for your left ventricle is the SVR also if you can be the mean arterial pressure. · if your patient does not have a pulmonary artery catheter and then also your systolic blood pressure if you don't have access to the other two · measurements of contractility is your ejection fraction that has to be measured by an echocardiogram or in the cardiac Cath lab so not something that you could do on your end

Greater Vessels, Heart Chambers and Pressures (pic slide 19)

· right atrium there's a 0 to 8; when you get down to the right ventricle you have like a systolic and a diastolic same thing in the pulmonary artery and the left ventricle and the aorta · so the pressures change as you move through the heart and notice also the pressures on the right side of the heart are much lower than the pressures on the left side of the heart that's because the right side of the heart only has to pump a short distance and into the lungs which is usually a pretty compliant system doesn't have a lot of resistance unless the pt has some kind of lung disease but the left side of the heart has to pump to all parts of the body so the pressures are higher there you know notice that the heart muscle is thicker on the in the left ventricle than it is in the right ventricle and that's just because of the job that the left ventricle normally has to do

Pulmonary Artery Pressure continue notes

· the pulmonary artery systolic pressure reflects the highest pressure during diastole so in the patients when it's filled the right ready to eject so systolic is contraction ejection so it's right before it's ready to contract and eject the fluid out that is normal range 15 to 30 · the diastolic is the reflects the lowest pressure in the pulmonary artery and that normalized range from 4 to 12 millimeters of mercury · 4 to 12 is very similar to the wedge pressure so some doctors don't want the catheter wedged because the chance of rupturing the vessel so they'll just go with the pulmonary artery diastolic because the pressure reading is the same

Arterial Pressure Monitoring nursing management notes

· watch for bleeding there because it is an artery if it comes out patient can bleed especially if it's in a bigger artery like the femoral artery patient can absolutely hemorrhage with that · it is directly into the artery so you want to watch for infections · keep a pressure bag on it so clots don't form over the tip because if they do they could travel and then you could have an emboli · good neurovascular checks to the hand and the fingers below the site so make sure that you're not causing any neurovascular impairment · in some cases sometimes you block out the blood flow and if they don't have good blood flow from their other artery down to their hand and that could cause necrosis

Vasoactive Medication Therapy: Nursing Implications notes

· you have to titrate them and usually there's more than one vasoactive drug going on at a time. sometimes they work against each other it seems like but you have to be very careful in just monitoring your patient closely · you want to titrate in small doses and you want to look for that therapeutic effect and some of them also can have toxic ranges so you have to be careful about that · want to know what your target parameters are so if the doctor says keep the mean arterial pressure greater than 65 or titrate to keep the mean arterial pressure greater than 65 or the cardiac index whatever the doctor orders · some of them are not compatible with each other so you have to know all of that and make sure that they you have enough Iv lines to run these medications because they can't run together simultaneously in one line · you have to titrate them and wean them in small increments because especially the vasopresor and the anatropous because you don't want to cause a rapid drop in the blood pressure · document everything for every 5 minutes at first when you started and then usually it's like every 15 minutes that you check the blood pressure and you document · once you reach a consistent level you sometimes they'll let you back off on taking the blood pressure every 15 minutes but you do still need to monitor these patients frequently · some of them if they get out of the vein and into the tissues they can cause that's called extravasation and it can cause especially the vasopressors because they're causing vasoconstriction and lack of blood flow to the tissue so patients can actually have tissue ischemia and necrosis and significant tissue damage if the catheter gets out of dislodge out of the vein and gets into the tissues and then if at all possible use a central line in order to run these because there's less chance of tissue necrosis

Hemodynamic Monitoring TX

·Hypovolemic Shock : IV fluids; Blood products · Cardiogenic Shock: Positive Inotropes; Revascularization ·Distributive Shock (Septic, neurogenic) : Pressors; IV fluids

Hemodynamic Monitoring SVR

·Hypovolemic Shock : ↑ · Cardiogenic Shock: ↑ ·Distributive Shock (Septic, neurogenic) : ↓↓

Hemodynamic Monitoring CVP

·Hypovolemic Shock : ↓ · Cardiogenic Shock: ↑↔ ·Distributive Shock (Septic, neurogenic) : ↓

Hemodynamic Monitoring (slide 36) BP

·Hypovolemic Shock : ↓ · Cardiogenic Shock: ↓ ·Distributive Shock (Septic, neurogenic) : ↓

Hemodynamic Monitoring PAWP

·Hypovolemic Shock : ↓↓ · Cardiogenic Shock: ↑↑ ·Distributive Shock (Septic, neurogenic) : ↓

Hemodynamic Monitoring CI

·Hypovolemic Shock :↓ · Cardiogenic Shock: ↓ ·Distributive Shock (Septic, neurogenic) : ↓

Central Venous Pressure

Ø Central Venous Pressure (CVP) or Right Atrial Pressure (RAP): •Measurement of pressure in the vena cava or right atrium •Reflects filling pressure of right ventricle (Preload) •Indicator of circulating blood volume and right-heart pumping strength •*Can be measured using a PA catheter or central venous catheter* -Tip of CVP catheter or proximal opening of PA catheter should be located near the entrance to the right atrium • *Can be measured continuously or intermittently* •Elevation: -Fluid volume excess (↓ or discontinue IVFs, give diuretics) -Poor right ventricular contraction •Decrease: -Fluid volume deficit (↑ IVFs) •Normal: 2-6 mm Hg (always read as a mean)

Leveling and Zeroing

•*Leveling the transducer:* Corrects for hydrostatic pressure changes in vessels above and below the heart • *Zeroing the transducer:* Corrects for any drift or deviation from baseline that may occur •Be sure to do both of these with initial setup, at the beginning of each shift and periodically throughout the shift, and *when values to not fit with clinical picture*

Mean Arterial Pressure (MAP)

•*MAP must exceed 65 mmHg for cells to receive the oxygen and nutrients needed to metabolize energy in amounts sufficient to sustain life* •Normal MAP = 70-92 mmHg •MAP greater than 100 mmHg is too high and can lead to blood clots and heart muscle damage (MAP greater than 100 is really too high and the blood the heart wouldn't be able to pump as effectively, have increased resistance against the heart pumping and if blood doesn't move forward it can lead to blood clots into heart muscle damage)

Central Venous Pressure notes 1

•A: Atrial contraction; C: Tricuspid valve moving towards the atrium in isovolemic contraction; V: Venous return filling the right atrium; Downslope after V wave: Rapid ventricular filling in early diastole · CVP is the measurement in the right atrium so it reflects that filling pressure or preload in that right atrium . it is an indicator of your circulating blood volume and the pumping strength of the right side of the heart most importantly that circulating blood volume · if your patient has a low CVP and that means they don't have enough fluid they're hypovolemic for whatever reason maybe they've been having nausea and vomiting or they've had surgery where they've lost a lot of blood or their heart isn't pumping effectively so the fluid is staying down in the periphery and it's not getting back up to the heart there's a lot of different reasons that can cause this so it's measured with the PA catheter

Vasoactive Medication Therapy: Inotropes •Dobutamine •Dopamine •Epinephrine •Milrinone

•Action: Improve contractility; ↑ Stroke Volume; ↑ Cardiac Output •Disadvantages: ↑ oxygen demand of heart. Note: Dobutamine can ↑ CO w/o a significant ↑ in heart rate (-great medication for patients who are in shock and hypotensive. one advantage that dobutamine has is that it can increase the cardiac output without causing significant increase in the heart rate so if you have a patient who is having cardiac issues anyway you don't want to increase the heart rate too much dopamine is a great drug to use. - these improve contractility so it's like pumping up like the bicycle pump - they do increase the oxygen demand of the heart because of the increased contractility)

Vasoactive Medication Therapy: Vasopressors Norepinephrine Dopamine Phenylephrine Vasopressin

•Action: ↑ BP by vasoconstriction •Disadvantages: ↑ afterload, ↑ cardiac workload; compromise perfusion to skin, kidneys, lungs, GI tract (- if pts severely hypotensive you want that afterload elevated some but it can go too far in the other direction. it does increase the cardiac workload because it makes the heart work harder to pump blood ou - t it can compromise perfusion to your skin, the kidneys, the lungs, and the GI tract because it's causing vasoconstriction so that would kind of keep blood flow from going to those areas. - so you have to be very careful and you have to do really really good assessments on your patient when they're on any of these medication)s

Vasoactive Medication Therapy: Vasodilators •Nitroglycerin •Nitroprusside

•Action: ↓ preload; ↓ afterload; ↓ oxygen demand of heart •Disadvantages: Hypotension (-vasodilators: so these are they dilate dilate the blood vessels so nitroglycerin dilates both the venous system and the arterial system so you'll see patients that are on nitroglycerin that have terrible headache because all the vessels in their head are dilating and causes a terrible headache so these decrease preload by vasodilating keeping fluid out in the periphery they decreased afterload by causing vasodilation makes it easier for the heart to pump and then they decrease the oxygen demand of the heart because it's making it easier making it easier for the heart to pump but they can drop the blood pressure so you have to be very very careful with that)

Effects of Sympathomimetics at Receptors

•Alpha1 (located in blood vessels, eyes, bladder, prostate) -Increases cardiac contractility, vasoconstriction -Dilates pupils, decreases salivary gland secretion -Increases bladder & prostate contraction •Alpha2 (presynaptic neurons and postsynaptic cells) -Inhibits norepinephrine release •--Promotes vasodilation and decreased BP -Decreases GI motility and tone

Effects of Sympathomimetics at Receptors Beta 1 and Beta 2

•Beta1 (located mostly in heart; also in kidneys) -Increases cardiac contractility, heart rate •Increases renin secretion, BP •Beta2 (located in smooth muscles of lung, liver, GI tract) -Decreases GI tone and motility -Bronchodilation -Increases blood flow in skeletal muscles -Relaxes smooth muscles of uterus -Activates liver glycogenolysis •---Increases blood glucose (-Beta 1 receptors located in kidney, but mostly in heart -Beta 2 receptors located mostly in smooth muscles of lung and GI tract, liver, and uterine muscle)

Pressure Monitoring System

•Catheter -Examples: arterial, central venous, pulmonary artery -Attached to fluid-filled, pressurized system •Monitor -Converts electrical signal to waveform and digital number •Transducer -Converts mechanical pressure into an electrical signal

CDC Guidelines for Prevention of Catheter-related Bloodstream Infections (CLABSI)

•Catheter Site Dressing Regimens: -Use chlorhexidine for skin antisepsis for insertion - dressing changes and Replace transparent dressings at least every 7 days •Needleless Intravascular Catheter Systems: -Minimize contamination risk by scrubbing the access port with appropriate antiseptic -Access the port only with sterile devices •Recommendations for Central Venous Catheters: -Avoid use of femoral vein -Subclavian vein is preferred over jugular vein •Maximal Sterile Barrier Precautions: -Use cap, mask, sterile gown, sterile gloves, and sterile full-body drape for insertions •Replacing Administration Sets: -Preplace administration sets that are continuously used, including secondary sets, no more frequently than 96-hour intervals, but at least every 7 days. •Catheter Securement Devices: -Use a suture-less securement device to reduce risk of infection

LOW Pulmonary Artery Wedge Pressure (PAWP)

•Causes: Inadequate circulating blood volume •Symptoms: Flat neck veins, clear lungs, low pulse pressure, decreased urine output, hypotension, and tachycardia •Management: Careful fluid or blood product replacement; monitor urine output, I&O, and daily weights (you would have all those symptoms of fluid volume deficit an daily weights very important)

Signs of Hemodynamic Compromise

•Changes in mental status (like confusion) •Shortness of breath •Hypotension •Tachycardia •Cold, clammy skin •Decreased urine output

PAD (diastolic) elevation:

•Conditions that affect the left heart -Angina, MI, Fluid Volume Execcive, Mitral stenosis, Left to right intra-cardiac shunts -Symptoms: Dyspnea, tachycardia, S3 or S4, bilateral crackles in the lungs •Low PAD: -Usually indicates a low preload state related to inadequate venous return to the left heart -Symptoms: flat neck veins, tachycardia, clear lungs, dry oral mucosa, poor skin turgor, hypotension, and decreased urine output. May advance to shock-like state.

Parasympathetic Response body response

•Constrict pupils •Increase salivation •Constrict bronchioles and increase secretions •Decrease pulse rate •Dilates blood vessels •Decrease blood pressure •Increase peristalsis •Constrict bladder •Increase urinary contraction

Sympathetic Response body response

•Dilate pupils •Dilate bronchioles •Decrease mucous secretions •Constrict blood vessels •Increase blood pressure •Increase pulse rate •Relax smooth muscles of GI tract •Decrease GI motility •Increase blood sugar •Relax bladder muscle •Increase urinary retention

Hemodynamic Monitoring

•Done to monitor cardiovascular function and blood volume •Place catheters in the vascular system and connect them to a transducer and monitor (invasive) •The transducer converts pressure in the vascular system into wave forms from which various pressures are measured to see how the heart is functioning •Done for critically ill patients with heart or fluid volume problems (-this is invasive, these have to go out directly into the heart and not everybody gets one a lot of times they don't use these anymore because of the risk for infection so they'll just go on their bp and other more less invasive ways to tell this - this is really only for the very critically ill patients with heart and blood volume problems)

Ejection Fraction (range for normal EF?)

•Ejection fraction: percent of end diastolic volume ejected with each heartbeat (from the left ventricle) • Left Ventricular Function Normal : Ejection Fraction is 55 - 60% • Mildly depressed cardiac contractility : Ejection Fraction is 40 - 55% • Profound LV dysfunction : Ejection Fraction is <40%

Elevated Pulmonary Artery Wedge Pressure meaning

•Elevated PAWP: any condition that increased the left ventricular end-diastolic blood volume -Causes: Fluid overload, LV failure, myocardial ischemia, mitral valve stenosis, cardiac tamponade -Symptoms: Tachycardia, exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, crackles in the lungs, S3 or S4 gallop, neck vein distension

Potential Complications of Pulmonary Artery Catheters

•Infection and sepsis -Asepsis for insertion and maintenance of catheter - tubing mandatory -Change flush bag, pressure tubing, transducer, and stopcock per policy •Air embolus (disconnection) •Ventricular dysrhythmias -During PA catheter insertion or removal and If tip migrates back from PA to right ventricle •PA catheter cannot be wedged/continuous wedge -May need repositioning •Pulmonary infarction or PA rupture -Balloon rupture (over inflation) - Prolonged inflation - Spontaneous wedging - Thrombus/embolus formation

Elevated Pulmonary Artery Pressure:

•PAS (systolic) elevation: •Any condition that acutely or chronically increases afterload of the Right Ventricle -Pulmonary HTN -Chronic lung disease -Pulmonary embolism -Hypoxemia •Symptoms: vary according to cause, severity, and duration of elevated pressure

Parasympathetic Response

•Parasympathetic system = cholinergic system •Receptors are either nicotinic or muscarinic •Acetylcholine or acetylcholinesterase released •A cholinergic agonist (parasympathomimetic or cholinergic) or an adrenergic antagonist (sympatholytic or adrenergic blocker or adrenolytic)

Pulmonary Artery Wedge Pressure

•Pulmonary Artery Wedge Pressure (PAWP) Monitoring: •Also known as: -Pulmonary Artery Occlusion Pressure (PAOP) -Pulmonary Capillary Wedge Pressure (PCWP) -Reflects the left end-diastolic pressure (LVEDP) as a measure of preload in the left ventricle •This is an indirect measurement •Must be measured using a PA catheter -NOT MEASURED CONTINUOUSLY! •Normal: 6-12 mm Hg

Pulmonary Artery Pressure continue

•Pulmonary artery pressure components: •Pulmonary artery systolic pressure (PAS): reflects the highest pressure generated by the RV during diastole -Normal range: 15-30 mm Hg •Pulmonary artery diastolic pressure (PAD): reflects the lowest pressure within the pulmonary artery -Normal range 4-12 mm Hg •Normal range: 15-30/ 4-12 mm Hg

Phlebostatic Axis

•Reference point that approximates the level of the right atrium •Measured at 4th ICS at ½ the AP diameter of the chest or roughly at mid-axillary line

Sympathetic Response

•Sympathetic system= adrenergic system •Four types of receptor organ cells: alpha 1, alpha 2, beta 1, beta 2 •Norepinephrine released •An adrenergic agonist (sympathomimetic) or parasympathetic antagonist (Parasympatholytic or anticholinergic or cholinergic antagonist or antispasmodic) will cause this response •Lytic: a substance which causes cellular destruction

Systemic Vascular Resistance

•Systemic Vascular Resistance: an estimate of left ventricular afterload -Represents an average of the resistance of all the vascular beds -The harder the heart has to work to pump blood out, the higher the myocardial oxygen requirement •SVR= MAP-CVP x 80/CO •Elevated SVR = vasoconstriction -Vascular resistance as with hypertension; can also be caused by hypothermia, compensatory mechanisms in hypovolemia and cardiac failure -Treat with vasodilators •Low SVR = vasodilation -Widespread vasodilation (caused by meds, shock states) -Treat with vasoconstrictors

Vasoactive Medication Therapy

•Used in all forms of shock to improve hemodynamic stability when fluid therapy alone cannot maintain adequate MAP •Purpose of use: -Increase strength of myocardial contractility -Regulate heart rate -Reduce myocardial resistance -Initiate vasoconstriction •These drugs do not treat the underlying cause of shock! •Address underlying problem(s); Ensure adequate fluid status

Cardiac Output Monitoring

•Uses a thermodilution method to calculate •Temperature changes are detected in blood flowing from a proximal point on the catheter to a thermistor near the distal tip •Data relayed to computer •Can be measured continuously or by bolus method

Vasoactive Medication Therapy: Nursing Implications

•Usually must titrate and monitor more than one vasoactive drug concurrently •Watch for nontherapeutic effects and drug toxicity •Know "normal" dose ranges; know starting range •Know target parameters, such as BP, MAP, CI, etc. •Incompatible with many other drugs •All must be weaned carefully in small increments to avoid rapid drop in BP •Document HR, BP (MAP) every 5 minutes until therapeutic effects achieved •Frequent monitoring while drip is running •Must monitor peripheral perfusion (pulses, color, temperature) frequently •Can cause tissue ischemia and necrosis if infiltrates -Specific agents used to reverse or minimize tissue damage •Use central line whenever possible

Vasoactive Medication Therapy

•Vasopressors: Stimulates smooth muscle contraction in capillaries and arteries -> vasoconstriction -> Rise in MAP -> improved tissue perfusion •Inotropes: Increase force of contraction of myocardial muscle -> Positive Inotropism -> Rise in MAP -> Improved tissue perfusion and oxygenation (- vasopressors help the heart to squeeze or contract better so it stimulates the smooth muscle of contraction in your capillaries and your arteries that causes vasoconstriction so if you have a patient whose blood pressure is too low you need to bring that blood pressure up you want to use a vasopressor so it'll cause constriction cause a rise in that mean arterial pressure and cause improved perfusion and oxygenation because the blood is carrying that oxygen around and - Inotropes is like a pump like a bicycle pump so it increases the force of contraction of the myocardial tissue which causes positive contractility which causes the rise in the mean arterial pressure and leads to improved tissue perfusion and oxygenation)