Hemodynamic Monitoring

Part I
(ABP, CVP, Ao)
MICU Competencies
2006-2007
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What is Hemodynamic Monitoring?

Non-invasive = clinical assessment & NBP
Direct measurement of arterial pressure
Invasive hemodynamic monitoring
2

Noninvasive Hemodynamic Monitoring

Noninvasive BP
Heart Rate, pulses
Mental Status

Skin Temperature
Capillary Refill
Urine Output

Mottling (absent)
3

Proper Fit of a Blood Pressure Cuff

Width of bladder = 2/3 of upper arm
Length of bladder encircles 80% arm
Lower edge of cuff approximately 2.5 cm
above the antecubital space

Why A Properly Fitting Cuff?

Too

small

causes false-high reading

Too

LARGE causes false-low reading

Indications for
Arterial Blood Pressure
Frequent titration of vasoactive drips
Unstable blood pressures
Frequent ABGs or labs
Unable to obtain Non-invasive BP
6

Supplies to Gather
Arterial Catheter
Pressure Tubing

Pressure Bag
Flush 500cc NS

Pressure Cable

Supplies to Gather
Sterile Gown (2)

Suture (silk 2.0)

Sterile Towels (3)

Chlorhexidine Swabs

Sterile Gloves

Mask

Leveling and Zeroing

Leveling
Before/after insertion
If patient, bed or transducer move
Zeroing
Performed before insertion & readings
Level and zero at the insertion site
9

Potential Complications
Associated With Arterial Lines
Hemorrhage
Air Emboli
Infection
Altered Skin Integrity
Impaired Circulation
10

Documentation
Insertion procedure note
ABP readings as ordered
Neurovascular checks every two hours
(in musculoskeletal assessment of HED)
Pressure line flush amounts (3ml/hr)
Tubing and dressing changes
11

Central Venous Pressure Assesses . . .

Intravascular volume status
Right ventricular function
Patient response to drugs &/or fluids

12

Central Venous Pressure (CVP)

Central line or pulmonary artery catheter
Normal values = 2 8 mm Hg
Low CVP = hypovolemia or venous return
High CVP = over hydration, venous return,
or right-sided heart failure
13

Leveling and Zeroing

Leveling
Before/after insertion
After patient, bed or transducer move
Aligns transducer with catheter tip
Zeroing
Performed before insertion & readings
Level and zero transducer at the phlebostatic
axis
14

Phlebostatic Axis
4th intercostal space, mid-axillary line
Level of the atria

(Edwards Lifesciences, n.d.)

15

More on Leveling and Zeroing

HOB 0 60 degrees
No lateral positioning
Phlebostatic axis with
any position (dotted line)
(Edwards Lifesciences, n.d.)

16

Dynamic Flush

Dynamic flush ensures the integrity

of the pressure tubing system.
Notice how it ascends - forms a
square pattern - and bounces below
the baseline before returning to
the original waveform.
Check dynamic flush after zeroing
any pressure tubing system

17

System Maintenance
Change tubing and fluid bag q 96hrs
No pressors through CVP port
Antibiotics, NS boluses, blood, & IV pushes
are allowed through the CVP line

18

Troubleshooting
Improper set-up and equipment malfunction
are the primary causes for hemodynamic
monitoring problems
Retracing the set-up process or tubing
(patient to monitor) may identify the problem
and solution quickly
Use your staff resources: Help All, Charge
Nurse, Educator, Preceptors, MICU experts
19

Troubleshooting
Damped Waveforms
Pressure bag inflated to 300 mmHg
Reposition extremity or patient
Verify appropriate scale
Flush or aspirate line
Check or replace module or cable

20

Troubleshooting
Inability to obtain/zero waveform
Connections between cable & monitor
Position of stopcocks
Retry zeroing after above adjustments
21

Continuous Airway Pressure (Ao)

Also known as Paw, Ao
Purpose:
Improves accuracy of hemodynamic
waveform measurements
Identification of end-expiration
Positive waveform deflections = positive
pressure ventilation
Negative deflections = spontaneous
inspiratory effort

22

Supplies to Gather
Pressure Cable
Pressure Tubing
Connector
(Edwards Lifesciences, n.d.)

23

Setting up the Ao
Discard infusion spike end & cap port
Connect pressure tubing to vent tubing
(using connector opposite heating cable)
Connect cables
Zero the tubing (leveling not necessary)
24

Troubleshooting Ao
Do not prime tubing with fluids!
Damping will occur with fluid or secretions
To evacuate any fluids, disconnect pressure
tubing from vent tubing and push air through
the pressure tubing with a 10 ml syringe
connected at one end until fluid-free
25

Pressure Measurement
1) Record Ao and CVP on the same strip
2) Find end-expiration by drawing a vertical line with a straight edge 200 ms prior to the rise or dip in Ao (1 large box)
associated with a breath.
3) Draw a horizontal line through the visually assessed average vascular pressure starting at end-expiration going backward
200 ms (1 large box).
4) Read the pressure at the horizontal line.

15
10
5
0
5

CVP=13
26

Assist-Control

CVP

Ao

200 ms

200 ms

27

CPAP with Pressure Support

CVP

Ao

200 ms

200 ms

28

CPAP without Pressure Support

Ao

200 ms

CVP

200 ms

29

40
30
20
10
0
10

Incorrect method!
This point was
identified as endexpiration for a pt.
who did not have an
Ao set up.

Correct method!
30 sec after the above
tracing, Ao was added & true
end-expiration clearly
identified.
30

Same patient 20 minutes later

4040
3030
2020
1010
00
10
10

31


15
10
5
0
5

CVP=13
32

Summary
Record Ao with CVP
Read mean CVP at end-expiration as
described. No need read vascular pressure at
any particular time in the cardiac cycle

33

Documentation of CVP
Include on waveform strip

Position of the HOB

Vasopressors and rates
Amount of PEEP
Scale
CVP measurement
Signature of the nurse

(post in green chart behind graphics tab)

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References & Resources

Burns, S. M. (2004). Continuous airway pressure monitoring. Critical Care Nurse, 24(6), 70-74.
Chulay, M., & Burns, S. M. (2006). AACN Essentials of critical care. McGraw-Hill: New York.
Edwards. (2006). Pulmonary Artery Catheter Educational Project. http://www.pacep.org
Edwards Lifesciences. (n.d.) Educational videos. www.edwards.com
MICU Routine Practice Guidelines. www.vanderbiltmicu.com
MICU Bedside Resource Books
MICU Education Kits (Red cart in conference room)
MICU Preceptors, Help All Nurses, & Charge Nurses
VUMC policies. http://vumcpolicies.mc.vanderbilt.edu

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