Hemodynamic  Case  Studies
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Hemodynamic Case Studies. Leanna R. Miller, RN, MN, CCRN-CMC, PCCN-CSC, CEN, CNRN, NP Education Specialist LRM Consulting Nashville, TN. Case Studies in Hemodynamics. Objectives Analyze the hemodynamic data of a patient with sepsis.

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Leanna r miller rn mn ccrn cmc pccn csc cen cnrn np education specialist lrm consulting

Hemodynamic Case Studies

Leanna R. Miller, RN, MN, CCRN-CMC, PCCN-CSC, CEN, CNRN, NP

Education Specialist

LRM Consulting

Nashville, TN


Leanna r miller rn mn ccrn cmc pccn csc cen cnrn np education specialist lrm consulting

Case Studies in Hemodynamics

  • Objectives

    • Analyze the hemodynamic data of a patient with sepsis.

    • Identify key hemodynanic abnormalities seen in patients with cardiogenic shock.

    • Describe the priorities in the management of a patient with acute respiratory distress syndrome (ARDS).


Leanna r miller rn mn ccrn cmc pccn csc cen cnrn np education specialist lrm consulting

Case Studies in Hemodynamics

Case Study 1

  • 45 - year old woman

  • stab wounds to the abdomen x 2, multiple lacerations, probable aspiration

  • 3 days post - op became restless

  • T 40.3 C (104.6 F)


Leanna r miller rn mn ccrn cmc pccn csc cen cnrn np education specialist lrm consulting

Case Study 1

HR 106

BP 78 / 44 / 55

Case Studies in Hemodynamics


Leanna r miller rn mn ccrn cmc pccn csc cen cnrn np education specialist lrm consulting

Case Studies in Hemodynamics

Case Study 1

HR 106

RAP / PAOP 1 / 4

BP 78 / 44 / 55

CI 4.5

PAP 17 / 7 / 11


Leanna r miller rn mn ccrn cmc pccn csc cen cnrn np education specialist lrm consulting

Case Studies in Hemodynamics

Case Study 1

PVRI 119

SVRI 858

SV 70.2

LVSWI / RVSWI 26.5 / 8.0


Leanna r miller rn mn ccrn cmc pccn csc cen cnrn np education specialist lrm consulting

Case Studies in Hemodynamics

Case Study 1

ABGs (.40 FiO2)

pH 7.26

pCO235

pO2 55

SaO2 .88

HCO3 12

SvO282%

P/F ratio 138


Leanna r miller rn mn ccrn cmc pccn csc cen cnrn np education specialist lrm consulting

Case Studies in Hemodynamics

Case Study 1

PaO2 / FiO2 Ratio (P/F)

  • 55 / .40

  • 138

    Normal = > 300

    ALI = < 250

    ARDS = < 200


Leanna r miller rn mn ccrn cmc pccn csc cen cnrn np education specialist lrm consulting

Case Studies in Hemodynamics

Case Study 1

  • Laboratory Values

    Sodium150

    Chloride 98

    Hgb / Hct 8.8 / 26.4


Leanna r miller rn mn ccrn cmc pccn csc cen cnrn np education specialist lrm consulting

Case Studies in Hemodynamics

Sepsis

  •  O2 demand 55%

  • peripheral shunting &

    delivery-limited VO2

  • sudden  in VO2 = early

    warning

  • VO2 remains low = poor

    outcome


Leanna r miller rn mn ccrn cmc pccn csc cen cnrn np education specialist lrm consulting

Case Studies in Hemodynamics

  • CI > 5.5

  • DO2I 250 - 500

  • VO2I 70 - 90


Leanna r miller rn mn ccrn cmc pccn csc cen cnrn np education specialist lrm consulting

Case Studies in Hemodynamics

Case Study 1

DOI2 = CI ( 1.38 x Hgb x SaO2) 10

4.5 X 1.38 X 8.8 X 0.88 x 10

481 mL/min/m2

(normal = 360 - 600 mL/min/m2)


Leanna r miller rn mn ccrn cmc pccn csc cen cnrn np education specialist lrm consulting

Case Studies in Hemodynamics

Case Study 1

VOI2 = CO X 1.38 X Hgb X (SaO2 - SvO2) X 10

4.5 x 1.38 x 8.8 x (.88 - .82) x 10

33 mL/min/m2

(Normal 220 - 290 mL/min/m2)


Leanna r miller rn mn ccrn cmc pccn csc cen cnrn np education specialist lrm consulting

Case Studies in Hemodynamics

Case Study 2

  • 54 - year old male with large anterioseptal MI

  • new episode pain

  • restless, dusky, new systolic murmur LLSB

  • 12 – lead: ST elevation, T wave inversion & Q wave in V2 - 4


Leanna r miller rn mn ccrn cmc pccn csc cen cnrn np education specialist lrm consulting

Case Study 2

HR 118

BP 80 / 42 / 55

Case Studies in Hemodynamics


Leanna r miller rn mn ccrn cmc pccn csc cen cnrn np education specialist lrm consulting

Case Studies in Hemodynamics

Case Study 2

HR 118

BP 80 / 42 / 55

CO / CI 3.2 / 1.56

PAP 58 / 32 / 40

PAOP / CVP 29 / 15


Leanna r miller rn mn ccrn cmc pccn csc cen cnrn np education specialist lrm consulting

Case Studies in Hemodynamics

Case Study 2

PVRI 564

SVRI 2051

LVSWI / RVSWI 8.84 / 5.78


Leanna r miller rn mn ccrn cmc pccn csc cen cnrn np education specialist lrm consulting

Case Studies in Hemodynamics

Case Study 2

ABGs (.40 FiO2)

pH 7.49

pCO225

pO256

SaO2.88

HCO321

SvO260%


Leanna r miller rn mn ccrn cmc pccn csc cen cnrn np education specialist lrm consulting

Case Studies in Hemodynamics

Case Study 2

PaO2 / FiO2 Ratio (P/F)

  • 56 / .40

  • 140

    Normal = > 300

    ALI = < 250

    ARDS = < 200


Leanna r miller rn mn ccrn cmc pccn csc cen cnrn np education specialist lrm consulting

Case Studies in Hemodynamics

Case Study 2

  • Laboratory Values

    Sodium144

    Chloride 98

    Hgb / Hct 12.1 / 36.3

    CO2 21


Leanna r miller rn mn ccrn cmc pccn csc cen cnrn np education specialist lrm consulting

Case Studies in Hemodynamics

  •  CO threatens DOI2

    levels

  • O2 demands are seldom except when catecholamines are used


Leanna r miller rn mn ccrn cmc pccn csc cen cnrn np education specialist lrm consulting

Case Studies in Hemodynamics

  • DOI2 300 - 400

  • VOI2 > 125

  • SvO2 > 60%

  • O2ER < 30%


Leanna r miller rn mn ccrn cmc pccn csc cen cnrn np education specialist lrm consulting

Case Studies in Hemodynamics

Case Study 2

SIMV 8

FiO2 / TV .60 /800

PaO2 / SaO2 65 / .92

pH 7.29

PaCO2 / HCO3 30 /16

Hgb / Temp 9.0 / 102 oF


Leanna r miller rn mn ccrn cmc pccn csc cen cnrn np education specialist lrm consulting

Case Studies in Hemodynamics

Case Study 2

DOI2 = CI ( 1.38 x Hgb x SaO2) 10

1.56 X 1.38 X 12.1 X 0.88 x 10

229 mL/min/m2

(normal = 360 - 600 mL/min/m2)


Leanna r miller rn mn ccrn cmc pccn csc cen cnrn np education specialist lrm consulting

Case Studies in Hemodynamics

Case Study 2

VOI2 = CI X 1.38 X Hgb X (SaO2 - SvO2) X 10

1.56 x 1.38 x 12.1 x (.88 - .60) x 10

73 mL/min/m2

(Normal 220 - 290 mL/min/m2)


Leanna r miller rn mn ccrn cmc pccn csc cen cnrn np education specialist lrm consulting

Case Studies in Hemodynamics

Case Study 2

  • Anion Gap

    • Na – (CO2 + Cl)

    • 144 – (98 + 21)

    • 25

      (Normal = 12 – 15)


Leanna r miller rn mn ccrn cmc pccn csc cen cnrn np education specialist lrm consulting

Case Studies in Hemodynamics

Case Study 3

  • 62 - year old male

    • 2 ppd smoking history

    • acute bacterial pneumonia

    • intubated & mechanically ventilated


Leanna r miller rn mn ccrn cmc pccn csc cen cnrn np education specialist lrm consulting

Case Study 3

BP100/90/93

HR 122

Case Studies in Hemodynamics


Leanna r miller rn mn ccrn cmc pccn csc cen cnrn np education specialist lrm consulting

Case Study 3

BP 100/90/93

HR 122

RAP / PAOP 6/8

PAP 38/18/25

C0 4.0

SvO2 .30

Case Studies in Hemodynamics


Leanna r miller rn mn ccrn cmc pccn csc cen cnrn np education specialist lrm consulting

Case Studies in Hemodynamics

Case Study 3

PaO2 / FiO2 Ratio (P/F)

  • 65 / .65

  • 108

    Normal = > 300

    ALI = < 250

    ARDS = < 200


Leanna r miller rn mn ccrn cmc pccn csc cen cnrn np education specialist lrm consulting

Case Studies in Hemodynamics

  • PEEP can  DOI2

  • WOB  VOI2

  • triggers inflammatory response

  • maldistributed blood flow   VOI2

  • ideal Hgb is 12


Leanna r miller rn mn ccrn cmc pccn csc cen cnrn np education specialist lrm consulting

Case Studies in Hemodynamics

 DOI2 until VOI2 plateaus


Leanna r miller rn mn ccrn cmc pccn csc cen cnrn np education specialist lrm consulting

Case Studies in Hemodynamics

Case Study 3

DO2= CO ( 1.34 x Hgb x SaO2) 10

4.0 X 1.34 X 9.0 X 0.92 x 10

457 mL/min

(normal = 900 - 1100 mL/min)


Leanna r miller rn mn ccrn cmc pccn csc cen cnrn np education specialist lrm consulting

Case Studies in Hemodynamics

Case Study 3

VO2= CO X 1.34 X Hgb X (SaO2 - SvO2) X 10

4.0 x 1.34 x 9.0 x (.92 - .30) x 10

308 mL/min

(Normal 220 - 290 mL/min)


Leanna r miller rn mn ccrn cmc pccn csc cen cnrn np education specialist lrm consulting

Case Studies in Hemodynamics

IN CONCLUSION


Leanna r miller rn mn ccrn cmc pccn csc cen cnrn np education specialist lrm consulting

Case Studies in Hemodynamics


Leanna r miller rn mn ccrn cmc pccn csc cen cnrn np education specialist lrm consulting

THE END


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