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Hemodynamic Monitoring Part I (ABP, CVP, Ao)

Hemodynamic Monitoring Part I (ABP, CVP, Ao). MICU Competencies 2006-2007. What is Hemodynamic Monitoring?. Non-invasive = clinical assessment & NBP Direct measurement of arterial pressure Invasive hemodynamic monitoring. Noninvasive BP Heart Rate, pulses Mental Status Mottling (absent).

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Hemodynamic Monitoring Part I (ABP, CVP, Ao)

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  1. Hemodynamic MonitoringPart I(ABP, CVP, Ao) MICU Competencies 2006-2007

  2. What is Hemodynamic Monitoring? • Non-invasive = clinical assessment & NBP • Direct measurement of arterial pressure • Invasive hemodynamic monitoring

  3. Noninvasive BP Heart Rate, pulses Mental Status Mottling (absent) Skin Temperature Capillary Refill Urine Output Noninvasive Hemodynamic Monitoring

  4. 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

  5. Why A Properly Fitting Cuff? • Too small causes false-high reading • Too LARGE causes false-low reading

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

  7. Arterial Catheter Pressure Tubing Pressure Cable Pressure Bag Flush – 500cc NS Supplies to Gather

  8. Sterile Gown (2) Sterile Towels (3) Sterile Gloves Suture (silk 2.0) Chlorhexidine Swabs Mask Supplies to Gather

  9. 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

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

  11. 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

  12. Central Venous Pressure Assesses . . . • Intravascular volume status • Right ventricular function • Patient response to drugs &/or fluids

  13. 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

  14. 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

  15. Phlebostatic Axis • 4th intercostal space, mid-axillary line • Level of the atria (Edwards Lifesciences, n.d.)

  16. More on Leveling and Zeroing • HOB 0 – 60 degrees • No lateral positioning • Phlebostatic axis with any position (dotted line) (Edwards Lifesciences, n.d.)

  17. 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

  18. 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

  19. 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

  20. 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

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

  22. 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

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

  24. 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)

  25. 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

  26. 15 10 5 0 -5 CVP=13 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.

  27. Assist-Control 200 ms { Ao { CVP 200 ms

  28. CPAP with Pressure Support 200 ms { Ao { 200 ms CVP

  29. CPAP without Pressure Support 200 ms { Ao { 200 ms CVP

  30. Incorrect method! This point was identified as end-expiration for a pt. who did not have an Ao set up. 40 30 20 10 0 -10 Correct method! 30 sec after the above tracing, Ao was added & true end-expiration clearly identified.

  31. 40 30 20 10 0 -10 40 30 20 10 0 -10 Same patient 20 minutes later

  32. 15 10 5 0 -5 CVP=13

  33. 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

  34. 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)

  35. 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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