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Hemodynamic Monitoring(ABP, CVP, Ao)
Anesthesia Technology Fundamentals
ANES 1502
College of DuPage
1
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
• Mottling (absent)
• Skin Temperature
• Capillary Refill
• Urine Output
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
4
Why A Properly Fitting Cuff?
• Too small causes false-high reading
• Too LARGE causes false-low reading
5
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 Cable
• Pressure Bag
• Flush – 500cc NS
7
Supplies to Gather
• Sterile Gown (2)
• Sterile Towels (3)
• Sterile Gloves
• Suture (silk 2.0)
• Chlorhexidine Swabs
• Mask
8
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 15
• 4th intercostal space, mid-axillary line
• Level of the atria
(Edwards Lifesciences, n.d.)
More on Leveling and Zeroing
• HOB 0–60 degrees
• No lateral positioning
• Phlebostatic axis with any position (dotted line)
16
(Edwards Lifesciences, n.d.)
Dynamic Flush 17
• 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.
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
23
(Edwards Lifesciences, n.d.)
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.
26
1510
50
-5CVP=13
27
200 ms
Assist-Control
Ao
CVP
{200 ms
{
28
CPAP with Pressure Support
Ao
CVP
200 ms
{200 ms
{
29
CPAP without Pressure Support
Ao
CVP
200 ms
{200 ms
{
30
403020100
-10
Incorrect method!This point was identified as end-expiration 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.
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40302010
0-10
Same patient 20 minutes later
40302010
0-10
32
1510
50
-5
CVP=13
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)
34
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
35