Hemodynamic Hemodynamic Monitoring Monitoring

for the for the Respiratory TherapistRespiratory Therapist

Jane Reynolds, MS, RN, RRTJane Reynolds, MS, RN, RRT

Definition of termsDefinition of termsPreloadPreload – amount of blood in the ventricle – amount of blood in the ventricle before contraction – before contraction – EEnd nd ddiastolic iastolic vvolumeolume– EDVEDV determines the amount of ‘stretch’ that is determines the amount of ‘stretch’ that is

placed on the myocardial muscleplaced on the myocardial muscle– That ‘That ‘stretchstretch’ determines the strength of the ’ determines the strength of the

next contractionnext contraction– The strength of the contraction determines how The strength of the contraction determines how

much blood is pumped out of the ventricle much blood is pumped out of the ventricle during the next systole ‘during the next systole ‘stroke volumestroke volume’’

– The stroke volume determines the The stroke volume determines the blood blood pressure and perfusing pressurespressure and perfusing pressures

Definition of termsDefinition of termsAfterload -Afterload - resistance to blood flowresistance to blood flow from from the ventricle; work that must be done to the ventricle; work that must be done to pump blood from the ventricle to the pump blood from the ventricle to the circulationcirculation

Resistance determined by Resistance determined by size of valve size of valve opening, blood viscosity and blood opening, blood viscosity and blood pressurepressure in pulmonary or systemic in pulmonary or systemic circulationcirculation

WorkWork – is the – is the oxygen consumedoxygen consumed by the by the myocardium to overcome the resistance to myocardium to overcome the resistance to flowflow

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Normal Circulatory PressuresNormal Circulatory Pressures

1.1. Preload to RVPreload to RV

2.2. Afterload to RVAfterload to RV

3.3. Preload to LVPreload to LV

4.4. Preload to LVPreload to LV

5.5. Afterload to LVAfterload to LV

1

2 3

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CirculationCirculation

Alveolar Alveolar Capillary Capillary

MembraneMembrane

Normal Alveolar Capillary MembraneNormal Alveolar Capillary Membrane

Begin Pulmonary EdemaBegin Pulmonary Edema

Interstitial EdemaInterstitial Edema

Pulmonary Edema - LatePulmonary Edema - Late

Pulmonary Artery CatheterPulmonary Artery Catheter

Pulmonary Artery CatheterPulmonary Artery Catheter

Arterial Blood Gas InterpretationArterial Blood Gas Interpretation

OxygenationOxygenation

SaturationSaturation

POPO22 27 mmHg27 mmHg 50%50%

40 mmHg40 mmHg 75%75%

60 mmHg60 mmHg 90%90%

95 mmHg95 mmHg 97%97%

150 mmHg150 mmHg 100%100%

Oxyhemoglobin Dissociation CurveOxyhemoglobin Dissociation Curve

Case Study 1Case Study 1An 18 year old white male was brought to the An 18 year old white male was brought to the ED by CFD after being rescued from his car ED by CFD after being rescued from his car following a high speed collision with a parked following a high speed collision with a parked truck. He is conscious, c/o of chest pain and truck. He is conscious, c/o of chest pain and is anxious. He was wearing his seat belt but is anxious. He was wearing his seat belt but still hit his chest on the steering wheel. His still hit his chest on the steering wheel. His vital signs are: T 37, P 113, RR 23, B/P 100/ vital signs are: T 37, P 113, RR 23, B/P 100/ 70. CT scan of chest was unremarkable and 70. CT scan of chest was unremarkable and he was brought to SICU for observation. He he was brought to SICU for observation. He continued to have fluctuations in his blood continued to have fluctuations in his blood pressure. A pulmonary artery catheter was pressure. A pulmonary artery catheter was placed.placed.

Case Study 1Case Study 1 AArearea NormalNormal 8 am8 am 10:3010:30 11:00 11:00

CVPCVP 0 0 toto 8 8 1010 44 88

PAPPAP 10 10 toto 22 22 2828 66 2222

PWPPWP 5 5 toto 1212 1515 77 1010

MAPMAP 70 70 toto 105 105 8585 4040 7070

COCO 44 toto 88 LPMLPM 5.95.9 2.52.5 5.75.7

HRHR 60 to 10060 to 100 110110 160160 9595

pHpH 7.35 7.35 to to 4545 7.377.37 7.227.22 7.397.39

PCOPCO22 35 35 to to 4545 4545 5252 4141

PaOPaO22 80 80 to to 100100 6565 5050 8888

PvOPvO22 39 39 toto 42 42 3939 2121 3838

Cardiac TamponadeCardiac Tamponade

Case Study 2Case Study 2 A 72 year old white female was admitted A 72 year old white female was admitted

to the MICU with an exacerbation of to the MICU with an exacerbation of COPD. She has emphysema and chronic COPD. She has emphysema and chronic bronchitis and a 40 pack year history of bronchitis and a 40 pack year history of cigarette smoking. Breath sounds are cigarette smoking. Breath sounds are bilaterally diminished, crackles and bilaterally diminished, crackles and rhonchi.rhonchi.

She has JVD and pedal edema. A She has JVD and pedal edema. A pulmonary artery catheter was placed as pulmonary artery catheter was placed as she had sustained hypotension and SOB. she had sustained hypotension and SOB. Her VS are: T 37, P118, RR 32, B/P Her VS are: T 37, P118, RR 32, B/P 150/90, FiO150/90, FiO22 .28, HB 22 Gm%. .28, HB 22 Gm%.

Case Study 2Case Study 2 NormalNormal NoonNoon 16001600 1800 1800

CVPCVP 0 to 80 to 8 2525 2020 1818PAPPAP 10 to 2210 to 22 5050 3535 3232PWPPWP 5 to 125 to 12 1515 1212 1010MAPMAP 70 to 10570 to 105 6060 7272 7575COCO 4 to 8 LPM4 to 8 LPM 3.93.9 4.54.5 4.74.7HRHR 60 to 10060 to 100 110110 9090 8888pHpH 7.35 to 457.35 to 45 7.357.35 7.397.39 7.387.38

PCO2PCO2 35 to 4535 to 45 6969 5555 5151PaO2PaO2 80 to 10080 to 100 4646 8585 7878PvO2PvO2 39 to 4239 to 42 3535 3838 3939

Case Study 3Case Study 3 A 25 year Hispanic male was admitted to A 25 year Hispanic male was admitted to

the SICU after a thoracotomy for repair of the SICU after a thoracotomy for repair of his aorta following a gun shot wound to his his aorta following a gun shot wound to his chest. He has bilateral chest tubes. He is chest. He has bilateral chest tubes. He is intubated and receiving full ventilatory intubated and receiving full ventilatory support. His chest tube drainage for the support. His chest tube drainage for the last hour was 400 ml. He has bloody last hour was 400 ml. He has bloody sputum and urine. His last CaOsputum and urine. His last CaO22 was was

10.4 volumes% with a PaO10.4 volumes% with a PaO22 of 110 and of 110 and saturation of 95%. VS T 36, P148, RR 14, saturation of 95%. VS T 36, P148, RR 14, B/P 65/44. B/P 65/44.

Case Study 3Case Study 3 NormalNormal 3 am3 am 5:305:30 11:00 11:00

CVPCVP 0 to 80 to 8 22 44 88PAPPAP 10 to 2210 to 22 1010 88 1515PWPPWP 5 to 125 to 12 66 55 1010MAPMAP 70 to 10570 to 105 4848 4040 6060COCO 4 to 8 LPM4 to 8 LPM 2.942.94 3.53.5 5.75.7HRHR 60 to 10060 to 100 150150 160160 140140pHpH 7.35 to 457.35 to 45 7.227.22 7.207.20 7.327.32

PCO2PCO2 35 to 4535 to 45 5555 5555 4949PaO2PaO2 80 to 10080 to 100 110110 9494 110110PvO2PvO2 39 to 4239 to 42 2929 2727 3939

Case Study 4Case Study 4

A 52 year old white male with shortness of breath and A 52 year old white male with shortness of breath and chest pain was admitted to the ED. ECG showed ST chest pain was admitted to the ED. ECG showed ST elevation in 4 leads and his cardiac enzymes were elevation in 4 leads and his cardiac enzymes were markedly elevated. His vital signs were stable, SpO2 markedly elevated. His vital signs were stable, SpO2 on NC at 2 LPM was 95%. He was taken to the on NC at 2 LPM was 95%. He was taken to the cardiac cath lab and a diagnostic cardiac angiogram cardiac cath lab and a diagnostic cardiac angiogram revealed 99% occlusion of his LAD. A coronary stent revealed 99% occlusion of his LAD. A coronary stent was placed and 15 minutes post intervention he began was placed and 15 minutes post intervention he began complaining again of severe SOB and chest pain. He complaining again of severe SOB and chest pain. He was taken back to the cath lab. A pulmonary artery was taken back to the cath lab. A pulmonary artery catheter was placed. A left heart catheterization catheter was placed. A left heart catheterization revealed progression of the MI. His LVEDP is 32 and revealed progression of the MI. His LVEDP is 32 and an intra aortic balloon was placed and counter an intra aortic balloon was placed and counter pulsation started at 1:1.pulsation started at 1:1.

Case Study 4Case Study 4 NormalNormal 9 am9 am 10:3010:30 1600 1600

CVPCVP 0 to 80 to 8 1010 88PAPPAP 10 to 2210 to 22 2828 2020PWPPWP 5 to 125 to 12 3535 1515MAPMAP 70 to 10570 to 105 7272 4747 6565COCO 4 to 8 LPM4 to 8 LPM 4.94.9 2.52.5 4.44.4HRHR 60 to 10060 to 100 110110 8080 6565pHpH 7.35 to 457.35 to 45 7.397.39 7.267.26 7.327.32

PCO2PCO2 35 to 4535 to 45 4040 5050 3838PaO2PaO2 80 to 10080 to 100 6565 4848 7575PvO2PvO2 39 to 4239 to 42 2828 3636

Intra Aortic Balloon Counter PulsationIntra Aortic Balloon Counter Pulsation

Case Study 5Case Study 5 A 55 year old AA male was admitted to the A 55 year old AA male was admitted to the

MICU with acute SOB, cough, HTN and MICU with acute SOB, cough, HTN and hypoxemia. He is oliguric and has required hypoxemia. He is oliguric and has required hemodialysis for the past 2 years. He is hemodialysis for the past 2 years. He is depressed and has not been following his depressed and has not been following his dietary and fluid restrictions and has dietary and fluid restrictions and has skipped his last 2 dialysis appointments. skipped his last 2 dialysis appointments. His VS are now T 37, P118, RR 35, B/P His VS are now T 37, P118, RR 35, B/P 200/135. He is receiving oxygen via venturi 200/135. He is receiving oxygen via venturi mask, FiOmask, FiO22 50%. He has a pulmonary 50%. He has a pulmonary artery catheter in place to monitor his artery catheter in place to monitor his cardiac status.cardiac status.

Case Study 5Case Study 5 NormalNormal 8 am8 am 10:3010:30 11:00 11:00

CVPCVP 0 to 80 to 8 2525 1919 1212PAPPAP 10 to 2210 to 22 4040 3232 2828PWPPWP 5 to 125 to 12 2222 1818 1515MAPMAP 70 to 10570 to 105 150150 110110 100100COCO 4 to 8 LPM4 to 8 LPM 3.43.4 4.14.1 5.75.7HRHR 60 to 10060 to 100 110110 9595 8686pHpH 7.35 to 457.35 to 45 7.327.32 7.397.39

PCO2PCO2 35 to 4535 to 45 4949 3838PaO2PaO2 80 to 10080 to 100 6060 7979PvO2PvO2 39 to 4239 to 42 3434 3838

Case Study 6Case Study 6A 36 year old female was admitted to the ED with a A 36 year old female was admitted to the ED with a

CC of SOB and chest pain. She has no CC of SOB and chest pain. She has no significant PMH, she does not smoke. She says significant PMH, she does not smoke. She says that she hurt her ankle about two weeks ago and that she hurt her ankle about two weeks ago and never went to the doctor about it. It is very never went to the doctor about it. It is very painful and she has been almost immobilized for painful and she has been almost immobilized for the past two weeks because it is just too painful the past two weeks because it is just too painful to walk on. She has a cough and says her SOB to walk on. She has a cough and says her SOB came on rather suddenly after she went down to came on rather suddenly after she went down to her basement to put some clothes in the laundry her basement to put some clothes in the laundry this morning. She is tachypneic, her MV is 12 this morning. She is tachypneic, her MV is 12 LPM.LPM.

Case Study 6Case Study 6NormalNormal 5 am5 am 24 hours later24 hours later

CVPCVP 0 to 80 to 8 2525 1212PAPPAP 10 to 2210 to 22 4040 2929PWPPWP 5 to 125 to 12 1010 99MAPMAP 70 to 10570 to 105 6565 7575COCO 4 to 8 LPM4 to 8 LPM 6.46.4 5.15.1HRHR 60 to 10060 to 100 110110 8484pHpH 7.35 to 457.35 to 45 7.367.36 7.397.39

PCO2PCO2 35 to 4535 to 45 4545 3838PaO2PaO2 80 to 10080 to 100 6565 8585PvO2PvO2 39 to 4239 to 42 3838 4141

Saddle Pulmonary EmbolismSaddle Pulmonary Embolism

Questions??Questions??

Thank you!Thank you!

You were great!!You were great!!

Thoraco-abdominal Thoraco-abdominal Pump Mechanism Pump Mechanism

Small VesselsSmall Vessels

                                                                                                          

Venous returnVenous return

Oxygen carried in the bloodOxygen carried in the blood

Chest x-ray of ARDSChest x-ray of ARDS

Normal Chest x-rayNormal Chest x-ray

CT Scan of ARDSCT Scan of ARDS

Left-Sided Heart FailureLeft-Sided Heart Failure

Pulmonary congestion occurs Pulmonary congestion occurs when left ventricle cannot pump when left ventricle cannot pump wellwellDyspnea upon exertion, Dyspnea upon exertion, orthopnea, and paroxysmal orthopnea, and paroxysmal nocturnal dyspneanocturnal dyspneaOliguriaOliguria

Right-Sided Heart FailureRight-Sided Heart Failure

Congestion of viscera and peripheral Congestion of viscera and peripheral tissues when right ventricle failstissues when right ventricle fails

Jugular vein distentionJugular vein distention

Dependent edemaDependent edema

HepatomegalyHepatomegaly

AscitesAscites

Weakness, anorexia, and nauseaWeakness, anorexia, and nausea

Weight gainWeight gain

Sphincters OpenSphincters Open

Sphincters ClosedSphincters Closed

Path Path of of

BloodBlood

Major Blood VesselsMajor Blood Vessels