HEMODYNAMICS

Carol Peyton Bryant, RN, MSN, ACNP, CCRN Priority Care, St. Marys

Objectives:
The participant will be able to discuss hemodynamic definitons (cvp,pa,pcwp,co,ci,svr and pvr) and how they relate to the respiratory patient. The participant will use critical thinking skills in assessing changes in respiratory status/ventilation with changes in hemodynamic status.

 INDICATIONS FOR HEMODYNAMIC MONITORING

Shock Pulmonary edema of uncertain etiology Postcardiac surgery Cardiac tamponade Acute respiratory failure Need to evaluate for fluid status/guideline for fluid resuscitation Need to evaluate hemodynamic response to potent pharmacologic agents MI
especially with an acute right or left ventricular failure Refractory pain Significant hypotension or hypertension

Blood pressure
Blood pressure=CO X SVR
Changes in blood pressure are caused by either a change in cardiac output or by systemic vascular resistance MAP Mean arterial pressure= SBP + (DBP x 2) = 70-105 mm Hg 3 The average blood pressure occurring in the aorta and its major branches during the cardiac cycle

Stroke volume: CO HR
The amount of blood ejected by the left ventricle during systole. N= 60-120 ml/beat Stroke Index: SV BSA The SV indexed for differences in body size by dividing by BSA. N= 30-65 ml/m2/beat Ejection Fraction: % of blood in the ventricle that is ejected during systole. Normally, greater than 50%.

Right Atrial Pressure-RAP

Normal Value 2-8 mm Hg Clinical Significance: Equivalent to central venous pressure. Abnormalities: Increased
Right ventricular failure, tricuspid valve abnormalities (stenosis or regurgitation), cardiac tamponade, right ventricular infarct, VSD with a left to right shunt. Pulmonary stenosis, Postive Pressure ventilation Pulmonary Hypertension
Active: hypoxemic pulmonary vasoconstriction Pa02 < 60 mm Hg.
Pulmonary Embolus COPD ARDS

Passive:
Mitral valve dysfunction either stenosis or regurgitation

Right Atrial Pressure-RAP

Decreased:
Hypovolemia Anything that vasodilates the body;
Endogendous systemic vasodilation
Septic Shock, Neurogenic Shock, Anaphylactic Shock

Venous vasodilation
Nitroglycerin or Morphine

Pulmonary Artery Pressure PAP or PAS/D

Systolic: 15-30 mm Hg Diastolic: 5-12 mm Hg Mean: 10-20 mm Hg Clinical Significance: PAP is equal to right ventricular pressure during systole while the pulmonary valve is open. IF the pulmonary vascular resistance is normal, the PADP is 1-4 mm Hg greater than PCWP and can be substituted for it in following the patients hemodynamic measurements.

 Abnormalities: Increased:
Hypervolemia, VSD with left to right shunt, Pulmonary HTN, Positive pressure ventilation, Mitral valve dysfunction (both), Tamponade, Left ventricular failure

Decreased: Hypovolemia Excessive vasodilation If the PADP is 5mm Hg > PCWP, consider acute respiratory distress syndrome, pulmonary emboli, or chronic obstructive pulmonary disease.

Pulmonary capillary wedge pressure PCWP or PAOP

Normal value 5-12 mm Hg Clinical Significance: pcwp is normally equal to left atrial presure; ~sensitive indicator of pulmonary congestion or left sided CHF.

 PCWP is not equal to LVEDP in the following situations: PCWP >LVEDP: Mitral Stenosis, patients receiving PEEP, Left atrial myxoma, pulmonary venous obstruction

PCWP< LVEDP:Stiff ventricle or Increased LVEDP (>25 mm Hg).

 Abnormalities: Increased
Left ventricular failure with resultant pulmonary congestions, acute mitral insufficiency, tamponade, decreased left ventricular compliance (hypertropy, infarction).

Decreased
Hypovolemia Vasodilation

Cardiac Output CO
Normal Value 4-8 L/min. Clinical Significance: CO=SV x heart rate/1000 Abnormalities: Increased
Sympathetic nervous system innervation (endogenous catecholamines ie. stress/exercise) Exogenous catecholamines (ie. epinephrine, dobutrex, dopamine, isuprel) Other positive inotropes ie. digitalis Infection, early sepsis Hyperthyroidism Anemia

Cardiac Output-CO
Decreased
Cardiac dysrhythmias, decreased contracting muscle mass (myocardial infarction, ischemia) mitral insufficiency, VSD. Increased SVR (afterload)- systemic or Pulmonary HTN, Aortic or Pulmonic stenosis or polycythemia Significantly increased or decreased heart rate. Either hyper or hypovolemia

Cardiac Index CI
Normal Value: 2.5-4 L/min. Clinical Significance: CI= CO/BSA Abnormalities: Increased: high output failure secondary to fluid overload, hepatocellular failure, renal disease, septic shock Decreased: hypovolemia, cardiogenic shock, pulmonary embolism, hypothyroidism, CHF with failing ventricle.

 Normal Value 900-1300 dyne/sec/cm-5. SVR= (MAP-RAP) x 80 /CO

Systemic Vascular resistance SVR

Clinical Significance: Resistance against which the left ventricle must work to eject its stroke volume. Abnormalities: Increased: hypervolemic vasoconstrictive states (hypertension, cardiogenic shock, traumatic shock). Decreased: septic shock, acute renal failure, pregnancy.

Remember
There is a inverse relationship with CI and SVR. If the CI is UP, the SVR will be DOWN. If the CI is DOWN, the SVR will be UP.

Pulmonary Vascular Resistance PVR

Normal Value: 150-250 dyne/sec/cm-5.
Clinical Significance: PVR=(mPAP-PCWP) x 80/CO. Abnormalities: Increased: cor pulmonale, pulmonary embolism, valvular heart disease, CHF. Decreased: hypervolemic states, pregnancy.

Scenario
65 year old woman admitted with a fractured hip. She had surgery 2 weeks ago. Earlier today she complained about chest pain, shortness of breath, and a feeling of doom. ABGs revealed respiratory alkalosis and hypoxemia. A RRT was called and she was transferred to ICU, the physician inserted a PA catheter into her right subclavian vein. He told the nurse it was placed so he could better diagnose and evaluate her thearpy. Her body surface area (BSA) is 1.6 m2.

Parameter Bp:112/84 MAP: 93 mm Hg HR: 110 RAP: 18 PAS/D: 55/32 mPA: 40 PAOP: 6 CO: 4.4 CI: 2.75

or normal

Why?

Parameter SaO2: 85% SV: 40 SVR: 1356 PVR: 618 Svo2: 58%

or normal

Why?

Dx: ______________ _________________ Considering her history, you would suspect ____________. You know that means we gotta travel to have _____________________(test) done. Goals for this patient ____________________ ____________________ ____________________