CATCH A WAVE.. INTRODUCTION NONINVASIVE HEMODYNAMIC MONITORING 4/12/2018

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1 WAVES CATCH A WAVE.. W I S C O N S I N P A R A M E D I C S E M I N A R A P R I L K E R I W Y D N E R K R A U S E R N, C C R N, E M T - P Have you considered that if you don't make waves, nobody including yourself will know that you are alive? Theodore Isaac Rubin Catch a wave and you ll be sitting on top of the world.. The Beach Boys INTRODUCTION Invasive hemodynamic monitoring assesses the condition of the heart, vascular network, and fluid volume. Just Like Plumbing!! NONINVASIVE HEMODYNAMIC MONITORING Paramedics use physical assessments Capillary refill Skin color, turgor, temperature, moisture Lung sounds Heart sounds Mental status Urine output 1

2 INVASIVE HEMODYNAMIC MONITORING Arterial Lines measures B/P Central Venous Lines Measures Right heart pressures Pulmonary Artery Lines Measures lung and Left heart pressures All pressure lines function the same the only difference is WHERE the line is placed and what it is monitoring. SO.. Let Us Discuss WHAT a Pressure Line is and HOW it Works PRESSURE LINE PRESSURE TUBING Special Nondistendable or rigid tubing Carries the wave energy to the transducer 2

3 PRESSURE TRANSDUCER Changes pressure energy into a visible waveform Displays on monitor Scaled to atmospheric pressure CALIBRATE SYSTEM Zero and flush line Off to patient, Open to air PHLEBOSTATIC AXIS CONTINUOUS FLUSH SYSTEM 4th Intercostal Space Mid Axillary Line 3

4 PRESSURE BAG PRESSURE LINE CABLE Sends the waveform signal from the transducer to the monitor for display MONITOR COMPLETE PRESSURE LINE SETUP 4

5 PRESSURE LINE WAVEFORM QUESTIONS ON PRESSURE LINE SETUP? INVASIVE HEMODYNAMIC MONITORING Arterial Lines Central Venous Lines Pulmonary Artery Lines (save for another day.) ARTERIAL LINES Inserted into the patient s arterial vascular system The radial artery is the preferred site. Other sites include brachial, axillary, femoral More reliable than NIBP or manual B/P The arterial line is an alternative trigger source for an intra-aortic balloon pump and enables access for sampling and blood gas analysis. 5

6 ARTERIAL LINE ARTERIAL BLOOD PRESSURE Systole-topmost peak-blood ejected from LV Diastole-lowest portion-runoff into vascular system Dicrotic notch-closure of aortic valve Mean pressure-average pressure during cardiac cycle Pulse Pressure-difference in systolic and diastolic ACCURACY OF WAVEFORM Fast Flush response MAP usually not affected by damped issues 6

7 MEAN ARTERIAL PRESSURE (MAP) Influenced most by diastolic level Unaffected by the location of line or method of B/P measurement Best parameter to use when making treatment decisions Between 65 and 110 mm Hg < 60 mmhg Hypoperfusion < 55 mmhg Significant hypoperfusion MAP FORMULA ARTERIAL LINES Complications Hematoma Hemorrhage Insertion site infection Median nerve neuropathy Pseudoaneurysm of the artery Arterial line thrombus Embolization Ischemic necrosis Digit, hand, leg, or foot ischemia Arterial air embolism 7

8 A WORD OF CAUTION. ART LINE COMPLICATIONS Never inject anything into an arterial line ever ART LINE COMPLICATIONS ART LINE COMPLICATIONS 8

9 QUESTIONS ON ART LINES? CENTRAL VENOUS PRESSURE Central venous pressure Blood pressure in vena cava/right atrium Pressures equal as no valves exist between locations Provides information about right ventricular preload Helpful as a guide for fluid therapy Tip of catheter in vena cava near right atrium CVP MONITORING CVP MONITORING Electronic pressure transducer Distal port of central line (brown) mmhg Same set up as arterial line Must be leveled and zeroed Old School 9

10 CENTRAL VENOUS PRESSURE WAVEFORM A wave - due to atrial contraction. Absent in atrial fibrillation. Enlarged in tricuspid stenosis, pulmonary stenosis and pulmonary hypertension. C wave - due to bulging of tricuspid valve into the right atrium X descent - due to atrial relaxation. V wave - due to the rise in atrial pressure before the tricuspid valve opens. Enlarged in tricuspid regurgitation. CENTRAL VENOUS PRESSURE WAVEFORM Systolic and diastolic pressures are indistinguishable Low-pressure, venous system Mean pressure R wave Measured at end exhalation Y descent - due to atrial emptying as blood enters the ventricle. CVP MONITORING ABNORMAL CVP Normal CVP 5 8 cmh mmhg Trends important Isolated fluctuations of little importance CVP High CVP secondary to: Fluid volume overload Vasoconstriction Right ventricular failure Pulmonary hypertension ARDS Chronic pulmonary disease Tricuspid valve dysfunction Mitral valve dysfunction Mechanical ventilation with PEEP Cardiac tamponade Chronic left ventricular failure Low CVP secondary to: Hypovolemia Vasodilation 10

11 ABNORMAL CVP WAVEFORMS CVP COMPLICATIONS Many CVP complications are related to the central line itself Infection Bleeding at site Blockage Inability to aspirate Infiltration Thrombus and embolization Pneumothorax QUESTIONS ON CVP? TROUBLESHOOTING PRESSURE LINES Cannot zero/flush system Cannot aspirate for sample Inaccurate readings Bleeding at site Infection Blocked unable to flush Ischemia 11

12 TRANSPORT CONSIDERATIONS HEMODYNAMIC PEARLS Locate and assure security of all lines Do NOT assume all are sutured in place Ensure connections are tight, pressure bags have fluid and all air is expelled, and flush systems are functional Most common issue during transport is line dislodgement If line is completely out of patient, apply direct pressure to site and assure bleeding control If partially withdrawn, may need to remove completely. Gently and steady withdraw line and control bleeding DO NOT REPLACE OR PUSH BACK IN The cardiovascular system works like plumbing-fluid in a system of tubes, pushed around by a pump All pressure lines function the same-the difference is where they are placed Trends are more important than single numbers Most common lines encountered will be CVP and Art lines Lines can assist with treatment, but do not take the place of a thinking clinician TREAT THE PATIENT, NOT THE MONITOR THANKS, PARAMEDICS!! Theodore The Beach Boys 12