Admission of patient CVICU and hemodynamic monitoring

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1 Admission of patient CVICU and hemodynamic monitoring Prepared by: Rami AL-Khatib King Fahad Medical City Pi Prince Salman Heart tcentre CVICU-RN

2 Admission patient to CVICU Introduction All the patients post open heart surgery need to be admitted to CVICU for close monitoring, The nurse caring for the patient must be alert at all times. Close monitoring of lines, waveforms and measurement are to be noted and recorded.

3 Admission patient to CVICU The first critical phase post operative care start at the completion of the surgical procedure, during transfer from the operating room to an intensive care unit bed, from one monitoring system to another, during transfer any sudden hypotension or hypertension could happen, arrhythmia, bleeding& unidentified problem with invasive catheter.

4 Admission patient to CVICU Ventilation is provided by a manual resuscitator bag (Ambu) connected to a portable oxygen cylinder, drug infusion should be placed on battery powered infusion pumps to ensure accurate infusion rate. A selection of cardiac medication should always be available in the event of an emergency during transport.

5 Admission patient to CVICU Upon arrival in the CVICU, the endotracheal is connected to a mechanical ventilator and the ECG and pressure lines are transuduced on the bedside monitor. A pulse oximeter is attached to one of the patient fingertips, medication di drip rates are confirmed or readjusted don controlled infusion pumps, preferably using the same pumps that were used in the operating room to avoid temporary disconnection from the patient, t the thoracic drainage system is connected to suction.

6 Admission patient to CVICU After connecting the patient nurses & respiratory therapist make sure that: 1- The patient is being well- ventilated by observing chest movement & auscultating bilateral breath sound. 2- The ECG demonstrates satisfactory rate and rhythm on the transport & and then on the bedside monitor. 3- The blood pressure is adequate on the portable monitor & remains so after the arterial line is transduced and calibrated on the bedside monitor.

7 Admission patient to CVICU How many staffs supposed to receive the patient post open heart surgery? 1-Primary nurse 2- Secondary nurse 3-Tertiary nurse

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10 Admission patient to CVICU Primary nurse 1- Obtain base line vital sings on transport monitor. 2- Taking handover from anesthetist & CVOR nurses. 3-Assess & record vital sings, chest tube & urine out put. 4- Perform & document head to toe patient assessment. 5- Ensure fluid & inotrope management is in accordance with physicians post op. order. 6- Perform 12 lead ECG & order Chest X-ray. 7- Send the blood to the laboratory routine blood investigation. 8- Document in nursing notes.

11 Admission patient to CVICU Secondary nurse ( Team leader) 1-Ensure breaks are on the bed & connected to the power outlet. 2- Connect monitors electrocardiogram electrodes to the patient. 3- Connect & zero transducers. 4- Elevate head of bed to 30 degree. 5- Attach saturation probe to the patient. 6- Take a rhythm strip & attach to patient file. 7- Secure Swan- Ganz catheter & Foleys catheter. 8- Start t IV maintenance according to the doctor order. 9- inform primary nurse about the size of endotracheal tube & its level, Invasive line site, chest drain numbers & sites, Foleys catheter size.

12 Admission patient to CVICU Tertiary nurse 1- Connect chest drains to low wall suction & measure drainage & report to the primary nurse. 2- Measure urine out put on admission. 3- Cover patient with warming blanket if needed. 4- With draw blood for routine laboratory investigation.

13 Admission patient to CVICU Post open heart surgery protocols in KFMC/ PSHC: 1- Clinical pathway

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16 Admission patient to CVICU Post open heart surgery protocols in KFMC/ PSHC 2- Pain Management protocol

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18 Admission patient to CVICU Post open heart surgery protocols in KFMC/ PSHC 3- Electrolyte protocol

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20 Admission patient to CVICU Post open heart surgery protocols in KFMC/ PSHC 4- Insulin Protocol ( If needed )

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22 Admission patient to CVICU Post open heart surgery protocols in KFMC/ PSHC 5- Heparin protocol ( If needed )

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24 Guidelines for removal of lines 1-The Swan-Ganz catheter should be removed when inotropic support & vasodilators are no longer necessary. 2- Any central line should be removed when no longer necessary to reduce the risk of infection. 3- The arterial line should be removed after a stable post extubation blood gas has been obtained. An additional ABGs obtained on room air is frequently worthwhile because it provides a relative indication of the patient baseline postoperative ti oxygenation.

25 Guidelines for removal of lines 4- The urinary catheter can be left in place if the patient is undergoing a vigorous diuresis or has an increased risk of urinary retention. It should other wise be removed once the patient is mobilized out of bed, usually on the second postoperative day. 5- Chest tubes should be removed when the total drainage is less than 100ml for 8 hours.

26 Hemodynamic monitoring

27 Hemodynamic monitoring Hemodynamics is the term used to describe the intravascular pressure and flow that occurs when the heart muscle contracts and pump blood through out the body.

28 Hemodynamic monitoring CVP Line Indication for CVP line: 1- Central venous pressure monitoring. 2- In adequate peripheral IV access. 3- Rapid infusion of IV fluid ( using large canula) 4- Drug administration. 5- Frequent venous blood sample.

29 Hemodynamic monitoring Pulmonary artery catheter (PA Catheter, Swan-Ganz) The pulmonary artery catheter has several functions. It allows for continues bedside hemodynamic monitoring, myocardial contractility and fluid balance can be assessed and managed.

30 Hemodynamic monitoring Pulmonary artery catheter (PA Catheter, Swan-Ganz) It measure pulmonary artery pressure, central venous pressure and allows for hemodynamic calculation to be determined. Cardiac out put can determined using thermo dilution method. The administration of fluid is not recommended with pulmonary artery catheter.

31 Normal values

32 Hemodynamic Parameters Hemodynamic Parameters Abbreviations Normal Values Mean Arterial Pressure MAP mm Hg Right Atrial Pressure RAP 2-6 mm Hg Central Venous Pressure CVP 2-8 mm Hg Pulmonary Artery Systolic Pressure PAS mm Hg

33 Hemodynamic Parameters Pulmonary Artery Diastolic Pressure PAD 6-12 mm Hg Pulmonary Artery Mean Pressure PAM mm Hg Pulmonary Artery Wedge Pressure PAWP, Wedge 8-12 mm Hg Cardiac Output CO 4-8 L/min Cardiac Index CI L/min Stroke Volume SV ml Stroke Volume Index SVI ml/m2 Systemic Vascular Resistance SVR dynes Systemic Vascular Resistance Index SVRI dynes Pulmonary Vascular Resistance PVR dynes

34 Intra arterial pressure Invasive technique for continuous monitoring arterial blood pressure Need frequent arterial blood sampling Catheter placed into a radial, brachial or femoral artery Pressurized heparinized fluid source attach to arterial catheter with pressure 300 mm Hg

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