Advanced Hemodynamics Flashcards by Kris Dobie

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left heart monitors

arterial line

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right heart monitors

central venous catheter
swan ganz
pulmonary artery catheter

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left heart vs right heart

right: pushes blood from RV out to lungs
right: deoxygenated and low pressure

left: pushes blood to muscles/circulation
left: oxygenated and high pressure

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non-compliant tubing

aka low compliant, aka rigid
tubing doesn’t expand with fluid pushing through it

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phlebostatic axis

at the level of the right atrium
midpoint between anterior and posterior chest, 4th intercostal space

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square waveform

produced by a fast flush

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over-damped system

caused by clot or air bubble
sluggish, short wave-form
one oscillation after releasing pigtail

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under-damped

hyper-responsive
tall wave-form
sometimes caused by excessive tubing
many oscillations after releasing pigtail

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dual/triple lumen central venous catheter

primary catheter used to interrogate right heart space
superior or inferior vena cava

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pulmonary artery catheter (Swan-ganz)

distal tip in pulmonary vasculature
yellow port: stay away (PA distal lumen)
red port: stay away (balloon port)
blue port: measures CVP/RAP and CO
White: for fluid infusions

measurements on tubing need to be measured during transport to make sure catheter doesn’t move.

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hypovolemic shock (hemodynamics)

hemorrhage/exsanguination
free water loss (DKA)
plasma loss

low volume

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cardiogenic shock

Left ventricular dysfunction
…diastolic failure
…systolic failure
…apical ballooning
…myocarditis

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Obstructive shock

cardiac tamponade
PE
Tension pneumothorax (compression)
congenital disease

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Distributive shock

container fail - leak (vasodilation)
Low volume back to right side of heart
sepsis
anaphylaxis
neurogenic shock

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Hemodynamic numbers (equations and norms)

Systemic vascular resistance:
[(MAP - CVP) / Q] x 80. Normal = 800-1200
Less than 800 = vasodilated
Over 1200 = vasoconstricted

Pulmonary vascular resistance:
[(mean PAP / Q) - PCWP x 80.
Normal 100-200
Over 200 = vasoconstricted
under 100 = vasodilated

Cardiac Output (Q)
Q = (SV x HR) / 1000. Normal 4-8L/min

Cardiac index (CI)
CI = Q/BSA. Normal 2-4 L/min/m3

pulmonary artery catheter measurements

Right side of heart
CVP aka right atrial pressure (2-6 mmHg)

Right ventricular pressure
Systolic 20-30 mmHg
diastolic 0-5 mmHg

Pulmonary artery pressure
Systolic 15-25 mmHg
diastolic 8-15 mmHg

Wedge pressure

Central venous pressures (right heart)

Monitor blood volume
monitor CV return and right ventricle function
administration of IV meds, fluid blood, TPN
Normal CVP 2-6 mmHg
A wave - atrial contraction
C wave - tricuspid valve bulging (starting to close)
X descent - right ventricle contracting
V wave - passive atrial filling
Y wave - tricuspid valve opens

Abnormal Right atrial pressure / Central venous pressure

Decreased CVP
…right atrial pressures
…vasodilation

Increased CVP
RV failure/infarct
Tricuspid valve insufficiency
COPD
Left-sided failure
…Left systolic failure, volume overload
Pulmonary hypertension
Cardiac tamponade
PEEP

Right ventricle pressure (right heart)

measured during insertion - no dicrotic notch
Notch on ascending side - anacrotic notch
Indicates atrial kick

Normal RVP
Systolic: 20-30 mmHg
Diastolic: 0-5 mmHg

Increased RVP
RV failure/chronic CHF
pulmonary hypertension/hypoxemia
Cardiac tamponade

Pulmonary artery pressure (right heart)

Measure PA systolic pressure
Normal: 15-25 mmHg

Measure PA diastolic pressure
Normal: 8-15 mmHg
Reflects RV systolic pressure

Indirectly reflects LV and-diastole pressure
…can be used to estimate wedge pressure; 2-4 mmHg higher than mean wedge pressure
dicrotic notch = closure of pulmonic valve
dicrotic notches are on descending (right) side

Abnormal pulmonary artery pressure (PAP) / PCWP (right heart)

Normal: 15-25 mmHg

Decreased PAP
hypovolemia
dampened waveform

Increased PAP
Fluid overload
atrial and ventricular defects
pulmonary problems
mitral valve regurgitation/stenosis
LV failure

PAP waveform

Similar to right ventricular waveform
Dicrotic notch denotes closure of pulmonic valve

Abnormal PCWP

Normal: 4-12 mmHg

Decreased PCWP
hypovolemia
vasodilator medications

Increased PCWP
LV failure
Mitral valve disease
Cardiac tamponnade
fluid overload

circle of resuscitation

Volume status HR SVR (systemic vascular resistance) If bradycardia, generally compensated though increased stroke volume. As stroke volume increased, SVR increases. low SVR = vasodilated high SVR = vasoconstricted More vasodilated = lower preload = lower cardiac output = higher HR More vasoconstrcited = more preload = better cardiac output (ie better stroke volume) For example: Low volume --> increased HR --> pt may normalize, or pt becomes vasoconstricted For example: Volume overload --> decreased HR --> vasodilated

**Distrubutive shock**

ie sepsis, anaphylaxis (Vasodilated) CVP: low Normal: 2-6 mmHg CI: low Normal 2-4 L/min SVR: low Normal 800-1200 PCWP: low Normal: 4-12 mmHg

**Obstructive shock**

Same as cardiogenic Usually trauma induced (cardiac tamponade, tension pneumothorax), or PE Contraction (output) and relaxation (filling) of left ventricle are impeded Vasoconstricted CVP: high Normal: 2-6 mmHg CI: low Normal 2-4 L/min SVR: high Normal 800-1200 PCWP: high Normal: 4-12 mmHg

**Neurogenic shock**

(Vasodilation) CVP: low Normal: 2-6 mmHg CI: normal/low Normal 2-4 L/min SVR: low Normal 800-1200 PCWP: low Normal: 4-12 mmHg

**Cardiogenic shock**

Same as obstructive Vasoconstricted ie myocarditis, acute MI, valvular issues Not able to move volume out of LV CVP: high Normal: 2-6 mmHg CI: low Normal 2-4 L/min SVR: high Normal 800-1200 PCWP: high Normal: 4-12 mmHg

**Hypovolemic shock**

Many compensatory mechanisms are impeded CVP: low Normal: 2-6 mmHg CI: low Normal 2-4 L/min SVR: high Normal 800-1200 PCWP: low Normal: 4-12 mmHg

**Right ventricular failure shock**

Right ventricle not able to move volume out CVP: high Normal: 2-6 mmHg CI: low Normal 2-4 L/min SVR: high Normal 800-1200 PCWP: low Normal: 4-12 mmHg