- arterial lines

- central venous lines

- Swan-Ganz lines/PA lines

• results from pumping action of the left ventricle of the

heart
• the level of arterial pressure at any point in arterial • arterial pressure is crucial for organ perfusion, monitored
vascular compartment reflects functioning of left invasively or noninvasively
ventricle • noninvasive monitoring is reliable for less ill patients but
less accurate in shock patients
o Example: overestimation (5-10 mmHg) not
• average pressure in patient’s arteries during one cardiac critical at high MAP (80 mm Hg), but significant
cycle at low MAP (55 mm Hg).
• a better indicator of perfusion to vital organs than systolic • invasive monitoring recommended for pts with circulatory
blood pressure (SBP) failure
• vital organs perfusion maintenance = MAP of 60 mmHg • inadequate MAP leads to organ perfusion problems and
o if MAP < 60 for a long time = end-organ hypotensive shock
manifestations (e.g., ischemia, infarction) • hypotension can be caused by severe bacteremia or
o if MAP drops significantly, blood will not be able hypovolemia
to perfuse cerebral tissues = loss of o treatable with drugs like dopamine and
consciousness = neuronal death vasopressors
• formula: SBP + (2*DBP)/3 • MAP helps diagnose hypertension and hypotension, aiding
• normal range: 70-110 mmHg treatment decisions for clinicians (Gamper G. et al., 2016)

• kidneys control arterial blood pressure

• too much fluid ▲ raises pressure, too little fluid ▼ lowers is a process that gives important information about adequacy of
pressure patient’s circulation, perfusion, and oxygenation of organ tissues
• arterial blood pressure is determined by: via Pulmonary Artery (PA) catheter and/or transpulmonary
o volume of renal output thermodilution
o amount of salt and water
Goals of Hemodynamic Monitoring
• kidneys change extracellular fluid volume to regulate renal
output • ensure perfusion adequacy
• ↑ extracellular fluid → ↑ blood volume → ↑ cardiac • early detection of perfusion inadequacy
output → ↑ arterial pressure • titrate therapy to specific hemodynamic endpoints in
• MAP determined by: CO (Cardiac Output) and SVR unstable patients
(Systemic Vascular Resistance) • differentiate among various organ system dysfunctions
• CO controlled by: IVV (Intravascular Volume), preload, ICU patients require standard basic hemodynamic monitoring :
afterload, contractility, HR (Heart Rate), and conduction.
• SVR regulated by: vasoconstriction and dilation • ECG
• renal system influences MAP via renin-angiotensin- • heart rate
aldosterone system (RAAS): • blood pressure
o cascade leads to aldosterone release • central venous pressure (CVP)
o aldosterone ↑ Na+ reabsorption in distal tubules • temperature
o ↑ plasma volume → ↑fluid • peripheral venous oxygen saturation (O2 sat)
• blood gas analysis
• ANS (Autonomic Nervous System) controls MAP using
baroreceptors in carotid sinus and aortic arch • intravascular volume status
• intake and output
• ANS adjusts CO and SVR for ideal MAP
 • urinary output • Systemic circulation: High pressure system, high
resistance to blood flow
Clinical Indications for PA Catheter Use

• Post myocardial infarction: Assess hemodynamics and

guide therapy. • preload is myocardial fiber stretch and ventricular volume
• Cardiac surgery: Monitor cardiac function. at diastole's end
• Major surgery with myocardial dysfunction or • left atrial pressure or pulmonary artery wedge pressure
preoperative hemodynamic optimization. checks left ventricular preload
• Resuscitation during fluid replacement: Assess left • right atrial pressure or CVP assesses right ventricular
ventricular function. preload
• Septic shock: Evaluate LV function and fluid status. • volumetric parameters offer a more precise measure for
• Diagnosing high and low-pressure pulmonary edema. right ventricular preload
• Measure oxygen transport for ventilation and perfusion
optimization.
• Pre-eclampsia and eclampsia: Monitor fluid status and • afterload is the myocardial tension during ventricular
intravascular volume. ejection.
• also described as resistance, impedance, or pressure to
eject blood.
• factors: ejected blood volume, ventricle size/wall
thickness, vascular impedance.
• sensitive measures of afterload is SVR for left ventricle,
PVR for right ventricle.
• afterload is inversely related to ventricular function
• increased resistance ➡ decreased contraction force ➡
reduced stroke volume
• increased resistance ➡ increased myocardial oxygen
consumption

• direct measurement of contractility by pressure volume

curves is difficult in the clinical setting;
• indirect measures include:
o echocardiographic determination of ejection
fraction,
o measurement of cardiac output,
o stroke volume
o right and left ventricular stroke work index in
o relation to systemic and pulmonary vascular
resistance.

• key parameters from pulmonary catheters: cardiac output

and stroke volume
• first assessment in hemodynamic monitoring
• adequate values ➡ generally sufficient tissue
oxygenation
• abnormal values ➡ potential threat to tissue oxygenation
needing treatment
Circulatory system is divided into two parts:

• Pulmonary circulation: Low pressure system, low

resistance to blood flow
 • increased LVEDV might prevent drop in stroke index but
can still detect dysfunction through ejection fraction
drop
• changes in ejection fraction and end diastolic volumes
provide early warning of ventricular dysfunction
• monitoring of these parameters not routinely available
• stroke volume or index thus becomes the single most
important piece of information regarding cardiac function

Cardiac Output – heart rate x stroke volume; amount of blood

pumped by ventricles each minute
Stroke Volume – amount of blood ejected with each cardiac
contraction/heartbeat

• heart rate, contractility, preload, and afterload affect

cardiac output
• abnormal cardiac output often due to stroke volume issues
• low stroke volume when blood volume is too low or left
ventricle is weak
• conditions like sepsis or exercise can increase stroke volume
• low stroke volume common in hemodynamic monitoring

• cardiac index is cardiac output adjusted for body size and

is superior to cardiac output
• some patients tolerate low cardiac index without issues
• tracking trends in cardiac index more valuable than single
data points
• monitoring cardiac index and tissue oxygenation enhances
identification of dangerous events

Damped Pressure Tracing

• stroke index, like cardiac index, customizes stroke volume
• Causes: Air bubbles, clots, catheter kinks.
to patient size
• Prevention: Proper catheter placement, ensure no air
• in heart malfunction, stroke index decreases
bubbles.
• in some cases (e.g., left ventricular failure, sepsis),
• Treatment: Catheter flushing, repositioning, or
compensatory mechanisms may delay stroke index decline
replacement.
• coronary artery disease with left ventricular dysfunction
➡ ventricle dilation ➡ increased LVEDV Abnormally High or L ow Readings

• Causes: Catheter position, system calibration, catheter

kinking.
• ejection fraction: amount of blood pumped with each • Prevention: Correct catheter placement, regular system
contraction in relation to available blood to be pumped calibration.
• Treatment: Reposition catheter, recalibrate system if
necessary.
No Pressure Available

• Causes: Catheter disconnection, catheter blockage.

• Prevention: Secure catheter connections, prevent kinks.
• Treatment: Reconnect catheter, clear blockage if present.

Damped Waveforms and Inaccurate Pressures

• Causes: Air bubbles, catheter kinks, clots.

• Prevention: Proper catheter placement, eliminate air
Phlebitis or L ocal Infection at Insertion Site bubbles.
• Causes: Contaminated insertion, poor hygiene. • Treatment: Flushing catheter, repositioning, or
replacement.
• Prevention: Sterile technique, proper site care.
• Treatment: Antibiotics for infection, site care. Abnormally L ow or Negative Pressures
Ventricular Irritability • Causes: Catheter malposition, poor connection.
• Prevention: Correct catheter placement, secure
• Causes: Catheter tip position, contact with heart wall.
connections.
• Prevention: Careful placement, monitor ECG.
• Treatment: Reposition catheter, verify connections.
• Treatment: Reposition catheter, antiarrhythmics.
Abnormally High Pressure Reading
Apparent Wedging of Catheter wi th Balloon Deflated
• Causes: Catheter overwedging, system error.
• Causes: Balloon not properly deflated, catheter wedged.
• Prevention: Proper catheter placement, system calibration.
• Prevention: Ensure proper balloon deflation.
• Treatment: Reposition catheter, recalibrate if necessary.
• Treatment: Reinflate balloon, reposition catheter.
Inappropriate Pressure Waveform
Pulmonary Hemorrhage or Infarction
• Causes: Catheter tip location, catheter movement.
• Causes: Trauma, catheter placement, clot formation.
• Prevention: Secure catheter position, minimize movement.
• Prevention: Gentle handling, monitor for clots.
• Treatment: Reposition catheter, stabilize.
• Treatment: Address bleeding, anticoagulants if clot.
No Pressure Available
“Overwedging” or Damped PAW
• Causes: Catheter disconnection, blockage.
• Causes: Catheter wedged too far, catheter kinking.
• Prevention: Secure connections, prevent kinks.
• Prevention: Proper catheter positioning.
• Treatment: Reconnect catheter, clear blockage if present.
• Treatment: Reposition catheter, check for kinks.
Noise or Fluctuation in Pressure Waveform
PA Balloon Rupture
• Causes: Catheter movement, interference.
• Causes: Balloon over-inflation, manufacturing defect.
• Prevention: Stabilize catheter, reduce interference.
• Prevention: Careful balloon inflation.
• Treatment: Secure catheter, eliminate sources of
• Treatment: Replace catheter, address complications. interference.
Infection

• Causes: Contamination, poor hygiene.

• Prevention: Sterile technique, aseptic care. • phlebostatic axis: nurse should align it with the stopcock
• Treatment: Antibiotics, catheter removal if needed. • located at 4th intercostal space, mid-axillary line, where
Heart Block During Catheter Insertion the right atrium is
• always use a leveling device, don't eyeball it
• Causes: Mechanical irritation, catheter placement. • every 10 cm above/below the axis affects pressure by 7.4
• Prevention: Careful insertion, monitor ECG. mmHg
• Treatment: Adjust catheter, treat arrhythmia if needed. • changing the bed's angle shifts the axis, so re-level and
zero for accuracy
 • Optimally dampened system: Square wave rises, plateaus,
and falls smoothly with minimal oscillations; ideal response.
• Overdampened system: Square wave rises and falls
gradually with slow oscillations; excessive damping.
• Underdampened waveform: Square wave has rapid
• zeroing: using atmospheric pressure as a reference to oscillations, overshoots, and undershoots; lacks damping.
measure other pressures
• ensures that the monitor shows only the actual vessel or
heart pressures
• sets the starting point for pressure measurements

Dobutamine: Increases heart's contractility and cardiac output;

used for heart failure or low cardiac output.
Dopamine: Boosts heart rate, cardiac output, and blood pressure;
used in shock or low blood pressure situations.
Digoxin: Strengthens heart contractions and controls heart rate;
used for heart failure and certain arrhythmias.
Milrinone: Increases heart contractility and dilates blood vessels;
employed for heart failure with low cardiac output.

• level the transducer to the phlebostatic axis

• turn off the stop-cock to the patient and remove the cap Diuretics: Increase urine output, reduce blood volume, lower heart
• don't contaminate the cap pressure; used in congestive heart failure to reduce fluid.
• press the 'zero' button on the monitor and wait for '0' to Vasodilators: Dilate blood vessels, decrease resistance, ease heart's
appear workload; used in hypertension and heart failure to lower preload.
• put the cap back and return the stop-cock to its original
position
• note: some transducer models may not require cap removal
Smooth muscle relaxants and alpha inhibitors: Dilate blood vessels,
for zeroing; check the manufacturer's instructions
reduce afterload, ease heart's work; used for hypertension.
ACE inhibitors: Block vasoconstrictor hormone, lower afterload,
manage heart failure and hypertension.
• Square wave test: Fast flush for 1-2 seconds, observe
waveform.
• Square wave: Sharp rise, plateau, sharp drop, followed by
oscillations.
• 3 types:
o Optimally dampened system
o Overdampened system
o Underdampened waveform