HEMODYNAMIC MONITORING
INTRODUCTION
The pulmonary artery catheter is a balloon-tipped multi-lumen catheter that allows for
invasive hemodynamic monitoring. The primary purpose of invasive hemodynamic
monitoring is the early detection, identification, and treatment of critically ill or injured
patients. By using invasive hemodynamic monitoring the nurse is able to evaluate the
patient's immediate response to treatment such as drugs and mechanical support.
Indications for Hemodynamic Monitoring:
Because there is no specific criteria or rule as to who should be hemodynamically
monitored, each patient’s circumstance must be evaluated individually. The risk vs. benefit of
placing a pulmonary artery catheter, as well as the expense need to be considered. General
indications for pulmonary artery pressure monitoring include:
Assessment of cardiovascular function (complicated MI, cardiogenic shock, papillary
muscle rupture)
Peri-operative monitoring of surgical patients with major systems dysfunction
Shock of all type (septic, hypovolemic, any shock that is prolonged or origin is
unknown)
Assessment of pulmonary status
Assessment of fluid status (dehydration, hemorrhage, GI bleed, burns)
Therapeutic indications (aspiration of air emboli, cardiac pacing )
Diagnostic indications (aspiration of arterial blood ,pulmonary hypertension)
Contraindications for placement of a pulmonary artery catheter include:
o Tricuspid or pulmonary valve mechanical prosthesis
o Right heart mass (thrombus and/or tumor)
o Tricuspid or pulmonary valve endocarditis
o Atherosclerotic heart disease without heart failure
o Angioplasty or other interventional procedures
Pulmonary Artery Catheter Features (available for adults and pediatrics):
Length – 60 to 110 cm
Caliber – 4 to 8 French
Balloon inflation volume – 0.5 to 1.5 ml
Balloon diameter – 8 to 13 cm
Material – Polyvinyl Chloride
Catheter markings – black bands mark catheter in 10cm increments
Accessories – thermistor wire for measuring cardiac output, fiberoptics for measuring
O2 and mixed venous saturation
Components of a Pulmonary Artery Catheter (PAC or Swan Ganz):
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The pulmonary artery catheter normally has four ports which include:
The proximal port which is used for central venous pressure monitoring
The distal port which measures pulmonary artery and pulmonary artery wedge
pressure
The balloon port with 1.5ml special syringe for measurement of pulmonary artery
wedge pressure
The thermistor connector to assist with cardiac output measurement
Insertion Sites:
A pulmonary artery catheter (PAC) or Swan Ganz Catheter (SGC) is inserted into a major
vein (subclavian, jugular or femoral) using an introducer sheath (this is the same sheath used
to place a triple lumen catheter). Preference considerations for cannulation of the great veins
are as follows:
o Right Internal Jugular Vein (RIJ) – This is the shortest and straightest path to the heart
o Left Subclavian vs. Right Subclavian- Compared to the right subclavian or left
internal jugular vein, the left subclavian is an easier approach to the supra-vena cava
as it is not necessary for the catheter to pass or course through any acute angles.
Femoral veins - These access points are distant sites, from which passing a SGC into the
heart can be difficult, especially if the right-sided cardiac chambers are enlarged. Often,
fluoroscopic assistance is necessary, but these sites are compressible and may be preferable if
the risk of hemorrhage is high.
Preliminary Steps for Insertion and Floatation of PAC:
The bedside monitor and Continuous Cardiac Monitor should be turned on 10 to 15 minutes
before insertion
Gather the following equipment:
o Swan Ganz Catheter
o Introducer Kit
o Supplies to create a sterile field
o Gowns, gloves and masks
o Betadine (or other skin cleansing agent such as Chlorhexadrine)
o 4x4’s
o Pressure bag
o 500ml NS or Heparin Premix
o 2 Disposable pressure monitoring kits with transducer (one for proximal and one for
distal port)
o Continuous cardiac output/Svo2 monitor with cables
o IV solution for Cordis and medication line
Nursing Responsibilities Pre-Insertion:
o Explain procedure to patient
o Assemble all equipment
o Set up all monitoring lines aseptically
o Prime all IV tubing and transducer flush lines (Pressure Bag @ 300 mmHg)
o Connect PAC cable to monitor and attach to transducer
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o Connect CVP cable to monitor and attach to transducer
o Check PAC packaging for to ensure sterility/expiration date
o Zero transducers (mid axillary)
o Place monitor in wedge/insertion mode (scale should be 30-60)
o Turn on and set continuous cardiac monitor/Svo2 monitor for insertion (make
sure previous patient data is erased)
Nursing Responsibilities During Insertion:
o Position patient for insertion (flat for femoral, Trendenlenburg for subclavian or
jugular)
o Assist with creating a sterile field
o With the assistance of the physician, open PAC and connect transducers to the distal
and proximal lumens
o Connect the IV line to the medication port
o Connect the cardiac output cable and Svo2 cables
o Remove the 1.5 ml syringe and connect it to the syringe port
o Zero catheter while still in package
o Inflate air into the balloon to assure balloon integrity prior to insertion
o After physician places sterile sheath over catheter, waveform presents should be
assessed on the monitor (usually a small shake of the catheter itself will confirm)
o Once physician inserts and advances the catheter to right atrium, he will request that
the RN inflate the balloon
o If for any reason during floatation of a PAC the physician wishes to withdraw the
catheter, the balloon must be deflated
Nursing Responsibilities Post-Insertion:
o Make sure that PAC cap is in the lock position so catheter will not migrate
o Secure catheter to patient with tape
o Apply occlusive dressing
o Set high and low alarms on monitor as appropriate for patient
o Double check to assure that physician has disposed of all sharps
o Double check to see that Chest X-ray was ordered
Nursing Documentation Post-Insertion:
o Vital signs, pulmonary artery pressures, Svo2 saturation (immediately after insertion
and per standard)
o PAC insertion site and how far it was advanced (in cm)
o Amount of air required to inflate balloon to obtain PAWP pressure
o Verification of X-ray placement of PAC
o Print and place waveform strips on nursing flow sheet
o Patient tolerance of procedure
o Medications given during procedure
Nursing Care of the Patient with a Pulmonary Artery Catheter:
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Nursing care of the patient with a PAC can be very complex. Nursing management of
these patients does not begin and end with writing numbers on a chart. The nurse must be
able to interpret the data obtained as well as being able to alert medical staff of potential or
actual complications. The following chart lists normal hemodynamic values.
Normal Hemodynamic Values
Normal
Hemodynamic Parameters Abbreviations
Values
70-90 mm
Mean Arterial Pressure MAP
Hg
Central Venous Pressure CVP 2-8 mm Hg
Pulmonary Artery Systolic 20-30 mm
PAS
Pressure Hg
Pulmonary Artery Diastolic
PAD 6-12 mm Hg
Pressure
10-15 mm
Pulmonary Artery Mean Pressure MPAP
Hg
Pulmonary Artery Wedge Pressure PAWP, Wedge 8-12 mm Hg
Cardiac Output CO 4-8 L/min
Cardiac Index CI 2.5-4 L/min
Stroke Volume SV 60-130 ml
Stroke Volume Index SVI 40-50 ml/m2
800-1200
Systemic Vascular Resistance SVR
dynes
Systemic Vascular Resistance 2000-2400
SVRI
Index dynes
150-300
Pulmonary Vascular Resistance PVR
dynes
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Abnormal Hemodynamic Values:
Increased Systolic Pulmonary Artery Pressure can be caused by any of the following:
o Any Factor that increases PVR
o Pulmonary Embolism
o Hypoxemia
o COPD
o ARDS
o Sepsis
o Shock
o Primary Pulmonary Hypertension
o Restrictive Cardiomyopathy
o Significant left-to-right shunting
Increased Diastolic Pulmonary Artery Pressure can be caused by any of the following:
o Any Factor that increases pulmonary artery systolic pressure
o Intravascular volume overload
o Left Heart Dysfunction
o Mitral Stenosis/Regurgitation
o Aortic Stenosis/Regurgitation
o Decreased LV Compliance
o Cardiac Tamponade/Effusion
Pulmonary Artery Systolic and Diastolic Pressure Decreased:
o Hypovolemia
o Severe Tricuspid or Pulmonic Stenosis
Increased Pulmonary Artery Wedge Pressure (PAWP):
o Left Heart Dysfunction
o Mitral Stenosis/Regurgitation
o Aortic Stenosis/Regurgitation
o Decreased Left Ventricular Compliance
o Intravascular Volume Overload
o Tamponade/Effusion
o Obstructive Left Atrial Myxoma
o Restrictive Cardiomyopathy
Decreased Pulmonary Artery Wedge Pressure (PAWP):
o Hypovolemia
o Pulmonary Embolism
BIBLIOGRAPHY
1. Suzanne.C.smeltzes, Brenda G Bare; “TEXT BOOK OF MEDICAL – SURGICAL
NURSING”, 10 th Edition, Lippincotl Williams & wilkins.
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2. Joyce.M.Black, Jane Hokanson Hawks, “MEDICAL SURGICAL NURSING”; 7 th Edition,
Elsevier publications.
3. Lewis, Heitkemper, Dirksen, O’ Brien, Buch ex; “MEDICAL – SURGICAL NURSING”; 7 th
Edition, Mosby publications.
4. Phips Wilma J, Shafer’s, “MEDICAL – SURGICAL NURSING”; 7 th Edition B.I.
Publications”.
5. http://dynamicnursingeducation.com/class_more.php?class_id=49&more=9
