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CRITICAL CARE / HEMODYNAMIC MONITORING
Critical Care Unit (ICU)
• No more than 2 patients per nurse (in CA)
• Physiologically unstable, greater risk for
complications
• Requires ongoing assessments and early
recognition and management of
complications
• Requires depth of knowledge of patho,
pharma, and advanced assessment,
monitoring, and decision-making skills
Transitional Care (Progressive or Step-
down Unit)
• Usually no more than 3 patients per nurse (in
CA)
• Transition between ICU and Med-Surg
• Closely monitored, but less frequent than
ICU
• More physiologically stable
• More cost-effective environment
Common ICU Patient Problems
• Mobility issues — skin breakdown, DVT
• Infections, sepsis, and multiple organ
dysfunction syndrome — particularly due to
invasive medical devices
• Nutrition — often hypermetabolic (due to
burns, trauma, injury, infection, sepsis, etc.),
catabolic (acute kidney injury), or
malnourished, so require increased calorie
count to meet healing needs; dietician should
be consulted; enteral (preferred) or
parenteral options
• Anxiety — heightened due to increased
noise, ICU environment, isolated
environment (esp. from family); increased
agitation, restlessness, HR; families may be
anxious as well
• Pain — needs to be considered even if
patient cannot verbalize; sedation may mask
evidence of pain
Common ICU Patient Problems
• Impaired communication — due to illness,
artificial airway, etc.; may cause distress;
always explain your procedures; use touch;
encourage visitation; consider pain
management and anti-anxiety meds prior to
procedures
• Sensory-perceptual problems — use clocks,
calendars, decrease noise
• Sleep deprivation — turn off lights and TV
at night so that they can sleep; sensory
overload from alarms, so make sure to
monitor alarm settings; may manifest as
delirium (ICU psychosis) especially in
advanced age patients; light massage (NOT
lower extremities), limit visiting hours to
allow for rest periods, cluster activities, dim
lights, open shades during day to use natural
light
• Family support — provide with as much
info as necessary, be truthful, don’t be
unrealistic

CRITICAL CARE / HEMODYNAMIC MONITORING
HEMODYNAMIC MONITORING
• Measurement of pressure, flow, and
oxygenation within the CV system
• Monitor trends in hemodynamic values;
single hemodynamic readings are rarely
helpful
• Reasons for hemodynamic monitoring: fluid
management, shock, heart failure, ARDS
(adult respiratory distress syndrome)
Invasive monitoring devices & equipment
• Arterial line
• Obtain arterial blood samples (ABG,
cultures)
• Obtain arterial BP
• Do not infuse medications (only normal
saline push)
• Venous line
• PICC line (Peripherally inserted central
catheter)
• Central venous catheter
• Obtain venous blood samples
• Monitor SvO2
• Infuse fluids and medications
• Obtain CVP (usually from proximal port
due to medication infusions in other ports)
• Pulmonary artery (PA) catheter
• ex: Swan Ganz catheter
• Obtain venous blood samples
• Obtain core temperature
• Monitor SvO2
• Obtain various cardiac BPs (but not
systemic arterial BP)
• Infuse fluids and medications (thru white
port, and only as a last resort, as infusion
interferes with pressure and temperature
readings)
Components for both arterial and PA lines
• Pressure tubing
• Rigid portion connects to the patient
• Flexible portion connects to the pressure
bag
• Tips must remain sterile at all times
• Flush system before connecting to patient!
• Spike flexible tubing to pressure bag
• Open one stop cock at a time to flush
and prime ports
• Air bubbles in tubing are a major source
of waveform errors
• Open-ended caps allow for flushing
without contaminating sterile lines
• Once system has been flushed, remove
open-ended caps and replace with close-
ended caps
• Color-coded stickers used to identify lines
• Red = arterial line
• Blue = venous line (or CVP on PA line)
• Yellow = distal port on PA line
• Do not add extra tubing extensions, as can
cause underdamping
• Tubing should be wide bore and limited
to 48 inches in length
• Fluid bag
• Usually normal saline, but sometimes
heparinized for pediatrics; heparin usually
avoided due to danger of HIT
• Usually 500 mL (1 L too big for pressure
bag
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Components for both arterial and PA lines
• Pressure bag
• Sleeve that fits over fluid bag
• Inflated to 300 mmHg
• Infuses approx. 3 mL/hr (add to I/Os)
• One pressure bag can be used for up to 3
lines/catheters, but each line/catheter will
have its own transducer
• Ex: one pressure bag may cover 1
arterial line, 1 proximal line for Swan
Ganz, and 1 distal line for Swan Ganz
• Transducer
• Connects to monitor
• Translates mechanical signal to an
electrical signal
• Monitor
• Amplifies electrical signal to display
waveforms
• Introducer (PA only?)
• Placed in the patient first, and the catheter
is then threaded through the introducer
• Catheter
• Line inserted into patient
• Plastic sheath around external portion
helps maintain sterility while line is inside
patient
• Multiple lumens
• Color coding depends on device (see
central venous lines and Swan Ganz for
examples)

CRITICAL CARE / HEMODYNAMIC MONITORING
Invasive Pressure Monitoring Terms
• Leveling transducer (aka “zeroing”)
• Process the same regardless of whether an
arterial line or PA catheter
• Balances transducer with atmospheric
pressure
• Reference point for zeroing is the
phlebostatic axis (which lies at 4th
intercostal space [ICS] mid-axillary line)
• Phlebostatic axis is used as an external
landmark to measure the level of the left
atrium in a supine patient
• Mark the phlebostatic axis with a
permanent marker!
• Phlebostatic axis stays accurate for
readings from supine to 30 degrees (for
most patients) and perhaps even up to
45-60 degrees (depending on patient’s
co-morbidities) (prone is also
acceptable, but lateral is not)
• If transducer is placed higher than
phlebostatic axis, then readings will be
falsely low
• If transducer is placed lower than
phlebostatic axis, then readings will be
falsely high
• Zeroing performed during initial setup
immediately after arterial line has been
inserted and the rest of the system is set up
• Turn off tubing to patient with the stop
cock at the transducer (otherwise blood
will come out of the line, risking
exsanguination)
• Open to air at transducer stop cock
• Monitor will show a “?”; hit “Zero”
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Invasive Pressure Monitoring Terms Troubleshooting
• Square-wave test — tests the accuracy of • If waveforms suddenly change:
the numbers; performed during a “fast • Check line connections (should be tight)
flush” (by squeezing plastic flanges at • Check lines for leaks or kinks
transducer or by pulling on the pigtail) — • Check transducer for cracks
creates a square wave; upright, straight • Check that all ports are connected
leveling off (once achieved, then stop fast • Check pressure in bag
flushing), then downward • Check fluid in bag
• Test should be performed every 8-12 • Check position of patient’s arm (wrist
hours, whenever the system is opened to board frequently used to immobilize wrist
air, or whenever accuracy of when radial artery used)
measurements is in question • Then contact physician
• Fast flush takes approx. 3 seconds and
uses approx. 10 mL of normal saline
• Underdamped (excessive ringing) — can
create inaccuracies in values; fast flush
followed by too many steep waveforms
• Falsely high BP
• Adding extra tubing to line
• Kink in line
• Overdamped (no ringing) — can create
inaccuracies in values; fast flush followed
by NO steep waveforms
• Falsely low BP
• No dicrotic notch
• (Less likely with Swan Ganz)
• Air in tubing
• Cracked transducer
• Insufficient pressure in bag
• Lack of fluid in bag
• Optimally damped (1-2 rings) — when
square wave test done appropriately; fast
flush followed by 1.5 of a steep waveform
before returning to normal
• Normal arterial pressure waveform with
dicrotic notch

CRITICAL CARE / HEMODYNAMIC MONITORING
Hemodynamic Monitoring Terms
• Cardiac output = CO = SV x HR
• Normal = 4-8 L/minute (depending on size
of patient)
• Cardiac Index = CI = CO/BSA
• Cardiac output adjusted for patient’s
body surface area (BSA) and therefore
tends to be more accurate
• Normal = 2.5-4.3 L/minute/m2
• Systemic vascular resistance = SVR =
([MAP-CVP] x 80)/CI
• Resistance that left ventricle must
overcome to pump blood into aorta (i.e.,
systemic afterload)
• Normal = 800-1,200 dynes/second/cm-5
• MAP = mean arterial pressure = (SBP +
[DBP x 2])/3 = SVR x CO
• Basis for autoregulation by organ
systems such as kidneys, brain, and
heart
• Sensed by baroreceptors in aortic arch
and carotid sinuses
• MAP largely unaffected by wave
reflection (retrograde flow caused by
vessel narrowing bifurcation), unlike
SBP and DBP
• Wave reflection increases SBP the
further the blood travels from the heart
(dorsalis pedis BP may be 20-25 mmHg
higher than central aortic pressure)
• Wave reflection diminished in
hypovolemia, hypotension, vasodilation,
and Valsalva maneuver
• Pulse pressure = SBP - DBP (normal = 40
mmHg)
• Arterial pressure is another measure of
systemic afterload
Hemodynamic Monitoring Terms
• Pulmonary vascular resistance = PVR =
([PAMP-PAWP] x 80)/CI
• Resistance that right ventricle must
overcome to pump blood into pulmonary
artery (i.e., pulmonary afterload)
• Normal < 250 dynes/second/cm-5
• PAMP = pulmonary arterial mean pressure
= (PASP + [PADP x 2])/3
• Central venous pressure = CVP = estimated
right-sided preload
• Synonymous with RAP (right atrial
pressure)
• Normal = 2-8 mmHg
• High = RV failure or volume overload
• Low = hypovolemia
• Can be obtained by ANY line that accesses
S or I vena cava (i.e., not just a PA
catheter)
• Pulmonary artery wedge pressure = PAWP =
estimated left-sided preload
• Synonymous with LAP (left atrial
pressure)
• Can also be found using PADP
• Normal = 8-12 mmHg
• Increases in heart failure and fluid volume
overload
• Very useful in determining how to correct
fluid imbalances
• Pulmonary artery pressure = PAP (another
measure for pulmonary afterload)
• PASP = pulmonary artery systolic pressure
• PADP = pulmonary artery diastolic
pressure = right-sided preload
• PAMP = pulmonary artery mean pressure
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Hemodynamic Monitoring Terms
• RVEDP = right ventricular end-diastolic
preload = actual right-sided preload
• LVEDP = left ventricular end-diastolic
preload = actual left-sided preload
• Frank-Starling’s Law = Increased
myocardial fiber stretch during filling —>
increased force of contraction
• i.e., increased preload —> increased SV
and increased CO —> increased O2 needs
of myocardium
• ScvO2 = central venous oxygen saturation
• Measured from a CVP catheter
• SvO2 = mixed venous oxygen saturation
• Measured from a PA catheter
• Some specialized PA catheters can
measure SvO2 continuously
• Compare to SpO2 to determine tissue
oxygenation; low means anaerobic
metabolism, leading to acidosis
• ScvO2/SvO2 = balance between
oxygenation of arterial blood, tissue
perfusion, and tissue O2 consumption
• High = 80-95% = excessive oxygenation,
sepsis (poor O2 extraction), hypothermia,
anesthesia
• Normal = 60-80%
• Low < 60% = decreased arterial
oxygenation, low CO, low Hgb, or
increased O2 consumption (increased
metabolic rate, pain, fever, movement)
• Peripheral BP: Increases more distal from
the heart; i.e., radial BP is (slightly) greater
than brachial, and dorsalis pedis is
(definitely) greater than brachial

CRITICAL CARE / HEMODYNAMIC MONITORING
Arterial Lines
• Also called a-line, art line, and arterial line
• Used to measure SBP, DBP, and mean
arterial blood pressure
• Also used to obtain arterial blood samples
• Must waste 3 mL when drawing blood
(same as for venous), which can be an
issue for anemic patients
• VAMP conserves blood by allowing
“wasted” blood to be flushed back into
patient
• Inserted percutaneously in a peripheral
artery (radial preferred, but also brachial,
pedis, and femoral), and then sutured or
secured in place
• Wave readings should show systole, diastole,
and the dicrotic notch in between
• Dicrotic notch = space between systole
and diastole
• Represents closure of the aortic valve on
the left side of the heart
• Represents closure of the pulmonary
valve on the right side of the heart
• May not be visible in some patients due
to valvar or cardiovascular issues
• Slight delay between QRS in the ECG and
the corresponding systole wave form in
the arterial pressure tracing
• Unusual wave readings:
• Heart failure —> systolic upstroke
slower
• Volume depletion —> SVP varies
greatly with mechanical ventilation,
decreasing during inspiration
• Dysrhythmias may decrease BP to
significant levels
Arterial Lines
• Allen test should be performed first to
determine suitability of arm limb for
insertion of arterial line
1. Compress both radial and ulnar
arteries
2. Have patient open and close hand
several times until palm blanches
3. Release only radial artery — palm
should become pink in seconds
4. Repeat process, releasing ulnar artery
— palm should become pink in
seconds
5. If either test results in palm remaining
blanched, then there may be
insufficient circulation for catheter
insertion
Central Venous Lines
• Becoming more common than PA lines
• One line (catheter) with multiple openings
along line
• Brown port = distal
• Gray (or blue) port = medial
• White port = proximal
• Maintain patency by injecting minimally
potent heparin into the line (usually limited
to 1.5 mL
• Draw heparin back out of the line (usually
by drawing out 3 mL) before infusing
anything
• If multiple lumens, then heparinize any of
the lines that are not currently in use
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Arterial line complications
• Hemorrhage
• Infection — change tubing per protocol
• Loss of arterial blood flow to hand and
fingers
• Assessment — monitor capillary refill,
warmth, sensation
• Blood loss from loose connection —
monitor closely
• Thrombus formation, embolus — use of a
pressure bag with normal saline can reduce
risk, so never let the pressure bag run dry
• Prevention:
• Use Luer-Lok connections
• Always check arterial waveform
• Active alarms (which will sound if
pressure falls)
• Change pressure bag, tubing, and
transducer according to agency policy
(72-96 hours)
• Check system every 1-4 hours to make
sure that:
• Pressure bag is inflated to 300 mmHg
• Fluid bag contains fluid (do not use
heparinized saline, as may cause HIT =
heparin-induced thrombocytopenia)
• System delivering 3-6 mL/hr of fluid

CRITICAL CARE / HEMODYNAMIC MONITORING
PA Catheter Overview PA-specific Components
• Swan Ganz
• Used to measure cardiac and PA pressures
(including PAWP), pace heart, obtain venous
blood samples, measure core temp, and
monitor SvO2
• Flow-directed catheter, as inflation of
balloon directs catheter’s path of travel
• Inserted by physician using sterile technique
• Major vein is used: internal jugular,
subclavian, femoral (not preferred due to
dirty nature of femoral area)
• Route = insertion point —> superior vena
cava —> right atrium (inflate balloon at
physician’s direction) —> tricuspid valve —
> right ventricle —> pulmonary valve —>
pulmonary artery (deflate balloon)
• Anti arrhythmic medications should be
readily available to treat lethal
dysrhythmias
• Chest x-ray used to confirm placement
prior to PA catheter use (and repeated
daily)
• Radiology brings chest x-ray to patient’s
room, not the other way around
• Note and document measurement at exit
point (in centimeters) to maintain proper
position
• Secure at point of entry, use occlusive
dressing
• Multiple lines (lumens):
• Distal (yellow) port and line measures
PAP when balloon deflated and PAWP
when balloon inflated; blood draw to
measure missed venous blood gases
• Proximal (blue) port measures CVP and
CO; medication infusion; fluid boluses
• Red port for inflation of balloon, used to
determine “wedge pressure”
• Note that balloon is latex, so
contraindicated for patients with latex
allergies
• Additional (white) lumens for fluid or
medication infusion, blood sampling, etc.
• Thermistor port located proximal to
balloon in distal line
• Measures temperature continuously,
used when measuring cardiac output
Measuring Cardiac Output
• CO measured by injecting 10 mL of room
temp D5W into blue port (make sure CO and
thermistor ports connected)
• Measure waveform produced
• Avg. of 3 waveforms, but discard
waveforms that are outliers
• Consider if patient is hypervolemic before
using additional 10 mL fluid injections
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PA Catheter Indications
• Conditions of shock (septic, hypovolemic,
cardiogenic)
• Evaluation of fluid volume status
• Evaluation of CO in complex medical
situations
• Prophylaxis for high-risk surgeries
• Differential diagnosis of pulmonary HTN
• Assessment of treatment response for
pulmonary HTN
• MI with complications
• Heart failure requiring inotropic,
vasopressor, and vasodilator therapies
• Transplantation work up
PA Catheter Contraindications
• Coagulopathy
• Endocardial pacemaker
• Endocarditis
• Mechanical tricuspid or pulmonic valve
• Hypokalemia, hypomagnesemia,
hypoxemia, and acidosis can all increase risk
of cardiac dysrhythmia during catheter
insertion
PA Catheter Complications
• Infection at the insertion site
• Ventricular irritability, which can lead to
potentially fatal dysrhythmias
• Prolonged wedging occluding pulmonary
blood flow, causing pulmonary vessel
necrosis and reduced blood oxygenation
• PA balloon rupture, causing air bolus or air
embolus
• Blood sepsis

CRITICAL CARE / HEMODYNAMIC MONITORING
Pressures and wave forms measured by the
Swan Ganz
• Central venous pressure (CVP)
• Measures right atrial pressure, RAP
• Indicates fluid volume status
• Normal = 2-8 mmHg
• Considered preload for the right side of
the heart
• Also an estimate of right ventricular end
diastolic pressure, or RVEDP
• Wave form is small hills (letters are
AXCVY instead of PQRST)
• Right ventricular pressure
• Normal = 0 during diastole, 25 mmHg at
peak, with no dicrotic notch
• Balloon and distal end needs to pass
through RV quickly to prevent stimulating
dysrhythmia (ventricular tachycardia)
• Pulmonary artery pressure
• Wave form contains systolic, diastolic, and
dicrotic notch (representing pulmonic
valve closure in this case, not aortic)
• Normal PAS = 20-30 mmHg
• Normal PAD = 10-15 mmHg
• Normal PAM = 10-20 mmHg
Interpreting Waveforms from Swan Ganz
Catheter
• PA and CVP waveforms may differ
depending if the patient is on a mechanical
ventilator or is using spontaneous ventilation
• Waveforms should be read right after the
end of expiration and immediately before
inspiration begins
Pressures and wave forms measured by the
Swan Ganz
• Pulmonary artery wedge pressure (PAWP)
• a.k.a. “wedge” or PAOP (pulmonary artery
occlusion pressure)
• Created when the distal balloon wedges in
branch of pulmonary artery and obstructs
blood flow
• Wave form changes from “pulmonary
artery wave form” to “pulmonary artery
wedge wave form”
• Wave form is small hills similar to CVP,
just slightly higher pressure
• Normal PAWP = 8-12 mmHg
• Usually within 5 mmHg of PAD
• PAWP is the middle / mean of waveform
• Estimates left atrial volume (or pressure)
and left ventricular end diastolic pressure
(LV preload)
Interpreting Waveforms from Swan Ganz
Catheter
• Spontaneous ventilation produces downward • Mechanical ventilation produces upward or
or negative deflection in waveforms upon
inspiration (because caused by negative
pressure)
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Pressures and wave forms measured by the
Swan Ganz
• Pulmonary artery wedge pressure (PAWP)
• Obtained by injecting air into red port,
using a 3 mL syringe that comes with the
system
• Do not use any other syringe, as this
syringe comes with a safety feature that
allows only 1.5 mL to be injected into
balloon
• An excess of 1.5 mL may cause balloon
to pop and create an air embolus in the
patient’s lung
• Balloon not be left inflated for more
than 10 seconds, as can cause necrosis
of pulmonary vessel and occlusion of
blood flow into pulmonary system
• Once reading obtained, passively allow
air to return to syringe that was used to
inject the air
• If balloon bursts, turn patient onto their
left side to prevent air embolus from
entering heart
Interpreting Waveforms from Swan Ganz
Catheter
positive deflection in waveforms upon
inspiration (because caused by positive
pressure)