Advanced Hemodynamics - Orlando Health

Advanced Hemodynamic Monitoring
Hemodynamic Applications
These cases will provide the opportunity to see how advanced hemodynamic monitoring may
assist in determining appropriate interventions for different situations.
Case 1
You are caring for a 29-year old male motor cycle crash patient with a BP of 74/30, heart rate
of 52. What should you do about his hypotension? You can’t be sure without knowing the
reason for it. In addition, the CVP reading is 1 mm Hg. This additional information indicates
that the patient has a diminished blood volume returning to the right heart, but still doesn’t tell
you what interventions should receive the highest priority. Further assessment reveals that the
patient sustained a C 7 fracture with severe extremity weakness noted. You now correctly
determine that the patient is in neurogenic shock, causing a loss of vasomotor tone, and that he
is hypotensive not because he has lost blood volume, but because neurogenic shock results in
massive vasodilation (decreased SVR), decreased blood return to the right atrium and
bradycardia. Note the patient’s pulse pressure; it is wide, indicating arterial vasodilation.
Oxygen delivery (DO2) and oxygen consumption (VO2) most likely will not be changed.
Stroke Volume Variation (SVV) in this case would be high, and can be used to guide your fluid
resuscitation. Considering the evident cause of his hypotension and bradycardia, advanced
hemodynamic monitoring is not immediately indicated. Taking all the data into consideration
allows you to intervene appropriately with a vasoconstrictor and IV fluids to fill the vascular
space.
Case 2
You are caring for a 79-year old male patient with a BP of 84/40, temperature 104° F (40º C),
heart rate 120 bpm, and SaO2 90% on 4 liters NC. He is admitted from a nursing home with
pneumonia. What is causing his hypotension? Note that the pulse pressure is wide, indicating
vasodilation and decreased left ventricular afterload. Additional information includes a CVP
reading of 1 mm Hg. What does this tell us? Only that we have a decreased right ventricular
end diastolic pressure/volume. Severe dehydration, blood loss, spinal shock and vasogenic
shock can reveal the same findings. However, we suspect that this patient is in early septic
shock considering his pneumonia and fever which also causes vasodilation (decreased SVR)
and a decreased preload. Further assessment reveals lung sounds include bilateral rhonchi, and
laboratory results show leucocytosis. This rules the patient in for severe sepsis. Upon
examining peripheral pulses, we note them to be bounding and skin turgor is poor. The cardiac
output will be high as the patient is in a hyperdynamic state. If oximetric measurements are
available, expect the SVO2/ScVO2 to be either high because oxygenated blood is being
shunted away and not being utilized by the tissues, or it could be low because of higher oxygen
consumption (VO2). Oxygen delivery (DO2) is probably normal. If the patient would be on a
ventilator and pulse contour analysis would be applied it would show a high Stroke Volume
Variation (SVV) because of the decreased preload volume. This patient will need to be fluid
resuscitated to improve preload and antibiotics need to be initiated. Ventilatory support and
possible inotropic support can be indicated if the condition deteriorates.
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