Advanced Hemodynamics - Orlando Health

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Advanced Hemodynamic Monitoring Case 3 You are admitting a 63-year old female with a BP of 84/70 and HR of 110 bpm. History reveals that she was admitted with a diagnosis of chest pain. Your assessment reveals bilateral crackles in her lungs, and heart sounds reveal S3-S4. So what do we do? Should we give diuretics or fluids? A pulmonary artery catheter is inserted and shows a PAOP of 26 mmHg, CVP 24 mm Hg, Cardiac Index is 2.1 L/min and the SVRI is 2800 dyne.sec.cm-5. This indicates that both left and right atrial filling pressures are elevated, she is vasoconstricted and has a decreased cardiac output. Stroke volume will be low, Oxygen delivery (DO2) and SVO2 will be low due to a decreased cardiac output. Oxygen consumption (VO2) can be high because of increased heart rate and cardiac muscle workload. To increase the cardiac output, a vasodilator, a diuretic and an inotrope can be used as guided by your hemodynamic profiles. Case 4 You are caring for a 31 year old male patient involved in a motor vehicle crash. His injuries include bilateral pulmonary contusions and a blunt abdominal trauma. He is intubated and being mechanically ventilated. He required multiple blood transfusions and received also an additional 6 liters of normal saline for a slow responding blood pressure of 91/55. The physician inserted a volumetric PA-catheter to guide the resuscitation. After several hours you noticed that the CVP increased to 28 mmHg and the PAOP to 32 mmHg. Does he need a diuretic because he could be in heart failure? Further hemodynamic assessment reveals a CI of 2.3 L/min, SVRI 2900 dyne.sec.cm-5 and an EDVI of 80 ml/m² with a REF of 31%. His abdomen is firm and distended, and his inspiratory pressures on the ventilator have been increasing steadily. You also noticed that his urinary output decreased to 15 ml/hr and the laboratory results show a lactic acid of 6.2. Because of possible abdominal compartment syndrome, the physician orders intra-abdominal pressure monitoring. The first reading reveals an intra-abdominal pressure of 31 mmHg. The patient has an intra-abdominal compartment syndrome and requires abdominal decompression. The increased intra-abdominal pressure increases the intra-thoracic pressure, which increases the CVP and PAOP. However, these increased cardiac filling pressures do not accurately reflect the preload as evidenced by the low EDVI and REF. Therefore a diuretic would worsen his condition even more by decreasing the preload (EDVI). Copyright 2010 Orlando Health, Education & Development 39
Post Test Advanced Hemodynamic Monitoring Directions: Complete this test using the bubble sheet provided. 1. Which of the following statements is true regarding the distal port of the pulmonary artery catheter A. It is connected to a pressure transducer and a flush device B. It is the port used for cardiac output injectate C. It allows continuous measurement of the pulmonary artery occlusive pressure D. It serves as an infusion port for vasoactive medications 2. During the insertion of the pulmonary artery catheter, how much air should be used to inflate the balloon? A. ½ ml B. 1 ml C. 1 ½ ml D. 2 ml 3. Which port must be connected to a transducer to allow waveform analysis during insertion of a pulmonary artery catheter? A. Pulmonary artery distal B. Proximal injectate port C. Proximal infusion port D. Cardiac Output port 4. Which of the following reflects normal pulmonary artery systolic and diastolic pressures? A. 120/80 mm Hg B. 20/5 mm Hg C. 25/15 mm Hg D. 45/25 mm Hg 5. Which one of the following statements about respiratory variation is true? A. Pulmonary artery pressure rises during inspiration in a spontaneously breathing patient. B. Pulmonary artery pressure falls during inspiration in mechanically ventilated patients C. Pulmonary artery pressure should be read at peak inspiration D. Pulmonary artery pressure should be measured at end expiration 6. The left ventricular preload is measured clinically with a pulmonary artery catheter by obtaining a A. Systemic vascular resistance B. Contractility pressure C. Pulmonary artery systolic pressure D. Pulmonary artery occlusive pressure (PAOP/PAWP) 7. In determining the amount of air used to wedge a pulmonary artery catheter, the best guideline to use is? A. Inflate until the wedge waveform is greater than the systolic B. Always instill 1 ½ cc air C. Instill the same amount of air used with the previous wedge Copyright 2010 Orlando Health, Education & Development 40
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Advanced Hemodynamics - Orlando Health

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