HEMODYNAMICS

MARK JOSHUA S. CRUZ RTRP

Hemodynamics
describe forces that
influence the
circulation of blood.
THE GENERAL HEMODYNAMIC STATUS OF THE PATIENT CAN BE MONITORED
NONINVASIVELY AT THE BEDSIDE BY ASSESSING THE HEART RATE (VIA AN ECG
MONITOR, AUSCULTATION, OR PULSE), BLOOD PRESSURE, AND PERFUSION STATE
Hemodynamic =
Circulation & perfusion
IT IS SIMPLY MONITORING OF BLOOD PRESSURES
The Heart as Two Pumps: An Overview
of Hemodynamic Pressure
Relationships
The right heart receives blood from the venous system (venous return) and pumps blood to the
pulmonary system.
The left heart receives blood from the pulmonary system and pumps blood to the systemic
circulation.
In normal states, both hearts pump at the same time and move the same amount of blood.
Both atria are filling chambers for the ventricles. Their pressures are about equal, and they have
the same waveform. When the atrioventricular valves open (tricuspid and mitral), the pressures
in the atrium and ventricle are equal; therefore, atrial pressure usually reflects the ventricle’s
filling pressure (end-diastolic pressure).

Both ventricles pump blood into arterial systems and create two waveforms: ventricular and
arterial. Their waveforms have the same shape characteristics, but their pressures are
significantly different. The right heart pumps to a low-resistance circuit, the lungs, and thus
produces a lower pressure. The left heart pumps to a high-pressure circuit, the body, so it has to
produce a high pressure.
flow are reflected backward through the
cardiopulmonary circuit as pressure
changes.
Pulmonary hypertension causes pressure to increase in the right heart and eventually the
venous system.
↑ Lung pressure → ↑ PAP → ↑ CVP → ↑ Venous congestion

A failing left ventricle will cause blood to “dam up” in the left heart, then the lungs, and
eventually alters the entire circuit.
→ ↑ LAP → ↑ PAWP → ↑ PAP → ↑ CVP → ↑ Venous congestion
Dynamic Relationship Between The
Two Hearts
Example: increased PAWP with normal PAP and CVP indicates a left heart problem that has not altered the
lungs or right heart
Blood pressure
Systemic arterial blood pressure (BP) is the force exerted against the walls of the arteries
when blood is pumped through them.
Measured by sphygmomanometer
Systolic blood pressure = during contraction = 100 – 140 mmHg
◦ Forcing blood through aorta (to systemic circulation) and pulmonary arteries (to lungs)

Diastolic blood pressure = during relaxation = 60 – 90 mmHg

◦ Heart chambers refills with blood
 3 factors that controls BP
a) Heart – pumps the blood
Rate and Contractility directly related to BP
b) Blood – amount of fluid in the circulation
Excess fluid increases BP
Loss fluid decreases BP
c) Vessels – affects the BP
Constriction increases BP
Dilation decreases BP
Adult normal blood pressure is 120/80 mm Hg
Infants and children younger than 10 years: 60 to 100/20 to 70 mm Hg

Hypotension in an adult is a systolic BP of less than 90 mm Hg

Hypertension in an adult is a systolic BP of 140 mm Hg or greater, a diastolic blood pressure of 90
mm Hg or greater, or both
Invasive hemodynamic monitoring
requires the use of the central venous and pulmonary artery catheters.
The central venous catheter measures the central venous pressure (right ventricular preload),
The pulmonary artery catheter measures the pulmonary artery pressure (right ventricular
afterload) and the pulmonary capillary wedge pressure (left ventricular preload).
◦ preload: The end-diastolic stretch of the muscle fiber.
◦ afterload: The resistance of the blood vessels into which the ventricle is pumping blood.
Arterial Catheter (Arterial Line)
Peripheral arterial lines should be used in patients with hemodynamic instability.
Most common peripheral artery sites:
◦ Radial
◦ Brachial
◦ Femoral

A strain gauge pressure transducer (the most commonly used transducer) is connected to the
system to provide a display of the pressure waveform and a digital reading of the arterial
pressure in mm Hg
 Normal Arterial Waveform
It represents the closing
of the aortic valve. If the
dicrotic notch is not
visible, the pressure is
most likely inaccurate, in
that the values are
lower than the patient’s
actual pressure. The
dicrotic notch may
disappear when the
systolic pressure drops
below 50 to 60 mm Hg.
At this point it is difficult
to palpate or hear a cuff
pressure
Pressures measured on arterial
waveform
Systolic Pressure
Diastolic Pressure
Pulse pressure: the difference between the systolic and diastolic pressures (normally about 40
mm Hg).
Mean arterial pressure (MAP): average pressure during the cardiac cycle (normally 80 to 100 mm
Hg).
◦ MAP = Systolic Pressure + (Diastolic Pressure X 2)
3
Complications of arterial catheters
Infection: risk may be reduced with removal of the catheter within 4 days.
Hemorrhage: make sure all connections in the system are tight.
Ischemia: note the color and temperature of the skin distal to the insertion site to determine
distal perfusion.
Thrombosis and embolization: a weak pulse distal to the puncture site may indicate thrombosis.
A continuous flush of saline and heparin through the system helps to avoid clot formation.
Troubleshooting for
arterial lines
 “Damped” pressure tracing
1) Occlusion of the catheter tip by a clot: correct by aspirating the clot and flushing with
heparinized saline.
2) Catheter tip resting against the wall of the vessel: correct by repositioning catheter while
observing waveform.
3) Clot in transducer or stopcock: correct by flushing system; if no improvement is seen in the
waveform tracing, disconnect the transducer and change the stopcock.
4) Air bubbles in the line: correct by disconnecting transducer and flushing out air bubbles
 Abnormally high or low pressure
readings
(1) Improper calibration: correct by recalibration of monitor and strain gauge.
(2) Improper transducer position:

Keep the transducer at the level of the patient’s heart.

below the level of the heart, the pressure reading will read higher than the actual pressure
above the level of the heart, the pressure reading will read lower than the actual pressure
 No pressure reading; causes include:
1) Improper scale selection: correct by selecting appropriate scale.
2) Transducer not open to catheter: correct by checking system and making sure the transducer
is open to the catheter
Flow-Directed Pulmonary
Artery Catheter
(Swan-Ganz Catheter)
Pulmonary Artery Catheter
a balloon-tipped catheter made of polyvinyl chloride that is used to measure central venous
pressure (CVP), pulmonary artery pressure (PAP), and pulmonary capillary wedge pressure
(PCWP), sometimes referred to as pulmonary artery wedge pressure (PAWP).
The catheter also allows for the aspiration of blood from the pulmonary artery for mixed
venous blood gas sampling and injection of fluids to determine QT.
The distal channel (lumen) is used for the measurement of PAP and for obtaining mixed
venous blood from the pulmonary artery
Pulmonary Artery Catheter
The proximal channel (lumen) is used for
the measurement of CVP or right atrial
pressure and for the injection of fluids to
determine QT.
The balloon inflation channel controls the
inflation and deflation of a small balloon,
located about 1 cm from the distal tip of
the catheter, and is used to measure
PCWP.
The fourth channel is an extra port for the
continuous infusion of fluid when
necessary
Insertion of the Pulmonary Artery
Catheter
The catheter is inserted through the brachial, femoral, subclavian, or internal or external jugular
vein
Once the vein is entered, the catheter is advanced into the right atrium, at which time the
balloon is inflated and the catheter flows through the right atrium, right ventricle, and into the
pulmonary artery, where it “wedges” into a distal branch.
Once the catheter wedges in a distal branch of the pulmonary artery, the PCWP may be
measured, and the balloon should then be deflated, allowing blood flow past the tip of the
catheter. Because blood flow is stopped distal to the wedge position when the balloon is
inflated, it should not be inflated any longer than 15 to 20 seconds or pulmonary infarction may
occur.
Central venous pressure monitoring
CVP
The central venous pressure (CVP) is the pressure
measured in a patient’s superior vena cava, just above the
right atrium
a measurement of right atrial pressure, reflects systemic
venous return and right ventricular preload.
The normal value is 3 to 8 cm H2O or 2 to 6 mm Hg
 CONDITIONS THAT INCREASE CVP CONDITIONS THAT DECREASE CVP

(1) Hypervolemia
(2) Pulmonary hypertension (1) Hypovolemia
(3) Right ventricular failure (2) Vasodilation (from decreased venous
(4) Pulmonary valve stenosis
tone)
(5) Tricuspid valve stenosis (3) Leaks or air bubbles in the pressure line
(6) Pulmonary embolism (4) Improper transducer placement (above
(7) Arterial vasodilation, the level of the right atrium)
(8) Left heart failure
(9) Improper transducer placement (below)
(10) Positive pressure ventilator breath
(11) Severe flail chest or pneumothorax:
Pulmonary artery pressure monitoring
PAP
Reflects the pressure inside the pulmonary arteries
an important measurement in the care of critically ill patients with sepsis, acute respiratory
distress syndrome (ARDS), pulmonary edema, and MI

Normal systolic PAP is 15 to 30 mm Hg.

Normal diastolic PAP is 5 to 15 mm Hg.
Normal mean PAP is 10 to 20 mm Hg.
Mixed venous blood sampling (PvO2)
Achieved by obtaining blood from the pulmonary artery
Normal PvO2 is 35 to 45 mm Hg. PvO2 reflects tissue oxygenation.
If this level drops after the initiation of or increase in PEEP, then a decrease in tissue
oxygenation has occurred, caused by a drop in QT because of PEEP. PEEP should be
decreased to maintain an adequate PvO2.
Conditions that increase Conditions that decrease
PAP PAP
(1) Pulmonary hypertension (resulting from (1) Decreased pulmonary vascular
hypercapnia, acidemia, or hypoxemia) resistance (pulmonary vasodilation); caused
by improved oxygenation, for example
(2) Mitral valve stenosis
(2) Decreased blood volume
(3) Left ventricular failure
Pulmonary capillary wedge pressure
(PCWP)
Measurement of pressure in the left side of the heart
The normal PCWP value is 5 to 10 mm Hg.
A PCWP value of more than 18 mm Hg usually indicates impending pulmonary edema.
Conditions that increase Conditions that decrease
PCWP PCWP
(1) Left ventricular failure (1) Hypovolemia
(2) Mitral valve stenosis (2) Pulmonary embolism (PCWP may be
normal or decreased)
(3) Aortic valve stenosis
(4) Systemic hypertension
Complications of Pulmonary Artery
Catheter Insertion
Damage to tricuspid valve
Damage to pulmonary valve
Pulmonary infarction
Pneumothorax
Cardiac arrhythmias
Air embolism
Ruptured pulmonary artery
Measurement of Cardiac Output
may be measured through the pulmonary artery catheter with the use of the
thermodilution technique
Fick equation:

QT =cardiac output (L/min)

VO2 = O2 consumption (mL/min)
[Ca-vO2] =arterial and mixed venous O2 content difference (milliliters of O2 per deciliter of
blood), also called vol%
Milliliters per deciliter (mL/dL) must be converted to mL/L to express the QT in L/min. This is
accomplished by multiplying the O2 content difference by 10.
Normal QT is 4 to 8 L/min.
50
Venous Oxygen Content
CvO2 is calculated with the following formula
CVO2 = (1.34 X Hb X SvO2) + (PvO2 X 0.003)
Arteriovenous O2 content difference
The normal C(a-v)O2, or arteriovenous O2 content difference, is 4 to 6 mL/dL.
An arteriovenous O2 content difference of less than 4 g/dL may be the result of increased QT
(less time for tissues to extract O2; therefore arterial and venous O2 are closer in value), septic
shock, or anemia.
An arteriovenous O2 content difference of more than 6 mL/dL may be the result of decreased
QT (more time for tissues to extract O2 because of slower blood flow; therefore a greater
difference is seen between arterial and venous O2 values).
Cardiac Index
correlates the patient’s QT for his or her specific BSA.
Normal CI is 2.5 to 4.0 L/min/m2
CI = Cardiac Output
Body Surface Area
Conditions that increase Conditions that decrease
a. Drugs that increase cardiac contractility a. Drugs that decrease cardiac contractility
(e.g., dopamine, epinephrine, digitalis)
b. Hypovolemia
b. Hypervolemia
c. CHF
c. Decreased vascular resistance
d. Increased vascular resistance
d. Septic shock (early stages)
e. MI
f. Septic shock (late stages)
g. Positive pressure ventilation
h. PEEP and CPAP
Stroke Volume
amount of blood ejected from the ventricle during ventricular contraction.
SV = Cardiac Output (mL/min)
Heart Rate (beats/min)
Normal SV is 60 to 120 mL/beat
Systemic Vascular Resistance
SVR
measurement of the resistance that the left ventricle must overcome to eject its volume of
blood (afterload)

Normal SVR is 11.25 to 17.5 mm Hg/L/min, or 900 to 1400 dyne X seconds X cm

Conditions that increase Conditions that decrease
a. Vasodilators (nitroprusside sodium,
a. Vasoconstrictors (dopamine, epinephrine) morphine, nitroglycerin)
b. Hypovolemia b. Hypercapnia
c. Hypocapnia c. Septic shock (early stages)

Hypercarbia acts as a direct vasodilator in the systemic

circulation and as a direct vasoconstrictor in the
pulmonary circulation.
Pulmonary Vascular Resistance
PVR
a reflection of the afterload of the right ventricle.

Normal PVR is 1.38 to 3.13 mm Hg/L/min, or 110 to 250 dyne X seconds X cm.
Conditions that increase Conditions that decrease

a. Vasoconstrictors (dopamine, epinephrine) a. Improved oxygenation (pulmonary

vasodilator)
b. Hypercapnia
b. Alkalemia (hypocapnia)
c. Hypoxemia
c. Vasodilating agents (nitric oxide,
d. Acidemia sildenafil, prostacyclin, nitroprusside)
e. Pulmonary embolism
f. Pneumothorax
g. Positive pressure ventilation
h. PEEP and CPAP
Hypercarbia acts as a direct vasodilator in the systemic
circulation and as a direct vasoconstrictor in the
pulmonary circulation.
Intrapulmonary Shunting
The portion of the QT that perfuses through the lungs without coming in contact with ventilated
alveoli.
Normally, intrapulmonary shunting is about 2% to 5% of the QT. This results from blood flow
through the bronchial, pleural, and thebesian veins.
Conditions that increase physiologic shunting
◦ Pneumonia
◦ Pneumothorax
◦ Pulmonary edema
◦ Atelectasis
Clinical shunt formula:

This formula requires a 100% Hb saturation of O2 in arterial blood.

Modified shunt equation:

Calculate a patient’s percentage of shunt given the following data
pH 7.37
PaCO2 45 mm Hg
PaO2 60 mm Hg
FiO2 0.40
PB 747 mm Hg
 Calculate a patient’s percentage of
QS/QT = (PAO2 – PaO2) (0.003)
shunt given the following data
4.5 + (PAO2 – PaO2) (0.003)
pH 7.37
= ___(572.95 – 75) (0.003)
PaCO2 55 mm Hg 4.5 + (572.95 – 75) (0.003)
PaO2 75 mm Hg = ___1.49____
FiO2 90% 4.5 + 1.49
= 1.49
PAO2 = (PB-47)(FiO2) – (PaCO2 X 1.25) 5.99
= (760 – 47) (.9) – (55 X 1.25) = 0.25 x 100
= (713)(.9) – (68.75) = 25%
= 641.7 – 68.75
= 572.95 mmHg
Interpreting shunt values
Less than 10% Normal
10% to 20% Abnormal intrapulmonary status, no
significance clinically
20% to 30% Significant intrapulmonary disease%, may be
life-threatening, and requires cardiopulmonary
support.
More than 30% Serious, life-threatening condition that
requires aggressive cardiopulmonary support
Hemodynamic Monitoring Information
by Sampling Location
Hemodynamic Changes in Common
Clinical Conditions
While evaluating a patient’s cardiopulmonary status, the respiratory therapist determines
that the patient has a 6-s capillary refill time. This reflects which of the following conditions?
A. Increased QT
B. Decreased peripheral perfusion
C. Hypertension
D. Sufficient perfusion to the extremities

Capillary refi ll is determined by compressing the nailbed of the patient and, after
releasing it, observing the time required for the nail to return to its original color.
Normal refill time is less than 3 s. The result in the problem indicates decreased
perfusion to the extremities, which could be caused by decreased QT. Both
extremities should be checked because reduced perfusion to one extremity could be
the result of vasospasm or a clot.
A patient in the cardiac ICU is intubated and is receiving mechanical ventilation with 40% O2. The
following data have been collected:

pH 7.41 HCO3 = 23 mEq/L

PaCO2 37 torr C(a-v)O2 = 8.1 vol%
PaO2 81 torr PCWP = 2 mm Hg

On the basis of these data, the respiratory therapist should recommend which of the following?
A. Administer a diuretic.
B. Institute PEEP at 5 cm H2O
C. Administer fluids.
D. Increase the FiO2.
The C(a − v)O 2 is the difference between the O 2 content in arterial and venous blood. The
normal value is 4 to 6 vol%. An elevated C(a − v)O 2 level indicates a greater difference
between the two, which suggests less O 2 in the venous blood. This results from a
decreased QT. Even though blood is flowing through the circulatory system at a slower rate
(decreased QT), the tissues will extract the O 2 at the same rate. This causes less O 2
content in the venous blood, which results in an increased C(a − v)O 2 level. Another value
in this question that is not normal is the PCWP, sometimes referred to as PAWP. The normal
value is 4 to 12 mm Hg. A decreased value, as in this problem, means a lower pressure in the
left side of the heart as a result of the decreased venous return caused by the decreased QT
or hypovolemia. This is best treated by increasing fluids.
The following data have been collected from a patient in the cardiac ICU:
pH 7.42
PaCO2 42 torr
PaO2 70 torr
HCO3- 25 mEq/L
SaO2 93%
PvO2 34 torr
SvO2 72%
P(A-a)O2 100 torr
Hb 14 g/dL

Based on these data, which of the following represents this patient’s intrapulmonary shunt?
A. 4%
B. 7%
C. 9%
D. 12%
After a cardiac arrest, a 48-year old female begins receiving mechanical ventilation. A pulmonary artery
catheter is in place. The following data are obtained:
BP 94/52 mm Hg
Pulse 116/min
A, The patient is hypotensive, which indicates a decreased SVR.
PCWP 6 mm Hg PCWP, a measure of left atrial pressure, is normal; therefore, left
PAP 40/22 mm Hg atrial pressure cannot be increased. Because QT is decreased, SV
would also be decreased. The PAP is elevated, which indicates an
QT 3.5 L/min increased resistance to blood fl ow in the pulmonary vasculature

Based on these data, which of the following has increased?

A. Pulmonary vascular resistance
B. Left atrial pressure
C. Stroke volume
D. Systemic vascular resistance
The respiratory therapist is assisting the physician in the insertion of a Swan-Ganz catheter. The patient
is hemodynamically stable at the time. The therapist would know the catheter tip has entered the
pulmonary artery when which of the followings pressures is observed?

A. 12/4 mm Hg
B. 24/10 mm Hg
C. 40/0 mm Hg
D. 110/75 mm Hg

B, 24/10 mm Hg is a normal value for PAP; therefore, when this value is observed during the
insertion of a Swan-Ganz catheter, you would know it was in the pulmonary artery.
The respiratory therapist is assisting the physician in the insertion of a Swan-Ganz catheter. The patient
is hemodynamically stable at the time. The therapist would know the catheter tip has entered the
pulmonary artery when which of the followings pressures is observed?

A. 12/4 mm Hg
B. 24/10 mm Hg
C. 40/0 mm Hg
D. 110/75 mm Hg

B, 24/10 mm Hg is a normal value for PAP; therefore, when this value is observed during the
insertion of a Swan-Ganz catheter, you would know it was in the pulmonary artery.
The respiratory therapist is assisting the physician in the insertion of a Swan-Ganz catheter. The patient
is hemodynamically stable at the time. The therapist would know the catheter tip has entered the
pulmonary artery when which of the followings pressures is observed?

A. 12/4 mm Hg
B. 24/10 mm Hg
C. 40/0 mm Hg
D. 110/75 mm Hg

B, 24/10 mm Hg is a normal value for PAP; therefore, when this value is observed during the
insertion of a Swan-Ganz catheter, you would know it was in the pulmonary artery.
The following data are collected from a patient receiving mechanical ventilation:
8: 00 PM 11:00 PM
PAP 24/12 mm Hg 42/20 mm Hg
PVR 2.1 mm Hg/L/min4.2 mm Hg/L/min
PCWP 6 mm Hg 7 mm Hg

On the basis of this information, these charges are most likely the result of which of the following?
A. Pulmonary embolus
A, This patient ’ s pulmonary wedge pressure (PCWP) is normal (e.g., 4
B. Left ventricular failure
to 12 mm Hg), which indicates normal left heart function. Both the
C. Aortic stenosis PAP and PVR are increased, which indicates restriction to blood fl ow
through the pulmonary arterial system; this is most likely the result of
D. Overhydration a pulmonary embolism. Overhydration should not be suspected
because the PCWP is normal, not elevated as seen in overhydration.
Study Hard, pray
harder!
AJA TOPRANKERS!