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Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Hemodynamic Monitoring and Transthoracic Lines,Deb Updegraff RN, CNS,Lucille Packard Childrens Hospital,Pat Hock RN, Nurse Educator,Winnie Yung , CNS,Hemodynamic Monitoring and Tra,1,Infants and children undergoing open heart surgery may require intracardiac monitoring.,The hemodynamic data can assist in the assessment of contractility, preload and afterload.,As the patient stabilizes post cardiac by-pass, intracardiac catheters (RA) may be left in place for vascular access reasons.,Infants and children undergoin,2,Whats the difference ?,“Percutaneous” vs “Transthoracic”,Percutaneous, Insertion site is through the skin.,Transthoracic,- Insertion is done while the chest is open and directly through,the myocardium.,Whats the difference ? Percu,3,Examples of Percutaneous lines,:,PICCs,Tunneled lines,Non-tunneled lines,Swan-Ganz thermodilutional catheters,Dialysis/CRRT catheters,Examples of Percutaneous lines,4,Examples of Transthoracic Lines,Examples of Transthoracic Line,5,Roth, S. 1998,Percutaneous,Central,Venous,Catheter,Left Atrial,Transthoracic,Catheter,Right Atrial,Transthoracic,Catheter,LA,RA,PA,Pulmonary,Artery,Catheter,Roth, S. 1998PercutaneousLeft,6,Hemodynamic Waveforms- Normal Heart,(CVP),Hemodynamic Waveforms- Normal,7,Right Atrial Pressure Monitoring,Indications,Measure right atrial pressure (RAP),Same as Central Venous Pressure (CVP),Assess blood volume; reflects preload to the right side of the heart,Assess right ventricular function,Infusion site for large fluid volume,Infusion site for hypertonic solutions,Right Atrial Pressure Monitor,8,Reasons for elevated RA pressure:,decreased right (or single) ventricle compliance,tricuspid valve disease,Intravascular volume overload,cardiac tamponade,tachyarrhythmia,Right Atrial Pressure,Mean: 1 to 7 mm Hg,Reasons for elevated RA pressu,9,Reasons for reduced RA pressure:,low intravascular volume status,inadequate preload,Right Atrial Pressure,Mean: 1 to 7 mm Hg,Reasons for reduced RA pressur,10,Right Atrial Pressure Monitoring,Complications,Pneumothorax,Hemothorax,Hemorrhage,Cardiac tamponade,Vessel, RA, or RV perforation,Arrhythmias,Air embolism,Pulmonary embolism,Thromboembolism,Infection,Right Atrial Pressure Monitor,11,Right Atrial Pressure Monitoring,Waveform Analysis,a wave,: rise in pressure due to atrial contraction,x decent,: fall in pressure due to atrial relaxation,c wave,: rise in pressure due to ventricular contraction and closure of the tricuspid valve,v wave,: rise in pressure during atrial filling,y decent,: fall in pressure due to opening of the tricuspid valve and onset of ventricular filling,Right Atrial Pressure Monitori,12,Right Atrial Pressure Monitoring,Waveform Analysis,Elevated RAP,RV failure,Tricuspid regurgitation,Tricuspid stenosis,Pulmonary hypertension,Hypervolemia,Cardiac tamponade,Chronic LV failure,Ventricular Septal Defect,Constrictive pericarditis,Decreased RAP,Hypovolemia,Increased contractility,Right Atrial Pressure Monitori,13,Elevated systemic ventricular end diastolic pressure,mitral valve disease,Large left-to-right shunt,intravascular volume overload,cardiac tamponade,tachyarrhythmia,Artifactual,Reasons for elevated LA pressure:,Elevated systemic ventricular,14,low intravascular fluid status,Inadequate preload,Artifactual,Reasons for reduced LA pressure:,low intravascular fluid statu,15,Reasons for elevated PA pressure:,mechanical obstruction of pul. circulation,pul. arteriolar smooth muscle hypertrophy,inflammatory response to CPB,mechanical obstruction of the airways,(for examples),acidosis and hypoxia,elevated LA pressure,unrestrictive VSD or large PDA,pul. hypertension,Reasons for elevated PA pressu,16,Nursing HOURLY assessment:,Air in line or stopcocks,Precipitates,Leaking at site,Increasing resistance,Condition of entrance sites,Dressing change policy at LPCH,Arterial line,prn (when seal is broken, wet, old blood, etc),Non-tunneled CVC,Q 7 days & prn (Tegaderm &,biopatch,),Tunneled CVC,Q7 days & prn (Tegaderm &,biopatch,),Intracardiac catheter,Q 7 days & prn (Tegaderm &,biopatch,),Nursing HOURLY assessment:Dres,17,Check coagulation labs (pt, ptt, INR, platelets),Transfuse if Platelets 1.5,Ensure Packed Red Blood Cells in cooler at bedside,(Remember two RN check for PRBCs. Instructions,for blood in cooler, taped to cooler),Ensure good vascular access,Ensure chest tube patency,Evaluate need for sedation.,(if too active, BP may bleeding),BEFORE,REMOVAL,Transthoracic Line,Check coagulation labs (pt,18,After,Removal of Transthoracic Line,Keep PRBCs for a minimum of 1 hour,Continuous hemodynamic monitoring for a minimum of 1 hour,(assess for signs of tamponade-dampening arterial wave form,narrowing pulse pressure and bleeding- blood in chest tubes,decrease blood pressure, pallor,altered LOC),Document vitial signs every 15 minutes,Check HCT if bleeding suspected,Ensure patency of chest tubes,Do not transfer patient for at least 2 hours,After Removal of Transthoracic,19,Pressure Line Safety,What is air vigilance and why is it so important?,Why is it unsafe to draw back or flush fluid into a line infusing vasoactive medications?,What precautions should be taken when discontinuing any pressure line?,Is it safe to get a patient out of bed to be held or to sit in a chair if they have a transthoracic pressure line?,What additional safety measures should be followed for transthoracic pressure lines?,Pressure Line SafetyWhat is a,20,References,Alspach.,AACNs Core Curriculum for Critical Care Nursing,. Saunders.,Berne and Levy.,Physiology,. Mosby.,Hazinski.,Manual of Pediatric Critical Care,. Mosby.,Kinney, Packa, and Dunbar.,AACNs Clinical Reference for Critical Care Nursing,. Saunders.,Kumm. Hemodynamic Monitoring. University of Kansas School of Nursing.,Kumm. Intra-arterial Pressure Monitoring. University of Kansas School of Nursing.,Slota.,AACNs Core Curriculum for Pediatric Critical Care Nursing,. Saunders.,Taleghani, Fred. Invasive lines, hemodynamic monitoring, and waveforms. LPCH, PICU.,References,21,
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