Hemodynamic monitoring

Monitoring the patient in shock requires vigilance on the part of the nurse The patient s heart rate, blood pressure, and ECG are monitored continuously. The urinary output is measured often (usually hourly), and an accurate intake and output is taken. Monitoring of central venous pressure via a central venous catheter will provide an estimation of the patient s fluid status. Sometimes additional hemodynamic monitoring is necessary with a pulmonary artery catheter. The use of a pulmonary artery catheter allows the nurse to monitor a number of parameters, such as cardiac output and peripheral vascular resistance The nurse adjusts therapy according to the primary health care provider s instructions. 

Anaphylactic patients with impending shock, for example, those with incontinence, sudden loss of hearing or vision, dizziness, or collapse, and those with profound or persistent hypotension, require slow intravenous infusion of a dilute epinephrine solution [0.1 mg in 1 ml (1 10,000)]. Continuous hemodynamic monitoring and dose titration by trained and experienced healthcare professionals are essential. Maximum infusion rates of 5-15 ig/min are recommended in adults [2,18,22]. 

Invasive hemodynamic monitoring in patients with HF entails placement of a right heart or pulmonary artery catheter (PAC). The catheter is inserted percutaneously through a central vein and advanced through the right side of the heart to the... 

All patients with significant disturbances in their acid-base status require continuous cardiovascular and hemodynamic monitoring. Because frequent assessment of the patient s response to treatment is critical, an arterial line is often placed to minimize patient discomfort with serial ABG collections. If... 

Continuous cardiovascular and hemodynamic monitoring should be used for significant pH disturbances, as the most serious sequelae of acid-base disorders include electrolyte abnormalities, cardiac dysrhythmias, and systemic hypotension. 

Pentobarbital (Nembutal) 1 0-1 5 mg/kg Up to 50 mg/minute 10-20 mcg/mL (typically titrated to EEG) Hypotension, respiratory depression, cardiac depression, infection, ileus Requires mechanical intubation, pressors, hemodynamic monitoring... 

Invasive hemodynamic monitoring should be considered in patients who are refractory to initial therapy, whose volume status is unclear, or who have clinically significant hypotension such as systolic BP <80 mm Hg. Such monitoring helps guide treatment and classify patients into four specific hemodynamic subsets based on cardiac index and pulmonary artery occlusion pressure (PAOP). Refer to textbook Chap. 16 (Heart Failure) for more information. 

Hypotension is an important dose-limiting adverse effect of nitroprusside and other vasodilators. Therefore, nitroprusside is primarily used in patients who have a significantly elevated SVR and often requires invasive hemodynamic monitoring. 

Ml In acute Ml, use nitrates only under close clinical observation and with hemodynamic monitoring. In general, do not use a long-acting form because its effects are difficult to terminate rapidly if excessive hypotension or tachycardia develop. 

The combination of loop diuretics and thiazides can mobilize large amounts of fluid, even in patients who have not responded to single agents. Therefore, close hemodynamic monitoring is essential. Routine outpatient use is not recommended. Furthermore, K+-wasting is extremely common and may require parenteral K+ administration with careful monitoring of fluid and electrolyte status. 

Continuous hemodynamic monitoring is essential during all phases of hypothermia. Cardiac monitoring is necessary because of the increased risk of arrhythmias. Cardiac output is decreased 5% for every 1°C of body temperature reduction. This is thought to be secondary to bradycardia, which has been shown to occur with hypothermia (3). A pulmonary artery catheter may be placed if there is any question of hemodynamic instability. Arterial catheters are used for continuous blood pressure measurement, as well as for access to arterial blood for blood gas and electrolyte analysis. 

The arterial and venous catheters are placed surgically under aseptic conditions. These catheters are used for hemodynamic monitoring, fluid and antibody treatments, and blood sampling. 

A 54-year-old man with severe triple vessel coronary artery disease took six modified-release diltiazem tablets 180 mg following an episode of severe angina, and 10 hours later developed bradycardia, hypotension, and severe pulmonary edema, but was free of chest pain (21). After intensive hemodynamic monitoring and noradrenaline treatment, his renal, respiratory, and cardiac problems recovered to baseline over the next 48 hours. Diltiazem overdose was confirmed by a diltiazem serum concentration of 1230 ng/ml (usual target range 40-160 ng/ml). 

No therapy for advanced/decompensated heartfailure studied to date has been shown conclusively to influence mortality. Treatment goals are directed toward restoration of systemic oxygen transport and tissue perfusion, relief of pulmonary edema, and limitation of further cardiac damage. Maximizing oral therapy and using combinations of shortacting intravenous medications with different cardiovascular actions often are needed to optimize cardiac output, relieve pulmonary edema, and limit myocardial ischemia. Invasive hemodynamic monitoring usually is required to provide immediate feedback on treatment efficacy and adverse effects. 

There are two general approaches to maximize therapy in the ad-vanced/decompensated heart failure patient. One is to use simple clinical parameters (i.e., signs and symptoms, blood pressure, and renal function), and the other is to use invasive hemodynamic monitoring. However, it is frequently necessary to combine the two approaches. 

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