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( can these notes/terms be written so its in complete sentences where a group of high school students can understand them) Hemodynamics & Vasoactive Medications 1. Hemodynamics ⮹ Hemodynamic monitoring assesses perfusion, fluid balance, and cardiac function in an intensive care setting (TABLE 1). ⮹ Vasoactive medications (vasopressors, inotropes) are given toî ‰BP and cardiac output. ⮹ Hemodynamic monitoring guides the titration of vasoactive medications to maintain adequate perfusion. Key hemodynamic concepts (FIGURE 1) include: ⮹ Preload: Blood volume in the ventricles at the end of diastole; determines how much the heart muscle stretches before contraction ⮹ Contractility: Strength of heart’s contraction; affects stroke volume ⮹ Stroke volume (SV): Blood volume ejected by the left ventricle per contraction ⮹ Afterload: Resistance the heart must push against to pump blood FIGURE 1. HEMODYNAMIC CONCEPTS CVP interpretation: High CVP indicates fluid overload (e.g., HF). Low CVP indicates hypovolemia (e.g., shock). Cardiovascular TABLE 1. HEMODYNAMIC MEASUREMENTS Measures of Perfusion Cardiac output (CO) (4-8 L/min) ⮹ Blood ejected per minute ⮹ Cardiac index (CI) is the CO adjusted for body surface area. Mean arterial pressure (MAP) (70-100 mmHg) ⮹ Average arterial perfusion pressure ≥65 mmHg is required for organ perfusion. Measures of Preload (Volume) Central venous pressure (CVP) (2-8 mmHg) ⮹ Reflects right ventricular volume î ‰CVP = fluid overload (HF) î €CVP = hypovolemia (shock) Pulmonary artery (PA) pressures (20-30/10 mmHg) PA wedge pressure (PAWP) (6-12 mmHg) ⮹ Reflects left ventricular volume ⮹ î ‰PA/PAWP = fluid overload (HF) ⮹ î €PA/PAWP = hypovolemia (shock) Measures of Afterload (Resistance) Systemic vascular resistance (SVR) (800-1200 dynes/ sec/cm⁵) ⮹ Measures resistance in the systemic circulation (aorta) ⮹ î ‰SVR = vasoconstriction ⮹ î €SVR = vasodilation Pulmonary vascular resistance (PVR) (<250 dynes/sec/cm⁵) ⮹ Measures resistance in the pulmonary circulation (pulmonary artery) © Bootcamp.com 4 2. Invasive Hemodynamic Monitoring Invasive hemodynamic monitoring involves the placement of arterial or venous catheters to read hemodynamic pressures (TABLE 2). ⮹ Hemodynamic readings are passed through pressurized tubing to a bedside transducer and converted into real-time waveforms. ⮹ Hemodynamic readings are inaccurate if the transducer is not leveled correctly or the system loses pressure (loose connections, pressure bag deflates). ⮹ Always assess the client's perfusion status and correlate it with hemodynamic readings. Cardiovascular TABLE 2. HEMODYNAMIC MONITORING CATHETERS Hemodynamic catheter maintenance ⮹ Ensure pressure bag remains inflated and that tubing and connections are tight with no kinks or air bubbles in line. Zero and level the transducer at the 4th ICS, midaxillary line (phlebostatic axis). ⮹ Mark this location with a permanent marker. ⮹ Re-zero the transducer after repositioning, if disconnected, or if questioning measurement accuracy. Type Use & Location Nursing Considerations Arterial catheter (A-line) ⮹ Use: Continuous BP monitoring, ABG sampling ⮹ Location: Radial or femoral artery Risk for thrombosis: Assess circulation distal to insertion (capillary refill, temperature). ⮹ Risk for bleeding: Hold pressure for ≥5 min after removal. Pulmonary artery catheter (Swan-Ganz) ⮹ Use: Measures PAP, PAWP, CO, and SVR/PVR ⮹ Location: Inserted through a central vein, advanced through the heart, and positioned in the pulmonary artery (PA) ⮹ The catheter tip sits inside the PA, where a balloon can be inflated to occlude the PA and measure the PA wedge pressure. Risk for PA occlusion if balloon is left inflated: Always deflate immediately after inflating for PAWP readings to prevent pulmonary infarction. Risk for ventricular dysrhythmias if the catheter irritates the myocardium: Notify the HCP for new dysrhythmias. Central venous access device (CVAD) ⮹ Use: Central venous access (medications, blood draws), measure CVP ⮹ Location: Internal jugular, subclavian, or femoral vein ⮹ î ‰risk for infection: Monitor site closely for signs of infection (fever, swelling, redness). © Bootcamp.com 2 3. Vasoactive Medications Vasoactive medications are IV medications used to treat hemodynamically unstable clients (shock, heart failure) (TABLE 3). Vasoactive medications include: ⮹ Vasopressors:î ‰BP by constricting blood vessels ⮹ Vasodilators:î €BP by dilating blood vessels ⮹ Inotropes:î ‰heart contractility toî ‰CO Vasoactive medications are selected and titrated based on which hemodynamic value is abnormal (FIGURE 2). For example: ⮹ Low CO î ˆ Inotropes toî ‰contractility ⮹ Low CVP (preload) î ˆ IV fluids ⮹ High CVP (preload) î ˆ Diuretics ⮹ Low SVR (afterload) î ˆ Vasopressors ⮹ High SVR (afterload) î ˆ Vasodilators Nursing considerations ⮹ Vasoactive medications are high-risk medications that can cause serious client harm (stroke, MI) if administered incorrectly. Dosing and titration ⮹ Vasoactive infusions can be ordered at a set rate or titrated (adjusted in increments) to achieve MAP, BP, and/or HR goals. ⮹ Carefully titrate medications based on prescribed hemodynamic parameters (e.g., MAP ≥65, SBP ≥90). ⮹ Administration ⮹ Clients on continuous IV vasoactive meds require continuous cardiac monitoring and VS every 15 min. ⮹ Vasoactive medications can cause tissue necrosis if given through a peripheral venous access device (PVAD). Give vasoactive medications through a CVAD to prevent extravasation (FIGURE 3). FIGURE 2. VASOACTIVE MEDICATIONS Cardiovascular FIGURE 3. EXTRAVASATION Arterial line care: Frequently assess perfusion distal to the insertion site. After removing an arterial line, hold pressure to the insertion site for at least 5 minutes to prevent bleeding. PA catheter care: Closely monitor clients for dysrhythmias. Deflate the balloon immediately after obtaining PAWP measurements to prevent pulmonary infarction. Vasoactive medication safety: Administer vasoactive medications through a central VAD instead of a peripheral VAD to prevent extravasation and tissue necrosis. Target MAP ≥65 mmHg: MAP must be ≥65 mmHg to maintain adequate organ perfusion. If MAP is low, correct hypovolemia first (give IV fluids) before administering vasopressors. © Bootcamp.com 3 3. Vasoactive Medications, Continued TABLE 3. VASOACTIVE MEDICATIONS AT A GLANCE Drug Class Effects & Nursing Considerations Vasopressors constrict blood vessels. norepinephrine dopamine (moderate dose) phenylephrine ⮹ î ‰SVR,î ‰BP (titrated for target MAP) Vasopressors are given for hypotension unresponsive to IV fluids, which should always be given first. ⮹ Monitor for extravasation: Treat with phentolamine. Vasodilators dilate blood vessels. nitroglycerin nitroprusside ⮹ î €SVR,î €BP ⮹ Monitor for hypotension and cyanide toxicity (nitroprusside). Inotropesî ‰cardiac contractility. dobutamine dopamine (high dose) milrinone ⮹ î ‰CO ⮹ Monitor for arrhythmias and hypotension. ⮹ Low CO î ˆ Inotropes ⮹ Low CVP î ˆ IV fluids ⮹ High CVP î ˆ Diuretics ⮹ Low SVR î ˆ Vasopressors ⮹ High SVR î ˆ Vasodilators

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