When the patient has the pictured hemodynamic monitoring device which port would the nurse use to measure a PA pressure?

Signs of volume overload – dyspnea, the presence of rales or crackles, pulmonary edema, increased jugular venous pressure and pitting edema of the ankles – may indicate a problem with increased preload. Medical interventions include a drug regimen of first line drugs – morphine, furosemide (Lasix), nitroglycerine and if necessary second line drugs like dopamine and Dobutamine. Morphine, in addition to relieving pain and anxiety, dilates peripheral vessels. This action redistributes blood, which pools in dependent areas, such as the legs, especially if the patient dangles his legs or has the head of the bed elevated. Pooling decreases the volume returned to the heart, which subsequently reduces the volume that a failing ventricle must manage. If the failing left ventricular ineffectively empties its contents, it can accept less blood from the pulmonary circulation, leading to blood pooling in the lungs, which can precipitate pulmonary edema. The dose of morphine, usually from 2 mg to 10 mg intravenously, is titrated according to the patient’s response. Some patients may experience hypotension due to arterial and venous dilation from only small doses, while others may require repeated high doses to achieve a therapeutic effect.

Furosemide is an effective diuretic that diminishes total body blood volume by boosting urine output, as long as the heart works well enough to perfuse functioning kidneys. The initial recommended dose is 0.5 to 1.0 mg/kg by slow IV injection. Customary IV doses range from 20 mg to 40 mg, although the amount may be as much as 100 mg in emergencies. Blood pressure needs careful monitoring when administering IV diuretics especially when given to patients who already have hypotension. These patients may need additional medications to support blood pressure during diuresis. Electrolyte monitoring is also critical. Reduced serum magnesium and potassium may cause significant heart rhythm disturbances.

Nitroglycerin, like morphine, produces venous dilation, redistributing blood volume to the peripheral areas and pooling blood away from the heart. Nitroglycerin is also effective in relieving cardiac chest pain because while it lessens the workload of the heart, it reduces cardiac muscle oxygen requirements. Additionally, higher IV nitroglycerin doses enhance oxygen delivery by improving circulation through the coronary arteries. Sublingual nitroglycerin is mainly a vasodilator that reduces preload in patients who take it for angina, whereas IV nitroglycerin in higher doses causes an arterial dilating effect reducing ischemia.

Dopamine, a precursor of norepinephrine, administered as a continuous infusion, affects preload by causing vascular constriction or dilation through its effect on the sympathetic nervous system. Its effect is dose dependent. Low-dose dopamine, 2 mcg/kg/min to 4 mcg/kg/min has peripheral vasodilating effects but causes little or no increase in renal perfusion or force of myocardial contraction (positive inotropy) as previously thought. However, it may promote diuresis, which would decrease preload, as would its vasodilating effect. Because dopamine at this dose range has no direct effect on blood pressure, look for other causes, such as vascular volume depletion, anxiety, and pain if a patient receiving this drug has fluctuations in pressure.

Moderate-range doses between 5 mcg/kg/min and 10 mcg/kg/min directly improve preload by causing venous constriction and increasing myocardial contractility through sympathetic stimulation. If a patient has acute pulmonary edema, dopamine is a second line treatment when the patient’s blood pressure is 70 mmHg to 100 mmHg and signs and symptoms of shock are present. Systemic and splanchnic (gut) vasoconstriction occurs when dopamine’s dose exceeds 10 mcg/kg/min. The risk of both myocardial and peripheral ischemia is greater as the dose increases. The need for supplemental oxygen should be evaluated, all chest pain promptly treated and peripheral perfusion indicators such as pulses and urine output closely monitored. Tachycardia may also be an adverse effect and for a patient who has coronary heart disease, the combination of increased contractility and tachycardia may significantly worsen ischemia.

Dobutamine, a synthetic catecholamine, is also administered as continuous IV infusion and is indicated for the treatment of acute pulmonary edema when blood pressure is > 100 mmHg and signs of shock are absent. It is also used to treat severe systolic heart failure. Its effects are dose dependent. Dobutamine increases myocardial contractility and heart rate, decreases left ventricular preload, and indirectly causes a peripheral vasodilatation further enhancing the reduction in preload. It is usually administered at 5 – 20 mcg/kg/min. Doses greater than 20 mcg/kg/min increase the risk for myocardial ischemia due to the oxygen demand of a higher heart rate.

Don appropriate personal protective equipment (PPE) based on the patient’s signs and symptoms and indications for isolation precautions.

The transducer system must be leveled and zeroed to provide accurate hemodynamic values.

Route tubes and catheters having different purposes in different, standardized directions (e.g., IV lines routed toward the head; enteric lines toward the feet).undefined#ref4">4

OVERVIEW

Transducer systems provide a catheter-to-monitor interface so intravascular and intracardiac pressure can be measured. The transducer detects a biophysical event and converts it to an electronic signal.

Fluid-filled pressure monitoring systems used for bedside hemodynamic pressure monitoring are based on the principle that a change in pressure at any point in an unobstructed system results in similar pressure changes at all other points in the system.

Intravascular and intracardiac pressure transducers detect the pressure generated in various areas of the cardiovascular system and convert that pressure wave into an electrical signal, which is transmitted to the monitoring equipment for representation as a waveform on the oscilloscope. Invasive measurement of intravascular (arterial) pressure requires insertion of a catheter into an artery. Invasive measurement of intracardiac (right atrial [RA] and pulmonary artery [PA]) pressure requires insertion of a catheter into the PA.

A single-pressure transducer system is used to measure pressure from a single catheter (e.g., arterial or central venous) (Figure 1). A double-pressure transducer system is used to measure pressure from two catheters (e.g., arterial and central venous) or two ports (e.g., PA and RA) from a single catheter (e.g., PA catheter) (Figure 2). A triple-pressure transducer system is commonly used to measure pressure from the arterial and PA catheters (Figure 3). With this system, arterial pressure, PA pressure, and RA pressure can be obtained. All hemodynamic values (PA, RA, and arterial) are referenced to the level of the atria. The external reference point of the atria is the phlebostatic axis.

Labeling the tubing reduces the chance of misconnection, especially in circumstances where multiple IV lines or devices are in use.3 Connections should not be forced, and equipment should only be used for its intended purpose.6 Forced connections or workarounds could indicate that the connection should not be made.

EDUCATION

• Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
• Provide the patient and family with an explanation of the equipment and the procedure.
• Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

1. Perform hand hygiene before patient contact. Don appropriate PPE based on the patient’s need for isolation precautions or risk of exposure to bodily fluids.
2. Introduce yourself to the patient.
3. Verify the correct patient using two identifiers.
4. Assess the patient for conditions that may warrant the use of a hemodynamic monitoring system, including hypotension, hypertension, cardiac failure, shock, hemorrhage, respiratory failure, fluid imbalances, and sepsis.

Preparation

1. Place the patient in the supine position with the head of the bed flat or elevated up to 60 degrees.1

PROCEDURE

1. Perform hand hygiene. Don appropriate PPE based on the patient’s need for isolation precautions or risk of exposure to bodily fluids.
2. Verify the correct patient using two identifiers.
3. Explain the procedure and ensure that the patient agrees to treatment.

Disposable Pressure Transducer System Setup

1. Follow the organization’s practice regarding the use of 0.9% sodium chloride solution or heparinized 0.9% sodium chloride solution in the flush solution for the pressure monitoring system. Consider using an arterial blood conservation system with the arterial pressure line.

   Rationale: The preferred solution for the flush bag is 0.9% sodium chloride solution. The decision to use heparin should be based on the clinical risk of occlusion and patient factors, such as heparin sensitivities.2

   Although heparin may prevent thrombosis, it has been associated with thrombocytopenia and other hematologic complications. Heparinized 0.9% sodium chloride solution for the flush bag comes as a premixed solution. Ensure that the solution contains the correct strength of heparin before hanging it.

2. Label the flush bag, indicating the date and time the solution was hung and the nurse's initials.

   Rationale: The label indicates when the flush bag needs to be changed.

3. Open the prepackaged pressure transducer kits, using aseptic technique.
   1. A single-pressure tubing kit can be used for RA or arterial monitoring (Figure 1).
   2. A double-pressure tubing kit can be used for PA and RA monitoring (Figure 2).
   3. A triple-pressure tubing kit can be used for arterial, PA, and RA monitoring (Figure 3).
4. Assemble the pressure transducers, pressure tubing, and stopcocks, if not preassembled by the manufacturer. Use the minimum number of stopcocks and the shortest tubing length possible to avoid overdamped and underdamped waveforms.
5. Tighten all connections.
6. Remove the air from the flush bag.
   1. Invert the flush bag.
   2. Spike the outlet port of the flush bag with the pressure tubing, keeping the drip chamber upright.
   3. Keeping the flush bag inverted, use one hand to squeeze the air out of the flush bag while activating the fast-flush device with the other hand, until all air is evacuated from the flush bag and the drip chamber is filled to the desired level, usually halfway.5

      Rationale: Evacuating air from the flush bag prevents air from being flushed to the patient if the bag runs out of 0.9% sodium chloride solution. Filling the drip chamber halfway prevents air bubbles from entering the tubing and allows the nurse to see that the solution is flowing during a manual flush of the invasive line.

7. Insert the flush bag into the pressure bag or device and hang it on the IV pole. Do not inflate the pressure bag.

   Rationale: Priming the tubing under pressure increases turbulence and may cause air bubbles to enter the tubing.

   Never allow air in a hemodynamic system. Air microemboli or macroemboli can migrate to major organs and present a potentially life-threatening complication.

8. Flush the entire system, including the transducer, stopcock, and pressure tubing, with the flush solution.

   Rationale: Flushing eliminates air from the system.

   1. Using the flush device, flush the solution from the flush bag through to the tip of the pressure tubing.
   2. Turn the stopcock off to the patient's end of the tubing (Figure 4).
   3. Using the fast-flush device, flush the solution from the flush bag through the stopcock.
   4. Replace the vented cap on the stopcock with a nonvented cap.

      Rationale: The manufacturer places vented caps to permit sterilization of the entire system. Replacing the vented cap with a nonvented cap prevents bacteria and air from entering the system.

   5. Open the stopcock to the transducer (Figure 5).
9. If using a double-pressure or triple-pressure tubing kit, repeat the system flush and replace the vented cap in each of the pressure transducer systems.
10. Inflate the pressure bag or device to 300 mm Hg.5

    Rationale: Inflating the pressure bag to 300 mm Hg allows 3 ml/hr of flush solution to be delivered through the catheter, thus maintaining catheter patency and minimizing clot formation.5

11. If using a pole mount, insert the transducers into the pole mount holder (Figure 6).
12. Trace tubing or catheter from the patient to point of origin.4
13. Connect the end of each transducer tube to the appropriate catheter port (e.g., PA, RA, arterial), maintaining the sterility of the end of the tube and the catheter port.
14. Label the pressure tubing, indicating the date of initiation or the date of change per the organization’s practice.3
15. Label the tubing at the connection site closest to the patient and the source when there are multiple access sites.3

Monitor Setup

1. Turn on the bedside monitor.
2. Plug the pressure cables into the appropriate pressure modules or jacks in the bedside monitor (Figure 3). Some monitors are preprogrammed to display the waveform that corresponds to the module or jack (e.g., first position, arterial; second position, PA; third position, RA).
3. Select the appropriate waveform label (e.g., PA, RA, arterial) in the hemodynamic monitoring system.
4. Following the manufacturer's instructions, set the appropriate scales for viewing of the complete waveform and accurate readings.

   Rationale: Waveforms vary in amplitude depending on the pressure in the system and the pressure wave being monitored. Scales may vary based on monitoring equipment and may be adjusted based on the patient's pressure levels.

Leveling the Transducer

1. Position the patient supine with the head of the bed between 0 and 60 degrees.1 If the patient cannot tolerate the supine position, use the lateral position at 20, 30, or 90 degrees or the prone position with the head of the bed flat.1
2. Locate the phlebostatic axis for the supine position (Figure 7).
   1. Draw an imaginary line along the fourth intercostal space (ICS) laterally along the chest wall.
   2. Draw a second imaginary line from the axilla downward, midway between the anterior and posterior chest walls. The point where these two lines cross is the level of the phlebostatic axis (Figure 7).
   3. Mark the point of the phlebostatic axis with an indelible marker.
3. Level the air-fluid interface of the transducer to the phlebostatic axis (Figure 7) (Figure 8).1 The patient should be supine or prone, or on his or her side.

   Do not level the arterial interface to the tip of an arterial catheter, which reflects the transmural pressure of a particular point in the arterial tree (e.g., radial artery) rather than the central arterial pressure.

4. Verify the correct angle reference using a laser light or carpenter's level.
   1. Pole mount: low-intensity laser
      1. Place the low-intensity laser leveling device next to the air-fluid interface (zeroing stopcock).
      2. Point the laser light at the phlebostatic axis.
      3. Move the pole mount holder up or down until the interface is level with the phlebostatic axis (Figure 8).
   2. Pole mount: carpenter's level
      1. Place one end of the carpenter's level next to the air-fluid interfaces (zeroing stopcocks).
      2. Place the other end of the carpenter's level at the phlebostatic axis.
      3. Move the pole mount holder up or down until the interface is level with the phlebostatic axis (Figure 8).
   3. Patient mount
      1. Place the air-fluid interface (zeroing stopcock) at the phlebostatic axis (Figure 8).

         Do not level the arterial interface to the tip of an arterial catheter, which reflects the transmural pressure of a particular point in the arterial tree (e.g., radial artery) rather than the central arterial pressure.

      2. Place a 4 × 4-inch gauze or hydrocolloid gel pad between each of the transducers and the patient’s skin.
      3. Secure each system in place with tape.
5. Wait for the patient's hemodynamic status to stabilize for 5 to 15 minutes after repositioning to obtain readings from the monitor.1

Zeroing the Transducer

1. Turn the stopcock off to the patient's end of the tubing (Figure 4).
2. Remove the nonvented cap from the stopcock, opening the stopcock to air.

   Rationale: Removing the cap allows the monitor to use atmospheric pressure as a reference for zero.

3. Push and release the zeroing button on the bedside monitor. Observe the digital reading until it displays a value of zero. Some monitors require that the zero knob be turned and adjusted manually. Some systems also may require calibration. Refer to the manufacturer's guidelines for specific information.

   Rationale: Zeroing negates the effects of atmospheric pressure.

4. Place a new, sterile, nonvented cap on the stopcock.
5. Turn the stopcock so it is open to the transducer (Figure 5).

   Rationale: Turning the stopcock permits pressure monitoring and maintains catheter patency.

6. Activate the hemodynamic pressure monitoring alarms.

Fast-flush Square Wave Test

1. Briefly activate the fast-flush device.

   Rationale: The fast-flush square wave test helps determine whether the transducer system is accurately reproducing the hemodynamic pressure and waveforms.

2. Observe for changes in the waveform on the monitor oscilloscope. When the fast-flush device is activated, a rapid increase in pressure and a square waveform should be evident. Before the pressure waveform returns, a sharp downstroke with one or two oscillations should appear when the fast-flush device is released.
   1. If the system is overdamped, the fast-flush waveform will display a square wave with an angled upstroke and downstroke and no oscillations (Figure 9). An overdamped wave form underestimates the systolic pressure; the diastolic pressure may not be affected.5
   2. If the system is underdamped, the square waveform will display multiple large oscillations (Figure 9). An underdamped waveform overestimates systolic pressure, and diastolic pressure may be underestimated.5

Completing the Procedure

1. Discard supplies, remove PPE, and perform hand hygiene.
2. Document the procedure in the patient's record.

MONITORING AND CARE

1. Check the level of the solution in the flush bag per the organization's practice and replace solution as needed.

   Rationale: Checking the solution level helps ensure catheter patency.

2. Check that the flush bag is maintained at 300 mm Hg5 at regular intervals and as needed per the organization's practice.

   Rationale: A pressure level of 300 mm Hg maintains catheter patency.

3. For arterial, RA, and PA lines, change the flush bag and hemodynamic monitoring system (pressure tubing, transducer, and stopcocks) every 96 hours, upon suspected contamination, or when the integrity of the pressure monitoring system has been compromised.3 Minimize access to the system to prevent infection. The flush bag may need to be changed more frequently if empty.
4. Zero the hemodynamic monitoring system during initial setup, before insertion, after insertion, when disconnection occurs between the transducer and the monitoring cable, when disconnection occurs between the monitoring cable and the monitor, and when the values obtained do not fit the clinical picture.
5. Check the hemodynamic monitoring system at regular intervals per the organization's practice and as needed. Ascertain that all connections are tightly secured and that there are no cracks in the system. Ensure that the system is closed, nonvented caps are on all stopcocks, and the system is free of air bubbles.

   Rationale: Checking the system ensures system integrity, safety, and accuracy. A crack or loss of integrity in the transducer can result in inaccurate hemodynamic readings.

6. Perform the fast-flush square wave test at least once per shift, after opening the catheter system for zeroing or drawing blood, and whenever the waveform appears to be distorted.1

EXPECTED OUTCOMES

• The pressure monitoring system is prepared aseptically.
• The hemodynamic monitoring system remains intact with secure connections.
• The phlebostatic axis is accurately identified.
• The air-fluid interface of the transducer is leveled to the phlebostatic axis.
• The pressure monitoring system is zeroed.

UNEXPECTED OUTCOMES

• Loose connections within the hemodynamic monitoring system
• Stopcocks left open to air without nonvented caps
• Air bubbles in the system
• Pressure bag inflated to less than 300 mm Hg5
• Air fast flushed to the patient (if the IV flush bag did not have all the air removed before using)

DOCUMENTATION

• Education
• Patient's response to the procedure
• Date and time of hemodynamic monitoring system preparation
• Hemodynamic monitoring system leveling and zeroing
• Type of flush solution
• Unexpected outcomes and related interventions

REFERENCES

1. American Association of Critical-Care Nurses (AACN). (2016). Pulmonary artery/central venous pressure monitoring in adults. Critical Care Nurse, 36(4), e12-e18. doi:10.4037/ccn2016268 (Level A)
2. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 41: Flushing and locking. Journal of Infusion Nursing, 44(Suppl. 1), S113-S118. (Level A)
3. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 43: Administration set management. Journal of Infusion Nursing, 44(Suppl. 1), S123-S125. (Level A)
4. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 59: Infusion medication and solution administration. Journal of Infusion Nursing, 44(Suppl. 1), S180-S183. (Level A)
5. McGee, W.T, Young, C., Frazier, J.A. (Eds.). (2018). Edwards clinical education: Quick guide to cardiopulmonary care (4th ed.). Retrieved April 27, 2021, from https://education.edwards.com/quick-guide-to-cardiopulmonary-care-4th-edition/220356# (Level M)
6. U.S. Food and Drug Administration (FDA). (2017). Tips for health care providers to reduce medical device misconnections. Retrieved April 27, 2021, from https://www.fda.gov/medical-devices/medical-device-connectors/tips-health-care-providers-reduce-medical-device-misconnections (Level D)

Adapted from Wiegand, D.L. (Ed.). (2017). AACN procedure manual for high acuity, progressive, and critical care (7th ed.). St. Louis: Elsevier.

AACN Levels of Evidence

• Level A - Meta-analysis of quantitative studies or metasynthesis of qualitative studies with results that consistently support a specific action, intervention, or treatment
• Level B - Well-designed, controlled studies, with results that consistently support a specific action, intervention, or treatment
• Level C - Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results
• Level D - Peer-reviewed professional organizational standards with clinical studies to support recommendations
• Level E - Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational standards without clinical studies to support recommendations
• Level M - Manufacturer's recommendations only