Hemodynamics

Carole Rance, RN, BSN, CCRN

Definition
The movement and forces
involved with the movement of
blood through the cardiovascular
system.
Hemo+dynamics=blood+always
changing

Cardiac Blood Flow

Important terms
Preload-The degree to which
muscle fibers stretch prior to
contraction.
Afterload-Initial resistance that
must be overcome by the
ventricles to eject blood through
the semilunar valves.
Systemic vascular resistanceThe resistance offered by the
peripheral vasculature.

Stroke Volume
The amount of blood ejected by the
left ventricle with each contraction.
SV=LVEDV-LVESV

Normal= 60-100mL
http://apbrwww5.apsu.edu/thompsonj/Anatomy%20&
%20Physiology/2020/2020%20Exam%20Reviews/Exam
%201/stroke%20volume%20diagram.bmp

Cardiac Output
The amount of blood ejected by the
left ventricle in one minute.

CO=SVxHR

drtedwilliams.n
et

Frank-Starling Law

http://apbrwww5.apsu.edu/thompsonj/Anatomy
%20&%20Physiology/2020/2020%20Exam
%20Reviews/Exam%201/Frank-Starling%20Law
%20of%20the%20Heart01.jpg

Mini Quiz
A 53 year old female has been vomiting
large amounts of red blood and is found to
have a hemoglobin of 4.4g/dL. Her HR is
130, BP 70/40, RR 28, SpO2 100%. She is
also showing signs of acute renal failure
(diminished urine output and elevated
BUN and creatinine).
What would be true?
A. Preload is low
B. Afterload is low
C. Preload is high
D. Preload is normal

Would we assume her cardiac output is

high, low, or normal?

Types of Invasive
Hemodynamic
Monitoring

Invasive arterial blood pressure

monitoring
Central venous pressure
monitoring
Pulmonary artery catheter
Arterial-based cardiac output
monitoring

http://www.usa.philips.com/healthcare-product/HC865240/intellivue-mx800-bedsidepatient-monitor

Arterial Lines
Indications
Invasive blood
pressure
monitoring of the
acutely ill
Risks
Infection
Thrombus/Embolu
s
Blood loss

http://www.sorbaviewshield.com/ph
otos/

Arterial Lines
Other uses
Blood sampling
Arterial blood gas
(ABG) sampling
Cardiac Output
monitoring (Flo
Trac)

(Drawing by Paul W. Schiffmacher, Thomas Jefferson University,

Philadelphia.)

Assisting with
Insertion

Prior to procedure
Verify informed consent.
Ready supplies (list available on
hospital policy).
Set-up single-pressure transducer
system.

Pressure line set-up

Assisting with
Insertion
Procedure
Assure sterile technique is
maintained.
Assist physician as requested.
Attach PRIMED tubing to
catheter.
Prime tubing as well as all side
ports.
Pressure bag should be in
place.

Initial Set-up
Attach pressure cable.
Level the arterial air-fluid interface
(zeroing stopcock) to the
phlebostatic axis (right atrium).
Zero the system.
May need to adjust
scale on monitor.
Observe waveform.
(From Wiegand, D.L. [2011]. AACN
procedure manual for critical care
[6th ed.]. St. Louis: Saunders.)

Zeroing pressure lines

All pressure lines are zeroed the
same way.
Be sure before starting the zeroing
procedure ensure that the arterial
air-fluid interface is leveled at the
phlebostatic axis.
Close the stopcock to the patient.
Open the stopcock to air.
Zero the line on the monitor.

Care and Maintainance

NEVER infuse medication to an
arterial line!
Dressing care, fluid changes, tubing
changes, are to be done following
your specific hospital policy.
Care should be taken to observe for
signs of decreased perfusion to
extremity the arterial line is located.
Check connections

http://seattleclouds.com/myapplications/dukeg/ican/Art
Line.html

www.aeronline.or
g

Drawing a Blood
Sample

May draw lab and arterial blood

gas samples.
Steps
Attach syringe to cleansed port.
Turn the stopcock off to the flush
bag.
Aspirate waste, turn the
stopcock off to the syringe and
discard.
Attach empty syringe and draw

Drawing a Blood
Sample

Turn the stopcock off to the

syringe and remove syringe.
Attach discard syringe, fast-flush
blood from port into the syringe,
and close stopcock to syringe
(discard).
Use fast-flush system to flush line
to patient.
Observe waveform

Arterial Waveform
When the pressure in the ventricle
is lower than the aortic root the
aortic valve closes which is
represented on the arterial
waveform by the dicrotic notch.

http://ccrnnurse.blogspot.com/2012/05/arterial-blood-pressuremonitoring.html

Pulse Pressure
Narrow pulse
pressure
preload
Cardiac
tamponade
Wide pulse
pressure
Part of
Crushings
Triad
Atherosclerosis

http://www.learning
aboutelectronics.co
m/images/Pulsepressure.png

Abnormal Waveform
Patterns

http://ht.edwards.com/r
esourcegallery/products
/pressuremonitoring/pdf
s/invasivehdmphysprinc
book.pdf

http://ht.edwards.com/r
esourcegallery/products
/pressuremonitoring/pdf
s/invasivehdmphysprinc

Square Wave Test

Fast-flush arterial line using
pressure-system (pig-tail)
There should be a sharp upstroke
terminating in a flat line.
Release the pig-tail.
The baseline waveform should
return to normal within 1-2
oscillations.
(From Darovic,
G.O., Zbilut, J.P.
[2002]. Fluid-filled
monitoring
systems. In G.O.
Darovic (Ed.),
Hemodynamic
monitoring [3rd
ed., p. 122].
Philadelphia: W.B.
Saunders.)

Overdampening
Falsely low systolic pressure and
falsely high diastolic pressure.
Interventions/troubleshooting
Check the patient!
Check level at the phlebostatic axis and
re-zero.
Check catheter and position.
Check line for air.
Check flush bag and pressure bag.
Aspirate and then fast-flush.
(From Darovic,
G.O., Zbilut, J.P.
[2002]. Fluid-filled
monitoring
systems. In G.O.
Darovic (Ed.),
Hemodynamic
monitoring [3rd
ed., p. 122].

Underdampening
Falsely high systolic blood pressure
and potentially falsely low diastolic
blood pressure.
Interventions/troubleshooting
Check the patient!
Check level at the phlebostatic axis and
re-zero.
Check catheter and position.
Check line for air.
Check the length of pressure
tubing
(From Darovic, G.O.,
Zbilut, J.P. [2002].
Fluid-filled
monitoring systems.
In G.O. Darovic (Ed.),
Hemodynamic
monitoring [3rd ed.,
p. 122]. Philadelphia:
W.B. Saunders.)

Troubleshooting Wavefo
rms

Documentation
You should document the
waveform per hospital policy
(typically once a shift).
Document arterial blood pressure
per unit policy and per patient
condition.
Arterial lines are documented in
the same area that peripheral and
central lines are by clicking add
LDA.

Removing Arterial Line

May be done by nurse at
bedside.
Follow your specific hospital
policy.
Key Points
Turn off arterial monitoring on
the monitor before removal.
You may need to remove sutures.
(DO NOT REMOVE CUTDOWN
SUTURES)

Pulmonary Artery
Catheters
Pulmonary Artery catheters
(Swan-Ganz catheter) are used
to assess the hemodynamic
status of critically ill patients.
Data provided
Cardiac Output (CO)
Pulmonary artery wedge pressure (PAWP)
or pulmonary artery occlusion pressure
(PAOP)
Central venous pressure (CVP) or right
atrial pressure (RAP)
Pulmonary artery pressure (PAP)
http://lifeinthefastlane.com/ccc/pulmonary-artery-

Insertion
Most commonly used with patients
following open heart surgery.
Usually inserted in the cath lab or
OR, but may be inserted at
bedside.
Hospital policy outlines the
procedure and supplies needed for
bedside insertion.

Insertion
The PA
catheter is
inserted
through an
introducer
(often
referred to
as a cordis).
X-ray
needed to
verify

https://www.youtube.com/watch?v=7pu
txZN7ij4

Central Venous Pressure

or Right Atrial Pressure
Terms commonly used
interchangeably.
CVP-Distal port of central venous
catheter
RAP- PA catheter lumen opening in
the right atrium

Central Venous
Pressure or Right
Atrium
Pressure
Provides information regarding
intravascular volume and preload.
Normal CVP is about 2-6mmHg
(varies per patient).
Location
Central line- Most distal port
(MUST REMOVE CAPS)
PA catheter-Blue line
(blue=venous)

CVP Waveform
Looks like ventricular fibrillation
May vary with respiration

http://www.icufaqs.
org/

Abnormal CVP
Causes of increased CVP
Right heart failure
Cardiac tamponade
Pulmonary embolism
Pulmonary hypertension
Chronic left ventricular failure
Tricuspid or pulmonic valve
dysfunction
Fluid overload

Abnormal CVP
Causes of decreased CVP
Hypovolemia
Decreased mean arterial
pressure
Venodilation
Treatment dependent on
cause

Mini Quiz
A 79 year old male who has ESRD
skipped his last 2 dialysis treatments
and presents with jugular vein
distention and peripheral edema.
Would his CVP most likely be high,
low, or normal?
Bonus Question
What would his treatment be?

Pulmonary Artery
Pressure
Provides the
systolic, diastolic,
and mean
pressures of the
pulmonary artery
Location
Pulmonary artery
Most distal lumen
Yellow line

Pulmonary Artery
Pressure
Normal values
Systolic 15-25mmHg
Diastolic 8-15mmHg
Mixed venous blood gases are
drawn from this port.
NOT TO BE USED FOR
INFUSION OR MEDICATIONS!

Pulmonary Artery
Waveforms

Looks similar to an arterial line

waveform just a smaller scale.

http://www.derangedphysiology
.com/php/PAC/2-insertion-ofthe-PA-catheter.php

Abnormal PA Pressures
Elevated PAP
Volume overload
Pulmonary Hypertension
Pulmonary embolism
Left heart failure
Mitral valve disease
Long-term systemic hypertension
COPD and sleep apnea
Low PAP
Volume depleted
http://www.cdc.gov/DHDSP/data_statistics/fact_sheets/fs_pulmonary_hyper

Pulmonary Artery
Wedge Pressure
Pulmonary artery wedge pressure
(PAWP) is used to provide an estimate of
pressures in the left side of the heart.
Normal Values 4-12 mmHg

Pulmonary Artery
Wedge

Pulmonary Artery
Wedge Pressure
Steps
Slowly inflate balloon with no more than
1.5mL of air.
Do not leave balloon inflated longer
than 8-15 seconds or 2 respiratory
cycles.
Observe for waveform changes
Measure wedge pressure at endexpiration.
Deflate balloon according to hospital
policy (should be passive).

Pulmonary Artery
Wedge Waveform
DO NOT EVER LEAVE BALLOON
INFLATED (this can cause lung
infarction/ischemia)

http://www.derangedphysiology.com/php/PAC/2-insertion-of-the-PAcatheter.php

Abnormal Values
High PAWP
Left heart failure
Cardiac tamponade
Mitral valve disease
Fluid overload
Low PAWP
Hypovolemia
http://www.uofmmedicalcenter.org/healthlibrary/Article/1
15853EN

https://www.youtube.com/watch?v=ND7F3
HIu_OI

Mini Quiz
Your patient has a PA catheter and
upon entering the room you see
this waveform for the PA pressure.

http://www.homesteadschools.com/nursing/courses/Cardiovascular
%20Nursing/images/04_09.jpg

What is your assessment?

What should you do?

Mini Quiz
Your patient has a PA catheter and
upon entering the room you see
this waveform for the PA pressure.
What is your assessment?
What should you do?

Mixed Venous Oxygen

Saturation (SvO2)
Measurement of the oxygen
content of blood after
returning back to the right
side of the heart.
Normal 60-80%
Used to tell us if the cardiac
output is sufficient to meet
tissue oxygen needs.

http://ht.edwards.com/resourcegallery/products/swanganz/pdfs/svo
2edbook.pdf

Cardiac Output
Cardiac output (CO) measures
how much blood the heart
pumps in one minute.
Normal CO is 4-8L/min
Measurement should be taken per
hospital policy or physician order.

How do you think PEEP would

affect CO?

Cardiac Output
CO doesnt take into account the
patients size, so cardiac index is a more
reliable measurement.
Cardiac index is calculated with the
patients body surface (BSA) in mind.
CO
CI= BSA
Normal Cardiac Index is 2.5-4 L/min/m2

Abnormal Cardiac
Output
Low CO
Heart failure/cardiomyopathy
Valve disease
Cardiac tamponade
Cardiogenic shock
Arrhythmias
Hypovolemia
High CO
Sepsis

Thermodilution
Method

Check height and weight are entered in

monitor.
Set computation constant
If not already connected, connect
closed system to proximal lumen of the
PA catheter (Blue port/Right atrium).
Administer room temperature injectate
bolus 3-5 times.
Discard outliers and those that do not
have normal curves.
Save cardiac output.

Cardiac Output
Waveforms

(From Urden, L.D., Stacy, K.M., Lough, M.E. [2002]. Thelan's critical care nursing: Diagnosis and management
[4th ed.]. St. Louis: Mosby.)

Closed Injectate
Delivery System

https://www.youtube.com/watch?v=isN
5pSiKQBo

Miscellaneous
Information
Obtain measurements at end
of expiration.
Why?

Use consistent head of bed

level for measurements
0-60 degrees is appropriate as
determined by patient condition

Removal of PA
Catheter and
Introducer Sheath

The PA catheter and introducer

sheath are removed separately!
When removing PA catheter ectopy
may occur.
Watch for arrhythmias

When removing the swan and

introducer sheath the patient should
hold his or her breath.

 Swan removal

(From Wadas, T.M. [1994]. Pulmonary artery catheter removal. Critical Care
Nurse, 14[3], 63-72.)

Air Embolus
PA pressures or an
obstruction in the
pulmonary
vasculature can occur.
Symptoms include:
respiratory distress,
cardiac
arrhythmias/arrest,
hypotension, AMS

Left-lateral
trendelenburg
position helps keep
air in the right atrium.

http://www.safeinfusiontherapy.com/images/french/
herz.png

Documentation
Waveforms (arterial, CVP, PAWP, and
PAP) should be documented per hospital
policy.
Numeric values should be documented
under
DocFlowsheets-> Vital Signs Complex> Invasive Hemodynamic Monitoring
The catheter should be documented in
the same area as other IV catheters are
located.
Add a PA catheter by clicking add
LDA and choosing introducer

Arterial-Based Cardiac
Output Monitoring
Minimallyinvasive
Provides
hemodynamic
measurements
Available in
some hospitals

http://ht.edwards.com/scin/edwards/s
itecollectionimages/products/mininva

Mini Quiz
How do you know what
computation constant to enter?
What is more reliable cardiac
output or cardiac index? Why?
You have a 70 year old patient
with a PA catheter in place. You
notice his cardiac rhythm has
switched from NSR to A-fib with
RVR. His ABP is 73/41 (52), HR is
160, RR is 28.
Would you expect his cardiac
output/cardiac index to be the

http://www.castenholz.org/ptguide/pacath_c
opy.JPG

http://www.clevelandclinicmeded.com/m
edicalpubs/diseasemanagement/pulmon
ary/pulmonaryhypertension/images/figure-5.jpg

Common Continuous
Infusions in Critical
Care

http://ehealthinnovation.org/what-we-do/projects/mitigating-risks-associated-withmultiple-iv-infusions/

Medication Types
Vasopressors- Cause
constriction of blood vessels,
leading to an increase of blood
pressure.
Vasodilators- Causes dilation of
blood vessels, leading to a
decrease of blood pressure.
Arterial
Venous
Mixed

Medication Types
Inotropes - Affects the
contractility or the force of
strength of the hearts
contractions.
Positive inotrope
Negative inotrope
Antiarrhythmics

Vasopressors

Dopamine
Hydrochloride
Hemodynamic effects
+ Inotrope
Chronotropic
Vasopressor
Uses
Hypotension not secondary to
hypovolemia
Decreased cardiac output
Symptomatic bradycardia
Use for prevention or treatment of
acute renal failure is controversial.

http://allmedtech.com/doinbindep
rs.html

Dopamine
Hydrochloride
Dosage
Suggested initial dosing is 1-5
mcg/kg/min as a continuous IV infusion.
May be titrated upward every 2-5
minutes to attain hemodynamic goals.
Normal dose range is 1-20 mcg/kg/min.
(higher doses up to 50 mcg/kg/min may
be considered)
If >20 mcg/kg/min is needed consider
another vasopressor.

Dopamine
Hydrochloride
Potential side effects/adverse
reactions
Tachycardia
Ectopy
Can cause severe damage to tissue if IV
extravasation occurs (NEED A CENTRAL
LINE ASAP).
Anxiety
Angina
Peripheral and visceral organ ischemia

Dopamine
Extravasation

http://www.joacp.org/article.asp?
issn=09709185;year=2012;volume=28;issue=4;
spage=534;epage=535;aulast=Bhosal
e

http://www.joacp.org/article.asp?
issn=09709185;year=2012;volume=28;issue=4;
spage=534;epage=535;aulast=Bhosal
e

Phenylephrine
Hydrochloride
Brand name: Neo-Synephrine
Hemodynamic effects
Potent vasoconstrictor
Lacks inotropic and chronotropic
effects
May reduce HR and CO
Uses of continuous infusion
Hypotension not secondary to
hypovolemia
Not first choice for most shock states

http://www.west-ward.com/products.php?
cid=122

Phenylephrine
Hydrochloride
Dosage
Normal concentration
40mg/250mL in D5W.
For Severe hypotension/shock
state begin infusion at 100-140
mcg/min.
Titrate to desired mean arterial
pressure.
Usual rate 40-180 mcg/min

Phenylephrine
Hydrochloride
Potential side effects/adverse
reactions
Angina
Pulmonary edema
Can cause damage to tissue if IV
extravasation occurs (NEED A
CENTRAL LINE ASAP).
Peripheral and visceral organ
ischemia

Norepinephrine
Brand name- Levophed
Hemodynamic effects
Potent vasoconstrictor
+ inotrope
Uses of continuous
infusion
Hypotension not
secondary to hypovolemia
Vasopressor of choice for
septic shock

http://www.xhbv.com/wpcontent/uploads/2010/12/n
orepinephrine.jpg

Norepinephrine
Dosage
Suggested initial dosing is 8 mcg12mcg/min
May be titrated 2mcg/min every
minute to desired MAP.
Normal dose range is 1-30mcg
(higher doses may be considered).

Norepinephrine
Potential side effects/adverse
reactions
Arrhythmias
Can cause severe damage to tissue if
IV extravasation occurs (NEED A
CENTRAL LINE ASAP).
Anxiety
Angina
Peripheral and visceral organ
ischemia

Vasopressin
Synthetic antidiuretic
hormone
Hemodynamic effects
Vasoconstrictor
Promotes reabsorption of
water in the renal tubule
Uses of continuous infusion
Hypotension
2nd or 3rd vasopressor for
septic shock
May be used to replace 1st or
2nd dose of epinephrine during
cardiac arrest.

http://checktheleads.com/20
14/12/bye-bye-byevasopressin/

Vasopressin
Dosage of continuous infusion
Standard concentration is
40units/100mL NS or D5W
Shock- 0.01-0.04units/min
Variceal hemorrhage-0.2-0.4
units/min
Potential side effects/adverse
reactions
Diaphoresis
GI symptoms

Epinephrine
Also known as adrenalin
Hemodynamic effects
Vasoconstrictor
+ inotrope
Chronotropic

http://acls-algorithms.com/wpcontent/uploads/2011/05/acls-drugsepi.jpg

Epinephrine
Uses of continuous infusion
To maintain heart rate and cardiac
output following CPR
Emergency management of
symptomatic bradycardia
Hypotension and shock
Used during ACLS during cardiac arrest.
Used as bronchodilator during
anaphylactic reaction, acute
bronchospasm, or severe asthma
exacerbation

Epinephrine
Dosage
Recommended
initial dosage is
1mcg/min. Titrate
to hemodynamic
goal.
Typical dose is 210 mcg/min

http://acls-algorithms.com/wpcontent/uploads/2011/05/acls-drugsepi.jpg

Epinephrine
Potential side effects/adverse
reactions
Arrythmias
Can cause severe damage to tissue if
IV extravasation occurs (NEED A
CENTRAL LINE ASAP).
Anxiety
Angina
Peripheral and visceral organ ischemia
Hyperglycemia

Vasodilators

Nitroprusside
Brand name-Nipride
Hemodynamic effects
EXTREMELY potent vasodilator
Uses
Hypertensive emergency
For immediate reduction in
preload and afterload in cardiac
failure or cardiogenic shock.

http://o.quizlet.com/i/UAhw__yNB5qi1xwQVbbU
5A_m.jpg

Nitroprusside
Dosage
**USE EXTREME CAUTION**
Profound hypotension can occur very
quickly.
If this happens stop the infusion, as the drug
has a short duration of action.
Initial dosage 0.250.3 mcg/kg/min (possibly
lower)
The average maintenance dose is 3
mcg/kg/min
The usual dosage range is 0.2510
mcg/kg/min IV.
Maximum dosage is 10 mcg/kg/min.

Nitroprusside
Considerations
Use cautiously in patients with
renal impairments
Not a good choice for patients
with increased ICP
Side effects/adverse reaction
Cyanide poisoning particularly
with high doses, renal
impairment, and prolonged use.

Nitroglycerin
Brand name-Tridil
Hemodynamic effects
Arterial and venous
vasodilator
Uses
Treatment of
angina/unstable unangina
Acute MI
Treatment of hypertension
(severe and emergent)

http://www.hospira.com/Images/0
409-1483-02_81-3288_1.jpg

Nitroglycerin
Dosage
Initially, 5 mcg/minute IV infusion.
Titrate by 5-20 mcg/minute IV
every 35 minutes until clinical
response, or to a dose of 20
mcg/minute IV.
The effective dosage range is 5
100 mcg/minute IV.
Side effects/adverse reactions
Headache (most common)

Nicardepine
Brand name-Cardene
Calcium channel blocker
Hemodynamic effects
Arterial vasodilator
Negative inotrope
Does not increase ICP.
Uses
Hypertension
If no central line available, peripheral
site should be changed every 12 hours.
http://www.pppmag.com/findit/product/305/C
ARDENE

Nicardepine
Dosage
Initiate therapy at 5 mg/hour as a
continuous IV infusion.
Increase 2.5 mg/hr every 15
minutes
When target BP achieved
decrease infusion to 3mg/hour
(15mL/hour), monitor and titrate
to lowest dose necessary to
maintain stable BP
Maximum rate 15 mg/hr

Nicardepine
Side effects/adverse reactions
May precipitate or exacerbate
heart failure
Peripheral edema
Flushing

http://www.pppmag.com/findit/product/305/C
ARDENE

Beta blocker Infusions

Labetalol
Used for treatment of
hypertension
Reduces afterload without a
substantial decrease in resting
HR, CO, or SV as compared to
other beta-blockers.
Dosage
Infusion: 2mg/min, then may
titrate up to 8mg/min

Beta Blocker Infusions

Esmolol
Used for short-term control of
HR, hypertension, acute MI, and
unstable angina.
Negative chronotropic and
inotropic effect, reduced
sympathetic outflow from CNS,
and suppresses renin release.
Dosage dependent on
indication

Diltiazem
Brand nameCardizem
Calcium channel
blocker
Hemodynamic uses
Dilates coronary and
systemic arteries
Slows conduction
through the AV node
Some negative

http://www.hospira.com/en/products_and_s
ervices/drugs/DILTIAZEM_HYDROCHLORIDE
_FOR_INJECTION

Diltiazem
Uses of continuous infusion
Ventricular rate control during A-fib/A-flutter

Treatment of PSVT that is unconverted by

adenosine, vagal maneuvers, or recurrent.
Dosage
Bolus may be used and repeated per
physician order.
Typical bolus dose is 0.25 mg/kg
administered as an IV bolus over 2
minutes.
Dose range is 5-15mg/hr.
Typically titrated by 5mg/hr at a time.

Diltiazem
Side effects/adverse reactions
Hypotension
Pulmonary edema
May precipitate or exacerbate
heart failure
1st degree heart block
Bradycardia

Antiarrhythm
ics

Amiodarone
Brand name-Cordarone
Both an antiarrhythmic
and a vasodilator
Class III antiarrhythmic
Negative inotrope
Uses of continuous infusion
Treatment of ventricular arrhythmias
Off label-Treatment of
supraventricular arrhythmias
Also can be used IV push during ACLS
to treat pulseless ventricular
arrhythmias.

https://www.nexterone.com/nexterone/Do
sing.htm

Amiodarone
Dosage
Bolus dose-150mg in
100mL of D5W infused
over 10 minutes
Loading infusion1mg/min for 6 hours
Maintenance infustion0.5mg/min

Amiodarone
Side effects/adverse reactions
Hypotension
Gastric disturbances
QT prolongation
Can cause severe pulmonary reaction
Amiodarone-induced pulmonary
interstitial pneumonitis,
hypersensitivity pneumonitis, or
pulmonary fibrosis
Many more potential side effects!

Lidocaine
Antiarrhythmic and local
anesthetic
Class IB
Use of continuous
infusion
Ventricular arrhythmias
No longer preferred choice.
Can be used when
amiodarone is unavailable,
contraindicated, or not

http://www.hospira.com/en/products_and
_services/drugs/LIDOCAINE_HYDROCHLO
RIDE_DEXTROSE

Lidocaine
Dosage
Loading dose: 1 to 1.5 mg/kg
IV; may repeat 0.5 to 0.75
mg/kg IV every 5 to 10
minutes
Maximum total loading dose
of 3 mg/kg
Dose range is 14 mg/minute
(2050 mcg/kg/min).

Lidocaine
Side effects/adverse reactions
Lidocaine toxicity
Dizziness, confusion, euphoria,
drowsiness, seizures,
respiratory depression
Cardiovascular effects
(bradycardia, hypotension,
conduction slowing, and cardiac
arrest)
This usually occurs after toxicity

+ Inotropes

Dobutamine
Hemodynamic effects
Potent + inotrope
Some + Chronotropic effects
Some vasodilator effects
Uses of continuous infusion
Increase cardiac output due to
CHF, cardiogenic shock, and
following cardiac surgery
Off label use- increase cardiac
output secondary to septic shock

http://www.berktree.com/assets/im
ages/default/dobutaminehydrochloride-in-5-dextroseinjection-solution-dobutamin-hclin-5-dex-500mg.jpg

Dobutamine
Dosage
Initial rate: 0.5-1 mcg/kg/min
Usual dose range: 220mcg/kg/min
Typical recommended maximum
dose is 20 mcg/kg/min
Side effects/adverse reactions
Hypertension
Ectopy/arrhythmias
Angina

Milrinone
Brand name: Primacor
Hemodynamic effects
Positive inotrope
Vasodilator
Little Chronotropic activity
Indications
Congestive heart failure
Decreased cardiac output

https://healthy.kaiserpermanente.org/static/dr
ugency/images/HOS27760.JPG

Milirone
Dosage
Bolus: 50mcg/kg over 10 mins
Infusion: 0.375-0.75mcg/kg/min
Side effects/adverse reactions
Hypotension
Ectopy/arrhythmias
Angina

IV Fluids

Isotonic Fluids
Osmolality of 250 to 375
mOsm/L
Expands intravascular
compartment

http://wildliferehabber.co
m/rehab-data/fluid-andelectrolyte-therapy

Isotonic Fluids
Isotonic Fluids
Normal saline; 0.9 NS
Lactated Ringers; LR
Dont give to patients with pH > 7.5
5% dextrose in water; D5W
Initially isotonic, but becomes
hypotonic
5% albumin
Nursing considerations
Watch for fluid overload

Hypotonic Fluids
Osmolality less than 250 mOsm/L
Will pull intravascular fluid into the cells

http://wildliferehabber.com/reha
b-data/fluid-and-electrolytetherapy

Hypotonic Fluids
Types of fluids
normal saline;0.45 sodium
chloride
0.2 sodium chloride
Nursing considerations
Can worsen
hypovolemia/hypotension
Do NOT give to patients with or
at risk for elevated ICP
Monitor for signs of peripheral

Hypertonic Fluids
Osmolarity greater than 375
mOsm/L
Will pull fluid from the
interstitial space (cells) to
the vascular compartment

http://wildliferehabber.co
m/rehab-data/fluid-andelectrolyte-therapy

Hypertonic Fluids
Fluid types
3% sodium chloride
25% albumin
5% Dextrose in 0.9 NS; D5.9
5% dextrose in 0.45 NS; D5.45
10% dextrose in water; D10W
Nursing considerations
Watch for fluid overload
Monitor blood sugar and

References
Hardin, S. R. & Kaplow, R. (2010).
Cardiac surgery essentials for
critical care nursing. Sudbury, MA:
Jones and Bartlett Publishers, LLC.
Wiegand, D. (2010). AACN procedure
manual for critical care, 6th edition.
St. Louis, MO: Elsevier Science.
Clinical Pharmacology Online
Database
Mosbys Nursing Skills