Hemodynamic Monitoring and

Transthoracic Lines
Purpose
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
What’s 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
 Non-invasive Vital signs

HR, BP, and RR Arterial oxygen

saturation
: Invasive Hemodynamic Monitoring
Arterial catheter
Central venous catheter
Pulmonary artery catheter
Percutaneous
Central
Venous
Catheter

PA
Pulmonary
LA Artery
Catheter
Left Atrial
Transthoracic
Catheter

RA
Right Atrial
Transthoracic
Catheter

Roth, S. 1998
CVP

The term "central venous pressure" (CVP)

is often used to describe the pressure
in the thoracic vena cava near the right
.atrium

It is used to assess the right ventricular

function and venous blood return to the
.right side of the heart
CVP is measured with a central venous 
.line in the superior vena cava

Normal CVP pressure is0 to 6 mm Hg 

with pressure monitoring system and
5-8cm H2O with water manometer
.system
-:INDICATIONS FOR CVP LINES ARE

fluid resuscitation , Continuing hypovolaemia

secondary to major fluid shifts or loss.
Parenteral feeding .
measurement or monitoring of central
venous pressure .
poor venous access .
Administration of irritant drugs(Long term IV
therapy)
Dialysis .
To asses cardiac function .
To take blood sample for testing .
 Types of central venous catheters

 Catheters are available which differ in length, internal

diameter, number of channels (access ports). Two useful
lengths are 20cm catheters for subclavian and internal jugular
lines, and 60cm catheters for femoral lines .

 Single lumen
 Double lumen (Triple - Quadruple
 Quintuple) .
COMMON CENTRAL LINE
INSERTION SITES
Subclavian vein (chest)

The Internal Jugular Vein(IJV)

the external jugular vein (EJV)

femoral vein (groin)(FV)

The Antecubital Veins

 The
Internal Subclavia
Jugular n vein
Vein
femoral vein
 DETERMINANTS

Cardiac Competence Blood Volume

reduced ventricular ( increased venous (
)function raises CVP )return raises CVP

CVP

Intra Aortic &

Systemic
Intra Peritoneal
Vascular Resistance
Pressure
)raises CVP(
)raises CVP(
:Reasons for elevated RA pressure

Sodium and water retention

Excessive IV fluids

Alterations in fluid balance

Renal failure
:Reasons for reduced RA pressure

low intravascular volume status •

may be due to hemorrhage •
severe vasodilation with
pooling of blood in the
extremities that limits
venous return
How to insert CVP
?..Line

Your central line will be put in at the hospital by a doctor
or specially-trained nurse.
 It is usually put in under a local anaesthetic, but
sometimes a general anaesthetic is used.
 Wash hand and use maximal sterile-barrier precautions
including
(a mask, a cap, a sterile gown, sterile gloves, and a large
sterile drape)
 You should not feel any pain when the tube is being put
in, but you may feel a bit sore for a few days afterwards.

First, your chest is cleaned with an antiseptic solution.

 A small cut is made in the skin near your collarbone and
the tip of the tube is threaded into a large vein. This is
called the insertion site.
 The tube is then tunnelled under the skin to reach the exit
site. The exit site is the place where the end of the tube
”How to insert CVP Line..? Con

The position of the exit site will vary from person
to person. You can ask the person who is going to
put the central line in where the exit site is likely
to be on your chest.

When the tube has been put in you will have
dressings covering the insertion and exit sites.
 For a few days you may have some pain or
discomfort where the tube has been tunnelled
under the skin. A mild painkiller such as
paracetamol will help to ease this.
Insert Central Line Post Central Line
Insert CVP Line
Phlebostatic Axis

4th intercostal space, mid-axillary line 

Level of the atria 

Edwards Lifesciences,(
).n.d 20
More on Leveling and Zeroing

HOB 0 – 60 degrees 

No lateral positioning 

Phlebostatic axis with 

any position (dotted
line)
).Edwards Lifesciences, n.d(

21
REMOVAL OF CENTRAL LINE..
 This is an aseptic procedure
 Wash your hand and wearing sterile gloves .
 The patient should be supine with head tilted down
 Ensure no drugs are attached and running via the
central line .
 Remove dressing
 Cut the stitches
 Ask the patient to take a breath and fully exhale.
 Slowly remove the catheter
 If it does not come out, try rotating it whilst pulling
gently.
 If this still fails, cover it with a sterile dressing and
ask an experienced person for advice or do it .
 The doctor or nurse may need to do a minor procedure to
remove it.
 When it is come out; you should Apply digital
pressure with gauze and ask the patient to remain
lying down until bleeding stops .
COMPLICATIONS FOLLOWING CVP
LINE INSERTION
 Malposition of the catheter
 Infection
 haematoma
 arterial puncture
 Pneumothorax
 haemorrhage
 sepsis
 air emboli
 Catheter embolism
 Thrombosis
 Haemothorax
 Cardiac tamponade
 Cardiac arrhythmias
Care of the Central
venous Catheter
 Use an aseptic technique when inserting the catheter and
any subsequent injections or changing fluid lines

 Keep the entry site covered with a dry sterile dressing

 Ensure the line is well secured to prevent movement (this

can increase risks of infection and clot formation)

 Change the catheter if there are signs of infection at the

site.

 Remember to remove the catheter as soon as it is no longer

needed. The longer the catheter is left in, the greater the
risks of sepsis and thrombosis
 ;con

 Some people suggest changing a catheter every 7 days to

reduce the risks of catheter related sepsis and thrombosis.

 However, providing that the catheter is kept clean (sterile

injections and connections) and there are no signs of
systemic sepsis, routine replacement may not be
necessary.
 : Direct Arterial Monitoring
Direct Arterial Monitoring Arterial
cannulation w/ continuous pressure
waveform display remains the
accepted standard for BP monitoring

: Indications
Arterial blood sampling
Continuous real time monitoring
: Arterial Pressure Monitoring
Radial
Ulnar
Femoral
Dorsalis pedis
Brachial and axillary

: Prerequisite
Adequacy of collateral flow to the hands must be
assessed by performing a modified Allen test
: Complications

Ischemia
Hemorrhage
Thrombosis/ Embolism
Cerebral air embolism
Skin necrosis Infection
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
Nursing intervention

Watch for hemorrhage and apply immediate pressure 

if the catheter is accidentally pulled off Prevent the
possibility of clot formation –give continues infusion
with heparinised solution
Proper flushing of catheter after the blood specimen 
is drawn
Inspect the extremity for signs of improper circulation 

Maintain strict aseptic technique 

Never inject any medication through this line 

09/01/2024 31
Indication

Thermister helps in assessing the 

.temperature
to monitor CVP, right atrial pressure, 
right ventricle pressure, pulmonary
artery pressure, cardiac output and
pulmonary artery wedge pressure
09/01/2024 33
09/01/2024 34
09/01/2024 35
09/01/2024 36
Swan Ganz
Cathetarization
Pulmonary arterial catheter 
 Hemodynamic Waveforms- Normal
Heart

)CVP(
PLACEMENT

mlr/2007
PLACEMENT

mlr/2007
HEMODYNAMIC
MONITORING
NURSING RESPONSIBILITIES
,Insertion .2
patient is often awake for the(
) procedure
a. Collaboration
b. Assist with equipment preparation
c. Monitor patients response to
treatment
e. Recording

09/01/2024 42
HEMODYNAMIC
MONITORING
NURSING RESPONSIBILITIES
Post-Insertion .3
Chest X-ray for placemen .a
Sterile OCCLUSIVE dressing, stabilization .b
of the catheter
Patient comfort .c
Assess and document pressures/data .d
Catheter maintenance .e
Monitor patients response .f

09/01/2024 43
HEMODYNAMIC
MONITORING
NURSING RESPONSIBILITIES
:Maintenance of the System 
a. Label and date lines, change tubing as per
unit policy
b. Maintain & change dressing
c. Alert for waveform and pressure changes
d. Maintain pressure/pressure bag
e. Keep balloon deflated between PCWP
readings
f. Collaboration and communication with
physician
g. Remember to care for the patient as well as
your equipment
09/01/2024 44
HEMODYNAMIC
MONITORING
NURSING RESPONSIBILITIES 
:Pre-Insertion .1
a. Patient & significant others
. teaching
b. Thorough baseline assessment
c. Equipment set-up
d. Positioning of the client
e. Equipment check (calibration, zero

09/01/2024 45
.. Thank you