BIOLOGIC CRISIS

PREPARED BY:
RONNIE M. AMAZONA, RN, MAN

22/08/2019 RICHARD C. LOGRO RN MAN PHD 1

 INTRODUCTION TO RESPIRATORY SYSTEM

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 INTRODUCTION TO RESPIRATORY SYSTEM

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 INTRODUCTION TO RESPIRATORY SYSTEM

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 INTRODUCTION TO RESPIRATORY SYSTEM

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 RESPIRATORY DISTRESS
SYNDROME (ARDS)
Is a life-threatening lung condition that prevents
enough oxygen from getting into the blood.

Is a sudden and progressive form of acute

respiratory failure
In which the alveolar capillary membrane becomes
damaged and more permeable to intravascular fluid
Resulting in severe dyspnea, hypoxemia and diffuse
pulmonary infiltrates.

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 Acute respiratory distress syndrome was first
described in 1967 by Ashbaugh and colleagues.
• ARDS is also referred with variety of terms like
• Stiff Lung
• Shock lung
• Wet lung
• Post traumatic lung
• Adult respiratory distress syndrome
• Adult hyaline membrane disease
• Capillary leak syndrome &
• Congestive atelectasis.
• Da Nang Lung
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 Criteria

• Acute onset
• Bilateral CXR infiltrates
• PA pressure < 18 mm Hg
• Classification
• Acute lung injury - PaO2 : F1O2 < 300
• Acute respiratory distress syndrome - PaO2 :
F1O2 < 200

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 ETIOLOGY & RISK FACTORS
Direct Lung Injury Indirect Lung Injury

Common causes Common causes

Aspiration of gastric contents or other Sepsis
substances. Severe traumatic injury
Viral/bacterial pneumonia Less common causes
Less Common causes Acute pancreatitis
Chest trauma Anaphylaxis
Embolism: fat, air, amniotic fluid Prolonged Cardiopulmonary bypass
Inhalation of toxic substances surgery
Near-drowning Disseminated intravascular coagulation
O2 toxicity Multiple blood transfusions
Radiation pneumonitis Narcotic drug overdose (e.g., heroin)
Nonpulmonary systemic diseases
Severe head injury
Shock
Massive blood transfusion.
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 SCHEMATIC REPRESENTATION OF PATHOPHYSIOLOGY OF ARDS
Lung injury

Damaged Type II alveolar cell Release of Vasoactive substances

(serotonin, histamine, bradykinin)
Surfactant production
Alveolocapillary Vascular
membrane narrowing &
Alveolar
permeability obstruction
Compliance and recoil
Bronchoconstriction

Outward migration
Atelectasis
of blood cells &
fluids from capillaries
Hyaline membrane
formation Pulmonary Edema

Lung
compliance
Impairment in
gas exchange

Pulmonary
ARDS hypertension
Mr sanjay. M. Peerapur, Principal, KLES Institute of Nursing Sciences, Hubli 10
 CLINICAL MANIFESTATIONS
Early signs/symptoms Late signs & symptoms
Restlessness Severe difficulty in breathing i.e., labored,
Dyspnea rapid breathing.
Low blood pressure Shortness of breath.
Confusion Tachycardia
Extreme tiredness Cyanosis (blue skin, lips and nails)
Change in patient’s behavior Think frothy sputum
Mood swing Metabolic acidosis
Disorientation Abnormal breath sounds, like crackles
Change in LOC PaCo2 with respiratory alkalosis.
If pneumonia is causing ARDS then client PaO2
may have
Cough
Fever

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 DIAGNOSITC EVALUATION
• History of above symptoms
• On physical examination
• Auscultation reveals abnormal breath sounds
• The first tests done are :
• Arterial blood gas analysis
• Bood tests
• Chest x-ray
• Bronchoscopy
• Sputum cultures and analysis
• Other tests are :
• Chest CT Scan
• Echocardiogram

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 COMPLICATIONS
Common complications are; Other complications are :

Nosocomial pneumonia: O2 toxicity,

Barotrauma stress ulcers,
Renal failure Tracheal ulceration,
Blood clots leading to deep vein
thrombosis &
pulmonary embolism.

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 MEDICAL MANAGEMENT
• Persons with ARDS are hospitalized and require
treatment in an intensive care unit.
• No specific therapy for ARDS exists.
• Supportive measures :
– Supplemental oxygen
– Mechanical respirator
– Positioning strategies
• Turn the patient from supine to prone.
• Another position is lateral rotation therapy
• Fluid therapy

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 TURNING PATIENT PRONE ON VOLLMAN PRONE
POSITIONER

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 PATIENT LYING PRONE ON VOLLMAN PRONE
POSITIONER

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 LATERAL ROTATION THERAPY BED

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 MEDICAL MANAGEMENT
• Medications :
– Antibiotics
– Anti-inflammatory drugs; such as corticosteroids
– Diuretics
– Drugs to raise blood pressure
– Anti-anxiety
– Muscle relaxers
– Inhaled drugs (Bronchodilators)

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 NURSING DIAGNOSIS
1. Ineffective breathing pattern related to decreased lung
compliance, decreased energy as characterized by
dyspnea, abnormal ABGs, cyanoisis & use of accessory
muscles.
2. Impaired gas exchange related to diffusion defect as
characterized by hypoxia (restlessness, irritability & fear
of suffocation), hypercapnia, tachycardia & cyanosis.
3. Risk for decreased Cardiac output related to positive
pressure ventilation
4. Ineffective protection related to positive pressure
ventilation, decreased pulmonary compliance &
increased secretions as characterized by crepitus, altered
chest excursion, abnormal ABGs & restlessness.

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 NURSING DIAGNOSIS
5. Impaired physical mobility related to monitoring
devices, mechanical ventilation & medications as
characterized by imposed restrictions of movement,
decreased muscle strength & limited range of
motion.
6. Risk for impaired skin integrity related to prolonged
bed rest, prolonged intubation & immobility.
7. Knowledge deficit related to health condition, new
equipment & hospitalization as characterized by
increased frequency of questions posed by patient
and significant others.

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 CRITICAL CARE
• HEMODYNAMIC MONITORING
• Cardiac Output

It is the measure of the volume of blood that is pumped out of the heart in a
duration of 1 minute.
Cardiac output is measured in terms of cubic dm (i.e. 1 liter).

The rate of cardiac output, by either the left or right ventricle at a given point
of time, is measured.

The average cardiac output in the resting phase for males is 5.6 L/min., while
this value for females is 4.9 L/min.

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• CO = HR x SV
• Cardiac output is the product of heart rate
and stroke volume. Stroke volume relies on
preload (mainly influenced by venous return
and circulating blood volume), afterload
(SVR) and cardiac muscle contractilty.

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 INTRODUCTION
Critically ill patients require continuous assessment of their cardiovascular

system to diagnose and manage their complex medical conditions.

This is most commonly achieved by the use of direct pressure monitoring

systems, often referred to as hemodynamic monitoring. Heart function is the

main focus of hemodynamic studies.

Hemodynamic pressure monitoring provides information about blood volume ,

fluid balance and how well the heart is pumping.

Nurses are responsible for the collection measurement and interpretation of these

dynamic patient status parameters.

HEMODYNAMIC MONITORING
 HEMODYNAMICS

 Hemodynamics are the forces which

circulate blood through the body.

 Specifically, hemodynamics is the term

used to describe the intravascular
pressure and flow that occurs when the
heart muscle contracts and pumps blood
throughout the body.
 DEFINITION
Hemodynamic monitoring refers to
measurement of pressure, flow and
oxygenation of blood within the
cardiovascular system.
OR
Using invasive technology to provide
quantitative information about vascular
capacity, blood volume, pump effectiveness
and tissue perfusion.

OR
Hemodynamic monitoring is the
measurement and interpretation of biological
sytems that describes the performance of
cardiovascular system
 PURPOSES

 Early detection, identification and treatment

of life threatening conditions such as heart
failure and cardiac tamponade.
 Evaluate the patient’s immediate response to
treatment such as drugs and mechanical
support.
 Evaluate the effectiveness of cardiovascular
function such as cardiac output and index.
 INDICATIONS

 Any deficits or loss of cardiac function:

such as myocardial infarction, congestive
heart failure, cardiomyopathy.

 All types of shock; cardiogenic shock,

neurogenic shock or anaphylactic shock.

 Decreased urine output from dehydration,

hemorrhage. G.I bleed, burns or surgery.
 SPECIALISED EQUIPMENTS NEEDED FOR INVASIVE
MONITORING

 A CVP, pulmonary artery ,arterial catheter

 A flush system composed of intravenous solution,tubing stop cocks

and a flush device which provides for continous and manual
flushing of system.

 A pressure bag placed around the flush solution that is maintained

at 300 mmhg pressure ;the pressurized flush system delivers 3-5ml
of solution per hour through the catheter to prevent clotting and
backflow of blood into the pressure monitoring system.

 A tranducer to convert the pressure coming from artery or heart

chamber into an electrical signal

 An amplifier or moniter which increases the size of electrical signal

for display on an occilloscope.
HEMODYNAMIC MONITER
 SETUP FOR HEMODYNAMIC PRESSURE
MONITORING
 Obtain barrier kit, sterile gloves and correct swan
catheter. Also need extra iv pole, transducer holder,
boxes and cables.

 Check to make sure signed consent is in chart , and that

patient and or family understand procedure.

 Everyone in the room should be wearing a mask.

 Position patient supine and flat if tolerated.

 On the monitor , press “change screen” button , then
select “swan ganz” to allow physician to view catheter
wave forms which inserting.

 Assist physician in sterile draping and sterile setup for

swan insertion.
 Setup pressure lines and transducers. Level pressure flush
monitoring system and transducers to the phlebostatic axis.

 Connect tubings to patient when patient is ready to flush the

swann.

 While floating the swann, observe for ventricular ectopy on the

monitor.

 After swann is in place, assist with cleanup and let patient know
procedure is complete.

 Obtain all the values. For cardiac output inject 10mls of D5w
after pushing the start button.

 Perform hemocalculations.

 Document findings in ICU flow sheet.

PHLEBOSTATIC AXIS
DETERMINANTS OF CARDIAC PERFORMNACE

 PRELOAD is the initial stretching of the

cardiac myocytes (muscle cells) prior to
contraction.
 AFTERLOAD is the pressure against
which the heart must work to eject
blood during systole.
 CONTRACTILITY is the inherent
strength and vigour of the heart's
contraction during systole.
METHODS OF HEMODYNAMIC MONITORING

 1.ARTERIAL BLOOD PRESSURE

 a)Non Invasive
 b)Intra arterial blood pressure
measurement
 2.CENTRAL VENOUS PRESSURE
 3.PULMONARY ARTERY CATHETER
PRESSURE MONITORING
NON INVASIVE ARTERIAL BP MONITORING

 With manual or automated devices

Method of measurement

 Oscillometry method of measuring blood pressure

with an automated cuff yields valid estimates of
mean pressure but questionable estimates of systolic
and diastolic pressures.
 Auscultatory (korotkoff sounds)

 Combination
 NON INVASIVE

HEMODYNAMIC
MONITORING
 LIMITATIONS

 Cuff must be placed correctly and must be

appropriately sized

 Auscultatory method is very inaccurate

(Korotkoff sound is difficult to hear)

 Significant underestimation in low flow

(shock)

 Oscillometric also mostly in accurate

( >5mmhg off directly recorded pressures)
DIRECT INTRA ARTERIAL BP MONITORING
 Intra-arterial BP monitoring is used to
obtain direct and continuous BP
measurements in critically ill patients who
have severe hypertension or hypotension
 COMPLICATIONS

 Local destruction with distal ischemia

 external hemorrhage
 massive ecchymosis
 dissection
 air embolism
 blood loss
 pain
 arteriospasm and
 infection.
 NURSING INTERVENTIONS
 Before insertion of a catheter, the site is
prepared by shaving if necessary and by
cleansing with an antiseptic solution. A
local anesthetic may be used.

 Once the arterial catheter is inserted, it is

secured and a dry, sterile dressing is
applied.

 The site is inspected daily for signs of

infection. The dressing and pressure
monitoring system or water manometer
are changed according to hospital policy.
 In general, the dressing is to be kept dry and air
occlusive.

 Dressing changes are performed with the use of sterile

technique.

 Arterial catheters can be used for infusing intravenous

fluids, administering intravenous medications, and
drawing blood specimens in addition to monitoring
pressure.

 To measure the arterial pressure, the transducer (when a

pressure monitoring system is used) or the zero mark on
the manometer (when a water manometer is used) must
be placed at a standard reference point, called the
phlebostatic axis .

 After locating this position, the nurse may make an ink

mark on the chest
 CENTRAL VENOUS PRESSURE MONITORING

The CVP, the pressure in the vena cava or

right atrium, is used to assess right
ventricular function and venous blood return
to the right side of the heart.

The CVP can be continuously measured by

connecting either a catheter positioned in the
vena cava or the proximal port of a
pulmonary artery catheter to a pressure
monitoring system
 PROCEDURE

 Before insertion of a CVP catheter, the site is

prepared by shaving if necessary and by
cleansing with an antiseptic solution.

 A local anesthetic may be used. The

physician threads a single lumen or
multilumen catheter through the external
jugular, antecubital, or femoral vein into the
vena cava just above or within the right
atrium
 NURSING INTERVENTIONS

 Once the CVP catheter is inserted, it is secured and a

dry, sterile dressing is applied.

 Catheter placement is confirmed by a chest x-ray, and

the site is inspected daily for signs of infection. The
dressing and pressure monitoring system or water
manometer are changed according to hospital policy.

 In general, the dressing is to be kept dry and air

occlusive.

 Dressing changes are performed with the use of sterile

technique.
 CVP catheters can be used for infusing
intravenous fluids, administering intravenous
medications, and drawing blood specimens in
addition to monitoring pressure.

 To measure the CVP, the transducer (when a

pressure monitoring system is used) or the
zero mark on the manometer (when a water
manometer is used) must be placed at a
standard reference point, called the
phlebostatic axis .

 After locating this position, the nurse may

make an ink mark on the chest
PULMONARY ARTERY PRESSURE MONITORING

 Pulmonary artery pressure monitoring is an

important tool used in critical care for assessing
left ventricular function, diagnosing the etiology
of shock, and evaluating the patient’s response
to medical interventions (eg, fluid administration,
vasoactive medications).
 Pulmonary artery pressure monitoring is
achieved by using a pulmonary artery catheter
and pressure monitoring system.
PULMONARY ARTERY PRESSURE MONITORING
 PULMONARY ARTERY CATHETER

 Development of the balloon-tipped flow

directed catheter has enabled continuous
direct monitoring of PA pressure.
Pulmonary artery catheter otherwise
known as “swan- ganz catheter”.
COMPONENTS OF CATHETER
 INSERTION OF PAC

 PA monitoring must be carried out in a critical care

unit under careful scrutiny of an experienced
nursing staff.

 Before insertion of the catheter , explain to the

client that;
 The procedure may be uncomfortable but not
painful.
 A local anesthetic will be given at the catheter
insertion site. Support of the critically ill client at
this time helps promote cooperation and lessen
anxiety.
 Procedure
 This procedure can be performed in the
operating room or cardiac catheterization
laboratory or at the bedside in the critical care
unit.Catheters vary in their number of lumens
and their types of measurement (eg, cardiac
output, oxygen saturation) or pacing
capabilities.

 All types require that a balloon-tipped, flow-

directed catheter be inserted into a large vein
(usually the subclavian, jugular, or femoral
vein); the catheter is then passed into the vena
cava and right atrium.
 In the right atrium, the balloon tip is
inflated, and the catheter is carried rapidly
by the flow of blood through the tricuspid
valve, into the right ventricle, through the
pulmonic valve, and into a branch of the
pulmonary artery.

 (During insertion of the pulmonary artery

catheter, the bedside monitor is observed
for waveform andECG changes as the
catheter is movedthrough the heart
chambers on the right side and into the
pulmonary Artery)
 When the catheter reaches a small pulmonary
artery, the balloon is deflated and the catheter is
secured with sutures.

 Fluoroscopy may be used during insertion to

visualize the progression of the catheter through
the heart chambers to the pulmonary artery.

 After the catheter is correctly positioned, the

following pressures can be measured:

 CVP or right atrial pressure

 pulmonary artery systolic and
 diastolic pressures, mean pulmonary artery
pressure, and pulmonary artery wedge
pressure).
 NORMAL RESULTS

 Normal pulmonary artery pressure is

25/9 mm Hg, with a mean pressure of 15
mm Hg.
 Pulmonary capillary wedge pressure is
a mean pressure and is normally 4.5 to 13
mm Hg.
 NURSING INTERVENTIONS
 Catheter site care is essentially the same as for a CVP
catheter. As in measuring CVP, the transducer must be
positioned at the phlebostatic axis to ensure accurate
readings .

 The nurse who obtains the wedge reading ensures that

the catheter has returned to its normal position in the
pulmonary artery by evaluating the pulmonary artery
pressure waveform.

 The pulmonary artery diastolic reading and the wedge

pressure reflect the pressure in the ventricle at end-
diastole and are particularly important to monitor in
critically ill patients, because they are used to evaluate
left ventricular filling pressures (preload)
 At end-diastole, when the mitral valve is
open, the wedge pressure is the same
as the pressure in the left atrium and
the left ventricle, unless the patient has
mitral valve disease or pulmonary
hypertension.

 Critically ill patients usually require

higher left ventricular filling pressures to
optimize cardiac output. These patients
may need to have their wedge pressure
maintained as high as 18 mm Hg.
 COMPLICATIONS

 Infection
 pulmonary artery rupture
 pulmonary thromboembolism
 pulmonary infarction
 catheter kinking,
 dysrhythmias, and
 air embolism.
 TECHNIQUES WITH PULMONARY ARTERY
CATHETER
 CARDIAC OUTPUT MONITORING
 THERMODILUTION
 CONTINUOUS CARDIAC OUTPUT MONITORING
 FICK'S CARDIAC OUTPUT MEASUREMENT
Fick’s Method - a generalization in physiology which states that blood flow is
proportional to the difference in concentration of a substance in the blood as it
enters and leaves an organ and which is used to determine cardiac output from
the difference in oxygen concentration in blood before it enters and after it leaves
the lungs .

 CO = VO2 (volume of O2 uptake)

---------
Ca-Cv
Where:
Ca = Arterial oxygen concentration, about 200ml/L
Cv = Venous oxygen concentration, about 150ml/L (measured with PA Catheter)
• So, in a normal person, with a body surface area
of 2m2 and thus with a VO2 of 250ml per minute,

• CO = 250ml / (200ml – 150ml)

• = 250 / 50

• = 5 L/min

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 DERIVED PARAMETERS

 Cardiac o/p measurements may be combined with systemic

arterial, venous, and PAP determinations to calculate a number
of variables useful in assessing the overall hemodynamic status
of the patient.
They are,
 Cardiac index = Cardiac output / Body surface area
 Systemic vascular resistance = [(Mean arterial pressure -
resistance CVP or rt atrial pressure)/Cardiac output] x 80
 Pulmonary vascular resistance = [(PAP - PAWP) / Cardiac
vascular resistance output] x 80
 Mixed venous oxygen saturation (SvO2)
(SvO2 = SaO2 - [VO2 / (1.36 x Hb x CO)] (6)
 NURSING RESPONSIBILITIES
 Site Care and Catheter Safety:
 A sterile dressing is placed over the insertion site
and the catheter is taped in place. The insertion
site should be assessed for infection and the
dressing changed every 72 hours and prn.
 The placement of the catheter, stated in centimeters,
should be documented and assessed every shift.
 The integrity of the sterile sleeve must be maintained
so the catheter can be advanced or pulled back
without contamination.
 The catheter tubing should be labeled and all the
connections secure. The balloon should always be
deflated and the syringe closed and locked unless
you are taking a PCWP measurement
 Patient Activity and Positioning:

 Many physicians allow stable patients

who have PA catheters, such as post
CABG patients, to getout of bed and sit.
The nurse must position the patient in a
manner that avoids dislodging the
catheter.

 Proper positioning during hemodynamic

readings will ensure accuracy.
 Dysrhythmia Prevention:

 Continuous EKG monitoring is essential

while the PA catheter is in place.

 Do not advance the catheter unless the

balloon is inflated.

 Antiarrhythmic medications should be

readily available to treat lethal
dysrhythmias.
 Monitoring Waveforms for Proper Catheter
Placement:

 The nurse must be vigilant in assessing

the patient for proper catheter placement.
 If the PA waveform suddenly looks like the
RV or PCWP waveform, the catheter may
have become misplaced.
 The nurse must implement the proper
procedures for correcting the situation.
Monitoring Hemodynamic Values for Response
to Treatments:

 The purpose of the PA catheter is to assist

healthcare team members in assessing
the patient’s condition and response to
treatment.
 Therefore, accurate documentation of
values before and after treatment changes
is necessary.
 Assessing the Patient for Complications Associated with the PA
Catheter:
 Occluded ports
 Balloon rupture caused by overinflating the balloon or
frequent use of the balloon.
 Pneumothorax - may occur during initial placement.
 Dysrhythmias - caused by catheter migration
 Air embolism - caused by balloon rupture or air in the
infusion line.
 Pulmonary thromboembolism - improper flushing
technique, non-heparinized flush solution.
 Pulmonary artery rupture - perforation during
placement, overinflation of the balloon, overuse of the
balloon.
 Pulmonary infarction - caused by the catheter migrating
into the wedge position, the balloon left inflated, or
thrombus formation around the catheter which causes
an occlusion.
 CONCLUSION
 Hemodynamics is the forces involved in blood circulation.
Hemodynamic monitoring started with the estimation of heart rate
using the simple skill of 'finger on the pulse' and then moved on to
more and more sophisticated techniques like stethoscope,
sphygmomanometer, ECG etc.

 The status of critically ill patients can be assessed either from non-
invasive single parameter indicators or various invasive techniques
that provide multi-parameter hemodynamic measurements.

 As a result, comprehensive data can be provided for the clinician to

proactively address hemodynamic crisis and safely manage the
patient instead of reacting to late indicators of hemodynamic
instability
 CIRCULATORY ASSIST
DEVICES

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Intra-aortic Balloon Pump (IABP)
 History
• Realization that coronary perfusion mainly
occurs during diastole -1950s
• Aspiration of arterial blood during systole with
reinfusion during diastole decreased cardiac
work without compromising coronary
perfusion – Harkin-1960s
• Intravascular volume displacement with latex
balloons - early 1960s
 Background
• Preload
• Afterload
• Coronary flow
• Myocardial oxygen consumption in the heart
is determined by:
– Pulse rate
– Transmural wall stress
– Intrinsic contractile properties
 Myocardial Oxygen Consumption
• Has a linear relationship to:
– Systolic wall stress
– Intraventricular pressure
– Afterload
– End diastolic volume
– Wall thickness
 Indications for IABP
• Cardiac failure after a cardiac surgical
procedure
• Refractory angina despite maximal medical
management
• Perioperative treatment of complications due
to myocardial infarction
• Failed PTCA
• As a bridge to cardiac transplantation
 IABP in Myocardial Infarction and Cardiogenic
Shock
• Improves diastolic flow velocities after
angioplasty
• Allows for additional intervention to be done
more safely
 IABP During or After Cardiac Surgery
• Patients who have sustained ventricular
damage preoperatively and experience
harmful additional ischemia during surgery
• Some patients begin with relatively normal
cardiac function an experienced severe, but
reversible, myocardial stunning during the
operation
IABP As a Bridge to Cardiac Transplantation
• 15 to 30 % of end stage cardiomyopathy
patients awaiting transplantation need
mechanical support

• May decrease the need for more invasive

LVAD support
 Other Indications for IABP
• Prophylactic use prior to cardiac surgery in
patients with:
– Left main disease
– Unstable angina
– Poor left ventricular function
– Severe aortic stenosis
 Contraindications to IABP
• Severe aortic insufficiency
• Aortic aneurysm
 Insertion Techniques
• Percutaneous
– sheath less
• Surgical insertion
 Positioning
• The end of the balloon should be just distal to
the takeoff of the left subclavian artery
• Position should be confirmed by fluoroscopy
or chest x-ray
 Timing of Counterpulsation
• Electrocardiographic
• Arterial pressure tracing
 Weaning of IABP
• Decreasing inotropic support
• Decreasing pump ratio
 Complications

• Limb ischemia
– Thrombosis
– Emboli
• Bleeding and insertion site
– Groin hematomas
• Aortic perforation and/or dissection
• Renal failure and bowel ischemia
• Neurologic complications including paraplegia
• Heparin induced thrombocytopenia
• Infection
 IABP Removal
• Discontinue heparin six hours prior
• Check platelets and coagulation factors
• Deflate the balloon
• Apply manual pressure above and below IABP
insertion site
• Remove and alternate pressure to expel any clots
• Apply constant pressure to the insertion site for a
minimum of 30 minutes
• Check distal pulses frequently
 Cardiopulmonary Bypass
The heart lung machine
The pump
The bypass machine
 History
• Concept of diverting the circulation to an
extracorporeal oxygenator – 1885
• Mechanical pump oxygenators – 1953
• Controlled cross circulation – 1954
• First series of intracardiac operations using a
pump oxygenator – 1955
 The Apparatus
• Pumps
– Simple roller pump
– Centrifugal pump
• Venous reservoir
• Oxygenator
• Heat exchanger
• Other
 Venous Reservoir
• Siphons blood by gravity
• Provide storage of excess volume
• Allows escape of any air bubbles returning
with the venous blood
 Oxygenator
• Provides oxygen to the blood
• Removes carbon dioxide
• Several types
– Bubble oxygenator
– Membrane oxygenator
– Microporous hollow-fiber oxygenators
 Heat Exchanger
• Also called the heater / cooler
• Controls perfusate temperature
– Warm and cold
 Cardiopulmonary Bypass
• Heparinization
• Total bypass
• Partial bypass
• Flowrates 2-2.5 l/min. per square meter
– Flowrates depend on body size
– Flowrates depend on cannula sizes
• Hypothermia
 Shed Blood
• Is aspirated with a suctioning apparatus,
filtered and return to the oxygenator
• A cell saving device may also be utilized during
and after bypass
 Blood Pressure
• Decreases sharply with onset of bypass
(vasodilatation)
• Mean arterial pressure needs to the above 50-
60 mm Hg.
• After 30 minutes perfusion pressure usually
increases (vasoconstriction)
 Oxygen and Carbon Dioxide Tensions
• Concentrations are periodically measured in
both arterial and venous lines
• Arterial oxygen tension should be above 100
mm Hg
• Arterial carbon dioxide tensions should be 30-
35 mm Hg
• A drop in venous oxygen saturation suggests
underperfusion
 Myocardial Protection
• Cold hyperkalemic solutions
– Produces myocardial quiescence
– Decreases metabolic rate
– Provides protection for 2-3 hours
– Blood vs. crystalloid
 Termination of Perfusion
• Systemic rewarming
• Flowrates are decreased
• Hemodynamic parameters
• Venous line clamping
• Pharmacologic support
• Neutralization of heparin
Complications of Cardio- Pulmonary Bypass
– Post perfusion syndrome
– Duration of bypass
– Age
– Anemia
– Other
 INTRODUCTION
An artificial heart is a prosthetic device
that is implanted into the body to replace
the biological heart.

Artificial heart a pumping mechanism

that duplicates the rate, output, and blood
pressure of the natural heart; it may
replace the function of a part or all of the
heart. 108
ARTIFICIAL HEART
HISTORY

109
Artificial heart are of three types

VENTRICULAR ARTIFICIAL

HEART

VENTRICULAR ASSIST DEVICE

TOTAL ARTIFICIAL HEART

110
 VENTRICULAR ARTIFICIAL
HEART
The jarvik-7 design incorporates two heart pumps that are connected to a
power console.
Each pump is small enough to be
implanted into the void that was left
behind from the extraction.

Both pumps receive power from a large

external console. The console pushes
air through the tubing.

Air enters inside the pump and is

expelled through a series of thin
flexible diaphragms.
111
 VENTRICULAR ASSIST
DEVICE
Ventricular assist device, invented by Dr Michael DeBakey was
implanted in 1966 at Methodist hospital in Texas.

Michael has pioneered the development

of heart pumps since the early 1960s.
In 1966, he performed the first
successful implantation of a ventricular
assist device.
The patient's heart recovered while the
VAD took over its pumping chores.

112
 TOTAL ARTIFICIAL
HEART
The AbioCor™ implantable replacement
heart is the first completely self-contained
total artificial heart. It is the product of
30 years of research, development,
and testing conducted by ABIOMED, Inc.
in order to extend and improve the lives of
patients who would otherwise die of heart
failure.

113
 ABIOCOR SYSTEM
The AbioCor, along with other
components is surgically
implanted; it is designed to fit
within chest and abdomen.
The AbioCor System consists of
the following implanted
components:
 Replacement Heart
 Implanted TET
 Implanted Controller
 Implanted Battery
114
 REPLACEMENT HEART
The thoracic unit weighs slightly more than two pounds (0.9 kg) and is
about the same size and shape of a natural heart.

It is made of titanium, and Angioflex, a polyurethane plastic.

The thoracic unit is implanted in the chest,

and connects to the right and left atria, the
aorta, and the pulmonary artery.

The thoracic unit contains two hydraulic

motors; one keeps the blood pumping from
each ventricle (blood pump), and the other
operates the motion of the four heart valves.

115
 IMPLANTED
TRANSCUTANEOUS ENERGY
TRANSMISSION (TET)

The implanted TET is an electric coil that

provides all of the AbioCor System’s
internal devices with electrical energy.

It is connected to the thoracic unit, the

implanted controller, and the implanted
battery.

The implanted TET is located on the

upper-left area of the chest (opposite of
the artificial heart).
116
 IMPLANTED CONTROLLER
The implanted controller is a small automatic computer located in the
abdomen of the patient’s body.

It is secured in a titanium case and connects to all internal

components.

The job of the implanted controller is to

oversee the internal components of the
AbioCor System.

The implanted controller is also able to

manage the artificial heart’s cardiac output
rate to make sure that the artificial heat
generates the necessary blood flow.
117
 IMPLANTED BATTERY
The implanted battery is placed in the abdomen,
opposite from the implanted Controller.
It is implanted when the implanted controller and the
artificial heart are placed in the patient’s body.
The implanted battery is kept in a titanium case, it
receives energy from the external TET.
It is connected to all other internal components.
If the patient were to separate himself from the
external TET and battery pack (such as to take a
shower), the implanted battery would provide energy
for 30 - 40 minutes.
118
 External Components:
TRANSCUTANEOUS ENERGY
TRANSMISSION (TET)
PATIENT-CARRIED ELECTRONICS.
PCE BATTERY BAG
PCE BATTERIES
PCE CONTROL MODULE
119
 TRANSCUTANEOUS ENERGY
TRANSMISSION (TET)
The external TET is placed directly over the location of the internal
TET to transfer energy through the skin.

If the patient is stationary and is near a power outlet, his source for
energy may be the console.
If the patient is mobile and has
no intentions of remaining in
the same location for a long
period of time, he may use the
PCE as a power source.
120
 PATIENT-CARRIED
ELECTRONICS
The patient using the AbioCor System is
not forced to stay in bed hooked up to the
system’s console;

He is also given the option to move around

and not have to depend on a power outlet to
power the system’s components.

If the patient chooses to be

mobile(movable) he may use the Patient-
Carried Electronics

(PCE) by plugging the external TET into

the PCE’s control module.
121
 PCE BATTERY BAG
PCE Battery Bag weighs : 10 pounds.

Carried by using : An attached shoulder strap (Abiomed).

Inside of the bag contains : Four batteries, plastic cardholders.

Outside of the bag contains : PCE control module.

122
 PCE BATTERIES
Each pair of PCE Batteries supplies the AbioCor’s internal system
with power for about one hour (Abiomed).
The battery bag can carry two pairs of PCE batteries.
The internal system may be supplied with power for about two
hours .
 Additionally, since the PCE batteries don’t last very long,
they must be changed several times a day so patient can take extra
batteries if necessary.

123
 PCE CONTROL MODULE

The PCE control module is to be placed in one of the

pockets of the PCE battery bag.

It is connected to the batteries by a battery cable and is

also connected to the external TET.

 If a problem occurs within one of the internal devices,

the control module immediately notifies the patient.

124
 FUNCTION

To maintain operation, the AbioCor System must first have a

source of power depending on whether or not the patient is
mobile.

This power source will either be the console or the PCE control
module.

If the power source detects a problem, an alarm light or an

alarm sound notifies the patient.

Otherwise, if no problems are detected the AbioCor System

follows a cyclic function and continues to operate. 125
 COST OF IMPLANTATION

Complete heart replacement device

can cost about $75,000.

Procedure expenses cost about

$175,000.

It is financed by the national heart

research fund.
126
 CONCLUSION
There are many obstacles to overcome before any TAH is widely
accepted.

The AbioCor System consists of a set of internal components and

external components.

The internal and external TETs work together to convert this

energy into usable energy for all internal components.

All of these provide power for the artificial heart and components
keep the artificial heart pumping blood and keep sending that
blood throughout the patient’s body.
127
“ARTIFICIAL HEART IS NOT AS A BRIDGE
TO
TRANSPLANTATION BUT AS A LIFE
EXTENDING DEVICE”

128
 Nursing Care of
Ventilated Patient
 Out lines:
• Objectives
• Definition of M.V
• Indications
• Modes of M.V
• Adjustment of M.V
• Complications of M.V
• Nursing Management
 Objectives
 To define what is the mechanical ventilator.

 To know what are the indications for M.V .

 To determine modes of mechanical ventilation

.

 To know how to adjust M.V .

 To know how to deal with complications of

M.V .
 To determine what is the nursing
management of ventilated patient .
Definition of Mechanical
Ventilator
• Is a machine that generates a controlled flow of gas
into a patient’s airways.
• Oxygen and air are received from cylinders or wall
outlets, the gas is pressure reduced and blended
according to the prescribed inspired oxygen tension
(FiO2), accumulated in a receptacle within the
machine, and delivered to the patient using one of
many available modes of ventilations.
 Indications
• Need for sedation/
neuromuscular blockage.

• Need to decrease systemic or

myocardial oxygen consumption.

• Use of hyperventilation to reduce

intracranial pressure.
 Indications
 Ventilation abnormalities

Respiratory muscle dysfunction

Respiratory muscle fatigue
Chest wall abnormalities
Neuromuscular diseases
 Indications
 Oxygenation Abnormalities

Refractory hypoxemia.
Need for positive end expiratory
pressure.
Excessive work of breathing.
Modes of Ventilation:
 Modes of Ventilation:

 The machine is not giving pressure breath.

 The Pt. breath spontaneously.
 The Pt. needs only specific FIO2 to maintain its
normal blood gases.
The machine controls the patient ventilation
according to set tidal volume and respiratory
rate . spontaneous respiratory effort of Pt. is
locked out , ( patient who receives sedation and
paralyzing drugs he will on controlled Mode).
 :
Machine allows the Pt to breath spontaneously
while providing preset FIO2 , and a number of
ventilator breaths to ensure adequate
ventilation without fatigue.
The Pt. triggers the machine with negative
inspiratory effort. If the Pt. fails to breath the
machine will deliver a controlled breath at a
minimum rate and volume already set.
Adjustment on the ventilator:
 The ventilator is adjusted so that the pt. is
comfortable and "in sync " with the machine.

 Minimal alteration of the normal cardiovascular

 and pulmonary dynamics is desired.

If the volume of ventilator is adjusted appropriately ,

the pt. arterial blood level will be satisfactory and there
will be no or little cardiovascular compromise.
 The Following Guidelines
are Recommended:
1. set the machine to deliver the required tidal
volume ( 6 to 8 ml/kg)

2. adjust the machine to deliver the lowest

concentration of the oxygen to maintain
normal PaO2 (80 to 100mmhg).The setting
may be set high and gradually reduced
based on ABGs result.
3. Record peak inspiratory pressure.

4. Set mode (assist/control or SIMV)and rate

according to physician order.

5. If Pt. is on assist/control mode , adjust

sensitivity so that the Pt. can trigger the
ventilator with the minimum effort( usually
2mmHg negative inspiratory force)
6. Record minute volume and measure carbon
dioxide partial pressure PaCO2, PH after 20
minutes of mechanical ventilation.

7. Adjust FIO2 and rate according to results of

ABG to provide normal values or those set
by the physician.
8. In case of sudden onset of confusion , agitation or
unexplained " bucking the ventilator " the Pt. should
be assessed for hypoxemia and manually ventilated
on 100% oxygen with resuscitation bag ( AMBU bag)
Bag – Valve – mask.

9. Patient who are on controlled ventilation and have

spontaneous respiration may " fight or buck " the
ventilator, because they cannot synchronize their
own respiration with the machine cycle.
Sedative and neuromuscular blocking agents
may be given such as:

 Pancuornium bromide(Pavulon)

 Midazolam

 Neuromuscular blocking agents block the

transmission of nerve impulses and result in
muscle paralysis.
Complications of M.V
 A- Decreased Cardiac Output
 Cause - venous return to the right atrium impeded by the
dramatically increased intrathoracic pressures during inspiration
from positive pressure ventilation. Also reduced sympatho-adrenal
stimulation leading to a decrease in peripheral vascular
resistance and reduced blood pressure.
 Symptoms – increased
 heart rate,
 decreased blood pressure and perfusion to vital organs, decreased
CVP,
 and cool clammy skin.
 Treatment – aimed at increasing preload (e.g. fluid administration)
and decreasing the airway pressures exerted during mechanical
ventilation by decreasing inspiratory flow rates and TV, or using
other methods to decrease airway pressures (e.g. different modes of
ventilation).
 B. Barotrauma
 Cause – damage to pulmonary system due to alveolar
rupture from excessive airway pressures and/or
overdistention of alveoli.
 Symptoms – may result in pneumothorax,
pneumomediastinum and subcutaneous emphysema.
 Treatment - aimed at reducing T.V, cautious use of PEEP,
and avoidance of high airway pressures resulting in
development of auto-PEEP in high risk patients
(patients with obstructive lung diseases (asthma,
bronchospasm), unevenly distributed lung
diseases (lobar pneumonia), or hyperinflated lungs
(emphysema).
 C. Nosocomial Pneumonia
 Cause – invasive device in critically ill patients becomes colonized
with pathological bacteria within 24 hours in almost all patients. 20-
60% of these, develop nosocomial pneumonia.
 Treatment – aimed at prevention by the following:
 Avoid cross-contamination by frequent handwashing
 Decrease risk of aspiration (cuff occlusion of trachea, positioning,
use of small-bore NG tubes)
 Suction only when clinically indicated, using sterile technique
 Maintain closed system setup on ventilator circuitry and avoid
pooling of condensation in the tubing
 Ensure adequate nutrition
 Avoid neutralization of gastric contents with antacids and H2
blockers
E. Decreased Renal Perfusion – can be treated
with low dose dopamine therapy.

F. Increased Intracranial Pressure (ICP) –

reduce PEEP

G. Hepatic congestion – reduce PEEP

H. Worsening of intracardiac shunts –reduce

PEEP
 . Other common potential
problems related to mechanical
ventilation:

 Aspiration,
 GI bleeding,
 Inappropriate ventilation
 (respiratory acidosis or alkalosis,
 Thick secretions,
 Patient discomfort due to pulling or jarring of ETT or tracheostomy,
 High PaO2, Low PaO2,
 Anxiety and fear,
 Dysrhythmias
 or vagal reactions during or after suctioning,
 Incorrect PEEP setting,
 Inability to tolerate ventilator mode.
Nursing Management of
Ventilated Patient
Nursing Management:

1. Promote respiratory function.

2. Monitor for complications
3. Prevent infections.
4. Provide adequate nutrition.
5. Monitor GI bleeding.
 PROMOTE RESPIRATORY
FUNCTION
1. Auscultate lungs frequently to
assess for abnormal sounds.
2. Suction as needed.
3. Turn and reposition every 2
hours.
4. Secure ETT properly.
5. Monitor ABG value and pulse
oximetry.
 Suction of an Artificial
Airway
1. To maintain a patent airway
2. To improve gas exchange.
3. To obtain tracheal aspirate
specimen.
4. To prevent effect of retained
secretions.
( Its important to OXYGENATE before
and after suctioning)
 MONITOR FOR COMPLICATIONS

1. Assess for possible early complications

Rapid electrolyte changes.
Severe alkalosis.
Hypotension secondary to change in
Cardiac output.

2. Monitor for signs of respiratory distress:

Restlessness
Apprehension
Irritability and increase HR.
3. Assess for signs and symptoms of
barotrauma(rupture of the lungs)
Increasing dyspnea
Agitation
Decrease or absent breath sounds.
Tracheal deviation away from affected
side.
Decreasing PaO2 level .

1. Assess for cardiovascular depression:

Hypotension
Tachy. and Bradycardia
Dysrhythmias.
 PREVENT INFECTION
1. Maintain sterile technique when suctioning.
2. Monitor color, amount and consistency of sputum.

 PROVIDE ADEQUATE NUTRITION

1. Begin tube feeding as soon as it is evident the patient will remain
on the ventilator for a long time.
2. Weigh daily.
3. Monitor I&O .

 MONITOR FOR GI BLEEDING

1. Monitor bowel sounds.
2. Monitor gastric PH and hematest gastric secretions every shift.
Questions!!!