Post-operative Invasive Cardiac Monitoring by Dorothy Beke.
Please note, that in this video, we will be folloing the guidlines used at Boston Children's Hospital.
Some of this information my need to be modified based on the equipment,
guidelines, and practices in place in your institution.
Hello, my name is Dorothy Beke. I'm a clinical nurse specialist in the cardiac intensive
care unit at the Children's Hospital Boston. Today, we'll be discussing the pediatric cardiac
post-operative patient and important nursing considerations.
I will present an overview of general post-operative considerations for the pediatric patient after
cardiopulmonary bypass, and strategies for managing the patient's care. In this first
video, I will be discussing sign-out and invasive monitoring.
Interdisciplinary Sign-Out.
All team members should listen to the interdisciplinary post-operative report. The interdisciplinary
team includes the bedside nurse, anesthesiologist, cardiac surgeon, and intensive care unit doctor.
It is important that the bedside nurse participates in the sign-out report. Another nurse should
care for the post-operative patient during this time.
Sign-out report should include details of the patient diagnosis and pre-operative condition,
intraoperative report, any medications used, and details of imaging studies, such as an
echocardiogram.
In closing the loop, information is summarized and the post-operative management plan is
discussed with the team. The patient's bedside nurse should clarify any information as needed.
Assessment and Invasive Monitoring.
It is crucial to understand the patient's cardiac anatomy, physiology, and circulation
in order to anticipate and treat potential post-operative complications. In the first
hour after surgery, establish a baseline for the patient and observe vital sign trends.
Assess intracardiac and central venous pressure waveforms, blood returns from these catheters.
Calibrate zero transducers at the level of the patient's right atrium. And have the doctor
assess a chest radiograph to ensure proper placement of catheters and tubes and to evaluate
lung fields. Obtain an initial electrocardiogram and assess for normal sinus rhythm.
Invasive Hemodynamic Monitoring.
Invasive hemodynamic monitoring may include arterial blood pressure and a central venous
pressure. Patients may also have intracardiac catheters including right atrial, left atrial,
or pulmonary artery catheters. If these catheters are present, this slide shows the usual pressures
and placement in the heart. Normally, the left atrial pressure is one to two millimeters
greater than the right atrial pressure. Both right and left atrial post-operative pressures
are normally six to eight millimeters mercury greater than the pre-operative pressures,
but should not be greater than 12 to 14 millimeters mercury.
The mean pulmonary artery pressure should be 10 to 20 millimeters mercury. The right
atrial catheter provides information about systemic venous return, intravascular volume,
and issues related to the right side of the heart. Normally, the saturation in the right
atrium is 72% to 75%.
Increased right atrial saturations may reflect a high cardiac output state, left to right
shunting of blood within the heart, overwhelming sepsis, or that the catheter tip is located
in the inferior vena cava near the renal veins. Decreased right atrial saturations may indicate
a low cardiac output state or that the tip of the right atrial catheter is located near
the coronary sinus.
The left atrial catheter is usually placed through the right upper pulmonary vein to
the left atrium. Left atrial catheter provides information about the pulmonary venous system,
systemic intravascular volume, left ventricular preload, afterload, function, and intracardiac
shunting. Normal left atrial saturation is 100%. Decreased left atrial saturation maybe
due to right to left intracardiac shunting or pulmonary venous desaturation.
Pulmonary artery catheter is usually threaded through the right ventricle and up through
the pulmonary valve into the main pulmonary artery. The pulmonary artery line provides
information about right ventricular function, obstruction in the right ventricular outflow
tract, pulmonary vascular reactivity, venous pressure in the lungs, and mean filling pressures
on the left side of the heart. Normal pulmonary artery saturation is usually 72% to 75% and
should be less than 80%. Decreased pulmonary artery saturation may be from low cardiac
output. Increased pulmonary artery saturation may be from a left to right shunt. For example,
from a residual ventricular septal defect.
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