3 (B) Monitoring and Equipment in ICU

Question 1

In ICU equipment, physios must

Answer 1

• Assess baseline values
• Know the practicalities
• Modify techniques or timing
• Monitor changes during treatment

Question 2

What are types of haemodynamic monitoring

Answer 2

• ECG
• Arterial catheter (art line)
– Modified for PiCCO technology
• Central venous catheter (CVC) (central line)
• Pulmonary artery catheter (Swan Ganz)

Question 3

What does the ECG measure. When might you pay attention to it?

Answer 3

• Heart rate
• Rhythm

When you’re about to do percussion

Question 4

When can an arterial line be?

Answer 4

• Radial / femoral / dorsalis pedis

Question 5

Practicalities of an arterial line

Answer 5

– Radial commonly splinted
– Monitor bp (systolic, diastolic, mean)
– Samples for blood gas analysis

Question 6

Baseline values arterial line

Answer 6

• 100‐140/60‐90, 80‐100 mmHg

* MAP = DBP + 1/3(SBP‐DBP)

Question 7

Things to note with arterial line

Answer 7

• Modify techniques or timing (eg flexion of wrist can affect wave)
• Zeroing
• Movement
– Site visible
– Axis altered
– Kinking
– Leaking
• Disconnection
– pressure

Question 8

Practacalities central venous catheter

Answer 8

– Measures central venous pressure (CVP)
– Delivers fluids /drugs
– Not useful during physiotherapy treatment

Question 9

Baseline values central venous catheter sponatenous breathing

Answer 9

• Baseline values: spontaneous breathing
3‐15 cm H2O
– Increased with PPV
– High ‐  volume, pulmonary HT, LVF
– Low ‐  volume, peripheral vasodilation

Question 10

Where can central venous catherter be inserted

Answer 10

Internal jugular vein

• Subclavian vein

Question 11

What is a PiCCO

Answer 11

Pulse‐induced Contour Cardiac Output
– Minimally invasive continuous CO monitoring
– Thermodilution catheter in the femoral or axillary artery
and a CVC

Question 12

What is a PA

Answer 12

Pulmonary Artery Catheter (PA)
• A balloon tipped flow directed catheter
• Via central vein to right heart – rests in pulmonary
artery
• Baseline values (all mm Hg; systolic/diastolic)

Question 13

Uses of a PA catheter

Answer 13

3
PiCCO
• Pulse‐induced Contour Cardiac Output
– Minimally invasive continuous CO monitoring
– Thermodilution catheter in the femoral or axillary artery
and a CVC
Pulmonary Artery Catheter (PA)
• A balloon tipped flow directed catheter
• Via central vein to right heart – rests in pulmonary
artery
• Baseline values (all mm Hg; systolic/diastolic)
PA catheter
Uses:
• Left‐sided heart failure
• Titration of vasoactive drugs
• Severe respiratory failure to optimise fluid treatment
• Perioperative/postoperative surgical procedure with
cardiovascular ± pulmonary dysfunction

Question 14

Practicalities of a PA catheter

Answer 14

• Practicalities:
– Internal jugular
– CXR post insertion
– Wave form
– Complications

Question 15

Modification of techniques or timing with PA catheter

Answer 15

• Modify techniques or timing:
– May be confined to bed
– Monitor changes during treatment
– Treatment post removal

Question 16

Types of respiratory monitoring

Answer 16

• Pulse oximetry
• ABG
• End tidal CO2
• Peak and pause airway pressure

Question 17

Difference Sp02 and Sa02

Answer 17

Sp02 - saturation of peripheral 02

Sa02 - needs blood gas done

Question 18

Things that stop pulse oximetry being reliable

Answer 18

Movement
Not being on correctly
Poor circulation
Nail polish

Question 19

What is PETC02

Answer 19

End Tidal C02
– estimate of PaCO2 (from PACO2)
– changes in CO2 production
– continuous data (trends) not intermittent
– main factor difference in PaCO2 and PETCO2
• deadspace ventilation (lack of Q)
– advantages – non invasive

Question 20

Practicalities of PETC02

Answer 20

– ETT placement (oesophagus, bronchi)

Question 21

What changes to monitor on end tidal C02 (PETC02)

Answer 21

Monitor changes during treatment
– Occlusion, dislodging
– Ventilation adjustments (PaCO2‐ETCO2 gradient)
• PEEP
• Clefts in the plateau phase
– Bronchospasm

Question 22

What is peak inspiratory pressure

Answer 22

• Peak inspiratory pressure (PIP < 40 cmH2O)
– maximum pressure in a set tidal volume
– varies due to resistance

Question 23

What is plateau pressure

Answer 23

• Plateau pressure
– end inspiratory pressure during a period of no gas flow
– plateau pressure should not exceed

Question 24

What is mean airway pressure

Answer 24

• Mean airway pressure

– average of the system pressure over the entire ventilatory period

Question 25

What is end expiratory pressure

Answer 25

• End expiratory pressure
– airway pressure at the termination of the expiratory phase
– equal to atmospheric pressure or the applied PEEP level

Question 26

What are the three aspects of the GCS?

Answer 26

Eyes
Motor
Verbal

Question 27

Normal ICP

Answer 27

– ICP 10‐15 mmHg

– CPP = MAP ‐ ICP

Question 28

Practicalities and modification altered Hb

Answer 28

oxygen delivery eg exercise

Question 29

Practicalities and modification altered platelets, prothrombin

Answer 29

clotting eg suctioning

Question 30

Practicalities and modification altered Na, K, Mg

Answer 30

Cardiac arrhythmias

Question 31

Practicalities and modification altered creatinine, urea

Answer 31

Renal failure

Question 32

Practicalities and modification altered WCC

Answer 32

infection

Question 33

What is Continuous Renal Replacement

Therapy and when is it used

Answer 33

• Acute renal failure

* Vascath - 2 lumens. One blue, one red.

Question 34

Precautions catheter location

Answer 34

– Catheter location
• Superior vena cava: care with neck position
• Subclavian: may preclude lying on that side
CXR post line insertion
• Femoral: no hip flexion
– Pump relies on pressure gradient
• Patient position eg tilt
• Intrathoracic pressure (manual hyperinflation)

Question 35

What is an IABP

Answer 35

Intra Aortic Balloon Pump (IABP) (LVAD)
• Through femoral artery ‐ linked to ECG
• Improves coronary artery perfusion
•  left ventricular afterload
–  myocardial and systemic blood flow
• LV failure, septic shock
• Mechanical complications secondary to AMI
• Prophylaxis prior to cardiac surgery /post cardiac surgery

Question 36

Practicalities and modification ventricular assist devices

Answer 36

• Haemodynamic alterations
– Positioning / PD effect
– Suctioning / MHI
• Femoral artery insertion
– No hip flexion