3 (B) Monitoring and Equipment in ICU Flashcards
In ICU equipment, physios must
- Assess baseline values
- Know the practicalities
- Modify techniques or timing
- Monitor changes during treatment
What are types of haemodynamic monitoring
• ECG • Arterial catheter (art line) – Modified for PiCCO technology • Central venous catheter (CVC) (central line) • Pulmonary artery catheter (Swan Ganz)
What does the ECG measure. When might you pay attention to it?
- Heart rate
- Rhythm
When you’re about to do percussion
When can an arterial line be?
• Radial / femoral / dorsalis pedis
Practicalities of an arterial line
– Radial commonly splinted
– Monitor bp (systolic, diastolic, mean)
– Samples for blood gas analysis
Baseline values arterial line
- 100‐140/60‐90, 80‐100 mmHg
* MAP = DBP + 1/3(SBP‐DBP)
Things to note with arterial line
• Modify techniques or timing (eg flexion of wrist can affect wave) • Zeroing • Movement – Site visible – Axis altered – Kinking – Leaking • Disconnection – pressure
Practacalities central venous catheter
– Measures central venous pressure (CVP)
– Delivers fluids /drugs
– Not useful during physiotherapy treatment
Baseline values central venous catheter sponatenous breathing
• Baseline values: spontaneous breathing 3‐15 cm H2O – Increased with PPV – High ‐ volume, pulmonary HT, LVF – Low ‐ volume, peripheral vasodilation
Where can central venous catherter be inserted
Internal jugular vein
• Subclavian vein
What is a PiCCO
Pulse‐induced Contour Cardiac Output
– Minimally invasive continuous CO monitoring
– Thermodilution catheter in the femoral or axillary artery
and a CVC
What is a PA
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)
Uses of a PA catheter
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
Practicalities of a PA catheter
• Practicalities: – Internal jugular – CXR post insertion – Wave form – Complications
Modification of techniques or timing with PA catheter
• Modify techniques or timing:
– May be confined to bed
– Monitor changes during treatment
– Treatment post removal
Types of respiratory monitoring
- Pulse oximetry
- ABG
- End tidal CO2
- Peak and pause airway pressure
Difference Sp02 and Sa02
Sp02 - saturation of peripheral 02
Sa02 - needs blood gas done
Things that stop pulse oximetry being reliable
Movement
Not being on correctly
Poor circulation
Nail polish
What is PETC02
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
Practicalities of PETC02
– ETT placement (oesophagus, bronchi)
What changes to monitor on end tidal C02 (PETC02)
Monitor changes during treatment – Occlusion, dislodging – Ventilation adjustments (PaCO2‐ETCO2 gradient) • PEEP • Clefts in the plateau phase – Bronchospasm
What is peak inspiratory pressure
• Peak inspiratory pressure (PIP < 40 cmH2O)
– maximum pressure in a set tidal volume
– varies due to resistance
What is plateau pressure
• Plateau pressure
– end inspiratory pressure during a period of no gas flow
– plateau pressure should not exceed
What is mean airway pressure
• Mean airway pressure
– average of the system pressure over the entire ventilatory period
What is end expiratory pressure
• End expiratory pressure
– airway pressure at the termination of the expiratory phase
– equal to atmospheric pressure or the applied PEEP level
What are the three aspects of the GCS?
Eyes
Motor
Verbal
Normal ICP
– ICP 10‐15 mmHg
– CPP = MAP ‐ ICP
Practicalities and modification altered Hb
oxygen delivery eg exercise
Practicalities and modification altered platelets, prothrombin
clotting eg suctioning
Practicalities and modification altered Na, K, Mg
Cardiac arrhythmias
Practicalities and modification altered creatinine, urea
Renal failure
Practicalities and modification altered WCC
infection
What is Continuous Renal Replacement
Therapy and when is it used
- Acute renal failure
* Vascath - 2 lumens. One blue, one red.
Precautions catheter location
– 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)
What is an IABP
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
Practicalities and modification ventricular assist devices
• Haemodynamic alterations – Positioning / PD effect – Suctioning / MHI • Femoral artery insertion – No hip flexion
