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NSCC 7520 > Advanced Hemodynamics > Flashcards

Advanced Hemodynamics Flashcards

1
Q

which port do you use for PA pressure (PAS, PAD) and for SVO2?

A

distal port

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2
Q

which port do you use for injecting 10mL fluid for CO calculations?

A

proximal

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3
Q

what is the thermister?

A

for temp/CO measurement

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4
Q

when does the balloon go up on a PA catheter?

A

only on insertion and PCWP

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5
Q

preload assessment and numbers

A

assessment: crackles (cardiogenic), POCUS, XRAY

numbers: CVP (right), PCWP (left), PAD (if no lung path, left)

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6
Q

afterload assessment and numbers

A

assessment: PP, cap refill, dBP

numbers: SVR (left), PVR (right), PAS (right)

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7
Q

contractility assessment and numbers

A

assessment: EF, Hx, Starling’s law

numbers: SVO2

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8
Q

sites for PA catheter

A

subclavian, internal jugular, femoral; inserted using aseptic technique

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9
Q

what does insertion of a PA catheter require?

A
  • introducer (cordis)
  • line must be fully checked for functionality (beyond patency) prior to insertion (ie. inflating/ deflating balloon, shaking distal port once pressure tubing is attached to ensure waveform is present)
  • nursing care (monitor for complications, observe waveforms)
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10
Q

should you adjust a PA catheter if it is spontaneously wedging or in the RV?

A

NEVER

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11
Q

nursing responsibilities prior to PA line insertion

A
  • gather supplies (pressure tubing/cables, saline bags)
  • prep pt (explain, anxiety, analgesia)
  • attach pressure cables to tubing and attach tubing to proper lumens
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12
Q

nursing responsibilities during PA line insertion

A
  • inflate/deflate balloon as requested
  • capture waveforms as PA line travels through:
    RA>RV>PA>PCWP
  • monitor for complications and ECG changes
  • ongoing pt support
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13
Q

nursing responsibilities post PA line insertion

A
  • measure internal length
  • CXR for confirmation/ r/o complications
  • get data (ScVO2, CO)
  • monitor for complications
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14
Q

do you level and zero a PA catheter?

A

yes

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15
Q

when do you read CVP and PCWP?

A

at end expiration

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16
Q

_____ blood enters the SVC/IVC. _____ blood leaves the lungs

A

deoxygenated, oxygenated

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17
Q

how does insertion of a PA catheter go?

A
  • PA inserted through cordis
  • once it hits RA, balloon inflated until the end of the process
  • this is done to have catheter flow with blood and prevent damage to heart structure
  • waveform from RA, RV, PA, and PCWP are captured (printed)
  • sutured in place and always x-rayed to confirm placement
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18
Q

complications of PA line

A
  • dysrhythmias (PVCs or worse!)
  • pneumothorax
  • balloon rupture
  • pulmonary infarction
  • pulmonary artery rupture
  • knotting
  • infection if in situ >72-96hrs
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19
Q

RA: normal pressure, determinant of CO, R or L side of heart

A
  • 2-6
  • preload
  • right heart
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20
Q

RV: normal pressure, determinant of CO, R or L side of heart

A

20-30
0-6

  • no determinant
  • not monitored for side of heart
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21
Q

PAS: normal pressure, determinant of CO, R or L side of heart

A

20-30
afterload
right heart

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22
Q

PAD: normal pressure, determinant of CO, R or L side of heart

A

8-15
preload
left heart

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23
Q

PCWP: normal pressure, determinant of CO, R or L side of heart

A

8-12
preload
left heart

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24
Q

CO and CI: normal pressure, determinant of CO, R or L side of heart

A

CO: 4-8L/min
CI: 2.5-4 L/min/m2

CO/CI is determined by HR and SV; when all other factors are considered it can provide direct info about contractility

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25
SVR: normal pressure, determinant of CO, R or L side of heart
800-1400 dynes/sec/cm5 afterload left heart
26
PVR: normal pressure, determinant of CO, R or L side of heart
100-250 dynes/sec/cm5 afterload right heart
27
stroke volume: normal pressure, determinant of CO, R or L side of heart
60-70mL determined by preload, afterload, contractility
28
SvO2: normal pressure, determinant of CO, R or L side of heart
60-80% O2 supply and demand balance
29
monitored numbers that are measured
- RA/CVP - PAS, PAD, PA mean - PCWP - CO - SVO2
30
monitored numbers that are calculated
- CI - SVR/SVRI - PVR/PVRI - O2ER
31
right atrial pressure (RAP or RA)
- same as CVP - proximal port of PA line sits inside right atrium
32
pulmonary artery pressure (PAP)
- normal: 25/10 "a quarter over a dime" - BP of lungs - tells us about pulm vasculature, patho (HTN), and sometimes L sided preload
33
pulmonary artery systolic (PAS)
- systolic pressure in pulmonary vasculature - Pulmonary arteries are small...so should not need a lot of pressure to push blood... - Elevated numbers here suggest...pulmonary HTN...could be lung pathology (ARDS, COPD), heart failure, congenital
34
pulmonary artery diastolic (PAD)
- in pts with normal lungs, it measures LVEDP - tells us about filling pressure on left side (preload) - if lung pathology or heart failure exists, PAD will be falsely elevated; then its not reliable for determining L sided preload
35
pulmonary capillary wedge pressure - PCWP (wedging)
- aka PAWP or PAOP - is the LVEDP - obtained when the balloon at the tip of the PA catheter is inflated and temporarily occludes the flow of blood in the branch of the pulmonary artery. Pressure sensed accurately reflects pressure in LV - just use PAD - BUT only when lungs are healthy
36
risks of wedging
1) left in wedge position too long = impede blood flow through lungs causing mechanical dead space and damage to lung tissue 2) balloon overinflated = rupture pulm artery (occurs in 2% population but >50% mortality rate)
37
what's an important concept about PAD and PCWP? what's the difference?
- usually not identical! - PAD is often 1-4mmHg > PCWP - PAD measures pressure from vascular tone, surrounding lung tissue, and blood as it flows. (PAD =PCWP + additional pressures) - PCWP does not measure all these pressures because it occludes blood flow
38
what if PAD is <= 4mmHg above the PCWP?
you can use PAD to determine L sided preload
39
what if difference is > 4mmHg?
you can presume there is significant lung pathology. PAD can't be used to reflect LVEDP
40
what if PCWP is > PAD?
- problem with monitoring system - PCWP should always be lower than PAD b/c PAD measures additional pressures that PCWP doesn't
41
how to perform a wedge
- level/zero/pt position - pt should be on back and HOB can be up to 45 degrees - inflate balloon 1-1.5cc - watch PA waveform - slow consistent easy gentle pressure - Inflate balloon with MINIMUM amount of air needed to obtain PCWP waveform - Only wedge for 2-3 resp cycles or max 10-15 secs – if longer, greater chance for hypoxemia - Read PCWP at END-EXPIRATION - Balloon deflates passively – do not draw back
42
what is SVR?
- systemic vascular resistance - resistance to ejection from the left side of the heart (left afterload) - usually calculated by obtaining CO readings
43
what does high SVR mean? low SVR?
high SVR = increased left sided afterload low SVR = decreased left sided afterload
44
what is PVR?
- pulmonary vascular resistance - resistance to ejection from the right side of the heart (right afterload) - a calculated value - PVR is increased in COPD, ARDS, pulmonary HTN
45
what does a high PVR mean?
increased afterload, stress on right heart, ? right heart failure
46
preload: right side measurements and if its high give which meds?
CVP, RA give diuretics, nitro
47
preload: left side measurements and if its low give which meds?
PCWP, PAD give fluids (crystalloids, colloids)
48
afterload: right side measurements and if its high give which meds?
PVR give vasodilators, NO, nipride, mili, dobutamine
49
afterload: left side measurements and if its low give which meds?
SVR give levophed, epi, phenyl
50
thermodilution
- aka manual outputs - injectate solution is either D5W or NS - amount is usually 10cc - inject through proximal port - fast and steady (4s max) - minimum of 3 CO's (within 10%) - average values
51
CO and thermodilution if its high or low
- when CO is low = longer for blood temp to return to baseline, so greater area under the curve - when CO is high = cooling fluid is carried faster through heart and temp returns to baseline faster, so smaller area under the curve
52
indexed values
- more sensitive values because they are specific to the patient - CI = CO/BSA - uses a pt's BSA and is more accurate
53
what other numbers are based on BSA?
SVRI and PVRI
54
contractility: if CO/CI is high what meds would you give? low?
high = beta blocker, calcium channel blocker low = dobutamine, mili, epi, dopamine
55
what's the difference between ScVO2 and SVO2?
- normal values for ScVO2 are slightly higher than SVO2 - ScVO2 readings are taken before blood enters right atrium (Vena Cava) *not affected by cardiac sinus delivering venous blood from myocardium - SVO2 samples are taken from pulmonary artery - so includes demands of the heart - hence it may be lower than ScVO2 *Drawn from the distal lumen of the PA line - goal is 70%
56
ScVO2/SVO2 < 60%
decreased supply increased demand tissue taking more O2
57
ScVO2/SVO2 >80%
increased supply decreased demand tissue needing less O2
58
causes of decreased SVO2
- low Hgb (ex. Bleeding) - low SaO2 (hypoxemia due to lung disease - low contractility (left ventricular damage due to acute MI) - increased O2 consumption (shivering, seizure)
59
causes of increased SVO2
- Increased O2 supply (patient receiving high FiO2) - Decreased O2 demand (over-sedated or paralyzed) - Catheter in wrong position - Sepsis (dead cells not needing 02 so it returns to the heart)
60
O2ER
- how much O2 the tissues are extracting relative to the O2 supply at this time - 25-35% SaO2 – SVO2/SaO2 = O2ER
61
O2ER < 25%
increased supply decreased demand
62
O2ER > 35%
decreased supply increased demand
63
echo
- visual of heart and motion - Estimate EF - TTE ( transthoracic) - TEE ( transesophageal) - can give some numbers that a PA would give * e.g. PAPs * e.g. RA

NSCC 7520 (5 decks)

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