Cardiac Clinical Monitorin Flashcards by Tricia Vantino

Normal CVP aka MRAP (mean right atrial pressure) range

1-10 mmHG

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Where should the CVP line sit in the heart

At the most distal part of the SVC but not in the RA

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Normal RV range

15-30 / 0-8 mmhg

25/5 average (quarter over a nickel)

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Normal PA range

15-30 / 5-15 mmhg

25/10 average (quarter of a dime)

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Normal mean PA range

10-20mmhg

15 avg

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Normal PAOP (wedge) range

5-15mmhg

10 avg

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Normal LVEDP (left ventricular end-diastolic pressure) range

4-12 mmHg

Avg 8 mmHg

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CVP port on PAC is used to estimate?

RVEDP
right ventricular end diastolic pressure

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Distal tip of PAC is used to estimate?

RV systolic pressure via the PA systolic reading.

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The upstroke of the PA tracing is produced by?

The opening of the pulmonic valve and is followed by RV ejection.

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The downstroke of the PA waveform, which contains the dicrotic notch, is produced by?

Sudden closure of the pulmonic valve leaflets (the beginning of diastole)

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Similarities and differences between PAOP and CVP waveform/readings

Both have a,c,v waves.
PAOP (5-15) is less likely to see c wave. Waveform as a whole should be at a higher baseline pressure because you are measuring LV pressures.

CVP measurements will be 0-10

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PAOP waveform - what do a, c, and v represent

a = LA systole
c = closure of mitral valve
v = filling of LA as well as volume displacement of mitral valve closure during LV systole

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The a wave on the cvp will correlate with what EKG event

a wave will follow the P wave (atrial depolarization, contraction)

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The c and v wave on the cvp will correlate with what EKG event

the c and v waves occur after the beginning of the ventricular contraction (QRS)

the v wave may not occur until shortly after the T wave

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What factors can create giant a waves aka cannon a waves?

Junctional rhythms
complete AV block
PVCs
ventricular pacing asynchronous
tricuspid or mitral stenosis
diastolic dysfunction
myocardial ischemia
ventricular hypertrophy

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What are 2 factors that can create large v waves?

Tricuspid or Mitral Regurg
Acute increase in intravascular volume

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What are two factors that can cause a loss of a waves or only v waves?

atrial fibrillation
ventricular pacing in the setting of asystole

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is the CVP a reliable measurement for fluid volume responsiveness?

No. But it still has value to it, just not for evaluating fluid responsiveness.

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What are better measures of fluid responsiveness than CVP?

Dynamic values such as SVV and PPV
stroke volume variant and pressure volume variation

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What change in SVV indicates fluid responsiveness

Small volume bolus and assess SVV. If there is less SVV occurs after bolus (ex 17% to 15%) the reduction indicates the patient will respond/require further preload augmentation

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What criteria must be met for SVV and PPV measurements to be accurate?

Patients must be mechanically vented with at least 7-6mL/kg tidal volume with no spontaneous respiratory effort and patients must be in sinus rhythm.

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In mechanically vented patients, the normal SVV? Above what % implies fluid admin should be given?

range for normal is 10-13%. Values higher than 12-13% imply patients will respond positively to an increase in preload.

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Goal PPV range?

10-15%. greater than 12% likely fluid responsive.

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Potential causes of elevated CVP

RV failure Tricuspid stenosis or regurg Cardiac Tamponade Constrictive pericarditis volume overload Pulm HTN chronic LV failure catheter whip catheter coiling

Potential causes of elevated PAP

LV failure Mitral stenosis or regurg L to R Shunt ASD or VSD Volume overload Pulm HTN "catheter whip"

Potential causes of elevated POAP

LV failure Mitral stenosis or regurg Cardiac tamponade Constrictive pericarditis volume overload ischemia

The mean or diastolic PA pressure should always be measured when? Why?

At the end of expiration. this the time when pleural pressures are most closely equal to atmospheric pressure (except when PEEP is being used)

LVEDP should be measured at what point the PAP recording?

Lowest most point after dicrotic notch. just before the upstroke of the v wave, or c wave if present

What are some circumstances PADP poorly correlates with PAOP?

When Pulm Vasc Resistance (PVR) is elevated (COPD, HPV, PE, ARDS, Hypercarbia) HR > 130bpm Severe Mitral or Aortic Regurg When lung zone III has changed to II or I (hypovolemia or PEEP)

Normal SVRI values

1760-2600 dynes

Normal SVR values

800-1200 dynes

Normal PVRI values

45-225 dynes

Normal PVR values

40 -225 dynes

Normal svo2

65-77%

Normal ScVo2

~70%

BP cuff that is too small can produce a ?

Falsely elevated BP

BP cuff that is too big can produce a ?

Falsely low BP

Transducer below the level of the heart can produce a?

Falsely elevated BP

Transducer above the level of the heart can produce a?

Falsely low BP

Which of the following conditions are associated with large 'v' waves on the central venous pressure waveform?

tricuspid regurg

A condition in which individuals exhibit reduced recognition of auditory alarms when subjected to a high visual workload is known as

inattentional deafness

The degree of ST elevation or depression on an ECG is measured between the isoelectric line and the

J point

For optimal positioning in an adult, an esophageal temperature probe sensor should be positioned about ______ cm from the nose.

45cm

Which of the following corresponds to the opening of the tricuspid valve on a central venous pressure waveform?

The y descent represents the opening of the tricuspid valve.

Most common and required diagnostic tool

ECG

what two leads to monitor for accurate ST segments

V2 and V3

where is the J point

end of QRS complex and beginning of ST

Incidence of perioperative ischemia in patients with CAD

20-80%

If the pateints Preop EKG was unremarkable, what leads should you monitor intraop?

V3-V5, III and aVF

What lead monitors narrow WRS rhythms best

Lead II

Which leads detects ischemia earliest and most frequently

V3 (86%), V4 (79%), V5 (65%)

What is the gain setting

The amplitude at which the ECG monitor is set

SVV or PPV more accurate for predicting fluid responsiveness?

PPV with the use of an arterial catheter

Normal cardiac INdex

2.8-3.6 L/min

When might you have tricuspid regurg but not have a large v wave on CVP tracing?

When RA has become very compliant (large/expanded) due to long term tricuspid regurg.

What does the a wave represent in the CVP tracing?

Atrial Contraction - End of Ventricular Diastole. P wave on EKG. When the ventricle is FULLY relaxed - it can receive the remainder of blood in the RA.

The size of the a wave on the CVP tracing is dependent on?

1. The volume of blood moving into the atrium 2. The compliance of the atrium

What does compliance of a heart chamber mean?

The ease with which the heart expands when filled with blood—the inverse of stiffness. High compliance = stretchy Low compliance = small/stiff

The x wave on the CVP tracing represents?

Start of atrial diastole. Pressure starts to decrease as RA begins to relax.

What does the c wave on the CVP tracing represent?

Tricuspid valve CLOSURE. the onset of early ventricular contraction. R wave on QRS complex.

What is one condition that may result in the loss of the c wave into the a wave?

Tachycardia

What does the x1 descent represent in a CVP tracing?

Downslope represents mid-ventricular systole. R-S EKG. The tricuspid valve and septum descend towards the apex of the heart as the ventricle squeezes, creating a bigger volume and less pressure in RA.

What does the v wave represent on the CVP tracing?

Late ventricular systole. T-wave on EKG. Blood enters RA, hits the CLOSED TV (which is pushing back due to RV contraction). v wave is measuring the back pressure.

When might you see a large v wave on a CVP tracing?

Suggestive of tricuspid regurg.

What is the amplitude of the v wave dependent on?

1. Compliance of RA 2. Volume filling the RA

What does the y descent on the CVP tracing represent?

Open tricuspid valve - volume leaving the RA, filling a relaxing RV, thus a drop in RA pressure. Diastolic EKG trace - after T-wave before P-wave.

Describe the arterial line response to this square wave test

Normal. 2 oscillations, quick up and downstroke

Describe the arterial line response to this square wave test

Under damped. too much energy, More than 2 oscillations

Describe the arterial line response to this square wave test

Over damped. Not enough energy. No oscillations

Stroke volume is calculated as

end diastolic volume minus the end systolic volume

MAP Calculation

MAP = DP + [1/3(SP-DP)] AKA MAP = DP + [1/3(PP)]

MAP Calculation

MAP = DP + [1/3(SP-DP)] AKA MAP = DP + [1/3(PP)]

What percent of patients scheduled for noncardiac surgery are at risk for CAD?

33%

What is happening in this arterial waveform? Why might this happen?

overdamped. Air bubbles in tubing, thrombus on catheter, catheter kinking, flexed wrist, loss of dicrotic notch. Underestimation of BP

What is happening in this arterial waveform? Why might this happen?

underdamped - overestimation of SBP. Decreased arterial compliance.

An underdamped arterial transducer system produces ?

An artificially high systolic BP - overestimated BP Underestimated DBP

Describe where to place your 5 precordial leads for EKG

V1: RSB, 4th ICS V2: LSB, 4th ICS V3: Equal distance between V2 and V4 V4: Midclavicular line at 5th ICS V5: Next to V4 along Anterior Axillary Line V6: Next to V5 along midaxillary line

How would you interpret: CVP - low PADP - low PAOP - low

hypovolemia Or transducer not at phlebostatic axis

How would you interpret: CVP - Normal or High PADP - High PAOP - High

LV Failure

PADP and PAOP correlate poorly when?

Pulmonary Vascular Resistance is elevated (COPD, PE, ARDS, Hypercarbia) HR > 130s Severe MR or AR When Pulmonary Zone III has changed to Zone II or I due to hypovolemia or PEEP)

How would you interpret: CVP - High PADP - Normal or Low PAOP - Normal or Low

RV Failure, TR or TS

How would you interpret: CVP - High PADP - High PAOP - Normal or Low

How would you interpret: CVP - High PADP - High PAOP - Normal

Pulmonary HTN

How would you interpret: CVP - High PADP - High PAOP - High

Cardiac Tamponade Transducer not leveled

How would you interpret: CVP - Normal PADP - Normal or High PAOP - High

LV myocardial Ischemia or MR

How would you interpret: CVP - Low PADP - High PAOP - Normal

ARDS

What things can increase SvO2

Left to Right Shunt Hypothermia Sepsis Cyanide Toxicity Wedged PAC Increased CO

What things can decrease SvO2?

Hyperthermia Shivering Seizures Hemorrhage Decreased CO