CVC Flashcards
What is A
ballon inflation port
what is B
thermistor
What is C
proximal port (PAP, CVP)
What is D
Distal port (PAP, PAWP)
what is E
fluids/ meds port
where is the line in wave A
Right atrium
where is the line in wave B
right ventricle
what is wave C
pulm art (PA)
what is wave D
pulm wedge pressure wave
PAWP
where is the swan
RA
where is the swan
RV
where is the swan
PA
where is the swan
PAWP
what is A
DBP
what is B
SBP
what is C
diacrotic notch
what is D
systole
what is E
diastole
what is G
aortic valve opens
what is H
pressure increase as blood flows into the aorta
what is I
aortic valve closes
what is J
pressure falls as blood flows out of the aorta
what is 1
reduced gradient of upstroke caused by aortic stenosis
what is 2
reduced pulse pressure caused by aortic stenosis
what is 3
bifid waveform caused by aortic regurg
what is 4
increased pulse pressure caused by aortic regurg
what is 5
steep down stroke cause by low SVR
what is 6
low dicrotic notch caused by low SVR
what is 7
high dicrotic notch caused by high SVR
what is A
normal A line
what is B
aortic stenosis A line
what is C
aortic regurg a line
what is D
low SVR a line
what is E
high SVR a line
what is A
IJV
what is B
carotid artery
what is C
needle
what is D
guidewire
what is E
catheter
what is 1
p wave
what is 2
R wave
what is 3
T wave
what is 4
a wave
what is 5
C wave
what is 6
v wave
what is 7
Y wave
what is 8
a wave
what is 9
x wave
what is A shaded
systole
what is B
diastole
what is C
x wave
RA relaxing and filling
what is D
V wave
R atrium is full
what is E
Y wave
RA is emptying
what is F
a wave
RA contraction
what is G
c wave
tricuspid valve closing
what is A
distal lumen port
what is B
balloon
what is C
thermistor
what is D
proximal injection
what is E
proximal medication port
what is F
balloon inflation stopcock
what is G
proximal injection hub
what is H
proximal medication hub
what is I
thermistor connector
what is J
distal lumen hub
what is A
suprclavicular fossa
what is B
clavicle
what is C
Sternocleidomastoid muscle clavicular head
what is D
sternal head
what is E
cricoid cartilage
what is F
suprasternal notch
what is A
balloon
what is B
balloon port with syringe
what is C
pulm art port/ distal port
what is D
cvp port
right atrial port
proximal port
what is E
thermistor port
what is 1
normal CO (4.3)
what is 2
low CO (2.5)
what is 3
high CO (8.2)
what test do you do prior to placing a radial art line
allens test, tests if ulnar blood flow is sufficient
what is risk of femoral art line
infection
thrombosis
what is risk of brachial art line
kinking
what is risk of axillary art line
kinking
infection
occlusion
nerve damage
what is benefit of art line placement with ultrasound
safer
more effective
what are indications for art lines
-current or anticipated hypotension
-wide blood pressure deviations
-end organ disease necessitating beat-to-beat blood pressure regulation
-multiple blood gas/labs
where do you zero a-line for cerebral perfusion
tragus
what is difference between cuff BP and cerebral BP
15-20 or 0.75 mmHg for every cm
when are art lines contraindicated
vascular insufficiency
smaller end arteries
true or false: preop art lines are sterile
False
they are aseptic
what materials do you need for art line
-rolled towel
-sterile towel
-tape
-arterial catheter
-lidocaine TB syringe or 25g needle
-pressure bag with transducer flushed and zeroed to phlebostatic axis
-2-0 silk on straight needle
-tegaderm x2
-CHG
-Sterile gloves
-US and probe cover
what else can you use as a probe cover
tegaderm
what are the steps to art line placement
-palpate/US artery
-CHG
-Lidocaine
-insert needle at 45
-drop angle after flashback
-advance 1-2mm
-insert wire
-thread catheter over wire
-remove wire and check for pulsatile flow
-attach high pressure tubing
-verify arterial waveform
-suture and tegaderm
what ultrasound view do you start with for art line placement
out of plane
what ultrasound view do you finish with for art line placement
in plane
where should wire/needle/catheter be in artery
in middle
where should bevel on art line needle be
bevel up
what is the supercool view on the butterfly for art line placement
bi plane view
arteries __________ under ultrasound, veins ________
arteries pulsate
veins wink
What does the dicrotic notch represent?
closure of aortic valve
as art lines move more distal SBP__________ and the upstroke is _________
SBP increases
steeper upstroke
as art lines move more distal DBP ________ and dicrotic notch is _________ and ________ sharp
DBP decreases
later and less sharp
how does aortic stenosis affect arterial waveform
reduced gradient of upstroke,
reduced pulse pressure
how does aortic regurgitation affect arterial waveform
bifid waveform
increased pulse pressure
what causes the bifid waveform on aortic regurgitation art line waveforms
backwards flow
how does Low SVR affect art waveform
steep downstroke
low dicrotic notch
how does high SVR affect art waveform
high dicrotic notch
what are the main complications of art line
hematoma
vasospasms
nerve damage
what are all the complications of art line
hematoma
bleeding
vasospasm
arterial thrombosis
emboli/thrombi
pseudoaneurisms
nerve damage
infections
necrosis
arterial drug injection
which art line placement has a higher risk of nerve damage
brachial
what are risk factors for art line complications
prolonged use
hyperlipidemia
repeated attempts
female
extracorporeal circulation
larger catheters in smaller vessels
vasopressors
what are indications for central line placement
-monitor cardiac filling pressure/CVP
-secure access for vasoactive or peripherally caustic drugs
-rapid infusion fluids (certain lines)
-inadequate PIC access
-PAC insertion (cordis)
-cardiac pacing
-aspiration of air emboli
-temporary hemodialysis
what is the law about IVs/fluids
poisuilles
what is poisuilles law equation
what are advantages/disadvantages of RIJ CVC
Advantages
accessible, good landmark
Disadvantages
Carotid puncture
what are advantages/disadvantages of EJ CVC
advantages
superficial location, safety
disadvantages
low success, kinks at SC
what are advantages/disadvantages of subclavian CVC
advantages
accessible, good landmarks
disadvantages
pneumothorax, effusion
what are advantages/disadvantages of antecubital CVC
advantages
limited complications
disadvantages
low success, thrombosis
what are advantages/disadvantages of femoral CVC
advantages
high success
disadvantages
sepsis
why do you not do L SCL lines
chylothorax
what are the pros of IJs
compressible, ease of insertion
straight shot for PAC
Less chance of pneumo
what are the cons of IJs
carotid artery puncture possible
difficult in obese/fat neck
increased infection rate
what are the pros of scl
reliable landmarks and positioning
no restrictions when in C-collor/tracheostomy
what are the cons of scl
more difficult than IJ
noncompressible (bleed)
risk of pneumo
what are the pros of femoral
ease of placement
compressible
no risk of pneumothorax
Trendelenburg not necessary
what are the cons of femoral
increased risk of thrombosis and infection
difficult to float PAC
potential for retroperitoneal hemorrhage
patient must be immobile
how do you position for RIJ
remove pillows, proper head/neck alignment
supine, head turned to left
what are the anatomic landmarks of RIJ
suprasternal notch,
clavicle,
sternocleidomastoid muscle
what muscle is carotid/IJ between
sternal and clavicular heads of the sternocleidomastoid
where is IJ in relation to the carotid
lateral and slightly anterior
what is the technique for RIJ insertion
-tilt head down to engorge vessel
-open kit, draw up meds
-flush each port with saline and close (except the distal/brown)
-identify landmarks such as sternocleidomastoid, sternal notch, carotid artery, and nipple/illiac crest
why do you not cap the brown/distal port
wire threads through it
the wire will touch anything within
4 feet
how many attempts do you make at one site
3-4
how many sites do you try before a new proceduralist
2 sites
what do you do if catheter is difficult to remove over wire
pull wire and catheter as one unit
where do you want the CVC to end up
cavoatrial junction, 3-5cm above RA
what is the method for SCL insertion
-feel clavicle with thumb and find curve of clavicle
-with index finger palpate sternal notch
-insert need and walk off clavicle at a flat trajectory towards the sternal notch
do you insert scl at a sharp angle
no, shallow angle off of clavicle to avoid pneumo
where do you aim needle in SCL line
towards sternal notch
where are artery and lung in relation to SCL vein
artery and lung are deep
what is the distance from R IJ to RA
15 cm
what is the distance from R SCL to to RA
15 cm
what is the distance from LIJ to RA
20 cm
what is the distance room L SCL to RA
25 cm
what is the distance from right femoral vein to RA
40 cm
Left 50cm
what is the distance from Right median basilic to RA
40 cm
what is the distance from L median basilic to RA
50 cm
what does the a wave of CVP represent
atrial contraction
what does c wave on cvp
isovolumetric ventricular contraction (prior to AV opening)
closure of tricuspid valve
what does the v wave of CVP represent
ventricular contraction and systolic filling of atrium
what are the three positive waves of CVP
A
C
V
what are the three negative waves of CVP
X
X1
Y
what does the x wave of CVP represent
start of atrial diastole
what does the X1 wave of CVP represent
downward pulling of the septum during ventricular systole
what does the y wave of CVP represent
descent represents opening tricuspid valve, atrial emptying
what are central venous line complications
-arterial puncture
-dysrhythmias
-misinterpretation of data
-infection
-pneumothorax/hemothorax
-airway comprimise
-tracheal puncture
-air embolus
-catheter wire shearing
-thrombophlebitis
-cardiac tamponade
-nerve injury
what causes dyrythmias in CVC placement
tip in RA, pull it back
what are indications for PA caths
LV dysfunction
two vessel disease/angina within 2 hours
symptomatic valvular disease
severe hypertensive with angina history
large operation with anticipation of intravascular volume changes
vascular surgery with clamp of major artery
what surgical case do you usually use PA cath in
open hearts
what are RELATIVE contraindications to insertion of a PAC
-transvenous pacemaker placed in the past 4-6 weeks
-frequent ventricular dysrhythmias uncontrolled with meds
-coagulopathy
-bifasiscicular block
-mobitz 2
-inability to insert into pulmonary artery
what creates an inability to insert into pulmonary artery
pulmonary HTN
pulmonary/tricuspid regurgitation
what is risk of coagulopathy in PAC placement
risk of pulm hemorrhage
what is risk of mobitz 2 and PA cath placement
transition to complete block
what are ABSOLUTE contraindications for insertion of a PAC
R atrial or R ventricular masses, tumors, or thrombosis
tricuspid/pulmonic valve stenosis
mechanical valve
tetralogy of fallot
what is the introducer for Swan
cordis
where is cordis usually placed
right IJ
when do inflate balloon in swan placement
in RA
where do you inject fluid for CO reading in SWAN
Right atrial/proximal/blue port
what is connected to red port on swan ganz
balloon port
what is the yellow port of swan
pulm art/distal port
where is the PAC at 15-20 cm
RA
what doesPAC tracing look like at 15-20 cm
RA so cvp tracing
where is PAC at 30 cm
RV
what does PAC tracing look like at 30 cm
in RV so PVC tracing
where is the PAC at 40 cm
pulm artery
dicrotic notch on tracing
where is the PAC at 50-55 cm
should be wedged
what is the limit of PAC distance
65 cm
what is BP calculation
CO x SVR
what is CO calculation
HR x SV
what are filling pressures related to
volume
ventral compliance
what affects compliance
ischemia,
diastolic dysfunction from valve disease,
intrathoracic pressures
what is normal RA pressure
5 mmHg
what is normal RV pressure
25/6 mmHg
what is normal PA pressure
25/9
what is normal PAWP
9 mmHg
what is normal LA pressure
8 mmHg
what is normal Left Ventricle Pressure
130/8
what is normal central aorta pressure
130/70 (90) mmHg
what is formula for CO
CO= HR x SV
what is a normal CO
5-6 L/min
what is formula for CI
CO/BSA
what is normal CI
2.5-4.0L/min
how fast do you push fluid for thermodilution measurement
3-5 sec
what is the accuracy of thermodilution
+/- 5-10%
what factors affect cardiac filling pressure
decreased/increased ventricular compliance
myocardial ischemia
valve dysfunction
increased filling/volume overload
decreased volume/blood loss
increased afterload
what causes PCWP to be > than LVEDP (overestimate)
positive pressure ventilation
PEEP
increased intrathoracic pressure
COPD
increased pulm vasc resistance
LA myxoma (tumor)
mitral valve disease
what causes PCWP< LVEDP (underestimate)
noncompliant left ventricle
aortic regurgitation (premature closure of mitral valve)
LVEDP>25 mmHg
how does PAC measure CO
thermodilution
how does thermodilution appear in low CO
higher, longer to return to normal
how does thermodilution appear in high CO
lower, quicker return to baseline
what are factors that effect the accuracy of thermodilution
inaccurate injectate temp or volume
rapid volume infusion during injection
resp cycle
inaccurate computation constant
patient is cold (thermal instability post CPB)
how do we utilize PAC data
-measure Co and optimize perfusion (with inotropes)
-detect, treat, and trend myocardial ischemia
-measure and optimize ventricular preload and volume in surgery with large volume shifts
-aortic cross clamp
detect, treat, and trend valvular dysfunction
what is calculatoin of CI
CO/BSA
what is normal CI
2.5-4.0 L/min
what is SV calculation
CO/HR
what is normal SV
60-90 mL/beat
what is calculation for stroke index
SV/BSA
what is normal SI
40-60 ml/beat
what is calculation for MAP
DBP+1/3 pulse pressure OR
(sys+ 2 diastolic)/3
what is the calculation fo systemic vascular resistance (SVR)
MAP-CVP/COx80
what is normal SVR
1200-1500 dynes/cm2
what are indications for pacing PAC
sinus node dysfunction
symptomatic bradycardia
second degree block
third degree block
digitalis toxicity
need for AV sequential pacing
LBBB
what are complications of PAC
carotid/SCL artery punction
perforation of RA, RV, pulmonary artery
cardiac dysrhythmias
heart block (RBBB)
knotting of catheter
improper therapy
PIV should be on the _________ side as SpO2
same
PIV should be on the _________ side as BP cuff
opposite
what are some positioning considerations with PIV placemtn
not in AC with bent arms
IV should _______ be on the same side as surgical extremity
not
what are monitoring considerations if arms are tucked
2 IVs, 2SpO2s, 2BP cuffs
what is the minimum size IV for sx
20g
what size IV do you use for blood loss/PRBVs
18g
why is it important to be able to see/monitor IV
avoid infiltration
what are some IV placement tips
side of vessel not on top, hold traction with thump
where is the best place to put IV? why?
biforcation, wont blow, tough skin,
once you get flash with IV how far do you advance catheter to enter vessel
1 cm
how do you determine what direction to point IV when using ultrasound
slide transducer proximally along the arm, ensure vein stays in the center of the screen. the angle of the probe tells you the path of the vein
which side of arm is basilic vein on
medial
which side of arm is cephalic vein on
lateral
what does basilic and brachial vein become
axillary vein
what does axillary and cephalic vein become
subclavian
what are benefits of basilic vein cannulation
success rate 60-75%
avoid trendelenburg
T/F long term arm cannulation is discouraged in basilic vein cannulation
true
where is resistance felt in basilic vein cannulation, how do we combat it
axillary region
abduction and external rotation of arm
running IV to help bypass valves (flush)
how do you help pass basilic vein cannulation up ipsilateral IJ
turn head towards side of venapuncture
what is distance from R basilic vein to RA
40 cm
what is distance from L basilic vein to RA
50 cm
what do we do for difficult IV
use ultrasound
use different locations
use volatiles to dilate vessels
EJ
angiocath
what are risks of mask induction in OR with no IV
laryngospasm
aspiration
prolonged stage 2 in adults (longer induction)
Pulm vascular resistance equation
PAP-PCWP/ CO x 80
Normal 100-300 dynes/cm2
Systemic vascular resistance equation
MAP-CVP/CO x 80
