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Principles 1 > CVL and pulm artery catheter > Flashcards

CVL and pulm artery catheter Flashcards

1
Q

10 indications for central venous line placement

A 
cvp monitoring
pulm artery cath
HD
aspiration air emboli
TPN
vasoactive drugs
repeated blood samples
cannulae placement
bad peripheral access areas
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2
Q

CVP measures

A

right atrial pressure: located junction of SVC and RA

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3
Q

CVP indicates 2 things:

A 
venous return (preload)(volume)
intravascular fluid volume
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4
Q

what two things cause falsely high CVP readings.

A

PEEP and positive pressure ventilation

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5
Q

normal CVP

A

1-8 mmHg

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6
Q

atrial contraction produces an initial spike then descent as blood leaves atrium and fills the ventricle.

A

a wave

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7
Q

Closed tricuspid elevates during isovolumic ventricular contraction.

A

c wave

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8
Q

downward movement of tricuspid valve during systole and atrial relaxation when the base of the heart descends

A

x descent

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9
Q

venous return against a closed tricuspid valve during systole

A

v wave

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10
Q

opening of tricuspid valve during diastole as atrial pressure is higher than ventricular pressure

A

y descent

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11
Q

what are the three systolic components of cvp waveform

A

a and c waves, x descent

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12
Q

what are the two diastolic components of cvp waveform

A

v wave and y descent

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13
Q

what 3 pathologies cause a large A Wave

A
  1. AV asynchrony
  2. pulm htn
  3. decrease RV compliance
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14
Q

what pathology causes no A wave and prominent C - V waves?

A

atrial fib (think, atria dont contract)

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15
Q

this pathology causes broad, tall systolic C - V waves

A

tricuspid regurg (regurg v wave)

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16
Q

this pathology causes tall end diastolic A wave with an early diastolic y descent

A

tricuspid stenosis

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17
Q

what two factors cause a distortion in CVP and PAOP monitoring due to a loss of A waves or only V waves

A

atrial fib and ventricular pacing (atrial asystole)

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18
Q

what 8 factors cause a distortion in CVP and PAOP monitoring due to giant A waves

A 
junctional rhythms
complete av block
pvcs
vent pacing
tricuspid/mitral stenosis
diastolic dysfunction
myocardial ischemia
vent hypertrophy
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19
Q

what 2 factors distort cvp and paop monitoring due to large V waves

A

tricuspid/mitral regurg

acute increase in intravascular volume

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20
Q

what is the large a wave seen with AV asynchrony/disassociation caused by

A

due to atrium
contracting against a closed tricuspid during
ventricular systole.

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21
Q

clinical conditions listed that cause high cvp

A 
lv failure
rv failure
pulm htn
cardiac tamponade
pulm embolism
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22
Q

clinical condition that causes low cvp

A

hypovolemia

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23
Q

causes of high cvp (right side of heart)

A 
rv failure
tricuspid stenosis/regurg
cardiac tamponade
constrictive pericarditis
volume overload
pulm htn
chronic lv failure
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24
Q

causes of high PAP [pulmonary arterial pressure] (lungs)

A 
lv failure
mitral stenosis/regurg
l-r shunting
asd or vsd
volume overload
pulm htn
catheter whip
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25
Q

causes of high paop (left side heart)

A 
lv failure
mitral stenosis/regurg
cardiac tamponade
constrictive pericarditis
volume overload
ischemia
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26
Q

Multitude of direct and indirect measurements
assessing volume and pressure which yield a
picture of cardiovascular and pulmonary function

A

PA pressure monitoring

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27
Q

two most important measurements from pac

A

cardiac

output and PAOP

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28
Q

common indications for pac

A
  • hemodynamic monitoring
  • differential diagnosis and managment of shock
  • diagnostic eval of major cardiopulmonary disorders
  • titration of therapys
  • optimization of vent support
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29
Q

4 contraindications for pac insertion

A

coagulopathy
thrombolytic treatment
prosthetic heart valve
endocardial pacemaker

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30
Q

complications of pac placement

A 
dysrhythmias
catheter knotting
thromboembolism
pulmonary infarction
infection - endocarditis
valvular damage
pulm vascular injury
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31
Q

Inflated balloon occludes a small segment of pulmonary circulation. The pressure
obtained is by

A

looking through the non-active occluded segment of the pulmonary circulation forward to the hemodynamically active pulmonary veins and LA.

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32
Q

paop (wedge pressure) reflects

A

representation of pulmonary venous and left atrial pressures

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33
Q

measures the back pressure (LV

preload) from the pulmonary venous system.

A

PAOP (PCWP)

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34
Q

Gives a more accurate estimation of LAP and thus

left ventricular preload than CVP

A

paop

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35
Q

normal paop

A

8-12 mmHg

36
Q

In supine position tip needs to be in lung zone

A

3

where a continuous full column of blood resides

37
Q

what three things could cause the pac balloon to reside in zone 1 and zone 2

A

PPV, hypovolemia and various positioning

38
Q

lung zone 1

A

PA>Ppa>Ppv

39
Q

lung zone 2

A

Ppa>PA>Ppv

40
Q

lung zone 3

A

Ppa>Ppv>PA

41
Q

lung zone 4

A

Ppa>PISF>Ppv>PA

42
Q

what lung zone is a continuous open system

A

lung zone 3

43
Q

what three zones do not have continous open system

A

1,2,4

44
Q

The uppermost part of the lung. Pulmonary capillaries are consistently compressed by alveoli, and no blood flow occurs. There are no visible a and v waves. The PAC tip in zone 1 records only alveolar pressures. Zone 1 PA pressures and PWP are meaningless

A

zone 1

45
Q

The upper third part of the lung. The pulmonary capillaries are open in systole and compressed by alveoli during diastole. The PAC tip in zone 2 records true PA systolic pressure, but PA diastolic pressure and PWP are meaningless.

A

zone 2

46
Q

The most dependent part of the lung (lower two thirds of the lungs). Pulmonary capillaries are consistently patent. PA systolic and diastolic, PA wedge pressures are all valid. In a supine patient most of the lung is in zone 3 and the majority of PACs are advanced to and wedge in zone 3 of the lung.

A

zone 3

47
Q

PEEP or hypovolemia can lead to

A

more lung areas becoming zones 1 and 2

48
Q

Conditions of PAOP > LVEDP

A 
Tachycardia greater than 130 bpm
• PEEP (5 cmH20 of PEEP ↑’s PAOP by 1 
mmHg)(*↑PVC)
• Catheter tip in zone 1 or 2 (↑PVC)
• COPD (*↑ PVC)
• Pulmonary venoocclusive disease
• Mitral regurgitation
• Mitral stenosis
49
Q

normal pap diastolic

A

1-4 mmHg > paop

50
Q

If PA diastolic climbs 4-5 mmHg higher than

PAOP it indicates

A

an increase in Pulmonary artery vascular resistance

51
Q

increase in Pulmonary artery vascular resistance is caused by

A

hypoxemia, pulmonary

embolism, acidosis and pulmonary vascular dz

52
Q

3 pathological conditions that result in normal PAOP

A

pulmonary embolism
pulm htn
rv failure

53
Q

3 pathological conditions that cause paop to be high

A

restrictive cardiomyopathy
cardiac tamponade
lv failure

54
Q

pathologic condition that causes paop to be low

A

hypovolemia

55
Q

no a and v waves noted
values unusable
balloon hyperinflation or prolonged inflation
false elevation in values

A

overwedging

56
Q

what causes a double peak look to pa wave

A

mitral regurg

57
Q

what wave is seen during pa balloon inflation

A

v wave

58
Q

most preferred site cvl insertion

A

rij

59
Q

most preferred site for longterm use cvl

A

sc vein

60
Q

insertion sites for cvl

A 
Subclavian vein
• Femoral vein
• Basilic vein
• External jugular vein
Right internal jugular
61
Q

distance to the junction of the venae cava and right atrium from subclavian

A

10 cm

62
Q

distance to the junction of the venae cava and right atrium from rij

A

15 cm

63
Q

distance to the junction of the venae cava and right atrium from lij

A

20 cm

64
Q

distance to the junction of the venae cava and right atrium from fem vein

A

40 cm

65
Q

distance to the junction of the venae cava and right atrium from right median basilic vein

A

40 cm

66
Q

distance to the junction of the venae cava and right atrium from left medial basilic vein

A

50 cm

67
Q

5 CVL Insertion Complications listed

A 
Vascular structure injury (carotid most common)
• Pleura injury
• Nerve bundle injury
• Lymphatic system injury
• Rare spinal canal injury
68
Q

Right Internal Jugular Vein (IJV)

Advantages

A 
–Easily identifiable landmarks
–Straight course to the SVC
–Easily accessible at the patient’s head
–High success rate (91-99%)
–Bleeding easily recognized and controlled
–Reduced risks of pneumothorax
69
Q

RIJ Disadvantages:

A

–Increased risk of infection
–Increased risk of unintentional carotid artery
puncture.
–Unable to access if patient is in cervical collar.

70
Q

right ij landmarks

A

found in groove between two heads of sternocleidomastoid

71
Q

Left IJV Site

• Advantages:

A

–Easily identifiable landmarks
–Easily accessible at the patient’s head
–Bleeding easily recognized and controlled

72
Q

Left IJV Site disadvantages

A

– Greater risk for pneumothorax because pleura is higher
– Thoracic duct enters the venous system at the junction of the LIJ and subclavian veins.
– Smaller vessel with a more overlap of the carotid artery.
– Catheter must traverse the innominate and enter the SVC more perpendicular leading to more vascular injuries.

73
Q

Subclavian Vein Site

• Advantages

A

–Infection risks are reduced
–Cervical instability (C-collar) trauma patients.
–Patient comfort
–Larger vessel doesn’t risk collapse.

74
Q

Subclavian Vein Site disadvantages

A

–Increased risk of pneumothorax
–More difficult landmarks in obese
–Less accessible
–More difficult to identify bleeding.

75
Q

External Jugular Vein(EJV) Site advantages

A

–Closer to surface
–More easily identified
–Preferred with patient with coagulopathy
–Less risk for IC puncture.

76
Q

External Jugular Vein(EJV) Site disadvantages

A

–Smaller vessel, more difficult to advance catheter

–Can be more easily kinked

77
Q

Advantages of U/S guided CVL Placement

A
  • less error

- real time feedback

78
Q

long axis of ultrasound shows

A

longitudinal plane

79
Q

short axis of ultrasound shows

A

transverse plane

80
Q

High Frequency Transducer frequency and advantages

A

7-15 mHz

superficial structure depth and crisp sharp images

81
Q

low frequency transducer frequency and advantage

A

2-5 mHz

deeper stucture depth

82
Q

waves bounce and return to probe for processing

A

Reflection:

83
Q

waves bounce away from probe

A

Refraction:

84
Q

Using 2-D, the CA can be differentiated from IJV

by assessing

A

compressibility and expandability - IJ compresses and exands

85
Q

flow blue

A

away

86
Q

flow red

A

toward

87
Q

transducer oriented caudad (down)

A

carotid is red

IJ is blue

Principles 1 (12 decks)

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