CVL and pulm artery catheter Flashcards
10 indications for central venous line placement
cvp monitoring pulm artery cath HD aspiration air emboli TPN vasoactive drugs repeated blood samples cannulae placement bad peripheral access areas
CVP measures
right atrial pressure: located junction of SVC and RA
CVP indicates 2 things:
venous return (preload)(volume) intravascular fluid volume
what two things cause falsely high CVP readings.
PEEP and positive pressure ventilation
normal CVP
1-8 mmHg
atrial contraction produces an initial spike then descent as blood leaves atrium and fills the ventricle.
a wave
Closed tricuspid elevates during isovolumic ventricular contraction.
c wave
downward movement of tricuspid valve during systole and atrial relaxation when the base of the heart descends
x descent
venous return against a closed tricuspid valve during systole
v wave
opening of tricuspid valve during diastole as atrial pressure is higher than ventricular pressure
y descent
what are the three systolic components of cvp waveform
a and c waves, x descent
what are the two diastolic components of cvp waveform
v wave and y descent
what 3 pathologies cause a large A Wave
- AV asynchrony
- pulm htn
- decrease RV compliance
what pathology causes no A wave and prominent C - V waves?
atrial fib (think, atria dont contract)
this pathology causes broad, tall systolic C - V waves
tricuspid regurg (regurg v wave)
this pathology causes tall end diastolic A wave with an early diastolic y descent
tricuspid stenosis
what two factors cause a distortion in CVP and PAOP monitoring due to a loss of A waves or only V waves
atrial fib and ventricular pacing (atrial asystole)
what 8 factors cause a distortion in CVP and PAOP monitoring due to giant A waves
junctional rhythms complete av block pvcs vent pacing tricuspid/mitral stenosis diastolic dysfunction myocardial ischemia vent hypertrophy
what 2 factors distort cvp and paop monitoring due to large V waves
tricuspid/mitral regurg
acute increase in intravascular volume
what is the large a wave seen with AV asynchrony/disassociation caused by
due to atrium
contracting against a closed tricuspid during
ventricular systole.
clinical conditions listed that cause high cvp
lv failure rv failure pulm htn cardiac tamponade pulm embolism
clinical condition that causes low cvp
hypovolemia
causes of high cvp (right side of heart)
rv failure tricuspid stenosis/regurg cardiac tamponade constrictive pericarditis volume overload pulm htn chronic lv failure
causes of high PAP [pulmonary arterial pressure] (lungs)
lv failure mitral stenosis/regurg l-r shunting asd or vsd volume overload pulm htn catheter whip
causes of high paop (left side heart)
lv failure mitral stenosis/regurg cardiac tamponade constrictive pericarditis volume overload ischemia
Multitude of direct and indirect measurements
assessing volume and pressure which yield a
picture of cardiovascular and pulmonary function
PA pressure monitoring
two most important measurements from pac
cardiac
output and PAOP
common indications for pac
- hemodynamic monitoring
- differential diagnosis and managment of shock
- diagnostic eval of major cardiopulmonary disorders
- titration of therapys
- optimization of vent support
4 contraindications for pac insertion
coagulopathy
thrombolytic treatment
prosthetic heart valve
endocardial pacemaker
complications of pac placement
dysrhythmias catheter knotting thromboembolism pulmonary infarction infection - endocarditis valvular damage pulm vascular injury
Inflated balloon occludes a small segment of pulmonary circulation. The pressure
obtained is by
looking through the non-active occluded segment of the pulmonary circulation forward to the hemodynamically active pulmonary veins and LA.
paop (wedge pressure) reflects
representation of pulmonary venous and left atrial pressures
measures the back pressure (LV
preload) from the pulmonary venous system.
PAOP (PCWP)
Gives a more accurate estimation of LAP and thus
left ventricular preload than CVP
paop
normal paop
8-12 mmHg
In supine position tip needs to be in lung zone
3
where a continuous full column of blood resides
what three things could cause the pac balloon to reside in zone 1 and zone 2
PPV, hypovolemia and various positioning
lung zone 1
PA>Ppa>Ppv
lung zone 2
Ppa>PA>Ppv
lung zone 3
Ppa>Ppv>PA
lung zone 4
Ppa>PISF>Ppv>PA
what lung zone is a continuous open system
lung zone 3
what three zones do not have continous open system
1,2,4
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
zone 1
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.
zone 2
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.
zone 3
PEEP or hypovolemia can lead to
more lung areas becoming zones 1 and 2
Conditions of PAOP > LVEDP
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
normal pap diastolic
1-4 mmHg > paop
If PA diastolic climbs 4-5 mmHg higher than
PAOP it indicates
an increase in Pulmonary artery vascular resistance
increase in Pulmonary artery vascular resistance is caused by
hypoxemia, pulmonary
embolism, acidosis and pulmonary vascular dz
3 pathological conditions that result in normal PAOP
pulmonary embolism
pulm htn
rv failure
3 pathological conditions that cause paop to be high
restrictive cardiomyopathy
cardiac tamponade
lv failure
pathologic condition that causes paop to be low
hypovolemia
no a and v waves noted
values unusable
balloon hyperinflation or prolonged inflation
false elevation in values
overwedging
what causes a double peak look to pa wave
mitral regurg
what wave is seen during pa balloon inflation
v wave
most preferred site cvl insertion
rij
most preferred site for longterm use cvl
sc vein
insertion sites for cvl
Subclavian vein • Femoral vein • Basilic vein • External jugular vein Right internal jugular
distance to the junction of the venae cava and right atrium from subclavian
10 cm
distance to the junction of the venae cava and right atrium from rij
15 cm
distance to the junction of the venae cava and right atrium from lij
20 cm
distance to the junction of the venae cava and right atrium from fem vein
40 cm
distance to the junction of the venae cava and right atrium from right median basilic vein
40 cm
distance to the junction of the venae cava and right atrium from left medial basilic vein
50 cm
5 CVL Insertion Complications listed
Vascular structure injury (carotid most common) • Pleura injury • Nerve bundle injury • Lymphatic system injury • Rare spinal canal injury
Right Internal Jugular Vein (IJV)
Advantages
–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
RIJ Disadvantages:
–Increased risk of infection
–Increased risk of unintentional carotid artery
puncture.
–Unable to access if patient is in cervical collar.
right ij landmarks
found in groove between two heads of sternocleidomastoid
Left IJV Site
• Advantages:
–Easily identifiable landmarks
–Easily accessible at the patient’s head
–Bleeding easily recognized and controlled
Left IJV Site disadvantages
– 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.
Subclavian Vein Site
• Advantages
–Infection risks are reduced
–Cervical instability (C-collar) trauma patients.
–Patient comfort
–Larger vessel doesn’t risk collapse.
Subclavian Vein Site disadvantages
–Increased risk of pneumothorax
–More difficult landmarks in obese
–Less accessible
–More difficult to identify bleeding.
External Jugular Vein(EJV) Site advantages
–Closer to surface
–More easily identified
–Preferred with patient with coagulopathy
–Less risk for IC puncture.
External Jugular Vein(EJV) Site disadvantages
–Smaller vessel, more difficult to advance catheter
–Can be more easily kinked
Advantages of U/S guided CVL Placement
- less error
- real time feedback
long axis of ultrasound shows
longitudinal plane
short axis of ultrasound shows
transverse plane
High Frequency Transducer frequency and advantages
7-15 mHz
superficial structure depth and crisp sharp images
low frequency transducer frequency and advantage
2-5 mHz
deeper stucture depth
waves bounce and return to probe for processing
Reflection:
waves bounce away from probe
Refraction:
Using 2-D, the CA can be differentiated from IJV
by assessing
compressibility and expandability - IJ compresses and exands
flow blue
away
flow red
toward
transducer oriented caudad (down)
carotid is red
IJ is blue