Hemodynamic Flashcards
hemodynamic monitoring purpose 5
assess hemostasis, trends observe adverse reactions assess therapeutic interventions manages anesthetic depth evaluate equipment function
standards for basic monitoring
1 qualified provider: during entire anesthetic procedure, except laboring, pain control (epidural)
4 things we monitor and how
- oxygenation: abg, mental status, low O2 alarm, O2sat
- ventilation: vent settings/alarms WOB, breath sounds
- Circulation: HR, ECG, pulse Ox, heart tones
- Temp: touch, continues- usually in peds
monitors to be used 6
1 ECG 2 BP 3 Precordial stethosope 4 pulse ox 5 Oxy analyzer 6 ETCO2
graphic display
ECG BP HR Vent status O2Sat
must hear
pulse ox ECG BP inspired O2 airway pressure
Esophageal or pericardial stethoscope
- continuous assessment of breath sounds and heart tones
- esophageal: intubated pt only, place @ 28-30cm into esophagus
- *very sensitive monitoring for Bronchospasm and changes is pediatric pts
ECG purpose
- detect arrhythmia, elyte changes, ischemia
- monitor HR(not pulse), pacemaker function
3 lead
RA, LA, LL
leads: I II III
* NO anterior (LAD) view
5 lead
RA, LA, LL, RL, chest lead lead I II III aVR, aVL, aVF, V 7 view of heart- including septum, LAD *lead II best view of P wave V4, V5 best ischemic detection
ECG box thingy
small box 0.04sec
lg box 0.2sec
300 150, 100, 75, 60, 50
Gain setting
amplitude, should be set at standardization
- 1mV signal produces 10mm calibration pulse
- can interpret ST accurately
Filtering
should be set to diagnostic mode
-filtering out low end of frequency bandwidth, can distort ST segment
ECG-acute ischemia 5 principles
- ST segment elevation >1mm
- T was inversion
- Development of Q waves
- ST segment depression/Flat
- Peaked T waves
Coronary anatomy, ECG and MI
Septal V1-4…L descending
Anterior I V1-4…L coronary artery
Inferior (posterior) II III aVF… R coronary art
Lateral I aVL V5-6… circumflex L
BP: SBP, DBP, pulse pressure, MAP
SBP: peak during systolic ventricular contraction **change in SBP correlate with change in myocardial O2 requirements
DBP: trough during diastolic ventricular relaxation
Pulse Pressure: SBP-DBP=PP
–widen means: aortic regurg
–narrowing means: blood loss, aortic stenosis, tamponade
MAP: DBP+ 1/3PP or SBP+2(DBP)/3
-time weighted averaged go arterial pressure during pulse cycle
*pulse moves peripherally distrots waveform exaggerated SBP and wider pp
NIBP, ways to obtain
palpating return of Arterial pulse while deflating
*under estimates SBP
-doppler: based on the shift in frequency of sound waves that is reflected by RBC moving though artery
-Auscultation: korotkoft-turbulent flow
-Oscillometry: fluctuations in cuff produced by arterial pulsations while deflating cuff
1st: SBP
max/peak: MAP
ceases DBP
-Automated: measures change in amplitude electronically
NIBP cuffs
bladder width 40% circus of extremity
bladder length encircle 80% of extremity
bladder over artery
falsely high
cuff too sm
loose
extremity below heart
falsely low
cuff too lg
above heart
too quick deflate
Invasive BP
- percutaneous catheter
- transduced generated pressure to electoral signal
- real time BP
- arterial sampling
IABP indication
deliberate hypotension vasoactive drugs repeat art sample wide swings in intra op BP risk of rapid BP changes rapid fluid shift end organ disease NIBP failure
IABP procedure
20g catheter
Allens test: occude both radial and ulnar, release ulnar hand should re-prefuse.?
continous flush 1-3ml/hr prevents thrombus
transducer…allows for rapid flush
minimize tube length, stiff tubing, calibration at heart
IABP leveling, dampening, overshooting
accuracy: zeroing and claibration
transducer at mid axillary line in supine pt R atrium
ear, circle of willis in sitting pt
dampening: (false low BP) kinking, air, too long of tubing, stopcocks
overshooting: stiff vessels
IABP waveform
rate of upstroke–contractility
rate of downstroke–SVR
exaggerated variations in size with Resp and Hypovolemia
**Dicrotic notch: closure of Aortic valve
Distal pulse amplification
as the pulse travels from the arterial to the periphery
increased SBP
decreased DBP
MAP not altered
*Dicrotic notch: become less and appears later
-pulse pressure widens
IABP complications
nerve damage, arterial aneurysm, retained guidewire, thrombosis, hematoma/hemorrhage, air embolism, vasospasm, skin necrosis, loss of digits, infection
Central line indications
measures R heart filling pressures if bigger gauge: rapid admin of fluid admin vasoactive drugs removal of air emboli pulm art cath transvenous pacing leads sample central venous blood
Central line site
RIJ 15cm LIJ 20cm and can damage thoracic duct subclavian, fem veins **L plural higher 7 french, 20cm in length no xray confirmation in OR must aspirate from all ports...if problem consider X-ray Tip in SVC just above junction of vena cava and RA T4/T5 carina
Central line contraindications
R atrial tumor, infection at site, Contralateral pneumo
Central Line risk
usually due to poor technique air/thromboembolism dysrhythmia hematoma carotid puncture pneumo vascular damage cardiac tamponade infection **guidewire embolism
CVP monitoring, purpose, normals: spont and mech
R atrium CVP= RAP= RV preload *view of R side of heart
mean RA pressure in a spont breathing pt= 1-7mmhg
mech vent rises 3-5mmhg (10-12)
should be measured at end-expiration
3 peaks: a c v 2 descents x y
Pulm artery pressure monitor does what
4lumens do what
R sided catheter used for direct assessment of: intracardiac presssures (CVP, PAP, PCWP) estimate LV filling pressures and LV function -CO, PVR, SVR -mixed venous oxygen saturation -pacing options -catheters: 7-9french 110cm length marked @ 10cm intervals 4lumens: 1st: *distal port PAP 2nd: 30cm more proximal CVP 3nd: lumen balloon 4th: wires for temp thermistor
pulm art pressure catheter indication
LV dysfunction valvular disease Pulm HTN CAD ARF, ARDS/resp failure shock/sepsis surg procedures: cardiac, aortic, OB **who benefits? severe shock **also must need to know how to interpret data
pulm art cath complications
**arrhythmias (v-fib, RBBB, complete heart block)
**PA rupture
catheter knotting
thromboembolism
air embolism
pneumo
pulm infarction
damage to heart structures wall/valves
balloon rupture
Pulm art Cath relative contraindications
WPW syndrome, complete LBBB
Cardiac output monitoring
thermodilation continuos theromdilation mixed venous oximetry-O2 consumption ultrasound pulse contour: flow trac
factors that can distort CVP, PAOP waveforms
loss of a waves: a-fib, vent pacing
giant a waves “cannon” a waves: junctional rhythms, complete HB, mirtial stenosis, diastolic disfunction, MI, vent hypertrophy
lg V waves- mitral regard, acute increase in intravascular volume
Transesophageal Echocardiograpy TEE
7cardiac parameters observed:
- ventricular wall characteristics and motion
- disease ex thickening
- valvue stricture and function
- Estimation of end-diastolic and end-systolic pressures and volume
- CO
- blood flow characteristics
- Intracardiac air and masses
TEE uses
unusual causes of Hypotension pericardial tanponade pulm edema aortic dissection myocardia ischemia valvular dysfunction
TEE complication
esophageal trauma dysrhythmisa hoarsness dysphagia *most common in awake pts*
