Hemodynamic Monitoring Flashcards
Purpose of hemodynamic monitoring
Assess homeostasis, trends, Observe for adverse reactions, Assess therapeutic interventions, Manage anesthetic depth, Evaluate equipment function
How we monitor oxygenation
Pulse ox, skin color, ABGs, 02 analyzer on machine
How we monitor ventilation
End tidal, breath sounds, flow volume loop, chest rise, movement of respiratory bag
How we monitor circulation
Pulse ox, capillary refill, pulses, a line, skin color, BP, HR, heart sounds
Minimal standard for monitoring
Ecg, bp, pulse ox, 02 analyzer, end tidal co2
Minimal standard on graphic display
Ecg, bp, hr, ventilation status, o2 sat
Considerations when choosing monitoring
Indications, contraindications, risks/benefits, techniques, alternatives, complications, cost
Hemodynamic monitoring
Stethoscope, ecg, bp (invasive or not), cvp, pap, PCwp, tee
What is precordial stethoscope
Continuous heart and breath sounds, goes into esophagus of intubated pts 28 cm, monitors bronchospasm and peds changes
Purpose of ecg
Arrythmia detection, monitor HR, detect ischemia, detect lyte changes, monitor pacemaker function
3 lead ecg electrodes, leads, views
RA, LA, LL. Leads I, II, III. 3 views, no anterior. No LAD view
5 lead ecg electrodes, leads, views
RA, LA, LL, RL, chest. I, II, III aVR, aVL, aVF, V. 7 views
Best lead for arrythmia, for ischemia
II. V5.
What gain and filtering capacity should be set at
Standardization. Diagnostic mode
What filtering capacity is
Filters out unwanted noise/artifact
Indicators of acute ischemia on ECG
ST elevation >1 mm, T wave inversion, Q waves, ST depression, flat or downslope >1 mm. Peaked T waves
Where posterior/inferior wall ischemia shows, artery
RCA. II, III, AVF
Where lateral wall ischemia shows, artery
Circumflex of LCA. I, AVL, V5-V6
Where anterior wall ischemia shows, arty
LCA. I, AVL, V1-4
Where anteroseptal ischemia shows, artery
LAD, V1-V4
What SBP and DBP correlate with
Myocardial o2 requirement changes. Coronary perfusion pressure
MAP calculation
SBP + 2DBP/3
What oscillometry does
Senses fluctuations in cuff pressure made by arterial pulsation when deflating bp cuff. 1st correlates w SBP, max at MAP, cease at DBP. How automatic cuffs work
What bladder width of bp cuff should be
40% of circumference of extremity
What bladder length should be
Encircles 80% of extremity
What creates a falsely high BP
Cuff too small or loose, extremity below heart, arterial stiffness in htn or PVD.
What creates a falsely low bp
Cuff too big, above heart, poor tissue perfusion, too quick of deflation
Complic of NIBP
Edema of arm, bruising, ulnar neuropathy, interferes IV flow, pain, compartment syndrome
Indications for arterial line bp
Elective hypotension, wide swings or rapid bp changes intra op, fluid shifts, titrate vasoactives, end organ disease, blood sampling
How to improve accuracy of a line
Remove air bubbles, limit tube length, limit stop cocks, small mass of fluid, stiff tubing, calibrate at heart
Where to zero a line when supine or sitting
Supine- mid axillary line (RA). Level of ear (circle of Willis)
A line wave forms: what rate of upstroke and downstroke show. Variations in size. Area under curve. Dicrotic north
Contractility. SVR. Hypovolemia. MAP. Aortic valve closure
Points on a line waveform 1-6
Systolic upstroke, systolic peak pressure, systolic decline, dicrotic notch, diastolic runoff, end diastolic pressure
Distal pulse amplification does what
For a line. SBP peak increases, DBP wave decreases, MAP same. Dicrotic notch becomes less and appears later
IABP complications
Nerve damage, hematoma, bleeding, thrombosis, air embolus, necrosis, loss of digits, vasospasm, arterial aneurysm, retained guidewire
Indications for CVL
Measure R heart filling p, assess fluid status, rapid admin fluids, give vasoactives, remove air emboli, insert transcutaneous pacing leads, vascular access, sample blood, PA cath
CVL: size, length, where tip should be
7 French, 20 cm length skin to RA junction. 15 if left side. 10 if subclavian. Within SVC above vena cava and RA. Below inferior border of blavice, above 3rd rib, T4/5 interspace,
Contraindications to CVL
RA tumor, infection at site
Risks of CVL
Air or thromboembolism, dysrhythmias, hematoma, carotid puncture, pneumo/hemothorax, vascular damage, tamponade, infection, guidewire embolism
What RA P should be. What happens w vent
1-7. 3-5 rise w vent
What a wave on CVP is
Peak coincides w max filling of RV. Used to measure RVEDP. Should be measured at end expiration
What wave form points are in CVP: a
A- diastole of ventricle (p wave right after, atria contracting
What c wave is cvp
Closure of tricuspid valve and isovolemic ventricular contraction. Tricuspid valve bulges back into atrium. Right ventricle contraction. Early suystole after QRS
What x wave is cvp
Atrial pressure decreases during ventricular contraction. Mid systole.
What v wave is cvp
Venous return against a closed tricuspid valve. Pt of RV systole (late). Right after t wave
What y descent is CVP
After ventricle relaxes, tricuspid valve opens d/t venous pressure, blood flows from atrium into ventricle. Diastolic collapse
Wave on cvp: end diastole, early systole, late systole, mid to late diastole, mid systole, early diastole
A wave, c wave, v wave, h wave, x descent, y descent
What PA pressure used for
CVP/PAP/PCWP, LV filling P and function, CO, mixed venous O2 sat, PVR, SVR, pacing option
PA size, length, lumens
7 or 9 French. 110 cm. Distal port, 2nd port 30 cm more proximal, 3rd lumen balloon, 4th wires for temp
Indications for PA monitoring
LV dysfunction, valvular disease, pulm htn, CAD, ARDS, Resp fail, shock, sepsis, ARF, cardiac/aortic/OB procedures
Complications of PA Catheter
Arrhythmias (V fib, RBBB, heart block), catheter knotting, balloon rupture, thrombo/air embolism, ptx, pulm infarct, PA rupture, endocarditis, damage to valves
Contraindications to PA insertion
Wpw syndrome, complete LBBB
What happens to wave form as PA inserted
CVP wave in RA, more turbulent and higher P in RV, SBP same and DBP rises in PA, more compact pressure when wedged
Distance from right IJ to : RA junction, RA, RV, PA, PA wedge
Cm. 15, 15-25, 25-35, 35-45, 40-50
PCWP a wave
contraction of the left atrium. small deflection unless there is resistance in moving blood into the left ventricle as mitral stenosis.
What c wave is PCWP
rapid rise in the left ventricular pressure in early systole, causing the mitral valve to bulge backward into the left atrium, so that the atrial
pressure increases momentarily.
What v wave is PCWP. Prominent wave means what
Blood enters LA in late systole. Prominent reflects mitral insufficiency causing large amts of blood to reflux into LA in systole
How to monitor CO
Thermodiluton, continuous thermodilution, mixed venous oximetry, ultrasound, pulse contour
What can cause loss of a waves in CVP/PAOP.
A fib, ventricular pacing
What can cause large v waves cvp and paop
Mitral regurg and acute inc in IV volume
What can cause giant a waves cvp and paop
Junctional rhythm, complete HB, mitral stenosis, diastolic dysfunction, myo ischemia, ventricular hypertrophy
What TEE observes
Ventricular wall traits/motion, valve structure/function, EF, CO, blood flow, intracardiac air or masses
Uses of TEE
Unusual causes of acute hypotension, tamponade, PE, aortic dissections, myo ischemia, valvular dysfunction
TEE complicaitons
Mostly in awake pts. Esophageal trauma, dysrhythmias, hoarseness, dysphagia
