Hemodynamic monitoring Flashcards
IABP complications
- Nerve damage
- hemorrhage/hematoma
- infection
- thrombosis
- air embolus
- skin necrosis
- loss of digits
- vasospasm
- arterial aneurysm
- retained guidewire
ECG complex
- each box, 0.04 seconds
CVC contraindications
- R atrial tumor
- Infection at site
ECG indicators of acute Ischemia
- ST segment elevation >/= 1mm
- T wave inversion
- development of Q waves
- ST segment depression
- Peaked T waves
CVC size
7 french
20 cm length
*not confirmed by xray in OR, aspirate blood from all ports
SaO2
ratio of oxyhemoglobin to all functional hemoglobin.
dichrotic notch
aortic valve closure
happens later in waveform the further art line is
Distance from RIJ to Wedge (pulmonary artery)
40-50 cm
PAP waveforms
Same as CVP but for left side
Cardiac output monitoring techniques
- thermodilution
- continuous thermodilution
- mixed venous oximetry
- ultrasound
- pulse contour
Pulmonary artery pressure monitoring
Measures left side of heart. Line goes through SVC, RA, RV to PA
Transesophageal echocardiography Complications
- esophageal trauma
- dysrhythmias
- hoarseness
- dysphagia
*more complications in awake patients
Changes in lead V1-V4
Anterioseptal ischemia
left descending coronary artery
Leveling art line
- Mid axillary line in supine pts
- level of ear (circle of willis) in sitting patients
Anterior view of heart
V3, V4
5 Lead ECG
- Leads I, II, III, aVR, aVL, aVF, V
- 7 views of the heart
Risks of CVC
air or thrombo-embolism
dysrhythmia
hematoma
Carotid puncture
pneumo/hemothorax
vascular damage
cardiac tamponade
infection
guidewire embolism
Complications of NIBP
- edema of extremity
- petechiae/bruising
- ulnar neuropathy
- interference of IV flow
- altered timing of IV drug administration
- pain
- compartment syndrome
Transesophageal echocardiography
7 cardiac parameters observed:
- ventricular wall characteristics and motion (look for ischemia)
- valve structure and function
- Estimation of end-diastolic and end-systolic pressures and volumes (EF)
- CO
- blood flow characteristics
- intracardiac air
- intracardiac masses
CVC location
Tip within the Superior Vena Cava (SVC), just above the junction of SVC and RA
- below the inferior border of clavicle and above the level of 3rd rib
Things that can distort CVP and PCWP
- loss of waves
- afib, ventricular pacing
- Giant a waves“cannon” a waves
- junctional rhythms
- complete HB
- mitral stenosis
- diastolic dysfunction
- myocardial ischemia
- ventricular hypertrophy
- Large v waves
- mitral/tricuspid regurgitation and acute increase in intravascular volume
- tamponade/pericarditis (both squeezing the heart)
Distance from RIJ to RV
25-35 cm
NIBP cuffs
- bladder width should be approximately 40% of the circumference of the extremity
- Bladder length should encircle 80% of extremity
- applied snugly, bladder centered over the arter and residual air removed.
DBP
- trough pressure during diastolic ventricular relaxation
- changes reflect coronary perfusion pressure
PAP assessment
- Intracardiac pressures (CVP, PAP, PCWP/PAWP)
- estimate LV fillin gpressures
- assess LV function
- CO
- mixed venous oxygen saturation
- Pulmonary Vascular resistance (PVR) Systemic vascular resistance (SVR)
CVP monitoring
Right atrial pressure = Right ventricle preload
normal = 1-7 mmHg
with mechanical ventilation = 4-10 mmHg
Distance from RIJ to PA
35-45 cm
CVP waveform
- “a” wave is point of maximal filling of RV and should be used for RVEDP
- machines “average” the measurement
- Should be measured at end-expiration.
- “c” closure of tricuspid valve and V contraction, tricuspid “bulges” back into the atrium slightly increasing the pressure
Changes in Lead I, AVL, V5-V6
Lateral wall ischemia
circumflex branch of left coronary artery
Thermodilution
Using known amount of known temperatured solution to inject in catheter in RA. Thermister on cathether (swan-ganz) measures change in temperature. Used to assess cardiac output
AANA minimal standard required monitors and monitoring information (on graphic display)
- ECG (HR and rhythm)
- Blood pressure
- pulse ox
- Oxygen analyzer
- end tidal carbon dioxide
- ECG
- BP
- HR
- ventilation status
- O2 sat
*Must document minimum of every 5 minutes!!
**Variable pitch tone must be audible with use of Pulse ox
Insertion sites of Central venous catheters
- right internal jugular (most common for anesthesia)
- left internal jugular vein
- subclavian veins
- external jugular veins
- femoral veins
Septal view of heart
V1, V2
3 Lead ECG
3 views of the heart, no anterior view
most important lead for ischemia
V
*all V leads
PCWP
Pulmonary Capilary wedge pressure
a wave: contraction of Left atrium
*usually a small deflection unless there is resistance moving blood into LV like in mitral stenosis.
c wave: rapid rise in LV pressure in early systole, causing mitral valve to bulge backward into LA, so atrial pressure increases momentarily
v wave: blood entering LA during late systole
*prominent v wave reflects mitral insufficiency causing large amounts of blood to reflux into the LA during systole
distance from RIJ to RA
15-25 cm
BP Oscillometry
Senses oscillations/fluctuations in cuff pressure produced by arterial pulsations while deflating a BP cuff
- 1st oscillation correlates with SBP
- maximum/peak oscillations occurs at MAP
- oscillations cease at DBP
Transesophageal echocardiography uses:
- unusual causes of acute hypotension
- pericardial tamponade
- pulmonary embolism
- aortic dissection
- myocardial ischemia
- valvular dysfunction
most important lead for rhythm changes
II
Falsely high PB
- cuff too small
- cuff too loose
- extremity below level of heart
- arterial stiffness- HTN, PVD
Changes in Lead I, AVL, V1-V4
Anterior wall ischemia
Left coronary artery
Lateral view of heart
I, aVL, V5, V6
Lead I = RA-LA
Pulse pressure
SBP-DBP
As location of BP moves out peripherally, you get exaggerated SBP and wider pulse pressure.
PAP catheters
- 7 or 9 french
- 110 cm length
- 4 lumens
- distal port PAP
- second port 30 cm more proximal CVP
- third lumen balloon
- fourth wires for temp
Distance from RIJ to Vena cava and RA junction
15 cm
Calculate MAP
SBP+2(DBP) / 3
low CVP reading
hypovolemia/shock
CVC indications
- measuring right heart filling pressures
- assess fluid status/blood volume
- rapid administration of bolus
- administration of vasoactive drugs
- removal of air emboli
- insertion of transvenous pacing leads
- vascular access
- sample central venous blood
Standard 2
- Oxygenation
- ventialtion
- circulation
- temperature
*Continually evaluated
inferior view of heart
II -RA-LL
III - LA-LL
aVF- LA+LL-RA
PAP complications
- arrhythmias
- catheter knotting
- balloon rupture (can rupture pulmonary vasculature
- thromboembolism; air embolism
- pneumothorax
- pulmonary infarction
- PA rupture
- infection
- damage to cardiac structures (valves, etc)
10.
SBP
- peak pressure generated during systolic ventricular contraction
- changes correlate to changes in myocardial O2 requirements
Esophageal stethescope
- Intubated patients only
- 28-30 cm
- shows temp too
- used in every pediatric case.
- very sensitive to bronchospasm
Indications for Art line
- elective deliberate hypotension
- wide swings in BP
- rapid fluid shifts
- titration of vasoactive drugs
- end organ disease
- repeated blood sampling
- failure of NIBP
Standard 1
Qualified provider must be with pt the entire time
SRNA
CRNA
MDNA
AA- need direct in room supervision
Precordial stethescope
taped to chest and used for continual assessment of heart and lung sounds.
Allen test
block radial and ulnar arteries, pt pump fist, release ulner artery first to make sure it can refill hand if radial artery gets “trashed” by art line.
Falsely low BP
- Cuff too large
- extremity above level of heart
- poor tissue perfustion
- too quick deflation
*improper cuff placement, dysrhythmias, tremors/shivering
Arterial pressure waveform
*the more distal the art line, the SBP will increase, DBP will decrease, MAP same, dichrotic arch is later
Art line sites
- radial
- ulnar
- brachial
- femoral
- dorsalis pedis
- axillary
to improve accuracy of art line
and forms of erro
- minimize tubing length
- limit stopcocks
- no air bubbles
- use non-compliant stiff tubing
- calibrated
forms of error: Dampening and overshooting
PAC indications
LV dysfunction
valve disease
Pulm HTN
CAD
ARDS/resp failure
shock/sepsis
AFR
Cardiac sugeries
high CVP readings
fluid overload
right heart failure
PE
tension pneumo
Pulse Oximeter
- measures hemoglobin saturation
- pulses red and intrared LED on and off several hundred times per second
- absorption of intrared light in blood–algorithm used to compute ration of infrared light signal and saturation
Changes in Lead II, III, AVF
(posterior)/ Inferior wall ischemia
Right coronary artery
Purpose of ECG
- detect arrhythmias
- monitor heart rate
- detect ischemia
- detect electrolyte change
- monitor pacemaker function
