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Critical Care > Hemodynamic Monitoring and Cardiac Surgery > Flashcards

Hemodynamic Monitoring and Cardiac Surgery Flashcards

1
Q

Hemodynamic Monitoring

A
  • can be invasive (arterial lines, PA catheter, central lines, SPO2) or non-invasive (VS, SPO2, end tidal CO2 monitoring - all things that can be done w/o poking people)
  • measurements of pressure, flow, and oxygenation w/in the CV system
  • tells us about heart function, fluid balances, the effects of drugs and fluids on CO
  • tells us about O2 demand and delivery w/in body (making sure we know how much is going in and how much is being taken by the body and coming back to be circulated again)
  • TRENDS ARE IMPORTANT
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2
Q

CO

A

normal: 4-8 L/min

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3
Q

CI

A

normal: 2.2-4
* more sensitive than CO b/c it’s based on body surface area of pt so more specific
* computer calculates CI once height and weight are entered

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4
Q

SV

A

stroke volume

amount of fluid being pumped, very dependent on amount of fluid available and HR

in order to have good stroke volume, need to have fluid and good stretch to accommodate the fluid

directly impacts CO (both fluid dependent)

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5
Q

SVI

A

stroke volume index

*preload, afterload, and contractility affect SV, and thus CO

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6
Q

MAP

A

normal: 65-105

represents maintained pressure w/in artery continuously (how much good circulation are arteries delivering to rest of body)

how to calculate: (systolic + (2 x diastolic))/3

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7
Q

Right Sided Heart Numbers

A

PAP - pulmonary artery pressure
-tells us about right side of the heart and pulmonary circulation

PAS: pulmonary artery systolic
normal = 20-30

PAD: pulmonary artery diastolic
normal = 8-15

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8
Q

PAWP/PCWP

A

pulmonary capillary/artery wedge pressure

indirect estimate of left atrial pressure, preload on the left side of the heart (if left ventricle is fluid overloaded, PAWP will be high b/c pathway of blood when fluid is overloaded is backwards - backs up into pulmonary circuit and causes balloon to read higher numbers)

measured via catheter (Swan-Ganz) inserted into peripheral vein and then threaded into branch of a pulmonary artery. Balloon on tip of catheter is inflated during insertion.

helps diagnose:

  • valve stenosis (particular mitral valve), if if valve is stenosed your going to see blood back up into the pulmonary circuit
  • severity of HF
  • pulmonary HTN
  • edema
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9
Q

Preload

A

volume in the ventricle at the end of diastole

dependent on fluid volume

CVP: preload for the right side of the heart, fluid returning to the right atrium and ventricle heart after circulating the body
-normal = 2-6 mm/h2O

PAWP: preload for the left side of the heart (left ventricular end diastolic pressure)
-normal = 6-12 mm/h2O

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10
Q

Afterload

A 
afterload = SVR
-normal = 800-1200

forces (the squeeze of aorta) pushing against ventricular ejection

affected by:

  • arterial pressure, high arterial pressure > lots of work for the heart to overcome
  • pressure of aortic valve: if it’s very stiff and doesn’t open a lot it’s going to create a lot of resistance
  • mass and density of blood: thick blood is not going to flow as well
  • high SVR = lots of squeeze
  • low SVR = jiggly floppy aorta noodle (no resistance, not a good sign)
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11
Q

Contractility

A

strength of contraction
-normal = 55-70%

affected by disease that affect the heart muscle

high contractility causes: adrenaline release, SNS stimulation

tx high contractility: negative inotropes (like beta blockers, CCBs)

low contractility causes: anything that effects heart muscle, age, cardiac disease such as HF, CAD, history of MI, genetics (usually caused by underlying cardiac disease)

tx of low contractility: cardiac surgery or meds depending on how sick they are

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12
Q

Frank Starling Law

A

more stretch = more force

affected by preload (need fluid in order to have good stretch)

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13
Q

Meds that increase contractility

A

epinephrine, dobutamine, dopamine, milrinone

*dobutamine and dopamine can cause tachycardia and dysrhythmias

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14
Q

Milrinone

A

positive inotrope

benefit = vasodilation effect on top of being contractility agent. relaxes vessels making it easier for heart to pump in addition to making it pump better

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15
Q

Pulse Pressure

A

difference between systolic and diastolic BP

normal = 1/3 of systolic

increased pulse pressure (widening): d/t increased systolic which may occur during exercise, stress or in individuals w/ atherosclerosis of the large arteries

decreased pulse pressure (narrowing): d/t HF, hypovolemia, cardiac tamponade

*at minimum, should be a least 30 points difference but get concerned when it’s less than 20

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16
Q

Pulmonary Artery Catheter

A

aka Swan-Ganz

multi-lumen catheter inserted via right side of the heart (at IJ)

provides right and left heart numbers

Ports:

  • distal: PAWP when balloon is inflated
  • medial: fluids, meds
  • proximal: CVP
17
Q

Pulmonary Artery Catheter - Risks and Nursing Care

A

infection: assess line q4hrs, make sure it’s clean and dressing is completely occlusive and intact and any drainage is addressed

bleeding

balloon dislodgement or bursting causing cut off of circulation or damage to pulmonary vessels: closely monitor where we are wedging pt. balloon should only be inflated when we need to obtain wedge pressure

catheter can migrate and move: measure catheter depth q8hrs and make sure that number is consistent

18
Q

SVO2

A

mixed venous gas (how much O2 is in blood after it circulates the body)
normal = 60-80%

*high O2 demand = low SVO2; low O2 demand = high SVO2

19
Q

causes of low SVO2

A

anything that increases demand:

  • fever (high temp increases O2 demand b/c of increase in metabolic rate)
  • MI (poses risk to cardiac muscle, so cardiac muscle is requiring more O2)
  • stress, activity (turning a pt causes SVO2 to tank b/c demand has increased by moving them, stop activity and come back to it after SVO2 has improved)

anything that decreases supply:

  • lack of O2 (hypoxemic - give O2)
  • lack of good cardiac function (anything that decreases contractility - MI, HF - not getting good supply b/c heart isn’t pumping it out)
20
Q

High SVO2

A

usually a good sign and means pt is improving

OR

pt has sepsis
-there is a phase of sepsis where numbers look good (hyperdynamic phase) then takes a turn for the worst

21
Q

Coronary Artery Bypass Graft (CABG)

A

bypass provides alternative source of blood flow by providing artery of vein and plugging it into somewhere that has good blood flow (maybe aorta or one of the stemming branches) and attach it further down on area of vessel where it was blocked therefore providing good blood flow to those areas again

can have a number of CABG’s done

conventional (open sternum, bypass machine) or minimally invasive (pt must be stable to get this)

22
Q

Bypass

A

2 catheters are placed: in aorta (aortic arch) and superior or inferior vena cava.

pull out and circulate blood to vessels w/o providing circulation directly to heart

ventricles don’t beat so surgeon can work on heart

23
Q

CABG Surgery - Roles

A 
surgeon
resident
circulating nurse
scrub nurse
perfusionist
24
Q

CABG Surgery - Intra-op

A 
basic anesthesia 
intubated
lines placed (Swan-Ganz and arterial lines)
chest opened
surgery starts
artery/vein harvest portion
chest closed
pt stabilized
taken off perfusion machine
sent to cardiac ICU to recover
25
Q

CABG Post-Op Care

A
  • hemodynamic monitoring
  • VS
  • UO
  • drain output (<100ml/hr, monitored q15min for first hour, q30min for second, then qh)
  • monitor for bleeding
  • post-op meds for dysrhythmias (meds to fix/prevent electrolyte imbalance, amiodarone to prevent abnormal rhythms)
  • tx pain
  • incision care
  • reorient and mental status checks (for s/sx of stroke)
26
Q

CABG Post-Op Complications

A

cardiac tamponade: when drains aren’t adequately working or bleeding is so bad w/in chest cavity, it compresses heart and heart cannot pump b/c there is no room for stretch.
-pt needs to go back to OR to be reopened to stop bleeding

hypovolemia: blood loss, tx w/ fluids (often blood)

fluid overload: pt is given too much fluids and sick heart can’t take it. tx by holding fluids, don’t give diuretics cause you don’t want to overdo it and have low BP, so usually just avoid fluid and try to monitor closely and wait it out

hyperthermia: result of anesthesia and rxn to meds. tx with other meds if it’s malignant otherwise use tylenol and cooling blanket

HTN: stress response, body clamps down and BP shoots up. Need to address early b/c ventricle and heart that has been disease for some time are not going to respond well to high BP

dysrhythmias: heart gets irritated anytime we do construction on it. most common is a-fib
bradycardia: has to do w/ surgeries that are close to pacemaking portion of heart. rhythm can be altered for a while.

27
Q

LVAD

A

mechanical pump inserted into left ventricle

pumps blood from left ventricle into ascending aorta

can be end-destination or bridge to transplant

considerations = psych eval b/c it’s easy to end your life with this, 24 hour support person is required

will need to be on anticoagulants (not always life-long)

*don’t have systolic and diastolic pressure b/c mechanical pump is continuous.

Very important for these pt to not have HTN b/c LVAD will not be able to overcome high BP

28
Q

Intra-aortic Balloon Pump (IABP)

A

inserted via subclavian, axillary, or femoral artery

balloon provides counter-pulsation therapy

balloon inflates and deflates at specific time to allow better blood flow

when heart is filling, balloon is inflated, which pushes blood back to coronary arteries to make sure they get good circulation

when heart is in systole (pumping), the balloon deflates which creates tiny amount of suction which helps pull out blood to go into the rest of body

*will pump person up on transplant list

29
Q

IABP: SE

A

perfusion issues to affected artery and areas below the artery
-monitor pulses on effected side

balloon moving: balloon sits just above renal arteries so it’s going to block perfusion to kidneys and cause kidney damage if it’s moved
-need to check position of balloon w/ daily x-ray and move it if it has migrated

emotional/mental effects of not being able to get out of bed

30
Q

Post-Op Care of Heart Transplant Pt

A
  • donor hearts are always paced after being implanted (w/ wires into the heart that are externally paced, not pads)
  • expect to see tachycardia and premature beats
  • immunosuppression meds (life-long)
  • anti-rejection meds (life-long)
  • antifungals/antibiotics (for protection b/c they are immunosuppressed, for long period after surgery but not life-long)
31
Q

Post-Op Heart Transplant Pt: Nursing Care

A

protective precautions in the immediate post-op period (no fresh flowers)

teaching on immunosuppression management

medication teaching

lab work (including heart biopsy to look for signs of rejection - 1-2 week intervals, then monthly)

32
Q

Type of Chest Tubes

A

traditional water seal: H2O in water seal and suction chambers

dry suction water seal: fluid only in water seal chamber

dry suction: one-way valve that lets air out, no water seal, no water in suction chamber

33
Q

Chest Tubes: Nursing Care

A
  • measure output
  • assess site for s/sx of infection
  • assess pt for s/sx of respiratory distress, cyanosis, subcutaneous emphysema
  • air leaks?
  • keep upright
  • prevent dependent loops
  • no clamping!
  • may strip depending on MD
  • always have clamps, occlusive sterile dressing, and sterile water at the bedside
  • transport depends on the pt and if they need continuous suction
34
Q

Chest Tubes: Complications

A

air leaks: continuous bubbling in water seal, or air leak indicator

accidental removal: can fall out, cover w/ occlusive dressing, leave one side open (controversial)

accidental disconnection: reconnect if possible or connect new atrium

Critical Care (14 decks)

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