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Hemodynamics Flashcards

1
Q

Law of laplace in cardiomyopathy

A

LV wall stress increases as LV wall thickness decreases

LV wall stress increases as LV radius increases

radius is directly related to stress

Thickness is inversely related to stress

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2
Q

Ohms law in hemodynamics

A

I=V/R

Flow= blood pressure/resistance

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3
Q

What is blood pressure

A

Force of circulating blood exerted on the blood vessel walls

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4
Q

Terms for manual blood pressure

A

Sphygmomanometer

Riva-Rocco

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5
Q

Too loose of a NIBP will cause what?

A

Overestimation of BP

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6
Q

Describe changes to BP in arms when patient is in lateral decubitus position

A

Lower arm-overestimates

Upper arm- underestimates

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7
Q

Define SBP in terms of oscillometry

A

Max pressure at which slope of oscillation amplitude increases

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8
Q

DBP in oscillometry

A

Minimum pressure at which slope of oscillation amplitude decreases

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9
Q

Actual measured values in automatic vs manual cuff pressures

A

Automatic: MAP

Manual: SBP and DBP

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10
Q

Below a MAP of 65 what BP technique is not useful in guiding hemodynamic therapy?

A

Oscillometry

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11
Q

Factors that impair oscillometry

A

Hemodynamic instability

Irregular heart rhythms

Cuff issues

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12
Q

Basis for and drawbacks of continuous NIBP

A

Photoplethysmography

-require calibration
-impacted by tone/perfusion
-sensitive to finger motion
-limited use in critically ill patients

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13
Q

Indications for arterial cannulation

A

If you’re thinking about it- DO IT

Barry

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14
Q

What to know about the Allen’s test

A

Patency of collateral circulation in hand from ulnar artery

Tests are only abnormal or normal….

Use a pulse ox on the thumb

Timeframe color should return to hand 5-15 seconds

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15
Q

Sensitivity/specificity of Allen’s test

A

80%

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16
Q

When to use US for art line placement

A

Lack of pulsatile flow

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17
Q

What are alternate sites to the radial artery?

A

Ulnar, brachial and axillary

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18
Q

Why do we not use lower extremity NIBP

A

They have not been validated!!!

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19
Q

Advantages to femoral line

A

Reflect central arterial pressure

Norepi infusion rates are reduced up to 30%

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20
Q

Risks of femoral cannulation

A

Cerebral embolization

Retroperitoneal hemorrhage (preform below inguinal ligament)

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21
Q

What to know about forearm pressures

A

Overestimate SBP and underestimate DBP

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22
Q

Electrical/mechanical time delay in
Ascending aorta and
Radial arterial catheter

A

AoV- 180msec

Radial-220 msec

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23
Q

2 limbs of arterial waveform

A

Anacrotic

Dicrotic

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24
Q

MAP calculation

A

1/3 SBP + 2/3 DBP

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25
Which phase of the cardiac cycle decreases the most in tachycardia?
Diastole
26
Early indicator of hemodynamic instability
SBP instability May also be greater indicator of organ blood flow
27
Physiologic contributions to peak systolic pressure
LV contraction Central arterial compliance Reflected pressure wave from vascular tree
28
What changes do we see in distal monitoring sites?
Increased peak pressure due to pulse amplification do to reflected pressure waves from distal noncompliant vascular tree
29
7 things you see in distal sites arterial line
High peak pressure Widened pulse pressure Delayed upstroke Delayed incisura Steeper diastolic runoff Prominent diastolic wave Decreased end diastolic pressure
30
What is systolic decline and when is it most rapid
Time when efflux from arterial compartment is > influx from LV -rapid in LV outflow obstruction
31
Why is diastolic pressure not 0?
Elastic recoil of the vessels- contributes to 40% of delivered stroke volume
32
What is end diastolic pressure
Pressure exerted on AoV by vascular tree Pressure seen by L coronary arteries
33
What lowers DBP?
Loss of elastic recoil Aortic insufficiency- regurg Distal monitoring
34
Causes of widened pulse pressure
Atherosclerosis Sepsis AI
35
Underdampening
systolic pressure overshoot due to resonance (Widened pulse pressure)
36
Over dampening
Slurred upstroke and loss of fine detail including dicrotic notch (Diminished pulse pressure)
37
Impact of under or over dampening on an arterial waveform MAP
Unchanged
38
Aortic stenosis artline
Narrow pulse pressure Delayed upstroke Parvus et tardus
39
(AI)Aortic regurgitation on artline
Double peak Wide pulse pressure Pulsus bisferiens
40
HOCM Artline
Spike and dome (mid systolic dysfunction)
41
Severe systolic LV dysfunction -artline
Alternating pulse pressure amplitude Pulsus alternans Very similar to paradoxus…
42
Tamponade on Art line
Pulsus paradoxus (>10mmhg in SBP with inspiration
43
What determines pulse pressure?
Directly proportional to change in circulatory volume (stroke volume) and inversely to arterial compliance (C) Pp= (SV)/C Hint: think of diastolic pressure and how it changes with compliance and then how a change in diastolic will change the PP
44
What is a wide or narrow pulse pressure?
Narrow: < 25% of SBP Wide: >50% of sBP
45
What’s the new vital sign you will always calculate?
Pulse pressure
46
What are the determinants of SV This is very important
Preload Contractility Afterload
47
If arterial compliance is unchanged, what does a change in pulse pressure reflect?
A change in stroke volume
48
What is preload?
RVEDV Or LVEDV VOLUME (wall tension)
49
What are surrogate measures of preload?
LVEDP, CVP and PAWP
50
When does CVP correlate with RVEDP?
In the absence of tricuspid valve disease
51
What conditions make digital readouts inaccurate?
High respiratory pressures Tricuspid regurgitation (common in ventilated patients)
52
Zeroing a CVP
STOPCOCK (not transducer) 5cm below the sternal angle
53
Utility of CVC according to Barry
Vasoactive medications
54
No fall in CVP during inspiration of mechanically ventilated patient What does this mean and what do we call the relationship?
Suggests CO will not increase with fluid Negative predictive value
55
CVP waveform components
A- end diastole C- early systole X-mid systole V- late systole H-mid to late diastole
56
Describe PAC floating waveforms
RA-CVP waveform RV-systolic increase, diastolic unchanged PA- diastolic STEP UP Wedge-similar to CVP
57
West zones
Zone 1, where alveolar pressure is higher than arterial or venous pressure; Zone 2, where the arterial pressure is higher than alveolar and venous, a relationship which changes during the respiratory cycle. Zone 3, where both arterial and venous pressure is higher than alveolar.
58
What pulmonary term will we NOT use and what will we use instead
FUCK PCWP (capillary) Use PAWP (wedge pressure)
59
Problems with PAC monitoring
Pressure gradients Changes in ventricular compliance
60
What indicates correct placement of a PA cath?
Minimal effect of airway pressure (peep) on PAWP measurement PAWP is not indicative of LVEDP in cases of high PEEP
61
PAC flotation tips
Patient head down will facilitate passing tricuspid patient RSD and head up may help pass RVOT Deep inspiration may augment venous return and facilitate catheter out of RVOT
62
Why are PAC readings extremely sensitive to artifact?
Long, more prone to clots/air/motion Mechanical tendency to overwedge Mitral valve disease distorts waveform
63
What is catheter fling?
Artifactual peaks and troughs that distort digital readings
64
What is overwedging and how do you correct?
Gradual rise in non-pulsatile waveform Tip against vessel wall Withdrawal of catheter
65
What does Pa waveform look like in MR?
Tall V wave overestimated on digital readouts
66
When do you get correct values for LVEDP?…
End diastole (R wave)
67
What may indicate Myocardial ischemia on a PAC waveform?
Rise in LVEDP -increased a height
68
Determinants of SVR
Vascular tone Hematocrit Plasma protein concentration Temperature
69
Define impedance
Resistance to changing flow Not- resistance to flow (SVR)
70
Surrogate measures for filling pressures related to preload
PAP and CVP
71
What is a poor positive predictor of fluid responsiveness because it has a complicated relationship?
CVP
72
Most sensitive detection of myocardial ischemia
Echo SWMA
73
Calculated values form PAC
SVR and PVR
74
Relative contraindication to PAC placement .
LBBB
75
Windkessel effect
The mechanical energy stored in the stretched elastin serves to maintain the blood pressure during diastole
76
When is end diastole measured in PAWP wave?
A wave
77
Two things seen in MI on a PAC tracing
Increased a wave (impaired diastole) Decreased LVEF (impaired systole) and or rise in LVEDP
78
MAP calculation- not BP based
CO*SVR

733 (10 decks)

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