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733 > Hemodynamics > Flashcards

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
Q

Which phase of the cardiac cycle decreases the most in tachycardia?

A

Diastole

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26
Q

Early indicator of hemodynamic instability

A

SBP instability

May also be greater indicator of organ blood flow

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27
Q

Physiologic contributions to peak systolic pressure

A

LV contraction

Central arterial compliance

Reflected pressure wave from vascular tree

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28
Q

What changes do we see in distal monitoring sites?

A

Increased peak pressure due to pulse amplification do to reflected pressure waves from distal noncompliant vascular tree

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29
Q

7 things you see in distal sites

A

High peak pressure
Widened pulse pressure
Delayed upstroke
Delayed incisura
Steeper diastolic runoff
Prominent diastolic wave
Decreased end diastolic pressure

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30
Q

What is systolic decline and when is it most rapid

A

Time when efflux from arterial compartment is > influx from LV

-rapid in LV outflow obstruction

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31
Q

Why is diastolic pressure not 0?

A

Elastic recoil of the vessels- contributes to 40% of delivered stroke volume

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32
Q

What is end diastolic pressure

A

Pressure exerted on AoV by vascular tree

Pressure seen by L coronary arteries

33
Q

What lowers DBP?

A

Loss of elastic recoil

Aortic insufficiency- regurg

Distal monitoring

34
Q

Causes of widened pulse pressure

A

Atherosclerosis

Sepsis

AI

35
Q

Underdampening

A

systolic pressure overshoot due to resonance
(Widened pulse pressure)

36
Q

Over dampening

A

Slurred upstroke and loss of fine detail including dicrotic notch
(Diminished pulse pressure)

37
Q

Impact of under or over dampening on an arterial waveform MAP

A

Unchanged

38
Q

Aortic stenosis artline

A

Narrow pulse pressure

Delayed upstroke

Parvus et tardus

39
Q

(AI)Aortic regurgitation on artline

A

Double peak

Wide pulse pressure

Pulsus bisferiens

40
Q

HOCM

Artline

A

Spike and dome (mid systolic dysfunction)

41
Q

Severe systolic LV dysfunction -artline

A

Alternating pulse pressure amplitude

Pulsus alternans

Very similar to paradoxus…

42
Q

Tamponade on Art line

A

Pulsus paradoxus (>10mmhg in SBP with inspiration

43
Q

What determines pulse pressure?

A

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
Q

What is a wide or narrow pulse pressure?

A

Narrow: < 25% of SBP

Wide: >50% of sBP

45
Q

What’s the new vital sign you will always calculate?

A

Pulse pressure

46
Q

What are the determinants of SV

This is very important

A

Preload
Contractility
Afterload

47
Q

If arterial compliance is unchanged, what does a change in pulse pressure reflect?

A

A change in stroke volume

48
Q

What is preload?

A

RVEDV
Or
LVEDV

VOLUME (wall tension)

49
Q

What are surrogate measures of preload?

A

LVEDP, CVP and PAWP

50
Q

When does CVP correlate with RVEDP?

A

In the absence of tricuspid valve disease

51
Q

What conditions make digital readouts inaccurate?

A

High respiratory pressures

Tricuspid regurgitation (common in ventilated patients)

52
Q

Zeroing a CVP

A

STOPCOCK (not transducer) 5cm below the sternal angle

53
Q

Utility of CVC according to Barry

A

Vasoactive medications

54
Q

No fall in CVP during inspiration of mechanically ventilated patient

What does this mean and what do we call the relationship?

A

Suggests CO will not increase with fluid

Negative predictive value

55
Q

CVP waveform components

A

A- end diastole

C- early systole

X-mid systole

V- late systole

H-mid to late diastole

56
Q

Describe PAC floating waveforms

A

RA-CVP waveform

RV-systolic increase, diastolic unchanged

PA- diastolic STEP UP

Wedge-similar to CVP

57
Q

West zones

A

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
Q

What pulmonary term will we NOT use and what will we use instead

A

FUCK PCWP (capillary)

Use PAWP (wedge pressure)

59
Q

Problems with PAC monitoring

A

Pressure gradients

Changes in ventricular compliance

60
Q

What indicates correct placement of a PA cath?

A

Minimal effect of airway pressure (peep) on PAWP measurement

PAWP is not indicative of LVEDP in cases of high PEEP

61
Q

PAC flotation tips

A

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
Q

Why are PAC readings extremely sensitive to artifact?

A

Long, more prone to clots/air/motion

Mechanical tendency to overwedge

Mitral valve disease distorts waveform

63
Q

What is catheter fling?

A

Artifactual peaks and troughs that distort digital readings

64
Q

What is overwedging and how do you correct?

A

Gradual rise in non-pulsatile waveform

Tip against vessel wall

Withdrawal of catheter

65
Q

What does Pa waveform look like in MR?

A

Tall V wave overestimated on digital readouts

66
Q

When do you get correct values for LVEDP?…

A

End diastole (R wave)

67
Q

What may indicate Myocardial ischemia on a PAC waveform?

A

Rise in LVEDP

-increased a height

68
Q

Determinants of SVR

A

Vascular tone
Hematocrit
Plasma protein concentration
Temperature

69
Q

Define impedance

A

Resistance to changing flow

Not- resistance to flow (SVR)

70
Q

Surrogate measures for filling pressures related to preload

A

PAP and CVP

71
Q

What is a poor positive predictor of fluid responsiveness because it has a complicated relationship?

A

CVP

72
Q

Most sensitive detection of myocardial ischemia

A

Echo

SWMA

73
Q

Calculated values form PAC

A

SVR and PVR

74
Q

Relative contraindication to PAC placement .

A

LBBB

75
Q

Windkessel effect

A

The mechanical energy stored in the stretched elastin serves to maintain the blood pressure during diastole

76
Q

When is end diastole measured in PAWP wave?

A

A wave

77
Q

Two things seen in MI on a PAC tracing

A

Increased a wave (impaired diastole)

Decreased LVEF (impaired systole) and or rise in LVEDP

78
Q

MAP calculation- not BP based

A

CO*SVR

733 (10 decks)

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