Hemodynamics #5 Flashcards
Phosphodiesterase Inhibitors action / indication
Second line drug not used often. (For beta receptor down regulation)
- Beta Receptor stimulation causes ATP to be converted to cyclic AMP
- CAMP makes everything happen with cell.
- cAMP broken down w/ phosphodiesterase
- beta downregulation due to continuous beta receptor stimulation.
- beta drugs are DC, phosphodiesterase inhibitors initiated.
Beta downregulation & steroid administration
Steroids tell RNA in cells to go into overdrive and create proteins which are used to create beta receptors
Cardiogenic shock vasopressin considerations
Pump failure - vasopressor stick a cork in the aorta.
-dopamine & Levophed May bridge temporarily.
Cardiogenic shock treatment
- Adding volume helps to a point then hurts,
- dopamine until dobutamine works
- dobutamine assists w/ decreasing afterload
- sodium Nitroprusside (nitropress) for vasodilation once BP maintained w/ dobutamine (let ventricles clear & prevent cardiomyopathies)
- IABP & LVAD therapy.
Normal Pressures: CVP CI PA PCWP SVR
CVP: 2-6 CI: 2.5-4.2 PA: 15-25(PAS) / 8-15 (PAD) PCWP: 4-12 SVR: 800-1200
CVP Waveform
Preload for R side of heart -hydration 1st, then RV function Waveform: Sloppy cursive M -A, C, V wave -CVP range: mean average of waves
Low CVP
- Hypovolemia
- Vasodilation / decrease preload
- Negative pressure ventilation
- spontaneous ventilation
- hyperventilation
High CVP
- Hypervolemia
- Obstruction upstream
- RV failure or RVI
- cardiac Tampanade
- positive pressure ventilation (always drops preload)
- pulmonary hypertension
- tight lungs
- PE
- pulmonic valve stenosis
- tricuspid stenosis / regurgitation
IJ Depth of Insertion (cm) CVP/ RA RVP PAP PCWP
IJ (10's) - Subclavian (+5) - Femoral (+20) CVP/ RA: 20 RVP: 30 PAP: 40 PCWP: 50
Subclavian Depth of Insertion (cm)
IJ (10's) - Subclavian (+5) - Femoral (+20) CVP/ RA: 25 RVP: 35 PAP: 45 PCWP: 55
Femoral Depth if Insertion (cm)
IJ (10's) - Subclavian (+5) - Femoral (+20) CVP/ RA: 40 RVP: 50 PAP: 60 PCWP: 70
Positive pressure ventilation benefits and complication
Right heart friendly during failure (gives Chambers ability to clear)
Not left heart friendly during failure (need to improve preload on left side)
RVP
-Not typically monitored
-can irritate ventricle causing VF/VT
-looks similar to VT
-Sharp upstroke and down stroke
-notching on ascending side indicates atrial kick
-Anachrotic Notch
-norm: systolic: 15-25, diastolic:0-5
(Diastolic Must be lower than CVP)
Pressures: Single vs fractional numbers
Single: mean numbers (preloads)
2 numbers: arterial (after loads)
PA waveform
R heart output, L heart preload
- Pulmonary compliance
- PAS: same as RVP
- PAD: higher than RVDP (pulmonic valve closes and hold pressure for backflow into RV)
Low PAP
- Dehydration
- RV failure or RVI (upstream blockage)
- pulmonary stenosis (upstream blockage)
High PAP
Blockage downstream
- fluid overload
- mitral stenosis or regurgitation
- left ventricular failure
- aortic stenosis/regurgitation
- high pulmonary vascular resistance / HTN (hypoxia)
- AV Communication (hole between AV chambers)
- PE, ARDS, HPVR
PA Placement
- head up R Tilt position
- Cath balloon down via jugular, subclavian, femoral into vena cava.
- balloon inflated upon CVP waveform.
- RVP waveform: balloon sails toward RV septum toward PA
- PA waveform (same systolic, higher diastolic than RVP) balloon is deflated.
PCWP Waveform
- balloon inflated (1.5 ml) wedges in R lung
- occluded blood from R heart, eliminating R heart pressures.
- Low amplitude rolling waveform (similar to CVP, looks like fine VF)
- diastole, mitral open. LVEDP
High PCWP
- Obstruction downstream
- left ventricular failure
- high SVR
- constrictive pericarditis
- mitral stenosis and regurgitation
- fluid overload
- pulmonary hypertension
- hypoxia
- ARDS
- aortic stenosis
Low PCWP
- Obstruction upstream
- RV failure
- dehydration
- vasodilation
Inadvertent wedge troubleshooting
Caused by migration or balloon inflation
- Confirm balloon is fully deflated
- Have patient cough forcefully or roll to side and back (increases intrathoracic pressure’s and can pop back in to PA)
- Withdraw catheter until waveform returns to PA waveform (pullback very slowly and carefully)
Inadvertent RV waveform troubleshooting
Step 1: inflate balloon
- pads tip of Cath
- sail back into PA
Step 2: deflate balloon, drawback until CVP waveform obtained.
- safest technique
- confirm balloon deflated otherwise tricuspid damage will occur
CHF Treatment (5)
- Decrease preload (nitro, MS, Lasix)
- Decrease afterload (Nitroprusside (Nipride), nesiritude (natrocor))
- Decrease rate (beta blocker: Carvedilol (coreg) only(alpha& beta properties))
- Inhibit RAA System (ace inhibitors (prils-analapril))
- Improve Contractility (dobutamine B1&2 2:vasodilation(after load reduction) & phosphodiesterase inhibitors)
